Arthroscopy performed more today by more surgeons to preserve, treat hip joint

Hip arthroscopy is a specialty area within orthopaedics that has seen steady growth in its popularity in the last decade due to an increased number of surgeons trained to perform hip arthroscopy, advances in technology, expanded indications and the seemingly greater numbers of patients today with hip pain who may find relief and experience better hip function after they undergo this minimally invasive surgery.

Orthopaedics Today Europe spoke with orthopaedists about what has led to hip arthroscopy being done more often today.

“I think everywhere, if something is new this could be the reason why it is frequently done and after some years it decreases,” Solveig Lerch, MD, said.

“I think the major reason why it is done more often is that surgeons get more experienced in arthroscopy and can treat more diseases than 20 years ago,” she said.

Technology aids progress

“Another reason more hip arthroscopy procedures are being done is the arthroscopy technology is improving and arthroscopy surgeons are able to treat much more in an arthroscopic way than 10 years or 20 years ago,” Lerch told Orthopaedics Today Europe.

There is no doubt advances in arthroscopy instrumentation have expanded the use and effectiveness of the procedure, according to Ali S. Bajwa, MPhil, FRCS (Orth), who said advances in fiber optics supported greater adoption of the procedure during the last decade. Such technology also has helped move its use beyond diagnostic techniques to a comprehensive treatment modality.

“The visualization of the hip is much better with a 70° scope and fixation devices are improving. We are seeing improvements in curved and flexible instruments. The hip is very snug, and those two things have made the most difference in visualization,” Bajwa told Orthopaedics Today Europe.

Other advances have been more incremental, he said, such as smaller anchors and all-suture anchors that do not use metal or plastic.

Better selected patients

A decade ago, hip arthroscopy procedures started to boom as indications for the treatment were more varied, Óliver Marín-Peña, MD, of Madrid, told Orthopaedics Today Europe. It was a largely diagnostic and exploratory procedure at the time, but that is not how the procedure is used today. Indications for hip arthroscopy are better defined, which has helped improve patient selection and led to better outcomes.

“There are some registries in the United Kingdom that say, in the last 10 years, they have seen an increase in hip arthroscopy by about 400%,” he said.

Currently, orthopaedic surgeons are better able to correctly identify proper patients who will benefit the most from the procedure, and proper patient selection is key, Marín-Peña said.

Tempering a patient’s expectation of the procedure is equally important, he said. A patient needs to understand a hip arthroscopy procedure will not necessarily cure 100% of the pain they are experiencing in their hip or groin. They must understand the procedure will perhaps only take away 80% of their pain, which is more realistic.

Osteoarthritis (OA) of the hip has long been an indication for hip arthroscopy, but OA is no more common than it was a few decades ago, according to Lerch, who began performing hip arthroscopy in 2009. What she has observed, however, are greatly expanded and new indications for the procedure.

Femoroacetabular impingement (FAI) is the most common indication for hip arthroscopy and Lerch and her colleagues encounter it frequently.

“We are a sports-related clinic and we have many athletes, so we see FAI often. Other diseases, such as loose bodies or adhesions, are not so common,” she said.

Patients present most often with Cam-type FAI lesions on the femoral side or Cam-type lesions in combination with pincer lesions on the acetabular side of the hip, rather than pincer lesions alone. When a patient has a Cam lesion they present with groin pain, mechanical symptoms, such as locking or sounds [in the hip], or giving way, she said.

From adhesions to loose bodies

There are other new indications for hip arthroscopy, as well.

“Adhesions is a little bit newer, or loose bodies, or in cases of hip replacement we take samples from the synovial tissue” via the arthroscope, Lerch said.

Adhesions may occur after resection of a Cam-type lesion at the head/neck junction. An adhesion of the capsule develops at that location because the bone was treated, according to Lerch, and when a patient presents with poor range of motion postoperatively they are often diagnosed with an adhesion.

Adhesions can be treated effectively with arthroscopy, she said.

Expanded indications drive use

Richard N. Villar, BSc, MA, MS, FRCS, a hip arthroscopy pioneer, told Orthopaedics Today Europe he expects hip arthroscopy indications to expand in the next 5 years to 10 years.

“Years ago, FAI was the hot topic in the conferences we all attended. Now it is the most common reason for hip arthroscopy. I see it expanding to issues of hip stability and periarticular hip arthroscopy, where you are looking at muscles outside the hip. If I was a young person starting out in hip arthroscopy in this day and age, I would be looking at hip stability and periarticular tissues. Coming into the mix, also, you have stem cells,” he said.

Villar expects orthobiologics to be another area that will expand the field and it is something he recommends young surgeons and fellows focus on.

“The three biggest areas will be stability, periarticular and orthobiologics. However, that comes with an ethical problem. Different countries see orthobiologics in different ways. If you were to try to do stem cell therapy in the Middle East, at the moment, it is impossible to do. That is an ethical issue. I am sure as time goes by, it will become a major contribution to hip surgery,” he said.

