Lwi

(L) adjacent to an area of grade IV articular loss (IV) from the ac-etabulum. (C) The torn edge of the labrum has been debrided, and chondroplasty is being performed. (D) This grade IV lesion demonstrated healthy surrounding articular surface and thus was a candidate for microfracture performed with an arthroscopic awl.

which was further supported by MRI findings (Figure 10.34B). Arthroscopy revealed the characteristic lesion of pigmented villonodular synovitis arising from the acetabular fossa, which was debrided (Figure 10.34C-F). More extensive disease emanated from the synovial lining of the capsule, which was most fully assessed by arthroscopy of the peripheral joint (Figure 10.34G).

Impinging Fragments

Impinging bone fragments may respond well to ar-throscopic excision.20 These fragments are usually the result of trauma. Degenerative osteophytes rarely benefit from arthroscopic excision as the symptoms are usually more associated with the extent of joint deterioration and not simply the radi-

ographically evident osteophytes that secondarily form. Posttraumatic fragments can impinge on the joint causing pain and blocking motion. These fragments are often extracapsular and require a capsu-lotomy, extending the dissection outside the joint for excision of the bone fragments. This necessitates thorough knowledge and careful orientation of the extraarticular anatomy and excellent visualization at all times during the procedure. In general, the dissection should stay directly on the bone fragments and avoid straying into the surrounding soft tissues. Various techniques aid in maintaining optimal visualization. A high-flow pump is especially helpful, maintaining a high flow rate without excessive pressure, which would worsen extravasation. Hypoten-sive anesthesia, placing epinephrine in the arthro-scopic fluid, and electrocautery or other thermal

device for hemostasis all aid in visualization for effectively performing the excision.

Case 6

An 18-year-old high school football player was treated conservatively for an avulsion fracture of the anterior inferior iliac spine of the left hip. The avulsed fragment ossified (Figure 10.35A,B), creating a painful block to flexion and internal rotation. Dissecting through the capsule anteriorly, the ossified fragment was excised arthroscopically (Figure 10.35C-F), eliminating the fragment (Figure 10.35G) and regaining full painfree range of motion.

Instability

Hip instability can occur but is much less common than seen in the shoulder because the hip joint has a more constrained ball-and-socket bony architecture. Recurrent posterior instability is usually associated with trauma.21,22 Atraumatic instability can occur due to an incompetent capsule, usually seen in hyperlax-ity states such as Ehlers-Danlos syndrome. Our observation has been that most atraumatic instability is anteriorly directed. In fact, when viewing the peripheral compartment, the femoral head can often be observed to sublux anteriorly during external rotation, even in asymptomatic individuals. In symptomatic cases, thermal capsulorrhaphy can be performed, addressing the capsule in a fashion similar to that described for the shoulder. Postoperative compliance with a limited range-of-motion protocol is imperative to achieving the optimal capsular response to the thermal treatment.

Case 7

A 17-year-old girl was referred for progressively worsening symptoms of right hip instability. Her medical history was remarkable for Ehlers-Danlos syndrome with severe ligamentous laxity of multiple joints. She

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