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ip Arthroscopy in Athletes.W. Thomas Byrd, MD

Arthroscopy has defined numerous elusive causes of disabling hip pain. In the past,athletes were resigned to living within the constraints of their symptoms, often relinquish-ing their competitive athletic careers. The most common lesions include labral pathology,articular damage, and disruption of the ligamentum teres. Careful clinical assessment isreliable at determining the existence of hip joint pathology, although variable in determiningits nature. Arthroscopy is effective at addressing numerous lesions, often allowing suc-cessful resumption of the athlete’s competitive career. This article details the assessmentof hip joint problems in the athlete with numerous illustrative examples highlighting variousforms of pathology that can be addressed.Oper Tech Sports Med 13:24-36 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS hip arthroscopy, athletes

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ports-related injuries to the hip joint have received rela-tively little attention. This trend is changing, but, until

ecently, there have been few publications in peer-reviewedournals and the topic has rarely been presented at scientific

eetings. This is because of 3 reasons. First, perhaps hipnjuries are less common than other joints. Secondly, inves-igative skills for the hip have been less sophisticated includ-ng clinical assessment and imaging studies. Thirdly, thereave been fewer interventional methods available to treat theip including both surgical techniques and conservative mo-alities and thus there has been little impetus to delve intohis unrecognized area.

As the methods of arthroscopy for this joint have becomeore reliable, a plethora of intra-articular disorders have

een uncovered that previously went undiagnosed andargely untreated. Uncovering the existence of these disor-ers has led to improved clinical assessment skills and im-roved imaging technology. Thus, more forms of pathologyre being recognized and there are now more methods avail-ble to treat these injuries.

The indications for hip arthroscopy fall into 2 broad cate-ories. In one, arthroscopy offers an alternative to traditionalpen techniques previously used for recognized forms of hipathology such as loose bodies or impinging osteophytes. Inhe other, arthroscopy offers a method of treatment for dis-rders that previously went unrecognized including labralears, chondral injuries, and disruption of the ligamentum

ashville Sports Medicine and Orthopaedic Center, Nashville, TN.ddress reprint requests to J.W. Thomas Byrd, MD, Nashville Sports Med-

icine and Orthopaedic Center, 2011 Church Street, Suite 100, Nashville,

yTN 37203. E-mail: info@nsmoc.com

4 1060-1872/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.doi:10.1053/j.otsm.2004.09.007

eres. Most athletic injuries fall into this latter category. In theast, athletes were simply resigned to living within the con-traints of their symptoms, often ending their competitiveareers, diagnosed as a chronic groin injury. Based on theesults of arthroscopy among athletes, it is likely that many ofhese careers could have been rejuvenated with arthroscopicntervention.1

ssessmentn a study of athletes undergoing arthroscopy, in 60% of theases, the hip was not recognized as the source of symptomst the time of initial treatment and were managed for anverage of 7 months before the hip was considered as a po-ential contributing source.1 The most common preliminaryiagnoses were various types of musculotendinous strainsTable 1). Thus, it is prudent to consider the possibility ofntra-articular pathology in the differential diagnosis when

anaging a strain around the hip joint. However, the inci-ence of intra-articular pathology is probably quite smallelative to other extra-articular injuries, and thus it is best toemper the interest for an extensive intra-articular workupor every hip flexor or adductor strain. What is important ishoughtful follow-up and reassessment of injuries, especiallyhen they do not seem to be responding as expected.A careful history and examination will usually implicate

hether the hip is potentially the source of symptoms.2 Evenf the hip is recognized as the source of the symptoms, therere many causes of hip joint pain that resolve spontaneouslyith conservative treatment such as capsular sprains, trau-atic effusion in absence of structural damage, and other as

et poorly defined entities. Also of note, early diagnosis does

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FfiTpassshows a lateral labral tear (arrow). (C) Sagittal image of a left hipshows an anterior labral tear with associated paralabral cyst (arrow).(Figure © J.W. Thomas Byrd.)

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Hip arthroscopy in athletes 25

ot always mean early intervention. High resolution MRI andadolinium arthrographic techniques have increased sensi-ivity and specificity for intra-articular disorders; however,specially at the elite and professional levels, there are manythletes who will demonstrate evidence of pathology simplys a consequence of the cumulative effect of their sport. Thus,he first step in assessing a potential candidate for arthros-opy is often just providing an opportunity see if symptomsill subside with a trial of conservative treatment (Fig 1A-C).It is important to note that athletes who sustain an intra-

rticular injury to the hip will often not be disabled by theirymptoms. Especially among contact and collision sports, itay be difficult to recount precisely when the injury oc-

urred. Over time, it may become evident only as the symp-oms of a seemingly minor injury fail to resolve and increas-ngly affect performance. In general, mechanical symptomsuch as intermittent catching or locking or sharp, stabbing inature, are more likely to benefit from arthroscopy.3 Thoseho simply describe aching with activities or aching inde-endent of activities are less likely to respond well.Hip symptoms are most commonly referred to the anterior