According to Villar, if impingement disappeared tomorrow there would still be a great need for hip arthroscopy. Pediatric hip arthroscopy and hip arthroscopy post-trauma are two areas where the procedure could see its next big expansion, he said.

Training supports expansion

Training has also played a key role in the procedure gaining a foothold among patients and orthopaedists, and so has better imaging, according to Lerch.

Lerch was trained in the technique by her senior surgeon Oliver Rühmann, MD, who began performing hip arthroscopy in the 1990s. She described — and she and Rühmann and colleagues studied and reported on — how ultrasound can quantify the extent of osteochondroplasty of Cam-type FAI lesions postoperatively. Using ultrasound following these procedures in patients with persistent groin pain is helpful for quick and early detection of inadequate head-neck junction resection in the anterolateral region of the hip with the need to perform a revision procedure.

Ajay Malviya, FRCS (Tr and Orth), learned hip arthroscopy from Villar, whom he called a leader in the field. Michael Dienst, MD, of Munich, is another pioneer in hip arthroscopy and these people have helped grow the field in Europe in several ways, said Malviya, who started performing hip arthroscopy as an independent consultant in 2011 after his fellowship with Villar.

“Since then that is one of my bread and butter surgeries,” Malviya said.

Training options

Many orthopaedic surgeons find that operating along with someone who is skilled at hip arthroscopy, such as one of these pioneers, is the ideal training scenario. However, cadaveric courses play an important role in expanded use of the procedure and have become more popular recently. What the courses do is provide an opportunity to practice on cadavers and develop triangulation techniques, Malviya said.

“There is more time to do those complex steps in cadavers and it is the best possible simulation technology we have,” Malviya said.

Surgeons as champions hip arthroscopy

Surgeons have played a big part in the expanded use of hip arthroscopy, according to Malviya. The more proficient they became with the procedure the more they tried to evolve its scope. Prior to 2004, hip arthroscopy was primarily for central compartment pathologies. Subsequently, as techniques improved and with the advent of FAI, impingement lesions in the peripheral compartment were added as an area of focus.

The present, and perhaps the future of hip arthroscopy, involves the periarticular space of the hip, the extracapsular area of the hip, Malviya said.

“One of the conditions we can deal with in this area is psoas tendinopathy for which you can do psoas tenotomy or debridement,” he said. And, although trochanteric bursitis and gluteus medius tendinopathy are pathologies outside the hip, “arthroscopically we can attempt to address them.”

He noted there is a lag time between what is new in hip arthroscopy and reports of the results and evidence for doing any of these newer procedures.

“The literature supporting the use of arthroscopy for these conditions is still sort of evolving,” as is the use of arthroscopy in the posterior part of the hip to release tendons that may tension the sciatic nerve which lies at the back of the hip, he said.

“That is a new area I would say is generating a lot of interest.”

Keeping skills sharp

Bajwa, who works in partnership with Villar in Cambridge and London, United Kingdom, said surgeons should actively perform hip arthroscopy procedures at least every 2 weeks to keep their skills sharp and stay ahead of the learning curve.

“I and Richard feel if one does not perform hip arthroscopies at least every 2 weeks, one gets rusty. You will not be at the same level of performance that one would like to be,” said Bajwa, who noted more than 1,000 arthroscopy procedures are performed annually at their clinic, the majority of which are hip arthroscopies.

“We see hip arthroscopy as two sectors. One is the general hip arthroscopy for femoroacetabular impingement, and the second is extreme hip arthroscopy for uncommon conditions. For uncommon conditions, we are very staunch believers you need to be treated at high volume centers, and for straightforward impingement surgery, we believe that should be happening more or less at every center.”

Patients more informed

More informed patients may also be contributing to the increased use of hip arthroscopy in Europe, according to sources. Malviya said his patients are more informed because of information available on the Internet, but its misinterpretation can cause problems because the patients who request that he treat them with hip arthroscopy have selected and focused only on the kind of results and outcomes they want to hear. Some patients may demand that a certain procedure be done for which they are not suited, he said.

“In the end, I hope we would do what is right for the patient.”

Lerch agreed there are more well-informed patients today who ask her specialized questions about hip arthroscopy.

“We also have patients who have more than a half year of groin pain and no one told them what the problem was. They are surprised we could perform a hip arthroscopy and are a little afraid because they did not hear about it before,” she said.

Villar said his hands-on hip arthroscopy fellowship program puts fellows in the operative setting three to four times a week and focuses less on research and more on time in the operating room. At the end of the year, he said fellows will have seen 400 to 500 hip arthroscopies.

