Hip Arthroscopy for Nonstructural Pathology

 

 

 

INTRODUCTION

 

Arthroscopy of the hip joint has become one of the fastest growing surgical procedures in the past decade. As the pursuit of addressing pathology of the hip joint via a minimally invasive technique has progressed, the understanding of the actual disease processes of the femoral-acetabular joint and its surrounding musculature has risen. Much has been written recently regarding methods to classify problems around the hip joint in an effort to streamline the diagnosis and treatment algorithm. Examples of this include labeling pathology according to location (Table 6-1) or as structural versus nonstructural (1).

Femoral acetabular impingement (FAI) of the hip has gained tremendous notoriety within recent literature (2,3). The author prefers to separate hip arthroscopy globally into a “pre and post” understanding of FAI. In early hip arthroscopy, the bony abnormalities of FAI were often not well understood. As such, routine hip arthroscopy did not address underlying bony impingement, even if present (4). Failure to address significant cam or pincer deformity may have contributed to a higher than acceptable progression of osteoarthritis and ultimately conversion to total hip arthroplasty (4,5). However, as the field has advanced, a better understanding of the structural relationship between the morphologic abnormalities of the femoral head/neck and the acetabulum has helped shed light upon the injuries seen relating to nonstructural disease. For the purposes of this chapter, we shall be focusing on issues that can be addressed via arthroscopy pertaining to nonstructural pathology of the hip joint.

Nonstructural pathology of the hip is a wide-ranging category of soft tissue, cartilage, and synovial disorders that effectively encompasses all disease processes not related to bony abnormalities. As indicated above, however, there is a vast interplay and overlap between structural and nonstructural disorders. Commonly seen nonstructural disorders include the spectrum of coxa saltans, gluteus medius tears, labral pathology, and bursitis (Table 6-2).

 

INDICATIONS

In many instances, soft tissue disorders of the hip can be managed in a conservative manner. It is extremely important during the patient workup to determine the duration of the pain, location of the pain, and provocative factors. In many instances, there is concomitant pathology associated with the presenting disorder that must be addressed, such as leg length discrepancies, sports hernias, muscular imbalance, and/or lumbar spine disease. A proper core-strengthening program coupled with adequate stretching can oftentimes negate the need for surgical intervention.

The most common indication for arthroscopic intervention for nonstructural hip pathology is persistent pain that has failed conservative measures. In general, the best indication for surgical intervention is recalcitrant hip pain with an identifiable etiology, particularly in patients without gross osteoarthritis. In some instances, concomitant procedures may be performed at the time of the hip arthroscopy to address the full spectrum of the hip pathology. The majority of the contraindications,

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for hip arthroscopy, aside from gross osteoarthritis or infection are structural in nature. Examples of this include moderate or severe acetabular dysplasia, coxa magna, Brooker 3 or 4 heterotopic bone, and excessive acetabular version (6).

 

 

TABLE 6-1 Hip Pathology: Location Based

Intra-articular Extra-articular

Peritrochanteric space Ischial space

 

 

 

TABLE 6-2 Nonstructural Pathology of the Hip

Coxa saltans (internal/external snapping hip) Gluteus medius tears

Labral tears

Bursitis (greater trochanteric, iliopsoas) Synovitis (PVNS)

 

 

PREOPERATIVE PLANNING

As with any orthopedic procedure, the hallmark of successful surgical intervention begins with matching proper patient selection with the proper procedure. The key to this success lies in the preoperative planning process. Once the patient history has directed the physician toward a specific pain generator location, a decision tree can begin that allows a broad spectrum of pathology to be narrowed to a small field. This in turn allows for an increase in successful outcomes.

A concentrated physical examination of the hip and the surrounding structures can help identify pathology such as lumbar disc disease, sports hernias, tight musculature, or mechanical symptoms. The authors recommend using reproducible provocative testing to ensure proper identification. Examples of these include flexion-adduction-internal-rotation testing (FADDIR) for impingement, McCarthy's test for labral tearing, OBER's test for illiotibial band (ITB) dysfunction, and a version of the flexion-abduction-external-rotation test (FABER) for internal snapping hip (7).

