Arthroscopy: The Journal of Arthroscopic and Related Surgery 7(2):204-211 Published by Raven Press, Ltd. 0 1991 Arthroscopy Association of North America

Arthroscopic Takatoshi

Surgery of the Hip Joint

Ide, Noriya Akamatsu,

and Ikumasa Nakajima

Summary: Hip arthroscopic examination of 196 joints was performed in 104 patients treated during the past 4 years. Of these, 11 joints were treated by arthroscopic surgery. We have developed a technique using a two-directional approach that facilitates a global view of joint areas and allows simpler performance of surgical procedures. Removal of loose bodies, joint debridement in osteoarthritis, and synovectomy in rheumatoid arthritis are good indications for arthroscopic surgery of the hip joint. Short-term follow-up was satisfactory, and a reduction of pain was obtained in all patients. Although the joint space of the hip is narrower and the operative technique is more difficult to perform than in the knee, we believe that arthroscopic surgery of the hip is a suitable method in selected cases. Key Words: Hip joint-Surgery-Tom labrumJoint debridement.

The hip joint has remained an unpopular joint for arthroscopy in spite of the fact that it is an important weight-bearing joint. The first application of arthroscopy of the hip was described by Burman (1931) (1) in a case report. However, difficulties with technical equipment have hampered progress during the past 50 years; a satisfactory view of the hip joint has been difficult to obtain. Beginning in 1984, we developed a technique that enlarges the field of view in the joint, and this method has been adopted as a routine technique in several facilities. There is still much debate over the role of arthroscopic surgery of the hip joint and whether this technique is useful. The purpose of this report is to describe our hip arthroscopic surgery technique and its possible applications. METHODS AND PATIENTS Anesthesia and position It has been found to be advantageous to administer general anesthesia, although spinal anesthesia From the Department of Orthopaedic Surgery, Yamanashi Medical College, Yamanashi, Japan. Address correspondence and reprint requests to Dr. T. Ide at 1110 Shimokato, Tamaho-cho, Nakakoma-gun, Yamanashi, Japan W-38.

might be used if adequate muscle relaxation can be achieved. The patient is positioned in a supine position on the fracture table. The joint space is widened by applying extension to the leg (Fig. 1). The force required to achieve the desired joint space width is between 20 and 40 kg of traction force. The traction forces should be reduced intermittently to prevent nerve traction palsies. Surgical approach As a general rule, the surgical approach to the hip has two portals (2,3). The first portal is made at the anterior aspect of the hip joint, and the second is made laterally (Figs. 2 and 3). The anterior approach technique is demonstrated in Fig. 4. A 19gauge spinal needle is introduced 1 cm lateral and distal to the midpoint of the line between the anterior superior iliac spine and the symphysis pubis. This point should be determined carefully because of the close proximity of the femoral neurovascular bundle. Therefore, palpation and marking of the femoral artery should be performed before positioning and draping the patient (Figs. 3 and 4). Ten to 40 ml of saline (0.9% NaCl) is injected in the joint space for distension using a 20-ml syringe after the insertion of the needle into the joint space of the hip. If the needle is inserted properly, a backflow of saline can always be obtained. The puncture site is

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FIG. 1. The position of the leg for hip arthroscopy using a fracture table. The hip was abducted and flexed slightly. Twenty to 40 kg of traction force is desired for joint space expansion.

prepared with a small skin incision of 4 mm. The subcutaneous tissue including muscle structures are gently divided longitudinally down to the joint capsule using a small, straight mosquito forceps to prevent nerve and arterial injuries (Fig. 4B). The arthroscopic sheath is introduced along the needle line with a blunt trocar. After touching the capsule, the tip is shifted distally while pushing it against the capsule to feel the protruded frontal edge of the acetabular labrum, the spherical shape of the femoral head, and the hollow of the joint gap (Fig. 5).

FIG. 2. Technique of two-directional arthroscopy of the hip joint with two arthroscope sheaths of the same diameter.

FIG. 3. The approach to the hip joint with two portals. The anterior approaching point is located 1 cm lateral and distal to a midpoint of the line between the anterior superior iliac snine and the symphysis pubis (A). The lateral portal is placed 2 cm proximal to the tip of the greater trochanter (B). ASIS, anterior SUperior iliac spine; SP, symphysis pubis.

