J. W. Thomas Byrd

Hip arthroscopy utilizing the supine position.

The purpose of this article is to demonstrate the merits of the supine position in arthroscopic surgery about the hip. Twenty consecutive patients successfully underwent arthroscopy by this technique. The procedure is performed on a standard fracture table with fluoroscopy. Traction is used to distract the hip for introduction of the instruments. Three standard arthroscopic portals are routinely used. Two portals are placed laterally over the superior aspect of the greater trochanter, and one is placed anteriorly. The procedure is effective and reproducible. It is user friendly to both the surgeon and the operating room staff. Additionally, the procedure uses existing operating room equipment with only minor modifications.

Diagnostic Accuracy of Clinical Assessment, Magnetic Resonance Imaging, Magnetic Resonance Arthrography, and Intra-articular Injection in Hip Arthroscopy Patients

Background Hip arthroscopy has defined elusive causes of hip pain. Hypothesis/Purpose It is postulated that the reliability of various investigative methods is inconsistent. The purpose of this study is to evaluate the diagnostic accuracy of these methods. Study Design Retrospective review of prospectively collected data. Methods Five parameters were assessed in 40 patients: clinical assessment, high-resolution magnetic resonance imaging, magnetic resonance imaging with gadolinium arthrography, intra-articular bupivacaine injection, and arthroscopy. Using arthroscopy as the definitive diagnosis, the other parameters were evaluated for reliability. Results Hip abnormality was clinically suspected in all cases with 98% accuracy (1 false positive). However, the nature of the abnormality was identified in only 13 cases with 92% accuracy. Magnetic resonance imaging variously demonstrated direct or indirect evidence of abnormality but overall demonstrated a 42% false-negative and a 10% false-positive interpretation. Magnetic resonance arthrography demonstrated an 8% false-negative and 20% false-positive interpretation. Response to the intra-articular injection of anesthetic was 90% accurate (3 false-negative and 1 false-positive responses) for detecting the presence of intra-articular abnormality. Conclusions In this series, clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature. Magnetic resonance arthrography was much more sensitive than magnetic resonance imaging at detecting various lesions but had twice as many false-positive interpretations. Response to an intra-articular injection of anesthetic was a 90% reliable indicator of intra-articular abnormality.

Hip arthroscopy: An anatomic study of portal placement and relationship to the extra-articular structures

The purpose of this study is to accurately describe the relationship of the major neurovascular structures to standard portals used in hip arthroscopy. Placement of three standard arthroscopic portals was simulated in eight fresh paired cadaveric hip specimens by placing Steinmann pins into the joint under fluoroscopic control. The specimens were then dissected and the relationship of the portals to the following structures was recorded: lateral femoral cutaneous nerve, femoral nerve, ascending branch of the lateral circumflex femoral artery, superior gluteal nerve, and sciatic nerve. The lateral femoral cutaneous nerve had divided into three or more branches at the level of the anterior portal. The anterior portal averaged only 0.3 cm from one of these branches. The average minimum distance from the anterior portal to the femoral nerve was 3.2 cm. The ascending branch of the lateral circumflex femoral artery averaged 3.7 cm from the anterior portal. A terminal branch of this vessel was present in three specimens 0.3 cm from the portal. The superior gluteal nerve averaged 4.4 cm superior to the anterolateral and posterolateral portals. The sciatic nerve averaged 2.9 cm from the posterolateral portal. From this study, these portal placements appear to be safe. Proper positioning depends on careful attention to the topographical anatomy about the hip. Avoidance of the important structures depends on proper positioning and proper technique in portal placement.

Labral lesions: an elusive source of hip pain case reports and literature review.

