E

Figure 45-19—Cont'd C, Computed tomography substantiates the intraarticular location of the fragments (arrows). D, Arthroscopic view medially demonstrates the loose bodies. E, Viewing anteriorly, the anterior capsular incision is enlarged with an arthroscopic knife to facilitate removal of the fragments. F, One of the fragments is being retrieved. G, Loose bodies are removed whole. (From Byrd JWT: Indications and contraindications. In Byrd JWT [ed]: Operative Hip Arthroscopy, 2nd ed. New York, Springer, 2005, pp 6-35.)

Thus, arthroscopy to address symptomatic fragments must include both the intra-articular and peripheral joint.7,8 Many can be debrided with shavers or flushed through large-diameter cannulas. Large ones can sometimes be morselized and removed piecemeal. However, often fragments may be too large to be removed through a cannula system and must be removed free hand with sturdy graspers. Once a portal tract has been developed, these larger graspers can be passed along the remaining tract into the joint in a free-hand fashion. Make sure to enlarge the capsular incision with an arthroscopic knife and the skin incision so that as the fragment is retrieved, it will not be lost in the tissues, either at the capsule or subcutaneous level.

Labral Tears

Labral lesions represent the most common indication for hip arthroscopy among athletes. Magnetic resonance imaging and magnetic resonance angiography are best at detecting labral pathology, but poor at identifying associated articular damage present in a significant portion of cases. These studies may also overinterpret pathology with lesions reported among asymptomatic volunteers, and among elite athletes, some damage may accrue simply as a consequence of the cumulative effect of their sport (Fig. 45-20). Traumatic labral tears may respond remarkably well to arthroscopic debridement (Fig. 45-21).14-18 However, at arthroscopy, be especially cognizant of any underlying degeneration that may have predisposed to the acute tear. There will often be accompanying articular damage, and the extent of this may be a significant determinant on the eventual response to debridement (Fig. 45-22). Also, with the evolving understanding of femoroacetabular impingement and its role in the development of labral and chondral damage, it is important to make a careful radiographic assessment of accompanying bony lesions of the anterior acetabulum or femoral head that may require reshaping (Fig. 45-23).19

Figure 45-20 Three National Hockey League players were referred, each with a 2-week history of hip pain following an injury on the ice. Each case demonstrated evidence on magnetic resonance imaging of labral pathology (arrows). These cases were treated with 2 weeks of rest followed by a 2-week period of gradually resuming activities. Each of these athletes was able to return to competition and have continued to play for several seasons without needing surgery. A, Coronal image of a left hip demonstrates a lateral labral tear (arrow). B, Coronal image of a right hip demonstrates a lateral labral tear (arrow). C, Sagittal image of a left hip demonstrates an anterior labral tear with associated paralabral cyst (arrow). (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-20 Three National Hockey League players were referred, each with a 2-week history of hip pain following an injury on the ice. Each case demonstrated evidence on magnetic resonance imaging of labral pathology (arrows). These cases were treated with 2 weeks of rest followed by a 2-week period of gradually resuming activities. Each of these athletes was able to return to competition and have continued to play for several seasons without needing surgery. A, Coronal image of a left hip demonstrates a lateral labral tear (arrow). B, Coronal image of a right hip demonstrates a lateral labral tear (arrow). C, Sagittal image of a left hip demonstrates an anterior labral tear with associated paralabral cyst (arrow). (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-21 A 25-year-old top-ranked professional tennis player sustained a twisting injury to his right hip. A, Coronal magnetic resonance imaging demonstrates evidence of labral pathology (arrow). B, Arthroscopy reveals extensive tearing of the anterior labrum (asterisk) as well as an adjoining area of grade III articular fragmentation (arrows). C, The labral tear has been resected to a stable rim (arrows) and chondroplasty of the grade III articular damage (asterisk) is being performed. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Figure 45-21 A 25-year-old top-ranked professional tennis player sustained a twisting injury to his right hip. A, Coronal magnetic resonance imaging demonstrates evidence of labral pathology (arrow). B, Arthroscopy reveals extensive tearing of the anterior labrum (asterisk) as well as an adjoining area of grade III articular fragmentation (arrows). C, The labral tear has been resected to a stable rim (arrows) and chondroplasty of the grade III articular damage (asterisk) is being performed. (Courtesy of J.W. Thomas Byrd, MD, Nashville, TN.)

Labral tears can be adequately accessed through the three standard portals. Similar to a meniscus in the knee, the task is to remove unstable and diseased labrum, creating a stable transition to retained healthy tissue. The most difficult aspect is creating the stable transition zone. Thermal devices have been quite useful at ablating unstable tissue adjacent to the healthy portion of the labrum. Caution is necessary because of the concerns regarding depth of heat penetration, but with judicious use, these devices have been exceptionally useful for precise labral débridement despite the constraints created by the architecture of the joint.

The natural evolution in arthroscopic management of labral pathology is from débridement to repair. Current methods of acetabular labral repair are in their infancy. A few have been attempted with mixed results. Reliable techniques remain to be developed but are probably not far off. In addition to technical advancements, there is much that remains regarding our understanding of labral morphology and pathophysiology. There is considerable variation in the normal appearance of the labrum including a labral cleft at the articular labral junction that can

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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