Pelvis, Hip, and Thigh

Pelvis, Hip, and Thigh

Hip Arthroscopy

Indications and Goals: Hip arthroscopy can be useful for both diagnostic and therapeutic purposes. Indications have expanded as techniques improve. Common indications include labral tears, synovial diseases, chondral injuries, early osteonecrosis, hip infection, ligamentum teres injuries, and internal snapping hip. Contraindications include ankylosed hips, advanced arthritis, open wounds, and inability to undergo traction.

Procedure and Technique: Hip arthroscopy can be done in either the supine or lateral decubitus position. Traction is applied using a fracture table or with a commercially available traction device. Fluoroscopy is used to facilitate the procedure. Time is monitored as traction is applied. Traction force is included until the hip is distracted enough to allow the arthroscopic cannula and instruments to be inserted into the joint. Both 30- and 70-degree arthroscopes are used. After distention of the joint, a pertrochanteric portal (usually anterior trochanteric, i.e., 1 to 2 cm anterior and superior to the greater trochanter) is used to insert the arthroscope. An anterior portal is then established (at the intersection of a line from the anterior superior iliac spine extending inferiorly and from the greater trochanter extending medially) using a spinal or colposcopy needle for localization. Special instruments and shavers are used to carry out the indicated procedure.

Post-surgical Precautions/Rehabilitation: Post-operative rehabilitation following arthroscopic surgery of the hip joint should emphasize range-of-motion and strengthening exercises, with a close monitoring of weight-bearing activities. Since many varied procedures can be performed arthroscopically, tissue healing and the loads placed upon joint structures should be the main determinants of the rate of progression with rehabilitation. Additional considerations may include addressing associated swelling and pain, muscle atrophy and neuromuscular control, cardiovascular conditioning, and gait training.

Expected Outcomes: The goals associated with rehabilitation following a hip arthroscopy are to maintain the overall function of the hip joint, return the individual to pre-injurious activity levels, and minimize the development of premature arthrosis. Adverse affects associated with hip arthroscopy are few, occurring in <5% of patients.

Return to Play: This depends entirely on the procedure performed. For soft tissue involvement, a return to participation may be within 1 month, whereas for bony work (FAI, etc.), a return to sport participation may be delayed for up to 6 months.

Recommended Readings

Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: Arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006;36(7):516-525. Review.

Khanduja V, Villar RN. Arthroscopic surgery of the hip: Current concepts and recent advances. J Bone Joint Surg Br. 2006;88(12): 1557-1566. Review.

McCarthy JC, Lee JA. Hip arthroscopy: Indications, outcomes, and complications. Instr Course Lect. 2006;55:301-308. Review.

Philippon MJ. New frontiers in hip arthroscopy: The role of arthroscopic hip labral repair and capsulorrhaphy in the treatment of hip disorders. Instr Course Lect. 2006;55:309-316. Review.

Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: A systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92. Review.

Shetty VD, Villar RN. Hip arthroscopy: Current concepts and review of literature. Br J Sports Med. 2007;41(2):64-68; discussion 68. Epub 2006 Nov 30. Review.

Shindle MK, Voos JE, Heyworth BE, Mintz DN, Moya LE, Buly RL, Kelly BT. Hip arthroscopy in the athletic patient: Current techniques and spectrum of disease. J Bone Joint Surg Am. 2007;89(suppl 3):29-43. Review.

Smart LR, Oetgen M, Noonan B, Medvecky M. Beginning hip arthroscopy: Indications, positioning, portals, basic techniques, and complications. Arthroscopy. 2007;23(12):1348-1353. Epub 2007 Oct 3. Review.

Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25(2):337-357, x. Review.

Figure 65. Standard Hip Arthroscopy Portals. Image A: The most common arthroscopic portal sites including the anterolateral viewing portal, the anterior portal, (just posterior to anterior line of ASIS), and mid-anterior portal. The distal anterolateral portal is effective for accessing the peritrochanteric compartment. Image B: Common set up, with the arthroscope in the anterolateral viewing portal and an instrument through the anterior portal. An accessory posterolateral portal in place.

Sports Hernia Repair

Indications and Goals: Sports hernia, also known as athlete’s hernia, Gilmore’s groin, and athletic pubalgia, refers to chronic inguinal or pubic area exertional pain in the absence of a true hernia. This may be a result of a hyperextension injury and can also affect the adductors. Affected athletes may have localized groin pain, adductor tightness or pain and pain with resisted sit-ups or crunches. Imaging is rarely helpful, but can be sued to rule out other diagnoses including osteitis pubis. Conservative treatment can include medication, physical therapy, and fluoroscopic guided injection.

Procedure and Technique: Pelvic floor repair involves reattaching the inferolateral edge of the rectus abdominis muscle to the pubis and adjacent anterior ligaments. The transversalis fascia can also be imbricated. Often, the adductors are also released about 2 to 3 cm from their pubic insertion.

Post-surgical Precautions/Rehabilitation: Post-operative rehabilitation depends solely upon the type of procedure performed and the preferences and guidelines of the surgeon. Acute ambulation can range from 1 day to 1 week, and a period of minimized activity can sometimes last for up to 6 weeks before allowing one to initiate lower leg and abdominal training exercises. Gradual flexibility and strengthening exercises can be incorporated based upon the tissue involvement, with care taken to avoid progressive abduction movements if the adductor muscle group is released during the procedure.

