Orthopedics

Patient 1

A 70-year-old woman with no history of trauma reported an 18-month history of right hip pain that began with feelings of discomfort in the right greater trochanteric and inguinal areas. Initially, she was restricted to walking short distances and limited her activities of daily living, but the pain worsened and changed to a sharp, stinging pain when walking or internally rotating her right hip.

Physical examination of the right hip revealed no significantly reduced range of motion in all directions, but she had a positive Patrick test and a positive anterior impingement test that was performed by placing the hip in 90° of flexion and then applying adduction and internal rotation. Plain radiographs of both hips showed no dysplasia or other bony abnormalities. Magnetic resonance imaging showed a 15×13-mm multilobulated and septated cystic lesion arising from the superolateral portion of right acetabulum with labral degenerative changes (Figure 1A). The patient underwent arthroscopic treatment for the lesion because pain had relieved after 6 months of conservative management, such as physical therapy, oral medications, and activity modification.

Figure 1: Magnetic resonance imaging of the right hip in patient 1 showing a multilobulated and septated cystic lesion at the superolateral portion of the acetabulum (A). Arthroscopic image taken from the anterolateral portal showing a paralabral cyst at the superior aspect of the acetabulaum (B). Arthroscopic image showing a visible extrusion of gelatinous liquid after punctuation of the cyst (C). Arthroscopic image taken after cyst decompression and debridement of the degenerative labral tissues (D).

Arthroscopic surgery was performed while the patient was under general anesthesia and in the supine position on a fracture table. Traction was applied to the hip until a vacuum sign was observed in the joint space. Two standard anterolateral and anterior portals were used. Arthroscopic examination confirmed the preoperative diagnosis of a paralabral cyst on the superior aspect of the hip (Figure 1B). A visible extrusion of gelatinous liquid was observed during direct decompression of the cyst (Figure 1C). All degenerative labral tissues were debrided using an arthroscopic thermal probe and a shaver (Figure 1D).

The patient had an uneventful hospital stay and was discharged with partial weight bearing using axillary crutches. One month postoperatively, she reported no symptoms excluding mild discomfort in the right hip when flexing the hip more than 90°. At final follow-up 2 years postoperatively, she reported no discomfort or pain with activities of daily living or walking. The Harris Hip Score improved from 58 to 93 points, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 69 to 26 points, and the University of California, Los Angeles (UCLA) activity score improved from 4 to 8 points.

Patient 2

A 41-year-old woman reported an insidious onset of right hip pain for 3 months. She reported no history of trauma. Her hip pain was aggravated when she changed positions or performed long-distance walking or running. Physical examination revealed nearly full hip range of motion, except for a limitation in internal rotation less than 10°, which resulted in sharp pain. She had a positive Patrick test and a positive anterior impingement test. Plain hip radiographs showed no dysplasia or other bony abnormalities. Magnetic resonance imaging showed a 21×18-mm multilobulated cystic lesion on the superior aspect of the right acetabulum (Figure 2A). After failure of conservative management for 6 months, she underwent arthroscopic surgery.

Figure 2: Magnetic resonance imaging of right hip in patient 2 showing a multilobulated cystic lesion at the superior aspect of the acetabulum (A). Arthroscopic view from the anterolateral portal showing radial flap tears and fibrillation of the superior labrum (B) with an adjacent superoposterior paralabral cyst (C). Arthroscopic finding after cyst decompression with debridement of the torn labrum (D). Magnetic resonance imaging at 6 months postoperatively showing complete cyst resolution (E).

Arthroscopy revealed radial flap tears and fibrillated margins of the superior labrum (Figure 2B) with an adjacent superoposterior paralabral cyst (Figure 2C). The cyst was decompressed using a shaver after punctuation with a knife and probe, and then the degenerative labral tears were debrided using an arthroscopic thermal probe and a shaver (Figure 2D).

Postoperatively, pain subsided slowly, with complete resolution of pain after 3 months. The patient has since returned to full participation in activities of daily living. Magnetic resonance imaging 6 months postoperatively showed cyst resolution (Figure 2E). At final follow-up 3 years postoperatively, she reported no discomfort or pain. The Harris Hip Score improved from 52 to 98 points, the WOMAC score improved from 61 to 16 points, and the UCLA activity score improved from 4 to 9 points.