First described in 1931 by Burman in a cadaver study. However, he declared “that it is impossible to separate the head of the femur from the acetabulum … It is manifestly impossible to insert a needle between the head of the femur and the acetabulum. One cannot, therefore, hope to see the acetabular fossa.” He was only able to see a part of the femoral head, the junction of the femoral head and neck, and the femoral neck.

Takagi was the first to report on the clinical application of hip arthroscopy in 1939.

Development of improved traction devices and instrumentation eventually made hip arthroscopy more versatile.

Initial slow development but recently rapid increase in enthusiasm for hip arthroscopy since the 1990s

Technically more demanding than arthroscopy of other joints with a longer learning curve even for experienced surgeons

Challenges:

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  Thick capsule, muscle envelope, and periarticular ligaments make distraction difficult.

  
  
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  Convex femoral head and deeply recessed in a bony acetabulum makes joint entry difficult.

  
  
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  Curvilinear articulating surface makes navigation difficult.

  
  
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  Deep joint due to periarticular muscles and soft tissues, as well as the thick capsule, makes maneuverability within the joint difficult.

  
  
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  Offers shorter recovery times and quicker return to activity than do open procedures

  
  
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  Many injuries now addressed arthroscopically had been largely undiagnosed and untreated until recently.

Key to success is careful patient selection

First determine if the source of pain is intra-articular.

Hallmarks of intra-articular hip pathology:

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  Groin pain usually increasing with activity but largely unresponsive to conservative treatment (e.g., ice, rest, nonsteroidal anti-inflammatory drugs [NSAIDs], and physical therapy)

  
  
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  Relatively well-tolerated activities: motion in a straight plane, activity on level surfaces

  
  
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  Poorly tolerated activities: torsional/twisting activity, prolonged hip flexion (e.g., sitting), rising from a seated position (causes pain/catching), activity on inclines

  
  
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  Presence of mechanical symptoms (clicking, catching, locking, or giving way/buckling) preoperatively is a favorable prognostic indicator for hip arthroscopy for any diagnosis except degenerative arthritis

  
  
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  A positive McCarthy sign is significantly correlated with intra-articular pathology (with both hips fully flexed: the pain is reproduced by extending the affected hip in external and/or internal rotation)

  
  
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  Relief of pain with an injection of an anesthetic into the hip joint can help distinguish between intra- and extra-articular pathology

Must rule out referred pain from lumbar or sacral areas, genitourinary tract, gastrointestinal system, and abdominal wall

Cautionary signs: ill-defined symptoms or examination findings, unreasonable expectations, a stiff hip

Radiographs

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  Plain films to look for osteophytes (make entry into the joint difficult), degenerative arthritis (indicator of poor prognosis), ossified and metallic loose bodies, anatomy of femoroacetabular impingement (FAI) and dysplasia ( Fig. 3-1 )

  
  

  
  

  
  

  

  
  

  
  

  A. AP Pelvis of a 40-year-old male martial artist with combined femoroacetabular impingement. B. Shows the line for cross-over with the solid line being the posterior wall of the acetabulum and the dashed line outlining the anterior wall demonstrating the cranial retroversion of the acetabulum seen with pincer type of impingement. The dashed arrow demonstrating the floor of the acetabulum touches the ilioischial line, as seen with coxa profunda. C. Includes an arrow pointing at the cam lesion.

  
  
  
  
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  Conventional computed tomography (CT) and magnetic resonance imaging (MRI) lack sensitivity and specificity in diagnosing labral pathology.

  
  
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  Gadolinium arthrography combined with high resolution, thin-cut multiplaning MRA (MR arthrography) with small field of view (focus on the affected hip rather than on the pelvis) is best for assessing labral pathology ( Fig. 3-2 ) .

  
  

  
  

  
  

  

  
  

  
  

  MRI gadolinium arthrogram—coronal view demonstrating a labral tear.

