The frequency of hip arthroscopies has been increasing explosivelyover the past years, leading to a hugely improved techniqueand greater understanding of the arthroscopic anatomyof the hip joint. Arthroscopic hip procedures can successfullytreat conditions previously unrecognized or only treatable byopen procedures
Current indications for hip arthroscopy include the presence ofSymptomaticacetabularlabral tears, femoroacetabular impingement, chondral lesions, osteochondritisdissecans, ligamentumteres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies. Less common indications include management of osteonecrosis of the femoral head, synovial abnormalities, crystalline hip arthropathy (gout and pseudogout), infection, and post-traumatic intra-articular debris.
Patient selection is an important issue for a potentially successful outcome,general parameters include younger patients, mechanical joint symptoms, unremitting joint symptoms, and no diagnosis has been made. Presence of the symptoms for more than six months withfailure of conservative treatment and reasonable expectations from the patient
A comprehensive inspection of the hip joint requires the combination of hip arthroscopy with traction and hip arthroscopy without traction. Although traction is necessary for access to the central compartment for evaluation of the direct weight-bearing cartilage, acetabular fossa, and ligamentumteres, the periphery of the joint can best be seen without traction.
A peripheral compartment starting point , without initial traction applied to the hip, is attractive because It hasthe advantage of entry outside of the joint, so minimal or no injury occurs to the articular cartilage or labrum and Traction time is significantly decreased
Hip arthroscopy with and without traction can be performed in the lateral or supine position. Both techniques are equally effective, and the choice simply depends on the surgeon’s preference. An advantage of the supine approach, which we preferred to use in this study, is its simplicity in patient positioning, application of traction and portals placement
Hip arthroscopy is considered a safe procedure, but like any other surgical procedure it has complications. Most reported complications are associated either with traction injuries or patient positioning, or other surgery-related injuries. Traction can cause nerve palsy or neuropraxia, mostly transient . Other traction-related complications include perineal integument injuries and genitoperineal skin
necrosis . Surgery-related complications include lateral femoral cutaneous nerve injury upon introducing the posterolateral portal or sciatic nerve injury upon introducing the anterolateral portal
The purpose of this study was to assess the role of hip arthroscopy in the management of hip joint pain . This was a prospective review of a consecutive series of 30 patients with heterogeneous group of indications over a 30-months period.There were 27 male and 3 female patients with a mean age of 29.5 years (range, 17 to 58 years). All patients had symptoms of ongoing hip pain for more than 6 months with no response to conservative measures
All patients were assessed with a modified Harris hip score and NHAS preoperatively andpostoperatively until most recent follow up, The follow-up ranged from 6 to 24 months (minimum 6 months ).Variables studied included age, sex, diagnosis, duration of symptoms, Preoperative and postop mHHS and NAHS
All cases showed significant improvements in all outcome measures , the Mean NAHS improved from 56.6 preoperatively to 80.6 postoperatively (mean improvement = 25.2 ), and Mean mHHS scores improved from 55.7 preoperatively to 79.9 postoperatively(mean improvement = 24 )
Excellent outcomes were shown in cases of osteoid osteoma excision and symptomatic loose body removal , good outcome was shown in case of isolated labral repair , while good and excellent outcome were shown in 52% of FAI cases
The median improvement for the following diagnoses was: 1 case of osteoid osteoma (mHHS= 39;NAHS= 38 ), 1 case of symptomatic loose bodies(mHHS: 32; NAHS : 33), 1 case of isolated labraltear (mHHS= 32; NAHS= 35),27 cases of Femoracetabular impingement (mHHS=24; NAHS=23).
Arthroscopic treatment of femoroacetabular impingement with labral repair resulted in superior improvement (6.8 points greater in all outcomes) compared with labral debridement
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Of thevariables studiedamong FAI cases, the most statistically significant finding was that older patients with longer duration ofsymptoms showed less improvements
Among 30 cases in our study, only 2 patients showed transient neurapraxia of the femoral nerve with percentage of 7%, All cases showed complete recovery on postoperative rehabilitation programs and conservative therapy
The results obtained throughout this study had revealed that hip arthroscopy can be performed for a variety of conditions provided it is properly selected for the appropriate patients, with reasonable expectations of success and an acceptable complication rate. Such results are consistent with many other recently published case series and systematic reviews.
Conclusion
Hip arthroscopy, although being technically demanding with a steep learning curve , is a valuable diagnostic and therapeutic procedure for patients with hip pain refractory to conservative therapy; hip arthroscopy can be performed for a variety of conditions provided it is properly selected for the appropriate patients, with reasonable expectations of success and an acceptable complication rate.
Young patients with short preoperative duration of symptoms are the most significant factors for patient selection that may be associated with superior outcome results of surgery in our study
Removal of symptomatic loose bodies, resection of osteoid osteoma and labral repair were recognized to be of the most gratifying of all arthroscopic procedures, hip arthroscopy was considered an effective treatment for patients with preoperative diagnosed problems as FAI syndrome
Recommendations
The key to a successful outcome of hip arthroscopy is largely dependent on patient selection. A well-performed procedure fails when performed for the wrong reasons. Proper patient selection includes not only selecting lesions amenable to arthroscopic intervention but also assessing the patient as a whole. The patient must have reasonable expectations of what may be accomplished with arthroscopy
Poor patient selection , preoperative cartilage damage or osteoarthritis in, and failure to recognize or inadequately address combined lesions may result in poor results of arthroscopic management, that needs further work up to be analysed which goes beyond the scope of our study.
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