Hip Arthroscopy Surgery v5

Introduction

On behalf of the orthopaedic team we would like to wish you a warm welcome to Wrightington Specialist Orthopaedic Hospital. 

This information booklet aims to answer any questions you may have about undergoing hip arthroscopy surgery at our hospital.  The booklet also aims to describe what you can expect from your hip surgery and how specialist techniques can help you recover sooner. 

We understand that you may feel nervous about surgery but our orthopaedic team will answer any questions you may have on your pre-operative visits and whilst you are an inpatient.  Please do not hesitate to ask any member of the team if you have any queries, concerns or are in need of guidance. 

Hip arthroscopy is often performed as day case surgery.  You will encounter a lot of orthopaedic staff.  Everyone works together to make your surgical experience as pleasant as possible whilst maintaining the highest quality of standards and care. 

• Consultant Surgeon 
• Orthopaedic Fellows, Registrars and Junior Doctors 
• Anaesthetists 
• Arthroplasty Practitioners 
• Ward Nurses 
• Physiotherapists 
• Occupational Therapists 
• Therapy Assistants 
• Theatre and Recovery Staff 
• Pharmacists 
• Radiographers 

What is a hip arthroscopy? 

The hip is a ball and socket joint between the pelvis and the thigh bone.  The upper end of the thigh is the ball part and fits into the socket in the pelvis.

Hip arthroscopy is a surgical procedure used to treat various problems inside the joint.  Your Consultant will explain the reason you require hip arthroscopy surgery

Arthroscopy or keyhole surgery is performed using an arthroscope, this is a small telescope approximately 1cm in diameter, it contains a light source and a tiny camera, and this is inserted through a small incision (cut) in the skin near the affected joint.  Other instruments can be inserted into the joint through further small incisions. The leg is placed in traction to create some space between the ball and socket for the instruments.  Even though the skin wounds look small after hip arthroscopy, it is considered a major operation and can take up to 3 hours to perform.  Recovery can take a long time afterwards as there is always some scar tissue that forms inside.  Physiotherapy and rehab are a very important part of hip arthroscopy and you must work hard to get the best out of your surgery.

Alternative treatments 

Your Doctor may suggest changes to help improve your symptoms.  This may include physiotherapy, modification of your daily and sporting activities, use of pain relieving medication and possibly an injection into the hip joint.

Your Doctor will discuss your treatment options with you.  If you are unsure of your options or treatment please discuss this with a member of the health care team.

Benefits of surgery 

1  Reduced pain and increased function.

70-75% of patients are pleased with the result of hip arthroscopy surgery in terms of pain relief and restoration of function.  10-15% of patients will see no change to their symptoms and 5-10% will have worse symptoms than prior to surgery.

2  Increased mobility

With a combination of reduced pain and improvement in function your overall mobility is likely to be improved.  This will help you return to a more active lifestyle.

Risk of Surgery 

It is important that you read and understand all of these potential risks prior to surgery.

Blood Clots 

• Deep vein thrombosis (DVT) (blood clot in the leg) 
• Pulmonary embolism (PE) (blood clot in the lung) 

Blood clots can occur after any operation but are more likely to occur following lower limb orthopaedic operations.  When these clots occur a blockage can develop in the veins of the leg causing swelling, pain and warmth.  Swelling in the leg after surgery is very common and can take time to resolve.  If there is any doubt you should seek the advice of your doctor. 

A blood clot in the lungs is termed a pulmonary embolus (PE).  In rare circumstances (1 in 1000) this can cause death. Symptoms of a PE include shortness of breath, sharp chest pain and blood coughed up in your phlegm. 

Preventative measures 

1. We mobilise patients as soon as possible following surgery.  This has the advantage of increasing blood flow to the leg and maintaining the circulation. 
2. You will need to wear elasticated stockings for 6 weeks following surgery. These are somewhat similar to flight compression stockings. 
3. We assess all patients’ individual risk of blood clots as recommended by the National Institute of Clinical Excellence (NICE).  Following risk assessment, most patients are advised to take blood thinning agents.  You will be advised by your doctor or nurse on how to take this medication and for how long. 

