Operative Hip Arthroscopy - part 7 ppsx

rotation of the hip also helps in delivering the ligament to the shaver brought in anteriorly. The most posterior portion of the fossa and the acetabular attachment of the ligament may be best accessed from the posterolateral portal. Indiscriminate debridement of the ligamentum teres should be avoided because of its potential contribution to the vascularity of the femoral head. CASE 4 A 16-year-old female cheerleader was referred with a 2-year history of intermittent pain and catching of her left hip following a twisting injury. Arthroscopy revealed a rupture of the ligamentum teres (Figure 10.33A); this was debrided with prompt symptomatic improvement (Figure 10.33B,C). Synovial Disease Various types of primary synovial disease have been encountered in the hip. 20 More often, secondary synovial proliferation may occur in response to other intraarticular pathology. A focal pattern of synovitis may occur emanating from the pulvinar within the acetabular fossa and is limited to this area. These lesions may be dense and fibrotic or exhibit proliferative villous characteristics. Presumably because of en- trapment within the joint, these lesions can be quite painful and respond remarkably well to simple debridement. More diffuse synovial patterns involve the lining of the capsule. A complete synovectomy can- not be performed, but a generous partial synovectomy can be carried out. This procedure necessitates access to the peripheral compartment after the traction has been released. C ASE 5 A 22-year-old woman was referred with a 3-year history of poorly defined left hip pain with no antecedent history of trauma. Radiographs revealed evidence of periarticular subchondral cyst formation suggestive of pigmented villonodular synovitis (Figure 10.34A), 162 J .W . THOMAS BYRD FIGURE 10.31. A 22-year-old hockey player with mechanical right hip pain. (A) Sagittal T2-weighted image of the right hip demonstrates evidence of anterior labral pathology (arrow). (B) Arthroscopic view from the anterolateral portal identifies a ra- dial fibrillated tear of the anterior labrum. The probe has been introduced from the anterior portal. (C) The damaged tissue is debrided with a full-radius resector. B C A which was further supported by MRI findings (Figure 10.34B). Arthroscopy revealed the characteristic lesion of pigmented villonodular synovitis arising from the acetabular fossa, which was debrided (Figure 10.34C–F). More extensive disease emanated from the synovial lining of the capsule, which was most fully assessed by arthroscopy of the peripheral joint (Figure 10.34G). Impinging Fragments Impinging bone fragments may respond well to arthroscopic excision. 20 These fragments are usually the result of trauma. Degenerative osteophytes rarely benefit from arthroscopic excision as the symptoms are usually more associated with the extent of joint deterioration and not simply the radi- ographically evident osteophytes that secondarily form. Posttraumatic fragments can impinge on the joint causing pain and blocking motion. These fragments are often extracapsular and require a capsu- lotomy, extending the dissection outside the joint for excision of the bone fragments. This necessitates thorough knowledge and careful orientation of the extraarticular anatomy and excellent visualization at all times during the procedure. In general, the dissection should stay directly on the bone fragments and avoid straying into the surrounding soft tissues. Various techniques aid in maintaining optimal visualization. A high-flow pump is especially helpful, maintaining a high flow rate without excessive pressure, which would worsen extravasation. Hypoten- sive anesthesia, placing epinephrine in the arthroscopic fluid, and electrocautery or other thermal CHAPTER 10: THE SUPINE APPROACH 163 FIGURE 10.32. A 47-year-old woman with 9-month history of right hip pain. (A) Radiographs reveal evidence of superolateral joint space narrowing, which has been described as indicative of early osteoarthritis due to an inverted labrum. (B) The hip is viewed from the anterior portal. The probe marks the torn edge of the labrum (L) adjacent to an area of grade IV articular loss (IV) from the acetabulum. (C) The torn edge of the labrum has been debrided, and chondroplasty is being performed. (D) This grade IV lesion demon- strated healthy surrounding articular surface and thus was a can- didate for microfracture performed with an arthroscopic awl. B D C A device for hemostasis all aid in visualization