The Application of Arthroscopic Techniques in the Diagnosis and Treatment of Hip-Related Conditions in China

The hip joint is the largest weight-bearing joint in the body and is surrounded by dense capsules and thick muscles. Hip arthroscopic techniques are suitable for the treatment of hip-related conditions. These minimally invasive techniques have rapidly developed in China since 2007. Moreover, they have been used in the treatment of gluteal muscle contracture, snapping hip syndrome, femoral acetabular impingement, acetabular labral injury, hip labral calcification, synovial chondroma, osteoid osteoma, synovitis, osteonecrosis of the femoral head, and developmental dysplasia of the hip. This technique has showed its advantage in the total debridement of lesions, precision treatment, and less trauma. However, we lack understanding of the overall development of arthroscopic techniques in China. This review illustrates the recent development of hip arthroscopic techniques in China and related research progress.

Hip Pain in Adults: Evaluation and Differential Diagnosis

Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes.

Total hip arthroplasty after hip joint gunshot injury

BACKGROUND

Gunshot injury of the hip joint was reported to constitute 2-17% of all extremity firearm injuries. However, there are few studies in the literature related to gunshot injuries of the hip joint. The aim of the current study was to present the results of 10 cases treated with arthroplasty following a gunshot injury to the hip joint together with the recommended treatment algorithm.

METHODS

Patients with a previous medical history of hip joint region gunshot injury who underwent total hip arthroplasty were retrospectively evaluated. Those with incomplete medical records or who were lost to follow-up were excluded. Patients were classified according to the severity of the previous gunshot injury to the hip joint region. Harris hip score (HHS) and Short Form-12 quality of life score were the main outcome measurements. Postoperative complications encountered during follow-up were recorded.

RESULTS

The mean age of the patients at the time of surgery was 29.9 years. The mean preoperative HHS was 25.2 points and it was 65.8 at the final follow-up. Patients with bullet fragments in the hip joint, classified as group 1, had better HHS, whereas those with contaminated hip joint with intestinal flora, classified as group 3, had worst HHS.

CONCLUSION

Hip arthroplasty after hip joint gunshot injury is a good treatment choice in young patients to reduce pain and regain functions. However, very high infection rates can be seen in patients with accompanying intestinal injury.

Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up

PURPOSE

To describe patient-reported outcomes (PROs) and return to play at any level in amateur soccer players undergoing hip arthroscopy for femoroacetabular impingement syndrome at short- to mid-term follow-up.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between March 2009 and June 2014. Patients who participated in amateur soccer within 1 year prior to surgery and intended to return to their sport after hip arthroscopy for femoroacetabular impingement syndrome were considered for inclusion in our study. Patients were excluded if they had a preoperative Tönnis osteoarthritis grade of 2 or greater, previous ipsilateral hip conditions or hip surgical procedures, or Workers' Compensation status. The patients from the initial group who had preoperative and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in our final group. In addition to PROs, data regarding the patients' return to soccer, surgical complications, and secondary surgical procedures were collected.

RESULTS

A total of 41 patients were eligible for inclusion in our study, of whom 34 (82.9%) had a mean follow-up period of 47.4 months. Five patients were not eligible because they did not intend to return to soccer. There were 15 male hips (44.1%) and 19 female hips (55.9%). The mean age at surgery was 20.8 ± 7.4 years. All PROs and the visual analog scale score improved significantly from preoperatively to latest follow-up. Of the 34 patients, 27 (79.4%) returned to soccer. Of the patients who returned to soccer, 19 (70.4%) were competing at the same level or a higher level compared with their highest level within 1 year of surgery. Regardless of competitive level, 21 patients (77.8%) reported that their athletic ability was the same as or higher than it was within 1 year of surgery.

CONCLUSIONS

Hip arthroscopy was associated with significant improvements in PROs for amateur soccer players. There was a high level of return to soccer and a high proportion of patients whose competitive level was similar or improved. As such, hip arthroscopy is a good option for soccer players, in the absence of underlying osteoarthritis, presenting with hip pathology.

LEVEL OF EVIDENCE

Level IV, case series.

Performance and Return to Sport After Hip Arthroscopy in the National Basketball Association

PURPOSE

To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players.

METHODS

NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ² was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008.

RESULTS

Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570).

CONCLUSIONS

The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls.

LEVEL OF EVIDENCE

Level III case-control study.

