22

the hip

how far we have come!

J. W. THOMAS BYRD, MD

Editor’s Note: In the first chapter of this section, Thomas Byrd reflects on the state of the field of hip arthroscopy. Tom seems the best person to do this. Soon after Jim Glick performed the first therapeutic arthroscopy in the early 1990s, Thomas followed with a series of patients and stands as the first true popularizer of this field. For many years, Thomas’s panache, fresh perspective, and generous supply of technical pearls has facilitated the launch and acceptance of hip arthroscopy. No doubt, Thomas would win, or be in the top 2 or 3 of, a vote for “Most Respected” among the hip surgeons in the world today.

Tom was also one of the first to recognize that hip and core muscles injuries occur together. I remember a phone call from him in the early 1990s. He was excited. “I have a player with both sets of injuries, Bill. There’s got to be a connection. I am convinced of it!” Tom described a star freshman ACC football player destined to go to the NFL. “Why don’t you do your surgery first? Then, we get him through the season. I will do mine [hip arthroscopy] at the end of the season.” We did that. The player exceeded expectations, and went in the top 5 of the draft 2 years later.

Tom and I began seeing a number of high-level athletes together in a cross-country way. Initially, ice hockey exceeded all other sports in terms of numbers of patients with the combined injuries. We speculated a “skate blade” theory. The hockey players repeatedly jump and land on thin blades. We speculated that somehow the thin blades transmitted powerful forces along narrow, vertical vectors directly into the balls and sockets; the muscle injuries came as a consequence to that. Then we saw at least one player in whom, seemingly, the complement sequence occurred. The latter star NHL defenseman initially ripped off all the adductor muscles plus his rectus abdominis muscle on one side off the pubic plate. Two years later, hip symptoms and new hip MRI pathology ensued on that same side. Possible reasons for the co-existence of the 2 sets of injuries are discussed more in other chapters.

Okay, enough chat. Let’s hear Thomas’s thoughts and reflections. As you read Thomas’s words, keep in mind that his spoken words flow effortlessly in a Southern accent. Don’t be afraid to smile. Read and listen closely. You will hear his happy Tennessean drawl resonating within carefully written words.

From this author’s perspective, it is real and can be explained by 3 independent forces that were at work in the world. First, in the 1990s, a few enthusiasts began looking more into the hip joint with the arthroscope, recognizing the existence of numerous disorders that historically had gone unrecognized and untreated.1–3 Previously, athletes were simply resigned to living within the constraints of their affliction, often with no explanation as to the source. Frankly, with the poor understanding of these hip disorders, frequently the athlete’s motivation and character would be called into question when he/she could no longer excel for unexplained reasons.

Second, in the first month of this millennium, Bill Meyers et al published their landmark article on athletic pubalgia.⁴ Groin disorders and their treatments in athletes have been recognized for decades on other continents where football meant soccer. It was a common affliction, but it was Meyers who put all of this together, especially in North America.

Third, in 2003, Professor Reinhold Ganz and his colleagues, the Bern Group, published the landmark article on FAI as a cause of joint damage in the native hip.⁵ Previously, it had been described only as an iatrogenic phenomenon with overcorrection of acetabular dysplasia.⁶ Impingement was not a new concept.

Cheilectomy for removing the bump associated with sequelae of childhood slipped capital femoral epiphysis was described in the German literature 100 years ago (Figure 22-1).⁷ Smith-Petersen, in his 1936 article, illustrated reshaping the acetabulum and the proximal femur in a pattern that, although primitive, is strikingly similar to what is described with today’s open techniques (Figure 22-2).⁸ Bill Harris et al, in the 1970s, advocated that there was no such thing as primary osteoarthritis of the hip; all osteoarthritis occurred secondary to something, and they wrote back then about the pistol grip deformity of the proximal femur (Figure 22-3).⁹ However, it was Ganz and his colleagues who tied all of this together with our current understanding of FAI with pincer, cam, and combined patterns.

It is unusual to observe symptomatic FAI in adolescents and young adults unless they are involved in athletic activities.10–12 These are individuals pushing their bodies beyond the reduced physiologic limits imposed by the altered morphology of FAI. Thus, the joint starts to break down with activities better tolerated by teammates and competitors with more normal joint morphology. This is a big problem in our athletes today, and stating that it is of potential epidemic proportion is not a severe overstatement. John Bergfeld, a legendary NFL team physician who evaluates many retired NFL players, commented that osteoarthritis of the hip is the most common disorder with which these retired players are plagued. Less active individuals just present in middle age with what used to be described simply as early age onset osteoarthritis.¹⁰

This author performed his first hip arthroscopy in 1990 armed only with a single article by Jim Glick from the 1988 Instructional Course Lectures publication.13 Jim described the lateral position, but we opted for supine just for simplicity, trying to mirror how we would manage a hip fracture. The case was a teenager with loose bodies for whom we chose to try arthroscopic removal as a less invasive alternative to a conventional arthrotomy (Figure 22-4). It worked, and over the ensuing 2 years, we did 2 more cases of loose body removal.

Related posts:

Putting It All Together—A Patient’s Perspective on the Core How the Core Universe Forms The Final Stage of Rehab—Getting All the Way Back The Other Muscles—Hip and Core Stability Biomechanics Presenting…the Core!

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