playing golf. Any movement of the hip was painful, and his symptoms were only partially alleviated by using crutches. Radiographs revealed mild degenerative changes but fairly good joint space preservation (Figure 15.5A). A bone scan and serologic testing were performed to rule out occult fracture, neoplasia, or infection. All results were unremarkable. Evaluation of the lumbar spine was also carried out to rule out a source of referred symptoms. An MRI of the hip was also unremarkable. Because of his recalcitrant symptoms, a fluoroscopically guided intraarticular injection of bupivacaine and corticosteroid was performed, which provided pronounced alleviation of his symptoms, but only for a few days. Arthroscopy was subsequently recommended. He was found to have extensive tearing of the anterolateral labrum as well as associated grade IV articular fragmentation of the acetabulum, which was excised (see Figure 15.5B,C). Postoperatively, he experienced pronounced symptomatic improvement and was able to return to his normal sports activities for the following 6 years.
A 69-year-old woman was referred with a 6-week history of spontaneous onset incapacitating sharp, stabbing right hip pain. Her history was remarkable in that she had undergone multiple screw fixation of a femoral neck fracture 9 years previously. However, she had been asymptomatic and unrestricted in her activities until her recent onset of symptoms. Radiographs revealed her fracture to be fully healed. Evidence suggested an intraarticular loose body, but also modest joint space narrowing (Figure 15.6 A). A CT scan further defined the extent of the intraarticular fragment (Figure 15.6B).
It was uncertain how much of her symptoms was simply due to the degenerative changes and how much might be attributable to the bone fragment. However, with her recent spontaneous onset of sharp stabbing pain and evidence of an intraarticu-lar fragment, it was thought that arthroscopy to retrieve the fragment was the next step in her management to remove this as a potential contributing source. At arthroscopy, the large loose body was identified and retrieved. However, there was also noted to be severe articular damage with grade IV changes of the acetabulum and grade III damage to the femoral head (see Figure 15.6C). Postopera-tively, the sharp stabbing symptoms were eliminated, but she continued to experience pain with daily activities. This was thought to be attributable to her underlying degenerative disease.
In this case, the patient experienced an acute episode of pain, mechanical symptoms, and clear evidence of an intraarticular loose body, all of which are normally good prognostic indicators of a potentially successful outcome of hip arthroscopy. However, radiographically, she had evidence of joint space loss reflecting underlying degenerative disease. In our experience, whenever there is radiographic evidence of degenerative disease, this is often the limiting factor in the response to ar-throscopy and should be considered an overriding poor prognostic indicator, even in the presence of more favorable clinical findings. Degenerative disease is also often a great imitator. It may present with gradually worsening activity-related symptoms, but also may present with the acute onset of pain in absence of any prodromal findings.
1. Dorell JH, Catterall A: The torn acetabular labrum. J Bone Joint Surg 1986;68B(3):400-403.
2. Klaue K, Durnin CW, Ganz R: The acetabular rim syndrome. J Bone Joint Surg 1991;73B:423-429.
3. Nishina T, Saito S, Ohzono K, et al: Chiari pelvic osteotomy for osteoarthritis: the influence of the torn and detached acetabular labrum. J Bone Joint Surg 1990;72B(5):765-769.
4. Byrd JWT: Labral lesions: an elusive source of hip pain: case reports and review of the literature. Arthroscopy 1996;12(5): 603-612.
5. Byrd JWT, Jones KS: Inverted acetabular labrum and secondary osteoarthritis: radiographic diagnosis and arthroscopic treatment. Arthroscopy 2000;16(4):417.
6. Hadley NA, Brown TD, Weinstein SL: The effect of contact pressure elevations and aseptic necrosis on the long term outcome of congenital hip dislocation. J Orthop Rev 1990;8(4): 504-513.
7. Maxian TA, Brown TD, Weinstein SL: Chronic stress tolerance levels for human articular cartilage: two non-uniform contact models applied to long term follow up of CDH. J Bio-mech 1995;28:159-166.
8. Cooperman DR, Wallensten R, Stulberg SD: Acetabular dys-plasia in the adult. Clin Orthop 1983;175:79-85.
9. Malvitz TA, Weinstein SL: Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years. J Bone Joint Surg 1994;76A:1777-1792.
10. Nishii T, Sugano N, Tanaka H, Nakanishi K, Ohzono K, Yoshikawa H: Articular cartilage abnormalities in dysplastic hips without joint space narrowing. Clin Orthop 2001;383: 183-190.
11. Noguchi Y, Miura H, Takasugi S, et al: Cartilage and labrum degeneration in the dysplastic hip generally originates in the anterosuperior weight bearing area: an arthroscopic observation. Arthroscopy 1999;15:496-506.
12. Michaels G, Matles AL: The role of the ligamentum teres in congenital dislocation of the hip. Clin Orthop 1970;71:199-201.
13. Ippolito E, Ishii Y, Ponseti IV: Histologic, histochemical, and ultrastructural studies of the hip joint capsule and ligamen-tum teres in congenital dislocation of the hip. Clin Orthop 1980;146:246-258.
14. Byrd JWT, Jones KS: Hip arthroscopy in the presence of dysplasia. Arthroscopy 19(10):1055-1060; 2003.
15. Centers for Disease Control and Prevention: Prevalence of self-reported arthritis or chronic joint symptoms among adults-United States, 2001. JAMA 2002;288(24):3103-3104.
16. AAOS Orthopaedic-Related Statistics. Rosemond, IL: American Academy of Orthopaedic Surgeons, 2000.
17. Lecouvet FE, VandeBerg BC, Melghem J, et al: MR imaging of the acetabular labrum: variations in 200 asymptomatic hips. AJR Am J Roentgenol 1996;167:1025-1028.
18. Tanabe H: Aging process of the acetabular labrum: an electron-microscopic study. J Jpn Orthop Assoc 1991;65:18-25.
19. Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald RH Jr: Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop 2001;382:232-240.
20. McCarthy JC, Nobel PC, Schuck MR, Wright J, Lee J: The watershed labral lesion: its relationship to early arthritis of the hip. J Arthroplasty 2001;16(8 suppl 1):81-87.
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