Iliopsoas Release

The spinal needle is placed directly on the lesser trochanter under fluoroscopy. With the arthroscope introduced, a second portal is then established. Adhesions or

Fig. 7. The surgical area remains covered in sterile drapes while the traction is then released and the hip flexed 45°. (Inset) Illustrates position of the hip without the overlying drape. (Courtesy of J.W. Thomas Byrd, MD.)

fibrinous debris within the bursa may need to be debrided to achieve clear visualization (Fig. 11). Staying next to the bone avoids straying into the medial soft tissues. As the iliopsoas is identified, the tendinous portion can be released (Fig. 12).

TREATMENT

Loose bodies represent the clearest indication for hip arthroscopy (Fig. 13) [11-13]. Most problematic loose bodies reside in the intraarticular compartment

Fig. 8. From the anterolateral entry site, the arthroscope cannula is redirected over the guide wire through the anterior capsule, onto the neck of the femur. (From Smith & Nephew Endoscopy, Ando-ver, MA, reprinted with permission. Copyright Smith & Nephew, Inc. 2003-2004; with permission.)
Fig. 9. With the arthroscope in place, prepositioning is performed with a spinal needle for placement of an ancillary portal distally. (From Smith & Nephew Endoscopy, Andover, MA. Copyright Smith & Nephew, Inc. 2003-2004; with permission.)

and are addressed with standard arthroscopic methods. However, many may remain hidden in the peripheral compartment and later become troublesome. Thus, arthroscopy to address symptomatic fragments must include both the intraarticular and peripheral joint [8]. Many can be debrided with shavers or flushed through large diameter cannulas. Large ones can sometimes be morsel-ized and removed piecemeal. However, often fragments may be too large to be removed through a cannula system and must be removed free-hand with sturdy graspers. Once a portal tract has been developed, these larger graspers can be passed along the remaining tract into the joint in a free-hand fashion. Make sure to enlarge the capsular incision with an arthroscopic knife and the skin incision so that, as the fragment is retrieved, it will not be lost in the tissues either at the capsule or subcutaneous level.

Tearing of the acetabular labrum represents the most common pathology encountered among athletes undergoing hip arthroscopy [1]. MRI and magnetic resonance arthrogram (MRA) are improving at detecting these lesions. However, care is necessary in interpreting these studies. Labrum degeneration occurs naturally as part of the aging process [14,15]. Studies have shown evidence of labral pathology even among asymptomatic volunteers, and some tears among athletes have been noted to become clinically asymptomatic without surgery [16-18].

Traumatic labral tears may respond remarkably well to arthroscopic debridement (Fig. 14) [19-23]. However, at arthroscopy be especially cognizant of any underlying degeneration that may have predisposed to the acute tear. There will often be accompanying articular damage, and the extent of this may be a significant determinant on the eventual response to debridement (Fig. 15). Femoroacetabular impingement has been recognized as a distinct entity that can result in labral tearing, articular breakdown, and osteoarthritis [3]. Pincer impingement occurs from an overhanging lip of bone from the anterior ace-

Femoral J/ neck

S /Medial / / synovial orbicularis

Fig. 10. (A) Peripheral compartment viewing superiorly demonstrates the anterior portion of the joint including the articular surface of the femoral head (FH), anterior labrum (AL), and the capsular reflection (CR). (B) Peripheral compartment viewing medially demonstrates the femoral neck (FN), medial synovial fold (MSF), and zona orbicularis (ZO). (Line art from Smith & Nephew Endoscopy, Andover, MA. Copyright Smith & Nephew, Inc. 2003-2004; with permission. Arthroscopic images courtesy of J.W. Thomas Byrd, MD.)

tabulum, and cam impingement occurs from a bony prominence of the anterior femoral head/neck junction. Traditionally, these have been resected with open surgical dislocation. These lesions can now be addressed arthroscopically in a much less invasive fashion [24,25]. This requires competent arthroscopic skills for the technically challenging aspects of this procedure (Fig. 16).

Femoral J/ neck

S /Medial / / synovial orbicularis

Fig. 10. (A) Peripheral compartment viewing superiorly demonstrates the anterior portion of the joint including the articular surface of the femoral head (FH), anterior labrum (AL), and the capsular reflection (CR). (B) Peripheral compartment viewing medially demonstrates the femoral neck (FN), medial synovial fold (MSF), and zona orbicularis (ZO). (Line art from Smith & Nephew Endoscopy, Andover, MA. Copyright Smith & Nephew, Inc. 2003-2004; with permission. Arthroscopic images courtesy of J.W. Thomas Byrd, MD.)

