hip pathology w mccormick 2017 mccormickortho.com

Transcription

1 hip pathology w mccormick 2017 mccormickortho.com

2 overview classification common hip pathologies FAI GT pain snapping workup treatments sample cases rehabilitation outcomes/complications

3 hip pathology classification V Vascular I Inflammatory N Neoplastic D Degenerative / Deficiency I Idiopathic C Congenital A Autoimmune T Traumatic E Endocrine mechanical congenital dysplasia FAI acquired trauma FAI non mechanical immune infection vascular (AVN)

4 hip pathology classification - anatomic groin adductor muscle anterior acetabular/labral fascial disruption flexion crease acetabular/labral iliopsoas tendon C-sign lateral acetabular/labral GT abductor tendon IT band (snapping) buttock posterior acetabular/labral sciatic

5 mechanical articular hip problems single event trauma dislocations/fractures/labral tears think shoulder dislocation cumulative trauma labral tear usually in setting of too much/too little bone cartilage injury point loading and shear

6 mechanical non articular hip problems ischiofemoral impingement sciatic entrapment tendon tears abductor hamstring fascial disruption (aka sports hernia etc)

7 onion layers limping pain behavior muscle activation pattern changes GT pain syndrome narcotic use mis-diagnoses *beware the young multiple comorbidity patient with symptoms>findings*

8 common hip pathologies labral tear GT pain syndrome snapping

9 labral tear what? groin pain flexion rotation lock/catch why?

10 labral tear not enough bone (dysplasia) bone not providing enough coverage (support) for femoral head labrum hypertrophies to provide that support

11 labral tear too much bone (FAI) at risk anatomy + at risk activity wild card reparative capacity young active at risk activities

12 FAI acetabular side (pincer impingement) overcoverage

13 FAI acetabular side too much bone everywhere

14 FAI - acetabular side too much bone in one area focal overcoverage

15 FAI femoral side CAM impingement not enough clearance

16 AIIS impingement (subspine impingement) not enough clearance possible history of AIIS avulsion **flexion crease pain with straight flexion can be tough to differentiate from anterior overcoverage/ant CAM/ant labral tear Image from Shibahara, healio 40(4):e725-e728

17 fascial disruption/core muscle/fai the hip bone s connected to the back bone restricted motion in hip demands more motion from low back, pubic symphysis puts abdominal fascia/muscles in vulnerable position Image from Larson cm. sports health (2):

18 Prevalence CT study of 100 joints (50 people) asymp 39% of hips had at least 1 predisposing factor M 48% > F 31% 74% of hips aspherical

19 GT pain syndrome abductor tendon tendinopathy/tear bursitis idiopathic **pain with resisted abduction is their usual pain** pain with high flexion and IR is usually only at GT

20 snapping - internal iliopsoas over anterior acetabular rim I can hear it anatomy + movement anatomy overcoverage (pushes the labrum into the way) can also happen with THA movement repetitive high flexion with rotation?compensation for lack of mobility elsewhere? iliopsoas release??? maybe in THA better to treat underlying cause in native joint

21 snapping external my hip dislocates ITB moving over GT I can see it ITB fenestration??? last resort Image from aaos orthoinfo external snapping hip

22 workup history FAI Arthrosis Abductor Tear RED FLAGS episodic episodic but ache at night episodic +/- ache all the time groin/csign buttock GT rad below knee worse with flexion rotation loosens up worse at night worse with standing/walking worse with any movement better with NSAIDs better with rest NSAIDs better with rest nothing improves it Image from Dooley Can Fam physician (1)42-47

23 workup exam FAI Arthrosis Abductor Tear RED FLAGS gait normal only limp when flared normal to antalgic limp walking aids with little demonstrable pathology n to low abd. strength normal +/- pain inhibition decreased abd strength unable to selectively activate glutei worse with flexion rotation straight flexion may be painless pain at GT with resisted abd unable to flex > 90 GT tenderness is not the usual pain GT tenderness not common GT tenderness may be the usual pain tenderness everywhere Image from Dooley Can Fam physician (1)42-47

24 workup - tests routine screen for bony pathology xray (AP pelvis, 45 degree Dunn view, false profile) FAI CT with 3D reformats screen for occult arthrosis preop planning MRI only if diagnosis uncertain AND your radiologists are experienced joint injection if multiple pain generators caution false negatives abductor tear MRI fascial disruption/core muscle injury MRI

25 treatment non operative/preoperative mechanism dependent abductor and core strengthening NSAIDs activity modification normalize gait/strength teach muscle control (vital for postop) not everyone with pathology is a surgical candidate arthrosis may be too advanced ability to successfully rehab is critical

26 treatment - operative address the underlying cause undercoverage PAO overcoverage acetabuloplasty AIIS recession CAM resection tendon tear repair fascial disruption repair

27 rehabilitation phase 1 manage inflammation regain motor control iliopsoas tendonitis raw bone surfaces

28 phase 2 gait strength emphasis on coordination, proprioception, balance

29 phase 3 non-sagittal plane endurance ROM? internal ok many are delayed

30 arthroscopy for FAI - outcomes mhhs yr survival 82.6% - M>F, young>old, BMI low>high Revision 5% at 2 yrs BMI, age, sex

31 arthroscopy for FAI - complications 8% DVT/PE 0.1% Infection deep 0.04%, superficial 1% femoral neck stress fracture 0.1% heterotopic ossification 0.8% traction related perineal numbness 1.4% ankle/foot pain 0.8% lateral thigh numbness -common postop, 1.6% beyond 6mo iatrogenic chondral/labral injury 2%

32 complications - avoidable wrong diagnosis radiculopathy missed secondary diagnosis fascial disruption

33 complications - avoidable residual deformity/pathology

34 complications - avoidable rehab too fast too slow just plain wrong

35 unknown capsular stiffness and inflammation poor response to NSAIDs, injections adhesions

36 less common hip pathologies ischiofemoral impingement sciatic entrapment hamstring avulsions

37 sample case 1 CAM FAI

38 sample case 2 - overcoverage

39 sample case 3 mixed FAI dancer

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41 postop

42 where is all this going? we have been here before shoulder pick up new diagnoses treat them in less invasive ways not everything is understood so not everything has a name/treatment yet subacromial impingement vs GT pain syndrome history and physical are paramount imaging can lead you astray what can I do? vs what should I do? rehab focuses on muscular control despite being more constrained

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