Penis Hip Capsules

Dorn Spinal Therapy

Spine Healing Therapy

Get Instant Access

be quite large.14 It is important to distinguish this from a traumatic detachment, which can also occur. Additionally, many labral tears, even in the presence of a significant history of injury, seem to occur due to some underlying predisposition or degeneration. Under these circumstances, even with reliable techniques, repair of a degenerated or morphologically vulnerable labrum would unlikely be successful.

Articular Cartilage Injury

A propensity for acute articular injury has been identified among athletes associated with a direct blow to the trochanter (Fig. 45-24).20 Chondroplasty can be effectively performed for lesions of both the acetabular and femoral surfaces. Curved shaver blades are helpful for negotiating the constraints created by the convex surface of the femoral head. Due to limitations of maneuverability, thermal devices have again been especially helpful in ablating unstable fragments. However, cautious and judicious use around articular surface is even more important because of potential injury to surviving chondrocytes.

Anterior Penis Point

Figure 45-22 A 23-year-old elite professional tennis player sustained an injury to his right hip. A, Coronal magnetic resonance imaging demonstrates evidence of labral pathology (arrow). B, Arthroscopy reveals the labral tear (arrows), but also an area of adjoining grade IV articular loss (asterisk). C, Microfracture of the exposed subchondral bone is performed. D, Occluding the inflow of fluid confirms vascular access through the areas of perforation. The athlete was maintained on a protected weight-bearing status emphasizing range of motion for 10 weeks with return to competition at 31/2 months. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-22 A 23-year-old elite professional tennis player sustained an injury to his right hip. A, Coronal magnetic resonance imaging demonstrates evidence of labral pathology (arrow). B, Arthroscopy reveals the labral tear (arrows), but also an area of adjoining grade IV articular loss (asterisk). C, Microfracture of the exposed subchondral bone is performed. D, Occluding the inflow of fluid confirms vascular access through the areas of perforation. The athlete was maintained on a protected weight-bearing status emphasizing range of motion for 10 weeks with return to competition at 31/2 months. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-23 A 16-year-old high school football player develops acute onset of right hip pain doing squats. A, Sagittal view magnetic resonance arthrogram demonstrates a macerated anterior labrum (arrows). B, Viewing from the anterolateral portal, a macerated tear of the anterior labrum is probed along with articular delamination at its junction with the labrum. C, The damaged anterior labrum has been excised, revealing an overhanging lip (arrows) of impinging bone from the anterior acetabulum. D, Excision of the impinging portion of the acetabulum (acetabuloplasty) is performed with a bur. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-23 A 16-year-old high school football player develops acute onset of right hip pain doing squats. A, Sagittal view magnetic resonance arthrogram demonstrates a macerated anterior labrum (arrows). B, Viewing from the anterolateral portal, a macerated tear of the anterior labrum is probed along with articular delamination at its junction with the labrum. C, The damaged anterior labrum has been excised, revealing an overhanging lip (arrows) of impinging bone from the anterior acetabulum. D, Excision of the impinging portion of the acetabulum (acetabuloplasty) is performed with a bur. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Penis And Hip Arthroscopic

Figure 45-24 A, Fall results in direct blow to the greater trochanter, and, in absence of fracture, the force generated is transferred unchecked to the hip joint. B, Arthroscopic view of the left hip of a 20-year-old collegiate basketball player demonstrates an acute grade IV articular injury (asterisk) to the medial aspect of the femoral head. C, Arthroscopic view of the left hip of a 19-year-old male who sustained a direct lateral blow to the hip, subsequently developing osteocartilaginous fragments (asterisks) within the superomedial aspect of the acetabulum. (From Byrd JWT: Lateral impact injury: A source of occult hip pathology. Clin Sports Med 2001;20:801-816.)

Microfracture of select grade IV articular lesions has been beneficial (see Fig. 45-22).18 As with other joints, it is best indicated for focal lesions with healthy surrounding articular surface. The lesion most amenable to this process is encountered in the lateral aspect of the acetabulum. This is followed by 8 to 10 weeks of protected weight bearing to neutralize the forces across the hip joint while emphasizing range of motion. Using this protocol, among a cohort of 24 patients, 86% demonstrated a successful outcome at 2- to 5-year follow-up.21

Ligamentum Teres Injury

Injury to the ligamentum teres is increasingly recognized as a source of hip pain in athletes (Fig. 45-25).1 The disrupted fibers catch within the joint and can be quite symptomatic. This disruption may be the result of trauma, degeneration, or a combination of both.22 The tear may be partial or complete with the goal of treatment being to d├ębride the entrapping, disrupted fibers. Our recent report documented excellent success in the arthroscopic management of traumatic lesions of the ligamen-tum teres. The average improvement was 47 points (100-point modified Harris hip score system), with 93% showing marked (>20 points) improvement.23

The acetabular attachment of the ligamentum teres is situated posteriorly at the inferior margin of the acetabular fossa and attaches on the femoral head at the fovea capitis. The disrupted portion of the ligament is avascular, but the fat pad and synovium contained in the superior portion of the fossa can be quite vascular. Debridement is facilitated by a complement of curved shaver blades and a thermal device. The disrupted portion of the ligament is unstable and delivered by suction into the shaver. A thermal device can also ablate tissue while maintaining hemostasis within the vascular pulvinar.

