JW Thomas Byrd

There has been much variation, as well as precision, in the description in the literature of portal placements for hip arthroscopy. The attention given to these detailed descriptions is important for two reasons (1) accessibility of the joint and (2) avoidance of the major surrounding neurovascular structures. The tip of the greater trochanter is the common landmark used in describing a variety of lateral por-tals.1-3 Equal variation can be found in the description of an anterior portal (Figure...

Physical Examination

The information obtained in the history is just a screening tool. It helps direct the examination, but it The most important aspect of inspection is stance and gait. The patient's posture is observed in both the standing and seated positions. Any splinting or protective maneuvers used to alleviate stresses on the hip joint are noted. While standing, a slightly flexed position of the involved hip and concomitantly the ipsi-lateral knee is common (Figure 3.2). In the seated position, slouching or...

Mzv

FIGURE 14.9. (A) Small labral tear (T) associated with posterior ganglion. A small tear at the margin of the articular cartilage and the labrum was seen arthroscopically in a position associated with the posterior ganglion. The tear is seen as a triangular flap in the 2 o'clock position. (B) Small labral tear. The tear was probed and found to be unstable, as shown herein. Both views are from the antero-lateral portal. H, head. FIGURE 14.10. Labral tear (T) debridement. The flap was debrided...

Disruption Of The Ligamentum Teres

The exact function of the ligamentum teres remains an enigma. Although its accompanying artery contributes to the vascularity of the epiphysis in childhood, its importance in the adult is less clear. The vessel remains patent in a variable percentage of adults and likely does little to contribute to the vascularity of the femoral head.38,39 The ligament contributes little to the stability of the joint, but it has been proposed that it has a windshield wiper effect that may facilitate...

Pxv

Passes under the lateral lip of the acetabulum entering the hip joint. (C) Distension of the joint disrupts the vacuum and facilitates adequate distraction. (D) The cannula obturator assembly is being passed over the Nitanol wire that had been placed through the spinal needle. mately 40 ml fluid and the intracapsular position of the needle confirmed by backflow of fluid. Distension of the joint enhances distraction (Figure 10.16C). It is important to note that the needle may inadvertently...

Conclusions

A comprehensive inspection of the hip joint requires the combination of hip arthroscopy with traction and hip arthroscopy without traction. Although traction is necessary for access to the central compartment for evaluation of the direct weight-bearing cartilage, ac-etabular fossa, and ligamentum teres, the periphery of the joint can best be seen without traction. Acknowledgments. The author thanks Dieter Kohn, MD, for his consistent support and advice for development of the technique Guenther...

Other Differential Diagnoses Of Extraarticular Hip Pain

Several other diagnoses must be considered in patients with groin pain, including other musculoskeletal disorders, as well as more severe visceral problems. Problems that we have encountered in patients with inguinal pain include inflammatory bowel disease, prostatitis, aseptic necrosis of the hips, herpes, pelvic inflammatory disease, and rectal or testicular can-cer.101 These other possible diagnoses emphasize the importance of a detailed, careful history and physical examination....

Neuromotor Control

Proprioceptive deficits routinely occur in conjunction with articular injuries. The acetabular labrum contains free nerve endings and sensory organs. It is believed that these free nerve endings contribute in no-ciceptive and proprioceptive mechanisms.16 The acetabular labrum also improves the stability of the hip joint by maintaining a negative intraarticular pres-sure.17 With injury to the labrum, this negative pressure is lost and stability of the hip is adversely affected, inhibiting normal...

Protocol For Arthroscopic Hip Debridement

All patients are different and should be treated according to their tolerance in therapy. It is important that these patients listen to their pain symptoms and adjust their program as needed. Immediate Post-Op Work on ROM within tolerance Active assisted ROM allowed to all planes without pain Educate patient on importance of avoiding pain with stretch Crutches are used for comfort - weight bearing as tolerated. Patient can wean off crutches as tolerated over first two weeks if not instructed by...

Compression Injury To The Perineum

Hip arthroscopy is unique in that the forces needed to distract the joint for arthroscopy necessitate counter-traction provided by a perineal post. This requirement introduces the potential for compression injury to the perineum and especially neuropraxia of the pudendal nerve. Soft tissue pressure necrosis of the perineum has been reported by Eriksson et al.8 This was an early experience and should be avoidable by proper padding and careful positioning. Nonetheless, it does emphasize the...

