Hip arthroscopy

Hip arthroscopy is performed under endotracheal anesthesia. The patient's position on the operating table is lying on the healthy side.

The traction system is set up using special additional supports. The operated joint is in the extension and neutral rotation position, with the lower limb abducted by 25°. The joint space is stretched to 10-15 mm. To monitor the stretching of the joint space, X-ray of the hip joint in a direct projection is performed in the operating room after the traction system is applied. If the joint space is not stretched enough on the control X-ray, distraction is continued and X-ray of the joint is repeated.

Before arthroscopy, external landmarks are applied and the projection of the proposed approaches is marked. Marking the joint is necessary for better orientation of the surgeon during the operation. After preparing the surgical field, external landmarks are applied to the skin: the contours of the greater trochanter of the femur, the anterior superior iliac spine, and the upper edge of the pubic articulation are designated. The pulsation of the femoral artery is determined and the projection of the femoral vascular-nerve bundle is marked. The sites of standard approaches to the joint are also marked.

Through the anterolateral approach perpendicular to the surface of the thigh in the direction of the femoral head, 30-40 ml of physiological solution with epinephrine (diluted 1:1000) is injected into the joint cavity using a syringe and a long spinal injection needle, which contributes to additional expansion of the intra-articular space. If the procedure is performed correctly, after removing the syringe, the injected liquid flows out under pressure through the needle located in the joint cavity. After removing the needle, a puncture incision of about 5 cm in length is made in the skin at the site of its entry with a scalpel. A blunt trocar placed in the arthroscope shaft is inserted into the joint. It passes directly above the greater trochanter along the outer surface of the femoral head under the lateral part of the acetabulum lip. Due to the normal anteversion of the femoral neck, with neutral rotation of the hip joint, the trocar block passes parallel to the anterolateral edge of the acetabulum. As the block advances into the joint after perforation of the capsule, the end of the trocar is slightly raised to avoid damage to the articular surface of the femoral head. The trocar is removed, and a 30-degree arthroscope with a diameter of 4.2 mm is inserted into the shaft. An arthroscopic camera and a light guide are connected, as well as an irrigation system. It is preferable to use a supply and outflow irrigation system with a roller pump, which allows monitoring and maintaining an optimal intra-articular pressure at a constant level (100-150 mm H2O).

After the arthroscope is inserted into the joint cavity, an anterior approach is performed. In its projection, a scalpel is used to make a puncture incision in the skin and, under arthroscopic control (it is better to use a 70-degree arthroscope for this), a trocar is inserted into the joint with rotational and translational movements in the arthroscope shaft towards the midline of the body at an angle of 45" to the frontal plane (in the cranial direction) and 30° to the sagittal plane (in the medial direction). A posterolateral approach is performed in a similar manner, to the shaft of which a fluid inflow tubing is connected. After creating all three approaches, the hip joint cavity is examined through three interchangeable shafts using 30-degree and 70-degree optics. With the help of a 70-degree arthroscope, it is convenient to examine the acetabulum tube, the peripheral part of the acetabulum floor and the femoral head, as well as the deep pockets of the acetabulum and the round ligament. When using 30-degree optics provide better visualization of the central parts of the acetabulum and the femoral head, as well as the superior part of the acetabulum.

The revision of the hip joint cavity begins with an examination of the acetabulum and the fat pad located in it, surrounded by the semilunar cartilage.

As the arthroscope is advanced forward into the acetabulum, the femoral head ligament is visualized; the transverse ligament can also be observed, but not in all cases, since its fibers are often intertwined with the joint capsule. By rotating the arthroscope clockwise, the anterior edge of the acetabular labrum and the iliofemoral ligament extending from it (Bigelow's Y-ligament) are examined; it is tightly adjacent to the anterior section of the joint capsule above the upper part of the femoral neck. By continuing to rotate the arthroscope, slightly pulling it back, the middle upper part of the lunate surface and the acetabular lips are examined. As the arthroscope advances forward along the joint space, the posterior section of the acetabular labrum and the ischiofemoral ligament separated from it by a cleft become visible.

Sometimes in the posterior region, using a posterolateral approach and 70-degree optics, it is possible to visualize the Weitbrecht ligament, which runs from the joint capsule to the head and posterosuperior part of the femoral neck in the form of a flattened cord.

By moving the arthroscope further down, sliding along the femoral neck, the zona orbicularis is examined - a circular ring that forms a ridge around the femoral neck.

Its fibers do not attach to the bone and become taut when the hip is in internal rotation. Their tight tension around the femoral neck can be mistaken for the acetabular labrum. To avoid this, the hip must be placed in external rotation, which allows the zona orbicularis fibers to relax and move away from the femoral neck. As the arbicularis fibers relax, synovial villi protrude from underneath them, clearly differentiating them from the acetabular labrum.

The surgeon's assistant, using alternate external and internal rotation of the hip, gives the necessary position to the femoral head to ensure better visualization of all parts of the joint and the articular surface of the femoral head.