  
  
  
  
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  74% Sensitivity, 83% specificity, and 78% accuracy in diagnosing anterior labral pathology

Hip dysplasia increased incidence of labral, chondral, and ligamentum teres lesions ( Fig. 3-3 )

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  Shallow bony acetabulum (usually with hypertrophied labrum) labrum playing an increased role in weight-bearing and joint stability exposure to greater joint reaction and weight-bearing forces increased risk of labrum inversion and tearing

  
  
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  Reduced chondral surface area increased contact forces overload leads to chondral wear as well as acute fragmentation and early degeneration (edge loading)

  
  
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  Lateral subluxation of the femoral head elongation or hypertrophy of the ligamentum teres ligament may become entrapped or undergoes a partial or complete degenerative rupture

  
  
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  Presence of dysplasia is not itself a poor prognostic indicator (as previously thought); response to treatment is dictated by the nature of the intra-articular pathology.

A. An AP pelvis of a patient with dysplasia. B. An MRI showing large labrum in dysplasia.

One must consider whether large bony dysmorphisms (e.g., FAI and dysplasia) causing labral and chondral pathology are best treated with osteotomies or other open bony procedures to address the underlying pathology.

Loose bodies (e.g., from trauma, synovial chondromatosis, osteoarthritis, and Legg-Calvé-Perthes disease): the clearest indication for hip arthroscopy

Classifications: ossified versus nonossified; osteoocartilaginous, cartilaginous, fibrous, or foreign

Labral lesions/tears

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  Controversy over etiology of labral tears: are they predominantly the result of bony impingement (the prevailing theory) or do they happen independently due to dynamic load or torque (e.g., sudden twisting or pivoting motions) as in the knee joint (McCarthy)

  
  
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  Typically present with moderate-to-severe, sharp and/or dull activity-related groin pain (e.g., pain with walking and pivoting); most patients also have night pain and painful mechanical locking

  
  
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  Pathology often overlooked: mean time from onset of symptoms to diagnosis is 21 months; mean number of health-care providers seen before definitive diagnosis is 3.3.

  
  
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  >80% of patients with atraumatic onset of symptoms related to labral tears have associated underlying bony pathology (FAI, dysplasia).

  
  
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  Positive impingement test: axial force with hip flexion-adduction-internal rotation shearing and compression forces on the labrum pain

  
  
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  Most tears are anterior or anterolateral and occur at the relatively avascular inner portion of the tissue.

  
  
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  May have bucket-handle tear after a posterior hip dislocation that may block closed reduction

  
  
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  Question if labral tears contribute to the progression of hip osteoarthritis (OA) or if labral débridement/repair alters the natural history: still need studies

  
  
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  >50% of all labral tears have associated chondral damage : damaged labrum joint fluid is pumped under the acetabular chondral surface with repetitive loading delamination of the articular cartilage fluid burrows beneath the subchondral bone forms a subchondral cyst.

Chondral lesions of the acetabulum or femoral head

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  Vast majority occur in the anterior quadrants of the acetabulum ( Fig. 3-4 )

  
  

  
  

  
  

  

  
  

  
  

  Arthroscopic photograph of a 21-year-old baseball player with FAI of the right hip. A. Shows chondral delamination of the anterolateral acetabular articular cartilage. B. Demonstrates this chondral lesion after chondroplasty.

  
  
  
  
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  Most frequently associated with a labral tear

  
  
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  Over years, flap lesions progress via a delamination mechanism.

  
  
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  “Lateral impact injury” can occur after a blow to the greater trochanter energy and load transferred to the joint surface

  
  
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  Grade of chondral lesion is most predictive of surgical outcome.

  
  
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  Chondral loss (especially of the femoral head) is poor prognostic indicator for arthroscopy.

Ligamentum teres rupture: an increasingly recognized source of hip pain; third most common pathology diagnosed in athletes undergoing hip arthroscopy ( Fig. 3-5 )

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  Can occur after a twisting injury even without hip subluxation/dislocation

  
  
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  Atraumatic degenerative cases associated with osteoarthritis and hip dysplasia

  
  
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  Imaging and physical examination findings not very specific

  
  
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  Usually present with groin pain and mechanical symptoms

  
  
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  Patients may avoid extending the hip while walking.

Arthroscopic photograph of a 32-year-old male with hip pain as a result of a tear of the ligamentum teres. The femoral head is to the left and the cotyloid fossa is on the right.