Xgo

A 16-year-old boy with pain and locking of the left hip from playing football. (A) Anteroposterior radiograph demonstrates congenital deformity of the joint with a 10-degree CE angle. (B) Computed tomography (CT) scan demonstrates evidence of a bone fragment within the femoral head (arrow). (C) Arthroscopic view from the posterolateral portal demonstrates an unstable full-thickness articular flap (asterisk). (D) Now viewing from the anterolateral portal, the fragment (asterisk) is...

Classification Of Acetabular Labral Tears

Pathologic alterations of the acetabular labrum are a documented cause of discomfort, clicking, and catching of the hip.11,15-17 Arthroscopy is an excellent method of diagnosis and treatment of this condition. Arthrography, computed tomographic (CT) arthrogra-phy, plain CT scanning, and magnetic resonance imaging (MRI) cannot rival the accuracy of direct intraarticular inspection.15,18-21 Only recently, Petersilge reported excellent results with MR arthrography.22 although this was not compared...

Joc

The piriformis muscle and the anatomic variations of its relationship to the sciatic nerve. (A) Ninety percent, the undivided sciatic nerve passes inferior to the piriformis muscle. (B) Seven percent, the divided sciatic nerve passes through and inferior the piriformis muscle. (C) Two percent, the divided sciatic nerve passes superior and inferior to the piriformis muscle. (Adapted with permission from Beaton and Anson.47) FIGURE 5.6. The piriformis muscle and the anatomic...

Case

A 21-year-old male collegiate baseball player developed acute onset of right hip pain doing squats while working out with weights. His symptoms persisted for 3 months despite restricting his activities and participation in a trial of physical therapy and nonsteroidal antiinflammatory medications. Radiographs were unremarkable, but an MRI revealed evidence of labral pathology (Figure 2.8A). With the history of injury, persistent mechanical symptoms refractory to conservative measures, and...

Developmental Dysplasia

Developmental dysplasia of the hip (DDH) is not a cause of hip pain. It is simply a morphologic condition that makes the hip vulnerable to an intraarticu-lar lesion that may then become symptomatic. The three most likely structures to be involved are the ac-etabular labrum, articular surface, and ligamentum teres. Accompanying a shallow bony acetabulum, the labrum may be enlarged, assuming a more important role as a weight-bearing surface as well as added responsibility for joint stability....

Arthroscopic Compartments Of The Hip Joint

Placement of portals and maneuverability of the arthroscope and instruments within the hip joint are more difficult than in other joints. This difficulty is related to various anatomic features a thick soft tissue mantle, close proximity of two major neurovas-cular bundles, a strong articular capsule, a relatively small intraarticular volume, permanent contact of the articular surfaces, and the sealing of the deep, central part of the joint by the acetabular labrum. Thus, if no traction is...

Capsule

The fibrous capsule is a thick and strong structure that encircles the proximal femur and the acetabular cup. Proximally, the capsular insertion is located 5 to 6 mm above the acetabular margin, leaving a little space beyond the acetabular labrum called the perilabral sul-cus. Inspection of this area is possible with a 70-degree arthroscope, pulling back the cannula to the edge of the joint. The point of insertion of the fibrous capsule to the femur varies. Anteriorly it is attached to the...

Direct Trauma To Neurovascular Structures

Injury to the sciatic nerve or femoral nerve or vessels is a disastrous complication of hip arthroscopy. Evidence from anatomic studies suggests that the structures are at a safe distance when proper technique in portal placement is observed.7 The reported clinical experiences also suggest that this is a relatively safe technique. However, one femoral nerve palsy has been reported.2 This author is also aware of one anecdotal case of laceration of the femoral nerve associated with arthroscopy of...

Michael Dienst

Anterior hip joint capsule in extension (A) and flexion (B). Flexion leads to a relaxation of the strong anterior il-iofemoral ligament (arrow) and to a significant increase of the in-traarticular joint space of the anterior and medial head and neck area (cadaveric hip joint). table with an additional traction frame or robotic limb-positioning device. The bony landmarks and the femoral neurovascular bundle are palpated and the longitudinal axis of the femoral neck is determined...

Traction

Leg Traction

For optimal viewing and safe surgery, at least 1.2 cm of distraction is required of the femoroacetabular joint. Two commercial distractors for the lateral approach are available from OSI and Innomed (Savannah, GA), designed by Dr. Glick and Dr. Joseph McCarthy, respectively. The OSI distractor has many advantages in that hip motion is adjustable during surgery and it has a continuous readout tensiometer. FIGURE 9.5. (A) Traditional fracture tables with the Chick table traction using a Buck's...

