Hip Arthroscopy

Hip Arthroscopy
Brandon Cincere, MD
979 E 3rd Street
Ste C430
Chattanooga, TN 37403
Phone 423-624-6584
Fax 423-624-6588
Overview
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What is Hip Arthroscopy?
Anatomy
History and Exam
Differential Diagnosis
Imaging
Indications
The Procedure
Post op
Specific Roles and Results
What is it?
Not this
Anatomy
• Congruent, Stable Ball and Socket
Anatomy
• Gliding (Articular)
cartilage covers
majority of femoral
head – The Ball
• The Cup/socket Acetabulum,
consists of articular
or gliding cartilage
Anatomy
• Labrum – the gasket runs
circumferentially, around the
socket
• Labrums acts as stabilizing
force, increasing volume and
Increasing surface area
creating negative IA pressure
• Acts a seal to resist fluid flow
to allow fluid to stay within
the central compartment,
maintaining low friction
environment and cartilage
nutrition
Capsule
History and PE
• Separated into 2 sources:
• Extra-articular - Outside
• Intra-articular - Inside
• “hip” pain – groin, lateral,
anterior thigh, buttock, lower
back
Symptoms
• Intra-articular hip pathology
• Typical pain pattern – anterior
groin/medial thigh
• “C” sign
• Pain worse with twisting activities,
ascending, descending stairs or
inclines
• Catching – in flexion to extension
(rising form a seated position) sharp
• Difficulty sitting with hip flexed for
long periods of time, putting on socks,
shoes, getting in/out car
History and Exam
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Abnormal Gait
Deep pain that can’t be palpated
Decreased range of motion
Tightness in muscles surrounding the hip
Hip muscle weakness
Positive Impingement tests
Differential Diagnosis
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Musculotendinous strain, hip flexors, adductors, hernia
Bony injury
Labral/chondral injury
Tendinitis
Stress/traumatic fracture
Childhood deformity
Developmental Dysplasia
Synovitis
Infection
Impingement
Arthritis
Referred from GU, Intraabdominal, abdominal wall, hernias,
Back pain, nerve compression
Will I need any tests/scans?
• Plain Xrays
• MRI/A
• CT scan
Imaging
• Plain Radiographs
– Arthritic changes, dysplasia, deformity, AVN,
Impingement, loose bodies, Fx, pelvis, lumbar
pathology
Imaging
• MRI
• Anesthetic Injection – 90% accuracy for
detecting IA pathology
Who should have Arthroscopic Hip
Surgery?
• The majority of patients are:
• Young, active individuals with a history of hip pain
during or after activity and of gradual onset that has
not responded to non-operative treatment
– anti-inflammatory medication and/or
– physiotherapy
• Patients with sudden onset of hip pain after a
traumatic injury.
• This procedure cannot be used to treat established
arthritis effectively
Indications
Indications
• Loose Bodies
– Clearest Indications,
obvious advantages
– LB from Trauma, OA,
synovial
chondromatosis
– FB - Bullets
Labral Lesions
Most common cause of mechanical
sx’s
Indications
• Chondral Injuries
Indications
• FAI – Femoral – Acetabular Impingement
– Distinct entity that results in labral tearing, articular
breakdown and OA
– + impingement, decreased ROM and Pinching
– Typically in younger more active adults
– Results from repetitive microtrauma to labrum at extremes
of ROM
Animation of FAI
• Cam
• pincer
FAI
• MRA findings associated with pts with
impingement
– 93% abnl Femoral head shape (cam)
– 95% acetabular chondral abnormalities
– 100% AS labral Tears
– All 3 findings in 88%
– Kassarjian 2005
Non – round object squeezing in a
round object – like a rock in a shoe
Indications
• Synovial Disease
– Synovectomy for:
• Inflammatory arthritides, synovial chondromatosis,
PVNS
• Focal vs diffuse
Indications
• Ruptured Ligamentum
Teres
– Can be a cause of painful
hip sx
– From twisting injury, disloc
– Catching senstation
– 3rd most common
pathology found in
athletes undergoing
arthroscopy
Indications
• Posttraumatic Osteophytes
– Impinging bone fragments secondary to trauma
Or Rim bone spurs blocking motion
Indications
• Instability
– Most commonly found in hyperlaxity states with
normal joint geometry
• Collegen vascular disorders – Ehlers-Danlos
Indications
• Adhesive Capsulitis (Frozen Hip)
– Rarely described in the hip
– Painful restricted ROM
– Precipitated by twisting or fall
– Post-surgical adhesions
Indications
• Septic Arthritis – Joint Infection
– With proper patient selection has advantage of
reduced morbidity
– Successful in acutely infected Total hip
replacement
• Early diagnosis
• Well-fixed components
• Sensitive bacterial
Who should NOT have this
