Hip Arthroscopy: State of the Art Seung J. Yi Florida Orthopaedic Institute Orthopaedics for Primary Care and Therapists ER HPI 24 yo F R hip pain x 4 months after twisting injury in flag football C sign pain ER PE Seated IR/ER leg: Greater troch palpation: Hip flexion impingement: + FADIR: + 1
AP/Lateral Modified Dunn 2
Acetabular Labral Tears Anatomy ring of fibrocartilage tissue deepens the socket maintains the fluid suction seal Injury from hypermobility or repetitive mechanical stresses associated Femoral Acetabular Impingement (FAI) 3
Femoral Acetabular Impingement (FAI) Femoral Impingement (Cam 9%) Acetabular Impingement (Pincer 5%) Combined (86%) Beck et al, JBJS B, 2005 Normal Cam Pincer Combination Treatment Activity modification Avoiding squats Raising seats NSAIDS Physical Therapy Goal Yes Hip flexor and Abductor strengthening Correction of muscle length deficits neuromuscular retraining NOT increasing ROM with a mechanical block 4
Diagnosting/Therapeutic Injection Intra articular injection Lidocaine versus Cortisone Surgery Hip distractor table to for traction Fluoroscopy Long arthroscopic instrument Hip arthroscopy, acetabuloplasty, labral repair, femoroplasty 5
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Rehab First 3 wks (highly variable surgeon to surgeon) Foot Flat Touch Down Weight Bearing 3 weeks CPM 0 90 Some surgeons prefer hip brace, starting PT After 3 6 wks WBAT Physical Therapy Outcomes https://vimeo.com/226506974/56f63996e2 Questions? 7
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Should we preserve the labrum? Acetabular articular surface with excised labrum showed signs of joint disease with reduced Safranin O staining for GAGs in 33% of the animals at 12 weeks Although the labrum had a poor blood supply, it did have the ability to heal in the animal model Outcome study of heterogenous patient population with hip pain. 38 procedures on 35 patients with minimum of 2 year follow up Harris Hip scores pre op & 1, 3, 6, 12, & 24 mo. postop or until subsequent procedure Variables studied: Age, sex, duration of symptoms, onset of symptoms, CE angle, diagnosis, worker s comp, and pending litigation. 9
Median Harris Hip scores improved from 57 to 85 10 cases ( 9 patients) underwent second procedure at avg of 10 mo. Diagnoses: Labral pathology = (23) without chondral injury = 31 point improvement with chondral injury = 18 point improvement Chondral damage = (15) = 18 point improvement Arthritic disorder = (9) = 14 point improvement Synovitis = (9) = 26 point improvement Loose bodies = (6) = greatest improvement = 34 points AVN = (4) Poor results of arthroscopy as a palliative procedure Cont to question role of arthroscopy in staging Perthes =(2) Synovial Chondromatosis = 1 Ligamentum Teres damage = 1 10
No significant difference in results based on CE angle (only one patient with dysplasia, i.e. CE angle < 20), work comp, or pending litigation. However, anecdotally work comp and litigation seemed to do better. Summary 112 hip scopes with chondrolabral dysfunction Mean follow up 2.3 yrs (2.0 2.9) Mean Modified Harris Hip Score improved from 58 to 84 Median patient satisfaction was 9 out of 10 10 (8.7%) patients were eventually converted to THA 11
Yi Hip Differential Dx Pearls Arthritis HPI Groin pain with walking/weightbearing Exam pain and limited motion with seated IR/ER leg Trochanteric Bursitis HPI Lateral hip pain with laying on it Exam Tenderness to palpation over greater trochanter FAI and Labral Tear HPI Anterior hip pain with tying shoes and squatting Exam Hip flexion impingement pain and +FADIR Back problem HPI Pain that radiates from low back into hip down the leg Exam Hip exam normal +/ straight leg raise or weakness Questions?? Thank You 12
Complications Abdominal compartment syndrome s/p hip arthroscopy 13
Surgery 14