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

Hip Extensors Table

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...

Traditional Surgical Approaches

Delayed Union Nonunion Decortication

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...

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,...

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

Piriformis Gemelli

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,...