hip arthroscopy

Saturday, August 26, 2017

It seems a rite of passage that a pro athlete will undergo surgery sometime in their career. Pushing a body to the limits of physiology and beyond, is an internal expectation of the athlete but when the body breaks, surgery may be offered as an option to repair the damage. There might be other alternatives to explore and that is where we find Isaiah Thomas, the Boston Celtic, soon to be Cleveland Cavalier guard. Last spring, Mr. Thomas injured his hip, tearing the labrum, a piece of cartilage that extends the depth of the hip joint, where the femur or thigh bone, comes together with the acetabulum, the bony socket of the pelvis. It is an injury that can be repaired by hip arthroscopy surgery, but some cases may also can be treated with rest and physical therapy. Mr. Thomas has become news because of the trade; will he be considered damaged goods because he chose not to have an operation?

There is no such thing as minor surgery. That describes an operation that happens to somebody else.  Arthroscopy (arthro=joint + scope=to see) is an operation where an orthopedic surgeon, using small cuts in the skin, introduces a camera and a variety of thin instruments to operate inside a joint and repair damage. The knee was the first joint to be attacked. It was a large joint with plenty of room to hold the camera and everything else that was needed. Over time, techniques improved, instruments became smaller and other joints, ike the hip, shoulder, ankle and wrist, could be attacked.

One big difference between knee and hip arthroscopy is the anesthetic. Knee arthroscopy can be done under regional anesthetic and the patient can be awake (or sedated) and even watch his own operation on the video screen. The hip joint is a much smallr space and the surrounding muscles need to be relaxed to allow the leg to be positioned and put under traction to make more room for the surgeon to put stuff like cameras inside. Practically, that means a general anesthetic and medications are then used to paralyze the patient to have no potential for the muscles to go into spasm and make visualization inside the hip joint that much tougher.

In addition to being small in space, the hip joint is surrounded by really important structures like major arteries and nerves. The surgeon needs to know the anatomy (and appreciate that everybody isn’t always built precisely the same way) to avoid inadvertently damaging something important.

  • Before the skin is cut, the patient’s body needs to be positioned and padded to prevent damage to nerves as traction is placed on the hip when the leg is pulled. Usually, the traction time is maxed out at 2 hours.

  • The next worry is to be precise about where to slide the camera and instruments into the joint. The anterior or front portal is placed within 1 ¼ inches (3.2 cm) of the femoral artery, vein and nerve. The posterior or back portal is even closer to the sciatic nerve (2.9 cm). The superior portal is within 1 ½ inches (4 cm) from the superior gluteal nerve and artery.

  • During and after the operation, there is risk of bleeding and infection.
  • And finally, there is the post operative rehab.

Fortunately, the more an orthopedic surgeon scopes a hip, the fewer complications occur and major complications happen infrequently, in less than 1.5% of cases. Appreciate though, that when a complication happens, it happens 100% to that particular patient.

The athlete’s decision to consider surgery depends upon whether the chance of recovery and return to play the same level of skill and performance is more likely with the operation, or perhaps better with physical therapy and rehab. Each injury has its own risk and reward. And for that reason, when Isaiah Thomas torn the labrum in his hip, he had to weight the pros and cons of surgery.

The Isaiah Thomas treatment decision is not news. There is no right or wrong. It only matters now because of an impending trade and his new team wanting him to pass his physical exam so that he isn’t considered “damaged goods”. Fortunately, his specific decision to go the physical therapy route isn’t written in stone. If he does well, life is good. If he doesn’t heal satisfactorily, the surgery option is still available and on the table. And it’s always good to have time on your side when having to decide.



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