Since the soft tissues of the joint, its muscles, and the articular-ligamentous apparatus were previously stretched and relaxed, no special efforts are required from the assistant to stretch the joint.

When performing the surgical stage of hip arthroscopy, arthroscopic instruments with a diameter of 2 to 3.5 mm are used, as well as a shaver with a nozzle diameter of 2.4 mm to remove intra-articular bodies, excise adhesions and treat areas of damaged cartilage.

At the end of arthroscopy, after revision and sanitation of the hip joint cavity, the remaining fluid is aspirated from the joint cavity and bupivacaine + epinephrine 0.25% solution is administered in the amount of 10-15 ml, the threaded rods are removed. Sutures are applied to the area of arthroscopic access, removed after 5-7 days, and aseptic dressings.

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Indications and contraindications for hip arthroscopy

Indications for diagnostic and therapeutic arthroscopy: presence of intra-articular bodies, damage to the acetabular labrum, osteoarthritis, damage to articular cartilage, avascular necrosis of the femoral head, rupture of the round ligament, chronic synovitis, joint instability, septic arthritis, condition after previous hip arthroplasty, history of surgical interventions on the hip joint.

The most typical contraindication to performing arthroscopy is ankylosis of the hip joint. With this pathology, it is not possible to expand the intra-articular space, which creates an obstacle to the introduction of instruments into the joint cavity. Significant disturbances in the normal anatomy of the bone or surrounding soft tissues as a result of previous trauma or surgery also exclude the possibility of performing arthroscopy.

Severe obesity is a relative contraindication to hip arthroscopy. With extreme density of soft tissues, even with long instruments, it may be impossible to reach the joint cavity.

Diseases that manifest as destruction of the hip joint are also considered a contraindication to arthroscopy.

Possible complications during hip arthroscopy and precautions

• Intra-articular infection (suppuration of an arthroscopic wound, coxitis, sepsis ).
• During surgery, in order to prevent the development of suppuration in the postoperative period, it is necessary to strictly adhere to the rules of asepsis and antisepsis.
• In the preoperative and early postoperative periods, broad-spectrum antibiotics may be prescribed.
• Damage to articular cartilage during insertion of arthroscopic instruments.
• To avoid this complication, it is necessary to insert instruments into the hip joint cavity without sudden movements and effort.
• Temporary pain syndrome.
• To relieve pain in the early postoperative period (first day), narcotic analgesics are prescribed.
• Subsequently, patients are prescribed non-steroidal anti-inflammatory drugs for 5-7 days.
• During arthroscopy, there is a risk of breakage of the arthroscopic instrumentation, which leads to the need to remove the foreign body from the joint cavity.
• To prevent this complication, it is necessary to ensure sufficient stretching of the joint space - up to 10-15 mm.
• If a breakage results in a free foreign body being formed in the joint, it is very important to maintain the position of the joint unchanged so as not to lose sight of the broken fragment and to be able to grasp and remove it with a clamp as quickly as possible.
• Traction injuries of the vascular-nerve bundle and capsular-ligamentous apparatus.
• To prevent this complication, it is necessary to avoid forcing distraction. Before the operation, the patient lies for 15-20 minutes on the operating table with minimal distraction force.
• Fluid extravasation.
• To prevent the flushing fluid from entering the subcutaneous tissue, the following rules must be observed:
  • do not allow the pressure in the flushing system to increase above the normal level;
  • shut off the fluid supply to the flushing system if the end of the arthroscope accidentally exits the joint cavity.

Postoperative rehabilitation of patients after hip arthroscopy

In the early postoperative period, it is important to provide the patient with adequate pain relief. The intensity of pain depends on the specific pathology and the extent of the surgical intervention performed during hip arthroscopy. For example, after removal of free intra-articular bodies, the patient practically does not feel pain after the operation, and the discomfort after the operation is much less than before it. Conversely, after abrasive arthroplasty for cartilage damage, the patient experiences more intense pain immediately after the operation. In the first day after the operation, pain relief is provided with narcotic analgesics, and then patients are prescribed non-steroidal anti-inflammatory drugs for 5-7 days (ketoprofen 100 mg 2-3 times a day).

Immediately after arthroscopic surgery, an ice pack is placed on the hip joint area. The body's attempts to conserve heat by constricting the superficial skin vessels lead to decreased capillary permeability and reduced bleeding. This changes the biological response of tissues to injury, reducing inflammation, swelling, and pain. Ice is used for 15-20 minutes every 3 hours for the first 24 hours, and sometimes for 2-3 days.

The dressings are changed on the next day after the operation. The dressings are changed every other day. The stitches are removed 7 days after the operation. In the early postoperative period, patients are allowed to sit down. This is due to the fact that when the hip joint is bent, its capsule relaxes, so patients feel more comfortable in a sitting position. It is recommended to get up using crutches in the first 2 days after the operation, but without putting weight on the operated limb. Functional rehabilitation treatment begins on the 2nd day after the operation. The rehabilitation program is individual for each patient, it depends on the pathology and the scope of the surgical intervention.