Status of Hip Arthroscopy in India: A Short Questionnaire Based Survey and Review of Literature

Abstract

Background

Hip arthroscopy is a minimally invasive technology for diagnostic and therapeutic interventions in various hip disorders. Over the past decade or so, the technology and understanding related to this surgery have improved by leaps and bounds; however, in India the overall pace has been limited. The present review highlights the status of hip arthroscopy in the Indian context.

Methodology

A small survey with five questions related to practice of hip arthroscopy among Indian orthopaedic surgeons was conducted. Additionally a PubMed database search was conducted to recognise and assess studies pertaining to hip arthroscopy originating from India.

Results

Forty-two responses were received for the questionnaire, out of which 38 surgeons performed hip arthroscopy in their practice; the overall numbers were very low with only one respondent performing more than 50 surgeries in a year. For 84.2% of the respondents, the practice was limited to less than ten surgeries per year. 63.2% of the surgeons affirmed that there has been no change in their practice of hip arthroscopies over the past 5 years, signifying the slow growth and limited application of the technique. Only nine studies pertaining to the topic were available in the literature search, out of which five were case reports. The most common indication was removal of intraarticular foreign bodies, followed by joint debridement and lavage, synovial biopsies and femoroacetabular impingement (FAI). The outcomes in all the studies were satisfactory.

Conclusion

Hip arthroscopy is in its nascent stages in India and much is still needed to be done for better implementation of the technique on a wider scale. Adequate training and continued medical education programme, with exposure to the experts in the field, will go a long way in better utilisation of the surgery in India.

Introduction

Arthroscopy as an entity had evolved exponentially ever since its inception in the early 1900s when pioneers like Takagi and Nordentoft began to scope knee joints [1]. In due course, with inventions of appropriate sized lenses, mirrors and instruments, this evolution progressed from diagnostic to therapeutic indications, from large to smaller joints (knee to ankle) and then low to even lower joints (subtalar and tarsometatarsal joints) [1]. As far as the hip joint is concerned, growth of arthroscopic procedures has been relatively slow due to the it being a deep-seated ball and socket joint with close vicinity to essential vessels and nerves [2]. Additionally, the indications of hip arthroscopy had been improperly recognised historically [2]. However, with a better understanding of the technique and instrumentation, hip arthroscopy has seen a very recent expansion from the early 1990s [3]. These improvements include better subcapsular access and joint exposure; a clear visual field of the joint surfaces, labrum, synovial fold, ligamentum teres, the junction of the head and neck as well as the trochanteric region [4]. This, in turn, has led to multiple indications for which hip arthroscopies are performed all over the world; femoroacetabular impingement (FAI), capsule laxity, loose bodies, gluteal tendinopathy and snapping hip syndromes [4]. In India, scoping other joints of the lower limb, like hip and ankle, is very limited and still considered to be in infancy, as compared to the knee [1]. The prerequisites of a long learning curve along with specific sophisticated instrumentation and set up, have not allowed hip arthroscopy in India to pick up the pace in a manner it has perhaps done in the west. The present study was conceptualised to evaluate the status of hip arthroscopy in India by a questionnaire-based survey of some leading arthroscopic surgeons in the country. Additionally, relevant literature was scrutinised and reviewed to ascertain the common indications for which these surgeries are being performed in India.

Materials and Methods

A small survey was developed on Google Forms with five questions related to Indian arthroscopic surgeons’ practice of hip arthroscopy; present status and growth in the field, indications, frequency and their opinion regarding hip arthroscopy being in its infancy in the country. The questions were carefully formulated to understand the present situation and the future scope of this surgery in India. The questionnaire was mailed to national orthopaedic association members practising arthroscopy, for their responses. Other orthopaedic groups were also contacted through social media platforms like WhatsApp and Facebook on multiple periodic instances to enhance the response rate and increase the number of inclusions in the study.

Search Strategy

A PubMed search was conducted on 17th June 2020 with keywords “Hip arthroscopy” [All Fields] This yielded 1942 hits. Further search for India specific research with keywords; “Hip arthroscopy “[All Fields] AND (“India” [MeSH Terms] OR “India” [All Fields]), yielded only 42 hits.

Selection of Studies (Inclusion and Exclusion Criteria)

Clinical studies of any design or types in the English language, originating from India and discussing aspects of hip arthroscopy were included. Animal studies, conference abstracts, posters, and non-Indian studies were excluded.

Data Collection

All the hits were screened independently based on the title and/or abstract, for inclusion. The full text of all the screened articles were read, and the relevant articles were zeroed upon. Discrepancies were resolved by consensus. A secondary search was also done from the reference lists of all selected articles.

Data Extraction

The data extracted from each included article were entered in pre-specified Microsoft excel sheets and included the authors’ names, type of study, diagnoses, relevant demographic parameters like age and gender, surgeries in brief, rehabilitation protocols and outcomes (Table 1).

