Stability

Once the patient can move smoothly through the range of motion it is time to further strengthen the affected muscles. Restoring strength to the hip-stabilizing muscles should begin in their shortened range. The gluteus medius functions primarily eccentrically in the initial contact to the midstance phase of gait to stabilize the pelvis on the femur in the frontal plane. Before developing eccentric strength, the gluteus medius must achieve isometric and concentric strength. Isometric...

Anesthetic and Analgesic Medications

Due to the ambulatory nature of this surgical procedure, the choice of anesthetic medications is directed toward those with short-duration profiles of action. Midazolam is frequently used as a premedicant. Propent, an agent consisting of equal volumes of propofol and pentathol, has proven to be a valuable anesthetic induction agent for short-duration cases. The mixture provides excellent cardiovascular stability during induction, and we have noted no delays in recovery or discharge compared to...

Surgical Indications

Despite the anatomic constraints of the hip joint, minimally invasive techniques to access this joint continue to evolve. As noted earlier, these efforts have paralleled an increased understanding of hip anatomy, improvements in joint distraction techniques whether the patient is in the lateral or supine position, as well as instrumentation developed specifically for the hip. In addition, developing clinical and radiographic expertise in diagnosing intra-articular lesions has resulted in an...

Intractable Hip Pain

Arthroscopy is not a substitute for clinical acumen. The myriad etiologies of inguinal and buttock pain include many extra-articular conditions. (See Chapters 1 and 2.) The vast majority of these cases are self-limited and will resolve with time and appropriate conservative management. Numerous psychological, emotional, and legal as well as physical issues can contribute to pain intensity, extent, and protractedness. Occasionally an intra-articular joint injection with Aristocort and Marcaine,...

Phase IIMiddle Phase Rehabilitation

Usually 7-10 days after surgery, the patient returns to the surgeon for reevaluation. A majority of the patients have progressed off of the crutches, the portal scars are healed, pain and swelling are diminishing, and mobility and muscle contraction are improving. At times, patients may still present with continued impairments such as pain, swelling, altered mobility and muscle length, poor static alignment, impaired muscle strength and endurance, diminished proprioception, and decreased...

References

Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E. Hip arthroscopy by the lateral approach. Arthroscopy 1987 3 4-12. 2. Edwards D, Villar R. Arthroscopy of the hip joint. Practitioner 1992 236 924,926,929. 3. Glick JM Hip Arthroscopy. In McGinty JB (Ed.), Operative Arthroscopy, New York Raven Press, 1991 663-676. 4. Keene GS, Villar RN. Arthroscopic anatomy of the hip An in vivo study. Arthroscopy 1994 10 392-399. 5. McCarthy J, Day B, Busconi B. Hip arthroscopy Applications and technique. J...

Conclusion

Each of the previously noted approaches is intended to achieve joint arthrotomy. Most of the procedures for which they are performed involve femoral head dislocation. (Figure 9.10.) For those surgeries not involving prosthetic replacement there is an attendant risk of developing osteonecrosis. Arthrotomy of the joint requires an inpatient hospital stay and a potentially extended rehabilitation course. For major joint reconstruction or bone grafting these postoperative sequelae are readily...

Trauma

Traumatic events about the hip joint are a frequent occurrence. While most fractures of the femoral neck or acetabu-lum are successfully treated by reconstituting the bony architecture, articular injuries can and do occur. Epstein reported that the high incidence of chondral damage present following a fracture dislocation of the hip warranted an arthro-tomy in every case.14 The high risks associated with open surgery in the early post-trauma period (infection, contracture, deep vein thrombosis,...

Extra Articular Conditions

The efficacy of arthroscopy in treating pathologic conditions in encapsulated environments (joints, bladder, etc) has spawned interest in further applications. Advancements in general surgery to endoscope soft tissue cavities have allowed treatment of inguinal hernias and gallbladder disease. Similarly, orthopedic arthroscopic procedures have begun to extend to extra-articular areas. As mentioned above, post-traumatic periarticular impinging ossification has been resected via the arthroscope....