Once the examination is completed, appropriate radiographs can be ordered. It is imperative to have true, nonrotated, radiographs. This is particularly useful when investigating for bony abnormalities. Standard hip series radiographs for the authors include an AP pelvis, a false-profile view of the hip, and a Dunn view lateral.

Additional radiographs of the lumbar spine are ordered if there is suspicion of concomitant pathology (8,9).

Noncontrast MRI has a limited ability to identify intra-articular pathology, and thus, the authors prefer the use of a gadolinium-enhanced MRI arthrogram. The arthrogram allows for better visualization of labral tears, loose bodies, ligamentum injuries, and identification of cartilage lesions. It should be pointed out, however, that the severity of cartilage pathology remains the most difficult lesion to accurately identify preoperatively. As such, careful examination of the plain radiographs for joint space preservation, in conjunction with the MRI arthrogram, is critical during preoperative evaluation. The absence of radiographic osteoarthritis has been shown to have a favorable effect on outcome after hip arthroscopy (10). The addition of an intra-articular anesthetic during the arthrogram has demonstrated some benefit in localizing joint pathology versus extra-articular sources (11). The lead author routinely requests either lidocaine or Depo-Medrol be added to the arthrogram injection; however, it should be noted that there is some debate regarding the risk of postoperative infection after intra-articular steroid injections.

Other adjunct imaging includes CT scanning with 3D reconstruction and ultrasound evaluation. CT scanning has been helpful in identifying structural abnormalities of the femoral head and acetabulum (12). Controversy remains over its benefit versus risk when considering the patient population and radiation risk. Dynamic ultrasound evaluation of the iliopsoas and the ITB has grown in popularity. Past limitations of this imaging modality were primarily linked to the technical expertise of the examiner; however, as the growth of the diagnostic ultrasonography for orthopedic use has exploded, these interpretive limitations appear to be disappearing (13,14).

 

 

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SETUP AND POSITIONING

Hip arthroscopy is routinely performed in either the supine or the lateral position (15,16,17). The authors primarily utilize the lateral position; however, the supine position is also utilized depending on facility and

equipment availability. Various commercial tables are available for either position, or, if necessary, a standard fracture table will suffice. A soft boot is applied to the operative foot and a well-padded perineal post is placed against the inner thigh of the operative leg to avoid perineal injury. Manual hand traction of 25 to 50 pounds is applied and maintained during the intra-articular portion of the procedure. Traction time should not exceed 90 minutes in order to limit risk of sciatic nerve injury. General or spinal anesthesia may be utilized for the procedure, with the goals of muscle paralysis and a low mean arterial blood pressure.

The operating room is set up in order to maximize mobility of the operative leg for evaluation of the static structures during osteoplasty. The author stands on the side of the operative leg with the C-arm brought across the patient's body, beneath the table. The majority of the central compartment work is performed using a 70-degree arthroscope utilizing a combination of the anterolateral portal (ALP), mid-anterior portal (MAP), and anterior portal (AP) (Fig. 6-1). Work in the peripheral compartment can be performed utilizing either a 30- or a 70-degree arthroscope. In addition to the standard portals listed above, accessory portals may be employed as well. These portals are discussed below when appropriate.

 

 

 

FIGURE 6-1 Standard arthroscopic portals for a right hip. ALP is initially created for viewing. The MAP and the AP are used for anchor placement. The PP is used for reaching the ligamentum and deep recess of the hip. The peripheral and peritrochanteric compartment portals are created anteriorly on the hip with care taken not to work medial to the ASIS.