“Hip arthroscopy is a very much a practical technique. The indications are fairly simple, but the doing is the hard part. You need people to do it safely. It is easy if you start without any supervision to have complications and it takes forever to do one. There is work now that shows clearly that as an individual progresses along the learning curve, the complication rate diminishes. Our job is to insert our fellows into their own jobs after a year well along their learning curve and without any complications along the way,” he said. – by Robert Linnehan and Susan M. Rapp

• References:
• Lerch S, et al. Int Orthop. 2015;doi:10.1007/s00264-014-2588-3.
• Malviya A, et al. Arthroscopy. 2015;doi:10.1016/j.arthro.2014.12.013.

• For more information:
• Ali S. Bajwa, MPhil, FRCS(Orth), can be reached at Villar Bajwa Practice, Princess Grace Hospital, 30 Devonshire Place, Marylebone, London, W1G 6PU, United Kingdom; email: alibajwa@doctors.org.uk.
• Soveig Lerch, MD, can be reached at Clinic for Orthopaedics/Traumatology/Sports Medicien, Klinikum Agnes Karll Laatzen/Klinkum Region Hannover, Hildesheimer Stra. 158, 30880, Laatzen, Germany; email: solveig.lerch@krh.eu.
• Ajay Malviya, FRCS (Tr and Orth), can be reached at Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, England; email: amalviya@nhs.net.
• Óliver Marín-Peña, MD, can be reached at Hip-Knee Orthopedic Department, University Hospital Infanta Leonor, C/ Gran Vía del Este, 80. 28031, Madrid, Spain; email: olivermarin@yahoo.es.
• Richard N. Villar BSc, MA, MS, FRCS, can be reached at Villar Bajwa Practice, Princess Grace Hospital, 30 Devonshire Place, Marylebone, London, W1G 6PU, United Kingdom; email: enquiries@villarbajwa.com.

Disclosures: Bajwa reports he is a consultant to Smith & Nephew Endoscopy and director of CAMBfix Ltd. Villar reports he is a consultant to Smith & Nephew Endoscopy. Lerch, Malviya and Marín-Peña report no relevant financial disclosures.

 

Can only athletes benefit from hip arthroscopy for femoroacetabular impingement?

Surgery is beneficial in non-athletes

The short answer is no. Hip arthroscopy has evolved into the preferred approach for surgical treatment of the majority of cases of femoroacetabular impingement (FAI). Although certainly athletes can and do improve from arthroscopic hip surgery for this common condition, many non-athletes also suffer from FAI and the majority can and do improve from arthroscopy as evidenced by patient-reported outcome measures. At least one key appears to be the proper treatment of the chondrolabral pathology and the causative skeletal deformities that most often affect both sides of the joint. On the acetabular side, not only are the typical focal pincer deformities yielding successful outcomes in the short-term and now mid-term, but even global pincer deformities such as protrusio and the more common profunda hip, are showing promising outcomes. On the femoral side, we now are learning the classically described anterolateral Cam deformity oftentimes extends into the anteromedial critical corner and sometimes posterolaterally. Sufficient eradication of these bony deformities, whether by open or less invasive arthroscopic means, may minimize the incidence of revision surgery because of inadequacy during the first surgery. Advances in arthroscopic labral reconstruction demonstrate encouraging basic science and clinical support in patients where the labrum is too damaged, degenerated and/or deficient to restore labral function via arthroscopic repair. The jury is still out as to whether outcomes from our current open and arthroscopic procedures for FAI will truly be durable and hip preservative, but mounting scientific evidence, albeit mostly from level 3 and level 4 studies, suggests surgical intervention in non-arthritic patients is helpful in both the athletic and more sedentary patient populations.

Dean K. Matsuda, MD, practices at DISC Sports and Spine Center, in Marina del Rey, Calif., USA. He is an Orthopedics Today Editorial Board member.
Disclosure: Matsuda reports no relevant financial disclosures.

Non-athletes may have lower outcome scores

Favorable results of hip arthroscopy in athletes with FAI have spawned the notion such patients may benefit more from this type of surgery. However, it is crucial to realize hip outcome scores are, to an extent, dependent on patients’ abilities to perform athletic tasks. The Nonarthritic Hip Score includes two items (high-demand sports and jogging) and the Hip Outcome Score includes an entire subset of questions related to sports. Clearly, patients not used to performing such activities, even under normal circumstances, are almost destined to score lower on these questions.

Further, only direct head-to-head comparisons, ideally through well-designed prospective randomized studies, would truly elucidate this matter. Have such studies been conducted for athletes vs. non-athletes with FAI? The answer is negative. The sole published comparative study, by Malviya and colleagues, showed no significant differences in the outcome scores at 6 months and 12 months postoperatively.

Athletic patients are likely to receive better postoperative care, likely leading to a faster rehabilitation. In addition, outcome scores are better suited to them. In the longer term, non-athletic patients seem to benefit equally from hip arthroscopy for FAI. Studies of a higher level of evidence are needed for a definitive answer.

• Reference:
• Malviya A, et al. Br J Sports Med. 2012;doi:10.1136/bjsports-2012-091184.

Nikolaos V. Bardakos, MD, is in private practice in Athens.
Disclosure: Bardakos reports no relevant financial disclosures.