Understanding Hip Arthroscopy
“Arthro” refers to a joint and “scope” refers to a camera. An arthroscopy is using tiny cameras and small tools to do minimally invasive work inside of a joint.
Hip arthroscopy is minimally invasive surgery inside the hip. The hip joint is one of the strongest joints in your body. The ball and socket fit together very tightly and it can be hard to get inside of the joint itself. To work inside the joint, doctors often have to put traction on the hip and pull the ball out of the socket slightly during surgery. While it is a tough process, the patient is asleep and we use up-to-date technology to make the process less traumatic than in the past.
The Hip Joint
The hip joint is a ball and socket joint. The ball is the femoral head, or the top of the femur or thigh bone. It sits inside the socket, the acetabulum, which is part of your pelvis. In between the ball and socket is the cartilage. The cartilage is like a bearing surface in the joint to help the bones move together smoothly.
The hip labrum is a special type of cartilage that goes around the ball and socket like a gasket or suction seal to hold the joint steady and in place. It’s a different type of cartilage than the cartilage on the end of the bones.
Hip Impingement
Hip impingement is also called femoroacetabular impingement or FAI. Femoral refers to the femur, or the ball. Acetabular refers to the acetabulum, or the socket. Impingement refers to pinching. When someone has hip impingement or FAI the ball and socket are set up so that there is some pinching.
A cam impingement is an irregularity on the ball, or femoral head, that bumps into the socket and can stop motion and cause stiffness or damage to the joint itself. A pincer impingement is an irregularity or bump of bone on the socket side that the ball runs into when it tries to move. The cartilage can get pinched in either type.
Hip Labral Tear
The stability of your hip affects a lot of your daily function, like sitting, standing, walking, running and sports activity. If your labrum is intact, it helps hold your hip stable. If you have a tear of the labrum, you lose that suction seal on the joint. Many patients develop a microinstability in the hip joint. The joint is not going to slide out of place, but it is shifting around more than it should which creates pain through the joint. The pain may be felt in the front of the hip or the back of the hip, and may cause hamstring or lower back pain.
Using a small camera and tiny tools through three small holes, a surgeon can put anchors or tiny screws into the bone of the socket and use stitches to hold the labrum back into place on the bone to restore the suction seal.
Hip impingement and labral tears have a tendency to go hand-in-hand, especially with someone who is very active and requires their body to do a lot of active flexion of the hip like crouching and squatting. If someone has pain from a hip impingement, the pain may be related to the impingement itself as well as to the injury to the labrum.
Non-Surgical Treatment for Hip Labral Tears
Most people who have labral tears or signs of impingement do not need surgery. Surgery is a last resort. The gluteus medias and other muscles around the hip are joint stabilizer muscles. Much of the pain from a labral tear and impingement comes from microinstability. Strengthening the muscles around your hip, in particular the gluteus medius, can stabilize the hip joint. The gluteus medius stabilizes your pelvis and your hip ball and socket and helps your entire leg to move more efficiently. It’s a very undertrained and underutilized muscle for many people since as a society we do a lot of sitting. For most people, a focus on strengthening this muscle with physical therapy can make the pain go away. A labral tear finding on an MRI doesn’t matter as much as your experience of pain.
Surgical Treatment for Hip Labral Tears and Hip Impingement
In an arthroscopic surgery, the camera and tools go into the body through small holes. It’s similar to a video game where you are looking at the screen as you work with your hands.
Surgical Treatment for Hip Labral Tears
In the labral repair surgery, the bone is cleaned up to make a good surface to adhere to. Small screws called anchors are put into the bone. Stitches are run between the anchors and the labrum to stitch the labrum back to the bone. Multiple anchors may be used depending on the specifics of the tear.
Surgical Treatment for Hip Impingement
A small machine called a burr shaves away the bumpy bone from an impingement to make a smooth surface.
Each joint has a capsule, like saran wrap, holding it into place. In the hip, the capsule is so thick that we need to make a purposeful cut to be able to see into the joint. After the repair, the capsule is sewn shut again.
Frequently asked questions
Can a hip arthroscopy treat arthritis?