 

CENTRAL COMPARTMENT PATHOLOGY

Once the patient has been positioned, fluoroscopy is taken in the AP and lateral position to ensure there is no malrotation of the pelvis. Confirmation of this increases the likelihood of success during osteoplasty procedures. After prepping and draping, a spinal needle is used to identify an ALP under fluoroscopy just off the anterior-superior edge of the greater trochanter (18). Access to the joint is performed carefully using a dilation technique to avoid damage to the articular cartilage and the labrum. The author prefers to utilize a 5.5-mm metal cannula for visualization; however, a 4.5-mm cannula, in conjunction with a posterior portal (PP) outflow, is employed in cases of severe acetabular overcoverage. An MAP is then created referenced off the ALP. This portal is approximately 3 finger's breadths away on a 45-degree angle from the ALP. If needed, the direct AP is created at the intersection of the anterior superior iliac spine (ASIS) and the top of the greater trochanter. A capsulotomy can be created connecting these portals via use of a capsular blade, an oscillating shaver, or an electrocautery device. The author prefers a capsular blade to minimize loss of tissue for potential repair at the conclusion of the procedure. In order to avoid soft tissue interference during labral repair, it is suggested to switch portals after the initial capsulotomy to ensure that the capsulotomy is complete.

Routine central compartment evaluation is done systematically to avoid missing pathology. The author initially inserts the probe and evaluates the articular cartilage of the femoral head and acetabulum, identifying and documenting potential lesions that may progress, if untreated, to fulminate arthritis. The articular cartilage of the acetabulum is traced up to the chondral-labral junction and probed. Oftentimes, the consequence of femoral cam impingement is the delamination of the chondral labral junction. Upon probing this border, the surgeon will note a “wave sign” (Fig. 6-2; Video 6-1). Treatment of this lesion is discussed below.

 

 

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FIGURE 6-2 The “wave” sign is seen here with disruption of the chondral-labral junction.

 

Next the acetabular labrum is probed and inspected for instability and/or erythema from the far anterior “5 o'clock” position, up around back to the “9 o'clock” position. If needed, the scope can be repositioned into the AP or PPs, respectively, to obtain appropriate visualization. Proper preoperative planning should make identification of the labral tear location easy as the structural abnormalities of the femoral head and/or acetabulum often correlate with the labral defect. Following this, the deep fovea region of the acetabulum is evaluated. Often, there is disruption of the ligamentum with a large amount of erythematous synovitis noted. Finally, the scope is relocated into the PP (if utilized) and the direct AP to evaluate for foveal loose bodies or chondral defects.

LABRAL PATHOLOGY (SEE VIDEO 6-2)

Within the past decade, there has been a philosophical shift in how labral tears are managed (19,20,21,22,23,24,25,26) (Fig. 6-3). Early studies by Byrd and Jones found an 83% survivorship at 10 years posthip arthroscopy with labral debridement (25). Similarly, other studies have also shown similar success rates without a rapid progression of hip osteoarthritis with limited labral debridement. However, as a better understanding of the function of the labral seal has become understood, coupled with improvements to arthroscopic hip instrumentation, the number of labral repairs versus debridement has grown exponentially. The ability to repair the labrum has been particularly effective in

 

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situations where extensive labral excision would have been previously required, thus potentially leading to acceleration of osteoarthritis.

 

 

 

FIGURE 6-3 Labral tearing is seen in a right hip with chondral labral damage also present.

 

Labral repairs can be performed via the standard three portals previously discussed. Utilization of the MAP has allowed for improved anchor placement as is permits divergence of the anchor from the edge of the acetabular rim. The goal of acetabular labral repair, as previously noted by Byrd, is to create a suction seal and not to create a bolster (Fig. 6-4A, B). The acetabular rim edge is thin. The amount of bone at the rim can vary, particular if acetabuloplasty has been performed. It is important to place the anchors on the capsular side of the acetabulum at the rim margin without violating the joint. Drilling of the acetabulum for anchor placement should be performed while visualizing within the acetabular socket. Keen attention should be paid to chondral bubbling as this may be a sign of vault violation.

