hip arthroscopy

Saturday, August 26, 2017

It seems a rite of passage that a pro athlete will undergo surgery sometime in their career. Pushing a body to the limits of physiology and beyond, is an internal expectation of the athlete but when the body breaks, surgery may be offered as an option to repair the damage. There might be other alternatives to explore and that is where we find Isaiah Thomas, the Boston Celtic, soon to be Cleveland Cavalier guard. Last spring, Mr. Thomas injured his hip, tearing the labrum, a piece of cartilage that extends the depth of the hip joint, where the femur or thigh bone, comes together with the acetabulum, the bony socket of the pelvis. It is an injury that can be repaired by hip arthroscopy surgery, but some cases may also can be treated with rest and physical therapy. Mr. Thomas has become news because of the trade; will he be considered damaged goods because he chose not to have an operation?

There is no such thing as minor surgery. That describes an operation that happens to somebody else.  Arthroscopy (arthro=joint + scope=to see) is an operation where an orthopedic surgeon, using small cuts in the skin, introduces a camera and a variety of thin instruments to operate inside a joint and repair damage. The knee was the first joint to be attacked. It was a large joint with plenty of room to hold the camera and everything else that was needed. Over time, techniques improved, instruments became smaller and other joints, ike the hip, shoulder, ankle and wrist, could be attacked.

One big difference between knee and hip arthroscopy is the anesthetic. Knee arthroscopy can be done under regional anesthetic and the patient can be awake (or sedated) and even watch his own operation on the video screen. The hip joint is a much smallr space and the surrounding muscles need to be relaxed to allow the leg to be positioned and put under traction to make more room for the surgeon to put stuff like cameras inside. Practically, that means a general anesthetic and medications are then used to paralyze the patient to have no potential for the muscles to go into spasm and make visualization inside the hip joint that much tougher.

In addition to being small in space, the hip joint is surrounded by really important structures like major arteries and nerves. The surgeon needs to know the anatomy (and appreciate that everybody isn’t always built precisely the same way) to avoid inadvertently damaging something important.

  • Before the skin is cut, the patient’s body needs to be positioned and padded to prevent damage to nerves as traction is placed on the hip when the leg is pulled. Usually, the traction time is maxed out at 2 hours.

  • The next worry is to be precise about where to slide the camera and instruments into the joint. The anterior or front portal is placed within 1 ¼ inches (3.2 cm) of the femoral artery, vein and nerve. The posterior or back portal is even closer to the sciatic nerve (2.9 cm). The superior portal is within 1 ½ inches (4 cm) from the superior gluteal nerve and artery.

  • During and after the operation, there is risk of bleeding and infection.
  • And finally, there is the post operative rehab.

Fortunately, the more an orthopedic surgeon scopes a hip, the fewer complications occur and major complications happen infrequently, in less than 1.5% of cases. Appreciate though, that when a complication happens, it happens 100% to that particular patient.

The athlete’s decision to consider surgery depends upon whether the chance of recovery and return to play the same level of skill and performance is more likely with the operation, or perhaps better with physical therapy and rehab. Each injury has its own risk and reward. And for that reason, when Isaiah Thomas torn the labrum in his hip, he had to weight the pros and cons of surgery.

The Isaiah Thomas treatment decision is not news. There is no right or wrong. It only matters now because of an impending trade and his new team wanting him to pass his physical exam so that he isn’t considered “damaged goods”. Fortunately, his specific decision to go the physical therapy route isn’t written in stone. If he does well, life is good. If he doesn’t heal satisfactorily, the surgery option is still available and on the table. And it’s always good to have time on your side when having to decide.



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the body’s directions

Wednesday, March 1, 2017

Another evening in the world of sport and another round of players being helped off the court. Last night, it was Kevin Durant with a medial collateral ligament sprain and worry that because of mechanism of injury, his anterior cruciate, the ACL, might be torn. Anterior, posterior, medial, lateral, the directions of the body can be a mystery, even to those inside the medical community. North, south, east, west, up, down don’t exist in medicine.

The body’s road map has many different directions. and it all starts with the anatomic positon, best illustrated by Da Vinci’s Vitruvian Man and the basic coordinate   :

  • The heart is the center of the body. Move away from the heart and you’re going distal, move closer to the heart, you’re now more proximal. The wrist is distal to the elbow, but the elbow is proximal to the wrist.
  • The front of the body is anterior and the back is posterior. But it’s important to look at Da Vinci’s man because the hands are a special case that we’ll visit in a bit.
  • Draw a line from the nose to the belly button and that is the midline. Move away from the midline and you’re lateral; move closer to the midline and you’re now The ear is lateral to the cheek and the nose is medial to the eye.
  • Up and down don’t exist. You’re either moving cephalad towards the top of head or caudad towards the bottom or the tail.

The anatomy directions are standard stuff and don’t change regardless of whether the patient is standing, sitting or lying flat. But some parts of the body have special directions.

The hand is special perhaps because its function is so important to the way the body works. Look again at how Da Vinci lines up his man. The arms are at the side with the palms facing forward. That can be confusing because the little finger, what many people consider the outside of the hand is really medial and the thumb is lateral. To avoid any confusion, directions in the hand are different.

  • The anterior hand is called the palmar surface and the back of the hand is called the dorsum.
  • The radius and ulna are the two bones in the forearm that connect to the wrist. The thumb is on the radius side and the little finger on the ulna. The midline of the hand runs from the tip of the middle finger to the wrist and stuff is described as either radial or ulnar. The index finger is ulnar to the middle finger but medial to the thumb.
  • Each finger has three joints named by the bones that meet at each (the thumb only has two), metacarpophalageal joint (MCP), proximal interphalangeal joint (PIP)and distal interphalangeal joint (DIP). Describing the fingernail, it is located on the dorsum of the finger, distal to the DIP joint.

The abdomen is divided into quadrants, the neck has zones, the eye has chambers, the foot has a plantar surface (the sole). There are special terms for most body parts that become the foreign language that is medicine and anatomy.

It’s important to understand the body’s directions to help people understand, through words, the geography of the body, and to help explain to one another where stuff is happening. For Mr. Durant and his MCL injury, the medial collateral ligament runs from the femur to the tibia on the medial part of the knee. If you tried to explain it as the inside part, that might be confusing because the MCL is not located inside the knee joint, but instead it is outside the joint towards the midline of the body.

Direction terminology is especially important when health professionals talk to each other so that can help visualize the body and the description of an injury, rash, lump or bump. East and west is good for maps but not for arms and legs, while up and down works for elevators. But in the medical world, using the same language makes good things happen.


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