Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program

Hip Arthroscopy in 2013

INOVA Annual Sports Medicine Program2013

Andrew B. Wolff, M.D.Washington Orthopaedics Washington Orthopaedics

and Sports Medicineand Sports MedicineWashington, DCWashington, DC

www.andrewwolffmd.comwww.andrewwolffmd.com

Hip Arthroscopy is a Means, Not an End

• Restore anatomy to:

– Relieve pain

– Improve function

– Improve longevity?

CAM lesion Bump removal vs. Sphericity

Pincer lesion Rim Trimming vs. Femoral Osteoplasty

Torn labrum Repair vs. Debride vs. Reconstruct

Cartilage defects Microfracture, Repair, Rim Trim

Instability Plication, capsular shift

Dysplasia Arthroscopy vs. PAO

Approach Open vs. Arthroscopic

Early arthritis Symptomatic Relief vs. 2 Surgeries

What Should We Treat?

• Make the correct diagnosis!

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Date of download: 5/28/2013

Copyright © The Journal of Bone & Joint Surgery, Inc. All rights reserved.

From: Femoroacetabular Impingement

J Bone Joint Surg Am. 2013;95(1):82-92. doi:10.2106/JBJS.K.01219

Fig. 1

A list of static and dynamic mechanical factors for prearthritic hip pain. AIIS = anterior inferior iliac spine, FAI = femoroacetabular impingement, SI = sacroiliac joint, and ITB = iliotibial band.

Figure legend:

• Make the correct diagnosis

• History and Physical are critical• Understand concomitant disease (i.e.,

sports hernia, lumbar spine pathology, etc.)

• Understand that there may be a mixed picture of symptoms such as sacroillitis, peri-pelvic tendinitis, ischial or troch bursitis

What Should We Treat?

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• Traumatic vs. Insidious– Twisting or torqueing

– Subluxation

– Dislocation, associated fracture

• Congenital / Developmental– DDH, Perthes, SCFE

• Other– Infection, PVNS, Osteonecrosis, Synovial

Chondromatosis

History

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Confirming the source of pain

• History

– Is it predominately lateral or posterior?

– Or is it in the groin?

– Pain and/or numbness going down the leg?

Confirming the source of pain

• History

– Can you push on it and make it hurt?

– Does your hip make noise?

– When it pops, does it hurt?

Confirming the source of pain

• History – What causes the

pain?–Twisting

–Running

–Prolonged sitting– Plane rides/ long car

rides

–Walking uphill

–Getting in/out of car

–Achy night pain?

Confirming the source of pain

• Where does it hurt?

• C-sign

Confirming the source of pain

• Intra-articular etiologies

Acetabular labrum tearsArticular cartilage:

DefectsOAPost-traumatic arthritisInflammatory arthritis

Joint capsule:LaxitySprainTightnessTear

Ligamentum teres tearInternal impingement

Bony deformities:FAIDDHSCFEPerthesStress fx.

OsteonecrosisLoose bodiesTransient synovitisInfection

Confirming the source of pain

• Extra-articular etiologies

Bursitis:TrochantericPsoasIschial

Muscular strain:IliopsoasGluteus mediusHamstrings

Snapping hip:ITBIliopsoas

Avulsion injuriesStress fractureSI pathologyMyositis ossificansHip pointerInfection

Confirming the source of pain

• Many patients don’t follow the textbook– Combined back and

groin pain

– Troch and groin pain

– Butt and groin pain

– Groin pain but negative anterior impingement sign

– Achy night pain

Inspection: Postural Analysis (Static)

Shoulder to Foot Symmetry

Inspection: Dynamic

• Sport performance• Standing single leg

squat• Trendelenburg• Standing single leg

raise• Sit-up• “Make it pop”

Palpation: Anterior Checklist

• Rectus Abd Insertion

• Pubic bone• Ext inguinal ring• Lower abd

quadrant• AIIS: direct rectus

femoris• ASIS• Anterior 1/3

Gluteus Medius/Tensor

Palpation: Posterior Checklist

• Paraspinous/axial spine

• SI joints• Ischial tuberosity• Posterior Iliac

Crest• Sciatic notch?