for ef- fectively performing the excision. CASE 6 An 18-year-old high school football player was treated conservatively for an avulsion fracture of the anterior inferior iliac spine of the left hip. The avulsed fragment ossified (Figure 10.35A,B), creating a painful block to flexion and internal rotation. Dissecting through the capsule anteriorly, the ossified fragment was excised arthroscopically (Figure 10.35C–F), elim- inating the fragment (Figure 10.35G) and regaining full painfree range of motion. Instability Hip instability can occur but is much less common than seen in the shoulder because the hip joint has a more constrained ball-and-socket bony architecture. Recurrent posterior instability is usually associated with trauma. 21,22 Atraumatic instability can occur due to an incompetent capsule, usually seen in hyperlax- ity states such as Ehlers–Danlos syndrome. Our ob- servation has been that most atraumatic instability is anteriorly directed. In fact, when viewing the peripheral compartment, the femoral head can often be ob- served to sublux anteriorly during external rotation, even in asymptomatic individuals. In symptomatic cases, thermal capsulorrhaphy can be performed, ad- dressing the capsule in a fashion similar to that described for the shoulder. Postoperative compliance with a limited range-of-motion protocol is imperative to achieving the optimal capsular response to the thermal treatment. CASE 7 A 17-year-old girl was referred for progressively wors- ening symptoms of right hip instability. Her medical history was remarkable for Ehlers–Danlos syndrome with severe ligamentous laxity of multiple joints. She 164 J .W . THOMAS BYRD FIGURE 10.33. A 16-year-old cheerleader with left hip pain following a twisting injury. Arthroscopic view from the anterolateral portal. (A) Disruption of the ligamentum teres (asterisk) is identified. (B) Debridement is begun with a synovial resector introduced from the anterior portal. (C) The acetabular attachment of the ligamentum teres and the posterior aspect of the fossa is addressed with a shaver from the posterolateral portal. A C B FIGURE 10.34. A 22-year-old woman with insidious-onset left hip pain. (A) AP radiograph demonstrates joint space preservation with multiple subchondral cysts of the femoral head suggestive of pigmented villonodular synovitis. (B) Coronal T2-weighted image of the hip demonstrates evidence of proliferative synovial disease (arrows). (C) The hip is viewed from the anterolateral portal. Synovial disease characteristic of pigmented villonodular synovitis is identified in the acetabular fossa. (D) Debridement of the fossa is begun with the shaver from the anterior portal. (E) Debridement of the fossa is then completed from the posterolateral portal. (F) Synovial disease of the posterior capsule extending underneath the posterior labrum is best debrided from the posterolateral portal because this portion of the capsule is not well accessed from the peripheral compartment. (G) With the traction released and the hip flexed, the arthroscope is then repositioned from the anterolateral portal into the peripheral compartment. Extensive synovial disease is present, which is debrided with a shaver introduced from an ancillary portal. This view especially illustrates the seaweed appear- ance ascribed to pigmented villonodular synovitis. F D B A C E G FIGURE 10.35. An 18-year-old man after bony avulsion of the left anterior inferior iliac spine. (A) AP radiograph reveals ossification around the acetabulum (arrow). (B) Three-dimensional CT recon- struction defines the dimensions of the fragment (arrow) creating a mechanical block to internal rotation. (C) Viewing from the anterolateral portal, a full-radius resector is used to develop the margins of the osteophyte (O), which lies anterior to the articular surface of the acetabulum (A). (D) An arthroscopic knife is used to incise the capsule, which is partially contained within the fragment. (E) Hemosta- sis, important for optimal visualization, is maintained with judi- cious use of the arthroscopic cautery. (F) The anterior capsule (C) has been fully released, and a burr is used to excise the fragment, exposing the anterior column of the pelvis (P). The anterior margin of the acetabulum (A) is at the bottom of the picture, and a portion of the femoral head (F) is in view on the left. (G) The postoperative radiograph reveals the extent of bony resection. B A C D F G E had undergone previous successful capsulorrhaphy of her right shoulder. She had sustained