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4C,D

FIG. 4. Technique of two-directional arthroscopy of the hip joint. A: Insertion of a spinal needle in the anterior approach. B: Division of subcutaneous tissue with a small, straight forceps. C: Penetration of the capsule with a sharp trocar. D: Installation of video camera and irrigation tubes.

The blunt trocar is now replaced by the sharp car, and the capsule is penetrated by rotating pushing the trocar gently but avoiding a violent (Fig. 4C). The sharp trocar is replaced again

troand jerk with

FIG. 5. The anterior approach. The hollow of the hip joint gap can be felt with a blunt trocar between the protruded frontal edge of the acetabular labrum and the spherical shape of the femoral head.

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the blunt device, and the sheath is maneuvered as far into the joint space as possible. The lateral approach, which provides a safe route for the arthroscope, is now performed. The palpable landmarks are the greater trochanter and the anterior superior iliac spine. The insertion point is placed 2 cm proximal to the tip of the greater trochanter, and a 19-gauge spinal needle is introduced. The backflow of the fluid again indicates the entrance into the joint. The arthroscopic sheath of the same size as used in the anterior approach is inserted into the joint laterally after a stab incision is made at the needle site. Inspection of the hip joint is performed with a Watanabe type 21 CLM arthroscope (Shinko Optical Co., Ltd., Tokyo, Japan) with a 5-mm diameter, and 0 and 30” optics (Fig. 6). Arthroscopy was monitored by a CCD micro video camera (Shinko Optical Co., Ltd.), and visual findings were recorded on videotapes and in photographs (Fig. 4D).

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FIG. 6. Instruments of arthroscopy of the hip. Watanabe type 21 CLM arthroscope motorized shavers, scissor, forceps, and abraders.

A gravitational irrigation is installed to clear the view through the arthroscope sheath. Gravitational inflow provides enough pressure to keep the visual field clean. The inflow-outflow system is installed with the same diameter as the scope sheath; therefore, the scope and surgical instruments can be interchanged between the portals. The inflow usually is supplied through the sheath of the opposite site from which the arthroscope has been inserted. The visual field of the hip joint was divided into five compartments and a blind region of the infraposterior area of the femoral head (Fig. 7). Patients Arthroscopic examination of the hip joint was carried out in 196 joints in 106 patients with various hip disorders at the Department of Orthopaedic Surgery of Yamanashi Medical College during the past 4.5 years between October 1984 and March 1989. Eighty-two patients were women and 24 were men. The ages of the patients ranged from 4 to 84 years (mean, 48 years). Indications for hip arthros-

FIG. 7. Visual compartment of the hip. The visual field of the hip joint was divided into five compartments, excluding the blind section of the infraposterior area of the femoral head. L, lateral compartment; W, weight-bearing compartment; M, medial compartment; N, femoral neck compartment; PL, posterolateral compartment.

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with a sheath of 5-mm diameter, 0 and 30” optics,

copy included osteoarthritis (the primary cause), avascular necrosis of the femoral head, rapidly destructive coxarthritis, and rheumatoid arthritis (Table I). Indications for surgery included partial resection of the tom labrum in three cases, joint debridement for osteoarthritis in two cases, synovectomy in three cases, and removal of loose bodies in three cases (Table 2). RESULTS The results of partial resection of the torn labrum were satisfying in all three cases. One of these cases, a 63-year-old woman, had for 20 years had pain in both hips during walking. In January 1988 she complained of a sudden onset of pain in the left hip while performing housework. On clinical examination, pain was triggered by abduction and internal rotation. Radiographs revealed osteoarthritis with acetabular dysplasia of both hip joints (Fig. 8); however, an obvious discrepancy between her pain and the radiographic findings existed. Arthroscopy revealed a longitudinal tear of the labrum at the anterosuperior attachment to the acetabulum with the tear interlocked between the acetabulum and TABLE 1. Indication Clinical diagnosis

of hip arthroscopy Cases

Joints

70 13 7 3 13

128 24 13 6 25

106

1%

Osteoarthritis Avascular necrosis Rapidly destructive coxarthritis Rheumatoid arthritis Others Total

