JW Thomas Byrd

The history of endoscopic in vivo examination of the human body is well known to students of arthroscopic techniques.1 This history dates back almost 200 years to the Austrian, Philipp Bozzini, who in 1806 devised the Lichtleiter (Austrian for light conductor). This instrument, designed for inspection of the rectum and vagina, actually gained clinical record for its use in inspection of the larynx and vocal cords.2

Instruments for viewing human anatomy were heralded as providing indisputable evidence of disease. Previously, only indirect evidence of various disorders was usually available. It is worthy to note that, at the time of Bozzini's invention, auscultation was the principal method of examining the human body. However, when auscultation skills and instruments were initially introduced, they were not without their detractors. Many physicians believed that it would necessitate that they abandon other examination methods that they had spent years developing and feared they might not possess the necessary skills for performing effective auscultation.2 Centuries later, these same barriers existed in the acceptance of modern arthro-scopic techniques.

Following Bozzini's initial design, crude cysto-scopes of various constructs were developed over the ensuing 100 years. All of these were limited by lack of an adequate light source. However, by the early 1900s, electricity was discovered and Edison had invented the incandescent light bulb. This accomplishment opened new horizons in the development of endoscopic instruments. In 1918, Kenji Takagi3 visualized the interior of a cadaveric knee joint with a cys-toscope. The first recorded attempt at arthroscopic visualization of the hip is attributed to Michael S. Burman4 in 1931 (Figures 1.1, 1.2). For his purposes, an arthroscope was constructed by Reinhold Wappler with a diameter of 4 mm, not dissimilar to the dimensions of our current arthroscopes (Figure 1.3). Bur-man used fluid distension for visualization, examining the interior of more than 90 various joints in cadaver specimens, correlating the arthroscopic anatomy with the gross anatomy on subsequent dissection. Twenty of these were hip joints.

Burman made several pertinent and prudent observations that still hold true today, more than over 60 years later. His examination of the hip did not use distraction, and the structures that he successfully visualized correspond with the structures that currently are discernible via arthroscopy without distraction (Figure 1.4). These aspects include much of the articular surface of the femoral head, seen by placing the hip through range of motion, and the intracapsular portion of the femoral neck. With this approach, the acetabulum, fossa, and ligamentum teres could not be visualized.

Burman noted that "visualization of the hip joint is limited to the intracapsular part of the joint." This statement still has much bearing in current applications of hip arthroscopy. Although arthroscopy has been used for release of a snapping iliopsoas tendon and for extracapsular bone fragments that impinge on the joint, intraarticular sources of pathology are most amenable to arthroscopic intervention.

Burman further stated:

"We experimented with a number of punctures and the anterior paratrochanteric puncture proved the best. . . . The anterior paratrochanteric puncture is undoubtedly the best and is made slightly anterior to the greater trochanter along the course of the neck of the femur. . . . The puncture is not hard to do and one can visualize the hip with it in almost every case. Originally we were skeptical as to whether anything could be seen in the hip joint, but we have had unusual success with this puncture."

The anterior paratrochanteric (or anterolateral; see Chapter 7) portal is clearly the workhorse portal for modern arthroscopy. Although there is some variation of the other portals described by numerous authors, this is the one position common to all and, according to an anatomic study, it is the safest.5

Burman continued:

"We have been careful to choose cadavers of slender build since our trochar is not long enough to puncture the hip of a well muscled person. . . . A special long trochar with a correspondingly long telescope should thus be used for the hip joint. The line of the femoral artery and the position of the head of the fe

Femoral Head ArthritisFemoral Head Arthritis
FIGURE 1.1. Dr. Michael Samuel Burman (1901-1975). (Reprinted with permission of New York Academy of Medicine.)

mur should be marked beforehand to avoid possible damage to the vessels. This should only be a theoretical accident."