Degenerative disease: perform arthroscopy with caution

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  Patients with degenerative changes apparent on plain hip radiographs are significantly more likely to have poor clinical results following hip arthroscopy than those with normal hip radiographs.

Persistent pain following hip dislocation

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  79% to 92% of traumatic hip dislocation patients who underwent arthroscopy were found to have osteochondral loose bodies within the joint despite some having no evidence of loose bodies on radiographs and CT scans.

  
  
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  In one study, all 14 hip dislocation patients had labral tears and chondral defects seen on arthroscopy; 79% had partial or complete tears of the ligamentum teres.

Osteonecrosis/avascular necrosis (AVN): for early cases to address concomitant pathology (e.g., loose bodies, synovitis, chondral flaps, and labral tears) and to more precisely stage AVN during the workup for a possible revascularization procedure

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  Not successful for end-stage disease with femoral head collapse

  
  
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  Best results in lower-grade lesions where loose bodies are found and removed

  
  
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  During core decompression: used for intra-articular observation to ensure no joint penetration and to ensure that the core track is within the avascular zone

Synovial disease (e.g., inflammatory arthritis, synovial chondromatosis, pigmented villonodular synovitis [PVNS])

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  Palliative

  
  
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  For diagnostic biopsy

  
  
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  Cannot do complete synovectomy arthroscopically

  
  
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  Results partially dependent on integrity of articular cartilage

Femoroacetabular impingement (FAI) described by Ganz

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  Cam impingement: when a nonspherical femoral head abuts the anterior acetabulum, particularly with hip flexion

  
  
  
  
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    Causes: poor head-neck offset, posttraumatic deformities, slipped capital femoral epiphysis (SCFE), femoral retrotorsion, coxa vara, femoral head AVN with flattening, sequelae of Legg-Calvé-Perthes disease

  
  
  
  
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  Pincer impingement: due to overcoverage of the acetabulum anteriorly or acetabular retroversion (see Fig. 3-1 )

  
  
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  Causes: acetabular retroversion (global or cranial), coxa profunda, protrusio

  
  
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  Majority have combined cam and pincer impingement (see Fig. 3-1C )

  
  
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  Present with groin pain, especially when sitting for prolonged periods and crossing the symptomatic leg; positive impingement test (pain with maximum internal rotation and adduction with the hip flexed to 90 degrees)

  
  
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  Limited range of motion (ROM), particularly of internal rotation

  
  
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  FAI repetitive microtrauma to the labrum at extremes of hip motion labral and chondral lesions (see Fig. 3-4 ) ?early-onset hip osteoarthritis

Atraumatic instability: capsular laxity with iliofemoral ligament deficiency

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  Less common in the hip than in the shoulder because of the hip’s intrinsic osseous stability

  
  
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  Not well delineated at this time

  
  
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  Associated with collagen vascular disorders (e.g., Ehlers-Danlos syndrome)

Irrigation and débridement (I&D) of a septic hip

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  Contraindications to arthroscopic (versus open) treatment: longstanding or recurrent infection, osteomyelitis, particularly virulent bacteria, extracapsular abscess (should get a CT scan or MRI before arthroscopy to assess)

  
  
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  Can perform arthroscopic I&D of an infected total hip arthroplasty (THA) patient if: early diagnosis, components well fixed, a sensitive microorganism

Adhesive capsulitis: characterized by painful restricted ROM often with a precipitating event (e.g., a fall or twist), predilection for middle-aged women, radiographs usually normal

Foreign bodies (e.g., bullets, broken trochanteric wire, acetabular screw that is backing out, broken guidewire fragment from cannulated screw fixation)

Painful THAs (e.g., débridement of porous beads due to metal-on-metal corrosion at the head-neck junction; synovial biopsy to assess for infection when the hip aspiration is negative but clinical suspicion is high; débridement of scar tissue and adhesions, removal of broken or migrated wires) ( Fig. 3-6 )

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  Hip arthroscopy either successfully treated or directly led to successful treatment in 8 of 12 THA cases with persistent pain and a nondiagnostic standard workup

A. An arthroscopic view of the neck ( white arrow with double head ) and base of the metallic femoral head ( white arrow ) in a patient with a total hip arthroplasty with broken wire— dashed arrow points to clamp of broken wire. B. A fluoroscopic view of same patient during removal of the broken wire.