roin and may radiate to the medial thigh. However, a veryharacteristic clinical feature which has been described is theC-sign.”2 A patient describing deep interior hip pain willften grip their hand above the greater trochanter with theirhumb lying posteriorly and the fingers cupped within thenterior groin. Casually viewed, it may appear that they areescribing lateral pain such as the iliotibial band or trochan-eric bursa, but characteristically, they are reflecting painithin the hip joint.On examination, log rolling the leg back and forth is theost specific maneuver for hip pathology since this rotates

nly the femoral head in relation to the acetabulum and cap-ule, not stressing any of the surrounding neurovascular orusculotendinous structures. More sensitive examinationaneuvers include forced flexion combined with internal

otation or abduction combined with external rotation. Flex-on with internal rotation is sometimes referred to as thempingement test.4 However, a joint irritated by a variety ofonditions will typically be painful with this maneuver, and

able 1 Preliminary Diagnoses (Other Than the Hip)

ip flexor strain (6)umbar disorder (5)nspecified muscle strain (4)dductor strain (3)

liopsoas tendinitis (2)rochanteric bursitis (2)amstring injury (2)iriformis syndrome (1)ciatica (1)I disorder (1)tress fracture (1)ontusion (1)alalignment (1)o not know (1)

hus it is not specific for impingement alone. It is postulated

igure 1 Three National Hockey League hockey players were re-erred, each with a 2-week history of hip pain after an injury on thece. Each case showed MRI evidence of labral pathology (arrows).hese cases were treated with 2 weeks of rest followed by a 2-weekeriod of gradually resuming activities. Each of these athletes wasble to return to competition and have continued to play for severaleasons without needing surgery. (A) Coronal image of a left hiphows a lateral labral tear (arrow). (B) Coronal image of a right hip

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26 J.W.T. Byrd

hat abduction with external rotation, translates the femoralead anteriorly, exacerbating symptoms associated the ante-ior labral pathology or subtle instability. These maneuversay normally be uncomfortable, so it is important to com-are the asymptomatic to the symptomatic side. Most impor-ant is not simply whether the maneuver is uncomfortable,ut whether it recreates the type of pain that the athletexperiences with activities. Sometimes, there may be an ac-ompanying click or pop. These may be indicative of pathol-gy but often occur in normal hips.For longstanding conditions, athletes may secondarily de-

elop extra-articular symptoms of tendinitis or bursitis oray simply have coexistent extra-articular pathology. A veryseful test for distinguishing the intra-articular origin ofymptoms is a fluoroscopically guided intra-articular injec-ion of anesthetic. The hallmark is temporary alleviation ofymptoms during the anesthetic effect. However, it is essen-ial that the athlete be able to perform activities that willredictably create pain before the injection to substantiatehe response to the anesthetic. If their symptoms are inter-ittent or unpredictable, then it is difficult to confirm that

bsence after the injection is solely attributable to the anes-hesia. With the more recent technology of gadolinium ar-hrography combined with magnetic resonance imagingMRI), always be certain to include anesthetic with the injec-ion to gain this most useful diagnostic response.

Radiographs are an integral part of the assessment of hipnjuries. This should include an anteroposterior (AP) film ofhe pelvis centered low to assess the hip joints and a frogateral of the affected side. A properly centered pelvis film isssential to assess various radiologic measurements indica-ive of abnormal hip morphology, such as dysplasia or im-ingement. It also allows assessment of the surrounding areasnd comparison of the asymptomatic hip to judge subtleadiographic asymmetries. The frog lateral, although not arue lateral of the joint but simply a lateral of the proximalemur, serves well as a routine screening film. False profileiews and cross-table lateral radiographs may be necessaryor further defining specific conditions.

MRI necessitates a high resolution study including a 1.5-Tagnet with a surface coil to reasonably assess the intra-

rticular structures.5 Lesser quality studies (ie, small magnetr open scanner) are unreliable in assessing the joint otherhan obvious disease such as avascular necrosis. Conven-ional MRIs are getting better at discerning labral pathologyut remain poor at detecting associated articular lesions. Of-en, indirect evidence of pathology may be the most reliablending.6 On T2-weighted images, asymmetric effusion in aymptomatic hip is significant indirect evidence of pathol-gy. Because of the low volume, noncompliant capsule, evenmall effusions are significant. Paralabral cysts are pathogno-onic of labral pathology and subchondral cysts are highly

ndicative of associated articular damage.

echanism of Injuryhe mechanism of injury can be as varied as the sports in

hich athletes participate. In general, hip disorders attribut- c

ble to a significant episode of trauma tend to respond bettero arthroscopy.7 This is because, other than the damage be-ause of trauma, the athlete usually has an otherwise healthyoint. Individuals who simply develop progressive onset ofymptoms in absence of injury tend to experience a less com-lete response. This is because insidious onset of symptomssually suggests either underlying disease or some predispo-ition to injury that cannot be fully reversed and may leavehe joint vulnerable to further deterioration in the future.ven the presence of an acute injury such as a twisting epi-ode, which is known to cause a tear of the acetabular la-rum, may be more likely if the labrum was vulnerable to

njury and may represent a less certain response to surgery.his vulnerability can be caused by abnormal labral mor-hology or underlying degeneration. Femoroacetabular im-ingement is increasingly recognized as a source of compres-ive lesions of the labrum.4 Conversely, the labrum may failrom excessive traction, such as in high-level tennis, in whichhe open stance creates extreme external rotation of the jointnd anterior translation of the femoral head.

