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Arthroscopic Hip Labral Repair

The hip is a ball and socket joint where the ball is formed by the upper end of the thigh bone (femur) and the socket is formed by the acetabulum, a cavity in the pelvic bone. The acetabulum is lined by smooth cartilage that forms a rim around the socket as an elevated ridge called the labrum. The labrum increases the depth of the socket, providing stability to the hip joint and attachment for muscles. A labral tear may occur as a result of a sports injury, accident or structural abnormality, causing pain and limiting movement of the hip. Arthroscopic hip labral repair is a procedure performed to repair a labral tear.

The arthroscopic procedure is performed using a narrow tube with a camera, called an arthroscope. Small incisions are made over your hip to reach the damaged labrum. The arthroscope is inserted through one of the incisions to provide your doctor with a clear view of the damage. Miniature instruments are then inserted through the other incisions to repair the tear. Depending on the extent and position of the tear, the labrum may be repaired with sutures (refixation) or the torn portion removed (debridement).

Following arthroscopic hip labral repair, you may be advised against bearing weight on the operated hip. Within the first few weeks of surgery, rehabilitation is introduced to help you heal and recover completely. Your physical therapist will design specific exercises to minimize pain and inflammation, improve flexibility, mobilization and range-of-motion, and strengthening of the hip. By week 12 you will be able to safely return to sports activities.

As with any surgery, arthroscopic hip labral repair may be associated with certain complications such as injury to surrounding blood vessels and nerves, infection and blood clots in the legs.

Hip Labral Reconstruction

The labrum is a ring of strong fibrocartilaginous tissue which lines the perimeter of the hip joint socket (acetabulum). The labrum serves many functions.  It acts as a shock absorber, lubricates the hip joint, and distributes the pressure equally throughout the cartilage. The labrum holds the head of the femur in place and prevents the lateral and vertical movement of the femoral head within the joint. It also deepens the acetabular cavity and offers stability against femoral head translation.

Labral tears may be caused by trauma, femoroacetabular impingement (FAI), hip hypermobility, dysplasia, and degeneration. It is a rare condition that can be seen in athletes playing sports such as ice hockey, soccer, golf and ballet. Structural abnormalities may also cause a hip labral tear.

Patients with a labral tear of the hip may experience hip pain, clicking or locking of the joint and restricted range of motion. Patients may also experience dull pain on movement of the hip joint that may not subside on rest.

Hip labral tears are often diagnosed based on symptoms, history, physical examination and radiological techniques. Magnetic resonance arthrography may be more appropriate for diagnosing hip labral tear.

Your doctor will recommend conservative treatment initially prescribing nonsteroidal anti-inflammatory drugs, steroid injections and referral to physical therapy. These methods may offer symptomatic relief in a few weeks to months.  If conservative treatment does not improve the pain then surgery is required to repair or reconstruct the torn labrum.

The goal of labrum reconstructive surgery is to restore the normal function of the labrum and prevent further damage to the cartilage.

Some of the surgical procedures include:

Arthroscopy

Small incisions are made on the hip joint. An arthroscope is passed through one of the incisions. The arthroscope is an instrument that has tiny camera attached to the end. It enables the surgeon to view the area being operated on a bigger screen and also identifies the torn cartilage.

Depending on the severity of the tea, the torn section of labrum may be removed or the torn ends reattached and secured to the rim of the bone using small anchors.

Anchors are screw-like structures that have sutures attached. These anchors are placed on the torn labrum and the sutures are pulled tightly re-attaching the tissue to the bone. Later the incisions are closed using dissolvable sutures.

Open surgery

Open surgery is performed in a similar way as arthroscopy but the torn labrum is treated by making a large incision over the hip area to access the joint.

Grafting

Grafting is indicated in chronic cases where the labrum is so severely damaged that it is unable to be repaired. This is done using a graft taken from the patient (autograft) or from donor tissue (allograft). The grafts are stitched to the native labral margins.

Advantages of arthroscopy over open surgery

  • Smaller incisions
  • Less bleeding
  • Less pain
  • Promotes faster healing

Post-operative care

The recovery following a hip labrum reconstruction will depend on the complexity of the surgery. Physical therapy is recommended as a part of a rehabilitation program which includes strengthening and stretching exercises to improve the function and movement of the joint.