Recognizing and Managing Snapping Hip Syndrome in Dancers

BACKGROUND

Snapping hip syndrome (SHS) is a common hip pathology in dancers. SHS can be either internal or external, resulting from muscle tendon tightness from repetitive hip flexion and extension, accompanied with hip abduction and/or external rotation. Muscular tightness may cause the tendon to become taut and snap over a bony prominence during hip movement, leading to muscular weakness and reduced range of motion from pain. Because SHS is poorly identified and can present similarly to other hip pathologies, many SHS incidences are underreported or misdiagnosed. Though SHS can begin as a harmless popping sensation, pain can become severe enough to limit dancers' activities and potentially result in the development of concomitant issues.

EVALUATION

Physical examination for snapping hip includes moving the hip from flexion, abduction, and external rotation (FABER) into extension, adduction, and rotated to a neutral position. Dynamic ultrasound can also be used to study SHS, as using this method allows clinicians to observe the snapping tendon in real-time. Radiographs and magnetic resonance imaging may serve to rule out other differential diagnoses.

MANAGEMENT

Conservative management through rehabilitative therapy is the standard for initial management. In severe cases, arthroscopic intervention may be useful in releasing tension in the pathological tendon. Active rest with training modifications should be attempted to mitigate further injury.

CONCLUSION

Early and comprehensive examination and management can help to reduce SHS risk and potentially decrease the ability of this debilitating condition to derail a dancer's career.

Management of traumatic hemipelvectomy through ERAS pathway: A case report

RATIONALE

Traumatic hemipelvectomy is a rare but life-threatening injury that involves separation of the pelvic ring from pubic symphysis usually results from high energy trauma and associated with other injuries.

PATIENT CONCERN

In this report, we describe a case of traumatic hemipelvectomy, who presented in hemorrhagic shock associated with other injuries such as: right groin injury with limitation of passive movement of right hip and knee joint, left pelvic visceral protruded out, and wrapped by peritoneum, all of the vulva and anal tear, lumbar vertebrae transverse process fracture.

DIAGNOSES

Traumatic hemipelvectomy.

INTERVENTIONS

The patient was managed through enhanced recovery after surgery (ERAS) pathway with multidisciplinary coordination.

OUTCOMES

Patient was able to walk with prosthesis or crutch, with associated injuries managed appropriately. The course was complicated with hemorrhagic shock and infection which were dealt promptly, with good recovery.

LESSONS

In our case, the multimodal management through ERAS path has helped decrease stress level, decrease complication, decrease morbidity, decrease the length of stay in the hospital, and aid in faster recovery.

Traumatic hip dislocation in pediatric patients

Traumatic hip dislocations constitute approximately 5% of all pediatric dislocations and typically result from high-energy trauma. However, pediatric hip dislocations can also occur as a result of minor energy due to flexibility of the joint structures of the immature hip. Children with a posteriorly dislocated hip present with the injured hip in flexion, adduction and internal rotation. Spontaneous relocation of hip dislocation is frequent and a thorough physical examination of the whole lower extremity is always required to reduce the chance of missing hip dislocation/subluxation. Dislocated hips should be emergently repositioned under general anesthesia. MRI is indicated after reduction and in patients after spontaneous relocation if labral interposition is suspected in plain radiographs.

Mastering the Physical Examination of the Athlete's Hip

In this review, we describe precise methods for evaluating the athlete's hip or groin with an emphasis on recognizing the most common extra-articular and intra-articular pathologies, including adductor strains, athletic pubalgia, osteitis pubis, and femoroacetabular impingement with labral tears.

Sex and growth effect on pediatric hip injuries presenting to sports medicine clinic

To compare sports-related hip injuries on the basis of sex and age in a cohort of young athletes. A 5% random probability sample of all new patients' charts over a 10-year time period was selected for investigation. The most common hip injury diagnoses, sport at time of injury, mechanism (acute/traumatic vs. overuse), and types (bony vs. soft tissue) were compared by sex and age (preadolescent vs. adolescent). Descriptive and χ-analyses were carried out. The interaction of sex and age with respect to hip injury over time was examined by two-way (sex, age) analysis of variance. A total of 2133 charts were reviewed; N=87 hip injuries. The main diagnoses for males included labral tear (23.1%), avulsion fracture (11.5%), slipped capital femoral epiphysis (11.5%), dislocation (7.7%), and tendonitis (7.7%). The main diagnoses for females were labral tear (59.0%), tendonitis (14.8%), snapping hip syndrome (6.6%), strain (4.9%), and bursitis (4.9%). The five most common sports/activities at the time of hip injury were dancing/ballet (23.0%), soccer (18.4%), gymnastics (9.2%), ice hockey (8.1%), and track and field (6.9%). Age by sex comparisons showed a greater proportion of the total hip injuries (38.5%) in males compared with females (8.2%) during preadolescence (5-12 years). However, in adolescence (13-17 years), the hip injury proportion was significantly higher in females (91.8%) compared with males (61.5%; P<0.001). Injury mechanism and type differed by sex, with females sustaining more chronic/overuse (95.1%) and soft tissue type injuries (93.4%) compared with males (50.0 and 53.8%, respectively; P<0.001). Females were found to have a sharper increase in hip injury proportion as they progressed through puberty compared with males (analysis of variance sex-by-age interaction; P<0.001). Hip injury mechanism and type differed significantly between males and females during growth. Notably, the proportion of hip injuries in the young female athletes showed a significantly greater increase with advancing age compared with males. Hip injuries in children and the interplay with growth, as it relates to injury predisposition, require further investigation to facilitate efforts aimed at prevention.