Table 1.

Review of Literature describing hip arthroscopy by Indian surgeons

S.No.	Author Year	Study Type	No. of patients	Age (years)	Gender	Diagnosis/Indications	Surgery	Rehabilitation	Outcome	Inference
1	Krishan et al. [5] 2018	Case Report	1	21	M	Intraarticular fracture fragment due to Right hip fracture dislocation	Arthroscopic loose body removal + 3 weeks skeletal traction	PWB after 3 weeks, progressing to FWB at 6 weeks	At 6 weeks, no pain, healed portals, no sinuses Normal hip movements and gait	This procedure prevents morbidity associated with open approach and has a faster rehabilitation and recovery cycle
2	Ramaswamy et al. [8] 2018	Case Report	1	15	M	Osteoid osteoma (OO) of left femoral neck	Arthroscopic excision + cancellous autograft	ROM exercise after 3 weeks and weight bearing after 1 month of surgery	At 14 months, no pain and no evidence of recurrence Normal ROM and gait	Early arthroscopic excision of a benign neck lesion like OO gives optimal results
3	Bagaria et al. [6] 2018	Case Report	1	21	M	Posterior hip D/L and fracture acetabulum with 2 intraarticular fragments	Arthroscopic retrieval	Mobilised on 1st postoperative day, PWB to FWB at 1 week	At 10 months, no symptoms, no AVN on MRI	Arthroscopy of hip to remove intraarticular loose fragments offers minimal invasion and faster rehab & recovery
4	Goyal [10] 2018	Case series	9 (6 other patients underwent open surgery)	Mean in 15 patients:27.5	NA	Cam type FAI due to AVN hip	Arthroscopic osteochondroplasty	ROM exercises started in 1st 2 days Immediate weight bearing	At mean follow up of 2 years statistically improved VAS, HHS and WOMAC scores Negative impingement tests Significant ROM improvement and no need of arthroplasty in any patient	In AVN sequelae symptomatic FAI can be treated doin osteochondroplasty arthroscopically, which allows earlier weight bearing than those requiring surgical dislocation of hip
5	Sood et al. [3] 2017	Prospective case series	5	Mean: 38.5	M	Synovial chondromatosis + loose bodies: 3 FAI: 1 Synovial biopsy: 1( case was diagnosed as tuberculosis)	Arthroscopic loose body removal; Resection of prominence at head neck junction in FAI; Synovial biopsy	-	At average follow up of 16.8 months, Harris hip score improved from average of 57.8 to 82.3	Arthroscopy is more advantageous than open arthrotomy with lesser complications like AVN and provides shorter rehab and early recovery
6	Tiwari et al. [12] 2015	Retrospective comparative cohort study	22 arthroscopies And 44 conservative (ATT)	Mean age: 10.18	14 M, 8 F 30 M,14 F	Tuberculosis of hip	Arthroscopic debridement + synovectomy(10) Only Synovectomy (6) Only Debridement(5) Partial cheilectomy (1)	Bed rest:2 days PWB + ROM afterwards Skin traction in conservative group:2 months f/b ROM exercises	Mean follow up of 45 & 47 months Modified HHS improved significantly in both groups but in arthroscopy patients its magnitude was better (p < 0.05) than ATT patients	Arthroscopy in tuberculosis hip is an emerging tool providing rapid relief and aids in diagnosis confirmation by biopsy. It is less invasiveday care procedure with good functional outcomes
7	Shukla et al. [11] 2014	Prospective Case series	5	Mean: 9.16	NA	Septic arthritis hip	Arthroscopic drainage + debridement + continuous suction + normal saline irrigation through 2 tubes (stopped when colour got clear)	Active ROM after drain removal, NWB for 2 weeks, f/b PWB for another 2 weeks	HHS improved from mean of 13.6 preoperatively to 98 at 3 months	Early arthroscopic decompression and lavage for septic hip joint can eradicate the infection with good functional outcome and lesser antibiotics requirements
8	Gupta et al. [7] 2009	Case report	1	18	M	Accidental bullet injury with 1 retained pellet in left hip joint	Arthroscopic debridement of hypertrophic synovium and pellet retrieval from supero-lateral acetabular wall by disimpacting with fine osteotome	PWB on POD-1 FWB at 1 month	Pain free and normal activity at 13 months	Arthroscopic retrieval of loose bodies, even like a bullet/pellet can be attempted as it provides faster rehab and recovery
9	Pardiwala et al. [9] 2007	Case report	1	13	M	Chondral cyst with unstable cartilaginous cap in stiff Perthes’ disease left hip	Diagnostic arthroscopy + excision of cyst and flap + microfracture of underlying bone	Bed rest and skeletal traction for 2 weeks, f/b NWB ambulation for 6 weeks FWB at 3 months	At 4 years, pain free with full ROM Ossification of focal epiphyseal defect	Stiff hip in Perthes’ disease due to chondral lesions can be improved with arthroscopic techniques

