Patient Presentation and Selection

Transcription

1 Patient Presentation and Selection Joshua Harris, MD August 7, 2016 Disclosures Research support: Smith & Nephew, Depuy Synthes, Ossur; Consultant: Smith & Nephew, NIA Magellan; Royalties: SLACK, Inc.; Editorial board: Arthroscopy, Arthritis Research UK; Committees: AANA, AOSSM, AAOS Goals Patient presentation Subjective Objective (physical exam) Patient selection Athletes Arthritis Dysplasia 1

2 History for hip pain Intra-articular problem: Deep anterior groin Sitting > standing Socks, shoes Log-roll (sleeping covers) C sign Between the fingers sign Extra-articular problem: Back, butt, lateral hip (i.e. everywhere else) Remember, both. History for hip pain Pain location intra-articular problems: Deep anterior (70%) Inquire coughing or sneezing or Valsalva pain Deep lateral (20%) pitfall abductor fatigue Check limp, abductor tendon pathology Deep posterior (10%) Check stride length (ischiofemoral impingement, DGS, PHS) If unsure, inject local anesthetic Diagnostic injection 2

3 Diagnostic injection Clinical and x-ray findings unreliable predictors of injection response Negative injection response strong negative predictor of FAI surgical outcome Positive injection response is poor predictor of FAI surgical outcome Amount of relief: 93% acetabular chondral injury 83% labral injury 82% FAI Snapping If you can see it: ITB/TFL lateral It s not the hip dislocating If you can hear it: Iliopsoas deep anterior If you can feel it: ITB/TFL Iliopsoas Labral tear Knee Physical Exam for Hip Based on the subjective history Should confirm suspected intra-articular vs extraarticular source of pain Could be both 3

4 Physical Exam for Hip Inspection (including gait) Palpation Motion Strength Special testing Impingement (subspine, anterior, lateral, posterior, TP, IFI) Instability (extension ER, ER recoil, dial, distraction, hip pivot shift) Snapping (iliopsoas [Ludloff, iliopsoas test], Ober) Stress fracture (Log roll, axial load, hop) B.A.R.F. = Blind Application of Radiographic Findings Asymptomatic 26 studies; 2,114 hips ALL asymptomatic 57% male, 43% female Cam: 37% Pincer: 67% 4

5 Asymptomatic 1,081 hips (55%M, 45%F; mean 67 y/o) 83% FAI; 10% dysplasia Neither predictive of OA Increased FAI morphology in: y/o competitive athletes Increased OA risk in: Lifetime competitive athletes Advanced imaging - MRI Prefer non-arthrogram Assess effusion Risks (infection, LFCN, capsular damage) Cost, time/scheduling May confound future injection outcome Advanced imaging - CT Radiation exposure Cost Optimal osseous evaluation Version Coverage Morphology 5

6 Patient selection Non-surgical management Rest, activity modification Oral NSAIDs Intra-articular injection PT However, none of these change the morphology or heal the labrum Patient selection Possible utility of PT evaluated via x-ray: Glute max squeeze view Patient selection Surgical indications: Failed non-surgical measures FAI, labral injury, +/- chondral injury Extra-articular impingement (AIIS, iliopsoas, PF, IFI) 6

7 Patient selection Surgical contra-indications: Dysplasia LCEA or ACEA <20, Tonnis >15, extrusion index >25% OA <2 mm joint space Tonnis 2 or 3 Asymptomatic Surgical considerations Pearls: Set realistic expectations with patients Especially rehab duration, RTS timing MCID, MDC, PASS Evaluate soft tissues Beighton, Brighton, EDS, CTD, genetics work-up Get 2 nd opinion open or arthroscopic colleague Careful EUA Carefully evaluate articular cartilage (long-term outcome) Sport-specific 7

8 Sport-specific At time of hip arthroscopy for FAI, high-level versus recreational athletes: Younger (20 versus 33 years old) Male more (62% vs 54%) Bilateral more (28% vs 16%) Conclusions Good history and physical examination Whenever you are having your anatomy sessions, pay particular attention, because Orthopedics is all anatomy, plus a little common sense Intra- vs extra-articular Treat patients, not x-rays Respect indications, contra-indications Address expectations Everyone is unique tailor your treatment Hip Sport 8