Contraindications to surgery

Introduction:

Not every patient with hip pain and abnormal imaging is a surgical candidate. Contraindications to hip arthroscopy fall into two categories: absolute contraindications, where the procedure should not be performed, and relative contraindications, where arthroscopy may still be appropriate but only after careful individualized judgment, often alongside a bony procedure.

Absolute Contraindications

Advanced Osteoarthritis1-2: Tonnis grade 2 or higher, or lateral joint space width of 2 mm or less, predicts poor outcomes and higher conversion rates to total hip arthroplasty. In an arthritic joint, the underlying problem is diffuse cartilage loss, not a focal, correctable lesion, arthroscopy cannot reverse that process.

Acetabular protrusion3: This prevents adequate joint distraction, which is required to create working space for arthroscopic instruments. Without safe distraction, the procedure cannot be performed without risking iatrogenic cartilage or neurovascular injury

Severe structural dysplasia1. A lateral center-edge angle below roughly 20° reflects a bony coverage deficiency, not a soft-tissue problem. Arthroscopy addresses labral and chondral pathology but cannot correct inadequate acetabular coverage; performing it in isolation risks accelerating joint breakdown by removing tissue (labrum, capsule) that the hip depends on for stability. These patients require a periacetabular osteotomy instead.

Joint ankylosis2. A fused or severely stiff joint cannot be distracted or navigated arthroscopically.

Recent acetabular fracture or extensive capsular rupture3. Active fracture healing and capsular disruption (which causes joint fluid extravasation) make arthroscopic visualization and safe fluid management impossible.

Relative Contraindications

Borderline dysplasia1. A lateral center-edge angle of 20–25°, particularly combined with a Tönnis angle above 10°, defines a genuine gray zone. Isolated arthroscopy, isolated periacetabular osteotomy, and combined procedures are all debated in current literature.

Obesity, poor motivation or unrealistic expectations2: These do not preclude surgery outright but are consistently associated with worse patient-reported outcomes and should be addressed in counseling before proceeding.