Fig. 11. The arthroscope and shaver are positioned within the iliopsoas bursa directly over the lesser trochanter, identifying the fibers of the iliopsoas tendon (IT) at its insertion site. (Courtesy of J.W. Thomas Byrd, MD.)

Labral tears can be adequately accessed through the three standard portals. Similar to a meniscus in the knee, the task is to remove unstable and diseased labrum creating a stable transition to retained healthy tissue. The most difficult aspect is creating the stable transition zone. Thermal devices have been quite useful at ablating unstable tissue adjacent to the healthy portion of the labrum. Caution is necessary because of the concerns regarding depth of heat penetration, but with judicious use, these devices have been exceptionally useful for precise labral debridement despite the constraints created by the architecture of the joint.

The natural evolution in arthroscopic management of labral pathology is from debridement to repair. Current methods of acetabular labral repair are in their infancy. A few have been attempted with mixed results. Reliable techniques exist

Fig. 12. An electrocautery device is used to transect the tendinous portion of the iliopsoas (black asterisks) revealing the underlying muscular portion (white asterisk) which is preserved. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 13. A 54-year-old Hall of Fame baseball player with a several year history of insidious onset, progressively worsening mechanical right hip pain. (A) An AP radiograph shows evidence of synovial chondromatosis as well as secondary degenerative changes. (B) Arthroscopic view of the intraarticular compartment demonstrates numerous lesions obliterating the acetabular fossa. (C) These are morselized and excised. (D) The peripheral compartment reveals more free-floating loose bodies. (E) Whole fragments removed from the peripheral compartment. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 13. A 54-year-old Hall of Fame baseball player with a several year history of insidious onset, progressively worsening mechanical right hip pain. (A) An AP radiograph shows evidence of synovial chondromatosis as well as secondary degenerative changes. (B) Arthroscopic view of the intraarticular compartment demonstrates numerous lesions obliterating the acetabular fossa. (C) These are morselized and excised. (D) The peripheral compartment reveals more free-floating loose bodies. (E) Whole fragments removed from the peripheral compartment. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 14. A 25-year-old top-ranked professional tennis player sustained a twisting injury to his right hip. (A) Coronal MRI demonstrates evidence of labral pathology (arrow). (B) Arthroscopy reveals extensive tearing of the anterior labrum (asterisk) as well as an adjoining area of grade III articular fragmentation (arrows). (C) The labral tear has been resected to a stable rim (arrows) and chondroplasty of the grade III articular damage (asterisk) is being performed. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 14. A 25-year-old top-ranked professional tennis player sustained a twisting injury to his right hip. (A) Coronal MRI demonstrates evidence of labral pathology (arrow). (B) Arthroscopy reveals extensive tearing of the anterior labrum (asterisk) as well as an adjoining area of grade III articular fragmentation (arrows). (C) The labral tear has been resected to a stable rim (arrows) and chondroplasty of the grade III articular damage (asterisk) is being performed. (Courtesy of J.W. Thomas Byrd, MD.)

for repair, but much remains to be elucidated regarding our understanding of labral morphology and pathophysiology. There is considerable variation in the normal appearance of the labrum including a labral cleft at the articular labral junction, which can be quite large [19]. It is important to distinguish this from a traumatic detachment, which can also occur. Additionally, many labral tears, even in the presence of a significant history of injury, seem to occur due to some underlying predisposition or degeneration. Under these circumstances, even with reliable techniques, repair of a degenerated or morphologically vulnerable labrum would unlikely be successful.

A propensity for acute articular fracture has been identified in athletes due to lateral impact injury (Fig. 17 A-C) [26]. Subchondral edema of the femoral head may provide indirect evidence of this injury. Mechanical symptoms can be significantly improved with excision of the fragment. Articular delamination

Fig. 15. A 23-year-old elite professional tennis player sustained an injury to his right hip. (A) Coronal MRI demonstrates evidence of labral pathology (arrow). (B) Arthroscopy reveals the labral tear (arrows), but also an area of adjoining grade IV articular loss (asterisk). (C) Microfracture of the exposed subchondral bone is performed. (D) Occluding the inflow of fluid confirms vascular access through the areas of perforation. The athlete was maintained on a protected weight-bearing status emphasizing range of motion for 10 weeks with return to competition at three and a half months. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 15. A 23-year-old elite professional tennis player sustained an injury to his right hip. (A) Coronal MRI demonstrates evidence of labral pathology (arrow). (B) Arthroscopy reveals the labral tear (arrows), but also an area of adjoining grade IV articular loss (asterisk). (C) Microfracture of the exposed subchondral bone is performed. (D) Occluding the inflow of fluid confirms vascular access through the areas of perforation. The athlete was maintained on a protected weight-bearing status emphasizing range of motion for 10 weeks with return to competition at three and a half months. (Courtesy of J.W. Thomas Byrd, MD.)

