Hip Impingement and Arthritis: Preservation vs. Total Hip Arthroplasty Jonathan R. Schiller, MD Assistant Professor of Orthopedics Warren Alpert Medical School of Brown University Director, Adolescent and Young Adult Hip Program Hasbro Children s Hospital Faculty Disclosures Jonathan R. Schiller, MD Has the following financial interest to disclose: Depuy-Mitek Division of Hip Arthroscopy - Educational Consultant Clinical Decision Support Program - Contributor Objectives Identify Hip Impingement Clinical exam Diagnostic tests Treatment options 1
Causes of Hip or Groin Pain Burnett, Clohisy et al. JBJS 2006 Average time from injury to accurate diagnosis 21 months Average of 3.3 providers seen before definitive treatment Anterior Hip Pain Muscle strains Contusion (hip pointer) Avulsions and apophyseal injuries Hip dislocation/subluxation Acetabular labral tears and loose bodies Proximal femur fractures Osteitis pubis Iliopsoas bursitis Stress syndrome SCFE Perthes disease Developmental dysplasia Osteoarthritis Lateral Hip Pain: Inflammatory Arthritis Avascular Necrosis Femora-acetabular Impingement Greater trochanteric bursitis Gluteus medius/minimus tear ITB syndrome Posterior Hip Pain Meralgia paresthetica Lumbar spine abnormalities Compression neuropathies Piriformis syndrome SI joint pathology Other Causes of Hip Pain: Abdominal (sports hernias and athletic pubalgia, inguinal hernias, appendicitis) Gynecologic (ovarian cysts, PID, pregnancy) Urologic (testicular, scrotal) Genitourinary (kidney stone, nephritis) Systematic Approach Don t ignore good hip Exposure: Inspection Palpation ROM Strength testing Provocative tests as indicated Physical Exam Physical Exam Gait: Can the affected leg bear weight Observe for: Antalgic (painful gait) Decreased stance phase Lurch (Trendelenburg)- laterally vs posteriorly Flat foot- no push off Wide feet > 4 inches apart Decreased step size Observe patient transfer from laying -> sitting -> standing Estimate height symmetry of iliac crests if asymmetric compare leg length 2
Femoroacetabular Impingement (FAI) Bony impediment of joint motion Abnormal acetabulum and/or proximal femur Abnormal anterior/superior acetabular rim Reduces clearance for motion flexion/int rot. FAI Age? Anterior groin, lateral hip pain Difficulty climbing stairs, getting out of chair/car, tying shoes, socks Popping, snapping, locking +C, restaurant sign FAI Physical Exam Trendelenburg/limp Painful/restricted hip flexion, abd, int rot. Weakness Tender psoas, rectus tendon, rectus Difficulty squatting +FABER/FADIR 3
FAI Imaging AP/frog /cross table lateral/false profile/air 3D CT Scan MRI Arthrogram labral tear, cartilage FAI and Osteoarthritis Little quality evidence supporting mechanical theory Kowalczuk et al. Does femoroacetabular impingement contribute to the development of hip osteoarthritis? A systematic review. Sports Medicine and Arthroscopy Review. 2015, Vol.23:174-179 Xray criteria for diagnosis for FAI Correlation b/w FAI and OA alpha angle >60 4
Management Physical Therapy Restoration of motion/strength Tendonopathies Abductor Piriformis Hip flexor The Perfect World Symptomatic <1 yr Inability to perform sport or activity Well defined FAI Good articular cartilage Good preop strength Normal BMI Courtesy Marc J. Philippon, MD, Hip Arthroscopy From Diagnosis to Patient Outcome Treatment Surgery Arthroscopy Arthroscopy+mini open Hip Dislocation Arthroplasty Most common reason for arthroscopy Labral Tear 70-80% success rate FAI 5
Case 1 49yo male 15yrs of right hip pain Pain at work, prolonged sitting and standing FROM, pain with flexion Strength 4/5 with pain flex, abd. +FADIR 6
Case 2 41yo male 2-3 yrs of right hip pain Pain with sitting, walking, can t bike Painful motion hip flex (90deg), abd. (45) +FADIR 7
Case 3 49yo female 10 years of left hip pain Difficulty working/adl s Limited motion and strength on left side FADIR+ 8
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Hip Arthroscopy or Arthroplasty Griffin et al. Outcomes of Hip Arthroscopy in the Older Adult. The American Journal of Sports Medicine. 2017, Vol. 45, No.8:1928-1936 Horner, et al. Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2017, Vol. 33, No. 2:464-475 Viswanath A. and Khanduja V. Can Hip arthroscopy in the Presence of Arthritis Delay the Need for Hip Arthroplasty? Journal of Hip Preservation Surgery. 2017, Vol. 4, No. 1: 3-8 Hip Arthroscopy or Arthroplasty 8-17 studies, 16K patients (9K >40yo) Significant improvement outcome scores after arthroscopy Scope to THA (mean 25 months) >40yo 18% >50yo 23% >60yo 25% Hip Arthroscopy or Arthroplasty Predictors of Failure Preop OA :joint space <2mm/ >50% joint space narrowing (Larson et al. Am J Sports Med, 2012) Failure 82% Radiographic OA 52%, No OA 12% >50yo and <2mm joint space (Philippon et al. Clin Orthop Relat Res, 2013) 81% accurately predicted THA 9x more likely THA 10
Hip Arthroscopy or Arthroplasty Predictors of Failure >40yo and OA (Kemp et al. Clin Orthop Relat Res, 2013) THA 7mos-5yrs 20x with only acetab OA Worse with femoral head OA 58x more likely for THA Grade 3 or 4 change acetab and femoral head THA 99% in 10yrs >50 vs. <30yo (Domb et al. Arthroscopy, 2015) THA 17% vs. 2% Repeat arthroscopy 15% vs. 4% Conclusion FAI common cause of hip pain FAI correlated with OA <40 years old significant improvement after hip arthroscopy >40 years old higher rate of conversion to hip replacement after arthroscopy Increases with obesity and age OA best indicator of conversion to hip replacement Thank You 11