Hip Arthroscopy
Jonathan E. Fow
Etiology
Arthroscopy of the hip has been performed for many years, but has become more mainstream over the last few years. Initially, it was used as a minimally invasive method of removing loose bodies. As we have learned more about variations in hip morphology, both congenital and acquired, the useful applications of hip arthroscopy have grown. Overall, hip arthroscopy can improve pain and function in 68% to 96% of surgical patients1 (Fig. 20-1).
Anatomy
Femoral acetabular impingement (FAI) is a cause of hip pain and debility. An anomalous, aspherical femoral head or anterosuperior “bump” on the femoral head and neck are features of controlled action motion (CAM) impingement (Fig. 20-2). An anterosuperior acetabular lip or retroverted acetabulum causes pincer impingement (Fig. 20-3). There is often a mixed morphology involving attributes of both CAM and pincer impingement. Femoral osteoplasty to reshape the femoral head and neck can treat CAM impingement, whereas acetabular osteoplasty can reshape the acetabular rim to improve pincer impingement.2 Both osteoplasty procedures result in improved range of motion (ROM) and function. Hip arthroscopy can address labral tears by both débridement and repair. Surgeons may perform microfracture or abrasion chondroplasty on the acetabulum also to débride cartilage lesions, and extraarticular pathology, such as gluteus medius tears, chronic iliotibial (IT) band snapping syndrome, and snapping psoas syndrome, can also be addressed endoscopically.
The complex mechanical interrelationships of the lumbar spine, hip, and lower extremity can functionally cause FAI despite near normal architecture. There can be functional impingement caused by hyperlordosis or the type of stress or activity imposed on the joint. In addition, often there exists multiple sources of pain such as degenerated discs, sacroiliac disorders, hip bursitis and IT band syndrome, hip flexor strains, and hernias. Diagnosis of FAI, loose bodies, and other causes of intraarticular or extraarticular hip pain must be confirmed while other possible sources of pain are ruled out. At the very least, patients should be aware of the risk that hip pain can be, and often is, multifactorial. Arthroscopy of the hip may only be able to address a percentage of the pain they experience.
Indications/Considerations
Patients who are seen in the office with hip pain are initially examined, their history reviewed, and radiographs taken. History of the patient’s hip pain may include chronic psoas strains, lumbar spine, and sacroiliac joint dysfunction. Transitioning to a higher or different level of activity (e.g., high school to college track) may precipitate hip pathology, as well as previous involvement and previous injuries in sports. FAI can also become symptomatic with changes in equipment, which affect body position such as shoes and bicycles.
Hip pathology is often described by a patient as groin or gluteal pain. Because hip pain can also radiate to the thigh and knee, patients may have had inappropriate knee arthroscopy.
PHYSICAL EXAMINATION: Examining the lumbar spine, hip, and knee and observing posture and gait are very important in evaluating a patient with hip pain. Consider pursuing evaluation in functional positions, especially during sporting activities (e.g., running, pushing, jumping, skating, lunging). Observe the relationship of the pelvis to the lower extremities, then examine the extremities. Examine the patient walking, standing, supine, lateral, and prone.
Standing:
Gait: Observe stride length, foot progression angle, pelvis rotation, stance phase, foot drop, clicking, popping, antalgic gait, Trendelenburg gait, pelvic wink (external rotation >40), short leg limp (IT band pathology, true/false leg length discrepancy).
Patient recreation of click: Psoas or IT band.
Alignment: Note shoulder height, scoliosis, pelvic tilt; grossly measure anterosuperior iliac spine (ASIS) to medial malleolus; note spinal alignment posterior and lateral (flat lumbar spine) hyperlordotic; and consider that which would functionally affect pelvic and acetabular orientation (e.g., weak abdominal musculature, gluteus, lumbar spine, tight hamstrings). Observe single-leg stance for pelvic balance.
Sitting:
Leg length, rotation, neurologic (motor: abduction: superior gluteal nerve L4 to S1; adduction: obturator nerve L2 to 4; knee extension: L2 to 4; knee flexion: L4 to S3 sciatic nerve; great toe extension: L5; extensor hallucis longus, plantar flexion: L4 to S1; sensory: dermatomal sensation).
Supine:
ROM: External rotation, internal rotation in hip neutral and 90° of hip flexion, popliteal angle, supine abduction, frog leg abduction (knee height), adduction.
Palpate: Inguinal region, pubis, ASIS, anteroinferior iliac spine (AIIS), Stinchfield test (straight leg raise versus resistance causing pain indicates iliopsoas and/or intraarticular pathology), inferior to AIIS (labrum, anterior capsule, rectus reflected). Note: Nondisplaced or stress fracture will also hurt with straight leg raise, heel strike, and log roll.
Provocative: FADIR (flexion, adduction, internal rotation) indicates FAI and labral pathology, FABER (flexion, abduction, external rotation) or Patrick test for groin, iliopsoas, lateral FAI, lateral-FAI flexion to extension in abduction (abduction), posterior labrum, and sacroiliac pathology); Thomas test: click may indicate labral tear and tightness represents iliopsoas contracture; McCarthy: full ROM from extension to flexion with external/internal rotation; Scour test: full flex and palpate superior acetabular rim for irregularity.
Lateral:
Palpate ischial tuberosity, greater trochanter, tensor fascia lata, IT band, piriformis, gluteus, sacrum, coccyx, sciatic nerve.
Ober (knee flexion and extension), test strength gluteus medius, gluteus minimus, Ely test in lateral tight quadriceps mechanism.
Prone:
Palpate sacroiliac joint, ischial tuberosity, spine, musculature. Ely test: rectus/quadriceps contracture.
