The success of hip replacement has been well documented over the years; however, treatment of the young, active patient with hip pain has remained a difficult problem. We have come to understand that the majority of the time this pain is due to a discrete injury or overuse resulting in tears of the labrum (a ring of cartilage that surrounds the socket), damage to the cartilage, or irritation of the muscles surrounding the hip. The hip joint is a ball (femoral head) and socket (acetabulum) joint that allows for smooth motion as long as the cartilage coating the ends of the bone is preserved and the bones are shaped properly. Femoroacetabular impingement (FAI) describes a condition where patients have an abnormal shape to their ball (Cam impingement) or socket (Pincer impingement). This creates a situation where the ball and socket do not fit together and results in mechanical impingement and damage to the structures within the hip.
Over the past decade surgical techniques have evolved to allow minimally invasive access to the hip joint. The use of the arthroscope (camera) is routine in orthopaedic surgery for the evaluation and treatment of many conditions of the knee, shoulder, elbow, wrist, and ankle. Arthroscopic surgery revolutionized the field of sports medicine, allowing a minimally invasive way to access joints with the ability to treat many conditions with less morbidity to the patient and quicker recovery times. Common surgeries that previously required larger, open incisions such as rotator cuff repair, anterior cruciate ligament reconstruction, and treatment of meniscal tears of the knee are now routinely performed arthroscopically.
Due to the deep location and limited space of the hip, it was considered one of the most difficult joints to access with a camera. By developing specialized instrumentation, techniques to perform arthroscopic surgery of the hip were pioneered. These minimally invasive techniques can now be used to treat FAI (be reshaping the ball and/or socket) and to treat damage to the labrum, cartilage, and musculature around the hip.
Non-operative measures including physical therapy to improve core and hip strengthening and range of motion, non-steroidal anti-inflammatory drugs (NSAIDs), activity modification, and weight loss are always the first line of treatment. In patients who fail these, an injection into the hip joint is considered. The ideal candidate for surgery is a patient who has a well preserved hip joint (no or minimal arthritis), a discrete labral tear on MRI, and underlying evidence of FAI. Patients who have failed all non-operative measures, have had an excellent response to the injection, and are motivated and willing to comply with the post-operative rehabilitation protocols have been shown to have the best results. In patients who already have underlying arthritis of the hip, arthroscopic surgery has been demonstrated to be ineffective and these patients may be better served to have an evaluation by a specialist in hip replacement surgery.
While many techniques are still evolving, what we currently know from the orthopaedic literature is that hip arthroscopy is successful for treating pain, improving quality of life, and returning patients back to their activities when other treatment options have failed. Future research will continue to help refine the technique of hip arthroscopy and provide more long term data on whether these procedures will help prevent or delay arthritis of the hip joint. Studies are currently underway to follow youth athletes and learn how to potentially prevent the development of hip impingement and labral tearing.