PWB partial weight bearing, FWB full weight bearing, NWB non-weight bearing, f/b followed by, ROM range of motion, POD post-operative day, NA not available, HHS Harris hip score, WOMAC Western Ontario and MacMaster Universities Osteoarthritis index, D/L dislocation, AVN avascular necrosis, MRI magnetic resonance imaging, FAI Femoro acetabular impingement, ATT anti-tubercular treatment

Results of the survey were analysed using Microsoft Excel 2019 and Statistical Package for the Social Sciences 2019 (SPSS v26).

Results

Survey

A total of 42 renowned orthopaedic surgeons from India participated in the survey. Thirty-eight of these surgeons perform hip arthroscopies in their practice. However, only one surgeon (2.6%) had a yearly frequency of more than 50 hip arthroscopies, while the overwhelming majority of 32 surgeons (84.2%) had limited practice, with less than ten surgeries per year. The remaining five surgeons (13.1%) performed cases between 10 and 30 per year. The main indication for hip arthroscopy for 28/38 surgeons was therapeutic (73.7%); the remaining ten surgeons performed their surgeries for diagnostic indications like visualising chondral defects or for taking biopsies. When asked about their opinions for a smaller number of hip arthroscopies being done in the country, 28 of the 42 respondents (66.7%) believed the reason to be a limited number of suitable indications with intraarticular loose bodies, FAI and biopsies to name a few. Technical challenges and long learning curves associated with the technique was held responsible by 17 surgeons (40.5%). Refusal by the patients themselves is another important reason in India with 12 of the respondents affirming it. The probable causes could be the cost factors, reluctancy towards newer methods and psychological factors and fears. To ascertain the changing trends of hip arthroscopy in India, the last question asked was concerning the change in patterns of the practice of the respondents in the past 5 years. 24 of the 38 surgeons (63.2%) who performed hip arthroscopies suggested that there was no change, while 14 of them responded in the affirmative. This signifies that at some centres, the overall indications, frequencies of hip arthroscopy in India is evolving over the past 5 years.

Literature

Krishan et al. reported a case of arthroscopic removal of an intraarticular fracture fragment, resulting due to fracture-dislocation of the right hip in a 21-year-old man [5]. They used the anterolateral portal for visualisation and anterior portal as the working portal for extraction and the patient was completely pain-free with regular hip movements and healed portals.

Similar methods were used by Bagaria et al. in a case to remove two intraarticular fragments following hip dislocation [6]. In both these studies, the authors concluded that such minimally invasive approach rather than an open surgery like safe surgical dislocation of the hip to retrieve loose bodies from the joint could provide faster rehabilitation and a quicker road to recovery.

Gupta et al. used hip arthroscopy aided by intra-operative fluoroscopy and fine osteotomes from revision total hip replacement set to extract an impacted bullet pellet in the acetabular wall of a 18-year-old male with persistent pain, difficulty in weight-bearing and locking episodes [7]. They concluded that despite not having appropriate instrumentations, if the surgeon is experienced enough, arthroscopic arthrotomy should be preferred over open surgeries for removal of intraarticular foreign bodies, to reduce morbidity and complications.

Arthroscopic excision and bone grafting aided by image intensifier have been successfully described for treatment of osteoid osteoma of the inferomedial portion of the anterior femoral neck [8]. Arthroscopic cyst excision has also been utilised in stiff hip due to Perthes’ sequelae presenting with a chondral cyst and an unstable cartilaginous flap [9]. These cases highlight that in hip stiffness and benign lesions of the hip, arthroscopic decompressions/excision could provide adequate symptomatic relief.

FAI is another indication for which hip arthroscopy is increasingly done worldwide. A 2018 study in India recognised this and operated 9/15 cases of FAI due to partial collapse of the femoral head at lateral periphery forming cam-type lesions; the other six cases were treated by open surgical dislocation [10]. The results showed improved functional scores and pain relief in all the patients regardless of the techniques used. Since the outcomes of open and arthroscopic techniques were both excellent and comparable, the authors concluded that arthroscopic method is more suitable as it avoids prolonged non-weight bearing and provides faster recovery.

Sood et al. performed five hip arthroscopies for various indications; loose body removal in three, FAI in 1 and synovial biopsy in one case, which was later diagnosed as tuberculosis [3]. They concluded that arthroscopy is apt for these indications with lesser complications and shorter rehabilitation providing faster recovery than open cases.

The septic hip is another indication for hip arthroscopy, wherein it is used for arthrotomy, debridement and lavage [11]. This technique could prove very useful in decompressing septic build up in the joints and eradicate the infection with excellent outcomes and lesser duration of antibiotics.