Access to this inferomedial portion of the joint is best accomplished from the anterior portal. External 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 pos-terolateral portal. Indiscriminate debridement of the ligamen-tum teres should be avoided because of its potential contribution to the vascularity of the femoral head.

Penis And Hip Arthroscopic

Figure 45-25 A 16-year-old cheerleader has a 2-year history of catching and locking of the left hip following a twisting injury. A, Arthroscopic view from the anterolateral portal reveals disruption of the ligamentum teres (asterisk). B, Debridement is begun with a synovial resector introduced from the anterior portal. C, The acetabular attachment of the ligamentum teres in the posterior aspect of the fossa is addressed from the posterolateral portal. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Penis And Hip Arthroscopic

Synovial Disease

Primary synovial disease may be encountered in athletes, but more often synovial proliferation occurs in response to other intra-articular pathology. Synovitis may be diffuse, encompassing the lining of the joint capsule, or focal, emanating from the pulvinar of the acetabular fossa. Focal lesions within the fossa may be dense and fibrotic or exhibit proliferative villous characteristics. Presumably, because of entrapment within the joint, these lesions can be quite painful and respond remarkably well to simple debridement. While a complete synovectomy cannot be performed, a generous subtotal synovectomy can be carried out. Enlarging the capsular incisions with an arthroscopic knife improves maneuverability within the intra-articular portion of the joint. For most synovial disease, arthroscopy of the peripheral compartment is necessary in order to adequately resect the diseased tissue.7,8,19

In the presence of arthritis, there will be arthroscopic evidence of various pathology including free fragments, labral tearing, articular damage, and synovial disease. With a meticulous systematic approach, each component can be addressed

Penis And Hip Arthroscopic

arthroscopically. Ultimately, with a well-performed procedure, the response to treatment will be mostly dictated by the extent of pathology, much of which cannot be reversed.24-27

Impinging Osteophytes

Post-traumatic impinging bone fragments, occasionally encountered in an active athletic population, may respond well to arthroscopic excision.28,29 Degenerative osteophytes rarely benefit from arthroscopic excision as the symptoms are usually more associated with the extent of joint deterioration and not simply the radiographically evident osteophytes that secondarily form. However, the post-traumatic type may impinge on the joint, causing pain and blocking motion. These fragments are often extracapsular and require a capsulotomy, extending the dissection outside the joint for excision (Fig. 45-26). This necessitates thorough knowledge and careful orientation of the extra-articular 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 visualiza-

Hip Capsule Block

Figure 45-26 An 18-year-old high school football player sustained an avulsion fracture of the left anterior inferior iliac spine. A, Three-dimensional computed tomography illustrates the avulsed fragment (arrow), which ossified, creating an impinging painful block to flexion and internal rotation. B, Viewing from the anterolateral portal, a capsular window is created, exposing the osteophyte (asterisk) anterior to the acetabulum (A). C, The anterior capsule (C) has been completely released allowing resection of the fragment along the anterior column of the pelvis (P). Postoperatively, the patient regained full range of motion with resolution of his pain. (From Byrd JWT: Arthroscopy of select hip lesions. In Byrd JWT [ed]: Operative Hip Arthroscopy. New York, Thieme, 1998, pp 153-170.)

Figure 45-26 An 18-year-old high school football player sustained an avulsion fracture of the left anterior inferior iliac spine. A, Three-dimensional computed tomography illustrates the avulsed fragment (arrow), which ossified, creating an impinging painful block to flexion and internal rotation. B, Viewing from the anterolateral portal, a capsular window is created, exposing the osteophyte (asterisk) anterior to the acetabulum (A). C, The anterior capsule (C) has been completely released allowing resection of the fragment along the anterior column of the pelvis (P). Postoperatively, the patient regained full range of motion with resolution of his pain. (From Byrd JWT: Arthroscopy of select hip lesions. In Byrd JWT [ed]: Operative Hip Arthroscopy. New York, Thieme, 1998, pp 153-170.)

Penis And Hip Arthroscopic

Figure 45-27 A 19-year-old female had undergone two previous arthroscopic procedures on her right hip for reported lesions of the ligamentum teres. Following each procedure, she developed recurrent symptoms of "giving way." A, Radiographs revealed normal joint geometry. B, She was noted to have severe diffuse physiologic laxity best characterized by a markedly positive sulcus sign. C, With objective evidence of laxity and subjective symptoms of instability, an arthroscopic thermal capsulorrhaphy was performed, accessing the redundant anterior capsule from the peripheral compartment. Modulation of the capsular response was controlled by a hip spica brace for 8 weeks postoperatively with a successful outcome. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Penis And Hip Arthroscopic

Was this article helpful?

0 0
American Football 101

American Football 101

Are you looking for a way to increase the capabilities of your football team? Is your football team leaving something to be desired? Are you looking to skyrocket your team's effectiveness with the most effective drills and plays?

Get My Free Ebook


Post a comment