Case Presentation 2018 ISMF Fellows Course. David Schub, MD Department of Orthopaedic Surgery, Sports Medicine Kaiser Permanente, San Diego

Transcription

1 Case Presentation 2018 ISMF Fellows Course David Schub, MD Department of Orthopaedic Surgery, Sports Medicine Kaiser Permanente, San Diego

2 Patient SH 35 year old male Works in sales. Recreational athlete. BMI 24.2 PMH/PSH: Hip Arthroscopy (3/11/2015) HPI: Per reports and outside clinic notes L groin and lateral hip pain starting in 2013 without specific injury moment Pain started developing after periods of long standing on his feet at work Occasionally had grinding sensations when turning or twisting Unable to exercise or play any sports due to his pain No relief from RICE, NSAIDs, Troch Bursa Injection Imaging: Per reports Xrays - large CAM, lateral CEA 36deg, no arthritis MRI - ant/sup labral tear with paralabral cyst, CAM deformity, alpha angle 70deg, no cartilage issue

3 Initial Procedure - Outside Facility Procedure: Right hip arthroscopy, labral repair, acetabuloplasty, femoroplasty, iliopsoas release March Outside Facility Pain lingered post-operatively 1 yr post-op felt almost worse than he did preop Groin pain Mechanical grinding sensation with hip rotation Unable to work without restrictions

4 Initial Kaiser Presentation - June 30, 2017 Over 2 yrs post index procedure Limited by pain throughout work and daily activities No change from his initial preop condition No benefit from medications and physical therapy Pain located deep in groin, +C sign, no lateral / posterior / radiating pain Pain mostly aching but sharp with any twist or rotation Exam: ROM: FF 100, ER/IR at 90deg 45/15, Ext all limited by pain and guarding +FADIR, +FABER (symmetric), +Stinchfield

5 Xrays - June 30, 2017

6 MR Arthrogram - Sept 22, 2017

7 Decision Making Non-Op? Able to get through daily activity and work - though with pain and accommodations Athletic, but mostly recreational Not interested in an injection Revision Surgery? No resolution of his pain, mechanical symptoms Residual bony deformity Persistent labral pathology Exam consistent with labral/fai pathology Decision: Revision Surgery Plan: CAM resection, labral reconstruction (allograft)

8 Surgery - Oct 13, 2017 Procedure: Left hip arthroscopy, labral reconstruction using gracilis allograft, acetabuloplasty, femoroplasty, capsular repair

9 Surgery - Oct 13, 2017 Procedure: Left hip arthroscopy, labral reconstruction using gracilis allograft, acetabuloplasty, femoroplasty, capsular repair

10 Surgery - Oct 13, 2017 Procedure: Left hip arthroscopy, labral reconstruction using gracilis allograft, acetabuloplasty, femoroplasty, capsular repair

11 Post-Op Protocol NWB LLE x 2 weeks, TDWB LLE x 4 weeks Hip Brace x 2 weeks Hip flexion limited to 90deg Hip abduction limited to 30deg CPM x 3 weeks (21 day rental at KP) 2+ hours per day, gradual increase 0-120deg Begin physical therapy at 2 weeks Initially working on motion only Recumbent stationary bike regimen can begin gradually after 2 weeks

12 Follow-Ups Oct 30, ~ 2 weeks post-op Doing well, minimal pain. Had been walking without crutches. Wounds c/d/i. Gentle AROM/PROM without pain. Dec 12, ~8 weeks post-op Doing well, almost no pain. Only used his crutches sporadically despite reminders. Back to work with minimal accommodations. Progressing well with therapy. Stationary bike use while at therapy. Wounds c/d/i. FF 100. ER/IR at 90deg 55/25. During wildfires he jumped a fence, wrangled a horse, and rode it to stables

13 Thank You!