Osteochondrosis dissecans: rarely in the hip, can remove the dissecate and then microfracture

Pipkin fractures of the femoral head

Crystalline hip arthropathy (gout and pseudogout): may present with extreme hip pain, difficult diagnosis if limited to the hip because patient may have a normal serum uric acid level with just a joint effusion on MRI

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  Arthroscopic treatment: copious lavage, mechanical crystal débridement, synovial biopsy for definitive diagnosis

Chondral cyst: focal, compressible chondral elevation detected on hip arthroscopy in a Legg-Calvé-Perthes patient with persistent hip stiffness

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  Flocculent fluid released on incision of the cyst, the underlying chondral defect was microfractured patient had immediate pain relief with continued painless ROM at 4-year follow-up

Hereditary multiple exostoses with a lesion in the hip joint causing pain and limited ROM

Giant-cell tumor of the ligamentum teres: a case report involving a 46-year-old woman with thigh/groin/buttock pain, full hip ROM, a positive impingement sign, and an MRI suggestive of a labral tear; tumor was successfully excised arthroscopically

Pediatric hip condition, for example:

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  Legg-Calvé-Perthes disease (e.g., for loose bodies)

  
  
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  Developmental dysplasia of the hip (typically to address a labral tear after osteotomy to correct the underlying dysplasia)

  
  
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  Septic arthritis

  
  
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  Juvenile rheumatoid arthritis (RA)

  
  
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  Slipped capital femoral epiphysis to address:

  
  
  
  
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    Chondrolysis as a result of pin penetration of the cartilage during fixation

    
    
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    Osteonecrosis from damage to retinacular vessels

    
    
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    Chielectomy for residual bump at femoral head-neck junction that may be impeding hip motion or causing pain from impingement ( Fig. 3-7 )

    
    

    
    

    
    

    

    
    

    
    

    AP Pelvis radiograph of a 17-year-old boy with hip pain and limited range of motion with evidence of residuals of slipped capital femoral epiphysis.

    
    

  
  

Possible indications for periacetabular osteotomy versus arthroscopy:

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  Moderate-to-severe hip dysplasia

  
  
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  Actual hip subluxation

  
  
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  Coxa valga greater than 140 degrees

  
  
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  Upsloping sourcil

Intractable hip pain resistant to conservative treatment and intra-articular injection with negative radiographic workup but mechanical symptoms: arthroscopy facilitates diagnosis in 40% of these cases

Extra-articular conditions

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  Snapping hip syndrome: three types

  
  
  
  
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    External/lateral: most common type, caused by snapping of either posterior border of iliotibial band (ITB) or anterior border of gluteus maximus over greater trochanter when hip moves from extension to flexion

    
    
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    Internal: painful snapping of iliopsoas tendon over the iliopectineal eminence, femoral head, or iliofemoral ligament

    
    
    
    
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      Arthroscopy better than open treatment: can eliminate snapping without nerve complications or weakness

      
      
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      70% to 80% Associated with intra-articular pathology that can be addressed concomitantly with hip arthroscopy

    
    
    
    
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    Intra-articular: caused by loose body/bodies in the joint (e.g., fracture fragment, piece of labrum, chondral flap), pain elicited by hip rotation

  
  
  
  
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  Iliopsoas bursitis

  
  
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  Greater trochanteric pain syndrome differential diagnosis:

  
  
  
  
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    ITB tendonitis

    
    
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    Trochanteric bursitis

    
    
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    Avulsion of the gluteus medius ± minimus tendon ( Fig. 3-8 )

    
    
    
    
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      Seen in 20% of women >65 years old undergoing THR

      
      
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      Repair arthroscopically if failed rehabilitation for hip abductor weakness

    
    

    
    

    
    

    

    
    

    
    

    Sagittal T2 MRI demonstrating an avulsion of the gluteus medius in a 32-year-old male with acute onset of hip pain, 4 weeks prior to the MRI.

