Keith R Berend and Thomas Parker Vail

Cure Arthritis Naturally

Cure Arthritis Naturally

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The appropriate application of hip arthroscopy to pediatric conditions requires a broad understanding of children's hip problems. In the end, the success of a hip arthroscopy in treating a pediatric hip condition depends as much on an accurate anatomic diagnosis as it does on technique. A dense constellation of intraarticular and extraarticular anatomic structures exists in close proximity to the hip joint. As such, multiple intraarticular and extraarticular pathologic conditions ranging from developmental to traumatic to infectious can be responsible for hip pain in the young active patient. Indeed, many of these conditions are specific to children and skeletally immature young adults. Traumatic etiologies include apophyseal injury, labral tears, chondral injury with or without loose body formation, and even hip dislo-cation.1-4 Legg-Calve-Perthes disease (LCP), slipped capital femoral epiphysis (SCFE), osteomyelitis, pyarthrosis, psoas compartment abscess, transient synovitis, femoral neck stress fractures, tumors, juvenile rheumatoid arthritis (JRA), and developmental dysplasia (DDH) account for the majority of atrau-matic causes of childhood hip pain. Table 14.1 outlines the indications for hip arthroscopy in children and the procedures described for each diagnosis. Because children are changing so rapidly with growth and development, the differential diagnosis of their complaints changes with time. Hip maladies tend to cluster at several stages of childhood. In general, age can be used as a guideline to narrow a differential diagnosis of hip problems. In general, developmental dysplasia presents in infants and older children, Legg-Calve-Perthes disease presents in children aged 4 to 10 years, slipped capital femoral epiphysis is seen in preteen or early teenage (generally obese) children, and labral injury may occur in older pediatric and adolescent patients following traumatic events.5 All these common musculoskeletal conditions may manifest during athletic participation.6 Although family members and children may associate a particular event with the onset of the hip pain, the underlying cause of the pain may actually be a more insidious process such as infection manifesting acutely. In some circumstances, the role of the traumatic event in the ini tiation of the hip pain is clear and unmistakable. However, when the trauma or athletic injury history is at all vague, sepsis should conclusively ruled out. This is especially true with the presentation of atraumatic hip pain in the young child (ages 0 to 6 years).7-9

Although it is clear that the role of hip arthroscopy in children remains limited, several conditions have been investigated and treated successfully using ar-throscopic surgery of the hip. Since Burman's description of the use of an arthroscope to visualize joints in a cadaveric model, arthroscopy has risen in popularity to become the most commonly performed orthopedic procedure in this country today.10,11 Despite the diverse applications of arthroscopy of the knee, shoulder, ankle, and wrist joints, arthroscopy of the hip has remained an infrequently performed procedure. The reasons for the delayed enthusiasm of surgeons for hip arthroscopy have been multifactorial: the relative technical difficulty of the procedure, the lack of well-documented clinical indications and proven results, and the potential risk of neurovascular injury. Surgeons have not previously had the opportunity to view the interior of the hip joint using a minimally invasive approach, thus limiting the understanding of occult sources of hip joint pain, especially in the active young patient. Finally, the majority of hip pathology in children occurs outside the actual joint space, further limiting the role of arthroscopy for this group of patients.

Hip pain that is persistent despite appropriate nonoperative treatment is a clinical entity that can be particularly difficult to manage when patients are young, and standard radiographic imaging is unrevealing. The advent of hip arthroscopy provides a minimally invasive avenue for diagnosis and treatment in these difficult cases. Thus, early reports on arthroscopy of the hip have centered on the utility of the procedure in providing a diagnosis in occult, intraarticular pathology. Enhanced understanding of the appropriate application of the procedure has led surgeons further into management and treatment of children's hip disorders. Nevertheless, refinement of the specific indications for arthroscopy of the hip and the efficacy of the procedure are only more recently becoming clearer in

TABLE 14.1. Indications for Hip Arthroscopy in Adolescence and Childhood.

Diagnosis

Therapy

Author

LCP disease: sequelae

Chondral debridement Loose body removal Osteochondral fragment excision

Bowen et al. 198629 Glick 1988 Kuklo et al. 199927 O'Leary et al. 200121 Berend and Vail 2001

Juvenile chronic arthritis JRA

Diagnostic Synovial biopsy Synovectomy

Holgersson et al. 198130

Kim et al. 199836

Septic arthritis/pyogenic

Irrigation and debridement

Blitzer 19937 Chung et al. 199319 Kim et al. 199836

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Treating Rheumatoid Arthritis With Herbs Spices Roots

Treating Rheumatoid Arthritis With Herbs Spices Roots

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