There are a variety of drill guides available for anchor placement, including curved guides. Additionally, the depth of the anchors and diameter of the anchors have increasingly decreased in order to accommodate for the spherical geometry of the acetabulum. Anchor variety currently includes knotted, knotless, and hybrid knotless/knotted configurations. Additionally, many of these anchors exist as either a single- or double-loaded anchors. The overall depth of anchor selections allows the surgeon a plethora of options for labral repair.

However, no matter the anchor choice utilized, care must be taken when repairing the labrum as the tissue is extremely delicate and iatrogenic injury is possible. Proper capsular-sided preparation of the acetabulum must take place in order to allow for placement of the anchor, particularly knotless anchors.

 

 

 

FIGURE 6-4 A,B: The labral suction seal has been restored utilizing a hybrid knotless anchor.

 

CHONDRAL-LABRAL INJURY

Chondral-labral junction injuries present the surgeon with an interesting confluence of pathology (27). These injuries involve delamination of the labrum and the adjacent articular cartilage off of the acetabulum. Such tears are routinely not seen on preoperative imaging. These lesions are recommended to be repaired. Some have recommended peeling down the labrum and cartilage as a unit and performing microfracture of the subchondral bone to create the potential for healing the cartilage when repaired with the labrum. Such a procedure is technically demanding, and the author will often defer to this when concomitant rim trimming is required. Instead, a thin piercing device is used to pass the suture through the labrum and the cartilage and repair them as a unit.

OSTEOCHONDRAL DEFECTS/MICROFRACTURE

Grade IV osteochondral defects (OCDs) are the only true indication for microfracture within the hip joint (28,29) (Fig. 6-5). The purpose of microfracture, same as with other load-bearing joints, is to stimulate the body to grow new cartilage in an area with a focal lesion. It is intended for lesions

 

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that are isolated with stable edges, not to exceed a surface area of 2.5 cm. A review of basic science reminds us that native hyaline cartilage is made of primarily type II cartilage, whereas fibrocartilage is the primary by-product of microfracture.

 

 

 

 

FIGURE 6-5 Grade IV OCD in a left hip.

Hip length microfracture picks and ring curettes are available from a variety of commercial suppliers. These instruments come in varying angles to allow for usage at different locations of the joint. The majority of microfracture procedures can be carried out utilizing the standard direct AP; however, accessory portals can be localized via an 18-gauge needle and created to ensure a successful working environment. Newer techniques utilizing drill holes in lieu of the mallet and picks are gaining popularity. The premise for this modification is to avoid impaction fractures as well as to eliminate potential failures due to bone clogging the microfracture holes. Furthermore, filling procedures of full-thickness articular cartilage defects of a large size have also begun to be employed arthroscopically. The use of autologous or allograft chondrocytes for OCD filling may result in improved hip scores and function (Fig. 6-6) (Bisshai, personal communication, 2014). No matter the technique employed, the principles of successful microfracture of the hip are the same as those of the other weight-bearing joints (Table 6-3). Postoperative rehabilitation for microfracture of the acetabulum entails partial weight bearing on the affected hip with crutch utilization for 6 weeks.

 

 

 

 

FIGURE 6-6 Arthroscopic transplant of allograft juvenile chondrocytes for a fullthickness grade IV OCD in a left hip.

 

 

 

TABLE 6-3 Microfracture Principles

 

1. Remove all cartilage down to the subchondral bone

2. Vertical walls are needed at the defect margins

3. The holes must penetrate the tidemark (2-6 mm below the subchondral bone)

4. The holes should be placed approximately 4-5 mm apart

5. The holes should be placed around the periphery first, followed by attention inward

 

 

 

 

LIGAMENTUM TERES INJURIES (SEE VIDEO 6-3)

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The function of the ligamentum teres in the mature adult has previously been not well defined. These lesions can occur as a traumatic or degenerative process. Previous reports have estimated the incidence of ligamentum teres tears during hip arthroscopy to be 4% to 51%, and they have been estimated to be the third most common reason for hip pain in athletes (30).