Neurovascular Structures

Lateral Femoral Circumflex Artery

The femoral neurovascular structures (nerve, artery, and vein) exit the pelvis under the inguinal ligament halfway between the anterior superior iliac spine and the pubic tubercle (Figure 6.6). They are relatively anterior to the hip joint, with the nerve being the most lateral. These structures lie on the anterior surface of the iliopsoas muscle, and thus the muscle separates the femoral neurovascular structures from the hip. The lateral femoral cutaneous nerve originates from the lumbar...

Posterolateral Portal

Posterolateral Branch

The posterolateral portal is positioned similar to the anterolateral portal except at the posterior margin of the greater trochanter (see Figure 7.2). Again, it is a relatively straight shot under fluoroscopic control, but it is facilitated by direct visualization through the arthroscope from the anterolateral portal. Maintaining direct visualization is of greater importance because the posterolateral portal gets closer to major structures, specifically the sciatic nerve. The posterolateral...

T Kevin Robinson And Karen M Griffin

With the patient positioned prone' the hip is maximally extended 30 degrees. FIGURE 17.8. With the patient positioned prone' the hip is maximally extended 30 degrees. rily by the symptoms. For this patient, a primarily home-based rehabilitation program may suffice. It relies on patient compliance, however. After initial exercise instruction about frequency and duration, the program can often be accomplished with the simplest FIGURE 17.9. (A' B) Abduction and adduction are measured....

Assessment

Sensation The Right Hip

The physician's history, examination, and diagnostic studies determine the patient's diagnosis and prognosis of surgical or nonsurgical treatment. The patient's history and the clinical evaluation assist in determining how the symptoms will respond to treatment. A course of presurgical treatment (prehab) may be indicated in some hip cases to regain neuromotor control and decrease stresses to the joint. An appropriate exercise program can, at times, help restore normal mechanics and minimize...

Subjective Data

The nursing interview is a communication process that focuses on the patient's developmental, psychologic, sociocultural, and spiritual responses that can be treated and supported with nursing and collaborative interventions. It is important for the nurse to be cognizant of the patient's comfort and anxiety levels, age, and current health status. These factors can influence the patient's ability to fully participate in the interview. The interview process has three phases. During the...

Diagnostic Round And Anatomy Of The Peripheral Hip Joint Cavity

Similar to the knee joint, the key to an accurate and complete diagnosis of lesions within the hip joint is a systematic approach to viewing. A methodical sequence of examination should be developed, progressing from one part of the joint cavity to another and systematically carrying out this sequence in every hip. For arthroscopic examination, the peripheral compartment of the hip can be divided routinely into the FIGURE 11.6. Introduction of the arthroscope to the hip joint periphery...

Visual Sweep And Anatomy

The acetabulum and its structures are viewed first and visually divided into thirds. Initially, the femoral head cannot be entirely viewed with the hip distracted however, the hidden portions will be observed when looking in the pericapsular area later in the procedure (Figures 9.22 through 9.26). With the 30-degree scope, start observing the ac- FIGURE 9.24. Arthroscopic view of a normal posterior cleft at the labral cartilaginous junction. FIGURE 9.24. Arthroscopic view of a normal posterior...

Imaging Features Of Hip Pathology

Osteonecrosis of the femoral head is an important cause of hip pain that may be idiopathic or seen in association with a number of underlying risk factors such as trauma, sickle cell disease, steroid use, alcohol abuse, radiation, and pancreatitis. MRI has assumed the leading role among other imaging modalities in the evaluation of osteonecrosis.1,3 With its ability to demonstrate fatty marrow and tissue water, MRI readily depicts changes in marrow content and marrow-based pathology (Figure...

General Technique

The technique described here has proved to be effective and reproducible.4-6 Three standard portals are used for hip arthroscopy anterior, anterolateral, and posterolateral (Figures 10.10, 10.11).7 The site of the anterior portal coincides with the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line across the superior margin of the greater trochanter. The direction of this portal courses approximately 45 degrees cephalad and 30 degrees...

Dictums On Hip Arthroscopy

Femoral Nailing Arm Position

Regardless of the position or technique that is chosen for performing this procedure, several dictums should be thoroughly understood. First, a successful outcome is most clearly dependent on proper patient selection. A technically well-executed procedure fails if performed for the wrong reason. This may include failure of the procedure to meet the patient's expectations. Second, the patient must be properly positioned for the case to go well. Poor positioning ensures a difficult procedure....