Joint Infection 

You will be screened for bacteria and MRSA before you come in for your operation to reduce the chance of infections.  This enables any treatment to happen and reduce the risk of infection to you and to others.  It is very important that there are no cuts, grazes or wounds on your legs when you come for surgery.  It may be worthwhile considering avoiding activities such as gardening for a few weeks prior to your surgery. 

We will also encourage you to lose weight, as being overweight significantly increases the chances of infection following surgery.  We also encourage smoking cessation as there is evidence that smoking increases your chances of infection with the wounds taking longer to heal. 

During the operation you may be administered intravenous antibiotics.  Your surgery will also take place in advanced air-flow operating theatres which help reduce the bacterial levels. 

Deep infection in a joint is a very serious complication.  - Fortunately this is rare (1 in 1000 procedures) however sometimes despite the strictest precautions, infections can occur.  More commonly one can develop a superficial infection on the surface but occasionally this can progress deeper.  If you think you have an infection please contact the hospital for advice. 

Nerve injury 

There are several nerves located around the hip and these can be damaged during hip arthroscopy surgery.  These nerves supply skin sensation and power the muscles in the leg.  Normally the nerves recover themselves over a period of weeks and months.  Occasionally the problems can be permanent and may lead to pain, weakness and loss of sensation. 

Blood vessel injury 

Although uncommon, bleeding during the surgery can occur and may result in the procedure being converted to an open procedure to control the bleeding. 

Traction injury

When traction is used during the operation to create space in your hip, the nerve in your groin can be damaged.  This can cause numbness to your groin.  For men, it can sometimes cause problems having an erection.  The nerve usually recovers within a few weeks, however can be permanent.  Bruising, pressure sores, skin abrasions and blistering may also be caused by the traction post placed between the legs during surgery.

Persistent pain 

There are some patients who are left with pain and discomfort following hip arthroscopy surgery.  5 to 10% will have worse symptoms than prior to surgery.

Bone formation in soft tissues

Bone forming in muscles around your hip, which may lead to loss of movement and stiffness in your hip. 

Fracture 

There are occasions when a bone may break during and after this procedure.  The risk is very low. 

Femoral head collapse 

This is a very rare complication where disruption of the blood supply to the femoral head causes bone death causing collapse of the femoral head.

Technical difficulties 

Breakage of surgical instruments can occur in your hip, this occurs in 1 in 500 cases.  Your surgeon may not be able to get a good view or access all areas of the hip, this occurs in 1 in 35 cases.  Damage to the joint surface may occur, this occurs in 1 in 35 cases.

Fluid leakage

This is when the irrigation fluid used during the procedure escapes into the soft tissues beneath the skin and sometimes into the abdominal cavity.  It is normal to have a small amount of fluid in the tissues after the operation.

Medical problems 

There is a small risk of developing a medical problem following surgery.  These include heart attacks, strokes and pneumonia. There is also a small risk of dying associated with this type of operation.  These risks will be discussed with you at the time of consultation with your surgeon and anaesthetist.  If there are any concerns your doctors may transfer your care to another speciality for ongoing treatment.

Summary 

Hip arthroscopy surgery is usually a successful operation, but as with any other surgery there are risks of complications, which may affect a small number of patients.

Out-patient clinic 

When you attend the out-patients clinic you will be entered onto the waiting list for your procedure.  Your consultant team will work closely with the admissions team and pre-operative assessment team to agree on a suitable date for your surgery.  Once this date has been agreed you will be notified in writing. 

You will be encouraged to reduce weight if necessary and stop smoking.  These two measures have been proven to lower complications following surgery. 

If there is availability and you have time your surgeon will send you to pre-operative assessment on the same day.  If you have complex medical problems you may be required to see the anaesthetist prior to surgery. 

Pre-operative assessment 

It is essential that you attend this appointment. 

During this visit you will undergo assessment to ensure you are fit for surgery. You will undergo simple checks on your heart, lungs and have blood tests taken.  Skin swabs will be taken to test for MRSA carriage.  You may require an x-ray and will be asked questions about your medical history.  It is important that you bring any relevant documentation and list of medications to this visit.  If you are on blood thinning tablets e.g.  aspirin, warfarin, clopidogrel or dipyridamole or contraceptive medicine please inform the nursing staff as you may have to stop these prior to surgery. This would only be under the direction of a doctor.

