Sports Medicine and Radiology

Transcription

1 Sports Medicine and Radiology The judicious utilization of a thorough history and physical examination and appropriately applied imaging studies will allow for accurate diagnosis and treatment of athletic injuries THE HIP Complex joint 1

2 H & P Detailed Patient must be in shorts PRESENTATION DIFFERENTIAL DIAGNOSIS Lower back SI Joint Urologic Gynocologic Hernia Nerve entrapment Hip Joint Piriformis Soft Tissue Hamstrings, Iliopsoas, Adductor, ITB 2

3 ATHLETIC PUBALGIA > 90% male Symptoms Chronic inguinal or pubic area pain in high performance athletes Pain localized to adductor and pubis Pain with resisted adduction Etiology Thought to be pelvic instability Surgical Treatment Pelvic floor reconstruction Rectus reattachment and adductor release OSTEITIS PUBIS Inflammation of the Pubis Symphysis Poorly understood Reported in almost all athletics Treatment Most respond to conservative therapy Surgery is rarely indicated 6/10/ Nerve Entrapment Syndrome Hockey Groin Syndrome - caused by tearing of the external oblique aponeurosis and entrapment of the ilioinguinal N. Implicated in groin pain in professional hockey players Fascial entrapment of obturator nerve at thigh entrance 3

4 OBTURATOR NERVE ENTRAPMENT Very uncommon Usually associated with: a well defined event invasive procedure May be entrapped In fascia of the adductor longus Pectineus muscles Etiology May occur after: pelvic fractures urologic procedures OBTURATOR NERVE ENTRAPMENT Symptoms Worsens with exercise Relieved by rest Surgical treatment Decompression of the nerve Inguinal and Abdominal Wall Hernias May be subtle US - can dynamically load muscle identifying enthesopathic injury to rectus abdominus and adductor muscles and assessing deficiencies in the posterior wall of inguinal canal 4

5 Football Seth, G.: Nonoperative Treatment for Proximal Avulsions of the Rectus Femoris in Professional American Football Am J. Sports Med cases Ave return three months Recommend non-op treatment Hockey Silvis, M., et al.: High prevalence of pelvic and Hip Magnetic Resonance Imaging Findings in Asymptomatic Collegiate and Professional Hockey Players. 21 profesional 18 collegiate 36% adductor-abdominal rectus dysfunction 64% Hip pathogic changes 77% asymptomatic Hockey players demonstrated MRI findings of hip or groin pathologic abnormalities COXA SALTANS INTERNA Snapping Hip Syndrome Iliopsoas tendon snaps over iliopectineal eminence Etiology Usually hyperextension injury Treatment Conservative Surgical 5

6 COXA SALTANS EXTERNA Iliotibial Band Syndrome Posterior ITB slinding or Greater Trochanter from ext to flex Oftentimes secondary R/O gluteal tendon tear Surgery? FAI/ LABRAL TEARS Receiving increased attention in news media Young athletic patients Improvements of diagnosis Increased awareness New Diagnosis? (FAI) FEMOROACETABULAR IMPINGEMENT Not a disease Pathomechanical process May lead to osteoarthritis Secondary Etiology of most FAI causing abnormalities has not been identified 6

7 FEMOROACETABULAR IMPINGEMENT Etiology of secondary OA Noted relationship of minor abnormalities of hip and early osteoarthritis Murray, R.O.: The aetiology of primary osteoarthritis of the hip, Br. J. Radio, 1965 Solomon, L. et al: Osteoarthrosis of the hip and its relationship to pre-existing deformities J.B.J.S Harris, W.H.: Primary osteoarthritis of the hip: a vanishing diagnosis. J. Rheumatol, 1983 FAI PATHOPHYSIOLOGY Developmental alterations of the Hip Femur - Cam lesion Acetabulum - Pincer lesion Malrotation of acetabulum and/or femur Malrotation of acetabulum and/or femur Secondary Arthritis Ganz, ert al: FAI: a cause of aosteoarthritis of hip. CORR

