Hip Preservation Timothy J Sauber MD Orthopaedic Update March 22, 2015 Nemacolin Woodlands Resort

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1 Hip Preservation Timothy J Sauber MD Orthopaedic Update March 22, 2015 Nemacolin Woodlands Resort Disclosures No disclosures relevant to this topic Objectives Evaluate and recognize common hip pathology radiographically Basic Physical Examination for young adult hip pathology Review indications for hip arthroscopy Indications for PAO Outcomes / Complications

2 Hip Radiographs AP Pelvis Hip Radiographs False profile Hip radiographs Dunn view

3 Hip Concepts Tonnis angle (Acetabular index) Nml 0-10 Dysplasia >10 Pincer <0 Hip Concepts Lateral center edge angle Nml Dysplasia < borderline Pincer >35 Hip Concepts Anterior center edge angle Nml Dysplasia <20 Look for upsloping dome

4 Impingement Cam Impingement Pincer Acetabular dysplasia Shallow, steep socket, limited anterior coverage Large labrum Structural instability Rim overload

5 MRI Philippon AJSM 12 Asymptomatic volunteers for MRI 73% found to have abnormal finding 69% found to have labral tear MRI Confirmation of diagnosis Potential for misdiagnosis The Labral Tear Radiology will more often than not call a positive labral tear. Look at the edema pattern in the acetabulum and femur. Help to differentiate between impingement and instability Physical Exam Starts with symptoms All laterally based hip pain is not bursitis!! Activity related / high flexion activities 1. Groin 2. Lateral 3. Posterior 4. Distal / Referred

6 Physical Exam Observe gait Look for limp Limb rotation Check hip joint ROM Flexion level pelvis IR / ER in 90 degrees Physical Exam Differences between L / R hip Nml IR 40 -> ER 45 Significantly decreased or significantly increased ROM IR 60 ER 90 hip instability / dysplasia Shift in ROM Physical Exam C- sign

7 Physical Exam Impingement FADIR Physical Exam Patrick s / FABER Physical Exam Apprehension Test

8 NATURAL history > 90 % of pts under 50 with OA have structural deformity 1 >50% of young pts with OA have dysplasia 2 In pts with Tonnis >15 and LCEA <16, survival to 65 free of severe OA is 0% 3 Presentation How good are we at diagnosing symptomatic dysplasia? months average time from syptoms to diagnosis (5mo-29y) 41.6 months average from start of medical care to diagnosis Average 3.3 providers to definitive diagnosis Variable initial diagnoses most commonly soft tissue injury / groin pull Presentation Common presenting complaints 4 Groin pain (72%) Lateral hip pain (66%) Thigh pain (29%) Posterior pain (18% - always associated with groin pain) Mechanical symptoms in 78% Most commonly snapping / popping (67%)

9 Surgical Options Hip Arthroscopy Normal hip anatomy, traumatic labral tears CAM impingement Mild pincer impingement Capsular plication Open / Arthroscopic Hip arthroscopy indications - dysplasia Maybe none? Mild dysplasia LCEA Non upsloping sorceal Reasonable anterior coverage (ACEA = or >LCEA) Findings more consistent with labral pathology (?trauma) than dysplasia Diagnostic scope prior to definitive mgmt No indication for labral debridement Failure of hip arthroscopy Retrospective review of 54 patients who failed hip arthroscopy 6 68% residual FAI 24% acetabular dysplasia Moderate to severe arthritis in 77% 63% able to be managed with revision hip preservation Review of 51 patients (17 & 34 controls) comparing PAO with and without failed prior hip arthroscopy 7 Comparable outcomes Proceed with caution!

10 Surgical Options Surgical dislocation Alternative to arthroscopy? 360 degree lesions Severe SCFE Perthes OATS / Allograft Labral Reconstruction Femoral head trauma Surgical Options Proximal Femoral Osteotomy Rotational deformities Flexion / Extension deformities AVN Perthes Indications for PAO Radiographic dysplasia Acetabular retroversion ADL limiting symptoms?activity related symptoms Age <40 BMI <30 (relative) Educated pt, reasonable expectations, compliant

11 PAO Bernese / Ganz PAO PAO Coverage correction Version correction Increased medialization Outcomes Retrospective review of 135 U.S. PAO cases 8 96% survival at 5 years 84% at 10 years Failure Age >35 Poor joint congruency LCEA <30 >40 9 Literature from Bern, Switzerland shows similar survival out to 25 years

12 Return to activity level Prospective review of 19 patients 5 8/19 pre-op doing low impact activities 18/19 post op doing low impact activities 8/19 post op doing high impact activites Positive factors Younger age Higher pre-operative level of function Overall hip preservation surgery, 71% return to higher level of activity after surgery Complications Major complications described as high as 30% Malunion Nerve Palsy ( Femoral > Sciatic) LFCN paresthesias more often than not Need for transfusion Biggest problem with early in learning curve pts is early failures Surgeon mentor Cadavers! 2 experienced surgeons for every case first 50 HS 19 year old female swimmer(d3) s/p pinning of acute SCFE in 2006 Arthroscopic synovectomy in 2008 for impingment Significant improvement in pain, return to swimming Rotational profile performed at this time indicated need for osteotomy No longer swimming competitively due to pain Dull anterior ache with with ADL s Severe with swimming/running

13 Physical Exam lbs BMI 23.9 No limp, no fixed deformity (+) FADIR Otherwise NVI distally R L ROM in flexion IR at ER at Abduction HS

14 HS MRI Severe artifact secondary to screw Labral tear read by radiologist No other significant intrarticular pathology

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16 Follow-up Follow 4 months WBAT LLE 0-95 degrees flexion without pain IR 25 at 90 ER 35 at 90 JM 27 y/o female R hip pain x years Failed NSAIDs / PT / injection / weight loss Groin / lateral pain ROM IRF 15, ERF45

17 JM JM JM MRI shows reasonably well preserved joint, no cystic changes Offered PAO Note.. Tonnis 1 changes.

18 JM JM JM 3 months No hip pain. Returning to ADLs, thinking about return to work ROM 0-90 IRF 20, ERF 45

19 JR 28 y/o male Fell off ski lift in Vermont Drove back to Pittsburgh with L Hip Pain No prior hip symptoms JR JR

20 JR JR MRI shows significant cartilage loss, free fragments in joint Possible posterior wall fracture / labral tear Offered surgical dislocation for repair JR

21 JR JR JR

22 JR F/U - 2 months post-op 50% PWB, no pain with ROM or ambulation Full active abduction strength Normal ROM Thanks for staying awake!! RS 19 year old male Senior in HS Activity / High flexion hip pain that has progressed to include moderate to severe pain with ADLs Pain x 5 years

23 RS L > R hip pain L hip 0-100, IR 10, ER 45 + Impingement + FABER to groin

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