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Arthroscopy an answer for many ‘not so old’ patients with hip pain

A patient’s guide to hip mobility, femoroacetabular impingement and hip arthroscopy

Hip pain in a patient considered much too young for a joint replacement has been a significant problem for some in the past.

If the pain was persistent and did not respond to time and simple conservative measures, doctors struggled to make the patients comfortable. Many believed that a simple diagnosis like strain or sprains or tendonitis would resolve it, and if there weren’t signs of arthritis, doctors were not able to adequately treat patients whose pain persisted.

Over the last 20 years, however, a new diagnosis has emerged: femoroacetabular impingement (FAI). More importantly, the physician’s ability to treat this diagnosis has evolved and improved, particularly with the increased use of non-invasive, arthroscopic surgery.

Dr. David Pearce and Dr. Adam Smith, Board-Certified Orthopedic surgeons, have been treating this condition at West Tennessee Bone & Joint Clinic with the latest techniques in arthroscopy for the last six years. Both are specially trained in hip arthroscopy and regularly treat FAI.

Anatomy of the hip joint

The hip joint is a “ball and socket” joint located where the thigh bone or femur meets the pelvic bone. The upper part of the femur is a round ball that fits inside the cavity in the pelvic bone to form the socket, also known as the acetabulum. The ball is normally held in the socket by powerful ligaments that form a complete sleeve around the joint capsule.

Both the ball and socket are covered with a layer of smooth cartilage, which acts as a sponge to cushion the joint, allowing the bones to slide against each other with little friction. A fibrocartilaginous rim called a labrum lines the rim of the socket and grips the head of the femur, securing it in the joint. The labrum acts as an “o-ring” or a gasket to ensure the ball fits into the socket.

Femoroacetabular impingement

FAI occurs when the ball does not have its full range of motion within the socket. This causes pain and a decreased range of hip joint motion. Most commonly, FAI is a result of excess bone that has formed around the head of the femur. It also commonly occurs due to overgrowth of the acetabular rim, or when the socket is angled in such a way that abnormal impact occurs between the femur and the rim of the acetabulum.

When the extra bone on the femoral head hits the rim of the acetabulum, the cartilage and labrum that line the acetabulum can be damaged. As more cartilage and labrum is lost, arthritis can develop.

Tears of the labrum can also fold into the joint space, further restricting motion of the hip and causing more pain. This is similar to what occurs in the knee of someone with a torn meniscus.

How does FAI occur?

The extra bone that leads to impingement is often the result of normal bone growth. Hip trauma can also cause FAI. The tears of the labrum or cartilage are often the result of athletic activities that involve repetitive pivoting movements or repetitive hip flexion.

Impingement can present at any time between the teenage years and middle age. Many people first realize a pain in their groin after prolonged sitting or walking. Walking uphill can also be difficult.

The pain can be a consistent dull ache or a sharp, popping sensation. Pain can also be felt along the side of the thigh and in the buttocks.

Medical imagery – X-rays and magnetic resonance imaging (MRI) – is crucial to diagnose FAI. An X-ray can reveal an excess of bone on the femoral head or acetabular rim. An MRI can reveal fraying or tears of the cartilage and labrum.

Treating the condition

Non-surgical treatment should always be considered first when treating FAI. The condition can often be resolved with rest, modifying one’s behavior, and a physical therapy or anti-inflammatory regimen.

If pain persists, it is sometimes necessary to differentiate between pain radiating from the hip joint and pain radiating from the lower back or abdomen. A proven method for differentiating between the two is by injecting the hip with a steroid and analgesic.

The injection accomplishes two things. First, if the pain is indeed coming from the hip joint, the injection provides the patient with pain relief. Secondly, the injection serves to confirm the diagnosis. If the pain is a result of FAI, a hip injection that relieves pain confirms that the pain is from the hip and not from the back.

Hip arthroscopy

Because of its lack of popularity in the United States, few orthopedic surgeons have advanced training in hip arthroscopy. However, as the procedure is becoming more accepted and more popular, more surgeons are becoming trained in this area of orthopedic surgery.

Hip arthroscopy is a minimally-invasive procedure. The use of an arthroscope means that the procedure is done using two or three small incisions rather than a more invasive open surgery that would require a much larger incision. These small incisions, or portals, are used to insert the surgical instruments into the joint.

The flow of saline through the joint during the procedure gives the surgeon excellent visualization. The surgeon is also aided by fluoroscopy, a portable X-ray apparatus used to ensure that the surgical instruments are inserted properly.

The instruments include an arthroscope, which is a long thin camera that allows the surgeon to view the inside of the joint, and a variety of shavers that allow the surgeon to cut away the excess bone or tissue. Specialized implants allow surgeons to repair torn labral tissue, as well.

Besides removing excess tissue and repairing damaged tissue, holes may occasionally be drilled into patches of bare bone where the cartilage has been lost. This technique is called microfracture and promotes the formation of new cartilage.

The procedure is normally done on an outpatient basis, which means the patient has the surgery in the morning and can go home that same day.

Recovery

After the procedure, patients are normally told to use crutches for the first two to four weeks to minimize weight-bearing. A post-operative appointment is normally held a week after the surgery to remove sutures. Most patients then begin physical therapy to improve strength and flexibility in the hip.

After six weeks of physical therapy, many patients can begin to resume more normal activities, but it may take three to six months for them to experience no pain after strenuous physical activity. As no two patients are the same, regular post-operative appointments with one’s surgeon are necessary to formulate the best possible recovery plan.

Who benefits from hip arthroscopy?

Patients who respond best to hip arthroscopy are active individuals with hip pain but need to preserve the amount of cartilage they still have.

Patients who have already suffered significant cartilage loss in the joint may be better suited to have a more extensive operation, which may include a hip replacement.

Studies have shown that 85 to 90 percent of hip arthroscopy patients return to sports and other physical activities at the level they were at before their onset of hip pain and impingement. The majority of patients clearly get better, but it is not yet clear to what extent the procedure stops the course of arthritis.

Patients who have underlying skeletal deformities or degenerative conditions may not experience as much relief from the procedure.

If you have nagging hip pain, it’s time to set up a visit with your orthopedic surgeon.