The Young Adult Hip: FAI. Jason Snibbe, M.D. Snibbe Orthopedics Team Physician, University of Southern California

Transcription

1 The Young Adult Hip: FAI Jason Snibbe, M.D. Snibbe Orthopedics Team Physician, University of Southern California

2 Introduction Femoroacetabular Impingment(FAI) Presentation and Exam Imaging Surgical Management of FAI and Labral Pathology Labral Based Fixation Rehabilitation

3 Hip Injuries Misdiagnosed In the past, athletes were told to live with it. Diagnositic Delay New Concepts Labral Preservation/Repair. Femoroacetabular Impingment New Instruments New distraction attachments. Longer instruments. Curved shavers and ablators. Overview

4 Extra-Articular Hip Pain Muscular Strain Iliopsoas Gluteus Medius Hamstring Bursitis Trochanteric Psoas Ischial Stress Fracture(Women) Avulsion Injuries Infection

5 Femoroacetablar Impingement(FAI) Syndrome now recognized as a cause of osteoarthritis Two types: Pincer or acetabular impingement Females Retroversion(cross over sign) Cam or femoral impingement involves abnormal femoral head-neck junction Males

6 Hip Pathology Pincer FAI Acetabular abnormality caused by linear contact between acetabular rim and femoral head-neck junction. Acetabular rim typically enlarged with associated labral damage. A

7 Cam FAI Caused by abnormal femoral head with increased radius Increased radius rubs against acetabulum resulting in inflammation and damage Can cause delamination of anterior acetabulum and tearing of labrum Hip Pathology

8 Presentation Patients typically years of age Mean delay in diagnosis: 7-21 months Groin pain is most common complaint Anterior groin: 92% Lateral hip: 59% Deep within the buttocks: 38% Worse with activity, especially repetitive twisting and pivoting motions Pain with prolonged hip flexion (sitting) Pain after activity McCarthy et al: CORR Burnett et al: JBJS Byrd: ICL 2007.

9 Physical Examination Log rolling(ir): Pain suggests intra-articular pathology C-sign: Hand cupped above greater trochanter with thumb over posterior aspect of trochanter and fingers gripping into groin Suggests intra-articular pathology Pain with flexion internal rotation(impingement test) FABER test: Anterior pain suggests tight anterior capsule and labral pathology. Always compare to contralateral side(cm or Fists). Used to follow patients post-operatively.

10 Anterior Impingement Test Hip is flexed, adducted, and internally rotated Pain with most intraarticular pathology Decreased internal rotation with impingment.

11 Physical Examination

12 AP Pelvis Acetabular Characteristics: Center edge angle Normal >25 degrees Acetabular inclination Acetabular version Crossover sign Presence of Osteoarthritis Femoral Characteristics: Head sphericity Head-neck offset Neck-shaft angle Trochanteric height X-rays

13 Acetabular Retroversion Cross over sign on plain radiographs. Anterior wall overlaps the posterior wall. Females Reynolds et al JBJS Br 1999.

14 AP Pelvis

15 Lateral

16 Abnormal alpha angle in FAI

17 MRI Arthrogram CAM lesion with associated labral pathology

18 SPECTRUM OF CARTILAGE LESIONS

19 SPECTRUM OF LABRAL LESIONS

20 Portal Placement ASIS 45 degrees Greater Troch

21 Sequence Elevate and dilate capsule anterior/lateral Osteoplasty of acetabulum Expose labral tear Debride delaminated acetabular cartilage(micro fx) Labral repair Traction down(limit to 2 hours) Osteoplasty of femoral neck

22 Arthroscopic Anatomy

23 Labral Pathology/Pincer

24 Acetabular Chondral Lesions Debridment Microfracture ACI Open technique MACI One step on scaffold Promising European data Juvenile Chondrocytes Used with fibrin glue

25 Labral Repair Ganz et al. JBJS 2006 Open dislocation with pincer and CAM bone resection Group I: Labral resection(20 patients) 2 years 28% excellent/48% good/20% moderate/4% poor Group II: Labral repair(32 patients) 2 years 80% excellent/14% good/6% moderate Significantly more osteoarthritis in Group I than Group II. P=0.009 The labrum acts like a seal that prevents fluid loss from the joint and protects the articular cartilage Ferguson et al. J Biomech 2000.

26 Labral Repair Larson et al. Arthroscopy 2009 Arthroscopic approach with pincer or combined pincer and CAM type impingement. Mean age 31y/o(I)/27y/o(II) Group I(36 patients) mean f/u 21.4 months Labral debridment HHS % excellent Group II(39 patients) mean f/u 16.5 months Labral repair HHS % excellent

27 Establish Suction Seal

28 FAI

29 Labral Reconstruction Labral Reconstruction IT band vs Allograft Indications Failed labral repair Calcified Labrum Hypoplastic labrum Labral debridment/resection Revision surgery

30 Labral Reconstruction

31 CAM resection

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33 Arthritis How much is too much? Doctor can you buy me some time???

34 Poor Prognostic Indicators Long standing symptoms >1 year Night Pain Persistant Limping Age? Its all about the cartilage 40 to 50 y/o women Dysplasia Byrd Psychology of the patient

35 Poor Prognostic Indicators Physical exam Lack of external rotation and flexion Significant difference side to side Limp Pain with flexion past 90 degrees Pain with abduction of the hip

36 Poor Prognostic Indicators Imaging 2-3 mm of narrowing compared to the contra-lateral side Sclerosis Osteophytes MRI Bone edema Full thickness acetabular chondral loss on the weight bearing portion Look the T2 pelvic coronal image without gadolinium

37 Complications Instability/Dislocation Center Edge angle Matsuda et al. Arthroscopy 2009 Nerve Palsy Limit distraction Padding Heterotopic Ossification Naprosyn 500mg bid for one month Femoral neck fracture Fluid extravasation Psoas Release Last? Trauma/Dislocation

38 Summary Understand variations of FAI Always examine the hip!! Labral Repair(LB fixation) Resect bone Gluteal based rehab Recovery based on chondral damage

39 Thank You