1
Overview and History of Hip Arthroscopy
J.W. Thomas Byrd
The history of endoscopic in vivo examination of the human body is well known to students of arthroscopic techniques.1This history dates back almost 200 years to the Austrian, Philipp Bozzini, who in 1806 devised the Lichtleiter (Austrian for light conductor). This instrument, designed for inspection of the rectum and vagina, actually gained clinical record for its use in inspection of the larynx and vo- cal cords.2
Instruments for viewing human anatomy were her- alded as providing indisputable evidence of disease.
Previously, only indirect evidence of various disorders was usually available. It is worthy to note that, at the time of Bozzini’s invention, auscultation was the prin- cipal method of examining the human body. However, when auscultation skills and instruments were ini- tially introduced, they were not without their detrac- tors. Many physicians believed that it would necessi- tate that they abandon other examination methods that they had spent years developing and feared they might not possess the necessary skills for performing effective auscultation.2 Centuries later, these same barriers existed in the acceptance of modern arthro- scopic techniques.
Following Bozzini’s initial design, crude cysto- scopes of various constructs were developed over the ensuing 100 years. All of these were limited by lack of an adequate light source. However, by the early 1900s, electricity was discovered and Edison had in- vented the incandescent light bulb. This accomplish- ment opened new horizons in the development of endoscopic instruments. In 1918, Kenji Takagi3 visu- alized the interior of a cadaveric knee joint with a cys- toscope. The first recorded attempt at arthroscopic vi- sualization of the hip is attributed to Michael S.
Burman4 in 1931 (Figures 1.1, 1.2). For his purposes, an arthroscope was constructed by Reinhold Wappler with a diameter of 4 mm, not dissimilar to the di- mensions of our current arthroscopes (Figure 1.3). Bur- man used fluid distension for visualization, examin- ing the interior of more than 90 various joints in cadaver specimens, correlating the arthroscopic anat- omy with the gross anatomy on subsequent dissec- tion. Twenty of these were hip joints.
Burman made several pertinent and prudent ob- servations that still hold true today, more than over 60 years later. His examination of the hip did not use distraction, and the structures that he successfully vi- sualized correspond with the structures that currently are discernible via arthroscopy without distraction (Figure 1.4). These aspects include much of the artic- ular surface of the femoral head, seen by placing the hip through range of motion, and the intracapsular portion of the femoral neck. With this approach, the acetabulum, fossa, and ligamentum teres could not be visualized.
Burman noted that “visualization of the hip joint is limited to the intracapsular part of the joint.” This statement still has much bearing in current applica- tions of hip arthroscopy. Although arthroscopy has been used for release of a snapping iliopsoas tendon and for extracapsular bone fragments that impinge on the joint, intraarticular sources of pathology are most amenable to arthroscopic intervention.
Burman further stated:
“We experimented with a number of punctures and the anterior paratrochanteric puncture proved the best. . . . The anterior paratrochanteric puncture is un- doubtedly the best and is made slightly anterior to the greater trochanter along the course of the neck of the femur. . . . The puncture is not hard to do and one can visualize the hip with it in almost every case. Origi- nally we were skeptical as to whether anything could be seen in the hip joint, but we have had unusual suc- cess with this puncture.”
The anterior paratrochanteric (or anterolateral; see Chapter 7) portal is clearly the workhorse portal for modern arthroscopy. Although there is some variation of the other portals described by numerous authors, this is the one position common to all and, according to an anatomic study, it is the safest.5
Burman continued:
“We have been careful to choose cadavers of slen- der build since our trochar is not long enough to punc- ture the hip of a well muscled person. . . . A special long trochar with a correspondingly long telescope should thus be used for the hip joint. The line of the femoral artery and the position of the head of the fe- 1
mur should be marked beforehand to avoid possible damage to the vessels. This should only be a theoret- ical accident.”
For the surgeon who only occasionally is chal- lenged by the role of arthroscopic surgery of the hip, size may be a relative contraindication, and even for an experienced arthroscopist it may preclude the abil- ity to enter the hip joint. Indeed, as recommended by Burman, extra-length cannulas and instruments are used but, in some cases, even these may not be ade- quate. Also, a careful appreciation of the orientation
of the major neurovascular structures is always criti- cal. There are anecdotal accounts such as a case of ir- reparable damage to the femoral nerve. This type of catastrophic scenario should be unlikely with basic understanding and orientation of the extraarticular anatomy.