LEVEL OF EVIDENCE III

Cross-sectional epidemiological study.

[Injury of the Obturator Internus Muscle--a Rare Differential Diagnosis in a Soccer Player]

BACKGROUND

Lesions/irritations of the obturator internus muscle (OIM) are rare, several differential diagnoses are possible.

PATIENT

This paper describes the case of an OIM injury in a professional football player.

RESULTS

On clinical examination, painful internal rotation of the hip joint was an indication for a lesion/irritation of the OIM. MRI was the procedure of choice for imaging. Movement analysis served to detect a functional malposition.

CONCLUSION

A short recovery time requires functional treatment as well as the use of orthopaedic aids to correct possible deformities.

The management of acute hip pain in the military: femoral neck stress fractures and tears of the acetabular labrum

Acute hip pain is a common presenting complaint amongst the military population. It can present in a variety of ways, with a broad range of differential diagnoses to consider. Most cases of acute hip pain in military patients tend to be traumatic in origin. Pathology within the hip can be a diagnostic challenge, as symptoms often overlap between differential diagnoses and examination findings are not always sensitive or specific. Any hip injury will potentially downgrade a military patient and can also be a significant cause of long-term morbidity. Being able to manage the patient with acute hip pain effectively will ensure that patients spend less time in the diagnostic chain and reach the definitive treatment they require to continue to carry out their primary role. This paper describes how best to manage military patients who present with acute hip pain. It covers the diagnostic challenges faced by clinicians, the differential diagnoses of acute hip pain and describes the management of some common injuries of the hip: tears of the acetabular labrum and femoral neck stress fractures.

[Clinico-epidemiologic and clinico-nosologic characteristic of the hip trauma as a component of polysystemic damage]

Clinico-epidemiological and clinico-nosological indices of the hip injury (HI) in a structure of polysystemic and polyorgan damage, depending on gender, age of the injured patients, as well as the main mechanisms and conditions of trauma, were investigated. Four hundreds of charts of stationary patients, the injured persons, suffering polytrauma, who were treated in The Ternopyl University clinic in 2008 - 2012 yrs, were analyzed. The HI, as a component of polysystemic damage, was revealed in 54 patients. In accordance to the ranking analysis data, the HI coexistence in polytrauma probably depends on gender and age of the injured persons (mainly the men of employable age). Mostly such injures have occurred while the traffic accident in 61.1% of observations and while domestic conditions - in 29.6%. Severity of coexistent HI in a polytrauma structure probably depends on their mechanisms. So, in falling down in most cases combination with other skeletal trauma and damage of head was noted; in a direct punch - with cranio-cerebral trauma; in coexistence of various mechanisms the most severe injuries have occurred with damage of several anatomo-functional regions, not the hip only, but head, thorax and abdomen.

[Athletic pubalgia and hip impingement]

Athletic pubalgia is a painful and complex syndrom encountered by athletes involved in pivoting and cutting sports such as hockey and soccer. To date, there is no real consensus on the criteria for a reliable diagnostic, the different investigations, and the appropriate therapy. Current literature underlines intrinsic and extrinsic factors contributing to athletic pubalgia. This review article reports upon two novelties related to the issue: the importance and efficience of prevention program and the association of femoro-acetabular impingement with the pubalgia.

Report of Galeazzi fracture resulting from a ballistic injury

BACKGROUND

Galeazzi fractures are a rare injury to occur in adults, which are typically associated with high energy trauma. To our knowledge, the reported cases in the literature have only been associated with motor vehicle accidents, falls from a height, or athletic endeavors. The application of the force in the setting of a Galeazzi fracture has been disputed, but it is believed to occur with the wrist in hyperextension and pronation.