a relatively atraumatic dislocation episode of her right hip 5 years previously that was reduced in an emergency room. Subsequently, she had experienced multiple subluxation/dislocation episodes that she had learned to reduce on her own or with the assistance of a family member. She had developed protective behavior to avoid these episodes but, even with precautions, would intermittently experience symptoms of her hip going out, causing her to fall. On examination, her greatest sense of instability and apprehension was created when translating the femoral head anteriorly with forced abduction and external rotation. Radiog- raphy revealed normal joint geometry, and an MRI was unremarkable. Because of persistent symptoms despite adequate precautionary measures, arthroscopy was recommended. A chronic disruption of the ligamentum teres was identified (Figure 10.36A). The disrupted fibers were debrided and thermal capsulorrhaphy was performed (Figure 10.36B–D). Postoperatively, range of motion was restricted for 8 weeks in a hip spica brace. She responded well with elimination of her pain and episodes of subluxation. Status Post Total Hip Arthroscopy Arthroscopy can be performed in the presence of a hip prosthesis. However, the indications are limited. 23–26 With a capacious capsule, it may be easy to distract the joint and insert the instruments with the technique as used for a native joint. Normally, distraction should CHAPTER 10: THE SUPINE APPROACH 167 FIGURE 10.36. A 17-year-old girl with a history of recurrent atraumatic right hip instability. (A) Viewing from the anterolateral portal, a chronic disruption of the ligamentum teres is identified (asterisk). (B) The disrupted fibers are debrided. (C) Viewing posteriorly, thermal shrinkage is begun with the laser introduced from the posterolateral portal. Note the band created (arrows) indicating a brisk capsular response. (D) Now viewing the peripheral compartment with the traction released and hip flexed, the anterior capsular laxity is most completely addressed with the laser introduced through an ancillary peripheral portal. B D A C not require much force. For some cases, it is less po- tentially damaging to the components to introduce the portals initially along the neck of the prosthesis. If fibrotic tissue is present, this can be debrided, develop- ing a space for visualization of the components. CASE 8 A 38-year-old man was referred for evaluation of his left hip. He had undergone a previous press-fit total hip arthroplasty with an uneventful postoperative course (Figure 10.37A). He developed acute pain when he stepped awkwardly off a step, jarring his left leg. He subsequently presented with an 18-month history of pain with any weight-bearing activities, and an extensive workup was negative for evidence of fracture, loosening, or infection. An arthroscopic evaluation was performed, identifying dense adhesions partially entrapped within the joint (Figure 10.37B–D). Post- operatively, the patient experienced resolution of the pain that had been plaguing him for the previous year and a half. References 1. Sampson TG: Complications of hip arthroscopy. Clin Sports Med 2001;20:831–836. 2. Bartlett CS, DiFelice GS, Buly RL, et al: Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma 1998;12:294–299. 3. Byrd JWT, Chern KY: Traction vs. distension for distraction of the hip joint during arthroscopy. Arthroscopy 1997;13:346–349. 4. Byrd JWT: Hip arthroscopy utilizing the supine position. Ar- throscopy 1994;10:275–280. 168 J .W . THOMAS BYRD FIGURE 10.37. A 38-year-old man with unexplained left hip pain, 21 months following a total hip replacement. (A) AP radiograph reveals a well-positioned press-fit prosthesis with no evidence of loosening. (B) Fluoroscopic view demonstrates the position of the arthroscope and shaver along the base of the neck, thus avoiding the articular surface of the prosthesis. (C) Debridement of the fibrous tissue exposes the neck of the prosthesis (N) and its junction with the ceramic head (arrow). (D) A dense portion of fibrous tissue (asterisk) was entrapped between the polyethylene liner of the acetabulum (A) and the femoral head component (F). Peripheral to this is the reformed capsule (C). B DC A 5. Byrd JWT: Hip arthroscopy: the supine position. Instr Course Lect 52:721–730; 2002. 6. Byrd JWT, Jones KS: Prospective analysis of hip arthroscopy with five year follow up. Presented at AAOS 69th annual meet- ing, Dallas, TX, February 14, 2002. 