Extract
Over the last decade, the management of hip injuries has evolved
substantially due to the advancement of techniques in arthroscopy and
diagnostic tools such as magnetic resonance imaging. Arthroscopy of the hip
remains a challenge due to the osseous and soft-tissue constraints of the hip.
Currently, various hip lesions, including labral tears, loose bodies,
femoroacetabular impingement, coxa saltans (snapping hip syndrome), ligamentum
teres injuries, and capsular laxity, can be successfully treated
arthroscopically. As continued improvements are made in surgical techniques
and in specifically designed instrumentation for the hip, the indications for
arthroscopy will continue to increase and arthroscopy of the hip will become a
standard procedure performed by an increasing number of orthopaedic
surgeons.
Over the last decade, the management of hip injuries has evolved
substantially due to the advancement of techniques in arthroscopy and
diagnostic tools such as magnetic resonance imaging. Arthroscopy of the hip
remains a challenge due to the osseous and soft-tissue constraints of the hip.
Currently, various hip lesions, including labral tears, loose bodies,
femoroacetabular impingement, coxa saltans (snapping hip syndrome), ligamentum
teres injuries, and capsular laxity, can be successfully treated
arthroscopically. As continued improvements are made in surgical techniques
and in specifically designed instrumentation for the hip, the indications for
arthroscopy will continue to increase and arthroscopy of the hip will become a
standard procedure performed by an increasing number of orthopaedic
surgeons.
After reviewing this article, the reader should: (1) have a basic
understanding of the intra-articular and extra-articular hip disorders that
commonly occur in athletes; (2) be able to generate a differential diagnosis
for hip pain; (3) have a basic understanding of the relevant anatomy, patient
history, and physical examination findings for an athlete who presents with
hip pain; and (4) be able to identify normal and abnormal findings on
radiographic and magnetic resonance imaging studies.
The differential diagnosis of hip pain in an athletic patient is quite
broad (Table I). A complete
history and physical examination are necessary in order to determine the
source and cause of the pain. It is still common to ascribe hip pain in an
athlete to a muscle strain or a soft-tissue contusion. However, hip pain may
arise from a number of soft-tissue structures in and around the hip joint, and
it is important to be able to differentiate extra-articular from
intra-articular abnormalities. The physician should elicit information from
the patient with regard to the specific location of the discomfort, the
qualitative nature of the discomfort (such as catching, clicking, instability,
stiffness, weakness, or decreased performance), the timing of the onset of
symptoms, the precipitating cause of symptoms, and any history suggesting
referred or systemic causes of hip
pain1. Byrd
described the "C sign," in which a patient cups his or her hand
above the greater trochanter in order to describe deep interior hip
pain2,3.
Back pain must be considered in the differential diagnosis and may exist in
combination with a hip disorder.
The key to the physical examination is to narrow down the differential
diagnosis to intra-articular pain, extra-articular pain, or central pubic
pain, which can be associated with athletic pubalgia (chronic groin pain on
exertion). Gait and posture should be assessed. The evaluation of posture and
limb position should focus on limb-length inequality, pelvic obliquity,
scoliosis, foot-progression angles, and muscle contractures. The examination
should begin with palpation of specific regions of the hip to localize
tenderness, to identify any areas of gross atrophy, and to delineate the
integrity of the muscular structures about the
hip4. When there is
an intra-articular disorder, palpable pain can rarely be elicited. Active and
passive range of motion should be evaluated with the patient in the supine
position5 and with
the hip flexed, and a complete neurovascular examination should be
performed.
Several additional tests can be performed to identify specific hip
disorders. Log rolling of the lower limb back and forth is a specific test for
intra-articular hip
pain2,3.
The Thomas test is used to evaluate the presence of a hip flexion contracture
by eliminating the effects of excessive lumbar lordosis on the perceived
extension of the
hip6. Painful
flexion, adduction, and internal rotation of the hip can indicate
femoroacetabular impingement or labral tears, especially if groin pain or
clicking is present. The FABER (flexion, abduction, and external rotation)
test is used to distinguish a sacroiliac problem or psoas pain and tightness
from hip disorders and is performed by placing the ankle on the affected side
across the nonaffected thigh (the figure-of-four position) to create flexion,
abduction, and external rotation of the affected hip. The McCarthy hip
extension sign will help distinguish if the pain is intraarticular and is
performed by placing both hips in flexion; the patient's pain will be
reproduced by extending the affected hip first in external rotation and then
in internal
rotation7,8.
Several tests have been described to detect piriformis
syndrome9-12.
At our institution, we most commonly place patients in a seated position and
have them perform active external rotation of the hip, against resistance,
from a position of full passive internal
rotation13.