For the surgeon who only occasionally is challenged by the role of arthroscopic surgery of the hip, size may be a relative contraindication, and even for an experienced arthroscopist it may preclude the ability to enter the hip joint. Indeed, as recommended by Burman, extra-length cannulas and instruments are used but, in some cases, even these may not be adequate. Also, a careful appreciation of the orientation

FIGURE 1.2. Dr. Burman performing an arthroscopic procedure at the Hospital for Joint Diseases in 1935. (Courtesy of Serge Parisien, MD; from Parisien,26 with permission.)

FIGURE 1.3. Photograph reprinted from Burman's article illustrates the arthroscopic instruments devised by Reinhold Wappler and used by Dr. Burman in his investigative studies. The upper portion is the telescope (measuring 3 mm in diameter); the lower portion is the trochar sheath (measuring 4 mm in diameter.) (From Burman,4 with permission.)

FIGURE 1.3. Photograph reprinted from Burman's article illustrates the arthroscopic instruments devised by Reinhold Wappler and used by Dr. Burman in his investigative studies. The upper portion is the telescope (measuring 3 mm in diameter); the lower portion is the trochar sheath (measuring 4 mm in diameter.) (From Burman,4 with permission.)

of the major neurovascular structures is always critical. There are anecdotal accounts such as a case of irreparable damage to the femoral nerve. This type of catastrophic scenario should be unlikely with basic understanding and orientation of the extraarticular anatomy.

The first clinical application of the arthroscope in the hip of a patient was reported by Takagi3 in 1939 (Figure 1.5). This report consisted of four hips, including two cases of Charcot joints, one tuberculous arthritis, and one suppurative arthritis.

The clinical implications of arthroscopic techniques, especially about the knee, began to flourish following the publication of the second edition of Atlas of Arthroscopy by Masaki Watanabe et al.6 in 1965 (Figure 1.6). Watanabe was a student of Takagi's. He also visited with Michael Burman in the evolution of his techniques.

However, following Takagi's report in 1939, the clinical applications of arthroscopy about the hip went unmentioned until the 1970s with Aignan's7 report of attempted diagnostic arthroscopy and biopsy of 51 hips. This study was presented at the 1975 meeting of the International Arthroscopy Association in Copenhagen. In 1977, Richard Gross described 32 diagnostic arthroscopic procedures in 27 children for a variety of pediatric hip disorders including congenital dislocation, Legg-Calve-Perthes disease, neuropathic subluxation, prior sepsis, and slipped capital femoral epi-physis.8 A second clinical series appeared in the pediatric literature in 1981 when Svante Holgersson et al.9 reported on the role of arthroscopy in assessing 15 hips in 13 children with juvenile chronic arthritis. Between these two series, there were two case reports on removal of entrapped cement fragments following total hip arthroplasty, one from the New York City Hospital for Special Surgery and one from Israel.10,11

The 1980s brought several important advancements that contributed to the applications of opera

FIGURE 1.4. Burman's illustration of the arthroscopic view of a hip visualizing the ridging of the neck of the femur, the junction of the neck and the femoral head, and a portion of the articular surface of the femoral head. (From Burman,4 with permission.)

tive hip arthroscopy. In 1981 Lanny Johnson12 addressed the role of arthroscopy of the hip joint in the second edition of his textbook, Diagnostic and Surgical Arthroscopy (Figure 1.7). In 1985, Watanabe13 also described the technique for carrying out the procedure in Arthroscopy of Small Joints. In 1986 Ejnar Eriksson et al.14 from Sweden described the forces necessary for adequate hip distraction. This was an in vivo study of patients undergoing arthroscopy as well as a study of unanesthetized volunteers, which included Professor Eriksson himself.

James Glick from San Francisco has been recognized as the single greatest influence on the development of hip arthroscopy in North America (Figure 1.8).

Motivated by the creative ideas of Lanny Johnson, Glick began performing the procedure in 1977. He recognized limitations of the technique in obese patients. Influenced by his partner, Thomas Sampson, in 1985 they modified the procedure and began placing the patient in the lateral decubitus position. Their preliminary experiences were reported in 1987.15 This and subsequent works have been the cornerstones on which other surgeons have founded their approach.16-18 Ar-throscopy by the lateral approach has been found to be accessible and reproducible. Additionally, a custom distractor has been developed that greatly facilitates arthroscopy in this position.