    
    

  
  

Open wounds, especially near portal placement sites

Systemic disease

Severe restrictions to joint entry (e.g., marked capsular restriction, arthrofibrosis, ankylosis, dense heterotopic ossification [HO])

Osteopenia/osteoporosis to the degree that the bone is unable to withstand the necessary traction forces

Bone tumors close to the joint

Sepsis with osteomyelitis or abscess formation

Reflex dystrophia

Risk factors for joint fluid extravasation: recent acetabular fracture , extensive capsular rupture

Morbid obesity (instrumentation may not be long enough to access the joint or strong enough to maneuver within the joint)

Advanced coxarthrosis

Caution in AVN because the fluid pressure and the traction may further compromise the blood supply to the femoral head

Complete routine preoperative protocol: i.e., consultation with appropriate medical, cardiology, and anesthesia colleagues; review of history, physical examination, radiographs, and lab tests; review consent form with patient and sign the correct joint in the preoperative holding area

Anesthesia

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  Almost always general anesthesia because complete muscle relaxation via a neuromuscular blockade is required so that one may use the least amount of force necessary to achieve sufficient joint distraction

  
  
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  May be performed under epidural anesthesia with adequate motor block to achieve required hip distraction

  
  
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  Can consider supplemental lumbar plexus block for perioperative analgesia

Hip joint: a large ball-and-socket diarthrodial or synovial joint ~0.5 cm distal to the middle third of the inguinal ligament

Two compartments

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  Central compartment: the weight-bearing part of the hip joint (corresponding joint surfaces of the acetabulum and femoral head), intracapsular and intra-articular

  
  
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  Peripheral compartment: the non–weight-bearing part of the femoral head and the femoral neck up to the capsule insertion, intracapsular but extra-articular, free-floating loose bodies can hide here

Femoral head: two thirds of a sphere, average head diameter at the equatorial plane: 48.3 mm (range 40 to 58 mm), flattened at the area of greatest load on the acetabulum

Acetabulum: a hemisphere with a peripheral horseshoe–shaped articular surface

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  nonarticular fossa ovalis inferomedially

  
  
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  typically oriented in ~45 degrees of abduction and 15 to 20 degrees of anteversion

Labrum: triangular fibrocartilage that runs circumferentially around the acetabular perimeter to the base of the fovea where the transverse acetabular ligament completes it by extending across the acetabular notch

Vascularized only on its outermost capsular perimeter

Contains free nerve endings (proprioceptors and nociceptors)

Some functions:

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    Provides negative intra-articular pressure in the joint

    
    
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    Acts as a tension band to limit expansion during gait when the loading leads to motion of the anterior and posterior columns

    
    
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    Elevated role in stability and weight-bearing in dysplastic patients

    
    
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    Functions as a seal/O ring to maintain synovial fluid in the central compartment, lubricating the joint and providing nutrition to the articular cartilage

  
  

Ligamentum teres: intra-articular but extracapsular, extends from the transverse acetabular ligament to the fovea of the femoral head, large ligament, main blood supply to the femoral head before 14 years of age but unclear function after that age, unclear stabilizing effect on the joint, tightens in external rotation

Capsule

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  Ligaments are capsular thickenings.

  
  
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  Does not attach to the labrum

  
  
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  Proximally: covers the labrum

  
  
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  Distally: attaches to the intertrochanteric line on the anterior femoral neck; attaches just proximal to the intertrochanteric crest on the posterior femoral neck therefore you can see more of the anterior than the posterior femoral neck arthroscopically

  
  
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  Anteriorly: consists primarily of the strong Y ligament of Bigelow (iliofemoral ligament, strongest ligament in the human body) which resists hip extension and external rotation

  
  
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  Anterolaterally: pubofemoral ligament (restricts hip abduction)

  
  
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  Posteriorly: Ischiofemoral ligament (restricts internal rotation)

Zona orbicularis: a ligament around the neck of the femur at the base of the femoral head, may help maintain the femoral head within the acetabulum, resists distraction forces

Fibers of Weitbrecht are medial and lateral synovial folds in the peripheral compartment, “the lighthouse of the peripheral compartment,” retinacular branches of the medial femoral circumflex artery pass deep to it to reach the femoral head, often incorrectly referred to as the “ligament of Weitbrecht” (which is in the elbow).

Psoas bursa: communicates with the anterior hip joint in 20% of patients.