Tuberculosis (TB) hip is an indication which may not be that prevalent in the developed parts of the world, but similar to the technique used for septic hip, in TB as well, arthroscopy can be used for both diagnostic and therapeutic indications. Tiwari et al. did a retrospective study wherein they compared 22 cases of TB hip for which arthroscopic debridement, synovectomy or both were done, with 44 cases managed medically [12]. 1 case of arthroscopy had partial cheilectomy done. After a mean follow up of almost 4 years, in both the groups the modified HHS improved significantly in all the cases, with the arthroscopic group showing a greater magnitude of improvement. Hip arthroscopy in such cases provides rapid relief and can aid in confirmation of tuberculosis by getting synovial samples for histopathology.

Overall, the literature is very scarce on hip arthroscopy in India. However, whenever it has been attempted for specific indications, outcomes have been optimal with rapid recoveries and without complications. This shows that the technique is a potent tool, and in skilful hands, the patients could benefit tremendously well.

Discussion

Hip arthroscopy, despite being on an upsurge all over the world, remains in its nascent stages in India. Exceptionally few centres are equipped with latest instrumentation, machinery and required expertise to perform these surgeries with minimal complications, which occur more in inexperienced hands; iatrogenic nerve damage, instrumental breakage, cartilage damage etc. [3, 13].

The present survey highlights this fact as although 38 out of 42 respondents had some experience with the surgery, 32 of them performed less than ten surgeries every year. To assess the chronology of hip arthroscopy in India, the PubMed database was searched for a periodic number of hits over the past 15 years (Fig. 1). Only 42 hits were obtained with keywords “hip arthroscopy” and/or India, out of which 27 hits belonged to the last five years and 37 hits to the last decade. There was no hit for a search before the year 2005. In comparison, the number of hits for “hip arthroscopy” was 1942 out of which 1311 belonged to last 5 years and 1831 to the last decade. There were only nine hits before 2005. Therefore, although the overall chronology in India seems similar to the world scenario, the extent in terms of numbers is very less. There were only nine relevant publications out of which only one was a comparative study; remaining were either case reports or small case series.

Fig. 1.

Comparison of evolution of hip Arthroscopy in India and the world (in terms of PubMed hits)

The respondents to the survey believed that this slow progress in India is mainly because of limited indications for this surgery, and lack of well-equipped centres and associated technical difficulties. In the studies reviewed, the main indications were the removal of loose bodies like fracture fragments, debridement and lavage for infectious nidus and abscesses, synovial biopsies and FAI. FAI is a common indication for arthroscopy in the world, with results similar to open techniques. [2] However, for Indians, the susceptibility for developing FAI in terms of hip anthropometry measurements is far below than the western population, and many cases are not seen in everyday practice [14]. Additionally, proper understanding with detailed evaluation of these cases are prerequisites for appropriate diagnosis and patients’ selection for arthroscopies [4]. This may be lacking at our centres because the technique is relatively new, and not many surgeons are exposed to it; therefore, open surgeries continue to be preferred. Only 1 case series from India accurately assessed outcomes of arthroscopic surgeries for cases of FAI, that was secondary to AVN, which in turn is a common hip pathology in India. [10] Sood et al. also published only 1 case of FAI in their series of five hip arthroscopies [3]. Acceptance of a relatively new method by the patients themselves is sometimes tricky, and adequate detailed counselling is crucial. Regardless of this, adverse consents could be another significant reason for a low number of hip arthroscopies in India, as believed by 12% of our respondents.

The practice of hip arthroscopy has not changed much in the past five years at the majority of Indian centres with only 14 of our respondents affirming the change. The paucity of literature from India supports this finding. Hip arthroscopy offers multiple advantages over open surgeries; lesser period of immobilisation, faster rehabilitation, possibilities of daycare surgeries, earlier recovery, lower complications and comparable outcomes [4, 15]. In India, it could also prove to be a very beneficial tool for the management of tuberculosis hip, which is a prevalent pathology in comparison to the west. Tiwari et al. showed its efficiency in such cases with the added advantage of confirming the diagnosis [12].

Therefore, there is a need to focus on continuous medical education and training of hip arthroscopic techniques, by collaborations with leading experts from all over the world. With adequate preparation and better facilities, India could witness growth in hip arthroscopies at a better pace to get at par with the rest of the world. Addendum of this tool to the armamentarium of Indian orthopaedic surgeons could help in better management of sports injuries and degenerative hips.

Conclusion

In India, the progress of hip arthroscopy is tepid with a scarcity of literature. However, with better training and more equipped centres, the Indian orthopaedic surgeons could imbibe the technique in their practice, which could aid in providing faster recovery with optimal functional outcomes in suitable patients.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.