Who Doesn t Need a Hip Scope?

Transcription

1 AOSSM 2013 Annual Meeting Chicago, Illinois July 14, 2013 I. Hip arthroscopy only helps if it is a hip joint problem A. Not always evident - Among athletes, 60% of intraarticular disorders treated for an average of 7 months for extraarticular diagnosis 1 B. History & physical exam most important 2 - Exam skills often not emphasized 3 C. Recent studies reflect on continued limitations of exam to clarify hip pathology 4 II. III. Contraindications (objective parameters) A. Tonnis 3 radiographic changes B. Severe joint space narrowing (< 2mm) 5 C. Results less favorable with Tonnis 2 changes, but not contraindicated D. Grade IV acetabular chondral lesions not a contraindication E. Femoral-sided articular changes in association with FAI less favorable 1. Femoral head well preserved until late in disease course 2. Femoral lesions indicate more advanced disease Do not operate based on MRI A. MRIs generally underestimate extent of damage subsequently found at arthroscopy 2 B. MRI changes often consequence of normal aging process or high level athletic activities - i.e., High prevalence of silent MRI findings among NHL players C. Diagnostic U/S intraarticular injection helps to establish clinical relevance of MRI findings (both positive & negative) 6 D. Why get an MRI? - Important to assess for disorders that arthroscopy might not detect, or might contraindicate arthroscopy (i.e., stress fracture, AVN, tumor, transient regional osteoporosis, etc.)

2 E. Peritrochanteric disorders 1. Chronic lateral hip pain ( bursitis ) that fails conservative treatment often due to abductor tendinopathies 2. MRIs may be too sensitive - Often present as incidental finding with age 3. May be clinically relevant source of pain and dysfunction, even among elderly, and can benefit from endoscopic repair 4. U/S guided injection of lesion provides clinical relevance, and may have therapeutic benefit IV. In-office ultrasound 6 A. Provides imaging of soft tissue lesions around hip B. Dynamic assessment of soft tissue snapping hip syndromes C. Precise intraarticular or extraarticular diagnostic/therapeutic injections D. Increasingly essential for comprehensive assessment & management of hip disorders - Distinct advantages for care that can be provided to patients V. Presentation A. Onset of symptoms variable (acute vs. insidious) and predictive value variable as well - With FAI, regardless of suddenness of symptom onset, it is culmination of cumulative effect of disorder present since childhood B. Character of symptoms 1. Mechanical symptoms (locking, catching, sharp stabbing pain) ideal, but not essential to success 7 2. Aching often present - Repercussion of activities (sometimes delayed) 3. Constant pain, independent of activities: watch out! 4. Secondary pain patterns not solved by surgery a) Not necessarily contraindication to surgery b) Pain management consult preop may be essential VI. Expectations A. Patient must have reasonable expectations of what may or may not be accomplished by procedure B. Unreasonable expectations will assure poor outcome C. Preoperative assessment may include modulating patient s expectations 2

3 VII. Physical therapy 8 A. Assess patient s commitment to their own recovery B. Help assess/modulate patient s goals & expectations C. Core & pelvic stabilization - Can provide dynamic unloading of FAI D. Identify & address compensatory disorders 1. Can help peel away complex layers 2 Reduce symptoms associated with compensatory disorders 3. Regain ability to compensate (!) E. 80% of postop problems corrected by modulation/modification of rehabilitation strategy VIII. Deciphering etiological factors A. Most hip disorders are multifactorial ( perfect storm ) 1. May never identify all factors 2. FAI logically explains secondary damage to the joint - But how & why are some athletes with FAI lifelong compensators? B. Failure associated with physiologic loads 1. Altered joint morphology can cause breakdown to occur with forces welltolerated by a normal joint - FAI can cause joint to fail due to forces and activities normally tolerated by a healthy hip 2. Correction of offending impingement may be successful and provide more favorable long-term outlook C. Failure due to supraphysiologic loads/activities 1. Pushing body beyond physiologic limits - i.e., dancers & gymnasts 2. Primarily non-operative management a) Modifications & conditioning to expand physiologic limits b) Surgical correction rarely successful c) Poorly conditioned athletes have less reserve to compensate for these supraphysiologic activities 3. Example of dysplasia a) Advantageous for allowing supraphysiologic motion b) Compounding factor as breakdown then starts to occur c) Secondary damage can be addressed with arthroscopic surgery (i.e., labral repair, but does not correct dysplasia or issue of supraphysiologic loads) 3

