HIP ARTHROSCOPY

Indications:
labral tears
Loose bodies
Acetabular and femoral head chondral flap lesions
Foreign body removal
Synovial chondromatosis
Collagen diseases with impinging synovitis
Crystalline hip arthropathies
Ruptured or impinging ligamentum teres
Capsular shrinkage (Ehlers-Danlos syndrome)
Post-traumatic conditions (e.g., Pipkin fracture)
After total hip arthroplasty
Osteonecrosis (early stages prior to collapse)
Extra-articular conditions

Acetabular Labral tears:
§ Symptoms include hip pain and often presents with catching, locking, or a painful click in the hip joint.
§ In addition to trauma, tears maybe associated with congenital or structural hip anomalies such as acetabular dysplasia, SCFE, and Legg-Calvé-Perthes disease
§ Most tears are anteriorly located
§ Chondral surface lesions of the acetabulum or femoral head eventually develop.
§ X-rays may show secondary degenerative changes like subchondral cyst of the anterior aspect of the roof of the acetabulum
§ Contrast enhanced(Gadolinium) MRI helps in accurate diagnosis in most cases

Loose bodies:
§ Locking or catching can occur with loose bodies, which maybe seen in association with synovial chondromatosis
§ CT with contrast is the ideal investigation for suspected loose bodies
§ Can be successfully removed using arthroscopy

Chondral lesions of the acetabulum or the femoral head
very difficult to diagnose and determine the extent of chondral lesions even with an MR arthrogram
Most lesions are located anteriorly and are seen mostly in association with a hip labral tear,
May also be seen in association with loose bodies, posterior dislocation, osteonecrosis, slipped capital femoral epiphysis, dysplasia, and idiopathic degenerative arthritis.
The common initiating site for labral as well as chondral injuries has been termed the watershed zone
when the damaged labral cartilage is subjected to repetitive loading conditions, joint fluid is pumped beneath acetabular chondral cartilage, causing delamination of the articular cartilage
Osteonecrosis
Arthroscopy helps to stage the changes in the articular surface to determine if osteotomy or bone-grafting is indicated, and it can aid in the treatment of the chondral flap lesions that are often associated with the disease
Arthroscopy should be reserved for patients with mechanical symptoms such as locking, buckling, or catching, suggesting the presence of a loose body, a labral injury, or a chondral flap lesion.
Ligamentum teres lesions:
Lesions can occur as a result of trauma(posterior dislocation, Pipkin #) or degenerative arthritis
Synovial lesions:
Arthroscopic synovectomy is very useful for the treatment of PVNS
Crystalline diseases such as gout or pseudogout can be treated with an arthroscopic examination and copious lavage, mechanical removal of crystals, and synovial biopsy and/or synovectomy if necessary.
Synovial chondromatosis: helps in removal of loose bodies, accurate diagnosis and synovectomy

Surgical Principles:
Supine or lateral decubitus position is used
The patient must be carefully padded to protect against neuropraxia and pressure.
Femoral head is distracted from the acetabulum to achieve 7 to 10 mm between their articular surfaces.
The three most common portals are the anterior portal, the anterior paratrochanteric portal, and the posterior paratrochanteric portal
The lateral femoral cutaneous nerve superficially and the ascending branch of the deeper lateral femoral circumflex artery can be injured with anterior portal
The anterior and posterior paratrochanteric portals are placed laterally over the superior margin of the greater trochanter at its anterior and posterior borders
Other portals include: direct anterior, proximal trochanteric and posterolateral