Osteitis Pubis Description

Osteitis pubis is a painful, inflammatory, noninfectious condition of the bone, periosteum, cartilage, and ligamentous structures around the pubic symph-ysis.1-5 It is considered the most common inflammatory condition of the pubic symphysis.5 It is not a rare condition, as proven by the large number of patient series published since its first description in 1923.6 The first description within the English literature was by Beer in 1924.7 Most of the early literature on this subject emerged from...

Info

Surgery Osteitis Pubis

Basic features Cultures Treatment Causes Positive Staphylococcus aureus most common Antibiotics, rest, debridement surgery Fever, tenderness, waddling gait, painful adduction and abduction X-ray, MRI, bone scan, CT-guided biopsy Inflammatory microtrauma instability No organism Rest, NSAIDS, steroid injections, surgery Overuse, microtrauma, pubic symphysis instability Tenderness, waddling gait, painful adduction and abduction ultimately challenging the physician, patient, trainers, and coaching...

Capsular and joint architecture

Femoral Attachment The Etabulum

The ilium, ischium, and pubic bones unite at the acetabulum, forming the innominate bone. During childhood, these bones are separated within the ac-etabulum by the triradiate cartilage, which fuses at skeletal maturity. The acetabulum has an inclined abduction angle of approximately 35 degrees from the horizontal and a forward flexed position of approximately 20 degrees Figure 6.8A,C . The articular surface of the acetabulum has a horseshoe or lunate shape Figure 6.9 . The central inferior...

Obturator Nerve Entrapment Description

Femoral Nerve Thickening

Chronic groin pain is a difficult problem to evaluate. The differential diagnosis for groin symptoms is broad and may include gynecologic, urologic, and colorectal diseases. Moreover, neuropathies of the cutaneous nerves around the hip have been highlighted as etio-logic factors for groin pain.35,37 Nonetheless, the information on this topic is sparse, partly because these injuries are rare. The literature on groin pain of neural origin has mainly focused on the genitofemoral, lateral femoral...

Vascular Supply To The Femoral Head

Ligamentum Teres Hip

Intraarticular isolation of the femoral head and neck makes it highly dependent on its tenuous vascular supply. Its susceptibility to circulatory compromise is an ongoing source of concern to physicians who treat hip pathology. Ischemic insult followed by avascular necrosis AVN of the femoral head, similar to other forms of osteonecrosis, has been clearly linked to certain disease states and types of exposure although it is less clearly associated with others and often purely idiopathic.10 AVN...

Piriformis Syndrome Description

The piriformis syndrome is characterized by nondisco-genic, extrapelvic, sciatic nerve compression in the area of the greater sciatic notch. The symptoms include pain and dysesthesias isolated to the buttock region, radiating to the hip or posterior thigh, and or occurring distally as radicular pain.42 The symptoms of piriformis syndrome are thought to be caused by entrapment of one or more divisions of the sciatic nerve by the piriformis muscle.43,44 The original description of this condition...

Athletic Pubalgia

Pubalgia Exercises

In this section we list others of the more commonly seen entities causing hip pain in athletes. More detail is provided on the entity called athletic pubalgia, a chronic inguinal or pubic area pain that occurs in highperformance athletes. Athletic pubalgia is the most common fixable problem in this group of athletes. Please refer to some of our other recent articles for other details about these syndromes. The present section, to a large degree, represents an update on these articles,89-92 in...

Lateral Uncovering Of The Femoral Head

Hip Dysplasia Symptoms Women

AP radiograph of the right hip of a 50-year-old woman, demonstrating classic characteristics of acetabular dysplasia. FIGURE 3.28. AP radiograph of the right hip of a 50-year-old woman, demonstrating classic characteristics of acetabular dysplasia. FIGURE 3.29. AP radiograph of the right hip of a 24-year-old woman with mechanical catching, suggestive of labral pathology. Signs of mild dysplasia include a slight valgus position of the femoral neck and slight lateral uncovering of...

Adhesive Capsulitis

Adhesive capsulitis of the hip has previously been described in the literature as case reports.75-79 The following profile of this condition is presented based on our experience and previously published information. Adhesive capsulitis of the hip presents and behaves similar to adhesive capsulitis in the shoulder. There may or may not be associated intraarticular pathology. Some respond to conservative treatment including oral antiinflammatory medication and physical therapy emphasizing range...