CASE REPORT

We describe a 27-year-old male who presented with multiple gunshot wounds that included his right forearm. The injury sustained to his right forearm resulted in a Galeazzi fracture, which after open reduction and internal fixation, demonstrated subluxation of the distal radioulnar joint in pronation.

CONCLUSIONS

We provide a novel mechanism of a Galeazzi fracture that demonstrates a method for sustaining the fracture pattern without the wrist in the typical position of hyperextension and pronation.

Emerging intra-articular causes of groin pain in athletes

Groin pain remains one of the most poorly understood conditions in clinical sports medicine. It may be caused by either extra-articular or intra-articular conditions. While extra-articular causes have been extensively studied and reasonably understood, a number of elusive intra-articular causes are emerging, many of which were previously unknown and therefore undiagnosed, leading to premature ending of many competitive careers. This article makes an attempt to look at various, elusive intra-articular causes of groin pain in athletes. This article also analyses the currently available evidence on trends in diagnosis and treatment for these conditions.

Femoroacetabular impingement predisposes to traumatic posterior hip dislocation

BACKGROUND

Traumatic posterior hip dislocation in adults is generally understood to be the result of a high-energy trauma. Aside from reduced femoral antetorsion, morphologic risk factors for dislocation are unknown. We previously noticed that some hips with traumatic posterior dislocations had evidence of morphologic features of femoroacetabular impingement (FAI), therefore, we sought to evaluate that possibility more formally.

QUESTIONS/PURPOSES

We asked whether hips with a traumatic posterior hip dislocation present with (1) a cam-type deformity and/or (2) a retroverted acetabulum.

METHODS

We retrospectively compared the morphologic features of 53 consecutive hips (53 patients) after traumatic posterior hip dislocation with 85 normal hips (44 patients) based on AP pelvic and crosstable axial radiographs. We measured the axial and the lateral alpha angle for detection of a cam deformity and the crossover sign, ischial spine sign, posterior wall sign, retroversion index, and ratio of anterior to posterior acetabular coverage to describe the acetabular orientation.

RESULTS

Hips with traumatic posterior traumatic dislocation were more likely to have cam deformities than were normal hips, in that the hips with dislocation had increased axial and lateral alpha angles. Hips with posterior dislocation also were more likely to be retroverted; dislocated hips had a higher prevalence of a positive crossover sign, ischial spine sign, and posterior wall sign, and they had a higher retroversion index and increased ratio of anterior to posterior acetabular coverage.

CONCLUSIONS

Hips with posterior traumatic dislocation typically present with morphologic features of anterior FAI, including a cam-type deformity and retroverted acetabulum. An explanation for these findings could be that the early interaction between the aspherical femoral head and the prominent acetabular rim acts as a fulcrum, perhaps making these hips more susceptible to traumatic dislocation.

Sports hip injuries: assessment and management

Over the past 10 years, the understanding, assessment, and management of hip pain and injuries in the athlete have improved. Traditionally, the evaluation of hip pain and injuries was limited to obvious disorders, such as hip arthritis and fractures, or disorders that were previously considered to be simply soft-tissue strains and contusions, such as groin pulls, hip pointers, and bursitis. Two parallel tracks of progress have improved understanding of the complexities of hip joint athletic injuries and the biomechanical basis of early hip disease. In the field of sports medicine, improved diagnostic skills now allow better interpretation of debilitating intra-articular hip disorders and their effects on core performance. In the field of hip preservation, there has been an evolution in understanding the effects of biomechanical mismatches between the femoral head and the acetabulum on the development of early hip damage, injury, and arthritis. The integration of these two parallel fields has accelerated the understanding of the importance of hip biomechanics and early hip injury in human performance and function.

Is posterior hip instability associated with cam and pincer deformity?

BACKGROUND

Posterior hip instability is an increasingly recognized injury in athletes; however, the function of patients after these injuries and an understanding of the pathoanatomy and underlying mechanism are currently unclear.

QUESTIONS/PURPOSES

We determined (1) the function of patients after these hip injuries using validated, self-reported outcome instruments and (2) the specific pathoanatomy sustained in these events to better understand the mechanism of posterior hip instability.