The first clinical application of the arthroscope in the hip of a patient was reported by Takagi3 in 1939 (Figure 1.5). This report consisted of four hips, in- cluding two cases of Charcot joints, one tuberculous arthritis, and one suppurative arthritis.
The clinical implications of arthroscopic tech- niques, especially about the knee, began to flourish following the publication of the second edition of At- las of Arthroscopyby Masaki Watanabe et al.6in 1965 (Figure 1.6). Watanabe was a student of Takagi’s. He also visited with Michael Burman in the evolution of his techniques.
However, following Takagi’s report in 1939, the clinical applications of arthroscopy about the hip went unmentioned until the 1970s with Aignan’s7report of attempted diagnostic arthroscopy and biopsy of 51 hips. This study was presented at the 1975 meeting of the International Arthroscopy Association in Copen- hagen. In 1977, Richard Gross described 32 diagnostic arthroscopic procedures in 27 children for a variety of pediatric hip disorders including congenital disloca- tion, Legg–Calvé–Perthes disease, neuropathic sub- luxation, prior sepsis, and slipped capital femoral epi- physis.8 A second clinical series appeared in the pediatric literature in 1981 when Svante Holgersson et al.9reported on the role of arthroscopy in assessing 15 hips in 13 children with juvenile chronic arthritis.
Between these two series, there were two case reports on removal of entrapped cement fragments following total hip arthroplasty, one from the New York City Hospital for Special Surgery and one from Israel.10,11
The 1980s brought several important advance- ments that contributed to the applications of opera-
FIGURE 1.1. Dr. Michael Samuel Burman (1901–1975). (Reprinted with permission of New York Academy of Medicine.)
FIGURE 1.2. Dr. Burman performing an arthroscopic procedure at the Hospital for Joint Diseases in 1935. (Courtesy of Serge Parisien, MD; from Parisien,26with permission.)
FIGURE 1.3. Photograph reprinted from Burman’s article illus- trates the arthroscopic instruments devised by Reinhold Wappler and used by Dr. Burman in his investigative studies. The upper por- tion is the telescope (measuring 3 mm in diameter); the lower por- tion is the trochar sheath (measuring 4 mm in diameter.) (From Bur- man,4with permission.)
tive hip arthroscopy. In 1981 Lanny Johnson12 ad- dressed the role of arthroscopy of the hip joint in the second edition of his textbook, Diagnostic and Surgi- cal Arthroscopy(Figure 1.7). In 1985, Watanabe13also described the technique for carrying out the procedure in Arthroscopy of Small Joints. In 1986 Ejnar Eriks- son et al.14 from Sweden described the forces neces- sary for adequate hip distraction. This was an in vivo study of patients undergoing arthroscopy as well as a study of unanesthetized volunteers, which included Professor Eriksson himself.
James Glick from San Francisco has been recog- nized as the single greatest influence on the develop- ment of hip arthroscopy in North America (Figure 1.8).
Motivated by the creative ideas of Lanny Johnson, Glick began performing the procedure in 1977. He rec- ognized limitations of the technique in obese patients.
Influenced by his partner, Thomas Sampson, in 1985 they modified the procedure and began placing the pa- tient in the lateral decubitus position. Their prelimi- nary experiences were reported in 1987.15 This and subsequent works have been the cornerstones on which other surgeons have founded their approach.16–18 Ar- throscopy by the lateral approach has been found to be accessible and reproducible. Additionally, a custom distractor has been developed that greatly facilitates arthroscopy in this position.
In the mid-1980s, Richard Villar from Cambridge,
FIGURE 1.4. Burman’s illustration of the arthroscopic view of a hip visualizing the ridging of the neck of the femur, the junction of the neck and the femoral head, and a portion of the articular surface of the femoral head. (From Burman,4with permission.)
FIGURE 1.5. Dr. Kenji Takagi (1888–1963). (Courtesy of Tokyo Teishin Hospital.)