Range of Motion: Supine/Prone

• Assess ranges:– Flexion

– Extension

– ROTATION prone and supine at 90 deg flexion

• Knee / Lumbar

Special Tests• Sensitive NOT

specific• Impingement• Laxity / Instability• SI joint• Piriformis Syndrome• ITB syndrome• HNP lumbar spine• Core Muscle Injury

(Sports Hernia)• Standard hernia

(valsalva)

Anterior Impingement TestPassive flexion to 90°

followed by forced adduction and IR

Leunig et al. Op Tech Orthop 2005

FABER Test

Vad et al. Am J Sports Med 2004

Confirming the source of pain

• Diagnostic injections

– Can be very helpful

– Consider using corticosteroid, not just lidocaine/marcaine

Confirming the source of pain

• Diagnostic injections– Inject other

potential sources of pain if clinically warranted

– Iliopsoas

– Troch bursa

– Piriformis

– SI joint

– Spine

Confirming the source of pain

•It’s the hip…now what?

•In non-arthritic hips most common source of pain is labral pathology secondary to FAI

Acetabular Labrum• Extends the

acetabulum beyond the bony socket

• Is present around the entire lunate surface of the acetabulum

• Is continuous with the transverse acetabular ligament inferiorly

Femoroacetabular Impingement

• Wenger et al. showed that 87% of patients with labral tears had underlying structural abnormalities (Wenger et al. CORR 2004)

• Ganz and colleagues introduced the concept of Femoroacetabular Impingement (FAI) as a cause of hip pain, labral tears, and early osteoarthritis(Ganz et al. CORR 2003)

CAM & PINCER ImpingementCAM & PINCER Impingement

PincerCAM

Espinosa et al J Bone Joint Surg 2006; 88-A: 225-239

FAI: FAI: Pincer TypePincer Type

contre-coup

contre-coup

FAI: FAI: Cam TypeCam Type

Set Up - Initial position• Complete Paralysis• Perineal pad, padded boots, foot holder• Start with legs abducted approx. 45

degrees

Check Fluoroscopic Images

Applied Traction

Expect suction seal release when adducting

“Vacuum sign”

Portal Placement

ASIS

Greater Troch

45 degrees

Localize with fluoroscopy

Localize with fluoroscopy

Find the vessels

Final Dynamic Exam

Some are easier…

Pre-op Post-op

than others.Pre-op Post-op

Pincer ImpingementPincer Impingement• Overcoverage of the acetabulum on the femoral headOvercoverage of the acetabulum on the femoral head

• Global or localGlobal or local

Rationale

1. Directly address the offending pathology causing impingement in pincer-type or mixed pincer-cam-type FAI

2. Protect from further impingement damaged labrum which has been repaired/reconstructed.

3. Resect areas of grade IV chondral damage

Pincer ImpingementPincer Impingement

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• Pre Operative PlanningPre Operative Planning– Know your goalsKnow your goals

– Focal resection for Focal resection for retroversion or general retroversion or general decompression for coxa decompression for coxa profunda profunda

– Measure LCEA, Acetabular Measure LCEA, Acetabular Inclination Angle and femoral Inclination Angle and femoral neck-shaft angle from AP pelvisneck-shaft angle from AP pelvis

– Measure ACEA from false Measure ACEA from false profileprofile

– Be cognizant of significant Be cognizant of significant femoral anteversionfemoral anteversion

Operative TreatmentOperative Treatment

• Pincer Bony ResectionPincer Bony Resection– Philippon, Wolff et al. Philippon, Wolff et al. Arthroscopy Arthroscopy

20102010– Change in the CE angle could be

determined by the following formula: Change in CE angle = 2.2 + (0.2 x [rim reduction in millimeters]).

– General rule: General rule:

The CEA decreases 2 degrees for The CEA decreases 2 degrees for every mm of bone resectedevery mm of bone resected

– Bottom line:Bottom line:– Don’t over-resect acetabular rimDon’t over-resect acetabular rim– Be cautious if CEA<30Be cautious if CEA<30

– Especially if acetabular Especially if acetabular inclination level is >10inclination level is >10

• If you take it off . . . – PUT IT BACK

• Beware small labrum (anterior zone)

• Beware DYSPLASIA!