7. Byrd JWT, Pappas JN, Pedley MJ: Hip arthroscopy: an anatomic study of portal placement and relationship to the extraarticular structures, Arthroscopy 1995;11:418–423. 8. Byrd JWT: Avoiding the labrum in hip arthroscopy. Arthros- copy 2000;16:770–773. 9. Byrd JWT: Hip arthroscopy for post-traumatic loose fragments in the young active adult: three case reports. Clin Sport Med 1996;6:129–134. 10. McCarthy JC, Bono JV, Wardell S: Is there a treatment for synovial chondromatosis of the hip joint. Arthroscopy 1997;13: 409–410. 11. Medlock V, Rathjen KE, Montgomery JB: Hip arthroscopy for late sequelae of Perthes disease. Arthroscopy 1999;15:552–553. 12. Byrd JWT: Labral lesions: an elusive source of hip pain: case reports and review of the literature. Arthroscopy 1996;12:603– 612. 13. Lage LA, Patel JV, Villar RN: The acetabular labral tear: an arthroscopic classification. Arthroscopy 1996;12:269–272. 14. Farjo LA, Glick JM, Sampson TG: Hip arthroscopy for acetabular labrum tears. Arthroscopy 1999;15:132–137. 15. Santori N, Villar RN: Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy 2000;16:11–15. 16. Byrd JWT, Jones KS: Prospective analysis of hip arthroscopy with two year follow up. Arthroscopy 2000;16:578–587. 17. Byrd JWT, Jones KS: Inverted acetabular labrum and secondary osteoarthritis: radiographic diagnosis and arthroscopic treatment. Arthroscopy 2000;16:417. 18. Gray AJR, Villar RN: The ligamentum teres of the hip: an arthroscopic classification of its pathology. Arthroscopy 1997;13: 575–578. 19. Byrd JWT, Jones KS: Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 20(4):385–391; 2004. 20. Byrd JWT: Hip arthroscopy: patient assessment and indications. Instr Course Lect 2003;52:711–719. 21. Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzger- ald RH Jr: Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop 2001;382: 232–240. 22. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J: The wa- tershed labral lesion: its relationship to early arthritis of the hip. J Arthroplasty 2001;16(8 suppl 1):81–87. 23. Hyman JL, Salvati EA, Laurencin CT, et al: The arthroscopic drainage, irrigation, and debridement of late, acute total hip arthroplasty infections: average 6-year follow-up. J Arthro- plasty 1999;14:903–910. 24. Nordt W, Giangarra CE, Levy IM, Habermann ET: Arthro- scopic removal of entrapped debris following dislocation of a total hip arthroplasty. Arthroscopy 1987;3:196–198. 25. Vakili F, Salvati EA, Warren RF: Entrapped foreign body within the acetabular cup in total hip replacement. Clin Orthop 1980;150:159–162. 26. Shifrin LZ, Reis ND: Arthroscopy of a dislocated hip replacement: a case report. Clin Orthop 1980;146:213–214. CHAPTER 10: THE SUPINE APPROACH 169 170 11 Hip Arthroscopy Without Traction Michael Dienst F or the past two decades, different centers in Eu- rope, 1–19 the United States, 20–37 and Japan 38–40 have been contributing to the development of standardized techniques and specification of indications for arthroscopy of the hip joint (HA), with most authors advocating the use of traction. 6,22,25,41 The technique of hip arthroscopy without traction, however, has been disregarded. Only a few investigators have presented their experiences using this procedure. 9,11,13,34,35,42–44 More recent reports have proposed different advantages of the nontraction technique. Klapper et al. also emphasized the low complication rate of this procedure. 34 Although traction is required for inspection of the direct weight-bearing cartilage, the acetabular fossa and the ligamentum teres, arthroscopy without traction is ideally situated for evaluation of the hip joint periphery. 13,43 Based on the classification of the arthroscopic compartments of the hip joint, the following review pre- sents detailed steps on performing this technique. A systematic mapping of that part of the joint that can be inspected without traction is included. Indications and contraindications are then specified and illus- trated with selected case examples. ARTHROSCOPIC COMPARTMENTS OF THE HIP JOINT Placement of portals and maneuverability of the arthroscope and instruments within the hip joint are more difficult than in other joints. This difficulty is related to various anatomic features: a thick soft tissue mantle, close proximity of two major neurovas- cular bundles, a strong articular capsule, a relatively small intraarticular volume, permanent contact of the articular surfaces, and the sealing of the deep, central part of the joint by the acetabular labrum. Thus, if no traction is applied to the hip, only a small film of synovial fluid separates the articular surface of the femoral head from the lunate cartilage and acetabular labrum (artificial space). The anatomy of the acetabular labrum must be considered when accessing the hip joint. The labrum seals the joint space between the lunate cartilage and the femoral head. Even under complete muscle relax- ation during anesthesia, the labrum maintains a vacuum force of about 120 to 200 N, which keeps the femoral head within the socket. 