The mechanism of tearing in traumatic tears is usually secondary to a dislocation or a violent twisting motion

(31). Degenerative tears can be seen in patients later in life or in those who have hip dysplasia (32). Both forms of tears can be extremely painful. Anecdotally, these tears may present themselves as pain, which radiates posteriorly through the buttock or as deep seeded joint pain. Arthroscopic evaluation will oftentimes find a scar “ball” of the torn ligamentum with accompanying inflammatory tissue (Fig. 6-7A, B).

The treatment of ligamentum teres ruptures is generally debridement. Intraoperative inspection of the fovea and the ligamentum is carried out with the use of a 70-degree scope through the anterolateral viewing portal. Routine debridement is not carried out during hip arthroscopy; however, if the ligamentum has tearing with excess scar tissue or synovitis, debridement is recommended. Using a curved shaver, access to the ligamentum can be reached most readily through the PP. The use of the MAP can also allow for functional access.

The belief that an intact ligamentum teres plays a secondary role in hip joint stability has led to the exploration of arthroscopic reconstruction. Early reports on reconstruction in patients with full-thickness tears with overt instability have yielded promising early results (30,33).

 

 

 

 

FIGURE 6-7 A: Arthroscopic evaluation of a ligamentum teres rupture with accompanying inflamed synovial tissue within the deep foveal region of the hip (B).

 

LOOSE BODIES (SEE FIG. 6-8 AND VIDEO 6-4)

One of the best indications for hip arthroscopy, regardless of patient age, is the removal of symptomatic loose bodies (34). When performed arthroscopically, it presents a much less invasive method and simpler recovery that an open methods. The etiology of the loose body oftentimes necessitates the need for other arthroscopic interventions, such as microfracture.

Removal of the loose bodies can be performed through any of the standard central compartment portals or via accessory portals. They can be removed via a variety of straight and angled graspers. Once a loose body has been grasped, it can be removed through a metal cannula, a slotted half pipe or through simply the soft tissue. Care must be taken to avoid losing the loose body in the soft tissue as it journeys out from the deep recess of the hip joint. Dilation of the soft tissues should be performed

 

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prior to excision in order to facilitate this. In the case of multiple loose bodies, such as synovial chondromatosis, there are a few pearls that should be considered to allow for an easier procedure. First, avoid making a connected capsulotomy. This will prevent the loose bodies from escaping into the periphery. Secondly, employ

multiple portals with cannulas at the onset to decrease fluid extravasation. These procedures, if there are numerous pieces, can take longer than normal and as such accommodations should be made. Finally, the author recommends fluctuating the pump pressure in cases of synovial chondromatosis in an effort to force the pieces out through larger bore cannulas.

 

 

 

 

FIGURE 6-8 Loose body.

 

SYNOVIAL DISORDERS

Synovial disorders encompass a wide range of pathology including PVNS, synovial chondromatosis, and other inflammatory disorders. Most synovial disorders can be managed nonsurgically; however, for those that require intervention, arthroscopy allows for great success. Total synovectomy arthroscopically is not feasible; however, an extensive synovectomy is generally sufficient to reduce the patient symptoms and aid in joint preservation.

The indications for arthroscopic intervention are the same as those outlined for other joints. The procedure is carried out through the standard AL viewing portal. Working access is obtained via the direct AP and the PP. The MAP allows for working as well; however, this portal is limited in its functionality for access to the deep acetabular region. Careful and meticulous work must be performed when removing synovial ossifications or the PVNS tissue. The author recommends limiting the capsulotomy during synovial chondromatosis surgeries to prevent escape into the peripheral tissues (Fig. 6-9). Recurrence of synovial chondromatosis after arthroscopic intervention has been reported to be approximately 7% (35). As such, careful follow-up is warranted to aid in future treatments.

 

 

 

FIGURE 6-9 Visualized are numerous ossified pieces of synovium that have populated the hip joint.