In the mid-1980s, Richard Villar from Cambridge,

Thomas Byrd Hip ArthroscopyJohnson Johnson Femoral Head
FIGURE 1.7. The author (right) with Lanny Johnson (left), a pioneer of arthroscopy as a clinician, scientist, and inventor. (Courtesy of Dr. J.W. Thomas Byrd.)

England, envisioned several useful roles for arthroscopy of the hip. He corresponded with James Glick and Richard Hawkins, who had published some of the few articles available on the topic at the time.15-19 Villar subsequently pioneered the technique in England and has taught the procedure to others now beginning to perform it in the United Kingdom. He has reported in detail his extensive experience with arthroscopic anatomy and operative arthroscopy.20,21

Brian Day from Toronto accurately envisioned the expanding role for operative hip arthroscopy and has written on the anatomy, indications, and nomenclature for this technique.22,23 Gary Poehling and Dave Ruch from Winston-Salem, NC, have explored the role of arthroscopy as a supplemental technique in the management of avascular necrosis of the femoral head.24 Down the road in Durham, Tad Vail has published his experience, useful in selecting potential candidates for hip arthroscopy.25 Serge Parisien from the Hospital for Joint Diseases in New York City authored several pertinent publications in the 1980s, and Joe McCarthy from Boston has been active reporting his experience in numerous aspects of hip arthros-copy.23,26,27

In the United States, little attention has been given to the prospect of performing hip arthroscopy without distraction.28 However, Henri Dorfmann and Thierry

Boyer, a pair of rheumatologists from Paris, France, have accumulated a large number of cases performed by this method.29,30 Dr. Dorfmann learned the techniques of arthroscopy training under Dr. Watanabe in Japan and pioneered his own method of hip arthros-copy, especially important for viewing the peripheral compartment. As rheumatologists, Drs. Dorfmann and Boyer especially focus on the role of synovial pathology as a source of hip disease. Their method is unsurpassed in being able to address the synovium and often complements the traditional distraction methods that have otherwise been most popular.

Dysplastic hip disease is quite prevalent in Japan.31 The association of labral lesions with dysplasia may explain why there have been several significant studies regarding labral lesions reported from Japanese cen-ters.32-34 In 1991, Ide et al.35 reported what, at the time, was the largest clinical series of arthroscopic procedures.

In Nashville, the author has redefined the application of the supine position and has gained increasing experience in the use of this approach in operative hip arthroscopy.36,37 Minor modifications to a standard fracture table facilitate many of the advantages attributed to the lateral position.

The progression and application of arthroscopic techniques for the hip have lagged behind those for other joints because of the unique challenges imposed by its anatomy. Although slower, the evolution of hip arthroscopy has paralleled that of other joints. Early clinical applications were followed by a hiatus of four decades. The reemergence of case reports and small clinical series was surrounded by uncertainty regarding the merits of the procedure. Arthroscopic investigation of the joint has subsequently expanded our

Thomas Byrd
FIGURE 1.8. The author (center) with James Glick (right) and Thomas Sampson (left). Jim Glick, the single greatest figure in modern hip arthroscopy, was motivated by Lanny Johnson and influenced in his techniques by his younger partner, Tom Sampson. (Courtesy of Dr. J.W. Thomas Byrd.)

knowledge of hip disease and injury. This investigative phase has been followed with a clearer understanding of the indications and technique. The evolution is not complete, but the foundation laid by many of these pioneers has provided the basis for the fundamentals of operative hip arthroscopy.

The maturation of arthroscopic methods has begun a transformation to endoscopic techniques for areas surrounding the hip. Already surgeons are able to address bone fragments outside the joint and to address lesions of the iliopsoas tendon. The incentive is to make surgical procedures less invasive. This category will undoubtedly soon include procedures in which the scope is used as an adjunct to arthroscopic and endoscopic assisted techniques. This development will be driven exponentially by the next generation of surgeons and scientists. Each clinician brings a unique perspective and experience that will benefit all those who struggle on the continually changing horizon of technology with which to battle hip disease.

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