Hip Injuries in the Workers Compensation Arena: Diagnosis and Treatment. Joshua S Hornstein, MD TOG Institute

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1 Hip Injuries in the Workers Compensation Arena: Diagnosis and Treatment Joshua S Hornstein, MD TOG Orthopaedics@Rothman Institute

2 Disclosures No Relevant Disclosures

3 Objectives Basic Anatomy Pathology and Imaging Treatment Potential complications Future advances

4 Basic Anatomy Hip is a classic constrained ball and socket joint Very vigorous ligamentous restraints Large, strong muscle groups cross the joint

5 Basic Anatomy Intra-articular (central) compartment Labrum Ligamentum Teres Iliopsoas tendon Pulvinar Peripheral compartment Peri-Trochanteric Bursa Gluteal muscles

6 History & Physical Examination History Mechanism of injury Duration of symptoms Trauma Activities that cause symptoms Treatment

7 History and Physical Examination Physical Examination Observation of gait Visual inspection Inguinal/femoral hernia Flexion contracture ROM Pain with palpation

8 History and Physical Examination Physical Examination FABER/FADIR Resisted crunch R/O other pathologies LS spine SI joint Piriformis syndrome

9 Pathology and Imaging Plain radiographs MRI +/-arthrogram CT Imaging studies must support history and PE and not supercede it!

10 Pathology and Imaging Hip arthroscopy 1980s Limited indications Limited by technology Femoroacetabular Impingement (FAI) First describe in Europe in early 1990s Treated with open hip dislocation?less invasive option

11 Pathology and Imaging FAI Multifactorial Anatomical variants Activity-specific Post-traumatic?Precursor to DJD

12 FAI (75%) Description of Patho-anatomy Cam lesion Convexity of femoral head-neck junction Pincer lesion Over-coverage of acetabulum Combination Labral tears Usual secondary to impingement lesions

13 Treatment FAI Intra-articular injection US/fluoro Dx and therapeutic Femoroplasty Acetabuloplasty Labral takedown v debridement Labral repair

14 Hip Preservation Surgery Address pathology as indicated Labrum repair v debridement Pincer excision Femoroplasty

15 Case Example-36 yo Female ER Tech, Slip and Fall on Wet Floor

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17 Peri-Trochanteric Pathology (25%) Trochanteric bursitis Gluteal tears RTC tear of the hip Iliotibial band External snapping hip syndrome

18 Treatment Options Non-Surgical NSAIDs PT Trochanteric bursa injection Activity modification Surgical Endoscopic Open +/- surgical dislocation IT band z-lengthening

19 Peri-Trochanteric Compartment Prox/dist peri-troch portals Bursectomy/IT band release Case example: 44 yo female fall onto lateral hip in office

20 Post-op Management WBAT with crutches x 4 weeks PT 7-10d post-op ROM, edema control, core strengthening ECASA 325 mg qd x 3 w for DVT/HO prophylaxis Outpatient procedure (1.5-3h surgical time)

21 Complications Surgical Neuropraxia Perineal LFCN Femoral Articular surface damage Vascular injury (vertical ASIS line) Abdominal compartment syndrome Technical Under-resection of bony pathology Eversion of labral repair Missed pathology Capsular deficiency/instability

22 Surgical Outcomes-FAI/Labrum Repairs in WC Salvo J et al, Orthopedics 2015;38 e94-98 Avg RTW 6.8 months, only 58% working without restrictions at final follow up Inferior PRO compared to non-wc cohort

23 Surgical Outcomes-FAI/Labrum Repair in WC Lee S et al, J of Hip Preservation Surg 2017; 4: % back at work without restrictions at 1 year post-op (MMI) RTW factors Longer duration of symptoms prior to surgery (3 m v 7 m) More concomitant Orthopaedic injuries Higher BMI

24 Surgical Outcomes-FAI/Labrum Tears in WC Stake CE et al, Am J Sports Med 2013 Oct;41(10): Hip arthroscopy for labral tears 86% RTW avg 82 days Lower PRO scores pre- and post-op in WC group Did not specify RTW modified or full duty

25 Surgical Outcomes Peri-Trochanteric Space in WC Rothman Institute Outcomes Study to begin 3rd quarter 2018 WC and non-wc patients to be included Non-WC: G/E 90%

26 Surgical Outcomes Fastest growing segment of Arthroscopy literature Now #2 behind shoulder in volume Outcomes Steep learning curve Overall 90% G/E results in general population Complication rate low but not insignificant Technical error/incorrect dx biggest cause of failure Better long term studies needed to evaluate

27 Other Sources of Hip Pain Core muscle injury Osteitis pubis Hip flexor strain/asis Inguinal Hernia Stress fracture Lumbar Spine

28 Core Muscle Injury AKA Sports Hernia Extreme hip flexion/rotation activities Pathology Tear of abdominal and/or adductor musculature from pubis Diagnosis of exclusion Can occur in either gender

29 Core Muscle Injury-Diagnosis History & Physical exam Typically attritional Chronic groin strain Deep-seated ache Antalgic gait Resisted crunch Diagnostic testing MRI/US/Xrays R/O testing

30 Treatment Usually treated by general surgeons Open repair of muscle/tendon disruption from pelvis Recovery time typically 4-12 weeks to return to normal activity

31 Future Advances Hip pathology is a very common problem in the working population New advances in understanding pathophysiology has led to better treatments

32 Future Advances Fastest growing segment in arthroscopy Steep learning curve Better imaging to help surgical planning Improved study designs to determine best practices

33 Conclusions Non-arthritic hip pathology is being more frequently recognized in the Workers Compensation population Non-operative management is the cornerstone of treatment Surgical intervention has become more prevalent in the last years

34 Conclusions Hip arthroscopy has come a long way from niche procedure to mainstream Sports Medicine Better recognized pathology It saw us but we didn t see it Improving imaging MRI-A and US

35 Joshua S Hornstein, MD Trenton Orthopaedic Rothman Institute

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38 Inguinal Hernia Can be from acute injury or repetitive heavy lifting Bowel exits through external ring of inguinal canal, causing pain Treated by general surgeon via open or laproscopic means

39 Peripheral Compartment Release traction and flex knee to deliver femoral neck into field Identify Cam lesion morphology and extent Fluoro assist

40 Diagnostic Arthroscopy Slightly longer scope and shaver Intra-articular Labrum Articular surfaces Ligamentum teres Psoas tendon Pincer lesion Fractures

41 Intra-Articular Pathologies (5%) Isolated labral tears Ligamentum Teres pathology?hip instability

42 Osteitis Pubis Inflammation in the symphysis pubis Usually from repetitive overuse Treated with rest, NSAIDs and low impact activity Rarely treated with steroid injection or surgery

43 Hip Flexor Strain/ASIS Fracture Mechanism of injury Resisted hip flexion Pathology Strain of either rectus femoris or iliopsoas Avulsion of AS (sartorius) occurs in peds population Treatment Rest and supportive care(3-6w)