Gait Training

Progression to full weightbearing with restoration of an efficient gait pattern is not advised if the Trendelenburg test is still positive. These patients may require a cane used in the contralateral upper extremity to help reduce torque at the pelvis and minimize the demand on the gluteus medius, minimus, and tensor fascia lata. Stability in unilateral stance is the most difficult activity for these muscles to perform and is essential for progression to more challenging and functional gait...

Arthroscopic Anatomy and Assessment of the Normal Femoral Head

Arthroscopic Anatomy

The gross and arthroscopic anatomy pertaining to hip arthroscopy is described in detail in the literature4,5 and earlier in this book. (See Chapter 5.) Because a full understanding of the normal is a prerequisite to recognizing the abnormal, this section illustrates the important intra-articular anatomy relevant to a systematic examination of the femoral head. For orientation purposes, the senior author rotates the arthroscope until the femoral head is positioned at the top of the screen and...

Hip Dislocation and Fracture Dislocation

Traumatic hip dislocation is a high-energy injury that usually results from a motor vehicle accident1,2 in an unrestrained individual.2,3 The treatment requires emergent relocation in addition to a thorough trauma evaluation, due to the high incidence of additional injuries.1 If closed relocation is not achieved, then open reduction is indicated. Thompson and Ep-stein4 type III or IV fractures are unstable and need to be openly reduced and repaired. The treatment of reducible dislocations and...

Treatment Interventions

Investments

The immediate postoperative phase is dominated by the acute vascular and inflammatory response to the surgery. Physical therapy intervention at this phase can best be summarized by the acronym PRICEM7 (Figure 17.1). This is the first tier of Fagerson's pyramid model of treatment intervention for the hip. The patient needs to protect the joint and ensure optimal loading by utilizing crutches with partial weightbearing. Crutches also allow for good postural alignment. The joint is protected...

Arthroscopy Following Total Hip Replacement

Most patients with painful total hip replacement do not require arthroscopic evaluation. The etiologies that generate symptoms following arthroplasty can usually be diagnosed by conventional means clinical (leg length discrepancy, abductor weakness, etc) radiographic (component loosening, mal position, trochanteric nonunion, etc) or by special studies such as a bone scan or aspiration arthrogram to detect subtle loosening or sepsis. When unexplained symptoms persist despite appropriate...

Portal Placement in the Supine Position Direct Anterior Portal

The direct anterior portal is commonly used in hip arthros-copy performed in the supine position, and during extensive synovectomy and debridement when in the lateral position. As noted above, the entry point for the arthroscope is at the perpendicular intersection of a horizontal line directed laterally from the symphysis pubis and a vertical line extended in-feriorly from the anterior superior iliac spine (ASIS). The superior margin of the greater trochanter has also been described as a...

Minimally Invasive Surgical Approaches

The surgical approach in any operative procedure, arthroscopic or open, is the foundation for success and safety. Hip arthroscopy has evolved significantly over the last 15 years, and the accurate anatomic mapping and delineation of safe entry points or portals to the hip joint has been a major factor in this evolution. The depth of the hip joint from the skin, the intervening muscle and capsule, and the proximity of major neurovascular structures make the arthroscopic approach in the hip...

Legg CalvePerthes Disease

Avascular necrosis of the skeletally immature femoral head, or Legg-Calve-Perthes disease, is characterized by os-teonecrosis of the ossific nucleus of the femoral head secondary to occlusion of the arterial or venous blood supply. After infarction, healing occurs by a process of creeping substitution and resorption of the dead bone, with deposition of new bone. The deformity of the femoral head and acetabu-lum may be extensive and can exceed the remodeling and healing capacity of the...

Positioning

The lateral approach requires that the patient be positioned in the lateral decubitus position with the affected hip up. Most surgeons use a modified fracture table. The positioning is similar to that used for lateral femoral nailing. Some centers still have access to a specially modified distraction device produced by Arthronix Corporation the Hip Distraktor , which can be fitted to a regular fluoroscopic surgery bed however, this apparatus is no longer in commercial production. Commercially...

