Disclosures. Objectives 11/18/2015. Hip Preservation in the Adolescent and Young Adult. Financial - None I do not perform total joint arthroplasty

Transcription

1 Hip Preservation in the Adolescent and Young Adult Alfred A. Mansour, III, MD Pediatric Sports Medicine and Hip Preservation UT-Ortho 59th Annual Edward T. Smith Orthopaedic Lectureship November 5-6, 2015 Disclosures Financial - None I do not perform total joint arthroplasty Objectives Discuss etiology of hip pain in young patients Review key exam findings Discuss treatment approaches Discuss pitfalls in treatment 1

2 Hip Pain Complex multilayered anatomy Broad differential Musculoskeletal Neurologic Gynecologic Gastrointestinal Vascular Hip Disease Clohisy JC, Beaulé PE, O'Malley A, Safran MR, Schoenecker P. AOA symposium. Hip disease in the young adult: current concepts of etiology and surgical treatment. J Bone Joint Surg Am Oct;90(10): Hip Pain - Musculoskeletal Intra-articular Labral Chondral Ligamentum teres Capsular laxity Adhesive capsulitis FAI femoroacetabular impingement Loose bodies Intra-articular tumors (PVNS, chondromatosis) 2

3 Hip Pain - Musculoskeletal Extra-articular Hip tendonitis/avulsion injuries Snapping hip Iliopsoas ITB Abductor tears Osteitis pubis Athletic pubalgia Nerve compression pathologies Hip Pain - History Location and Quality C-sign Anterior, Posterior, Lateral Discrete injury Limitations Recreating pain Avoidance maneuvers Associated symptoms Catching/locking/popping Audible snap Instability Hip Pain 101: The labrum is painful Both to the patient AND the surgeon/therapist Underlying causes 3

4 Hip Pain The Labrum Labral Tears Repetitive hip flexion or pivoting Skeletal deformities Femoroacetabular Impingement (FAI) Abnormal morphology + abnormal contact during terminal motion Hip pain and labral degeneration Types Cam Pincer Byrd JW, Jones K. Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up, Arthroscopy, 27;10, 2011: pp Femoroacetabular Impingement (FAI) Cam Byrd JW, Jones K. Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up, Arthroscopy, 27;10, 2011: pp

5 Femoroacetabular Impingement (FAI) Pincer Byrd JW, Jones K. Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up, Arthroscopy, 27;10, 2011: pp FAI Sharp anterior groin pain Deep flexion, IR, abduction Lateral or posterior if extensive Difficulty squatting/cutting Limited flexion and IR FAI Radiographs 5

6 FAI Radiographs FAI 3D CT Development Dysplasia of the Hip (DDH) Inadequate osseous coverage leads to mechanical overload 6 anterolateral acetabular rim labrum Radiographs/Advanced imaging critical 7 lateral center-edge angle of Wiberg (LCEA) anterior center-edge angle of Lequesne (ACEA) Acetabular index (AI) Femoral head extrusion index To nnis angle 6

7 AP Pelvis Lateral Center Edge Angle Normal 25 Clohisy JC, Carlisle JC, Beaulé PE, Kim YJ, Trousdale RT, Sierra RJ, Leunig M, Schoenecker PL, Millis MB. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am Nov;90 Suppl 4: False Profile Pelvis Anterior Center Edge Angle Normal 20 Clohisy JC, Carlisle JC, Beaulé PE, Kim YJ, Trousdale RT, Sierra RJ, Leunig M, Schoenecker PL, Millis MB. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am Nov;90 Suppl 4: Treatment FA morphology FAI FA morphology + impingement symptoms = FAI Abnormal contact Extremes of motion Increasing flexibility Pilates-based PT program Alteration of positions to relieve contact Activity modification Corticosteroids 7

8 Treatment Nonoperative FAI Limited evidence in the literature 0-90% successful More successful for mild deformities Postural rehabilitation Avoid PROM and stretching Wall PD, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM R May;5(5): Treatment Nonoperative DDH Murphy et al, JBJS pts followed to 65 years old All patients with any of the following factors developed premature OA LCE<16 AI>15 Uncovering of femoral head >31% Subluxation (break in Shenton s line) - poor Treatment - Surgical Intervention Goals Diagnostic evaluation of cartilage and labrum Treat cartilage and labrum Address underlying sources of impingement Address underlying sources of mechanical overload 8

9 Surgical Intervention Arthroscopy Stab incisions Ambulatory surgery 4 Rs Repair Reconstruct Resect Release Surgical Intervention Open Surgery 5 Rs Repair Reconstruct Resect Release Reorient Surgical Hip Dislocation Proximal Femoral or Pelvic Osteotomy Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br Nov;83(8): Periacetabular Osteotomy (PAO) Developed by Ganz 16 ~30 years ago Allows significant correction with stable fragment position Decrease pain and delay THA (hopefully) Incomplete osteotomy of posterior column 4 cuts with reorientation 9

10 PAO Pubic ramus PAO Ischium PAO Ilium Ilium Ischium along posterior column 10

11 PAO Fragment Reorientation Image courtesy of Perry Schoenecker preop postop Outcomes - FAI Arthroscopic FAI surgery (2yr f/u) 8, % return to sports Open FAI surgery (12-70 month f/u) 9, % return to sport 11