However, these broad generalizations must be tempered inhe competitive athlete. Individuals who participate in con-act and collision sports simply may not be able to recounthich traumatic episode or series led to the onset of symp-

oms. Remember that significant intra-articular damage canccur from an episode without the athlete developing inca-acitating pain. They may be able to continue to compete andubsequently undergo work up only when symptoms fail toesolve. Injury can occur from any contact or collision sportr sports involving forceful or repetitive twisting of the hip.he aging joint may also be more vulnerable. These param-ters do not exclude many sports.

A particular entity has been identified associated withcute chondral damage.8 It is mostly encountered in physi-ally fit young adult males. The characteristic feature is aateral impact injury to the area of the trochanter (Fig. 2).oung adult males are apt to be participating in contact andollision activities in which this mechanism is frequent. Withood body conditioning, they have little adipose tissue over-ying the trochanter so much of the force of the blow iselivered directly to the bone. This force is then transferrednchecked into the hip joint, resulting in either shearing ofhe articular surface on the medial aspect of the femoral headt the tide mark or compression of the articular surface on theuperior medial acetabulum, exceeding its threshold. Theesult is a full-thickness articular fragment from the femoralead or articular surface breakdown of the acetabulum, pos-ibly with loose bodies, depending on the magnitude of ace-abular chondral, or chondro-osseous cell death (Figs. 3 and). This mechanism is dependent on peak bone density astherwise the force would result in fracture rather than de-ivery of the energy to the surface of the joint. The injury willsually result in immediate onset of symptoms but may note disabling. It may be assessed as a groin pull, with workupnsuing only when symptoms fail to resolve.

Ice hockey is a sport that seems to present a particularlyigh prevalence of hip pathology. Hip flexibility is a premium

onsideration in this sport. The joint is subjected to violent

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Hip arthroscopy in athletes 27

nd repetitive torsional maneuvers and also subjected to rel-tively high-velocity impact loading. Thus, the labrum is sus-eptible to tearing from the twisting maneuvers, whereas therticular surface is vulnerable to impact injury. Often, acutepisodes are simply superimposed on the cumulative effect ofears of exposure (Fig. 1A-C).

Golf is another illustrative sport that seems to have a pre-ilection for precipitating hip symptoms. It is not a contact or

Figure 2 Fall results in direct blow to the greater trochanteunchecked to the hip joint.

igure 3 Arthroscopic view of the left hip of a 20-year-old collegiateasketball player shows an acute grade IV articular injury (asterisk)o the medial aspect of the femoral head. (Figure © J.W. Thomas

yrd.) (Color version of figure is available online.) v

ollision sport, but the golf swing does incorporate a signifi-ant element of twisting on the hip joint. Additionally, it is aport in which participants can compete with advancing age,ven at the professional level. Thus, there is the greater sus-eptibility to injury of an aging hip as well as the cumulative

in absence of fracture, the force generated is transferred

igure 4 Arthroscopic view of the left hip of a 19-year-old man whoustained a direct lateral blow to the hip subsequently developingsteocartilaginous fragments (asterisks) within the superomedialspect of the acetabulum. (Figure © J.W. Thomas Byrd.) (Color

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ffect of repetitive trauma over a prolonged career. Tennishares many of these same attributes.

In a study of athletes undergoing arthroscopy, injury to theigamentum teres was the third most common finding (Ta-le 2).1 Historically, rupture of the ligament is associatedith hip dislocation. It has been recognized that injury canccur without dislocation, but this has been described only asase reports.9-12 Disruption appears to be attributable to awisting injury and is increasingly recognized as a source ofntractable hip pain. In a study by this author of 23 cases of

able 2 Diagnoses For Hip Arthroscopy

abral pathology (27)hondral damage (23)igamentum teres damage (11)rthritic disorder (7)ysplasia (5)oose bodies (3)mpinging osteophyte (2)vascular necrosis (1)ynovitis (1)erthes disease (1)

Figure 5 A 54-year-old Hall of Fame baseball player wworsening mechanical right hip pain. (A) An AP radiosecondary degenerative changes. (B) Arthroscopic viewobliterating the acetabular fossa. (C) These are morselizefree-floating loose bodies. (E) Whole fragments remove

Byrd.) (Color version of figure is available online.)

raumatic injury to the ligamentum teres, 17 (74%) occurredithout accompanying dislocation of the hip.13

reatmentrthroscopy has found a role in the treatment of numerousnd varied forms of intra-articular pathology of the hip.14,15

he basic principles for accessing the joint have been wellefined.16-21 It is important to follow these to perform therocedure as effectively as possible. Some cases will be moreifficult than others. Thus, it is essential to assure that therocedure is performed with technical precision to make it asasy as possible. Accessing the joint for arthroscopy is not aemarkable technical accomplishment. More important iserforming the procedure as atraumatically as possible.Loose bodies can be extracted and arthroscopy offers an

xcellent alternative to arthrotomy, previously indicated forhis condition (Fig. 5).22-24 Most problematic loose bodieseside in the intra-articular compartment and are addressedith standard arthroscopic methods. However, many may