Patients with dysplasia often have a positive anterior apprehension test (pain
with extension and external
rotation)14.
On the basis of the history and physical examination, various categories
can be eliminated and the differential diagnosis further narrowed. The
conventional radiograph then can provide a great deal of information. In our
practice, we routinely make an anteroposterior radiograph of the pelvis, a
Dunn lateral radiograph (90° flexion, 20°
abduction)15,16,
and a false-profile
radiograph17.
Several radiographic indices have been described to differentiate normal from
abnormal osseous anatomy. The anteroposterior radiograph of the pelvis should
be carefully examined in order to exclude malalignment, impingement, subtle
fractures, or evidence of dysplasia. Osseous landmarks should be identified,
including the ilioischial line, the iliopectineal line, the anterior
acetabular wall, the posterior acetabular wall, the tear drop, and the
acetabular roof (sourcil). Careful attention should always be paid to the
femoral neck, including its cortical integrity and trabecular pattern, in
order to exclude the possibility of a nondisplaced fracture. A Dunn lateral
radiograph is useful for identifying a cam lesion associated with
femoroacetabular impingement, and a false-profile radiograph is useful in
evaluating coverage of the anterior portion of the femoral head. Radiographs
should be carefully scrutinized for deviations from normal osseous anatomy,
and the joint space should be assessed on all three radiographic views.
Radiographic indices should include the femoral neck-shaft angle, the
Tönnis angle (Fig.
1)18,19,
the center-edge angle of
Wiberg19,20
(Fig. 2), femoral head-neck
offset, and the acetabular
version18,20,21
(Fig. 3). Siebenrock et al.
studied the effect of pelvic tilt on acetabular version and demonstrated that
radiographic signs of acetabular retroversion, such as the so-called crossover
sign and the posterior wall sign, are inaccurate if pelvic inclination is not
taken into
account22. They
recommend making anteroposterior radiographs of the pelvis in neutral rotation
and in a standardized position of pelvic inclination, which is indicated by
the distance between the symphysis and the sacrococcygeal joint (approximately
32 mm in men and 47 mm in
women)22.
Despite a thorough history and physical examination, it is oftentimes
difficult to distinguish extra-articular from intra-articular pain. In nearly
all patients with hip pain, a fluoroscopically or ultrasound-guided
intra-articular injection of anesthetic medication is invaluable as a tool to
determine if the hip pain is due to an intra-articular abnormality of the hip
joint. A positive response to an intra-articular injection has been shown to
be a 90% reliable indicator of an intra-articular
abnormality23.
For patients who have been diagnosed with symptomatic femoroacetabular
impingement, a computed tomography scan with three-dimensional reconstructed
images may be acquired preoperatively to better assess the osseous
abnormalities and determine how much resection is necessary. In addition, if
excessive anteversion or retroversion is suspected, a magnetic resonance
imaging or computed tomography study may be acquired to assess femoral
version.
Traditionally, magnetic resonance imaging of the hip was performed with use
of a large-body coil within the magnet bore in order to detect an occult
fracture or osteonecrosis, but this method provided very poor in-plane
resolution and little or no detail of the labrum or the articular cartilage.
More recently, higher spatial resolution has been achieved with use of surface
coils. Because hip pain can come from many sources, every magnetic resonance
imaging study of the hip that we perform at our institution includes a
screening examination of the whole pelvis, acquired with use of coronal
inversion recovery and axial proton density sequences. Detailed hip imaging is
obtained with use of a surface coil over the hip joint, with high-resolution
cartilage-sensitive images acquired in three planes (sagittal, coronal, and
oblique axial) with use of a fast-spin-echo pulse sequence and an intermediate
echo time. Many authors advocate the use of magnetic resonance arthrography of
the hip for evaluation of labral pathology and articular
cartilage24-26.
However, this increases the cost and imaging time and also converts magnetic
resonance imaging into an invasive
procedure27. Mintz
et al.28 used an
optimized protocol to evaluate ninety-two patients prior to hip arthroscopy
and concluded that noncontrast imaging can identify labral and chondral
disorders noninvasively. Given the complex three-dimensional geometry of the
hip joint, magnetic resonance imaging should utilize all three standardized
planes of imaging (coronal, sagittal, and axial). In all three planes, the
articular cartilage will appear as an intermediate signal overlying the
low-signal cortical bone when fast-spin-echo sequences are obtained.
The sagittal images are best used to evaluate the weight-bearing portion of
the femoral head and acetabulum. These images are optimal for the evaluation
of the anterior aspect of the labrum (Figs.