Expected Outcomes: Evidence-based concensus and reporting is not available to guide clear-cut decision making following a repair. Anecdotally, some have reported a 7- to 10-recovery period, while others encourage 6 to 8 weeks of minimal activity. The literature supports both open and laparoscopic repairs with respect to producing excellent results, but a quicker return to participation with the less-invasive technique as would be expected. The surgical procedures are relatively quick to perform, and both short- and long-term complications are rarely reported. Anecdotally, clinicians have reported athletes who have undergone a sports hernia repair on one side followed by the other side requiring a repair anywhere between 6 months to 2 years later. There is no evidence to support the rationale for such cases.

Return to Play: Return to play is usually delayed for 2 to 3 months. Earlier return may be possible for newer, more limited procedures. Care should be taken to return to sport participation too soon which may result in a delayed or absent successful repair.

Recommended Readings

Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, Long JN, de la Torre JI, Garth WP, Vasconez LO. Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg. 2005;55(4):393-396.

Diesen DL, Pappas TN. Sports hernias. Adv Surg. 2007;41:177-187. Review.

Edelman DS, Selesnick H. “Sports” hernia: Treatment with biologic mesh (Surgisis): A preliminary study. Surg Endosc. 2006;20(6): 971-973. Epub 2006 Apr 19.

Swan KG Jr, Wolcott M. The athletic hernia: A systematic review. Clin Orthop Relat Res. 2007;455:78-87. Review.

Figure 66. Sports Hernia. A: Opposing pulls of rectus abdominus and adductor longus through iliac insertion as a mechanism of injury. B: Direct suture repair of anterior abdominal wall. This technique involves the direct suture repair of the rectus abdominus insertion and posterior wall of the inguinal canal. Retraction of the spermatic cord and evaluation of the transversalis fascia of the posterior wall of the inguinal canal, (Figure B), as well as the insertion of the rectus abdominus to the pubic tubercle. When attenuated, these structures are repaired, utilizing only 5 to 6 nonabsorbable sutures to reapproximate the rectus tendon, conjoined tendon, and fascia back to a roughened bony bed upon the pubic tubercle insertion site and shelving portion of the ilioinguinal ligament.

Snapping Hip Release

Indications and Goals: Snapping hip, also known as coax saltans, can be caused by either the iliopsoas tendon snapping over the iliopectineal eminence (internal) or the iliotibial band and/or gluteus maximus tendon snapping over the greater trochanter (external). The snapping is often reproducible by the patient. Internal snapping can be reproduced by passively flexing and extending the hip, especially from an abducted/flexed position to an adducted/extended position. Application of pressure over the iliopsoas tendon can stop the snapping and confirm the diagnosis. Dynamic bursography or ultrasound may also be helpful. External snapping can be reproduced with hip flexion. A positive Ober’s test (the patient lies on his side with the affected leg up and with the hip extended and abducted; the patient cannot adduct the hip from this position) may also be present.

Procedure and Technique: Surgery involves release of the affected tendon(s). For internal snapping, fractional release of the tendon is carried out. This can be accomplished through an open incision in the groin beginning 1 cm proximal to the lesser tuberosity or arthroscopically through an extra-articular approach. External snapping is addressed with either Z-lengthening or release of the iliotibial band/tract.

Post-surgical Precautions/Rehabilitation: Rehabilitation initially involves healing of the external wound closure, with gentle range of motion to prevent post-operative internal adhesions. A gradual progression from passive to active range of motion of the involved area will restore function within a few weeks, and return to participation is based upon the demands of the goals set forth. Care should be taken to begin passive and active hip extension, particularly with hip rotation involvement, as well as caution with active hip flexion activities.

Expected Outcomes: Results appear to be comparable between open and arthroscopic procedures, with good outcomes.

Return to Play: Since this is a soft tissue procedure, return to play can be relatively early, i.e., 4 to 6 weeks.

Recommended Readings

Byrd JW. Evaluation and management of the snapping iliopsoas tendon. Instr Course Lect. 2006;55:347-355. Review.

Flanum ME, Keene JS, Blankenbaker DG, Desmet AA. Arthroscopic treatment of the painful “internal” snapping hip: Results of a new endoscopic technique and imaging protocol. Am J Sports Med. 2007;35(5):770-779. Epub 2007 Mar 9.

Ilizaliturri VM Jr., Martinez-Escalante FA, Chaidez PA, Camacho-Galindo J. Endoscopic iliotibial band release for external snapping hip syndrome. Arthroscopy. 2006;22(5):505-510.

Ilizaliturri VM Jr., Villalobos FE Jr., Chaidez PA, Valero FS, Aguilera JM. Internal snapping hip syndrome: Treatment by endoscopic release of the iliopsoas tendon. Arthroscopy. 2005;21(11):1375-1380.

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Jul 9, 2020 | Posted by in SPORT MEDICINE | Comments Off on Pelvis, Hip, and Thigh
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