METHODS

We reviewed the records of all 22 athletes presenting to our clinics with a posterior acetabular rim fracture confirming a posterior hip instability episode. Radiograph, CT, and MRI findings were documented in all patients. Intraoperative findings were recorded in patients undergoing surgery. There were 19 males and three females with an average age of 22 years (range, 13-31 years). Minimum followup was 2 years (average, 4 years; range, 2-16 years).

RESULTS

The mean modified Harris hip score was 94, Hip Outcome Scores for Activities of Daily Living and Sport were 99 and 87, respectively, and 20 of 22 athletes returned to sport. The most common constellation of pathoanatomy was a posterior labral tear with rim fracture, anterior labral tear, capsular tear, ligamentum teres avulsion, and chondral injury of the femoral head with loose bodies. Sixteen of the 18 patients with femoroacetabular impingement (FAI) had a twisting or noncontact mechanism of injury.

CONCLUSIONS

When posterior hip subluxation is recognized and avascular necrosis avoided, these athletes generally have high functional outcome scores and high rates of return to sport. There is an apparent association between the occurrence of posterior hip instability and the presence of structural abnormalities often associated with FAI, which may contribute to a mechanism of FAI-induced posterior subluxation.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Hip arthroscopy: evolution, current practice and future developments

Arthroscopic examination and treatment is an ever-increasing part of modern orthopaedic practice in this age of minimally invasive surgery. Arthroscopic procedures have been widespread in surgery of the knee and the shoulder for many years; however, the hip until relatively recently, has been largely neglected. Even now hip arthroscopy is not widely available; this may be due to the complexity of the procedure, the requirement of specialist equipment and a reportedly long learning curve. On the other hand, it has gone through a period of rapid growth over the last decade and is being performed in large numbers routinely in some centres around the world. Hip arthroscopy now provides excellent visualisation of not only the articular surfaces of the hip joint but also of the peritrochanteric or extra-articular space around the hip. Pathology of both the femoral head and the acetabulum along with the soft tissues of the hip, namely the ligamentum teres, the acetabular labrum, the synovial folds and synovium, is readily diagnosed. Modern techniques provide therapeutic options for a myriad of conditions and allow modulation of pathological processes early. Additionally hip arthroscopy is a relatively safe procedure with few complications and contraindications. However, the key to good outcomes is in the careful selection of patients and meticulous surgical technique. The aim of this review is to bring the reader up to date with an overview of the evolution of arthroscopy of the hip, review the current practice and explore possible future developments.

Arthroscopic debridement of the isolated Ligamentum Teres rupture

PURPOSE

Most tears of the Ligamentum Teres (LT) are diagnosed when treating other hip pathologies. The purpose of this study was to evaluate the outcome of arthroscopic surgery for a unique group of patients with symptomatic isolated Ligamentum Teres rupture of the hip.

METHODS

The study included 29 patients who suffered from an isolated Ligamentum Teres rupture of the hip and were treated with an arthroscopic debridement from 2003 to 2008. Patients with femoroacetabular impingement or other hip pathologies except Ligamentum Teres tear were excluded. Clinical results were measured preoperatively and postoperatively with the modified Harris Hip Score (MHHS) and Non-Arthritic Hip Score (NAHS). The mean age was 25 years (SD ± 11) with a mean follow-up time of 2.5 years (SD ± 1.5).

RESULTS

At the last follow-up, the mean MHHS improved from 70 to 86 [mean difference = 16 (95% CI 4-27)] and the mean NAHS improved from 64 to 86 [mean difference = 22 (95% CI 10-33)]. Five patients have had a second arthroscopic debridement due to symptomatic recurrent tears.

CONCLUSION

Arthroscopic debridement alone of the isolated Ligamentum Teres rupture has a short-term beneficial result in more than 80% of cases.

Imaging of triathlon injuries

Injuries in triathletes are common and are mostly overuse injuries. Rotator cuff tendinitis is the most common complaint from swimming, but the incidence of tendinopathy and rotator cuff tears on magnetic resonance imaging is comparable in triathletes without and with shoulder pain. Cycling injuries are mainly to the knee, including patellar tendinosis, iliotibial band syndrome, and patellofemoral stress syndrome, and to the Achilles tendon and the cervical and lumbar spine. Running is associated with most injuries in triathletes, during both training and racing, causing the athlete to discontinue the triathlon. In addition to knee injuries from running, triathletes may also develop foot and ankle, lower leg, and hip injuries similar to single-sport distance runners. Some injuries in triathletes may be mainly symptomatic during one of the three sports but are exacerbated by one or both of the other disciplines.