4-A, 4-B, and 4-C). The coronal images are best used to evaluate
the weight-bearing, suprafoveal margin of the head and dome and to evaluate
the superior portion of the labrum. These images also demonstrate the
trochanteric bursa and the tendinous insertions of the gluteus medius and
minimus and the muscle bellies of the obturator internus, obturator externus,
quadratus femoris, and adductors (Figs. 5-A
through 5-D). The oblique axial plane is oriented along the long
axis of the femoral neck and allows evaluation of the anterolateral portion of
the femoral neck. The degree of cam impingement can be quantified by
calculating the alpha angle, which measures the loss of offset at the
head-neck
junction29
(Figs. 6-A and 6-B).
Nötzli et al. evaluated the magnetic resonance imaging scans of
thirty-nine patients who had a positive impingement test and groin pain
compared with the scans of thirty-five asymptomatic control patients and
demonstrated that the average alpha angle was 74° for patients with
impingement compared with 42° for control
patients29. Axial
images are most useful to identify the regional neurovascular bundles;
specifically, the sciatic nerve and the obturator and femoral neurovascular
bundles, where the nerves are seen in cross section and discrete fascicles can
be discerned. Axial images are also useful to identify the posterior portion
of the labrum, which can be associated with a previous hip subluxation or
dislocation (Figs. 7-A through
7-D).
As recent literature has emerged to support the association between
acetabular labral tears and early onset arthritis of the
hip30,31,
interest in arthroscopic management of labral disorders of the hip has
expanded. Labral tears and related conditions can arise from a variety of
different causes, which are reviewed here.
Traumatic Labral Tears
Classically associated with major trauma to the hip, such as posterior
dislocation, traumatic labral tears are now also more commonly being diagnosed
with magnetic resonance imaging in athletes, who may experience pain or a
feeling of catching after a minor twisting or slipping injury
(Fig. 8). Alternatively, tears
may stem from more chronic repetitive activities and from the lower-extremity
stances assumed during sports activity, especially when such activity includes
hyperflexion. Although episodes of discrete and major trauma that lead to
tears have most often been associated with disorders of the posterior portion
of the
labrum32,33,
it is the anterior portion of the labrum that has been demonstrated to be more
frequently torn in most North American series, which have tended to include
large subsets of athletes as
patients28,31.
Femoroacetabular Impingement
Femoroacetabular impingement is a well-described pathologic condition that
can lead to osteoarthritis of the
hip34. The first
category of femoroacetabular impingement is the camtype lesion, which is
caused by shear forces of the nonspherical portion of the femoral head against
the acetabulum. This results in a characteristic pattern of anterosuperior
cartilage loss over the femoral head and corresponding dome, as well as labral
tears (Figs. 9-A through 9-D).
Predisposing factors that have been associated with femoroacetabular
impingement include slipped capital femoral epiphysis, abnormal extension of
the femoral head epiphysis, malunion of a femoral neck or head fracture, and
femoral
retroversion34-38.
The second category of femoroacetabular impingement is the pincer-type
lesion, which is a result of repetitive contact stresses of a normal femoral
neck against an abnormal anterior acetabular rim as a result of so-called
overcoverage, which results in degeneration, ossification, and tears of the
anterosuperior portion of the labrum as well as the characteristic
posteroinferior "contre-coup" pattern of cartilage loss from the
femoral head and corresponding
acetabulum39. In
this setting, the acetabular labrum fails first, which leads to degeneration
and eventual ossification, which worsens the overcoverage. Several conditions
may predispose to pincer-type impingement, including acetabular protrusio,
acetabular retroversion, malunion of an acetabular fracture, or overcoverage
secondary to previous surgery, such as can occur with a periacetabular
osteotomy36.
Overall, the pincer-type lesion has limited chondral damage compared with the
deep chondral injury that is associated with cam-type impingement.
Although isolated femoral-side or acetabular-side impingement can occur,
the majority of cases of femoroacetabular impingement involve a combination of
lesions. Beck et al. analyzed 302 hips and found that only 9% had isolated cam
impingement and 5% had isolated pincer
impingement40. The
majority of cases (86%) had a combination of femoral and acetabular
lesions.
Capsular Laxity and Hypermobility of the Hip
Labral tears may also arise in patients who have inherent hypermobility of
the hip, which predisposes them to labral microtrauma, degeneration, and
possibly separation, over the course of
time41,42.
Capsular laxity may be secondary to an underlying soft-tissue disorder, such
as Marfan syndrome or Ehlers-Danlos syndrome, or may represent a physiologic
variant in patients with generalized hypermobility. Magnetic resonance imaging
can show a redundant capsule; however, optimal surgical treatment strategies
for these conditions have not yet been fully elucidated.