 

 

 

ILIOPSOAS TENDON DISORDERS

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Coxa saltans, or snapping hip, is an often undertreated pathology of the hip. Internal snapping hip entails the tendinous portion of the iliopsoas tendon “snapping” overtop of the femoral head with hip movement (36). It is oftentimes associated with far anterior labral tears. The success rate of iliopsoas release is high; however, the surgeon and patient must be aware of the possibility of residual hip flexor weakness and the risk of heterotopic ossification.

Treatment of the disorder can be achieved by either releasing the fibers intrasubstance or at their insertion on the lesser trochanter (36,37). There are three documented surgical release techniques to treat the disorder. The first involves releasing the tendon while the hip is under traction. While viewing through the ALP and working through the AP or MAP, the scope is directed anteriorly at the top of the femoral head. Next, a window cut is made through the anterior capsule and resection is performed to allow for visualization of the tendon fibers (Fig. 6-10). A hip blade, oscillating shaver, or radiofre-quency device is then used to release the tendon's fibers without disrupting the muscular portion.

 

 

 

FIGURE 6-10 A window has been made through the anterior capsule at the level of the femoral head to expose the iliopsoas tendon for release.

 

Technique two is performed through the peripheral compartment without traction. While working through the AP, a cut is made through the medial capsule at the level of the synovial fold. Flexing the hip to approximately 45 degrees and placing mild external rotation on the hip will allow for the capsule to float away from the femoral head and neck. The tendon can be released using one of the above devices.

The final method of release entails releasing the tendon from the lesser trochanter. Again, flexing the hip to 20 degrees will aid in visualization. An iliopsoas bursectomy is performed to allow for visualization. The muscular fibers of the iliacus are maintained during the release.

Postoperatively, the patient is placed on 50 mg of indomethacin twice a day for 2 weeks to decrease the risk of heterotopic ossification. Crutches are also employed for 3 weeks. Physical therapy is begun as soon as the first week, with a concentration on core strengthening.

PERITROCHANTERIC SPACE

The peritrochanteric space is an oftentimes a forgotten area of pathology in hip arthroscopy. Disorders of the peritrochanteric space include external snapping hip, greater trochanteric bursitis, and gluteus medius tendinopathies.

 

The portals utilized for peritrochanteric space are located along the anterior aspect of the hip. Initial portal placement is localized with a spinal needle along the anterior border of the tensor fascia lata. Upon penetrating the skin, the needle is redirected posteriorly into the trochanteric bursa at the level of the vastus lateralis ridge. Fluoroscopic assistance can aid in portal localization. Care must be taken to avoid the gluteus medius insertion. The second portal is placed proximal to the first portal at or slightly proximal to the tip of the greater trochanter. Once this working portal is established, a blunt instrument, such as a switching stick, can be introduced in a sweeping motion to develop the space. Accessory portals can be made under direct visualization as needed for any additional work.

 

SNAPPING ILLIOTIBIAL BAND

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Snapping ITB, also known as coxa saltans externa, is a condition that is most often managed nonoperatively.

The condition presents as an audible and sometimes painful disorder of the hip occurring during activities that require repetitive flexion, extension, and abduction of the hip. In instances of recalcitrant nonsurgical treatment, arthroscopic has been shown to be extremely successful (38,39).

There are several methods to endoscopically treat snapping ITB syndrome. No matter the technique chosen, the principle of treatment is to eliminate tension on the ITB via a tendon relaxation. The authors preferred technique entails a modified cruciate incision. The ITB is viewed from the AP and an arthroscopic knife or radiofrequency device is utilized via a percutaneous approach distally approximately 8 cm away. A 30 - or 70-degree arthroscope may be used in the peritrochanteric space for viewing. The cutting device is used to make an 8- to 10-cm vertical incision in the ITB. Next, two 1- to 1.5-cm horizontal incisions are made in the ITB at the midportion of the vertical incision. A shaver can then be utilized to debride the incisions to prevent scarring back over. Alternative techniques that have been described include a Z-plasty and a diamond tenotomy, though these are less reliable and may result in considerable scarring.

