Hip Cases from Clinic: Refining your history and physical

Transcription

1 Hip Cases from Clinic: Refining your history and physical Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery 11/20/2017 Case #1 Healthy 21 M College Soccer Player No specific injury but 4 years of ongoing L.Hip pain Worse over last 6 mo. PT for 6 mo. with no improvement 5/10 sharp groin pain, worse with prolonged sitting and running Unable to continue playing soccer due to pain. 1

2 History PMH: None PSH: Wisdom Tooth extraction Allergies: NKDA Meds: None Social: Full time Student No Tobacco FHx: None Physical Exam: Left Hip Normal Gait Non-tender to palpation Flexion: 115 (120) Extension: 10 (10) IR: 20 (30) ER: 50 (50) 5/5 strength throughout + FADIR -Ober s, Log roll. 2

3 Imaging 3

4 FAI: Basics Clinical Question What is the best surgical treatment for Cam predominant FAI in Athlete who fails non-operative management? 4

5 Diagnosis and Treatment Options Diagnosis: Femoracetabular Impingement: Cam lesion subtype Treatment Options: Non-Op Physical Therapy Activity Modification Rest Surgery Outcomes in Athletes Byrd et al athletes with 2 year follow up after hip arthroscopy 90% returned to sport (95% pro, 85% collegiate) Nho et al AJSM 35 Athletes Varsity High School to Professional Significant improvement in PRO 79% return to play within 1 year 10 5

6 11/20/2017 Patient Studies demonstrate: Arthroscopic femoroplasty with labral repair in athletes result in significant improvement in symptoms and return to play. Taken to OR for Arthroscopic femoroplasty and labrum repair Labral Tear and Cartilage Injury 6

7 11/20/2017 Labral Repair Femoroplasty Images 7

8 Removal of Cam lesion Case 2 CC: left hip pain HPI: 64F geologist p/w 1 year left hip pain located on lateral aspect of hip. 4/10. No traumatic event. Insidious onset. Initially improved and then worsened over the course of the year. In 1/2015, she noticed pronounced weakness, which was new. No improvement with PT. Intra-articular corticosteroid injxn in 10/2015, which helped. However, persistent weakness preventing her from working exercising at gym. PMHx/PSHx: no previous hip injury or surgery Meds: None 8

9 Trendelenberg Gait 9

10 Imaging Imaging 10

11 Gluteus Medius Tears Atraumatic, insidious onset of lateral-sided hip pain Degenerative tear commonly in setting of chronic trochanteric bursitis Most common Acute traumatic injury Iatrogenic Avulsion after total hip replacement 11

12 Anatomy Treatment Options? 12

13 Operative Techniques Approach Open vs. Endoscopic Repair End-to-End Suture anchors Partial-thickness Transtendinous Repair Full thickness Completion of tear and suture bridge repair Back to Our Case 1) Left hip endoscopic gluteus medius repair 2) Iliotibial band release (lengthening) 3) Bursectomy of trochanteric bursa 13

14 Gluteus Medius Tear 14

15 Repaired Gluteus medius 29 Case #3 HPI: 63yo healthy man, h/o staged bilateral MoM THA (Oct/Dec 2010, OSH) via posterior approach Persistent L groin pain post-operatively Constitutional sx s negative, R hip no symptoms Attempted NSAIDs, PT PMH: None significant PSH: Bilateral THA (Left Oct 2010; Right Dec 2010) 30 15

16 Hip range of motion Flex. Ext. IR ER Abd. Add. left right L leg- pain w/ aslr and any rotation of hip referred to groin. Hip strength Flexion Extension Abduction Adduction Left Right Provocative Tests: Flexion/Internal rotation for labral tear: negative Log roll test: negative FABER test: positive Ober s test negative Straight leg raise: negative Positive Stinchfield- rested straight leg raise Case Presentation 16

17 Imaging MRI: No evidence of pseudotumor/ AMR Intact gluteus medius/ abductor complex Case Presentation Outside Hospital Workup Labs: ESR, CRP- wnl Serum Co, Cr - wnl 3 Phase Bone Scan: Negative. No evidence of uptake c/w osteolysis/loosening, infection MRI: Negative. No evidence of pseudotumor, adverse metal reaction (AMR) Given constellation of symptoms, Left groin pain with aslr, recommended guided CSI 17

18 Case Presentation RT, 63yo M with L hip pain Received fluoroscopic-guided corticosteroid injection, which provided complete, temporary relief Background Anterior iliopsoas impingment (IPI) is a rare, poorly understood condition Up to 4.3% of patients with persistent groin pain after THA 1 May be related to changes in hip biomechanics following THA Or related to direct mechanical irritation 1. Lachiewicz and Kauk. JAAOS (2009) 18

19 Background Iliopsoas anatomy Confluence of psoas and iliacus mm., insert to anteromedial lesser trochanter Anatomic variation: iliacus length, separate/conjoined tendons, overlying bursa Clinical Presentation Persistent groin pain, activity-related/ transfers Pain with resisted hip flexion (aslr), little/no pain with passive leg raise Often little/no pain with ambulation Lachiewicz and Kauk. JAAOS (2009) Retrospective case series (2012) 10 cases of iliopsoas tendinitis 9 patients underwent guided tendon injection; 8/9 had relief All underwent endoscopic iliopsoas release (at the level of the lesser trochanter) Mean follow up: 20 months (12-60) 8/10 (80%) complete relief, 2/10 partial relief Mean post-op WOMAC score 84 (60-95) from 34 (24-46) Full (5/5) hip flexion strength obtained by 3 months post op (0.5-6) No complications 19

20 Our Case 20

21 21

22 Thank You Alan Zhang, MD /20/