of the anterior acetabulum is a characteristic arthroscopic finding associated with cam impingement, and should alert the surgeon to this condition (Fig. 18 A-G). Chondroplasty can be effectively performed for lesions of both the acetabular and femoral surfaces. Curved shaver blades are helpful for negotiating the constraints created by the convex surface of the femoral head. Due to limitations of maneuverability, thermal devices have again been especially helpful in ablating unstable fragments. However, cautious and judicious use around articular surface is even more important because of potential injury to surviving chondrocytes.

Microfracture of select grade IV articular lesions has been beneficial (Fig. 15) [23]. As with other joints, it is best indicated for focal lesions with healthy surrounding articular surface. The lesion most amenable to this process is encoun-

Fig. 16. A 16-year-old high school football player develops acute onset of right hip pain doing squats. (A) Sagittal image MR arthrogram demonstrates a macerated anterior labrum (arrows). (B) Viewing from the anterolateral portal, a macerated tear of the anterior labrum is probed along with articular delamination at its junction with the labrum. (C) The damaged anterior labrum has been excised, revealing an overhanging lip of impinging bone from the anterior acetabulum. (D) Excision of the impinging portion of the acetabulum (acetabuloplasty) is performed with a burr. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 16. A 16-year-old high school football player develops acute onset of right hip pain doing squats. (A) Sagittal image MR arthrogram demonstrates a macerated anterior labrum (arrows). (B) Viewing from the anterolateral portal, a macerated tear of the anterior labrum is probed along with articular delamination at its junction with the labrum. (C) The damaged anterior labrum has been excised, revealing an overhanging lip of impinging bone from the anterior acetabulum. (D) Excision of the impinging portion of the acetabulum (acetabuloplasty) is performed with a burr. (Courtesy of J.W. Thomas Byrd, MD.)

tered in the lateral aspect of the acetabulum. This is followed by 8 to 10 weeks of protected weight bearing to neutralize the forces across the hip joint while emphasizing range of motion. Using this protocol, among a cohort of 24 patients, 86% demonstrated a successful outcome at a 2- to 5-year follow-up [27].

Injury to the ligamentum teres is increasingly recognized as a source of hip pain in athletes (Fig. 19) [1]. The disrupted fibers catch within the joint and can be quite symptomatic. This disruption may be the result of trauma, degeneration, or a combination of both [28]. The tear may be partial or complete, with the goal of treatment being to debride the entrapping, disrupted fibers. A recent report by these authors documented excellent success in the arthroscopic management of traumatic lesions of the ligamentum teres. The average improvement

Fig. 17. A 20-year-old male collegiate basketball player with painful catching of the left hip following a fall with lateral impaction of the joint. (A) MRI revealed extensive signal changes in the medial aspect of the femoral head characterizing the subchondral injury associated with his fall. (B) A full-thickness chondral flap lesion (*) associated with the injury is identified. (C) The unstable portion has been excised. (From Byrd JWT. Hip arthroscopy in athletes. In: Byrd JWT, editor. Operative hip arthroscopy. 2nd edition. New York: Springer; 2005. p. 195-203; with permission.)

Fig. 17. A 20-year-old male collegiate basketball player with painful catching of the left hip following a fall with lateral impaction of the joint. (A) MRI revealed extensive signal changes in the medial aspect of the femoral head characterizing the subchondral injury associated with his fall. (B) A full-thickness chondral flap lesion (*) associated with the injury is identified. (C) The unstable portion has been excised. (From Byrd JWT. Hip arthroscopy in athletes. In: Byrd JWT, editor. Operative hip arthroscopy. 2nd edition. New York: Springer; 2005. p. 195-203; with permission.)

was 47 points (100-point modified Harris Hip score system) with 93% showing marked (>20 points) improvement [29].

The acetabular attachment of the ligamentum teres is situated posteriorly at the inferior margin of the acetabular fossa and attaches on the femoral head at the fovea capitis. The disrupted portion of the ligament is avascular, but the fat pad and synovium contained in the superior portion of the fossa can be quite vascular. Debridement is facilitated by a complement of curved shaver blades and a thermal device. The disrupted portion of the ligament is unstable and delivered by suction into the shaver. A thermal device can also ablate tissue while maintaining hemostasis within the vascular pulvinar.

