Preface

Unlock Your Hip Flexors

Unlock Your Hip Flexors

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This book is the outgrowth of a paradox. Despite quantum advances in radiologic imaging procedures during this generation, many patients with unremitting hip joint symptoms have remained without a specific diagnosis. At the fulcrum of this dilemma are the constraints of conventional magnetic resonance imaging techniques. Unlike the knee joint, where MRI accuracy for detecting meniscal tears is high, analogous MR sequences applied to the hip joint are not nearly as sensitive or specific. McCarthy and Busconi demonstrated, when comparing independent readings of MR images to arthroscopically confirmed labral tears, that the radiologic test had a less than 5% chance for visualizing the abnormality.1 Several other authors have corroborated this finding.2,3

Fueling this paradox further, clinicians are increasingly averse to performing surgical interventions for diagnostic purposes. This is especially true in the hip. Conventional surgical approaches, such as the posterolateral approach often utilized during total hip replacement, may result in osteonecrosis of the unresected femoral head. Alternative methods, such as the anterolateral or transtrochanteric approach, may result in protracted muscle weakness or trochanteric nonunion. Other well-documented risks of open arthrotomy, such as heterotopic bone formation, neurovascular injury, deep vein thrombophlebitis, wound and joint infection have further made clinicians reticent about performing diagnostic arthrotomy. In addition, the inpatient stay associated with the open procedure is costly and commits the patient to an extended rehabilitation program.

Despite the previously noted limitations, patients are more active than ever before. They are living longer, are active physically and athletically later in life, and have higher expectations than previous generations. They are subjecting their hip joints to higher peak and torque loads through their activities or trauma. Thus it is not surprising that there are an increasing number of patients developing unremitting hip joint symptoms.

It is in this context that this book on advances in detection and treatment of early hip disease is so timely. The advent of arthroscopic, minimally invasive techniques to visualize the hip joint has greatly facilitated the understanding of articular cartilage injury and spawned the development of specific treatments.

The application of arthroscopic techniques to the hip joint has been a long time in coming. The relative depth of the hip when compared to other joints, the curvilinear contours of the articular surfaces, the thickness of the capsule, and the intra-articular negative joint pressure have all contributed to making the hip joint, until recently, appear inaccessible. However, improvements in distraction techniques, dedicated instruments for use in the hip, and developing surgical expertise have surmounted the anatomic constraints such that hip arthroscopy in skilled hands can now be performed safely as an outpatient procedure.

The 20 chapters in this book are divided into four principal sections. The first five chapters represent patient assessment. Because of the limitations of prior hip joint diagnostic techniques noted above, we have had to devise techniques that improve the clinician's diagnostic acumen in the office and in the radiology suite. The chapters in this section con tain specific history and physical examination signs that are statistically correlated with the presence of labral tears and loose bodies. The advent of gadolinium-enhanced arthro-MRI scanning, pioneered by my collaboration with Dr. William Palmer of Massachusetts General Hospital and Dr. Arthur Newberg of New England Baptist Hospital, has greatly increased the radiologic sensitivity for detecting labral lesions.

Because of the extensive musculotendinous tissue envelope in which the hip resides, as well as the bony, chondral, synovial, and soft tissue lesions that occur, the chapter on treatment algorithms is especially useful, not only for orthopedists but also for primary care physicians and nurse practitioners.

The second major section focuses on operative preparation. Appropriate indications for arthroscopy, when conservative care has not resolved symptoms, are discussed. Patient safety is of utmost importance, and for that reason specific chapters are devoted to patient positioning, specific distraction principles, anesthesia considerations, and safe portal placement, with tools designed exclusively for the hip.

The third major section discusses specific pathologic entities within the hip, many of which were heretofore unrecognized. Many loose bodies, if unmineralized, are not well seen by CT or MRI but are readily identified and treated arthroscopically. Labral and chondral injuries unequivocally occur, provoke symptoms, and do not have healing potential; the importance of early recognition and treatment is thus underscored. Hip disease occurs in all age groups; thus the relevance of a chapter on pediatrics.

The final major section of this book addresses patient recovery and outcome. These factors are largely influenced by any surgical complications, thus a chapter on occurrence and avoidance. In addition, the hip requires not only smoothly functioning, contoured articular surfaces but also strong supporting musculature; thus a chapter is devoted to incremental rehabilitation. The proper indications for arthroscopic hip surgery can be assessed only in light of specific outcome analysis. Previous hip scoring systems have limited application because of their focus on end-stage arthritis and total joint replacement. The young, highly physically active patients who have arthroscopic intervention have required development of a statistically validated outcome scoring system. This system is discussed in chapter 19.

I am indebted to the 1400 patients who have entrusted me to arthroscope their hip joints. This privilege has allowed me to learn much about early hip disease. I will continue to devote my energies to further understanding even while developing improved treatment techniques. I hope that the readership finds this comprehensive treatise as informational and stimulating as I have found its preparation.

I am indebted to many people who have helped make this book possible. To my parents, who provided me with educational opportunities and intellectual zeal. To my teachers in the classes and science programs at the University of Notre Dame and Georgetown Medical School, who stimulated my mind and my soul and prepared me for a career in orthopedic surgery. To my orthopedic mentors at Tufts University, especially Henry Banks, who nurtured my education and trusted me with his patients. To Hugh Chandler at the Massachusetts General Hospital, whose surgical skills, personal wit, and passionate devotion to his patients I will forever emulate. To William Harris, my fellowship mentor, whose analytical dedication to every aspect of hip joint surgery will forever stimulate me. To my friends and colleagues at the New England Baptist Hospital, especially Roderick Turner and Benjamin Bierbaum, who entrusted me as a partner and collaborator. To the authors, whose curiosity, wisdom, and reflective skills were paramount in completing their work. Special thanks to my office staff, operating room staff, and the Tufts residents and Aufranc fellows whom I have the privilege of working with. To Jo-Ann Lee, whose professionalism, excellence in research, and attention to detail are an inspiration and ensured that this book would be completed. And to Rob Albano, Josh Pasternak, and the editorial staff at Springer-Verlag, who have handled every detail of narrative and visual material with patience, organization, and thoroughness.

Joseph C. McCarthy, MD

References

1. McCarthy J, Day B, Busconi B: Hip arthroscopy: Applications and technique. J Am Acad Orthop Surg 3(3):115-122, 1995.

2. Edwards DJ, Lomas D, Villar RN: Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy. J Bone Joint Surg Br 77(3):374-376, 1995.

3. Dienst M, Seil R, Godde S, Georg T, Kohn D: [Arthroscopy for diagnosis and therapy of early osteoarthritis of the hip]. Orthopade 28(9):812-818, 1999.

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