Diagnostic Hip Arthroscopy

Diagnostic hip arthroscopy is a minimally-invasive surgical technique used to accurately provide intraoperative information and potentially treat certain intra-articular (such as labral tears, chondral defects, and femoroacetabular impingement) and extra-articular (such as capsular tears, ischiofemoral impingement, and pediatric deformities) hip pathologies. The use of this procedure in the United States is becoming more common; annual rates are increasing by as much as 365% since 2004. Within this rapid increase of utilization, the three most common procedures being performed with diagnostic hip arthroscopy are labral repair, femoroplasty, and acetabuloplasty. In this case, a young female athlete is being assessed for left anterior hip pain recalcitrant to nonoperative management. The patient was placed in a supine position with an anterolateral portal and modified anterior portal being placed into the left hip. A puncture capsulorrhaphy was performed to examine the labrum, femoral head, and transverse ligament. Then, the medial structures and peripheral compartment were visualized. Throughout the procedure, the only treatable hip pathology identified was labral fraying consistent with a minor labral tear. It was determined that the fraying was not significant enough to require surgical repair, so labral debridement was chosen. Other areas of labral fraying and fatty degeneration were identified, but they were not significant enough to be treated intraoperatively. The procedure was completed with no complications.

Orthopedics; hip joint; cartilage, articular; labrum.

Hip pain in young adults and adolescents has an annual incidence of 0.44%, but the presence of symptoms in this population usually reflects a higher significance for pathologic disorders.¹ Diagnosing hip pathology in younger patients becomes challenging when their symptoms are non-specific and physical findings are not clear. Furthermore, imaging studies can miss up to 10% of hip injuries in patients.² Hip pathology can be intra-articular (such as labral tears, femoroacetabular impingement (FAI) , synovial disease, and chondral defects) or extra-articular (such as capsular tears, ischiofemoral impingement, and piriformis debridement). Diagnostic hip arthroscopy is a minimally invasive surgical technique that can more accurately grade this pathology and potentially provide intraoperative therapeutic benefits. In this case, the patient had a minor labral tear. Labral tears often occur more frequently in women between the ages of 15–41 years old.³ These tears typically occur in the anterosuperior region. Diagnostic hip arthroscopy has emerged as an alternative modality to radiographic imaging that more accurately identifies and treats this hip pathology. This case was resolved with arthroscopic labral debridement. Overall, hip arthroscopy is becoming more popular in the United States with an increase in annual rates as high as 365% from 2004 to 2009.⁴

This patient is a 24-year-old female who arrived at the office with a chief complaint of left anterior hip and groin pain for the past 3 months. The patient used to be a college athlete and remains active playing in a competitive soccer league. She stated that her hip has made clicking sounds with internal rotation for the past few years, but that the pain is relatively new. The patient rated the pain as a constant, aching 4/10 pain that increases to a 6/10 after playing soccer. She also claimed that her left hip feels more stiff after running and is no longer relieved with NSAIDs or rest. She attempted physical therapy for 4 weeks with no relief. Corticosteroid injection showed minimal benefit that lasted less than a week. This patient had no pertinent past medical history.

Physical examination showed no tenderness on palpation to her pelvis and bilateral thighs. The patient’s pain was exacerbated when her left hip was brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction. An audible snapping sound was also heard with this maneuver. The patient had a normal lower extremity range of motion bilaterally and no sensory loss or paresthesia.

This patient underwent a complete pelvic screening evaluation that included an anteroposterior (AP) view, a cross-table lateral view, and a frog lateral view. X-ray imaging showed no signs of FAI, joint depression, developmental dysplasia of the hip (DDH), tumor, arthritis, or structural trauma. 

When labral tears are suspected, a magnetic resonance arthrogram (MRA) is found to be the imaging study of choice in identifying pathology. MRA has been found in previous studies to have a sensitivity ranging from 60–91%, a specificity of 44%, and a positive predictive value of 93%.3 MRA was negative for labral tears and identified no additional structural abnormalities in this patient. Although all imaging was negative for a labral tear, a patient with her symptoms cannot be ruled out for a labral tear until she undergoes a diagnostic hip arthroscopy.  

Female patients with labral tears of the hip are normally associated with those who play sports that require repetitive pivoting motions on a loaded femur. This occurs in sports such as soccer, ice hockey, ballet, and golf. It is suspected that women are at a higher risk for these tears due to a higher incidence of acetabular dysplasia and joint laxity. Previous studies have shown that up to 61% of patients have an insidious onset,⁵ and it is believed to be associated with microtrauma in the end-range motion positions of hyperabduction, hyperextension, and external rotation. Pain is often noted during periods of increased physical activity, such as rising from a seated position or squatting.⁶

Patients with labral tears usually receive initial nonoperative treatment options that consist of rest, NSAIDs as needed, physical therapy, and/or hip injections with or without steroids. However, there is no long-term follow-up data found in the literature on conservative management of hip labral tears. Furthermore, there is no data that shows which therapeutic exercises in physical therapy are most effective.⁷ 

Surgical treatment is usually started once conservative management fails. Arthroscopic debridement of the labrum and/or arthroscopic labral repair are more invasive options. Arthroscopic debridement of labral tears is indicated when the tear is not amenable to surgical repair. Results are promising with up to 89% of patients claiming “improved status” at an average of 16.5 months after the procedure.³ Arthroscopic surgical labrum repair is indicated for full-thickness tears at the labral-chondral junction. Unfortunately for both procedures, long-term outcomes are not well documented in the literature.³

Diagnostic hip arthroscopy was chosen due to the patient’s failure with conservative management and imaging being unable to identify any hip pathology. The goal of this arthroscopic procedure was to examine intra-articular structures of the hip (such as the labrum, femoral head, transverse ligament, medial structures, and the peripheral compartment), identify pathology, and treat any pathology present. During the procedure, some fraying of the labrum was identified. However, the labral damage was not severe enough to require surgical repair, so it was determined during the procedure that labral debridement was the best option.