Access to this inferomedial portion of the joint is best accomplished from the anterior portal. External rotation of the hip also helps in delivering the ligament to the shaver brought in anteriorly. The most posterior portion of the fossa and the acetabular attachment of the ligament may be best accessed from the pos-terolateral portal. Indiscriminate debridement of the ligamentum teres should be avoided because of its potential contribution to the vascularity of the femoral head.

Fig. 18. A 20-year-old hockey player with a 4-year history of right hip pain. (A) AP radiograph is unremarkable. (B) Frog lateral radiograph demonstrates a morphological variant with bony buildup at the anterior femoral head/neck junction (arrow) characteristic of cam impingement. (C) A 3D CT scan further defines the extent of the bony lesion (arrows). (D) Viewing from the anterolateral portal, the probe introduced anteriorly displaces an area of articular delamination from the anterolateral acetabulum characteristic of the peel-back phenomenon created by the bony lesion shearing the articular surface during hip flexion. (E) Viewing from the peripheral compartment the bony lesion is identified (*) immediately below the free edge of the acetabular labrum (L). (F) The lesion has been excised, recreating the normal concave relationship of the femoral head/neck junction immediately adjacent to the articular surface (arrows). Posteriorly, resection is limited to the mid portion of the lateral neck to avoid compromising blood supply to the femoral head from the lateral retinacular vessels. (G) Postoperative 3D CTscan illustrates the extent of bony resection. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 18. A 20-year-old hockey player with a 4-year history of right hip pain. (A) AP radiograph is unremarkable. (B) Frog lateral radiograph demonstrates a morphological variant with bony buildup at the anterior femoral head/neck junction (arrow) characteristic of cam impingement. (C) A 3D CT scan further defines the extent of the bony lesion (arrows). (D) Viewing from the anterolateral portal, the probe introduced anteriorly displaces an area of articular delamination from the anterolateral acetabulum characteristic of the peel-back phenomenon created by the bony lesion shearing the articular surface during hip flexion. (E) Viewing from the peripheral compartment the bony lesion is identified (*) immediately below the free edge of the acetabular labrum (L). (F) The lesion has been excised, recreating the normal concave relationship of the femoral head/neck junction immediately adjacent to the articular surface (arrows). Posteriorly, resection is limited to the mid portion of the lateral neck to avoid compromising blood supply to the femoral head from the lateral retinacular vessels. (G) Postoperative 3D CTscan illustrates the extent of bony resection. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 18 (continued).

Primary synovial disease may be encountered in athletes, but more often synovial proliferation occurs in response to other intraarticular pathology. Syno-vitis may be diffuse, encompassing the lining of the joint capsule or be focal, emanating from the pulvinar of the acetabular fossa. Focal lesions within the fossa may be dense and fibrotic or exhibit proliferative villous characteristics. Presumably, because of entrapment within the joint, these lesions can be quite painful, and respond remarkably well to simple debridement. Although a complete synovectomy cannot be performed, a generous subtotal synovectomy can be performed. Enlarging the capsular incisions with an arthroscopic knife improves maneuverability within the intraarticular portion of the joint. For most synovial disease, arthroscopy of the peripheral compartment is necessary to adequately resect the diseased tissue [8,24].

In the presence of clinical evidence of arthritis, there will be arthroscopic evidence of various pathology including free fragments, labral tearing, articular damage, and synovial disease. With a meticulous systematic approach, each component can be addressed arthroscopically. Ultimately, with a well-performed procedure, the response to treatment will be mostly dictated by the extent of pathology, much of which cannot be reversed [30-33].

Fig. 19. A 16-year-old cheerleader has a 2-year history of catching and locking of the left hip following a twisting injury. (A) Arthroscopic view from the anterolateral portal reveals disruption of the ligamentum teres (asterisk). (B) Debridement is begun with a synovial resector introduced from the anterior portal. (C) The acetabular attachment of the ligamentum teres in the posterior aspect of the fossa is addressed from the posterolateral portal. (From Byrd JWT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 2004;20(4): 385-91; with permission.)

Fig. 19. A 16-year-old cheerleader has a 2-year history of catching and locking of the left hip following a twisting injury. (A) Arthroscopic view from the anterolateral portal reveals disruption of the ligamentum teres (asterisk). (B) Debridement is begun with a synovial resector introduced from the anterior portal. (C) The acetabular attachment of the ligamentum teres in the posterior aspect of the fossa is addressed from the posterolateral portal. (From Byrd JWT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 2004;20(4): 385-91; with permission.)