Surrounding neurovascular structures: femoral nerve and artery anteriorly; lateral femoral cutaneous nerve (LFCN) anterolaterally (usually divides into 3 or more branches at the level of the anterior portal); sciatic nerve, and gluteal vessels posteriorly

Anterior capsule most relaxed with hip flexion; posterior capsule most relaxed in external rotation; capsule overall tightest with full hip extension

Choice based on surgeon preference and training

Supine (popularized by Byrd)

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  Pros: familiar orientation of the joint ; can use a standard fracture table with a standard perineal post for traction ; ease of conversion to open anterior or anterolateral approach

  
  
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  Cons: pannus in obese patients can interfere with instrument movement

Lateral decubitus (popularized by Glick )

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  Pros: in obese patients the pannus and buttock drop away from the operative field, increasing maneuverability ; easier access to posterior portal (particularly valuable in the presence of a large anterolateral osteophyte blocking portal access ); familiarity with the position for arthroplasty surgeons who use the lateral decubitus position

  
  
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  Cons: more time needed to position the patient ; must either manipulate the standard fracture table or use special traction devices attached to a standard operating table

Typical room set-up ( Figs. 3-9 and 3-10 )

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  On the operative side (if supine) OR posterior to the patient (if lateral decubitus): surgeon, scrub nurse, backtable with instruments, and sterile Mayo stand with the most commonly used instruments (placed over the patient’s torso)

  
  
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  On the contralateral side (if supine) OR anterior to the patient (if lateral decubitus): arthroscopic video tower monitor, fluoroscopy screen (although this can be at the foot of the table instead)

Photograph ( A ) and drawing ( B ) of the operating room set-up for hip arthroscopy.

A. Photograph of Mayo stand table with hip arthroscopy instruments. B. The back table prior to draping of a hip arthroscopy patient.

Table

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  For the supine position:

  
  
  
  
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    Patient supine on a standard fracture table

    
    
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    Abduct the contralateral hip (makes room for the C-arm between the legs)

  
  
  
  
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  For the lateral position:

  
  
  
  
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    Patient lateral decubitus with operative hip superior (protect neurovascular structures in axilla)

    
    
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    Pad the contralateral leg (special care to protect the peroneal nerve at the fibular head)

    
    
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    Fracture table, but must reposition the perineal post and traction device OR

    
    
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    Standard operating table with commercially available distraction device

    
    
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    Swing the C-arm under the table for anteroposterior views if needed

  
  
  
  
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  Tensiometer can monitor the traction forces (senior author [MRS] has not found this to be useful)

  
  
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  Perineal post: well-padded against the operative leg’s medial thigh

  
  
  
  
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    Provides countertraction for hip distraction

    
    
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    Large surface area distributes traction forces to protect the perineum

    
    
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    Lateralizes the hip to optimize the distraction vector

  
  

Large C-arm fluoroscopy

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  To confirm necessary distraction

  
  
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  To assist with portal placement if necessary

  
  
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  Must be sterilely draped if used after the leg is prepped and draped

Arthroscope (“scope”)

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  30-degree scope: best for viewing the central acetabulum and femoral head and superior acetabular fossa, useful in the peripheral compartment

  
  
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  70-degree scope: best for viewing the acetabular labrum, acetabular rim, anterior capsule, inferior acetabular fossa, most peripheral aspects of the joint

Fluid pump optional (senior author uses gravity)

16-Gauge 6-inch spinal needle for portal placement

Nitinol guidewire (threaded through the spinal needle)

Extra-long cannulas (4.5, 5.0, and 5.5 mm) with blunt and sharp obturators/trochars (senior author does not use the sharp obturators/trochars)

Arthroscopic probe (rigid and flexible) to palpate and manipulate structures

Curved instruments to maneuver around the femoral head

Slotted cannulas for curved instruments: the slot is one third of the cannula pipe, the sharp tip of the instrument should always be inside the slot to prevent iatrogenic injury

Electrothermal device(s)

Long motorized shaver(s) and burr(s)

Modified meniscal biters—straight and back biters

Long, narrow curettes

Loose body retrievers

Long, narrow rongeurs

Straight and angled picks for microfracture

Suture passing and retrieving instruments