emain hidden in the peripheral compartment and later be-ome troublesome. Thus, arthroscopy to address symptom-

several-year history of insidious onset, progressivelyshows evidence of synovial chondromatosis as well asintra-articular compartment shows numerous lesions

excised. (D) The peripheral compartment reveals morethe peripheral compartment. (Figure © J.W. Thomas

ith agraphof thed andd from

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Hip arthroscopy in athletes 29

tic fragments must include both the intra-articular and pe-ipheral joint.25 Many can be debrided with shavers orushed through large diameter cannulas. Large ones canometimes be morselized and removed piecemeal. However,ften fragments may be too large to be removed through aannula system and must be removed freehand with sturdyraspers. Once a portal tract has been developed, these largerraspers can be passed along the remaining tract into the jointn a freehand fashion. Make sure to enlarge the capsularncision with an arthroscopic knife and the skin incision sohat, as the fragment is retrieved, it will not be lost in theissues either at the capsule or subcutaneous level.

Traumatic labral tears may respond remarkably well torthroscopic debridement (Fig. 6).26-30 However, at arthros-opy be especially cognizant of any underlying degenerationhat may have predisposed to the acute tear. There will oftene accompanying articular damage, and the extent of thisay be a significant determinant on the eventual response toebridement (Fig. 7). Also, with the evolving understandingf femoroacetabular impingement and its role in the devel-pment of labral and chondral damage, it is important toake a careful radiographic assessment of accompanying

ony lesions of the anterior acetabulum or femoral head thatay require reshaping (Fig. 8).31

Labral tears can be adequately accessed through the 3 stan-ard portals. Similar to a meniscus in the knee, the task is toemove unstable and diseased labrum creating a stable tran-ition to retained healthy tissue. The most difficult aspect isreating the stable transition zone. Thermal devices haveeen quite useful at ablating unstable tissue adjacent to theealthy portion of the labrum. Caution is necessary becausef the concerns regarding depth of heat penetration, but withudicious use, these devices have been exceptionally usefulor precise labral debridement despite the constraints createdy the architecture of the joint.The natural evolution in arthroscopic management of la-

Figure 6 A 25-year-old top-ranked professional tennis pMRI shows evidence of labral pathology (arrow). (B) A(asterisk) as well as an adjoining area of grade III articulato a stable rim (arrows), and chondroplasty of the gradeJ.W. Thomas Byrd.) (Color version of figure is available

ral pathology is from debridement to repair. Current meth- T

ds of acetabular labral repair are in their infancy. A few haveeen attempted with mixed results. Reliable techniques re-ain to be developed but are probably not far off. In addition

o technical advancements, there is much that remains re-arding our understanding of labral morphology and patho-hysiology. There is considerable variation in the normalppearance of the labrum including a labral cleft at the artic-lar labral junction, which can be quite large.21 It is impor-ant to distinguish this from a traumatic detachment whichan also occur. Additionally, many labral tears, even in theresence of a significant history of injury, seem to occurecause of some underlying predisposition or degeneration.nder these circumstances, even with reliable techniques,

epair of a degenerated or morphologically vulnerable la-rum would unlikely be successful.Chondroplasty can be effectively performed for lesions of

oth the acetabular and femoral surfaces. Curved shaverlades are helpful for negotiating the constraints created byhe convex surface of the femoral head. Because of limitationsf maneuverability, thermal devices have again been espe-ially helpful in ablating unstable fragments. However, cau-ious and judicious use around articular surface is even moremportant because of potential injury to surviving chondro-ytes.

Microfracture of select grade IV articular lesions has beeneneficial (Fig. 7).30 As with other joints, it is best indicatedor focal lesions with healthy surrounding articular surface.he lesion most amenable to this process is encountered in

he lateral aspect of the acetabulum. This is followed by 8 to0 weeks of protected weight bearing to neutralize the forcescross the hip joint while emphasizing range of motion. Bysing this protocol, among a cohort of 24 patients, 86%howed a successful outcome at 2- to 5-year follow-up.32

Injury to the ligamentum teres is increasingly recognizeds a source of hip pain in athletes (Fig. 9).1 The disruptedbers catch within the joint and can be quite symptomatic.

ustained a twisting injury to his right hip. (A) Coronalcopy reveals extensive tearing of the anterior labrumentation (arrows). (C) The labral tear has been resectedicular damage (asterisk) is being performed. (Figure ©.)

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30 J.W.T. Byrd

combination of both.33 The tear may be partial or completeith the goal of treatment being to debride the entrapping,isrupted fibers. A recent report by these authors docu-ented excellent success in the arthroscopic management of

raumatic lesions of the ligamentum teres. The average im-rovement was 47 points (100-point modified Harris Hipcore system) with 93% showing marked (�20 points) im-rovement.13

The acetabular attachment of the ligamentum teres is sit-ated posteriorly at the inferior margin of the acetabular fossand attaches on the femoral head at the fovea capitis. Theisrupted portion of the ligament is avascular, but the fat padnd synovium contained in the superior portion of the fossaan be quite vascular. Debridement is facilitated by a com-lement of curved shaver blades and a thermal device. The

Figure 7 A 23-year-old elite professional tennis playerevidence of labral pathology (arrow). (B) Arthroscopy revIV articular loss (asterisk). (C) Microfracture of the expoof fluid confirms vascular access through the areas of pebearing status emphasizing range of motion for 10 weekJ.W. Thomas Byrd.) (Color version of figure is available

isrupted portion of the ligament is unstable and delivered c

y suction into the shaver. A thermal device can also ablateissue while maintaining hemostasis within the vascularulvinar.Access to this inferomedial portion of the joint is best

ccomplished from the anterior portal. External rotation ofhe hip also helps in delivering the ligament to the shaverrought in anteriorly. The most posterior portion of the fossand the acetabular attachment of the ligament may be bestccessed from the posterolateral portal. Indiscriminate de-ridement of the ligamentum teres should be avoided be-ause of its potential contribution to the vascularity of theemoral head.

