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Arthrodesis and Resection Arthroplasty of the Hip

Key Points Indications for arthrodesis of the hip include young active patients with arthritis in whom other forms of reconstruction will likely fail at an unacceptably high rate. Surgical technique greatly influences outcome; sparing the abductor mechanism is key for later reconstruction. The optimal position for hip fusion is 20 to 30 degrees of flexion, 5 to 7 degrees of adduction, and 5 to 10 degrees…

Femoral Head–Sparing Procedures for Osteonecrosis of the Hip

Key Points Early diagnosis is critical to maximize success with femoral head–sparing surgical procedures for osteonecrosis. One should select the least invasive procedure possible for a given stage of osteonecrosis. Use of core decompression or percutaneous drilling procedures is appropriate only in precollapse disease. Success rates with femoral head–sparing procedures are much lower if more than 2 mm of femoral head collapse is present or if the…

Femoral Osteotomy

Key Points Intertrochanteric femoral osteotomy has lost popularity today. Interest in addressing torsional deformities of the femur has recently come back to the fore. Proximal femoral osteotomies are often used in the context of femoroacetabular impingement (FAI) surgery and/or treatment of hip dysplasia. Osteotomies have shifted more proximally: femoral neck and intracapital osteotomies. Femoral osteotomy must be performed with consideration for the long term (i.e., with…

Pelvic Osteotomies for Hip Dysplasia

Key Points The Bernese periacetabular osteotomy (PAO) can improve pain and function in adolescent and young adult patients with symptomatic acetabular dysplasia and minimal degenerative changes. PAO allows medialization of the hip center, improved lateral and anterior coverage, and correction of version abnormalities of the dysplastic acetabulum. Hip arthroscopy and open femoral head-neck osteochondroplasty with PAO can be used to treat combined intraarticular pathology and concurrent…

Open Surgical Dislocation for Structural Hip Problems

Key Points Surgical hip dislocation (SHD) combined with a sliding osteotomy of the greater trochanter provides a 360-degree overview for correction of structural hip problems and is a safe approach with a low complication rate. SHD can be used for correction of intraarticular and extraarticular femoroacetabular impingement (FAI; Video 54.1 ), for residual Perthes deformities (Legg-Calvé-Perthes disease [LCPD]), for severe slipped capital femoral epiphysis (SCFE) using…

Hip Arthroscopy for Structural Hip Problems

Key Points Structural abnormalities are the main causes of labral pathology in the hip. Femoroacetabular impingement (FAI) and developmental hip dysplasia are causes of osteoarthritis in the hip. Arthroscopy is an effective, reproducible, and less invasive method of treating intraarticular problems in the hip. Morphologic/structural alterations that accompany most of these lesions should be treated at the time of hip arthroscopy. Arthroscopy cannot address the structural…

Hip Arthroscopy for Nonstructural Hip Problems

Key Points Numerous nonstructural hip disorders may be amenable to arthroscopic intervention. Successful operative hip arthroscopy is first dependent on proper patient selection, careful patient positioning, and accurate portal placement. Routine hip arthroscopy should include both central and peripheral compartments. Snapping hip syndromes, including iliopsoas tendon and iliotibial (IT) band, can be addressed. Various disorders reside in the peritrochanteric space, including bursitis and abductor tendinopathies; they…

Metastatic Disease Around the Hip

Key Points Metastatic bone disease is a relatively common problem that will become more common as the population ages. Pain and loss of mobility as a result of bone metastasis can severely impair a patient's quality of life. The treatment of bone metastasis is a multidisciplinary endeavor, and treatment decisions should be made collectively. Surgery is often an integral part of the palliation of metastatic bone…

Primary Malignant Bone Tumors

Key Points Primary malignant tumors about the hip are rare. Early recognition is critical in curative treatment. Chemotherapy or radiation may be indicated, depending on histology. Durable limb salvage techniques are applicable to most patients. Introduction Primary malignant processes frequently present in the hip region. Prompt recognition of these patients is critical, as a window for cure often exists. These lesions are treated with resection with…