If you have a long term illness, heart, lung or metabolic (diabetes, thyroid) condition an anaesthetist will examine you to ensure you are fit for surgery.  It may be necessary for you to be seen by a specialist if you have a more serious health problem.  If you are not considered fit for surgery the operation will be cancelled.  You will receive an out-patient appointment with your consultant who will discuss alternative treatment options.

Please tell the doctor or pre-assessment nurse if you are already taking these medications for other reasons, or if you are taking another medication called pregabalin. 

How long will I be in hospital? 

For most patients discharge will be the day of their operation. 

You will only be discharged home when you are medically stable and can manage safely. 

Admission 

The day you are admitted will be the day you undergo surgery.  Please follow the fasting guidelines, which you will have received from the pre-operative assessment clinic or in the letter you receive from our Admissions Department. 

Reminder: Please ensure you have a bath or shower before you arrive at the hospital.  We need you to be as clean as possible to keep the operation site as clean as possible to reduce the risk of infection. 

It is also important that you do not apply creams or make up after your bath or shower.  If you shave your legs, please do not shave for at least three weeks prior to the operation.  Shaving is known to increase infection rates in joint replacement unless conducted immediately before the operation.  It is not known whether hair removal creams increase infection risk, and these may be best avoided. 

You will normally be admitted on the morning of your surgery to Ward D or OAU at Wrightington Hospital.  Following your operation you will be transferred to one of the orthopaedic wards. 

Please do not bring too many possessions into hospital with you as storage space is limited. Bring well-fitting comfortable flat shoes to walk in and some comfortable slippers.  There may be some swelling in your foot after your surgery, therefore consider this when selecting suitable footwear. 

On admission the final checks prior to surgery will be undertaken.  If your temperature is low you may be warmed, using blankets, as this has been shown to minimise the risk of infection. 

Occasionally delays in theatre or unexpected changes to the operating list may mean you have to wait longer than anticipated.  If this happens you may be offered a drink, after discussion with your anaesthetic team. You may wish to bring a book or a magazine with you to pass the time. 

The anaesthetic 

When you are admitted onto the ward you will be seen by the anaesthetist who will discuss your anaesthetic choices and post-operative pain relief with you. 

From the start of the anaesthetic until the end of your operation your anaesthetist will stay with you for the whole time watching your condition very closely.  Your heart rate, blood pressure and breathing are monitored and your body temperature is kept normal using a specialist warming blanket. 

The operation 

The operation will be carried out under general anaesthesia; this will send you to sleep for the duration of the operation.  You will then carefully be positioned on the operating table and traction is applied to the leg to open up the hip joint, thus allowing access to the joint for the arthroscope and other instrumentation. 

The Surgeon will then make two (sometimes three) small incisions, around 2cm long, into the skin in order to carry out the procedure. 

The skin will be closed with stitches and small dressings applied.

After the Operation

You will spend a short time in the recovery area of the operating theatre department where you will be closely monitored after your operation.  You will then be taken back to the ward.  The staff here will: 

1  Check your general condition 

2  Take your observations: pulse, blood pressure and oxygen levels 

3  Check your wound dressing 

4  Assess your pain control 

Some discomfort will be experienced following the operation so oral pain relief medication will be given to help ease the discomfort.  After the operation you may get an injection of blood thinning medication (to reduce the risk of clots forming in your blood). 

A Physiotherapist will visit you on the ward to show you how to use your crutches and arrange your outpatient physiotherapy sessions.

Pain relief 

You will have regular pain relief prescribed.  If you feel your pain relief is inadequate at any time then you must let the ward nurses know so they can help you to get more comfortable. 

Deep breathing exercises 

This helps to keep your chest as clear as possible.  Take 3 or 4 deep breaths.  Try to breathe as deeply as possible and after the last breath try to “huff” out the air.  This may stimulate a cough.  Some people may experience a productive cough after anaesthetic. 

Discharge 

Before you can be discharged from the hospital we will check that:

• You have had something to eat and drink. 
• Your bladder is functioning correctly. 
• You are able to walk, aided with crutches. 
• Your wound has been checked 
• You have been given suitable pain relief medication and instruction on how to take them. 
• You have been given contact telephone numbers for information and advice if required. 
• You have been given an outpatient appointment. 