Posttraumatic impinging bone fragments, occasionally encountered in an active athletic population, may respond well to arthroscopic excision [34,35]. Degenerative osteophytes rarely benefit from arthroscopic excision as the symptoms are usually more associated with the extent of joint deterioration and not simply the radiographically evident osteophytes that secondarily form. However, the posttraumatic type may 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 (Fig. 20). 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.

Fig. 20. An 18-year-old high school football player sustained an avulsion fracture of the left anterior inferior iliac spine. (A) A 3D CT scan illustrates the avulsed fragment (arroW) which ossified, creating an impinging painful block to flexion and internal rotation. (B) Viewing from the anterolateral portal, a capsular window is created, exposing the osteophyte (asterisk) anterior to the acetabulum (A). (C) The anterior capsule (C) has been completely released allowing resection of the fragment along the anterior column of the pelvis (P). Postoperatively, the patient regained full range of motion with resolution of his pain. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 20. An 18-year-old high school football player sustained an avulsion fracture of the left anterior inferior iliac spine. (A) A 3D CT scan illustrates the avulsed fragment (arroW) which ossified, creating an impinging painful block to flexion and internal rotation. (B) Viewing from the anterolateral portal, a capsular window is created, exposing the osteophyte (asterisk) anterior to the acetabulum (A). (C) The anterior capsule (C) has been completely released allowing resection of the fragment along the anterior column of the pelvis (P). Postoperatively, the patient regained full range of motion with resolution of his pain. (Courtesy of J.W. Thomas Byrd, MD.)

Hypotensive anesthesia, placing epinephrine in the arthroscopic fluid and elec-trocautery or other thermal device for hemostasis all aid in visualization for effectively performing the excision.

Hip instability can occur, but is much less common than seen in the shoulder. There are several reasons but, most principally, this is due to the inherent stability provided by the constrained ball-and-socket bony architecture of the joint. Also, the labrum is not as critical to stability of the hip as it is in the shoulder as there is no true capsulolabral complex. On the acetabular side, the capsule attaches directly to the bone, separate from the acetabular labrum [14]. An entrapped labrum has been reported as a cause of an irreducible posterior dislocation, and a Bankart type detachment of the posterior labrum has been identified as the cause of recurrent posterior instability [36,37]. These cir cumstances have only rarely been reported, but may be recognized with increasing frequency as our understanding and intervention of hip injuries evolves.

Instability may occur simply due to an incompetent capsule. This is seen in hyperlaxity states and less often encountered in athletics. The most common cause is a collagen vascular disorder such as Ehlers-Danlos syndrome. With normal joint geometry, thermal capsular shrinkage has continued to meet with successful results (Fig. 21). If subluxation or symptomatic instability is due to a

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Fig. 21. A 19-year-old female had undergone two previous arthroscopic procedures on her right hip for reported lesions of the ligamentum teres. Following each procedure, she developed recurrent symptoms of "giving way." (A) Radiographs revealed normal joint geometry. (B) She was noted to have severe diffuse physiologic laxity best characterized by a markedly positive sulcus sign. (C) With objective evidence of laxity and subjective symptoms of instability, an arthroscopic thermal capsulorrhaphy was performed, accessing the redundant anterior capsule from the peripheral compartment. Modulation of the capsular response was controlled by a hip spica brace for 8 weeks postoperatively with a successful outcome. (Courtesy of J.W. Thomas Byrd, MD.)

Fig. 21. A 19-year-old female had undergone two previous arthroscopic procedures on her right hip for reported lesions of the ligamentum teres. Following each procedure, she developed recurrent symptoms of "giving way." (A) Radiographs revealed normal joint geometry. (B) She was noted to have severe diffuse physiologic laxity best characterized by a markedly positive sulcus sign. (C) With objective evidence of laxity and subjective symptoms of instability, an arthroscopic thermal capsulorrhaphy was performed, accessing the redundant anterior capsule from the peripheral compartment. Modulation of the capsular response was controlled by a hip spica brace for 8 weeks postoperatively with a successful outcome. (Courtesy of J.W. Thomas Byrd, MD.)

dysplastic joint, it is likely that bony correction for containment is necessary to achieve stability.

Based on this author's observations, we have found that posterior instability is associated with macrotrauma. This is due to the characteristic mechanisms of injury, including dashboard injuries and axial loading of the flexed hip encountered in collision sports. Atraumatic instability, or instability due to repetitive microtrauma, is anterior and develops when the normally occurring anterior translation of the femoral head exceeds the physiologic threshold and becomes pathologic. Symptoms may be due to primary instability or secondary intra-articular damage, or a combination of both.

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