Three cases are presented highlighting varied aspects of labral lesions as a primary or contributing source of mechanical hip pain; including one chronic labral tear associated with old trauma, an acutely entrapped labrum, and a degenerative labral tear associated with osteoarthritis. The diagnosis of labral lesions may be elusive. Arthrography, double-contrast arthrography followed by computerized tomography, and magnetic resonance imaging all have been reported in the assessment of these lesions with variable success. Often, the clinical presentation, including history and physical examination, will yield useful information. A fluoroscopically guided intra-articular injection of the hip is a very useful diagnostic tool for differentiating an intra-articular source of hip symptoms, such as labral lesions, from an extra-articular source. Labral tearing can readily be assessed by arthroscopy and many can be successfully addressed by operative arthroscopy. However, there are many variations in the arthroscopic anatomy of the acetabular labrum.

The Development and Validation of a Self-Administered Quality-of-Life Outcome Measure for Young, Active Patients With Symptomatic Hip Disease: The International Hip Outcome Tool (iHOT-33)

PURPOSE The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders. METHODS This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥ 4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients). RESULTS Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points. CONCLUSIONS We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up

PURPOSE We report the results of arthroscopic management of femoroacetabular impingement with 2-year follow-up. METHODS All patients undergoing hip arthroscopy were prospectively assessed with the modified Harris Hip Score. Arthroscopic correction of femoroacetabular impingement was first performed in 2003. The cohort of this study consists of the first 100 consecutive cases that had achieved 2-year follow-up. RESULTS There was 100% follow-up at 2 years. The mean age was 34 years (range, 13 to 76 years), with 67 male and 33 female patients. There were 63 cam, 18 pincer, and 19 combined lesions. Acetabular articular damage was found in 97 cases, femoral damage was present in 23, and there were 92 labral tears. The median improvement was 21.5 points, with 79 good and excellent results. No patient required revision to total hip arthroplasty, but 6 patients underwent a subsequent arthroscopic procedure. There were 3 complications including a transient neurapraxia of the pudendal nerve and a transient neurapraxia of the lateral femoral cutaneous nerve, which resolved uneventfully, and 1 mild case of heterotopic ossification. CONCLUSIONS We report favorable outcomes for the arthroscopic management of femoroacetabular impingement in our early experience in the first 100 consecutive cases. The high incidence of significant articular damage observed at the time of arthroscopic intervention is concerning.

A geographic zone method to describe intra-articular pathology in hip arthroscopy: cadaveric study and preliminary report.

PURPOSE Our purpose was to develop an alternative method to divide the acetabulum and femoral head into different zones based on anatomic landmarks clearly visible during arthroscopy to facilitate reporting the geographic location of intra-articular injuries. METHODS Two vertical lines are positioned across the acetabulum aligned with the anterior and posterior limits of the acetabular notch. A horizontal line is positioned aligned with the superior limit of the notch perpendicular to the previous lines. The lines divide the acetabulum into 6 zones. Numbers are assigned to each zone in consecutive order. Zone 1 is the anterior-inferior acetabulum. The numbers progress around the notch until zone 5 is assigned to the posterior-inferior acetabulum. Zone 6 is the acetabular notch. The same method is applied to the femoral head. Six experienced hip arthroscopists were instructed in the zone and clock-face methods and were asked to identify and describe the geographic locations of lesions at the acetabular rim, acetabular cartilage, and femoral head in the same cadaveric specimen. RESULTS The zone method was more reproducible than the clock-face method in the geographic description of intra-articular injuries on the acetabulum and the femoral head. CONCLUSIONS Among a group of expert hip arthroscopists, the zone method was more reproducible than the clock-face method. CLINICAL RELEVANCE The presented method divides the acetabulum into 6 different zones based on the acetabular notch. The zones are the same for right- and left-side hips. The same method is applied for the femoral head allowing, for the first time, a geographic description of pathology.

