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Partial limbectomy Evaluation of cartilage surfaces

2 (associated with trauma and athletics)

Athletics

Debridement chondral injury Partial limbectomy Removal of loose body Decompression of ganglion

7 (4 with antecedent hip pathology: LCP' DDH' SCD)

LCP, Legg-Calve-Perthes disease; MVA, motor vehicle accident; AVN, avascular necrosis, FVFG, free vascularized fibular graft; DDH, developmental dysplasia of hip, SCD, sickle cell disease

LCP, Legg-Calve-Perthes disease; MVA, motor vehicle accident; AVN, avascular necrosis, FVFG, free vascularized fibular graft; DDH, developmental dysplasia of hip, SCD, sickle cell disease

FIGURE 14.2. Intraoperative fluoroscopy image of instrument placement. Intraoperative fluoroscopy image shows the position of the 30-degree arthroscopic camera and an arthroscopic shaver instrument in place. Note the distension of the joint obtained with controlled traction and gravity-assisted inflow.

the hip for new onset of pain secondary to an extension of the chondral delamination and is now doing well. The third patient had continued mechanical symptoms and pain after a motor vehicle accident and underwent hip arthroscopy after 24 months of nonoperative therapy. The patient had loose bodies that were successfully resected arthroscopically (Figure 14.3). He remains symptom free at 2.5-year follow-up.

Seven of the patients presented with hip pain and mechanical symptoms after an injury sustained during athletic training or competition. These seven patients underwent eight arthroscopic procedures. Of these patients, four had a previous history of hip disease, likely placing them at increased risk of intraar-ticular hip injury. The first, an 11-year-old active boy, was diagnosed and treated for LCP disease as a younger child, but was pain free and was able to participate in sports. He presented with acute onset of pain after a twisting injury occurred during sporting activity. A chondral injury and a separate degenerative labral tear were identified arthroscopically, and a partial chon-droplasty of the femoral head and resection of the unstable labral tear were performed. The second patient had a similar presentation, also with a known previous history of Perthes' disease. This 15-year-old boy presented after an injury that occurred while playing softball. Radiographic evaluation was remarkable only for findings of previous Perthes' disease, but no loose bodies or fractures were noted. At arthroscopy, a labral tear was identified and resected back to a stable base. An unstable chondral flap was also apparent and addressed arthroscopically. No significant synovitis or degenerative changes were noted. The patient had prompt resolution of symptoms and relief of pain after the procedure. Twenty-three months following the initial arthroscopy, the patient had a more insidious onset of pain and decreasing range of motion in the same hip. Repeat arthroscopy was performed. A new femoral chondral lesion was noted, as was a small degenerative tear in the acetabular labrum. These were resected using standard arthroscopic instruments and the patient has remained symptom free for 26 months. More detailed case examples of the role of arthroscopy in LCP are given next.

The third of our patients who presented with hip pain following an injury in the setting of previous hip pathology sustained during sports had sickle cell disease, but she had not had complaints of hip pain before her injury. This 17-year-old girl presented with 6 months of pain and mechanical symptoms after an injury that occurred while running. At the time of ar-throscopy, a loose body was identified and removed. The presumed donor site was identified on the femoral head and was also addressed arthroscopically with de-bridement back to a stable margin (Figure 14.4). She had complete resolution of symptoms and has been painfree for more than 4 years.

Athletic trauma was also identified in a 14-year-old girl who was treated with bracing for DDH as a child. She was asymptomatic until 6 months before her presentation when she fell while playing softball. She noted the acute onset of left hip pain that did not resolve despite treatment with nonsteroidal medications and physical therapy. Figure 14.5 shows the prearthroscopy radiographs. During her workup she underwent an MRI scan that demonstrated an ac-etabular labral tear. Because of her positive radiographic findings and her continued pain despite 6 months of conservative treatment, she underwent ar-throscopic examination. At arthroscopy she was noted

Hip Loose Bodies
FIGURE 14.3. Arthroscopic excision of loose body. Standard ar-throscopic instruments, including an aggressive shaver, are used routinely to excise loose bodies, as shown, from the hip joint. A large loose body is seen below the arthroscopic instrument. View is from the anterolateral portal.
Arthrodesis DdhChondroplasty Mri

FIGURE 14.4. Loose body donor site (D) on femoral head. Friable, loose, and degenerative fibrocartilage, presumed to be a donor site for a loose body, which was extracted, is shown. Again, standard arthroscopic instrumentation can be used to perform chondral shaving or chondroplasty to these pathologic areas. View is from the an-terolateral portal.

