Contraindications to surgery

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. While we call them absolute contraindications for the sake of simplicity, these pathologies often occur on a spectrum, and borderline patients may be surgical candidates based on their specific presentations. Only in their extreme presentations do these pathologies represent true absolute contraindications.

Absolute Contraindications

1. Advanced Osteoarthritis: Tonnis grade 2/3, particularly with joint space narrowing, 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.

2. Acetabular protrusion: Acetabular protrusion 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 injur

3. Severe structural dysplasia: 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 typically require a periacetabular osteotomy instead.

4. Joint ankylosis: A fused or severely stiff joint cannot be distracted or navigated arthroscopically.

5. Recent acetabular fracture or extensive capsular rupture: Active fracture healing and capsular disruption (which causes joint fluid extravasation) make arthroscopic visualization and safe fluid management challenging. These patients should have arthroscopic procedures delayed or avoided altogether.

Relative Contraindications

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

2. Obesity: Obesity makes accessing the deep hip joint with arthroscopic tools more challenging. It is also associated with poor patient reported outcome measures post-operatively. These patients may benefit from weight loss prior to proceeding with surgery.

3. Poor motivation or unrealistic expectations: These do not preclude surgery, but are consistently associated with worse patient reported outcomes and should be addressed in counseling before proceeding. The rehab after hip arthroscopy can be prolonged and challaning and patients must be motivated and engaged to make a full recovery.