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Patient Not healthy enough for surgery
Severe arthritis
Severe deformity
Severe obesity
Superficial infection in the area
Previous hip surgery that blocks access
Avascular necrosis of the bone/fracture
Who should NOT have this
The Procedure
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Steep Learning Curve – not just any surgeon
General Anesthesia ………..complete paralysis
Traction
Fluoroscopy – live x-ray
Most important is consistency of the setup and comfort level of the surgeon/staff
Evaluation
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Femoral Head
Acetabulum
Pulvinar
Ligamentum teres
Labrum – circumferential
Zona orbicularis
Femoral Neck
Peripheral Head and neck junction
Iliopsoas attachment
Central and peripheral compartments
Incisions
• 3 standard portals
– small incisions
Central
Peripheral Compartment
synovium, labral seal, vessels, head deformity
Peritrochanteric Space
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Lateral Compartment
IT band
Bursa
Tendon tears
Post – Op Rehab
• Based on DX & TX
• Outpatient procedure – no hospital
stay – go home same day
• Early Physical Therapy- not aggressive
• Passive motion on Stationary bike
immediately, elliptical, pool
• Crutches –
– Debridement/repair – 2-4 wks short
tem until functional AROM
– Microfracture – TTWB 6 – 8 wks
• Back to Work 1-2 weeks based on
comfort and occupation
• Running – not allowed until pain and
swelling are gone, good hip stability –
2-3mos
• Back to sport specific activities – 6 mos
Potential Complications
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All surgery carries a risk. Specific risks to hip arthroscopy are:
Infection ?
Thrombosis ?
Bleeding ?
Stiffness ?
Fracture ?
Residual symptoms ?
Other - due to the fact the procedure is performed using traction, muscular discomfort
around the hip and lower back and very occasionally, temporary numbness in the groin and
thigh can occur.
Complications
• AANA reviewed 1491 published cases
– Reported 1.34% complication rate
– Decreased with
• Modern distractor
• Traction time monitoring
• Padding perineal posts greater than 9 cm
Labrum Results
• Debridement - labral tissue from the hip joint
may remove its protective effect on joint
cartilage, leading to eventual chondral damage
and premature osteoarthritis
– Outcomes for Debridement 68-82% Successful
• Worse outcomes with associated articular damage – 21%
(Byrd 2000 2 year f/u)(Farjo 1999)
– >50% associated with some type of articular damage
• Preop Studies for associated articular findings relatively
ineffective
• 436 consecutive scopes, 261 labral tears, 73% assoc with
chondral damage (McCarthy 2001)
Labrum Results
• Larsen Arthroscopy 2009
– Labral refixation resulted in
better Modified HHS and a
greater % of good to
excellent results compared
to debridement with min 1
yr f/u
• Philippon JBJS BR 2009
– Min 2 yr f/u, repair was
statistically significant
independent predictor of
better functional scores
Labrum
• Clinical Outcomes 4.8 year f/u
• Traumatic cause, secondary gain, smokers
were significant negative predictors
• Preop activity level predictor of outcome and
return to activity
• Chondral (Gliding cartilage) damage and
arthritis significant predictors of outcome
Results
• Philippon JBJS Br 2009
• Outcomes following Hip Arthroscopy for FAI with
associated chondrolabral dysfunction, min 2 year f/u
– Predictors of better outcome
• Better Pre-op modified HHS
• Joint space >2mm
• Repair labral pathology instead of debridement
– 10 of 112 pts went on to THA within ave. 16 months
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Pts significantly older at time of scope
Had less joint space - arthritis
Lower mean preop mod HHS
Poor cartilage condition
No difference in gender, body mass index, or cam size
• Philippon 2007
– 45 professional
athletes underwent
arthroscopic
treatment for FAI
• 93% rtn to
professional level
Treat the FAI lesion and the Labrum
Arthroscopic
tx’s overall do
better than
open tx’s
Further Outcome Studies
• Demonstrating prevention or slowing the
progression of arthritis***********
• Labral reconstruction like ACL reconstruction
Thank you
Brandon Cincere, MD
OrthoSouth
979 E 3rd Street
Ste C430
Chattanooga, TN 37403
Phone 423-624-6584
Fax 423-624-6588
Sports Medicine and Orthopaedic Surgery
Treating Sports related injuries, fractures,
Shoulder, Hip & Knee Arthroscopy
University of Tennessee Clinical Instructor Orthopaedics and Sports Medicine
Bibilography
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