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TABLE 2. Indication

of arthroscopic the hip

Methods Removal of loose bodies Synovectomy Joint debridement Partial resection of labrum

surgery of Joints 3 3 2 3 II

Total

the femoral head in the left hip. The appearance was quite similar to a bucket-handle tear as is found in meniscal injuries. Partial resection of the torn labrum was performed by arthroscopic surgery (Fig. 9). Additionally, arthroscopy revealed loss of cartilage in the weight-bearing area of both femoral heads and the acetabulum. The patient’s symptoms were relieved after this procedure. Joint debridement was performed on two patients with severe osteoarthritis of the hip joint. One of the patients was a 56-year-old woman whose left hip had been replaced with a cementless total hip system 2 years before. Although the patient had substantial relief of pain in the left hip joint postoperatively, continuous pain persisted in the right hip joint. On examination of the right hip, ranges of motion of 10” abduction, 10” adduction, 60” flexion, 0” internal rotation, and 15” external rotation were found. Radiographs revealed severe osteoarthritis with subluxation of the right hip joint (Fig. 10). Arthroscopic examination showed that the joint space was filled with synovial debris with an adhesion between the capsule and the femoral head. The joint was debrided with motorized shavers, forceps, and abraders (Fig. 11). One month postoperatively, the range of motion had increased to 70% with pain relief at follow-up of 8 months. Arthroscopic synovectomy of the hip was performed in three cases. All three patients with rheu-

FIG. 8. Tom acetabular labrum in the left hip of a 63-year-old woman. Anteroposterior roentgenogram of the hip shows osteoarthritis with acetabular dysplasia.

matoid arthritis were classified as stage III. Villous formation, proliferative synovitis and deep cartilage erosions penetrating to the subchondral bone were observed. Synovectomy was performed with powered intraarticular shavers, basket forceps, and scissors (Fig. 12). After surgery there was no significant recovery of joint motion, and pain was reduced only temporarily in all patients. Removal of loose bodies and fragments produced good results. In all three patients with loose bodies, pain was reduced, and the range of motion was improved. One of the patients was a 67-year-old woman who complained of severe pain in both hip joints. Radiographs showed severe degenerative osteoarthritic changes of the left hip joint; however, the right side seemed to be unaffected. Arthroscopic examination was performed in both hip joints to determine treatment methods. Loose bodies were arthroscopically visualized in the right hip

9A-C

FIG. 9. Tom acetabular labrum in the left hip of a 63-year-old woman. Preoperative arthroscopic view of the left hip with the anterior approach. A: Detached, tom labrum; the denuded femoral head. B: Partial resection of the tom labtum with scissor and forceps. C: Arthroscopic view after procedure. Arthroscopy,

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FIG. 10. Adhesions between the capsule and the femoral head in the left hip of a 56-year-old woman. Anteroposterior roentgenogram of the hip shows osteoarthritis with acetabular dysplasia of the left hip and cementless total hip replacement of the right hip.

11A

11

FIG. 11. Adhesions between the capsule and the femoral head in the left hip of 56-year-old woman. Preoperative arthroscopic view of the right hip with the anterior approach. A: Detached, tom labrum and denuded femoral head. B: Joint debridement of the adhesion with motorized shaver. C: Arthroscopic view after the procedure.

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FIG. 12. Rheumatoid arthritis in a 47-year-old woman. Arthroscopic synovectomy of the hip was performed. Motorized shaver was inserted through a third portal (anterolateral portal).

joint. A large fragment was removed anterior portal (Fig. 13). This patient total hip replacement of the left hip mained asymptomatic in both hips for surgery.

through the underwent a and has reI year since

DISCUSSION Arthroscopic examination of the knee joint is a common method of diagnosis and treatment. However, the indications for arthroscopic examination of the hip joint have been limited. The value of arthroscopy of other major joints such as the knee, ankle, elbow, and the shoulder has been docu-

mented thoroughly, but reports regarding the value of arthroscopy of the hip have been rare (4-6). Hip arthroscopy has gone relatively undeveloped while arthroscopy in other joints has advanced remarkably. The reasons for this lack of development are primarily due to the anatomy of the hip. The hip joint is composed simply of a ball and socket joint, and therefore there are few disorders and traumas that originate in the soft tissue as they do in the meniscal and cruciate ligaments in the knee joint. Therefore, radiographic and clinical examination are sufficient to identify hip disorders such as osteoarthritis or aseptic necrosis of the femoral head. Furthermore, these disorders are visible to the naked eye at surgery, and therefore the more technically difficult hip arthroscopic examination has not been necessary (7,8). In 1984 we developed a new technique that allows a larger view of the joint area (Fig. 14), and our method has been accepted as a routine technique in several medical facilities; our final objective is arthroscopic surgery of the hip joint (9-11). The following considerations are reasons for performing arthroscopic surgery of the hip. In rheumatoid arthritis, most patients complain about more pain in other joints than the hip, but the hip is still affected. Invasion of synovial membranes and destruction of the hip joint progresses relatively silently and/or with less severe symptoms. Although synovectomy of other joints is a well-established method of treatment in rheumatoid arthritis when conservative

FIG. 13. LetI: Cartilage fragment with subchondral bone in the hip of a 67-year-old woman with bilateral painful hips. Right: The loose body in the right hip joint (cartilage fragment with subchondral bone) during and after removal.