Postoperatively, the patients are placed on crutches for 7 to 14 days, and then, physical therapy may commence. Core strengthening and stretching are emphasized during the recovery phase. Excessive physical activity is avoided for 2 to 3 months postoperatively.

GREATER TROCHANTERIC BURSECTOMY

Greater trochanteric bursitis is often seen as a by-product of a tight ITB or in cases of snapping ITB. Similar to coxa saltans, it is most often managed nonoperatively. In cases that are refractory to conservative care, endoscopic bursectomy, in combination with ITB recession, has been shown to be highly successful. Viewing from the distal AP, a shaver can be introduced into the proximal AP and used to sweep away adhesions. Once the space has been opened, the shaver can be used to carry out the bursectomy. It is important to address all concomitant pathology associated with the bursitis, as bursectomy alone has demonstrated variable results (40,41).

GLUTEUS MEDIUS TENDINOPATHIES

The gluteus medius tendon has been called “the rotator cuff of the hip.” The role of the gluteus medius is to allow for abduction of the hip and to maintain the pelvic plane during ambulation. Tears of the gluteus medius are oftentimes missed on arthroscopic evaluation due to the fact that the tears usually lie deep rather than superficial

(42). A good physical examination, coupled with MRI findings, will oftentimes point to a deep tear that is covered by the superficial gluteus medius tissue. However, care should be taken to ensure that the MRI findings are not incidental. The patient's complaints and examination most corroborate the MRI tear findings in order to justify the need for repair.

Repair of the gluteus medius is performed very similarly to that of a rotator cuff repair. Debridement of the edges of the tears is performed. The footprint of the greater trochanter is roughened and prepared to accept the tendon repair. Once prepared, conventional rotator cuff anchors and passing devices can be used to complete the repair.

Postoperatively, the patient is maintained on crutches for 6 weeks. Abduction bracing is an option, with the goal of limiting adduction past neutral in mind. Therapy can be initiated as early as 1 to 2 weeks postoperatively provided the repair is protected. Return to jogging activities can commence approximately 3 to 4 months postrepair.

PEARLS AND PITFALLS

 

Hip arthroscopy complications are most often correlated with traction time, malpositioned perineal posts, and fluid extravasation (43,44).

 

Labral preservation and repair should be considered in any case where a good repair is possible. Extreme care should be taken during acetabuloplasty to avoid injury to the tissue. The use of a clear, hooded burr for acetabuloplasty is recommended. The hooded side can be spun to protect the labral tissue during the procedure.

 

During labral repair, utilization of the MAP will provide an appropriate trajectory to the acetabular rim for anchor placement.

 

During anchor placement, the surgeon should view from inside the joint while drilling to ensure the acetabulum is not violated.

 

 

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Clear boundary markings of the ASIS and the posterior aspect of the hip should be made prior to incision.

Keeping these landmarks in perspective will prevent the surgeon from drifting into dangerous neurovascular areas during accessory portal placement.

 

Gluteus medius tears tend to be on the deep surface. As such, unroofing of the tendon is oftentimes required to identify and address the pathology. However, degeneration of the gluteus medius is a common process, and the exam findings must match the suspected pathology if a repair is to be carried out.

 

Trochanteric bursitis is related to a greater spectrum of symptoms known as “greater trochanteric pain syndrome.” As such, it is important to address all underlying pathology (coxa saltans externa, gluteus medius/minimus tendinopathies) in order to increase the operations success rate.

 

SUMMARY

The spectrum of nonstructural hip disorders contains an immense array of pathology that often has concomitant pathologies. It is important to address these disorders via a systematic evaluation of the hip. Portal placement, while elementary, often holds the key to allowing a surgeon to perform a smooth surgery. Utilization of fluoroscopy during portal placement can be invaluable. Finally, an evolving understanding of the interplay between structure and nonstructural pathology within the hip will allow for short- and long-term success for the patient.

 

 

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