Imaging of hip injuries in dancers

Dancers are quite prone to injuries in the hip region. Imaging plays a key role in evaluation of the pain resulting from such injuries, as proximity of structures and cross-innervation can result in a clinical dilemma regarding the specific injury, and thus origin of the pain generator. Advanced imaging techniques, including MRI, ultrasound, and multidetector CT, are becoming increasingly important in the workup of injuries in athletes, yet radiographs remain an essential component. This article presents a variety of injuries in the hip and groin region that may be seen in dancers and discusses the utility of basic and advanced imaging modalities.

Symptomatic hip plica: MR arthrographic and arthroscopic correlation

Two cases of unilateral hip pain are reported in which MR arthrography demonstrated a prominent band medial to the ligamentum teres, running in the AP direction, consistent with a hip plica. Both patients underwent hip arthroscopy with resection of the band. No labral tear or additional intra-articular pathological features was identified in either case. Both patients became asymptomatic following surgery and have remained such. The pathology report demonstrated the specimens to be a synovial band with fibroconnective tissue. This is the first MR arthrographic report of the identification and resection of a symptomatic hip plica. The symptomatic plica may represent an alternative diagnosis for mechanical hip pain.

The multifaceted etiology of acetabular labral tears

Acetabular labral tears have been the focus of much attention in recent years. With the increased use of hip arthroscopy and magnetic resonance arthrography, the infrequent labral tear has proved to be more prevalent than previously thought. The majority of labral tears occur due to an underlying anatomic abnormality. Anatomic abnormalities that can lead to labral tears include femoracetabular impingement, acetabular retroversion, abnormal femoral head, Legg Calvé Perthes, slipped capital epiphysis, capsular laxity, and dysplasia of the hip. Tears in the labrum may lead to the advancement of osteoarthritis. Optimal management of a labral tear may involve addressing underlying anatomic abnormalities in addition to the labral tear itself.

Acetabular labral tears following pregnancy

Acetabular labral tears are usually seen in individuals in whom the hip is exposed to elevated axial and torsional forces. In our experience we have encountered a series of female patients in whom symptom onset was during pregnancy or obstetric labour. We reviewed our patient database to identify all patients who had undergone hip arthroscopy in our hospital. The records of female patients who had a labral tear on arthroscopy and in whom symptom onset was clearly documented to be during pregnancy or labour were identified. We report three cases of acetabular labral tear occurring during pregnancy or labour. This represents 7% of all female patients undergoing hip arthroscopy during a two-year period. Ligamentous laxity and altered cartilage matrix during pregnancy may predispose to acetabular labral injury. Clinicians need to be aware of this possible intra-articular lesion in peripartum patients presenting with hip or buttock pain, and manage appropriately.

Sonography of Morel-Lavallee lesions

OBJECTIVE

The purpose of this series was to retrospectively characterize the sonographic appearance of posttraumatic Morel-Lavallée lesions.

METHODS

After Institutional Review Board approval was obtained, a search of the radiology information system database with correlation to medical records identified 21 posttraumatic fluid collections of the hip and thigh in 15 patients. Sonographic images were retrospectively reviewed by 1 author to characterize the echogenicity, homogeneity, shape, margins, location, compressibility, and vascularity of the fluid collection. Results were correlated with the age of the fluid collection and aspiration results where possible.

RESULTS

All fluid collections (21/21) were located between the deep fat and fascia, with a shape that was fusiform in 12 (60%) of 20, flat in 5 (25%), and lobular in 3 (15%) (shape not determined in 1 case). Regarding echogenicity, 15 (71%) of the 21 collections were hypoechoic, and 6 (29%) were anechoic; 13 (62%) were heterogeneous, and 8 (38%) were homogeneous. The lobular fluid collections were all less than 2 weeks of age, and the flat fluid collections were all greater than 6 months of age. All homogeneous fluid collections were greater than 8 months of age. There was no relationship between the age of a fluid collection and its echogenicity. Conclusions. Morel-Lavallée lesions had a variable appearance, being more homogeneous and flat or fusiform in shape with a well-defined margin as the lesions aged. All Morel-Lavallée lesions were hypoechoic or anechoic, compressible, and located between the deep fat and overlying fascia.

[Rotator cuff tear of the hip]

We report the observations of two women with a recurrent periarthritis of the hip complicated by a spontaneous rupture of the tendons of the gluteus medius and minimus. These patients usually complain from an acute lateral hip pain and show a Trendelenburg gait. When the rupture is complete, clinical evaluation reveals a drop of the pelvis on the non-stance side and resisted rotation starting from the extreme external rotation position is weak. MRI plays a key role in the diagnosis and the evaluation of a possible surgical repair. Hip rotator-cuff rupture is probably insufficiently diagnosed by ignorance. Nonetheless, optimized handling could relieve the pain of most these patients and improve the disability of some of them.