Primary synovial disease may be encountered in athletes,ut more often synovial proliferation occurs in response tother intra-articular pathology. Synovitis may be diffuse, en-

ed an injury to his right hip. (A) Coronal MRI showse labral tear (arrows) but also an area of adjoining gradechondral bone is performed. (D) Occluding the inflow

on. The athlete was maintained on a protected weight-return to competition at 3 and a half months. (Figure ©.)

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Hip arthroscopy in athletes 31

ating from the pulvinar of the acetabular fossa. Focal lesionsithin the fossa may be dense and fibrotic or exhibit prolif-

rative villous characteristics. Presumably, because of entrap-ent within the joint, these lesions can be quite painful and

espond remarkably well to simple debridement. Although aomplete synovectomy cannot be performed, a generousubtotal synovectomy can be performed. Enlarging the cap-ular incisions with an arthroscopic knife improves maneu-erability within the intra-articular portion of the joint. Forost synovial disease, arthroscopy of the peripheral com-artment is necessary to adequately resect the diseased tis-ue.25,31

In the presence of clinical evidence of arthritis, there wille arthroscopic evidence of various pathology including freeragments, labral tearing, articular damage, and synovial dis-

Figure 8 A 16-year-old high school football player develomagnetic resonance arthrogram shows a macerated antera macerated tear of the anterior labrum is probed along wThe damaged anterior labrum has been excised, revealacetabulum. (D) Excision of the impinging portion of(Figure © J.W. Thomas Byrd.) (Color version of figure

ase. With a meticulous systematic approach, each compo- o

ent can be addressed arthroscopically. Ultimately, with aell performed procedure, the response to treatment will beostly dictated by the extent of pathology, much of which

annot be reversed.34-37

Posttraumatic impinging bone fragments, occasionally en-ountered in an active athletic population, may respond wello arthroscopic excision.14,38 Degenerative osteophytes rarelyenefit from arthroscopic excision because the symptoms aresually more associated with the extent of joint deteriorationnd not simply the radiographically evident osteophytes thatecondarily form. However, the posttraumatic type may im-inge on the joint causing pain and blocking motion. Theseragments are often extracapsular and require a capsulotomyxtending the dissection outside the joint for excisionFig. 10). This necessitates thorough knowledge and careful

e onset of right hip pain doing squats. (A) Sagittal imagerum (arrows). (B) Viewing from the anterolateral portal,icular delamination at its junction with the labrum. (C)overhanging lip of impinging bone from the anterior

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igure 9 A 16-year-old cheerleader has a 2-year history of catchingnd locking of the left hip after a twisting injury. (A) Arthroscopiciew from the anterolateral portal reveals disruption of the ligamen-um teres (asterisk). (B) Debridement is begun with a synovial re-ector introduced from the anterior portal. (C) The acetabular at-achment of the ligamentum teres in the posterior aspect of the fossas addressed from the posterolateral portal. (Figure © J.W. Thomas

yrd.) (Color version of figure is available online.) a

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igure 10 An 18-year-old high school football player sustained anvulsion fracture of the left anterior inferior iliac spine. (A) A 3-di-ensional computed tomography scan shows the avulsed fragment

arrow), which ossified, creating an impinging painful block to flex-on and internal rotation. (B) Viewing from the anterolateral portal,

capsular window is created, exposing the osteophyte (asterisk)nterior to the acetabulum (A). (C) The anterior capsule (C) haseen completely released allowing resection of the fragment alonghe anterior column of the pelvis (P). Postoperatively, the patientegained full range of motion with resolution of his pain. (Figure ©

.W. Thomas Byrd.) (Color version of figure is available online.)

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Hip arthroscopy in athletes 33

lization at all times during the procedure. In general, theissection should stay directly on the bone fragments andvoid straying into the surrounding soft tissues. Various tech-iques aid in maintaining optimal visualization. A high-flowump is especially helpful, maintaining a high-flow rateithout excessive pressure, which would worsen extravasa-

ion. Hypotensive anesthesia, placing epinephrine in the ar-hroscopic fluid, and electrocautery or other thermal deviceor hemostasis all aid in visualization for effectively perform-ng the excision.