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FIG. 14. Arthroscopic view of the right hip through the anterior approach. Avascular necrosis of the femoral head of a 45year-old man. LT. ligamentum teres; L, lateral; M, medial.

management has failed, synovectomy of the hip joint is still a rare procedure (12). The reasons for the rarity of the hip joint synovectomy probably are related to diff%zulties in diagnosis, and the high risk of femoral head necrosis if the head is temporarily luxated in an open operation. In this study, arthroscopic synovectomy of the hip in stage III rheumatoid arthritis reduced pain temporarily and postponed the need for further surgery if the articular cartilage was damaged severely. The procedure might have been more helpful if performed before the articular cartilage had been destroyed. Another use for hip arthroscopy is for joint debridement in osteoarthritis. Debridement of adhesions between the joint capsule and the femoral head produced good results with relief from pain and increased range of motion. In the treatment of dysplastic hips, most of the patients have been treated operatively in a two-stage procedure, correcting the deformity with various kinds of osteotomies first and correcting the hip arthrosis by a total hip arthroplasty secondarily. However, patients with degenerative arthritis of the hip often reach a critical point in their 4Os, at which time their symp-

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toms indicate that a total hip arthroplasty is necessary. Surgery usually is postponed for at least another 10 years because the long-term performance of total hip arthroplasties is uncertain. Arthroscopic debridement of the hip could postpone total hip arthroplasty by providing pain relief in these cases. Partial resections of the torn labrum were also performed. The acetabulum labrum embraces the femoral head tightly and enhances the stability of the hip joint. A labral rupture in the dysplastic hip was often observed during arthroscopy and during other conventional examinations such as arthrographies. Although the acetabular labrum has not been considered responsible for symptoms in osteoarthritis of the hip joint, it is suspected that tears of the labrum sometimes produce pain in the hip like a meniscal tear in the knee. Our results indicate that partial resection of a torn labrum is beneficial in reducing pain in selected cases. Arthroscopic surgery of the hip joint by a twodirectional method has just begun and is still far from perfection. We have endeavored to make this technique more useful for patients who are afflicted with hip disorders. REFERENCES 1. Burman MS. Arthroscopy of the direct visualization of the joint. J Bone Joint Surg 1931;4:669-95. 2. Ide T, Akamatsu N, Nakajima I. Arthroscopy of the hip joint. Arthroscopy (Jpn) 1986;11:21-5. 3. Ide T, Akamatsu N, Nakajima I. Experience with arthroscopy and arthroscopic surgery. Arthroscopy (Jpn) 1987; 1287-91. 4. Altenberg AR. Acetabular 5. 6. 7. 8.

9.

10. 11.

labrum tears: a cause of hip pain and degenerative arthritis. South Med J 1977;70:174-5. Shifrin-LZ. Reis ND. Arthroscopy of a dislocated hip replacement: a case report. Clin Orthop 1980;146:213-4. Watanabe M. Arthroscopy of small joints. Tokyo: IgakuShoin, 1985:97-103. Eriksson E, Arvidsson I, Arvidsson H. Diagnostic and operative arthroscoov of the hio. OrthoDedics 1986:9:169-78. Goldman A, Min&ff J, Price A, et & A postenor arthroscopic approach to bullet extraction from the hip. J Trauma 1987;27: 1294-3000. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery on the hip joint. Kotsu-Kansetsu-Jintai 1989;2:665-74. Ikeda T, Awaya G, Suzuki S, et al. Tom acetabular labrum in young patients. / Bone Joint Surg [Br] 1988;70:13-6. Witwity T, Uhlmann RD. Fischer J. Arthroscopic management of chondromatosis of the hip joint. Arthroscopy 1988;4:55-6.

12. Gondolph-Zink B, F’uhl W, Noack W. Semiarthroscopic ovectomy of the hip. In? Orrhop 1988;12:31-5.

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