Mr Simon Jennings BSc, MB BS, FRCS, Dip Sports Med FRCS (Trauma & Orthopaedics)

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1 Mr Simon Jennings BSc, MB BS, FRCS, Dip Sports Med FRCS (Trauma & Orthopaedics) Consultant Orthopaedic Surgeon Northwick Park Hospital 107 Harley Street RSM 16 th September 2010

2 Orthopaedic Surgeon Knee & Hip surgery Sports Injuries Trauma Elite Sport Rugby League (London Broncos/Harlequins RL) Rugby Union (Harlequins) Team GB Judo

3 Variation in presentation Groin Pain Is this a groin problem? Vast differential diagnosis for groin pain

4 Differential Diagnosis of Groin Pain in Traumatic Causes Subluxation or dislocation Fracture or stress fracture Hematoma Contusion Labral Pathology Femoroacetabular impingement Hypermobility Trauma Dysplasia Infectious/Tumorous/Metabolic Conditions Septic arthritis Osteomyelitis Benign neoplasms of bone or soft tissue Malignant neoplasms of bone or soft tissue Metastatic disease of bone an Athletic Patient Inflammatory Conditions Rheumatoid arthritis Reiter syndrome Psoriatic arthritis Chondral Pathology Lateral impaction Osteonecrosis Loose bodies Chondral shear injury Osteoarthritis Capsule Pathology Laxity Adhesive capsulitis Synovitis or inflammation

5 Differential Diagnosis of Groin Pain in Nonmusculoskeletal Causes Psoas muscle abscess Spine problems Hernia Endometriosis Ovarian cyst Peripheral vascular disease Unknown Etiology Transient osteoporosis of the hip Bone marrow edema syndrome Synovial Proliferative Disorders Pigmented villonodular synovitis Synovial chondromatosis Chondrocalcinosis Metabolic Causes Paget disease Primary hyperparathyroidism an Athletic Patient Extra-Articular Pathology Coxa saltans (internal or external) Psoas impingement Abductor tears (rotator cuff tears of the hip) Athletic pubalgia Trochanteric bursitis Ischial bursitis Osteitis pubis Piriformis syndrome Sacroiliac pathology Tendinitis (hip flexors, abductors, adductors)

6 Trauma

7 Trauma

8 Trauma

9 Trauma

10 Anatomical Approach All possible structures Eliminate / target through clinical diagnosis Investigation Xray MRI / MRA US (+injection) CT Bone Joint Tendons Ligaments Muscles Blood Vessels Nerves etc

11 Beware! Referred pain with misleading symptoms Knee Spine Intra abdominal pathology Multiple Pathology Coexistent hip and groin pathology etc

12 Beware! Internet

13 Beware! The Media

14 Hip Joint Causes of Groin Pain Intra-Articular Labral Tear FAI Loose body Capsular Laxity Ligamentum Teres Chondral Damage Extra-Articular Iliopsoas tendinitis ITB Gluteus Medius/Minimus Trochanteric Bursa Stress Fracture Adductor Strain SIJ

15 Hip Joint Causes of Groin Pain Intra-Articular Labral Tear FAI Loose body Capsular Laxity Ligamentum Teres Chondral Damage Extra-Articular Iliopsoas tendinitis ITB Gluteus Medius/Minimus Trochanteric Bursa Stress Fracture Adductor Strain SIJ

16 Orthopaedic Surgeon

17 Orthopaedic Surgeon Surgical treatment When not to operate Appropriate Referral Positive result much more likely with correct diagnosis Full work up Cannot succeed without appropriate and skilled rehabilitation Team approach

18 Basics History Diagnosis Examination Investigation Imaging Special Tests Treatment Non-surgical Surgical

19 Labral Tear Sport Repeated pivot/hip flexion Gradual onset of symptoms (recreational) May relate to specific traumatic event (elite) Clinical 87% Groin pain Dull ache + sharp groin pain with activity/walking 50% clicking /catching

20 Labral Tear C-sign FADIR FABER

21 C- Sign

22 FADIR

23 FABER

24 Labral Tear Imaging Plain Xray MRI / MRA (90% sensitivity, 100% specificity) US & Injection Treatment Surgical Open vs Arthroscopic Debridement / Repair Good short term results Often seen in FAI

25 FAI Femoroacetabular (FAI) Impingement Forms Lavigne et al. 2004

26 FAI

27 Plain Xray AP Pelvis Cross Table Lateral Imaging

28 Line drawing AP radiograph retroverted acetabulum - crossover sign left hip normal (anteverted) acetabulum right hip

29 AP radiograph of the pelvis crossover sign - indicative of a retroverted acetabulum

30 Line drawing AP radiograph showing the pistol-grip deformity (arrow).

31 Plain Xray

32 Imaging MRI / MRA CT Ultrasound Injection

33 MRI Labral Tear

34 MRI - cam-type FAI Shindle M. K. et.al. J Bone Joint Surg 2007:89:29-43

35 MRI - forty-one-year-old patient with cam-type FAI Shindle M. K. et.al. J Bone Joint Surg 2007:89:29-43

36 Real Life

37 Real Life

38 Real Life

39

40 3d Reconstruction CT Cam type FAI

41 +ve impingement test, decreased internal rotation, groin pain abnormal alpha angle of 74 on CT Shindle M. K. et.al. J Bone Joint Surg 2007:89:29-43

42 Real Life

43 Surgical Treatment Open Surgery Hip dislocation Major surgery Longer recovery Full exposure Arthroscopic Surgery Smaller incisions Faster recovery Access can be difficult Time consuming Steep learning curve Special equipment

44 Hip Arthroscopy Growth area in orthopaedics Media loves the idea Theory sound prevent OA Major Surgery Risk Rehabilitation Elite athlete? Poor Prognostic indicators for arthroscopy: >2mm joint space narrowing >50% joint space narrowing = high failure rate Eccentric femoral head position Symptoms suggestive of OA rest/night pain without activity

45 Hip Arthroscopy

46 Hip Arthroscopy

47 Hip Arthroscopy

48 Hip Arthroscopy Training

49 Hip Arthroscopy Labral Tear Debride Reattach FAI Cam = Osteochondroplasty Pincer = Trim acetabulum (Labrum!)

50 Hip Arthroscopy Labral Tear Femoral Head Acetabulum

51 Hip Arthroscopy Labral Tear Debridement

52 Hip Arthroscopy Labral Tear Debrided

53 Fluoroscopic imaging

54

55 The extent of the deformity - cam-type impingement (intra-operative photograph of a dislocated femoral head) Beaulé P. E. et.al. J Bone Joint Surg 2009:91:

56 Before

57 After

58 Hip Arthroscopy Cam Lesion

59 Hip Arthroscopy Cam Lesion

60 Hip Arthroscopy Cam Lesion

61 Hip Arthroscopy Clearing Cam Lesion

62 Hip Arthroscopy Clearing Cam Lesion Femoral Head

63 Hip Arthroscopy Burr to remove Cam Lesion Labrum

64 Hip Arthroscopy Labrum Femoral Head Femoral Neck

65 Rehabilitation Dependent on surgical Procedure Physiotherapy Promote ROM, muscle strength Graduated return to activity Tailored to individual profile Teamwork

66 Thank You Any Questions?

67

68 World Cup Year

69 ?

70 ?

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