Patients Undergoing a Hip Arthroscopy
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Questions and Answers
Do I need a hip arthroscopy?
The arthroscopic surgery for the hip is performed largely for patients who have normal or near normal surface cartilage but have pain from the hip. In other words they may have near normal movements and X-rays may be reported as normal. The pain is because of mechanical problem like tear or excess build up of tissue or bone in the joint, etc.
The main symptoms patients have are pain around hip – it can be all the time pain or pain with certain activities or sport. It is often sharp but can be toothache like pain. The pain is often located in groin but it can be all around hip. Most patients have periods of having no or low intensity pain and periods of worse pain. Often activity like running, jogging, sport cause ag-gravated period of bad pain for a few hours to few days then it goes back to its normal and repeats again and again. Patients often give up their much loved sport or fitness activity as a result of fear of having the bad pain. When the pain is bad patients or family may notice a limp.
What tests will I need?
Most patients may already have had an x-ray by their GP or treating surgeon. Often it is report-ed as normal. If you have not had an x-ray I would normally do one in the clinic. I would also get MRI scan with or without injection in the hip depending on your particular case. Occasion-ally I may get a CT scan of the hip to plan the operation.
How long does it take to make a diagnosis?
It depends on which hospital you come to. In the NHS it may take a few weeks to few months depending on the complexity and tests required. In private hospitals it may be much quicker. Usually with in 1-2 weeks.
What do you do in a hip arthroscopy?
Arthroscopic Surgery of the hip is essentially a key hole surgery for the hip joint and occasion-ally surrounding structures.
Once a clear diagnosis is made I would explain to you in detail about what work needs doing for your hip and how I propose to do it along with chances of improvement and risks and complications.
What are the risks and complications of hip arthroscopic surgery?
Like any surgical procedure, there are risks and complications with arthroscopic surgery. The overall chances of complications is 2%. The list of complications is as below.
Infection very small risk less than 0.3%
Bleeding it is very uncommon to have bleeding bad enough to need blood transfusion
Thrombosis and embolism (clot in leg or lung) uncommon because of early mobility and use of mechanical devises such as stockings and calf pump.
Nerve injury 1-2% risk of nerves going funny because of the stretch or pressure in hip or foot (because of the boot). Most of these settle down in 6 week to 6 months after the surgery
Injury to cartilage
Injury to genitalia or groin
Broken instruments requiring further surgery
Inability to do the procedure because of difficulty in reaching the joint or distracting the joint (too deep or too stiff and space can not be created safely)
When can I drive after the operation?
Most people are able to drive after 4-6 weeks of the operation. Patients have to self certify whether they can control the vehicle or not. I can not certify either way. Please also check with insurers about it.
When can I go back to work?
Work is very different for individuals. For some it is desk job others manual work. Generally most people can return to work 4-6 weeks after surgery it however does depend on what they do and how much work needed doing in their operation.
When can I start enjoying sport again?
The rehabilitation plan is generally to allow most people to get back to the normal mobility by 6-8 weeks and sport ready by 12 weeks. It does however change depending on what sport you do (for example swimming and cycling can start sooner but contact sport may be delayed) and how much work was done at the time of procedure. The physiotherapist will generally be able to tell you what time you would be fit for sport.
In general – you are under general anaesthetic (go to sleep) for the procedure. We use a special distractor to put tension on the leg to create some space in the hip joint. It is confirmed by x-ray machine. Under x-ray control long needles are placed in the space created in the hip joint and that track is made a little bigger to allow camera and instruments to see and treat problems in the hip joint. I would take pictures during the procedure to explain to you later what the problem was and what was done about it.
The operation lasts 45 min to 1.30 hours depending on what needs doing.
At the end of the operation I would give local anaesthetic and you will have sutures for the little wounds.
Most patients can walk on the leg in a few hours and have crutches for support.
Most patients go home the same day as their operation.
REMEMBER YOUR WOUNDS MAY LEAK FLUID FOR 24 HOURS
What is the recovery period after the operation?