8 RADIOGRAPHIC ANALYSIS Plain radiographs AP pelvis Frog lateral Cross table lateral False profile Dunn lateral MRI with gadolinium arthrogram Sagittal Coronal Axial Radial 8

9 ALPHA ANGLE 9

10 FAI TREATMENT Conservative -benefits questionable Activity modification, NSAIDS Surgery - Timing? Correction of bony abnormality Labral preservation LABRAL TEARS Torsional maneuvers of the hip joint generate substantial strains in the anterior acetabular labrum Dy, C., et.al.: J. Bone Joint Surg., LABRAL TEARS Observations by Ganz and colleagues have identified FAI as predominate cause of labral tears in nondysplastic hip Ganz, et al: CORR 2003 Lavigne, M., et al: COOR,

11 HIP LABRUM Enhances stability by maintaining negative intra-articular pressure Decreased co-efficient of friction Takeche, H., et al, J. Jpn Orthop. Assoc., 56:1982. Absence of labrum increases cartilage surface consolidation Increases contact pressures of head against acetabulum FAI/ LABRAL TEARS Receiving increased attention in news media Young athletic patients Improvements of diagnosis Increased awareness New Diagnosis? Hockey Phillipon, M.: Arthroscopic labral repair and treatment of FAI in professional Hockey players. Am. J. Sports med players 26 retrun to play 2 -reop 11

12 Football Kelley, Bryan, T.: Hip injuries and labral tears in the NFL AM. J. Sports Med 2008 Hip Injuries 10% of all injuries in football Frequently intra-articular Sports Hip Triad Labral tears Adductor strains Rectus strain Labral tears missed if adductor strain not improving suspect labral tear Hockey Bizzini, M., et al: FAI in Professional Hockey Players Am. J. Sports Med., players Open decompression 3 returned to play at same level 2 retunred to minor league HIP LABRUM Important sealing function Seals fluid expression Chondroprotective Provides proprioception Ferguson, S.J., et al: J. Biomechanics, 2003 Kim, Y.T., and Azuna, H.: Clin. Orthop, 320:

13 HIP LABRAL TEARS May contribute to arthritis Hip at risk Developmental dysplasia Chronic tears Chondral lesions McCarthy, J.C., et.al.: Clin. Orthop., The role of labral lesions to development of early degenerative hip disease.393: 2001 HIP LABRAL TEARS Debridement Easy Facilitates return Predispose to Arthritis? Repair Younger Patients Adequate tissue Surgeon preference Experience BIOMECHANICS A breach of integrity of labral function lead to decreased femoral stability during extreme ROM Crawford, M., et al.: The Biomechanics of the hip labrum and the stability of the hip. Clin. Ortho.,

14 CLINICAL OUTCOMES OF SURGICAL TREATMENT Open Surgical Treatment Espinosa, et al: Treatment of FAI with labral refixation. JBJS Retrospective case series 52 patients- 35 labrum reattached Labral reattachment found to have significant improvement in pain and functional scores CLINICAL OUTCOMES OF SURGICAL TREATMENT Arthroscopic Surgery Philippon, M, et al: Surgical Treatment of FAI in 45 professional athletes. Knee Surg. Sports Traumatol Arthrosc, % return within 1.6 years 5 re-op for adhesions, osteoarthritis Significant number of concurrent surgeries Chondral defects CLINICAL OUTCOMES OF SURGICAL TREATMENT Arthroscopic Treatment Byrd, J.W., et al: Arthroscopic Femoroplasty for FAI. CORR 2008 Minimum one year f/u 200 pts - 83% improvement Philippon, et al: Outcome of FAI and Chondrolabral dysfunction. (B) JBJS Prospective study with 112 pts, minimum 2 year f/u < less than 2 mm joint space narrowing did well Labral repair did better than debridement Older patients more likely to undergo THR 14

15 Clinical Outcomes of Surgical Treatment Arthroscopic Treatment Larson, C.M., et al: Early outcome measures of FAI surgery. Arthroscopy 2008 Mean 9.9 months Prospective cohort of 96 patients Significant improvement of outcome measures 15