45–47 To overcome the vacuum force and passive resistance of the soft tissues, traction is needed to separate the head from the socket, to elevate the labrum from the head, and to allow the arthroscope and other instruments access to the narrow artificial space between the weight-bearing cartilage of the femoral head and acetabulum. However, if traction is applied, the joint capsule with the iliofemoral, ischiofemoral, and pubofemoral ligaments is tensioned and the joint space peripheral to the acetabular labrum decreases. Thus, to maintain the space of the peripheral hip joint cavity for better visibility and maneuverability during arthroscopy, traction should be avoided. In consequence, Dorfmann and Boyer 11,13 divided the hip arthroscopically into two compartments sep- arated by the labrum (Figure 11.1). The first is the central compartment, comprising the lunate cartilage, the acetabular fossa, the ligamentum teres, and the loaded articular surface of the femoral head. This part of the joint can be visualized almost exclusively with traction. The second is the peripheral compartment, con- sisting of the unloaded cartilage of the femoral head, the femoral neck with the medial, anterior, and lateral synovial folds (Weitbrecht’s ligaments), and the articular capsule with its intrinsic ligaments including the zona orbicularis. This area can be seen without traction and is described subsequently here. 43 OPERATIVE TECHNIQUE Operating Room Setup The placement of personnel and equipment for HA without traction does not differ from the general HA setup (Figure 11.2). Surgeon, assistant, and scrub nurse with instrument table are on the ipsilateral side. The image intensifier is placed on the opposite side. The arthroscopy unit with video monitor and image intensifier with monitor are placed toward the foot. Positioning, Distension, and Portals Hip arthroscopy with and without traction can be performed in the lateral 20,22 or supine position. 25,39,43 Some authors claim that there are advantages to the lateral position, including better access to the posterolateral area 48,49 and better application of traction in line with the femoral neck. 50 However, for HA without traction, I favor the supine position. 13,35,43,51 From my experience, the decision whether to use the supine or lateral position for the traction technique appears to be more a matter of individual training and habit of use. However, the almost exclusive use of the anterolateral portal (as indicated below) during HA without traction makes the supine position preferable for this part of HA. Cadaver experiments and in vivo experience 52 have shown that free draping and a good range of movement are important to relax parts of the capsule and increase the intraarticular volume of the area that is inspected (Figure 11.3A,B). 53 This consideration is important for safe movement of the scope to avoid dam- age to the cartilage of the femoral head and synovial folds and unwanted sliding of the scope out of the joint. The distending effect of irrigation fluid pressure is of minor importance because the pressure should not be increased over 70 mm Hg to reduce the risk of development of a severe soft tissue edema. Klapper et al. 34 do not use a pump and prefer to control distension of the capsule and irrigation pressure by adjusting the sus- CHAPTER 11: HIP ARTHROSCOPY WITHOUT TRACTION 171 Iliac crest central compartment peripheral compartment acetabular labrum Iliac crest surgeon fluoroscopy unit fluoroscopy monitors scrub nurse and mayo arthroscopy unit assistant FIGURE 11.1. Arthroscopic compartments of the hip joint accord- ing to Dorfmann and Boyer. 11,13 (Reprinted with permission from Dienst et al. 44 ) FIGURE 11.2. Operating room setup. (Reprinted with permission from Dienst et al. 44 ) [...]