Labral Tears / Femoro- Acetabular Impingement / Hip Arthroscopy/THA
Hip Anatomy Labrum Fovea Femoral Head Articular Cartilage Ligamentum Teres
Labral Tears
Function of Labrum Deepens acetabulum by 20% Creates a seal of the hip joint Maintains hydrostatic pressure enhancing lubrication Maintains negative pressure enhancing stability Reinforces acetabular rim Protects edge of articular cartilage
Labral Tears Causes FAI (50%) Degenerative Trauma Developmental Dysplasia
Dysplasia
Trauma
FAI Pincer Cam
Protrusio
Pincer FAI
Cam FAI
FAI
Labral tear Symptoms Groin pain Buttock pain Clicking Locking Stiffness
Labral tear Signs Restricted ROM IR in flex Positive impingement Pain with forced flex ext
So Anyone Groin pain Irritable hip No arthritis
Think labral tear
Investigation Xray
Exclude other causes of groin pain OA RhA Tumours Fractures
Look for anatomy that predisposes to impingement Protrusio Lateral and anterior bumps
Bone scan Exclude arthritis Exclude other pathology
MRI Exclude other pathology Look for bumps Assess chondral damage Check labrum
Cam Labral Tear
Remember Sensitivity 30-90 % Specificity?? 20 % asymptomatic patients labral tear on mri
Remember Can have labral tear that does not hurt
So Symptoms and signs must fit
If they don t Probably something else
Remember Can have labral tear with negative investigations
So Signs and symptoms fit Other pathology excluded
Treatment warranted
Treatment Not all need surgery
First line Stretches Modification activity Analgesia NSAIDs Tolerance Injection steroid
Image Guided Intra-articular Injections with LA/Corticosteroid For diagnosis of intraarticular pathology 88% sensitive 100% specific 90% accurate
If first line inadequate Surgery
Surgery Repair labrum Resection labrum Correcting pathological anatomy Acetabular resection Removal bump
Surgery Open Arthroscopic
Technique GA Traction Table to distract hip joint Image intensification
Degenerate tears
Traumatic tears
Correct bony pathology
Acetabular Osteoplasty
Femoral Osteoplasty
Hip Arthroscopy Rehabilitation Plenty of advice little evidence Principles First 6 weeks Protect repaired tissue Avoid bony overload (prevent fracture) 6-12 weeks Regain ROM and normalise gait 3-6 months Strengthening and plan for return to sports
Rehab Protocol for Labral Repair or Femoral Osteectomy Week 1-3 Touch weight bearing Stationary bike Limit hip ROM Flexion 0-90 Abduction 0-25 External Rotation 0-25 Weeks 4-6 Partial weight bearing (25-50%) Gentle passive ROM hip within above limits Weeks 7-12 Full weight bearing Full active ROM hip and knee 3-6 months Stretching Closed chain strengthening Core strengthening Non-impact activity (elliptical trainer) progressing to light jogging 6 months Return to sports
FAI results in Restricted rom Labral tears Chondral damage Premature arthritis
Chondral damage
FAI is the most common cause of early onset idiopathic OA
Remember Arthroscopy wont help chondral damage
So Once there is significant chondral damage scope is not indicated
And that If there is a labral tear in the presence of OA Dealing with the labral pathology wont help
Results Labral and FAI Surgery 80% good to excellent results 80% return to sports?prevent/slow progress of arthritis Poor results with arthritic changes
What if there is significant OA?
Treatment Activity modification Wgt loss Analgesia NSAIDs
These fail Surgery
Surgery Total hip replacement
Remember Difficulty does not increase with severity of disease
Remember Results are independent of timing of surgery
Remember Complication rates do not increase with age
So Only indication for Sx is pain that justifies going through the surgery
THA Uncemented Good bearing surface Regular surveillance
Thank you