Hip Arthroscopy in Athletes: 10-Year Follow-Up

Background Arthroscopy is a well-accepted technique in the management of many athletic-related hip disorders, yet little quantitative outcomes data have been reported. Purpose To report the results of hip arthroscopy in a consecutive series of athletes with 10-year follow-up. Study Design Case series; Level of evidence, 4. Methods Since 1993, all patients undergoing hip arthroscopy at our institution have been prospectively assessed with a modified Harris hip score preoperatively and then postoperatively at 1, 3, 6, 12, 24, 60, and 120 months or until a subsequent procedure was performed. The variables studied included age, sex, type of sport, level of sport, diagnosis, duration of symptoms, onset of symptoms, and center edge angle. Fifty-two procedures were performed on 50 patients who had achieved 10-year follow-up. Fifteen patients developed symptoms in the course of athletic activities and their cases represent the substance of this study. Results Follow-up information was available for all 15 patients (11 men and 4 women). The average age was 31.7 years (range, 14–70 years). Type of sport involved included football (3), tennis (3), basketball (2), golf (2), and others (5); with 9 recreational, 4 high school, and 2 intercollegiate athletes. Diagnoses included chondral damage (8), labral tear (7), arthritis (5), avascular necrosis (1), loose body (1), and synovitis (1). The median improvement in the modified Harris hip score was 45 points (from 51 preoperatively to 96, on the 100-point scale), with 13 patients (87%) returning to their sport. All 5 athletes with arthritis eventually underwent total hip arthroplasty at an average of 6 years. There were no complications. Conclusion Arthroscopy to address hip injuries in athletes can result in substantial improvement with durable results. However, arthritis is a prognostic indicator of poor long-term outcomes.

Arthroscopic Surgery for Isolated Capitellar Osteochondritis Dissecans in Adolescent Baseball Players Minimum Three-Year Follow-Up

Background Osteochondritis dissecans of the capitellum of the humerus usually occurs in adolescence and is caused by the valgus forces associated with excessive throwing. Hypothesis Arthroscopic surgery is an appropriate procedure for this condition. Study Design Retrospective cohort study. Methods Arthroscopic surgery was performed on 10 baseball players (average age, 13.8 years) with osteochondritis dissecans whose symptoms had been apparent for an average of 9 months before the operation. Follow-up at an average of 3.9 years included use of a standard rating scale, radiographs, and a questionnaire regarding return to sport. Results There were two grade I, one grade II, two grade IV, and five grade V lesions. Symptoms and objective findings correlated poorly with the grade of the lesion. The postoperative score averaged 195, reflecting excellent results. Radiographically, the primary lesion was still apparent in one patient, secondary degenerative changes were evident in one patient, and, in one patient, the lesion was still evident and degenerative changes had occurred. Only four athletes returned to organized baseball. Conclusions Arthroscopic surgery for symptomatic osteochondritis dissecans of the capitellum in adolescent baseball players can provide excellent rating scores with intermediate follow-up but does not assure return to baseball.

Traction versus distension for distraction of the joint during hip arthroscopy

Distraction is the most popular technique used in hip arthroscopy. It has been postulated that, if adequate distraction cannot initially be achieved with traction, it will be overcome by distension. The purpose of this study is to quantitate the additive effects of traction and distension in achieving distraction of the hip joint for arthroscopy. Eleven consecutive patients undergoing hip arthroscopy in the supine position on a fracture table were studied. Radiographs of the hip were obtained before and immediately after applying 50 pounds of traction. The hip was then immediately distended with 40 mL saline, and a third radiograph was obtained. After correcting for magnification, distraction was measured for traction alone (DT) and traction plus distension (DTD). A paired t-test was used to compare DT and DTD. Additionally, the ratio of distraction attributed to distension was compared with distraction attributed to traction ([DTD--DT]/DT) and was defined as the delta percent (delta %). Adequate distraction for arthroscopy was able to be achieved in all cases. Distraction due to traction alone (DT) ranged from 2.8 mm to 10.3 mm, with an average of 6.2 mm. Distraction due to traction plus distension (DTD) ranged from 4.8 m to 10.3 mm, with an average of 7.2 mm. The difference between DT and DTD was statistically significant (P < .05). The change in distraction due to distension (delta %) ranged from 0% to 81% with an average of 22%. This study shows that distension may facilitate distraction but the degree is variable.