Hip instability can occur but is much less common thaneen in the shoulder. There are several reasons but, mostrincipally, this is because of the inherent stability providedy the constrained ball and socket bony architecture of the

oint. Also, the labrum is not as critical to stability of the hips it is in the shoulder because there is no true capsulolabralomplex. On the acetabular side, the capsule attaches directlyo the bone, separate from the acetabular labrum.39 An en-rapped labrum has been reported as a cause of an irreducibleosterior dislocation and a Bankart-type detachment of theosterior labrum has been identified as the cause of recurrentosterior instability.40,41 These circumstances have onlyarely been reported but may be recognized with increasingrequency as our understanding and intervention of hip in-uries evolves.

Instability may occur simply because of an incompetentapsule. This is seen in hyperlaxity states and less often en-ountered in athletics. The most common cause is a collagenascular disorder such as Ehlers-Danlos syndrome. Withormal joint geometry, thermal capsular shrinkage has con-inued to meet with successful results (Fig. 11). If subluxa-

Figure 11 A 19-year-old woman had undergone two prlesions of the ligamentum teres. After each procedurRadiographs revealed normal joint geometry. (B) She wterized by a markedly positive sulcus sign. (C) With objean arthroscopic thermal capsulorrhaphy was performedcompartment. Modulation of the capsular response was ca successful outcome. (Figure © J.W. Thomas Byrd.) (C

ion or symptomatic instability is caused by a dysplastic joint, m

t is likely that bony correction for containment is necessaryo achieve stability.

Based on this author’s observations, we have found thatosterior instability is associated with macrotrauma. This isecause of the characteristic mechanisms of injury, includingashboard injuries and axial loading of the flexed hip en-ountered in collision sports. Atraumatic instability, or insta-ility because of repetitive microtrauma, is anterior and de-elops when the normally occurring anterior translation ofhe femoral head exceeds the physiologic threshold and be-omes pathological. Symptoms may be caused by primarynstability or secondary intra-articular damage or a combina-ion of both.

ehabilitations with any joint, physical therapy is an integral part of

acilitating and optimizing recovery after arthroscopic sur-ery of the hip. This is a functional progression based on theype of pathology, the procedure performed, and the even-ual goals of the athlete.42-44 An early goal is to normalize theait pattern based on symptoms and motor control. Crutchesre often beneficial for 4 to 5 days until no noticeable limp isresent. For arthritic conditions, crutches may be useful foreveral weeks while symptoms are subsiding. For microfrac-ure cases, a strict protected weight-bearing status is main-ained for 8 to 10 weeks to neutralize the forces across theoint surfaces while emphasizing motion to stimulate a po-ential fibrocartilaginous healing response.

In general, range of motion is pushed only to tolerance.nlike the knee or the shoulder, some reduced range of

arthroscopic procedures on her right hip for reporteddeveloped recurrent symptoms of “giving way.” (A)d to have severe diffuse physiologic laxity best charac-idence of laxity and subjective symptoms of instability,ing the redundant anterior capsule from the peripheralled by a hip spica brace for 8 weeks postoperatively withersion of figure is available online.)

eviouse, sheas notective ev, accessontrol

otion is often well tolerated by athletes and may be unno-

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34 J.W.T. Byrd

iced. Functionally, individuals can compensate very effec-ively for diminished mobility. In fact, pushing the endanges of motion may be counterproductive and only serve toxacerbate the athlete’s symptoms. However, there are someircumstances in which reduced motion is a functional prob-em, precipitating treatment and can be improved with ar-hroscopic debridement. Thus, range of motion may be arincipal focus of the rehabilitation process, such as withemoroacetabular impingement and adhesive capsulitis.45

Closed chain, low impact exercises are gradually transi-ioned to a functional rehabilitation program simulating thethlete’s eventual activities in a controlled environment. Typ-cally, 1 month is necessary to recuperate from the acutespects of surgical intervention. Gradual resumption of un-estricted activities generally progresses at 2 to 3 months,epending on the nature of the pathology and the athlete’sunctional response.

Athletes with arthritic conditions can be expected to re-over more slowly and less completely. Microfracture casesecessitate approximately three months of deliberate restric-ions. Capsulorrhaphy for symptomatic instability also re-uires a period of immobilizaton, usually in a hip spica braceor a period of 6 to 8 weeks with cautious resumption ofctivities to avoid recurrent problems.

esultsn a study by Byrd and Jones1 of 42 athletes, the averagemprovement using a modified Harris hip rating system100-point maximum) was 35 points (preoperatively 57;ostoperatively 92). Ninety-three percent showed at least 10oints of improvement. Also, of those questioned, 76% re-urned to their sport symptom free and unrestricted or ateast at an increased level of performance, whereas 18% ei-her chose not to return or were unable to return to theirrimary sport.After understanding the potential benefits of an arthro-

copic procedure, the next issue of paramount importancemong athletes is how quickly they will recover. According tohe same study, the greatest improvement (67%) was noted

igure 12 Average modified Harris hip scores among athletes at var-ous intervals of follow-up. (Figure © J.W. Thomas Byrd.)

fter the first month. Maximal improvement was achieved by T

months, and these results were maintained among thosethletes with 5-year follow-up (Fig. 12).