Benign Bone Tumors

Key Points Many benign tumors about the hip require only observation and reassurance provided to the patient. The aggressiveness of treatment is matched to the aggressiveness of the tumor. Surgical treatment for benign tumors most commonly consists of curettage or marginal excision. Benign bone tumors about the hip and pelvis represent a varied group of rare lesions. As benign entities, they are characterized by autonomous growth…

Evaluation of Bone Lesions Around the Hip

Key points Characteristics that make an osseous lesion more likely to be malignant include an associated soft tissue mass, periosteal elevation, a permeative appearance, large size, and rapid growth. A well-planned biopsy is critical and should be undertaken (or at least directed) by the surgeon performing the definitive procedure. Metastatic disease and hematopoietic disease (multiple myeloma, lymphoma) are far more common than is primary disease (such…

Hip Dislocation and Femoral Head Fractures

Key Points Hip dislocations and femoral head fractures are the result of high-energy trauma and usually are associated with other injuries. Posterior hip dislocations are much more common than anterior dislocations. Patients who have sustained a posterior hip dislocation usually present with the hip in a position of flexion, internal rotation, and adduction; those with an anterior dislocation present with the hip in marked external rotation…

Acetabular Fracture

Key Points In evaluating acetabular fractures, accurate imaging of the pelvis is needed with plain radiographs, oblique radiographs, and, frequently, three-dimensional imaging. Treatment is guided by classification of the fracture pattern and assessment of the fracture location and displacement, along with patient-specific considerations, such as age and bone quality. Operative approach for open reduction and internal fixation is based on fracture pattern; classification and choice of…

Intertrochanteric Fractures

Key Points The treatment of intertrochanteric femur fractures is almost always operative. Compression hip screws are best used in stable fracture patterns and are associated with low rates of complications when properly positioned within the center of the femoral head. Cephalomedullary nails have been the implant of choice for unstable intertrochanteric fractures and for reverse–oblique fractures. The compression hip screw has been as effective in treating…

Femoral Neck Fracture

Key Points In the physiologically young and active adult, the goals of fixation are to preserve the femoral head, achieve union, and avoid osteonecrosis. Open reduction and internal fixation (ORIF) through a single Watson-Jones anterolateral or a dual incision (Smith-Petersen and accessory) approach allows for full visualization and accurate reduction of the fracture. Variables such as time to surgery, role of capsulotomy, and the method of…

Adolescent Cam Impingement: Etiology and Treatment

Key Points Cam morphology leading to femoroacetabular impingement syndrome (FAI) may develop through both primary (idiopathic) and secondary mechanisms. Evidence suggests that primary cam deformities may be a product of physeal overload or trauma during skeletal growth, likely around the time of growth plate closure. Sex, genetics, race, and high-intensity sport participation are risk factors for primary cam development. Recognized secondary causes of cam abnormalities are…

Inflammatory Arthritis in the Child and Adolescent

Key Points Presentation is frequently loss of function rather than pain. Isolated hip arthritis is very rare. Autoantibodies are frequently absent. Medication and physical therapy are the primary treatments for juvenile idiopathic arthritis (JIA). Surgical therapy may be indicated if medical management has failed. Surgical synovectomy and osteotomy are rarely indicated. Contracture release may be beneficial for young patients with joint preservation and marked limitation of…

Slipped Capital Femoral Epiphysis

Key Points Slipped capital femoral epiphysis (SCFE) is primarily a posterior migration of the epiphysis on the metaphysis in the skeletally immature patient. The cause of SCFE is unknown; however, relative weakening of the physis compared with the size and activity of these patients is often a contributing factor. The most common age for the occurrence of SCFE is the adolescent period, which is generally considered…

Legg-Calvé-Perthes Disease

Key Points A permanent deformity of the femoral head resulting in premature osteoarthritis is the most important sequela of Legg-Calvé-Perthes disease, also known as Perthes disease. Biologic and mechanical factors contribute to the pathogenesis of the femoral head deformity. The degree of femoral head deformity, age at onset of the disease, extent of head involvement, lateral pillar height, and Catterall head-at-risk signs are important prognostic factors.…