... JWT (ed) Operative Hip Arthroscopy New York: Thieme, 1998 :7 24 Sampson TG, Farjo LA: Hip arthroscopy by the lateral approach: technique and selected cases In: Byrd JWT (ed) Operative Hip Arthroscopy New York: Thieme, 1998:105–122 Klapper R, Dorfmann H, Boyer T: Hip arthroscopy without traction In: Byrd JWT (ed) Operative Hip Arthroscopy New York: Thieme, 1998:139–152 Klapper RC, Silver DM: Hip arthroscopy. .. of hip arthroscopy in the diagnosis and treatment of hip disease Can J Surg 1995;38(suppl): S13–S 17 McCarthy JC, Busconi B: The role of hip arthroscopy in the diagnosis and treatment of hip disease Arthroplasty Rounds 1995;18 :75 3 75 6 Byrd JWT: Hip arthroscopy utilizing the supine position Arthroscopy 1994;10: 275 –280 Byrd JWT, Chern KY: Traction versus distension for distraction of the joint during hip. .. 1989;3:203–211 5 Gondolph-Zink B: Die Hüftarthroskopie Aktuel Probl Chir Orthop 1991;40:35–43 6 Eriksson E, Arvidsson I, Arvidsson H: Diagnostic and operative arthroscopy of the hip Orthopedics 1986;9:169– 176 7 Villar RN: Hip Arthroscopy Oxford: Butterworth Heinemann, 1992 8 Gondolph-Zink G, Puhl W: Einsatzmöglichkeiten der operativen Hüftarthroskopie Arthroskopie 1990;3 :71 77 9 Dorfmann H, Boyer T,... during hip arthroscopy Arthroscopy 19 97; 13: 346–349 Sampson TG, Glick JM: Indications and surgical treatment of hip pathology In: McGinty JB, Caspari RB, Jackson RW, Poehling GG (eds) Operative Arthroscopy, 2nd ed Philadelphia: Lippincott-Raven, 1996:10 67 1 078 Glick JM, Sampson TG: Hip arthroscopy by the lateral approach In: McGinty JB, Caspari RB, Jackson RW, Poehling GG (eds) Operative Arthroscopy, ... of arthroscopic partial limbectomy Arthroscopy 2000;16:11–15 Hawkins RB: Arthroscopy of the hip Clin Orthop 1989;249: 44– 47 Byrd JWT, Pappas JN, Pedley MJ: Hip arthroscopy: an anatomic study of portal placement and relationship to the extraarticular structures Arthroscopy 1995;11:418–423 Glick JM, Sampson TG, Behr JT, Schmidt E: Hip arthroscopy by the lateral approach Arthroscopy 19 87; 3:4–12 McCarthy... report Arthroscopy 1993;9 :70 7 70 8 66 Blitzer CM: Arthroscopic management of septic arthritis of the hip Arthroscopy 1993;9:414–416 67 Chung WK, Slater GL, Bates EH: Treatment of septic arthritis of the hip by arthroscopic lavage J Pediatr Orthop 1993;13:444– 446 68 Carls J, Kohn D: Arthroskopische Therapie der eitrigen Koxitis Arthroskopie 1996;9: 274 – 277 69 Byrd JWT: Complications associated with hip arthroscopy. .. from the hip J Trauma 19 87; 27: 1294–1300 63 Villar RN: Hip arthroscopy Review B J Hosp Med 1992; 47: 763 76 6 64 Schindler A, Lechevallier JJC, Rao NS, Bowen JR: Diagnostic and therapeutic arthroscopy of the hip in children and adolescents: evaluation of results J Pediatr Orthop 1995;15:3 17 321 65 Bould M, Edwards D, Villar RN: Arthroscopic diagnosis and treatment of septic arthritis of the hip joint... LippincottRaven, 1996:1 079 –1088 Byrd JWT: Hip arthroscopy: the supine position In: McGinty JB, Caspari RB, Jackson RW, Poehling GG (eds) Operative Arthroscopy, 2nd ed Philadelphia: Lippincott-Raven, 1996: 1091–1099 Parisien JS: Hip arthroscopy: supine position In: Parisien JS (ed) Techniques in Therapeutic Arthroscopy New York: Raven, 1993:23.1–23.9 Glick JM: Complications of hip arthroscopy by the lateral... without traction Contemp Orthop 1989;18:6 87 693 Byrd JWT: Labral lesions: an elusive source of hip pain Case reports and literature review Arthroscopy 1996;12:603–612 McCarthy JC, Mason JB, Wardell SR: Hip arthroscopy for acetabular dysplasia: a pipe dream? Orthopedics 1998;14: 977 – 979 Ide T, Akamatsu N, Nakajima I: Arthroscopic surgery of the hip joint Arthroscopy 1991 ;7: 204–211 Suzuki S, Awaya G, Okada Y,... approach to hip arthroscopy Arthroscopy 1988;4:141–142 10 Gondolph-Zink B, Puhl W, Noack W: Semiarthroscopic synovectomy of the hip Int Orthop 1988; 2:31–35 11 Dorfmann H, Boyer T: Hip arthroscopy utilizing the supine position Arthroscopy 1996;12:264–2 67 12 Hempfling H: Das Hüftgelenk In: Hempfling H (ed) Farbatlas der Arthroskopie grosser Gelenke, 2nd ed Stuttgart: Fischer, 1995:511– 571 13 Dorfmann . Arthroscopy 19 97; 13:346–349. 4. Byrd JWT: Hip arthroscopy utilizing the supine position. Ar- throscopy 1994;10: 275 –280. 168 J .W . THOMAS BYRD FIGURE 10. 37. A 38-year-old man with unexplained left hip pain, 21. specificity of preoperative radiologic methods for intraarticular hip joint lesions, indicating hip arthroscopy for patients with unclear hip pain is not uncom- mon. 17, 23,25,36,48, 57 59 However, preoperative. 1995;11:418–423. 8. Byrd JWT: Avoiding the labrum in hip arthroscopy. Arthros- copy 2000;16 :77 0 77 3. 9. Byrd JWT: Hip arthroscopy for post-traumatic loose fragments in the young active adult: three case

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