12 Outcomes - DDH Steppacher et al, CORR hips, mean 20yr f/u 60% survival (no THA) Worse outcomes: patients >29 years at time of surgery preoperative OA grade of 2 Survival (Tonnis 0 = 81%; Tonnis 1 = 65%; Tonnis 2 = 13%) postoperative extrusion index 20% or more Combined Arthroscopy and PAO for Dysplasia Ross et. al AJSM Level IV 73 hips in 71 patients Combined approach Labral tears 65.8% Acetabular cartilage lesions 68.5% Higher incidence in LCE <15 or AI >20 Combined Arthroscopy and PAO for Dysplasia Domb et al Arthroscopy Level IV, 2.4yr f/u 17 patients 100% chondrolabral pathology 12/17 labral repairs 13/16 (82%) excellent results 12

13 Defining the underlying problem HIP PAIN 17 y.o female Active competitive dancer Mild hip pain for years Significant symptoms precluding dance since 3/13. Tried PT, act mod, CSI with mild relief. Continued ant groin pain with activities. Pinch sensation anteriorly. Also buttock region pain. +Impingement sign (IR 30) X-rays LCE 18, AI 8 Anterior CE 17; alpha angle 72 13

14 3d CT MRI 14

15 Options? Hip arthroscopy with labral debridement/repair PAO Painful labrum early failure 15

16 4.5 months postop Outcome Returned to collegiate level competitive dance at 8 months. Complex Deformity 29 y.o male with right hip pain and catching for 4 months. Mild continued pain after PT and CSI. IR (-5) R; IR (5) L. ER 40 B 16

17 17

18 Options and concerns? Comprehensive Treatment Hip arthroscopy Labral repair Cyst decompression Subspine decompression (AIIS) Open osteochondroplasty PAO periacetabular osteotomy Intra-articular work Labral tear with chondral flap After debridement and repair 18

19 Reorientation 1 year postop 1-year postop 19

20 No pain. Full activities. Case courtesy of Dr. Perry Schoenecker 10+8 Fatigue, limp, no prev tx Initial x-ray - - limps w/ basketball games, no pain 10+8, limps, w/o pain Manipulating acetabular fragment: lateral tilt, antevert, medialize & anterior tilt Bernese PAO 20

21 10+8, limps, w/o pain 17 y/o, post PAO 6yrs Asymptomatic Pt. called my hip is hurting no my right one 21y/o 10 yrs post-op 6 mos post-op R Now basketball coach at University 21

22 When to heal with steel (or metal on plastic)? Advanced age Advanced OA (Tonnis 2 or 3) Poor preoperative joint congruity Conclusions Define the underlying cause of the hip pain Determine most suitable way to treat the underlying pathology 4 vs 5 R s of hip preservation surgery Repair Reconstruct Resect Release Reorient Sometimes a 6 th R may ultimately be the answer REPLACEMENT References 1. Nofsinger C, Kelly B. Methodical Approach to the History and Physical Exam of Athletic Groin Pain, Oper Tech Sports Med, 15, 2007: Tibor LM, Sekiya JK. Differential Diagnosis of Pain Around the Hip Joint, Arthroscopy, 24; 12, 2008: Byrd JW, Jones K. Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up, Arthroscopy, 27;10, 2011: pp Wall PD, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM R May;5(5): Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br Nov;83(8): Clohisy JC, Carlisle JC, Beaulé PE, Kim YJ, Trousdale RT, Sierra RJ, Leunig M, Schoenecker PL, Millis MB. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am Nov;90 Suppl 4: Clohisy JC, Beaulé PE, O'Malley A, Safran MR, Schoenecker P. AOA symposium. Hip disease in the young adult: current concepts of etiology and surgical treatment. J Bone Joint Surg Am Oct;90(10): Byrd JW, Jones K. Arthroscopic Management of Femoroacetabular Impingement in Athletes. Am J Sports Med : 7S 9. Naal FD, Miozzari HH, Wyss TF, Nötzli HP. Surgical hip dislocation for the treatment of femoroacetabular impingement in high-level athletes. Am J Sports Med Mar;39(3): Nho SJ, Magennis EM, Singh CK, Kelly BT. Outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes. Am J Sports Med Jul;39 Suppl:14S-9S. 11. Novais EN, Heyworth BE, Stamoulis C, Sullivan K, Millis MB, Kim YJ. Open surgical treatment of femoroacetabular impingement in adolescent athletes: preliminary report on improvement of physical activity level. J Pediatr Orthop Apr-May;34(3): Ross J. Zaltz I, Nepple J, Schoenecker P, Clohisy J. Arthroscopic Disease Classification and Interventions as an Adjunct in the Treatment of Acetabular Dysplasia, Am J Sports Med : 72S 13. Murphy SB, Ganz R, Müller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am. 1995;77: Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res Jul;466(7): Domb BG, LaReau JM, Hammarstedt JE, Gupta A, Stake CE, Redmond JM. Concomitant Hip Arthroscopy and Periacetabular Osteotomy. Arthroscopy Jul 29. pii: S (15) Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias: technique and preliminary results. Clin Orthop Relat Res. 1988;232:

23 Questions Hip Capsule in hip preservation Questions and case examples 23

24 What about the capsule? Increasing evidence of the importance of the hip capsule as stabilizer Initially ignored in hip arthroscopy Multiple reports of postoperative dislocation Capsulotomy or capsulectomy Data Complete capsular closure (of T) better than partial closure at 2yr f/u 16 Biomechanical data suggests Iliofemoral ligament critical stabilizer against increased ER and hip anterior translation 17 What about the capsule? 17 y.o female Persistent hip pain 2 hip scopes with labral repair 24

25 Restore anatomy Close the capsule Reconstruct if necessary 18 y.o s/p right hip scope 1 year postop no recurrence 25