Among athletes, the best results have been seen for im-inging osteophytes, loose bodies, and rupture of the liga-entum teres (Fig. 13). Impinging osteophytes are uncom-on, but when recognized, the structural problem can be

orrected, thus often resulting in pronounced symptomaticmprovement. Loose bodies have traditionally been recog-ized as the clearest indication for arthroscopy. Predictableesults have been further confirmed in the athletic popula-ion. Rupture of the ligamentum teres is an entity that hasnfrequently been reported in the literature. A propensity forhis injury has been identified among athletes, being the thirdeading diagnosis, and responds remarkably well to arthro-copic debridement. More average results have been reportedor labral tearing and chondral injury. The results are poor inhe presence of clinical evidence of arthritis, but those pa-

igure 13 Results based on specific diagnoses. (Figure © J.W.homas Byrd.)

igure 14 Results based on the onset of symptoms. (Figure © J.W.

homas Byrd.)

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Hip arthroscopy in athletes 35

ients undergoing microfracture fared better than with simplehondroplasty.

The nature of the onset of symptoms seems to at leastartially influence the results. Those with a specific history ofsignificant traumatic event fare the best (Fig. 14), whereas

hose of insidious onset did the worst. Patients with acutenset of symptoms fared only slightly better than those withn insidious onset, suggesting that, even in the presence of aodest explainable injury, some type of predisposition

hould be suspected and the results of arthroscopy may beess certain.

Among the reported group of athletes, one third competedt the collegiate, elite, or professional level (Fig. 15). Theseroups had a higher baseline preoperative score than theecreational and high school athletes. This suggests that thesethletes are functioning near the physiologic limits of theody and at a level in which small deficits may significantly

nfluence the athlete’s performance.

onclusionshe indications for hip arthroscopy have been well estab-

ished. The results among athletes appear to be favorable and,n fact, are somewhat better than those reported among aeneral population.

Intra-articular disorders in athletes may go unrecognizedor a protracted period of time, most commonly being diag-osed as a strain. With an increasing awareness of these intra-rticular problems and the intensity of services often avail-ble to athletes, joint injuries are now being diagnosedarlier. However, this emphasis for earlier diagnosis must beempered. It is still likely that extra-articular injuries vastlyutnumber injuries within the joint and thus one shouldvoid the temptation for an extensive intra-articular workupor every simple muscle strain. Also, it is unknown whetherarly diagnosis necessitates early intervention. There is muchhat is not understood regarding the natural history of somef these intra-articular disorders. Thus, although perhaps it is

igure 15 Results based on level of sport. (Figure © J.W. Thomasyrd.)

ifficult to say that a labral lesion identified by MRI will heal,

t is uncertain how many of these may become clinicallyuiescent and asymptomatic or whether some of the signalhanges evident on imaging may be caused by remote traumahat had previously become silent.

Nonetheless, arthroscopy has defined various sources ofntra-articular hip pathology. In many cases, operative ar-hroscopy may result in significant symptomatic improve-ent. For some, arthroscopy offers a distinct advantage over

raditional open techniques, but, for many, arthroscopy nowffers a method of treatment where none existed before.

eferences1. Byrd JWT, Jones KS: Hip arthroscopy in athletes. Clin Sports Med

20:749-762, 20012. Byrd JWT: Investigation of the symptomatic hip: Physical examination,

in Byrd JWT (ed): Operative Hip Arthroscopy. New York, NY, Thieme,1998, pp 25-41

3. O’Leary JA, Berend K, Vail TP: The relationship between diagnosis andoutcome in arthroscopy of the hip. Arthroscopy 17:181-188, 2001

4. Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: acause for osteoarthritis of the hip. Clin Orthop 417:112-120, 2003

5. Erb RE: Current concepts in imaging the adult hip. Clin Sports Med20:661-696, 2001

6. Byrd JWT, Jones KS: Diagnostic accuracy of clinical assessment, MRI,MRA, and intraarticular injection in hip arthroscopy patients. Am JSports Med 32:1668-1674, 2004

7. Byrd JWT, Jones KS: Prospective analysis of hip arthroscopy. Arthros-copy 16:578-587, 2000

8. Byrd JWT: Lateral impact injury: A source of occult hip pathology. ClinSports Med 20:801-816, 2001

9. Delcamp DD, Klarren HE, VanMeerdervoort HFP: Traumatic avulsionof the ligamentum teres without dislocation of the hip. J Bone Joint Surg70A:933-935, 1988

0. Barrett IR, Goldgert JA: Avulsion fracture of the ligamentum teres in achild. A case report. J Bone Joint Surg 71A:438-439, 1989

1. Ebrahim NA, Salvolaine ER, Fenton PJ, et al: Calcified ligamentum teresmimicking entrapped intraarticular bony fragments in a patient withacetabular fracture. J Orthop Trauma 5:376-378, 1991

2. Kashiwagi N, Suzuki S, Seto Y: Arthroscopic treatment for traumatichip dislocation with avulsion fracture of the ligamentum teres. Arthro-scopy 17:67-69, 2001

3. Byrd JWT, Jones KS: Traumatic rupture of the ligamentum teres as asource of hip pain. Arthroscopy 20:385-391, 2004

4. Byrd JWT: Indications and contraindications, in Byrd JWT (ed): Oper-ative Hip Arthroscopy. New York, NY, Thieme, 1998, p 7-24

