Elizabeth A. Howse

Ischiofemoral space decompression through posterolateral approach: cutting block technique.

Ischiofemoral space impingement has become an increasingly recognized extracapsular cause of atypical hip, deep gluteal, and groin pain that can be treated endoscopically. We present a minimally invasive posterolateral technique that preserves the attachment of the iliopsoas tendon and quadratus femoris insertion while decompressing the ischiofemoral space by resecting the lesser trochanter. Furthermore, we present tips to perform this technique in a manner that minimizes the potential for damage to the sciatic nerve. This technique also allows the surgeon to treat concurrent hip pathology arthroscopically.

Basic Hip Arthroscopy: Supine Patient Positioning and Dynamic Fluoroscopic Evaluation.

Hip arthroscopy serves as both a diagnostic and therapeutic tool for the management of various conditions that afflict the hip. This article reviews the basics of hip arthroscopy by demonstrating supine patient positioning, fluoroscopic evaluation of the hip under anesthesia, and sterile preparation and draping. Careful attention to detail during the operating theater setup ensures adequate access to the various compartments of the hip to facilitate the diagnosis of disease and treatment with minimally invasive arthroscopy. Furthermore, having a routine method for patient positioning and operative setup improves patient safety, as well as operative efficiency, as the operative team becomes familiar with the surgeons standard approach to hip arthroscopy cases.

Arthroscopic Treatment of Bucket-Handle Labral Tear and Acetabular Fracture

Traumatic hip dislocations are associated with chondral and labral pathology as well as loose bodies that can be incarcerated in the joint. These types of injury often lead to traumatic arthritis. In some cases an osseo-labral fragment may become incarcerated in the joint that is not readily visualized preoperatively. In place of open surgery, hip arthroscopy permits a technique to remove loose bodies and repair labral tears to restore joint congruity and achieve fracture reduction and fixation.

Tissue engineering and the future of hip cartilage, labrum and ligamentum teres

As the field of hip arthroscopy continues to evolve, the biological understanding of orthopaedic tissues, namely articular cartilage, labral fibro-cartilage and the ligamentum teres continues to expand. Similarly, the need for biological solutions for the pre-arthritic and early arthritic hip continues to be a challenge for the sports medicine surgeon and hip arthroscopist. This article outlines existing biological and tissue-engineering technologies, some being used in clinical practice and other technologies being developed, and how these biological and tissue-engineering principals may one day influence the practice of hip arthroscopy. This review of hip literature is specific to emerging biological technologies for the treatment of chondral defects, labral tears and ligamentum teres deficiency. Of note, not all of the technologies described in this article have been approved by the United States Food and Drug Administration and some of the described uses of the approved technologies should be considered ‘off-label’ uses.

Basic Hip Arthroscopy: Anatomic Establishment of Arthroscopic Portals Without Fluoroscopic Guidance.

Hip arthroscopy has gained popularity in recent years for diagnostic and therapeutic hip preservation management. This article details the establishment of arthroscopic portals of the hip, specifically the anterolateral and modified anterior portals without fluoroscopic guidance. The anterolateral portal is established anatomically, and the modified anterior portal is then established under arthroscopic guidance. A through understanding of the hip anatomy allows for these portals to be made both safely and reliably for hip arthroscopies in the modified supine positioned patient. The reduced use of fluoroscopy with this technique lowers the risk of ionizing radiation exposure to the patient and surgeon.

Arthroscopic Excision of Acetabular Osteoid Osteoma: Computer Tomography–Guided Approach

Osteoid osteoma is a benign osteoblastic tumor that occurs in the subcortical shaft and metaphysis of the long bones of the lower extremities; however, intra-articular lesions are also possible. Intra-articular osteoid osteomas are rare, and clinical symptoms are often less specific and, thereby, may lead to misdiagnosis. The definitive treatment for osteoid osteoma is the excision of the nidus. We present the case of a 23-year-old man with a 4-year history of right anterior hip pain, subsequently diagnosed with a subarticular osteoid osteoma located in the right anterior acetabulum. Hip arthroscopic excision of the juxta-articular osteoid osteoma is presented as an effective treatment, with the advantage of less potential damage to normal bone and cartilage, as well as the additional benefits available with hip arthroscopy.

Arthroscopic treatment of slipped capital femoral epiphysis screw impingement and concomitant hip pathology.

Impingement caused by screws used for stabilization of slipped capital femoral epiphysis can be treated arthroscopically. Although troublesome screws have traditionally been removed by open techniques, arthroscopic removal can successfully be achieved. In addition to affording the patient the benefits of minimally invasive surgery, surgeons also have the ability to arthroscopically address any concomitant hip pathology responsible for pain, including femoroacetabular impingement and labral tears.

Basic Hip Arthroscopy: Diagnostic Hip Arthroscopy

Hip arthroscopy is increasing in popularity for the diagnosis and management of hip preservation. The basics of hip arthroscopy positioning, fluoroscopic assessment, and portal establishment are reviewed in the first 2 parts of this series. This article is the third installment in which we describe a systematic approach to performing a diagnostic hip arthroscopy. A mastery of diagnostic arthroscopy is necessary for surgeons treating hip disorders.

Single-Portal Arthroscopy of the Central Compartment of the Hip

Since hip arthroscopy has become a standard of orthopaedic practice, the indications have continued to expand as it has proved to be a helpful diagnostic, as well as therapeutic, tool. Access to the hip joint, however, remains challenging for the orthopaedic surgeon who does not routinely perform hip arthroscopy. We present a single-portal arthroscopic technique, showing the feasibility of single-portal arthroscopic access to the hip joint, as well as describing basic indications and instrumentation for single-portal hip arthroscopy. Single-portal hip arthroscopy is ideal for the patient who needs to undergo diagnostic hip arthroscopy or for treatment in patients with simple hip pathology (e.g., removal of loose bodies or debridement).

Hip Pathology: Overload Syndromes

It is our belief that overload syndromes of the hip joint occur due to abnormal anatomy, which results in mechanical changes of motion and the displacement of force. There are several anatomical and pathologic processes (both intra- and extra-articular) that result in an abnormal hip joint. Due to the variety of initiating pathology, overload syndromes of the hip can present in a multitude of complaints and subsequent diagnoses involving both the hip (labral tears, instability, subluxation) and surrounding structures (osteitis pubis, lumbar spine pain, unilateral sacroiliac joint pain). Regardless of the inciting cause, these symptoms occur because the patient’s anatomy allows for too much movement within the hip joint (laxity) and/or not enough movement (impingement or stiffness). As the patient repetitively stresses their hip, they not only develop symptoms but an accumulative effect that can ultimately result in additional pathology. This chapter thus demonstrates a “unified hip theory,” exhibiting how overload of the hip may result in a multitude of pathologies and subsequently a variety of symptoms.