Arthroscopic Management

Hip arthroscopy can be performed in either the supine approach, as popularized by Byrd [22], or the lateral approach [23], popularized by Glick and McCarthy. This procedure is generally performed on a fracture table to apply gentle hip distraction and allow for fluoroscopy. Philippon [2] has developed a modified supine position (see Fig. 16) in which the table is tilted 10° to keep the femoral neck parallel to the floor, the hip is slightly flexed 10° and internally rotated, and the lower extremity is in neutral abduction. General anesthesia or a spinal anesthetic is given for optimal muscle relaxation. An oversized peroneal padded post is used to minimize pudendal nerve injury, and the feet are also well-padded. Fluoroscopy is used to obtain hip joint distraction of approximately 1 cm, and can help to access the hip joint. Modified arthroscopic flexible radiofrequency (RF) probes [24] and extended shavers have been developed to improve access to the hip joint.

Proper operating room setup and portal placement are crucial for this procedure. Portal placement consists of two main working portals—anterior and anterolateral portals in the paratrochanteric region. Additional portals can made

Fig. 16. Modified supine position for hip arthroscopy.

posteriorly, but care is used to avoid the sciatic nerve. Distal accessory portals can be used for accessing the peripheral compartment to perform femoral neck osteoplasty (see Fig. 5) and to perform trochanteric bursectomy [25,26]. Access of the hip joint can be achieved using long spinal needles and introducing cannulas over a flexible guide wire. This can be done under fluoroscopic guidance, allowing the anterior portal to be placed under direct visualization and avoiding iatrogenic chondral and labral injury [27,28]. Seventy and thirty-degree scopes can be sued interchangeably to maximize visualization. A diagnostic arthroscopic examination of the central compartment can be done systematically to evaluate the labrum from anterior to posterior, to locate possible cartilage lesions on both the acetabular and femoral side and potential ligamentum teres tear and loose bodies in the fovea, and to assess capsular abnormalities (eg, capsular laxity). The labrum and labrocapsular junction are closely evaluated for structural integrity and probed to rule out detachment to the acetabular rim and acetabular rim lesions. This is best achieved by moving the arthroscope to different portals.

Synovitis may be present, particularly in athletes who continue to participate in sports despite hip injury. A partial synovectomy should then be performed first to improve visualization with a motorized shaver. Radio frequency probes can also be useful to minimize bleeding.

In managing labral tears, the surgeon should focus on preserving healthy labral tissue in order to maintain its role as a secondary joint stabilizer and to minimize potential arthrosis [9]. Fraying from labral tears should be debrided to stability with motorized shavers and RF probes. Intrasubstance labral tears can be stabilized by placing an absorbable suture through the defect and retrieving the suture through the capsule. Detachment of labral tears off the acetabular rim is best managed with arthroscopic labral repair using bioabsorb-able suture anchors. The peripheral limited blood supply may give a potential healing response for labral repairs and maximize labral function.

Adjacent cartilage lesions should be debrided and stabilized with the use of shavers and RF probes to minimize further propagation. Grade IV chondral lesions can managed with microfracture techniques to stimulate fibrocartilage.

Partial ligamentum teres tears can cause impingement and be a source of disabling pain. Arthroscopic debridement can be difficult secondary to sphericity of the femoral head. Flexible RF probes and curved shavers can overcome this challenge, and the ligamentum teres can be debrided to a stable remnant.

Global capsular laxity can be addressed with capsular plication at the level of the iliofemoral ligament, as described by Philippon [2]. Localized capsular elongation adjacent to the labral tear can be managed with capsulorraphy created by a focal contracture of the capsule with the use of RF probes [10].

Loose bodies, most commonly found in the fovea region, are essentially removed with arthroscopic graspers and shavers [18].

After addressing labral tears and their associated lesions in the central compartment, the peripheral compartment is evaluated to assess cam-type impingement and abnormalities in the head and neck junction and potential loose bodies.

The peripheral compartment is entered by placing the arthroscope in the anterior portal and releasing traction with the extremity in neutral, and then the hip is flexed at 45° [26]. Bump deformities and osteophytes at the femoral head and neck junction are usually anterolateral and adjacent to the labral tear [9]. Femoral neck osteoplasty can be achieved arthroscopically with the use of motorized burrs and shavers [26].

Painful snapping iliospoas tendonitis can be relieved through partial releases performed arthroscopically. Glick [29] has described an endoscopic extra-articular release of the iliospoas tendon through the use of two portals at the level of the lesser trochanter and fluoroscopic guidance. Philippon [2] has performed intra-articular partial iliopoas releases in athletes at level of the anterior capsule (see Fig. 17). There is a potential concern of hip flexor weakness, but muscle strength is regained with strengthening exercises. The potential risk of fluid extravasation is also increased with this procedure.

Athletes, particularly runners, are at risk of iliotibial band syndrome and trochanteric bursitis [30]. Endoscopic releases can be performed with Z lengthening of the iliotibial band and endoscopic bursectomy. This procedure can be performed by making a distal accessory portal approximately 4 cm from the anterolateral portal [25]. Endoscopic bursectomy can be achieved with an RF ablator [24].

Removal of calcific tendonitis of the gluteus medius tendon has been reported with endoscopic techniques [31]. After removal and debridement of the tendon, abductor strength was markedly improved with the aid of physical therapy.

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