The procedure is generally a day case. So most patients would be able to go home the same day. Most would have crutches and allowed to walk on the operation leg with full weight. The wounds will keep leaking fluid for a day or so and that is normal and expected.
We expect most patients will have pain and some bruising for 2-6 weeks. Generally most patients are fine by 4 weeks.
Physiotherapist is very important after the operation and contributes to the successful outcome of the operation.
The physiotherapists will be attending you in the hospital before discharge and give you basic instructions and training. After that they will arrange for you to come back around 3-4 weeks after operation when usually bruising and pain are much settled and start working with you.
The general aim is to get you more or less normal mobility by 6 weeks and work towards sport by 12 weeks. As you can understand people are different in their surgical treatments and ability and this is therefore very individualised by the physiotherapists.
In the initial first few days to first few weeks you will need help at home for small day to day activities, because walking with crutches can be tricky.
What is FAI?
FAI stands for femoro-acetabular impingement.
This simply means there is blockage of movement in the hip created by excess bone or bony bump usually in front of the hip.
It can be on the edge of the ball (called CAM) or socket (called pincer). It can be on both ball and socket (called combined CAM and Pincer).
Why does it (FAI) happen?
Exact cause of FAI is uncertain. I believe it is probably a combination of things that leads to FAI. In some people it is genetic or so to say runs in family. It can be because of childhood condition such as SUFE (slipped upper femoral epiphysis). In some others it could be environmental such as contact sport in teenage years. Often it is a combination of things rather than one specific reason.
How does arthroscopy help with FAI?
Hip arthroscopy helps by removing excess bone through key hole surgery and stop the pain. It may not stop the process of arthritis.
What is labral tear?
Labrum is a cartilaginous lip like extension from the socket. When the bump or FAI hits junction of this lip with the lining of the socket cartilage repeatedly it starts to tear away from socket or become torn and tattered. This being a sensitive area can cause pain. This is also usually the beginning of arthritis process in the hip.
Sometimes violent trauma can cause tear in labral cartilage without FAI or bone bump.
MRI or MRI arthrogram are good investigations to see if this is torn and also confirm if this is the source of your pain. The scan is best when performed by specialist radiology doctors who perform this investigation routinely.
How does arthroscopy help with labral tear?
Hip arthroscopy can see and glue back the torn part using a special probe or using sutures. It can also remove the bone impingement that caused the tear. Occasionally the tear is bad and can not be repaired. When it can’t be repaired it is excised.
What other conditions hip arthroscopy can help with?
Arthroscopic hip surgery helps with mechanical problems such as FAI and labral tear. It also helps with
loose bodies – free bits of bone flying in the joint
Excision of excess tissue
Repair of ligaments
Excision of trochanteric bursa
Repair of tendons
Release of tendons such as psoas tendon
Treatment of infection (in selected cases)
What are the advantages of arthroscopic surgery?
It is a key hole surgery – it minimises the surgical injury of the normal tissue whilst addressing the problem.
Key hole surgery gives better access to the hip joint and better visualisation of the joint com-pared to mini-open procedure.
The recovery after arthroscopy is quicker because the damage to the tissues is minimised.
The hospital stay is minimised.
It allows early mobility hence some of the complications of prolonged bed stay are minimised.
What is the alternative for hip arthroscopic surgery?
Mini-open surgery and surgical dislocation of the hip are the alternative procedures.
In mini-open surgery a small cut is made at the front of the hip and procedure is performed under direct vision however it gives visualisation of a relatively small area of the hip. Meaning anything beyond this area can not be changed or fixed.
In surgical dislocation of the hip – as the name suggests bone is cut to reflect important muscle outside hip and hip is taken out of joint to do the procedure. At the end everything is put back and repaired with screws to fix the bone fragment. This procedure gives excellent visualisation of the hip but involves a large incision and surgical injury of significant amount of normal soft tissues outside the hip.