Instrumentation

Arthroscopic access to the hip joint requires specialized instrumentation that allows controlled, atraumatic penetration of the periarticular soft tissues, abductor musculature, and hip joint capsule. Because of the depth of the hip joint from the surface, specially designed extra-long arthroscopic instruments are generally required to enter the hip joint and perform any necessary procedures. In selected smaller individuals who have thin soft tissue envelopes, it is sometimes possible to use...

Traditional Surgical Approaches

Anterolateral Approach The Hip

Any discussion regarding minimally invasive approaches to the hip joint is predicated by the context in which it developed. The hip joint is the most deeply recessed joint in the body. Because of the many musculotendinous investing structures surrounding it, a number of open surgical approaches were developed. Each of these methods, importantly, passes through fascial planes between muscles supplied by major nerves. These planes are well detailed by Henry.1 Indications for hip surgery have...

Microangiographic Studies and Spalteholz Staining

The microvascular anatomy of 10 acetabula was determined using a modification of the Spalteholz tissue-clearing technique described by Crock 1967 34 and Arnoczky 1982 .35 Six male adult cadavers with an average age of 71 range, 62-82 years were obtained from the Gross Anatomy Laboratory. The femoral circumflex arteries and the internal iliac arteries of each cadaver were exposed, sequentially incised, and cannulated with a Foley catheter. The catheter balloon was inflated, and all adjacent...

Treatment Algorithms

McCarthy, and Jo-ann Lee During the history and physical, the clinician should note whether the hip pain is primarily in the anterior groin, in the buttocks or posterior thigh, or in the lateral aspect of the hip and thigh. Though there is some overlap, each of these regions has particular etiologies of pain associated with it. If patients with acute anterior groin pain following injury have negative radiographs and are able to ambulate and bear some weight,...

Contents

1 Assessment of the Painful Hip 3 Joseph C. McCarthy, Brian D. Busconi, and Brett D. Owens 2 Differential Diagnosis of the Painful Hip 7 Brian D. Busconi and Brett D. Owens Arthur H. Newberg and Joel S. Newman Christian P. Christensen, Joseph C. McCarthy, and Jo-ann Lee 7 Anesthesia Considerations 69 Donald Foster and Robert Bode 8 Patient Positioning and Distraction 73 J. Bohannon Mason, John O'Donnell, Michael B. Mayor, Brian D. Busconi, Brett D. Owens, and Jo-ann Lee Joseph C. McCarthy, J....

Labral Tears

The diagnosis of labral tear remains largely clinical. These lesions often present with mechanical symptoms, including buckling, catching and painful, restricted range of joint motion. Evolving radiographic studies, including high-contrast or gadolinium-enhanced arthro MRI scanning, have improved the diagnostic sensitivity for labral injuries. See Chapter 3. Hip arthroscopy allows a comprehensive evaluation of labral anatomy. Visual inspection is possible for all quadrants of the joint. In...

Perioperative Management

Position Arm Dependent Position

Hip arthroscopy as performed at the New England Baptist Hospital is generally an outpatient surgery procedure. The majority of patients undergoing hip arthroscopy are categorized as ASA I and II. Although in one series patient ages ranged from 17 to 69 years,1 most are young adults. They have few serious comorbid conditions and usually require minimal pre-anesthetic testing. Some patients present with severe chronic hip pain and are narcotic tolerant due to long-term analgesic use. Despite...

Anatomy

Femoral Sheath

The pelvis is formed from the fusion of three separate centers of ossification the pubis, ischium, and ilium. All fuse into a single bone by early adolescence. The site of convergence and fusion of all three centers of ossification is the tri-radiate cartilage, which eventually fuses and forms the mature acetabulum. In addition to these primary centers of ossification, the adolescent has seven other centers of secondary ossification, which include the iliac crest, ischial apophysis, anterior...

Assessment of the Painful

Hip Adductor Tendonitis Mri

Busconi, and Brett D. Owens Patients who present to a physician with hip pain will generally have a definable diagnosis based on a thorough history, physical examination, and radiologic evaluation. There exists a subset of patients, however, who develop intractable hip pain with reproducible physical findings yet escape a definitive diagnosis despite extensive noninvasive radiologic evaluation. This pain is often refractory to nonoperative management including rest,...