Acetabular labral tears of the hip in women

Acetabular labral tears are a major cause of hip dysfunction in young patients and a primary precursor to hip osteoarthritis. In addition, labral disease more commonly occurs in women and can present with nonspecific symptoms. It is possible to diagnose, quantify, and treat labral tears before the onset of secondary joint deterioration. However, the diagnosis requires a high index of suspicion, special attention to subtle patterns of presentation, and timely consideration for imaging studies. Treatment options are still evolving and include a wide array of nonsurgical and surgical techniques. Treatment should also address secondary dysfunction that can be associated with hip pathology. An initial trial of conservative management is recommended and failure to progress is an indication for surgical consultation.

Sports-related acute and chronic avulsion injuries in children and adolescents with special emphasis on tennis

Acute and chronic sports-related muscle and tendon injuries are not infrequent in youngsters. In particular, the physis is prone to trauma as it constitutes the weakest part of the immature skeleton. The type of sports activity determines the location of the lesion. Most commonly, apophyses of the hip and pelvis are subject to avulsion. The purpose of this paper is to give a short overview of the pathogenesis, location, prevalence and imaging characteristics of acute and chronic avulsion injuries in the immature skeleton, with special emphasis on tennis-related injuries. Tennis-related injuries particularly involve apophyses of the ischial tuberosity, the anterior inferior or superior iliac spine and the iliac crest.

Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation

The Morel-Lavallee lesion is a serous collection in the region of the greater trochanter, resulting from a closed degloving injury at the deep fascial interface. Imaging demonstrates characteristic appearance in relation to this lesion, differentiating it from other mass lesions. We report a case of Morel-Lavallee lesion in an adolescent, with ultrasound and MRI correlation.

Hip disorders in the adolescent

This article deals with common hip problems in the adolescent age group. Some of these problems, such as slipped capital femoral epiphysis, require urgent surgical treatment. Early detection is essential. Other problems, such as many of the athletic injuries, are less urgent but important to patients who desire rapid return to full athletic capacity. The emphasis here is on understanding the conditions and diagnosis. Surgical options are mentioned but not detailed. Office management, where appropriate, is discussed against the background of the natural history of the conditions. The intended audience is primary care physicians and orthopedic surgeons who may have limited exposure to some of these conditions.

Classification and localization of acetabular labral tears

OBJECTIVE

The purpose of this study was to compare the findings on hip MR arthrography (MRA) with the published MRA and arthroscopic classifications of hip labral tears and to evaluate a clock-face method for localizing hip labral tears.

DESIGN/PATIENTS

We retrospectively reviewed 65 hip MRA studies with correlative hip arthroscopies. Each labrum was evaluated on MRA using the classification system of Czerny and an MRA modification of the Lage arthroscopic classification. In addition, each tear was localized on MRA by using a clock-face description where 6 o'clock was the transverse ligament and 3 o'clock was anterior. These MRA findings were then correlated with the arthroscopic findings using the clock-face method of localization and the Lage arthroscopic classification of labral tears.

RESULTS

At MRA, there were 42 Czerny grade 2 and 23 grade 3 labral tears and 22 MRA Lage type 1, 11 type 2, 22 type 3 and 10 type 4 tears. At arthroscopy, there were 10 Lage type 1 flap tears, 20 Lage type 2 fibrillated tears, 18 Lage type 3 longitudinal peripheral tears and 17 Lage type 4 unstable tears. The Czerny MRA classification and the modified MRA Lage classification had borderline correlation with the arthroscopic Lage classification. Localization of the tears using a clock-face description was within 1 o'clock of the arthroscopic localization of the tears in 85% of the patients.

CONCLUSIONS

The Lage classification, which is the only published arthroscopic classification system for hip labral tears, does not correlate well with the Czerny MRA or an MRA modification of the Lage classification. Using a clock-face description to localize tears provides a way to accurately localize a labral tear and define its extent.