FIGURE 14.4. Loose body donor site (D) on femoral head. Friable, loose, and degenerative fibrocartilage, presumed to be a donor site for a loose body, which was extracted, is shown. Again, standard arthroscopic instrumentation can be used to perform chondral shaving or chondroplasty to these pathologic areas. View is from the an-terolateral portal.

to have a large degenerative acetabular labral tear extending from the superior to the anterosuperior location (Figure 14.6). This finding is in agreement with those of Noguchi et al., who demonstrated that, in DDH, most prearthritic hips and all arthritic hips have labral tears in this location.35 A partial limbectomy

Arthritic Femoral Head

FIGURE 14.5. Developmental dysplasia of the hip (DDH). AP radiograph of the hip demonstrates poor superior acetabular coverage with a well preserved and congruous joint space. The patient had acute onset of mechanical hip pain following an injury while playing softball. Magnetic resonance imaging (MRI) revealed a torn ac-etabular labrum.

Developmental Dysplasia Hip View

FIGURE 14.6. Degenerative tear (T) of the anterosuperior and pos-terosuperior labrum in DDH. At arthroscopy, the patient had a large degenerative tear of the acetabular labrum extending from anterior to posterior. This was resected to a stable base. View is from the anterolateral portal.

FIGURE 14.5. Developmental dysplasia of the hip (DDH). AP radiograph of the hip demonstrates poor superior acetabular coverage with a well preserved and congruous joint space. The patient had acute onset of mechanical hip pain following an injury while playing softball. Magnetic resonance imaging (MRI) revealed a torn ac-etabular labrum.

FIGURE 14.6. Degenerative tear (T) of the anterosuperior and pos-terosuperior labrum in DDH. At arthroscopy, the patient had a large degenerative tear of the acetabular labrum extending from anterior to posterior. This was resected to a stable base. View is from the anterolateral portal.

(labral excision) was performed. It was also noted that the articular cartilage of the hip was normal throughout, and no evidence of osteophyte formation was seen. The patient had 1 year of relief from her symptoms, but then presented with the onset of new, achy pain in the groin. She described her pain as being different from her previous pain at that time. She was also noted to have significant pain in the provocative position of adduction and internal rotation. Repeat MRI failed to demonstrate a recurrent labral tear. From the information gained at arthroscopy, normal cartilage without degenerative changes, it was thought that she was a candidate for a periacetabular osteotomy in an attempt to provide increased coverage and to prevent the eventual development of osteoarthritis. She underwent this procedure and is doing well at 4 months postoperatively (Figure 14.7).

The remaining three patients who sustained injury to the hip during athletics did not have an appreciable antecedent pathologic diagnosis of the hip. The first patient, a 13-year-old girl, sustained a posterior hip dislocation while snow skiing. She presented with popping and pain in the hip 4 months after the injury. MRI evaluation revealed a small ganglion in the posterior portion of the hip (Figure 14.8A). A possible labral tear was seen on MRI (Figure 14.8B), and the presence of the cyst and mechanical symptoms prompted ar-throscopic evaluation. At arthroscopy, she was noted to have a tear of the posterior labrum in area of her cyst

Femoral Head Arthritis

FIGURE 14.7. Ganz periacetabular osteotomy for DDH. After labral excision, the patient had 1 year of relief from symptoms. The information gained from arthroscopy, of normal articular cartilage, was used as an indication for periacetabular osteotomy. Arthros-copy before osteotomy can be beneficial to demonstrate cartilage wear and stratify patient outcomes from osteotomy.

FIGURE 14.7. Ganz periacetabular osteotomy for DDH. After labral excision, the patient had 1 year of relief from symptoms. The information gained from arthroscopy, of normal articular cartilage, was used as an indication for periacetabular osteotomy. Arthros-copy before osteotomy can be beneficial to demonstrate cartilage wear and stratify patient outcomes from osteotomy.

(Figure 14.9A,B). This tear was resected via the arthro-scope and she is now symptom free (Figure 14.10).

The second patient is a 15-year-old cheerleader who noted the insidious onset of hip pain after start ing her cheerleading season. She gave a history of popping, clicking, and locking in the hip. After conservative management failed to provide relief, she underwent arthroscopic examination that, despite a normal MRI study, revealed a flaplike or bucket-handle labral tear, which was resected arthroscopically (Figure 14.11).

The third patient in the group who sustained a hip injury during athletics was 15 years old when he felt the sudden onset of anterolateral thigh pain while playing basketball. With continued complaints of radiating thigh pain, an MRI revealed a small acetabu-lar labral tear (Figure 14.12), which was resected with the arthroscope (Figure 14.13A,B).

The remaining young patients in our series had no antecedent trauma or injury. Six patients had ar-throscopy of the hip for late sequelae of LCP disease. As mentioned, it is common for patients with irregularly shaped femoral heads to present with new mechanical symptoms. Four of our patients had similar presentations of chronic hip pain accompanied by mechanical symptoms and either degenerative changes or loose bodies noted on radiographs. The other two patients had radiographic findings and MRI results of OCD consistent with incomplete healing of the femoral head.

Case examples of each indication are given. The first is a 12-year-old boy who was treated for LCP discovered at age 6 years. He complained of daily pain requiring home schooling and narcotic pain medications. He presented for a second opinion as to hip arthrodesis. His radiographs, including a recent arthro-gram, revealed a relatively congruous joint surface,

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