4 IX. Dysplasia 9-12 A. Arthroscopy contraindicated in young adults 1. Does not address etiology 2. Labral repair, resection, etc. represents only symptomatic treatment a) Deleterious long-term consequences b) May provide sufficient symptomatic improvement for precipitation of further secondary damage and subsequently less successful long-term outcome of corrective PAO B. Middle-aged adult with good joint space preservation 1. May still be candidate for PAO 2. Severity of labral & chondral damage may contraindicate PAO 3. Severity of chondral damage often underestimated on imaging (MRI/MRA) 4. Arthroscopy may be an appropriate option a) Less invasive symptomatic treatment may be acceptable to patient b) Staging procedure to assess severity of secondary intraarticular pathology - Status of articular damage may influence consideration for subsequent PAO C. Middle-aged adult with moderate secondary labral & chondral damage 1. Results of arthroscopy suboptimal, but not necessarily contraindicated 2. Alternative is intraarticular injections & activity modification until ready for THA - May not be preferable for some patients 3. Cautious about labral repair a) Hypertrophic distorted morphology b) Success questionable in absence of addressing underlying etiology 4. Cautious in labral debridement a) Selective debridement of damaged portion unlikely to accelerate degenerative disease b) Excessive labral debridement can accelerate degenerative disease & joint subluxation D. Dysplasia (or borderline dysplasia) with acetabular retroversion 1. Carefully assess for presence of dysplasia with retroversion (i.e., cross over sign) 2. Acetabuloplasty ( rim trimming ) to correct radiographic retroversion in presence of dysplasia can lead to severe iatrogenic instability problems 4

5 E. Borderline dysplasia with cam impingement 1. Among symptomatic cases, arthroscopy can be helpful in assessing the pattern of secondary joint pathology and thus the underlying etiology a) Hypertrophic labral changes associated with dysplasia b) Pathological cam impingement results in advanced acetabularsided articular damage with preservation of the femoral articular surface until late in the disease course c) Dysplasia results in earlier femoral-sided articular changes and deterioration of both sides of the joint 2. Capsular management in arthroscopy important to avoid iatrogenic instability a) Limit capsulotomy for exposure of cam lesion b) Consider capsular closure if extensive capsulotomy necessary for exposure X. Conclusions A. Few objective parameters that contraindicate hip arthroscopy B. Subjective parameters may be more important to patient selection C. Problems & poor results associated with hip arthroscopy are at least as much the result of poor choices as poor technique REFERENCES 1. Byrd JWT, Jones KS: Hip arthroscopy in athletes. Clin Sports Med, 2001;20(4): Byrd JWT, Jones KS: Diagnostic accuracy of clinical assessment, MRI, gadolinium MRI, and intraarticular injection in hip arthroscopy patients, Am J Sports Med, 2004;32(7): Byrd JWT: Patient Selection and Physical Examination. In Byrd JWT (ed) Operative Hip Arthroscopy Third Edition, New York, Springer, 2013, Martin RL, Irrgang JJ, Sekiya JK: The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates. Arthroscopy, 2008;24(9): Philippon MJ, Schroder E Souza BG, Briggs KK. Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy Jan;28(1): Jones KS, Potts EA, Byrd JWT: Perioperative Care. In Byrd JWT (ed) Operative Hip Arthroscopy Third Edition, New York, Springer, 2013, O Leary JA, Berend K, Vail TP: The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy, 17(2): ; Coplen EM, Voight ML: Rehabilitation of the hip. In Byrd JWT (ed) Operative Hip Arthroscopy Third Edition, New York, Springer, 2013, Ross JR, Zaltz I, Nepple JJ, et al: Am J Sports Med, July Supplement, Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med, 2011;39:72S- 78S. 10. Kain MS, Novais EN, Vallim C, et al: Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia. J Bone Joint Surg (Am) 2011;93 Suppl 2: Parvizi J, Bican O, Bender B, et al: Arthroscopy for labral tears in patients with developmental dysplasia, a cautionary note. J Arthroplasty, 2009;24(6 Suppl): Byrd JWT, Jones KS: Hip arthroscopy in the presence of dysplasia, Arthroscopy, 19(10): ;2003 5