hip injuries in the athelete+arthroscopy of the hip
DESCRIPTION
Surgical Treatment of FAITRANSCRIPT
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Bill Bose, M.D.Advanced Orthopaedics, LLC
Providence Medical Park Plaza
Suite B 114
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HIP INJURIES IN THE ATHELETE
ARTHROSCOPIC TREATMENT OF FAI
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Life Story in 1 slide
College - LSUMedical School - LSUOrthopaedic Internship
and ResidencyFellowship –Univ. Florida
– “Adult Reconstruction” 1993
3 Years Practice – Faculty USA
13 years private practice
4 yr4 yr5 yr (1) yr
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HIP AND PELVIS ANATOMY
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• Ball-and-socket joint
• Femur – ball
• Acetabulum – socket
• Articular cartilage – surface material
• Labrum - cartilage around rim of acetabulum
©2008 Smith & Nephew, Inc. All rights reserved.
Femur
Acetabulum
Articular Cartilage
Labrum
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HIP JOINT ANATOMY
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Strength and Stability
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Strength and Stability
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TYPES OF HIP INJURIESTrauma
Contusionsfractures
Sports injuries or overuse injuriesstrainstendonitis
Developmental Things you are born withMay become symptomatic
by sports or excessive movements in sports
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Contusions of Hip
“Hip Pointer”contusion of soft
tissue and bone where minimal soft tissue covering over the bone.
Iliac crestGreater trochanter
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FRACTURES ABOUT THE HIP• FRACTURES• Iliac Wing
• Direct blow to side of Hip or fall onto the knee
MVA/Football/cyclingTYPES
Head/Neck/Proximal Femur
acetabulumPubic Rami
Elderly population with minor or even no trauma
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Stress Fractures
“Micro-cracks”“Overuse”Pain with weightUsually no surgery
required.
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TRAUMATIC DISLOCATION
BO JACKSONFemoral head comes
out of the socketAbrades of cartilage,
tears labrumLead to post-
traumatic arthritis or AVN
Shortened and IRSurgical emergency
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HIP SOCKET FRACTURES
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SPRAINS/STRAINSaround the hip
Sprain – tearing of some of the fibers of a ligament or tendon.
Strain – “muscle pull”
Tearing of some of the fibers of a muscle
Abdominal strain“Sports Hernia”
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ACUTE MUSCLE STRAINSDiscrete event –
immediate painGroin Strain –
tearing of adductor muscles at attachment to pelvis
Hamstring Strain – tearing of posterior thigh muscles
Quad strainAbdominal strains
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ACUTE MUSCLE STRAINS
Iliopsoas “hip flexor” strain
Can be acute due to explosive muscle
contraction of the Hip Flexor muscles
soccer
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Overuse Injuries
Tendon injury due to repetitive micro trauma to the tendon - tendonitisIliopsoas tendonitis or “Snapping Hip
Syndrome”Rectus Femoris
tendonitis
Sprinters, kickers
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Hip Overuse Syndromes
ITB friction syndrome or “Bursitis”CrestTrochanterTightness
Runners
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Piriformis syndrome
Unusual cause of buttock pain
May irritate the sciatic nerve
Pain increased with activity
Piriformis stretchingMUST make sure
lumbar spine is not cause
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SacroilitisInflammation of the
SI jointGradual onsetFigure of 4Buttock or lower
back
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FAIFemoroacetabular Impingement
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NON TRAUMATIC HIP PAIN7 million people visit the doctor for hip painClimbing stairs, or bending to tie shoes,
sports, ADLNormal x-ray and MRIthe determination of the cause of the pain
wasn’t clearPractical treatment NOT available30-50 with chronic hip pain “live with it until
you are an age when a THA is more feasible”
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HIP ARTHROSCOPYTremendous
advancementhip
arthroscopy – 3-4 ½” incisions
Diagnose and treat hip pain
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• Lack of room between femur and acetabulum
• Femur and acetabulum rub together
• More common in athletic men
• Strenuous activity aggravates pain
• Prolonged stationary seating may intensify pain
• Pincer – excessive growth around acetabulum
• Cam – neck of femur abnormally shaped
©2008 Smith & Nephew, Inc. All rights reserved.
