JW Thomas Byrd

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Sports-related injuries to the hip joint have received relatively little attention. This trend is changing but, until recently, there have been few publications in peer-reviewed journals and the topic has rarely been presented at scientific meetings. There are three reasons. First, perhaps hip injuries are less common than injuries to other joints. Second, investigative skills for the hip including clinical assessment and imaging studies have been less sophisticated. Third, there have been fewer interventional methods available to treat the hip, including both surgical techniques and conservative modalities, and thus there has been little impetus to delve into this unrecognized area.

The evolution of arthroscopy has been intimately tied to sports medicine. The motivating principle has been a less-invasive technique that facilitates quicker return to unrestricted athletics. It is now recognized that this basic sports medicine principle applies well to all individuals, whether the goal is to accomplish an earlier return to the workplace or simply a return to normal daily activities.

However, hip arthroscopy has followed a distinctly different route. It began as a surgical alternative to only a few recognized forms of hip pathology. These indications included removal of loose bodies that could otherwise only be addressed by an extensive arthro-tomy and arthroscopic debridement for degenerative arthritis to postpone the need for hip arthroplasty.1,2

Neither of these early indications found much application in an athletic population. However, as the basic methods of hip arthroscopy were developed, it began to be performed for select cases of unexplained hip pain. Arthroscopy revealed that there are numerous intraarticular sources of disabling hip symptoms that were previously unrecognized and are now potentially amenable to arthroscopic intervention3,4; these include tearing of the acetabular labrum, traumatic injury to the articular surface, and damage to the ligamentum teres among others.

The indications for hip arthroscopy fall into two broad categories. In one, arthroscopy offers an alternative to traditional open techniques previously employed for recognized forms of hip pathology such as loose bodies or impinging osteophytes. In the other, arthroscopy offers a method of treatment for disorders that previously went unrecognized including labral tears, chondral injuries, and disruption of the liga-mentum teres. Most athletic injuries fall into this latter category. In the past, athletes were simply resigned to living within the constraints of their symptoms, often ending their competitive careers, with a diagnosis of a chronic groin injury. Based on the results of ar-throscopy among athletes, it is likely that many of these careers could have been resurrected with ar-throscopic intervention.5

MECHANIsM OF INJURY

The mechanism of injury can be as varied as the sports in which athletes participate. In general, hip disorders attributable to a significant episode of trauma tend to respond better to arthroscopy.6 This is because, other than the damage due to trauma, the athlete usually has an otherwise healthy joint. Individuals who simply develop progressive onset of symptoms in absence of injury tend to experience a less-complete response, because insidious onset of symptoms usually suggests either underlying disease or some predisposition to injury that cannot be fully reversed and may leave the joint vulnerable to further deterioration in the future. Even the presence of an acute injury such as a twisting episode, which is known to cause a tear of the acetab-ular labrum, may be more likely if the labrum was vulnerable to injury and may represent a less certain response to surgery. This vulnerability can result from abnormal labral morphology or underlying degeneration.

However, these broad generalizations must be tempered in the competitive athlete. Individuals who participate in contact and collision sports simply may not be able to recount which traumatic episode led to the onset of symptoms. Remember that significant in-traarticular damage can occur from an episode without the athlete developing incapacitating pain. The athlete may be able to continue to compete and subsequently undergo workup only when symptoms fail to resolve. Injury can occur from any contact or collision sport or sports involving forceful or repetitive twisting of the hip. The aging joint may also be more vulnerable. These parameters do not exclude many sports.

A particular entity has been identified associated with acute chondral damage.7 It is mostly encountered in physically fit young adult men. The characteristic feature is a lateral impact injury to the area of the trochanter (Figure 13.1). Young adult men are apt to be participating in contact and collision activities where this mechanism is frequent. With good body conditioning, they have little adipose tissue overlying the trochanter, so much of the force of the blow is delivered directly to the bone. This force is then transferred unchecked into the hip joint, resulting in either shearing of the articular surface on the medial aspect of the femoral head at the tidemark, or compression of the articular surface on the superior medial ac-etabulum, exceeding its structural threshold. The result is a full-thickness articular fragment from the femoral head or articular surface breakdown of the ac-etabulum, possibly with loose bodies, depending on the magnitude of acetabular chondral, or chondro-osseous cell death (Figures 13.2, 13.3). This mechanism is dependent on peak bone density, as otherwise the force would result in fracture rather than delivery of the energy to the surface of the joint. The injury usually results in immediate onset of symptoms, but may not be disabling. It may be assessed as a groin pull, with workup ensuing only when symptoms fail to resolve.

Ice hockey is a sport that seems to present a particularly high prevalence of hip pathology. Hip flexibility is a premium consideration in this sport. The joint is subjected to violent and repetitive torsional maneuvers and also subjected to relatively high-velocity impact loading. Thus, the labrum is susceptible to tearing from the twisting maneuvers, while the articular surface is vulnerable to impact injury. Often, acute epi-

FIGURE 13.1. Fall results in direct blow to the greater trochanter and, in absence of fracture, the force generated is transferred unchecked to the hip joint.
FIGURE 13.2. Arthroscopic view of the left hip of a 20-year-old collegiate basketball player demonstrates an acute grade IV articular injury (asterisk) to the medial aspect of the femoral head.

sodes are simply superimposed on the cumulative effect of years of exposure (Figure 13.4A-C).

Golf is another illustrative sport that seems to have a predilection for precipitating hip symptoms. It is not a contact or collision sport, but the golf swing does incorporate a significant element of twisting on the hip joint. Additionally, it is a sport in which participants can compete with advancing age, even at the professional level. Thus, the greater susceptibility to injury of an aging hip exists, as well as the cumulative effect of repetitive trauma over a prolonged career. Tennis shares many of these same attributes.

FIGURE 13.3. Arthroscopic view of the left hip of a 19-year-old man who sustained a direct lateral blow to the hip, subsequently developing osteocartilaginous fragments (asterisks) within the su-peromedial aspect of the acetabulum.

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