FIGURE 1.6. Dr. Masaki Watanabe (1911–1994). (Courtesy of Tokyo Teishin Hospital.)
England, envisioned several useful roles for arthros- copy of the hip. He corresponded with James Glick and Richard Hawkins, who had published some of the few articles available on the topic at the time.15–19Vil- lar subsequently pioneered the technique in England and has taught the procedure to others now beginning to perform it in the United Kingdom. He has reported in detail his extensive experience with arthroscopic anatomy and operative arthroscopy.20,21
Brian Day from Toronto accurately envisioned the expanding role for operative hip arthroscopy and has written on the anatomy, indications, and nomencla- ture for this technique.22,23Gary Poehling and Dave Ruch from Winston-Salem, NC, have explored the role of arthroscopy as a supplemental technique in the management of avascular necrosis of the femoral head.24Down the road in Durham, Tad Vail has pub- lished his experience, useful in selecting potential can- didates for hip arthroscopy.25 Serge Parisien from the Hospital for Joint Diseases in New York City authored several pertinent publications in the 1980s, and Joe McCarthy from Boston has been active reporting his experience in numerous aspects of hip arthros- copy.23,26,27
In the United States, little attention has been given to the prospect of performing hip arthroscopy without distraction.28However, Henri Dorfmann and Thierry
Boyer, a pair of rheumatologists from Paris, France, have accumulated a large number of cases performed by this method.29,30 Dr. Dorfmann learned the tech- niques of arthroscopy training under Dr. Watanabe in Japan and pioneered his own method of hip arthros- copy, especially important for viewing the peripheral compartment. As rheumatologists, Drs. Dorfmann and Boyer especially focus on the role of synovial pathology as a source of hip disease. Their method is unsurpassed in being able to address the synovium and often complements the traditional distraction meth- ods that have otherwise been most popular.
Dysplastic hip disease is quite prevalent in Japan.31 The association of labral lesions with dysplasia may explain why there have been several significant stud- ies regarding labral lesions reported from Japanese cen- ters.32–34 In 1991, Ide et al.35 reported what, at the time, was the largest clinical series of arthroscopic procedures.
In Nashville, the author has redefined the applica- tion of the supine position and has gained increasing experience in the use of this approach in operative hip arthroscopy.36,37 Minor modifications to a standard fracture table facilitate many of the advantages at- tributed to the lateral position.
The progression and application of arthroscopic techniques for the hip have lagged behind those for other joints because of the unique challenges imposed by its anatomy. Although slower, the evolution of hip arthroscopy has paralleled that of other joints. Early clinical applications were followed by a hiatus of four decades. The reemergence of case reports and small clinical series was surrounded by uncertainty regard- ing the merits of the procedure. Arthroscopic investi- gation of the joint has subsequently expanded our
FIGURE 1.7. The author (right) with Lanny Johnson (left), a pio- neer of arthroscopy as a clinician, scientist, and inventor. (Courtesy of Dr. J.W. Thomas Byrd.)
FIGURE 1.8. The author (center) with James Glick (right) and Thomas Sampson (left). Jim Glick, the single greatest figure in mod- ern hip arthroscopy, was motivated by Lanny Johnson and influ- enced in his techniques by his younger partner, Tom Sampson.
(Courtesy of Dr. J.W. Thomas Byrd.)
knowledge of hip disease and injury. This investiga- tive phase has been followed with a clearer under- standing of the indications and technique. The evolu- tion is not complete, but the foundation laid by many of these pioneers has provided the basis for the fun- damentals of operative hip arthroscopy.
The maturation of arthroscopic methods has be- gun a transformation to endoscopic techniques for ar- eas surrounding the hip. Already surgeons are able to address bone fragments outside the joint and to ad- dress lesions of the iliopsoas tendon. The incentive is to make surgical procedures less invasive. This cate- gory will undoubtedly soon include procedures in which the scope is used as an adjunct to arthroscopic and endoscopic assisted techniques. This development will be driven exponentially by the next generation of surgeons and scientists. Each clinician brings a unique perspective and experience that will benefit all those who struggle on the continually changing horizon of technology with which to battle hip disease.
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