Hip Dysplasia
The shallow acetabulum associated with hip dysplasia causes subluxation and
abnormal contact stresses of the femoral head on the labrum, which can show
varying degrees of degeneration, frank tearing, or detachment. While few
arthroscopic options exist to address the osseous pathology inherent in
dysplastic hips, arthroscopic débridement of labral tears may provide
symptomatic
relief43. However,
the literature is relatively devoid of studies demonstrating such results in
this patient population, for whom open acetabular osteotomy remains a
reasonable, well-described surgical alternative for selected
patients44,45.
Psoas Impingement
Labral tears typically occur anterosuperiorly in association with
femoroacetabular impingement or dysplasia. Less commonly, labral injury may
occur in an atypical anterior location in the absence of osseous
abnormalities. This pattern of injury is related to compression of the
anterior capsulolabral complex by the psoas tendon where it crosses the
acetabular rim. This injury may be treated with either labral
débridement or repair combined with a partial psoas release at the site
of compression.
Degenerative Labral Tears
As osteoarthritis of the hip progresses in severity, the degenerative
process may affect the health of the labrum as well as the cartilage.
Arthroscopic débridement of osteophytes and a frayed or loose labrum
can relieve mechanical symptoms in some
patients46, but
research has suggested that even early degenerative joint disease is
associated with significantly worse outcomes (p < 0.0001) following hip
arthroscopy than the outcome seen in patients with nonosteoarthritic hips, and
the procedure on such patients should be considered with
caution47.
Hip instability can be traumatic or atraumatic in origin. Traumatic
instability ranges from subluxation to dislocation with or without concomitant
injuries and may occur in athletic competition secondary to a forward fall on
the knee while the hip is flexed or a blow from behind while the athlete is
down on all four
limbs48. Hip
dislocations have been reported in American football, rugby, basketball,
soccer, biking, skiing, gymnastics, and
jogging49-51.
Once the diagnosis of a hip dislocation is made, a fracture of the femoral
neck must be ruled out followed by urgent reduction to minimize long-term
complications such as
osteonecrosis52-54.
Due to the relatively low-energy mechanism of injury, most hip dislocations
sustained during athletic activities are pure dislocations with either no
associated fractures or only small fractures of the acetabular rim. Hip
arthroscopy has recently provided a new way to address loose bodies, chondral
injuries, and femoral head and labral
disorders55,56.
Traumatic posterior subluxation of the hip is a potentially devastating
injury that may be misdiagnosed as a simple hip sprain or strain. The
mechanism of injury is similar to a hip dislocation but, due to less energy,
the hip subluxates rather than dislocates. The radiographic workup should
include oblique radiographs to evaluate for a fracture of the posterior lip.
Magnetic resonance imaging has played an important role in the evaluation of
traumatic instability. Moorman et
al.57, who
performed magnetic resonance imaging on seven American football players in
whom traumatic posterior subluxation of the hip was suspected, defined a
characteristic triad of findings that included hemarthrosis, a posterior
acetabular lip fracture, and an iliofemoral ligament disruption
(Figs. 10-A, 10-B, and 10-C).
Aspiration of the hip under fluoroscopy to decrease intracapsular pressure may
be warranted. Arthroscopic intervention is useful for the removal of loose
bodies and for the treatment of labral pathology and chondral injuries.
Magnetic resonance imaging is also useful in detecting osteonecrosis and thus
serves as a useful aid in the decision-making process with regard to when or
even whether an athlete can return to play.
Figure 11 provides a general
treatment algorithm for the management of subluxation or dislocation of the
hip in
athletes55.
Disorders of the lateral or peritrochanteric space, previously grouped into
the "greater trochanteric pain syndrome," can now be addressed
endoscopically58-65.
Recalcitrant trochanteric bursitis, external coxa saltans, and gluteus medius
or minimus tears are three entities that can be treated effectively with this
technique.
Trochanteric Bursitis
Trochanteric bursitis is characterized by chronic aching pain of an
intermittent nature over the lateral aspect of the hip. Diagnosis is confirmed
by history, physical examination, and the response to injections. Although
magnetic resonance imaging is not necessary to make the diagnosis,
fluid-sensitive images may reveal increased signal intensity of the
trochanteric bursa.
External Snapping Hip (Coxa Saltans)
This condition results when a thickened portion of the posterior margin of
the iliotibial band or the anterior gluteus maximus tendon slides over the
greater trochanter. With the hip extended, this band lies posterior to the
greater trochanter and slides anteriorly over it during hip flexion. Diagnosis
is confirmed by history, physical examination, and dynamic ultrasound display
of real-time images of the iliotibial band snapping over the greater
trochanter.
