Indications and Contraindications for Hip Arthroscopy
John C. Clohisy, MD
This presentation will review the 1) established indications, 2) contraindications and 3) controversial indications for hip arthroscopy.
The surgical treatment of symptomatic hip disease has markedly changed over the past several years. A variety of joint preservation procedures (arthroscopy, osteotomy, safe dislocation) have gained popularity in treating pre-arthritic and early arthritic hip disorders. Most notable has been the dramatic increase in the utilization of hip arthroscopy. The broader application of arthroscopic techniques has provided effective treatment for a variety of disorders. Nevertheless, there remains controversy regarding the appropriate indications and possible overutilization of this surgical procedure.
Successful application of arthroscopy is dependent upon strict diagnostic criteria, careful patient selection, appropriate indications and precise surgical technique. This presentation will review the current indications, contraindications and controversial indications for hip arthroscopy.
1) Established Indications for Hip Arthroscopy
- a) FAI (common)
- FAI is the most common current indication for hip arthroscopy. The majority of FAI disease patterns are amenable to arthroscopic treatment. In addition to correction of structural impingement, associated soft tissues abnormalities should be treated. The arthroscopic procedure should evaluate and treat:
- acetabular rim impingement deformities
- acetabular labral lesions
- articular cartilage lesions
- femoral impingement deformities
- b) Isolated intra-articular abnormalities (labral tears, chondral flaps, loose bodies, ligamentum teres tears, synovitis)
- Isolated intra-articular abnormalities (in the absence of structural hip disease) are relatively uncommon but are certainly encountered in a hip arthroscopy practice. These disorders are commonly the result of major trauma, minor trauma or overuse and can include:
- labral tears
- chondral flaps
- ligamentum teres tears
- loose bodies
- c) Adjunctive procedure to open joint preservation surgeries
- Hip arthroscopy can provide excellent visualization of the central compartment and can be combined with open procedures. This allows the combination of precise arthroscopic management of intra-articular abnormalities with major extra-articular structural corrections (PAO and PFO).
- d) Benign intra-articular neoplasms (synovial chondromatosis and PVNS)
- Benign intra-articular neoplasms can be treated with hip arthroscopy in certain situations. Arthroscopic access to disease should be assessed preoperatively. Advantages and disadvantages relative to an open procedure should be considered.
- e) Periarticular soft tissue procedures (psoas lengthening, IT band release, abductor repair)
- The application of arthroscopy for periarticular soft tissues disorders is expanding, yet the results of such procedures are limited. Continued clinical outcome studies are needed to solidify the efficacy of these procedures. Tendon lengthening and releases should be undertaken with caution as these procedures can markedly change the muscle function and balance about the hip.
- Compensatory soft tissue disorders in the presence of intrinsic hip disease commonly resolve with correction of the primary hip disorder.
- a) Advanced intra-articular disease
- Joint preservation procedures are less effective in the presence of established secondary OA (Tonnis 2 or 3). In borderline cases, preoperative evaluation should carefully assess the integrity of the articular cartilage. Male FAI patients in the 30-50 age group commonly have extensive intra-articular disease despite mild radiographic findings. Symptomatic treatment and eventual THA should be considered for most patients with Tonnis grade 2 and 3 OA.
- b) Major DDH (structural instability)
- Major DDH (LCEA <20, ACEA <15, AI >15) is associated with mechanical overload of the acetabular rim due to structural deformity of the acetabulum. Hip arthroscopy cannot correct the pathomechanics of the joint. In appropriate cabdidates, definitive treatment should encompass surgical correction of the underlying hip deformity (acetabular reorientation).
- c) Severe, “Nonfocal” FAI patterns
- Hip arthroscopy is appropriate for the majority of FAI disease patterns. There is a subset of complex FAI disease patterns that are better managed with open surgical techniques.
- SCFE: residual SCFE deformities with a slip angle >30 degrees, complex head-neck malformations, malrotation and/or shortening
- Perthes: residual Perthes deformities with aspheric femoral head, short neck, varus neck, high trochanter, associated acetabular deformities (dysplasia, retroversion)
- Severe acetabular retroversion: Anterosuperior over-coverage, posterior wall sign, ischial spine sign, posterosuperior insufficiency, borderline dysplasia
- Posterolateral and posterior head-neck junction lesions: femoral cam lesions that are superior and/or posterior to retinacular vessels.
- Extra-articular impingement: femoral neck, trochanteric, periacetabular deformities less accessible with arthroscope (evaluation and treatment)
- d) Inaccessible hip joint
- obesity, scar tissue, heterotopic ossification, soft tissue noncompliance, etc
- Borderline DDH: (LCEA 20-25 degrees, ACEA 15-20, AI 10-15) The cut-off values for acetabular reorientation versus arthroscopy have not been defined. Patient history, exam, radiographs and imaging should be considered.
- “Functional” hip instability: The diagnosis of “functional” instability due to soft tissue imbalance and/or laxity is controversial. Diagnostic criteria and outcomes of surgical treatment are limited.
- “Super-obese” patients: Technical issues and limitations of arthroscopic instruments can compromise surgical technique and outcomes in the super-obese patient.
- Periarticular soft tissue disorders: Growing interest in soft tissue diseases about the hip. Current indications for surgery are controversial and clinical outcomes limited (piriformis syndrome, sciatic neurolysis, etc)
- FAI: Moderate acetabular retroversion- The cut-off values for acetabular reorientation versus arthroscopy have not been defined.
- Femoral lesions superior and slightly posterior to the retinacular vessels- Optimal surgical technique and access to posterior femoral lesions is controversial.
2) Contraindications for Hip Arthroscopy
3) Controversial indications for hip arthroscopy
There are excellent indications for hip arthroscopy with the most common being FAI followed by isolated intra-articular hip abnormalities. Hip arthroscopy can also be an effective adjunct to open joint preservation techniques. The major contraindications include established OA and major structural deformities not amenable to arthroscopic correction. Future studies are needed to delineate the indications for several controversial indications.
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