• If it’s torn traumatically . . . – More rare– Fix when you can– Remove what you

must– Think “hoop fibers”

– No segmental resection

Post-op care

• Crutch-aided walking for 2-3 weeks

• PT x approx 12 weeks

• Return to full activities 3-6 months

Post-operative Principles

• Properly done post-operative rehab is crucial

Post-operative Principles

• Commonly seen problems– Hip flexor tendonitis

– Avoid active hip flexion and hip flexor strengthening for as long as possible

– Anterior hip capsule contracture– Early stretching gentle stretching can help– At 6 week mark, if motion not progressing

will have patients spend minimum of 10 minutes daily in prone FABER position getly pressing pelvis to floor

Post-operative Principles

• Commonly seen problems

– Limp– Patients should remain on crutches until

they are able to walk with normal gait

– Emphasize normal gait pattern – heel to toe with achievement of terminal stance and hip extension for toe off of involved.

Post-operative Principles

• Soft tissue mobilization and stretching– Scar massage at week 2– Initial soft tissue massage gently at

weeks 1-2-- iliopsoas, rectus femoris, adductors gluteus medius and piriformis.

– Progress to more aggressive soft tissue work at week 4 if needed

– active release, dry needling, Graston techniques can be very helpful

Post-operative Principles

• Aquatic Therapy

– Can be a very useful adjunct

– Not mandatory

– Can begin at 2 weeks post-op

Post-operative Principles

• Can see full post-op protocol and aquatic therapy protocol at: www.andrewwolffmd.com

• Protocol is in evolution. Suggestions welcome.

• andywolffmd@gmail.com

What does the literature say?What does the literature say?

Current Concepts Review | January 02, 2013

Femoroacetabular Impingement

Asheesh Bedi, MD ; Bryan T. Kelly, MD

MedSport, University of Michigan Orthopaedics, Domino’s Farms, Lobby A, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106. E-mail address:

abedi@umich.edu

Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71st Street, New York, NY 10021

Disclosure statement for author(s): PDF

Investigation performed at the University of Michigan, Ann Arbor, Michigan, and the Center for Hip Pain and Preservation, Hospital for SpecialSurgery, New York, NYCopyright © 2013 by The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2013 Jan 02;95(1):82-92. doi: 10.2106/JBJS.K.01219

TABLE I Grades of Recommendation for Femoroacetabular Impingement (FAI)

Grade*

Pathophysiology B

Injury patterns B

Etiology C

Nonoperative treatment I

Surgical treatment B

Open versus arthroscopic approach I

Improvement in hip kinematics C

Prevention of osteoarthritis I

*A = good evidence (level-I studies with consistent findings) for or against recommending intervention, B = fair evidence (level-II or level-III studieswith consistent findings) for or against recommending intervention, C = poor-quality evidence (level-IV or level-V studies with consistent findings)for or against recommending intervention, and I = insufficient or conflicting evidence, therefore not allowing a recommendation for or againstintervention.

The Journal of Bone and Joint Surgery20 Pickering StreetNeedham, MA 02492 USA

Copyright © 2013. All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.STRIATUS Orthopaedic Communications

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What’s coming? / Hot What’s coming? / Hot TopicsTopics

•Better global understanding of hip pathology

–3D imaging and modeling

–Image guided bony resection

–Improved coordination with osteotomy surgeons

•Capsuloligamentous management

•Articular cartilage mgmt

•Labral reconstruction

Labral Reconstruction Indications

• Revision– Previous labral resection/ aggressive

debridement with persistent pain and no arthritis

• Primary– “Hip at risk” with irreparable labrum

Revision

Primary: “Hip at risk”

25 yo, 12 yrs s/p SCFE pinning in situ

Primary: “Hip at risk”

27 yo former NCAA basketball player 8 yrs of hip pain

Labral recon case• 38 year old female triathlete

• 3 yrs s/p labral repair with persistent pain

• Referred for worsened symptoms and

inability to return to running

Articular cartilage

Thank You

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