Tears of the Gluteus Medius or Minimus
Tears of the gluteus medius or minimus tendons share similarities to tears
of the rotator cuff tendons in the shoulder. As with rotator cuff tears in the
shoulder, it has been hypothesized that gluteal tears are associated with
increasing
age66,67.
Physical examination reveals a slight Trendelenburg gait, pain, and weakness
with resisted abduction of the hip when compared with the contralateral
extremity. The combination of abductor weakness, persistence of symptoms after
conservative treatment, and a positive magnetic resonance imaging result that
shows increased signal in the tendon confirms the diagnosis of gluteus medius
tears.
The surgical techniques for hip arthroscopy in the supine and lateral
position have been well
described2,68-71.
In this review, we will focus on the arthroscopic anatomy and techniques of
the peritrochanteric space. The peritrochanteric space, or lateral compartment
of the hip, can be easily entered after routine evaluation and treatment of
central and peripheral compartment disorders have been performed.
The same portals used to treat central and peripheral compartment disorders
can be used to gain access to the peritrochanteric space. The first portal
used is the anterior portal (Fig.
12). It provides the best access into the peritrochanteric space
and allows for orientation to the anatomic landmarks. The portal is placed 1
cm lateral to the anterior superior iliac spine within the interval between
the tensor fasciae latae and the sartorius. The canula is then swept back and
forth between the iliotibial band overlying the trochanteric bursa and the
greater trochanter and is freely mobile in this space.
A distal posterior portal is placed between the tip of the greater
trochanter and the vastus tubercle along the posterior one-third of the
greater trochanter. A third portal can be placed proximal to the tip of the
greater trochanter in line with the distal posterior portal. Proper portal
placement is critical to visualizing the peritrochanteric space, and the
surgeon must first be familiar with the anatomic landmarks of the lateral
compartment of the hip.
On entry into the space, the surgeon first must become oriented to the
gluteus maximus insertion at the linea aspera and visualize the vastus
lateralis (Fig. 13).
Inspection proceeds proximally and anteriorly from the vastus lateralis to the
gluteus minimus. The fibers of the gluteus medius are found just posterior to
the minimus and can be probed to visualize any possible tears at the abductor
tendon insertion. Finally, the arthroscope is directed laterally toward the
iliotibial band (Fig. 14). In
hips with recalcitrant trochanteric bursitis, a shaver can be used to
débride the trochanteric bursa alone, which can provide soft-tissue
decompression and relieve symptoms.
If snapping of the iliotibial band (external coxa saltans) has been
refractory to nonoperative treatment, a release can be performed along the
posterolateral portion of the greater trochanter, beginning at the vastus
tubercle insertion and extending to the tip of the greater trochanter in a
z-type manner (Fig. 15).
Variations of this technique may be performed on the basis of instrumented
palpation of the fibers under the greatest amount of tension.
The gluteus medius tendon can be examined in a manner similar to the
examination of the subacromial space of the rotator cuff in the shoulder
(Fig. 16). When a repairable
tear is identified, the edges are débrided and the attachment site of
the tendon to the greater trochanter is prepared with a full-radius shaver in
a manner similar to preparation of the rotator cuff footprint. Suture anchors
are placed into the footprint of the abductor in a standard fashion.
Fluoroscopy is helpful in directing the anchors in the appropriate direction.
Once the anchors are placed, the sutures are retrieved and passed sequentially
through the edges of the gluteus medius tendon with a suture-passing device
and tied under arthroscopic visualization with an arthroscopic knot pusher
(Fig. 17).
Our current experience has been promising with regard to the use of
arthroscopic bursectomy in the treatment of recalcitrant trochanteric
bursitis, iliotibial band release in the treatment of external coxa saltans,
and decompression of the peritrochanteric space and suture-anchor tendon
repair to the greater trochanter in the treatment of focal isolated tears of
the gluteus medius and minimus tendons. These entities have classically been
treated in an open surgical manner. As knowledge of arthroscopic anatomy of
the hip, imaging modalities, and clinical examination improves, diseases of
the lateral peritrochanteric space of the hip will be more effectively
treated.
Arthroscopy of the hip is a rapidly evolving field that has shown promising
results in the short term. With use of this modality, conditions such as
labral tears, loose bodies, femoroacetabular impingement, coxa saltans,
ligamentum teres injuries, and capsular laxity have been treated successfully.
As the indications for hip arthroscopy continue to increase, further studies
are necessary in order to test the long-term effectiveness of these
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