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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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