Some of the possible complications associated with surgery include:

  • Joint stiffness
  • Recurrent pain
  • Infection at operated site
  • Bleeding
  • Nerve damage

Hip Preservation Surgery

The hip is a ball and socket joint comprising of the femur (thigh bone) and the pelvic bone. The head of the femur (ball) articulates with a cavity (socket) called the acetabulum in the pelvic bone. To facilitate smooth and frictionless movement of the hip joint, the articulating surfaces of the femur head and acetabulum are covered by spongy articular cartilage. Injury, wear-and-tear and certain diseases can result in the wearing away of the cartilage tissue, causing painful rubbing of bones. Hip replacement surgeries have long been the choice of treatment, where the damaged parts of the joint are removed and replaced with a prosthesis. However, in young active patients, the prostheses are highly prone to wear-and-tear, and the need for repeat surgery. Hip preservation is a surgery that overcomes the limitations of joint replacement.

Some of the conditions indicated for hip preservation surgery include:

  • Femoroacetabular impingement (FAI): friction in the hip joint from abnormal bony irregularities
  • Hip dislocation: head of the femur moves out of the socket
  • Hip dysplasia: congenital hip condition characterized by a shallow acetabulum
  • Labral tear: tear or separation of the labrum, a cartilaginous ring that surrounds the socket and seals the hip joint
  • Avascular necrosis: disrupted blood flow to the hip joint, causing death of bone tissue

Hip preservation surgery includes various techniques:

  • Periacetabular osteotomy: Periacetabular osteotomy is a surgical procedure to treat hip dysplasia. This involves cutting the acetabulum from the pelvic bone and repositioning it with screws to allow for a better fit of the femoral head. The procedure reduces pain, restores function and prevents further deterioration of the hip joint, thereby increasing the life of the hip joint and postponing total hip replacement.
  • Surgical hip dislocation: Surgical hip dislocation is a surgical technique that involves the dislocation of the hip joint during surgery to facilitate easy access to the inside tissues of the hip joint. It helps your surgeon to clearly view and treat abnormalities present deep into the hip joint.
  • Femoral osteotomy: An osteotomy is a surgical procedure that involves cutting and reshaping of a bone. The femur is cut at the end close to the hip joint and realigned so that it forms a normal angle. This improves the distribution of force placed on the joint and prevents wear-and-tear of the cartilage.
  • Hip arthroscopy: Arthroscopy, also referred to as keyhole or minimally invasive surgery, is a procedure in which an arthroscope is inserted into a joint to check for any damage and repair it simultaneously. Hip arthroscopy is a surgical procedure performed through very small incisions to diagnose and treat various hip conditions.

The various hip preservation surgeries for severe hip pain and dysfunction in young and active patients have been found to be beneficial, and avoid or delay the need for hip replacement surgery.

Core Decompression for Avascular Necrosis of the Hip

The hip joint is a ball and socket joint, where the head of the thigh bone (femur) articulates with the cavity (acetabulum) of the pelvic bone.

Sickle cell disease, a group of disorders that affect the hemoglobin or oxygen carrying component of blood, causes avascular necrosis or the death of bone tissue in the hip due to lack of blood supply.

Avascular necrosis commonly affects the head of the femur. Necrosis leads to tiny cracks on the bone which finally causes the head of the femur to collapse.  The condition causes pain due to increased pressure in the blood vessels of the bone marrow at the region of the necrosis.

Early stages of avascular necrosis can be treated by core decompression surgery, which reduces pressure, promotes blood flow and encourages healing of the bone.

Indications

Core decompression is indicated in the early stages of avascular necrosis, when the surface of the head is still smooth and round.  It is done to prevent total hip replacement surgery, which is indicated for severe cases of avascular necrosis and involves the replacement of the hip joint with an artificial device or prosthesis.

Surgical Procedure

Core decompression is done under spinal or general anesthesia. The patient is placed on their back in supine position. Live X-ray imaging or fluoroscopy is used to guide your surgeon during the procedure.

A small incision is made on your hip and a guide wire is passed from the incision through the neck of the femoral bone to the necrotic area in the femoral head. A hole is then drilled along the wire. The necrotic bone is then removed. This reduces the pressure immediately and creates space for the new blood vessels to grow and nourish the existing bone.

The cavity that is left behind in the bone is sometimes filled with bone graft taken either from another part of your body or a cadaver.  Sometimes synthetic bone graft material is used. The incision is then closed with sutures. Another variation of the same surgery involves drilling very small diameter holes from a single point. The surgical wound in this case is very small and may require only a single suture.

Post-Operative Care

After the operation, crutches are to be used for 6 to 12 weeks to prevent weight bearing at the hip joint until the femur bone heals completely. You will be able to resume your regular activities 3 months after the surgery.

Advantages

The advantages of core decompression include the following:

  • Prevents complications of collapse of the femoral head
  • Preserves bone of the femur
  • Delays the need for total hip replacement where the diseased femur head is replaced with an artificial prosthesis.

Risks and Complications

As with all surgeries, core decompression may be associated with certain complications such as:

  • Fracture along the core track
  • Perforations in the femoral head
  • Deep vein thrombosis