Hip arthroscopy: current concepts and review of literature

Diagnosis and treatment of intra-articular hip problems in young patients present a challenge to hip surgeons. Previous studies have shown that non-invasive investigations such as radiography, computed tomography and magnetic resonance imaging provide limited help. Non-operative treatment is likely to result in persistent symptoms, and surgical options for intra-articular hip problems involve open arthrotomy of the hip joint, which carries potential risks associated with joint dislocation. Arthroscopy of the hip joint, therefore, seems to be an attractive option. It was once thought that introduction of a straight arthroscope into the ball-and-socket hip joint was almost impossible. Hip arthroscopy has seen several advances since then, and the speed at which it developed in recent years directly corresponded to the rate at which the conditions affecting the hip joint were identified. Athletes and other young individuals with hip injuries are increasingly being diagnosed with an ever evolving series of conditions. Many of these conditions were previously unrecognised and thus left untreated, resulting in premature ends to the patients' competitive careers. Hip arthroscopy, as with any procedure, is not without risks. The procedure is not widely available as it requires specialist equipment and takes a long time to learn. Complications are few, occurring in <5% of patients.

Du diagnostic au traitement de la rupture de la coiffe de hanche : à propos d'un cas

OBJECTIVE

To report a case of spontaneous gluteus medius tear repaired surgically in a 42-year-old woman patient without any other antecedent other than diabetes. PATIENT AND METHODS-RESULTS: Trochanteric pain evolving for 7 months led to scintigraphy objectifying a hyperfixation of the trochanter and ultrasonography showing an inflammatory gluteus medius tendon. These examinations were supplemented by magnetic resonance imaging and tomodensitometry visualising the tendon rupture but no marked fat degeneration of the muscle despite atrophy of this one. Surgical exploration confirmed the presence of a major rupture of the gluteus medius tendon, which was reinserted through an osseous trench. Rehabilitation involved protecting the tendon, by an installation of the member in abduction and passive mobilization from the third postoperative day, with a move to partial support on day 45. The result after 16 months was excellent, the patient returning to work 8 months after the surgery without any residual pain.

CONCLUSION

The spontaneous rupture of the gluteus medius, often ignored, can occur in young subjects and induce limited function, often well corrected by reinsertion surgery.

Acetabular labral tears of the hip: examination and diagnostic challenges

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging. Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.

Clinical presentation of patients with tears of the acetabular labrum

BACKGROUND

The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis.

METHODS

We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded.

RESULTS

The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status.

CONCLUSIONS

The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Labral tears, extra-articular injuries, and hip arthroscopy in the athlete

Labral tears in athletes can lead to disabling hip pain and affect their athletic performance. Other intra-articular lesions, including chondral injuries, capsular abnormalities, and ligamentum teres tears, commonly coexist with acetabular labral tears. Isolated athletic injury or repetitive traumatic activity can lead to labral tears; however, underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing athletes to labral pathology must be addressed. Recent studies have demonstrated lesions associated with acetabular labral tears, and that labral tears rarely occur as isolated injuries. Return to sport is favorable in athletes who have labral tears if they are properly treated with arthroscopic intervention.

The painful hip: new concepts

Hip pain is a common condition, and the work-up often includes imaging. This article reviews the normal MR anatomy of the hip and the imaging findings of internal derangements, snapping hip, and femoral acetabular impingement. We will describe the role of MR arthrography in evaluating the patient with suspected labral and articular cartilage abnormalities, as well as the pitfalls in interpretation. We will review the causes of a snapping hip, and the role of sonography in evaluating and guiding treatment of the snapping iliopsoas tendon. We will also review the radiographic and MRI signs of femoroacetabular impingement (FAI), a cause of early degenerative joint disease and hip pain.

Occult acetabular fracture in an elderly runner

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 79-year-old African American male runner sustained a left hip injury while jogging on a running track. Initial radiographs did not show any bony injuries and the patient was diagnosed with hip tendonitis. The patient was initially treated conservatively with medications and referred to a local physical therapy clinic for thermal modalities and therapeutic exercises. The patient failed to show any improvement despite a period of conservative treatment. The author examined the patient 6 months postinjury at a university physical therapy department.

DIAGNOSIS

The author suspected the presence of a possible fracture and the patient was referred to an orthopaedic surgeon. Subsequent radiographic imaging studies including a CT scan revealed a supra-acetabular fracture. The patient underwent a total hip arthroplasty approximately 1 year after the initial injury and has since recovered well.

DISCUSSION

It is not uncommon for runners or joggers to develop hip or pelvic pain, but there has been no prior report in the literature of the occurrence of an acetabular hip fracture while jogging. This resident's case problem illustrates the challenges of arriving at an accurate diagnosis in the presence of a rare fracture and the need for careful follow-up, especially among elderly individuals with cognitive deficits.