Arthritis is inflammation of the joint: arthro- is the joint and -itis is the inflammation. Most commonly, arthritis is the loss of articular cartilage inside of the joint. People might colloquially say bone-on-bone arthritis, where the cartilage is completely gone and the bone is touching the bone. If someone has arthritis, hip arthroscopy does not work.
Once you start to lose cartilage in the joint, fixing your labrum or smoothing out impingement is not going to provide long-term pain relief. It’s very difficult for your body to differentiate between pain from an impingement and pain from arthritis. Even if a surgeon did a hip arthroscopy and fixed your labrum and fixed the impingement, you would still have pain from the arthritis.
Is there an age limit for hip arthroscopy?
There is not an age limit for hip arthroscopy, but it tends to be for people who are under the age of 50. The deciding factor is not age but rather whether or not you have arthritis. Someone who is older than 50 and who does not have arthritis but does have a torn labrum or impingement may be a good candidate. It’s not about the age, it’s about the person.
What is recovery like from the hip arthroscopy? How long do you miss work? Do you need physical therapy?
The full recovery, with a return to sport timeline, is six to twelve months. To be able to walk around and live your life, most people take about three months.
How much time you take off work depends on what you do for work. If you do a desk job, most people can go back after about two weeks. If you’re doing something that involves some standing and sitting, like being a doctor, six weeks is more likely. If you have to do heavy lifting, climbing ladders, running, jumping, climbing on ropes, three months is likely. We want to make sure you have adequate recovery to protect yourself before you do anything more strenuous.
You will need physical therapy. Those patients who are able to routinely stay on top of therapy and stay on top of their strengthening tend to do better afterwards.
Are there exercises or activities people can do to help prevent a torn labrum?
It’s difficult to prevent a torn labrum because it can happen “just because”. You can strengthen the gluteus medius and hip stabilizing muscles to make your hip stable so a torn labrum won’t bother you. The more mobile and strong you keep your hip joint, the more chance that you don’t have pain from a labral tear. Strengthening the hip functional stabilizers, gluteus medius, gluteus minimus, hamstrings, core muscles, hip functional mobility – working on these exercises is important to your overall health in general and can prevent you from having a painful labral tear.
How do you tell the difference between hip arthritis and impingement and if you’ll need a hip replacement or a hip arthroscopy?
When a doctor gives you a physical exam and moves your hip around, the pain from hip arthritis and the pain from hip impingement look very similar. Imaging helps show the difference. X-rays show the bone and the alignment of the bone, while MRIs show the soft tissue in the area.
Even though you cannot see the cartilage on the x-ray you can see where the cartilage should be. If you have an x-ray of a joint and there’s no space between the bones, the cartilage is gone and you have painful arthritis. An arthroscopy won’t help, but if non-surgical treatments don’t help you can talk with your doctor about a hip replacement.
If you have pain in your hip with no arthritis, if you have signs of hip impingement, or if an MRI shows a tear of the labrum and hip impingement, you’ll try non-surgical treatments first and then a hip arthroscopy if the non-surgical treatments don’t work well.
Can taking anti-inflammatories to reduce pain during exercise potentially cause damage by masking the pain that is in there?
It would be difficult to do enough of an activity to cause true, irreversible damage to a joint that could be masked with anti-inflammatories. Anti-inflammatories would not be strong enough to not feel the pain.
However, it is not a good idea to use anti-inflammatories to push through pain. They can be helpful in the short-term, but if you’re taking them on a regular basis to get through something, you should speak with a doctor.
If you have osteoarthritis and a confirmed impingement, are you at more of a risk to tear the labrum?
If you have osteoarthritis and a confirmed impingement, your labrum is likely torn.
Labral tears come in different types. Clean-cut labral tears where the labrum is intact but torn from the bone are often an acute injury. When people have arthritis, they tend to have degenerative tearing of the labrum that is more like a rope fraying.
If someone has arthritis and hip impingement, they probably have degenerative tearing of their labrum. If someone has an MRI that shows both arthritis and a labral tear, the labral tear is part and parcel with the arthritis. The cartilage and the labrum both degenerated in the joint, and fixing the labrum would not fix the pain in that joint.