Diagnostic hip arthroscopy has been shown to benefit patients with extra-articular pathology that includes recalcitrant trochanteric bursitis, snapping hip syndromes, and gluteus medius tendon tears. Arthroscopy should also be considered for intra-articular hip pathologies such as septic arthritis, FAI lesions, assessment of chondral defects, and acetabular labral tears.8 Patients with full-thickness tears at the labral-chondral junction are better candidates for arthroscopic labral repair (instead of debridement). Arthroscopic labral debridement is indicated in those with labral tears that are not amenable to surgical repair.

Hip arthroscopy is contraindicated in those with severe osteoporotic bone, hip ankylosis, open wounds, and joint contractures.^9,10 Poor prognostic indicators with the arthroscopic repair of the hip are those with associated arthritic changes. In patients with concomitant structural abnormalities (such as FAI and DDH), labral debridement has been frequently inadequate; those patients may benefit from other joint-preserving arthroscopic procedures. Furthermore, hip arthroscopy and isolated labral treatment in these patients may accelerate the process of arthritis.⁹ 

There are some pathologies for which arthroscopy has been proven to be effective in treating, but open surgical techniques have shown better outcomes. Some examples of pathologies that arthroscopy should not be the default procedure for include acetabular dysplasia, Legg-Calve-Perthes disease, and chronic slipped capital femoral epiphysis (SCFE). 

Morbid obesity is a relative contraindication, so obese patients should consider weight loss and physiotherapy prior to arthroscopic surgery. These patients should be aware that they typically have worse outcomes due to their higher association with osteoarthritis.¹¹ Obesity is associated with lower overall postoperative outcomes and a much higher rate of revision surgeries.^10-11

Diagnostic hip arthroscopy was first introduced to cadavers in 1931; it was not clinically applied to a patient until 1939. However, there was a low number of clinical studies and reports done on this procedure until the 1980s.^8,11 The proper use of distraction was a significant development for visualizing the central compartment, which led to a large increase in utilization during this timeframe. The arthroscopic indications expanded from intra-articular pathologies to extra-articular pathologies (as well as pediatric hip disorders). This later led to the first textbook on hip arthroscopy being published by Richard Villar; he became the founding member and president of the International Society for Hip Arthroscopy (ISHA) in 2008. ISHA then published several manuscripts on surgical techniques, which helped further advance the procedure globally. From 2002–2013 (internationally and in the United States), the use of hip arthroscopy has increased by as much as sevenfold. Throughout the United States, the three most common hip arthroscopic procedures being performed are labral repair, femoroplasty, and acetabuloplasty.¹¹

Patients undergoing diagnostic hip arthroscopy are commonly placed on a supine fracture table with a lateralized perineal post under general anesthesia. The two portals used are the anterolateral (placed 1 cm adjacent to the anterior-superior border of the greater trochanter) and modified anterior (placed slightly lateral and distal to the site of intersection of a sagittal line distally through the anterior superior iliac spine and a transverse line across the tip of the trochanter), which enter using fluoroscopic or ultrasound guidance. Intra-articular visualization through the arthroscope is optimized when the medium fluid flow rate is 0.7 L/min, fluid pressure is balanced with mean arterial pressure, and dilute epinephrine (1:100,000) is present in the arthroscopic field.¹² During this procedure, the surgeon evaluates the central and medial compartments of the hip to provide necessary intraoperative information to properly treat the patient. Diagnostic hip arthroscopy typically lasts less than an hour, and operative times vary depending on what pathology is identified. Patients are usually discharged from the hospital on the same day as the procedure.

There are a wide variety of complications that come with this highly skilled procedure, but overall complication rates in recent studies ranged from 1.4–7.3%.^4,8,10 The three most common complications are neuropraxia (0.92%), iatrogenic chondral and labral injury (0.69%), and heterotopic ossification (0.60%). Major complications only amounted to 4.8% of all complications, with the most common one being abdominal fluid extravasation.¹¹ The conversion rate to total hip replacement is 4.2%.⁴ 

Diagnostic hip arthroscopy is a minimally-invasive surgical technique for identifying pathology and providing operative information that may not be evident with available imaging modalities.² In this case, an anterolateral and modified anterior portal was used with the patient in a supine position to look for pathology throughout the left hip. The anterolateral portal was placed using a spinal needle and fluoroscopic guidance, 1–2 cm anterior and superior to the anterosuperior border of the greater trochanter. A small skin incision was then made with an 11 blade.  This is followed by placement of a cannula and dilators. A second spinal needle was then placed at the midline between the superior greater trochanter and the ASIS, with confirmation on intra-articular placement using arthroscopic visualization. The procedure then began with a puncture capsulorrhaphy to start identifying structures within the hip. After examining the medial structures and the peripheral compartment, the only pathology identified during the procedure was fraying of the labrum and slight yellow discoloration. The more severe areas with fraying were treated arthroscopically with labral debridement, while less severe fraying was not treated intraoperatively. No other significant hip pathology was found throughout the procedure. There were no intraoperative complications associated with this operation.

Standard arthroscopic equipment; fluoroscopic equipment.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.