Cam
Pincer
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• Labrum - Layer of cartilage lining rim of socket
Rubbing of the bony impingement:
• causes injury or degeneration and tearing of this gasket
• Can cause locking or “catching” in joint
• MRI with dye injection needed to confirm diagnosis
©2008 Smith & Nephew, Inc. All rights reserved.
Femur Removed for Detail
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• From trauma, degenerative disease
•or friction from torn labrum
• Cause “catching” in the joint
• Not easy to detect with x-ray
©2008 Smith & Nephew, Inc. All rights reserved.
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• Articular cartilage - covers ball and socket
• Provides cushioning and protection
• over time with continued impingement, it can be torn or damaged by high impact sports, leading to degeneration
• Fragments can protrude into joint and cause pain – loose bodies
• Bone no longer protected from friction by the Cartilage and leads to arthritis and eventually a Hip Replacement
©2008 Smith & Nephew, Inc. All rights reserved.
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FAI Patient HistoryLong duration
hip/groin pain (2yrs)Painful snappingNormal x-ray
(subtle clues)Normal plain MRI
of hip and or lumbarNo response L-esb
Not AVNNot troch bursitisITB friction, psoas
tendon or iliopsoas bursitis
Intra articular source??
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FAIIntra articular
injection positiveMcCarthy’s sign C – signContrasted MRI –
30/40 false negativeOnly 60% positive
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FAI
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FAI
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Young Patient (51)With Hip pain
???THA
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NORMAL
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FAILead to cartilage
wear arthritisArrest or stop the
impingement process
goal is to preserve the native hip joint as long as possible
Postpone or avoid THA
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Chondral Damage - Arthritis
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Treatment is designed toDelay or Prevent OA and THA
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SO WHAT ARE GOINGTO DO ABOUT IT???
treatment
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OPEN PROCEDURE FOR FAI10 yrs agoAnterior incisionAvoid nerves and arteryCut through muscles8-12 inch incision3-4 days in hospitalRisk of AVNLarge blood lossLong recovery 6-12 mthsStiffnessResults mediocre
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ARTHROSCOPY OF THE HIP
8-10 yrs agoBegan using a tool
adapted from the knee and shoulder
3 or 4 small incisions
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ARTHROSCOPY OF THE HIP
New techniqueMANY ADVANTAGES
– open techniqueOutpatient surgeryImproved resultsQuicker recoveryLess painMajor advancement :
Alex Rodriquez
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Arthroscopy as toolAble to visualize
pathologyTreat pathology
Less spaceLonger distance
from the skinCurved joint surfaceTechnically difficult
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HIP ARTHROSCOPY
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Normal Articular Cartilage
VisualizeCartilage,FoveaLoose bodies
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Labrum
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Early Chondral Delamination
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Chronic/Degenerative Tear90%
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Labral Resection
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Labral Resection
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Lateral and Medial limitsof the Resection
mediallateral
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Resected Labrum
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•• 10% tears are repairable
•THE Labrum may be repaired - anchors and sutures
•Smooth edges of labrum - shaver blades or RF energy
•Remove torn tissue
•Repair with suture anchors
©2008 Smith & Nephew, Inc. All rights reserved.
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Labral Repair
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REPAIR OFTORN LABRUM
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REPAIRED LABRUM
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Peripheral Compartment
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Femoral Osteochondroplasty
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Re-establish Head-Neck Offset
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FEMORAL OSTEOCHONDROPLASTY
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PostopResection Crutches x 72 – One Crutch X 4
weekscycling at pod 2Full ROM pod 2Quad and Abductor
@ one weekSports 2 mths
Labral Repair – crutches TTWB 4-6
weeksNo ER – damage
repairFlexion on cycle ok
one week6 weeks begin
rotationSports 3-4 mths
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• Relieve pain
• Improve joint stability
• Remove loose bodies
• Repair tears and damage
• May delay onset of osteoarthritis
• May delay need for total hip replacement
• Improve quality of life
• Optimize activities of daily living
©2008 Smith & Nephew, Inc. All rights reserved.
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Return to sportsIndividualize
3-4 mths
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QUESTIONS???