You should make arrangements for your transport home from hospital as it is likely that you will be advised not to drive for 4 to 6 weeks.  You also need to have a responsible person to look after you for 48 hours following your operation. 

You will have stitches in the wounds.  These will be removed by the district Nurse, GP or Practice Nurse approximately 14 days after your operation.  It will be necessary for you to keep your wounds clean and dry until this time. 

Once at Home 

Pain - Some discomfort in the hip is expected following the surgery, you may also experience pain in the lower back, buttock, knee and ankle.  Continue to take the pain killers as prescribed once you go home.  The soreness should improve week by week, however as you increase your activity it is quite normal to find a small increase in your pain levels.  This is often a result of the muscles and ligaments around the hip resuming activity. 

Swelling - Following the surgery there will be a degree of swelling and bruising to the hip.  This is normal and should improve over a few weeks.  It is also normal to have some swelling to the lower leg and foot/ankle. Resting on the bed with the leg up should help reduce this swelling.  Any severe pain, increased redness or tightness in the calf should be assessed by you GP, or local Walk in Centre. 

Wound care - It is normal following the surgery to have some blood stained fluid seepage from the wound sites, this should resolve after a few days.  Notify your Doctor if your wound appears red, you have any new discharge or you have an unexplained increased temperature.

Your dressing should remain in place until your stitches are removed.  If the Ward have provided you with replacement dressings and it is necessary for you to change your dressing:

• wash your hands 
• remove the old dressing 
• do not touch the wound or stitches 
• replace with a new dressing, try not to touch the padded area of the dressing 

Some numbness around the incision site is normal, this usually resolves over a period of time. 

Getting about - The Physiotherapist will have instructed you how to use your crutches before you leave the ward. 

Following your surgery you will be asked not to put your full weight through your leg for a period of 4 to 6 weeks.  This will depend on the procedure you have had carried out.  Please continue to use both your crutches until instructed otherwise by your Physiotherapist.

Physiotherapy - It is important for your rehabilitation that you receive physiotherapy input after your discharge home, initially to restore range of motion, then to work on core stability and finally to increase strength. It is important to follow the instructions given by your Physiotherapist to gain the best results from your surgery. You will be provided with instructions for your Physiotherapist if you are not attending Wrightington. 

Driving - It is advised that you do not drive until either you are walking normally without crutches or you have been advised that it is safe to drive at the 6 week check, in the Outpatient Department. 

Returning to work - You can return to work when you can function safely and with reasonable comfort.  Most people can return to work at about 6 weeks, however if your job involves standing for long periods or is of a manual nature you may need up to 12 weeks. 

Returning to exercise & sport - Most patients can begin light activities (cycling, swimming) within a few weeks. 

Sports training can resume at 3 months.  Competitive sports should be delayed for 6 months. 

If your symptoms before your surgery stretches back over many years it may take up to 12 months for full recovery. 

Follow-up 

Although you have been discharged from hospital having made satisfactory progress following your operation, we are still here to support your recovery should you need us.   

If you have any concerns regarding your recovery, or think you may be developing a problem, please contact the helpline who will be able to offer advice, arrange additional support or organise a review if required.  It is particularly important that you contact us if you are concerned about your wound. 

Arthroplasty Practitioner: 01257 256372 (manned office hours) 

Out of these hours please contact the ward where you had your operation 

Hip arthroscopy is a planned day case surgery, if for any reason you are required to stay overnight your relatives can contact the Patient Flow Team after 3:30pm on the day of surgery to find out which ward you will be allocated to post-operatively: Patient Flow Team: 01942 778989

Also seek advice if you notice any excessive bleeding or any difficulty with breathing.  If you become urgently unwell please call 999. 

If you have clips or stitches they will need to be removed about 14 days after your operation.  The nursing staff will let you know the arrangements that have been made for this to be done. 

You will have a clinic or telephone appointment approximately 6 to 8 weeks after your surgery. This will often be with the Arthroplasty Practitioner.  This is to ensure you are progressing well and to answer any questions you may have. 

You will routinely have a physiotherapy follow-up appointment.  It is important to continue the exercises at home which you were shown in hospital.