5. Sampson TG, Glick JM: Indications and surgical treatment of hip pathol-ogy, in McGinty J, Caspari R, Jackson R, et al (eds): Operative Arthroscopy(ed 2). New York, NY, Lippincott-Raven, 1995, pp 1067-1078

6. Byrd JWT: Hip arthroscopy utilizing the supine position. Arthroscopy10:275-280, 1994

7. Byrd JWT: The supine position, in Byrd JWT (ed): Operative Hip Ar-throscopy. New York, NY, Thieme, 1998, pp 123-138

8. Glick JM, Sampson TG: Hip arthroscopy by the lateral approach, inMcGinty J, Caspari R, Jackson R, et al (eds): Operative Arthroscopy(ed 2). New York, NY, Raven Press, Ltd., 1995, pp 1079-1090

9. Byrd JWT: Arthroscopy of the hip and applications: supine position, inChow JC (ed): Advanced Arthroscopy. New York. NY, Springer-Verlag,2000, pp 293-321

0. Sampson TG, Farjo L: Hip arthroscopy by the lateral approach, in Byrd,JWT (ed): Operative Hip Arthroscopy. New York, NY, Thieme, 1998,pp 105-122

1. Byrd JWT: Operative hip arthroscopy (video). New York, NY, Thieme,1998

2. Byrd JWT: Hip arthroscopy for post-traumatic loose fragments in theyoung active adult: Three case reports. Clin Sport Med 6:129-134, 1996

3. McCarthy JC, Bono JV, Wardell S: Is there a treatment for synovial

chondromatosis of the hip joint? Arthroscopy 13:409-410, 1997

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

36 J.W.T. Byrd

4. Medlock V, Rathjen KE, Montgomery JB: Hip arthroscopy for late se-quelae of Perthes Disease. Arthroscopy 15:552-553, 1999

5. Dienst M, Gödde S, Seil R, Hammer D, Kohn D: Hip arthroscopywithout traction: In vivo anatomy of the peripheral hip joint cavity.Arthroscopy 17:924-931, 2001

6. Byrd, JWT: Labral lesions: An elusive source of hip pain: case reportsand review of the literature. Arthroscopy 12:603-612, 1996

7. Lage LA, Patel JV, Villar RN: The acetabular labral tear; An arthroscopicclassification. Arthroscopy 12:269-272, 1996

8. Farjo LA, Glick JM, Sampson TG: Hip arthroscopy for acetabular la-brum tears. Arthroscopy 13:409, 1997

9. Santori N, Villar RN: Acetabular labral tears: result of arthroscopicpartial limbectomy. Arthroscopy 16:11-15, 2000

0. Byrd JWT, Jones KS: Osteoarthritis caused by an inverted acetabularlabrum: Radiographic diagnosis and arthroscopic treatment. Arthros-copy 18:741-747, 2002

1. Byrd JWT: Hip arthroscopy: Evolving frontiers. Oper Tech Sports Med14:58-67, 2004

2. Byrd JWT, Jones KS: Microfracture for grade IV chondral lesions of thehip. Proceedings of AANA 23rd Annual Meeting, Orlando, FL, April25, 2004. Arthroscopy 20:41, 2004 (abstr)

3. Gray AJR, Villar RN: The ligamentum teres of the hip: an arthroscopicclassification of its pathology. Arthroscopy 13:575-578, 1997

4. Farjo LA, Glick JM, Sampson TG: Hip arthroscopy for degenerativejoint disease. Arthroscopy 14:435, 1998

5. Villar RN: Arthroscopic debridement of the hip: A minimally invasive

approach to osteoarthritis. J Bone Joint Surg 73-B:170-171, 1991(suppl 2)

6. Santori N, Villar RN: Arthroscopic findings in the initial stages of hiposteoarthritis. Orthopedics 22:405-409, 1999

7. Byrd JWT, Jones KS: Prospective analysis of hip arthroscopy with fiveyear follow up. Presented at AAOS 69th Annual Meeting, Dallas, TX,February 14, 2002

8. Byrd JWT: Arthroscopy of select hip lesions, in Byrd JWT (ed): Oper-ative Hip Arthroscopy. New York, NY, Thieme, 1998, pp 153-170

9. Seldes RM, Tan V, Hunt J, et al: Anatomy, histologic features, andvascularity of the adult acetabular labrum. Clin Orthop 382:232-240,2001

0. Paterson I: The torn acetabular labrum: A block to reduction of adislocated hip. J Bone Joint Surg 39B:306-309, 1957

1. Dameron TB: Bucket-handle tear of acetabular labrum accompanyingposterior dislocation of the hip. J Bone Joint Surg 41A:131-134, 1959

2. Griffin KM, Henry CO, Byrd JWT: Rehabilitation after hip arthroscopy.J Sport Rehabil 9:77-88, 2000

3. Griffin KM, Henry CO, Byrd JWT: Rehabilitation, in Byrd JWT (ed):Operative Hip Arthroscopy. New York, NY, Thieme, 1998, pp 177-202

4. Henry C, Middleton K, Byrd JWT: Hip rehabilitation following arthros-copy, IOI Theater, AAOS Annual Meeting, Orlando, FL, February 16-21,1995

5. Byrd JWT, Jones KS: Adhesive capsulitis of the hip. Arthroscopy 20:

15-16, 2004