solutions for hip pain in the active patient...take home points • hip pain can be a significant...
TRANSCRIPT
Solutions for Hip Pain in
the Active Patient
Chetan Deshpande MD, FACS
Chatham Orthopaedic Associates
Savannah, GA
disclosures
• none
hip replacement
• One of the most successful orthopaedic procedures
• 350,000+ per year
• With appropriate education and pain management
length of stay is 4 -23 hours
• 90-95% success rate at 10 years
• 80-85% success rate at 20 years
take home points
• Hip pain can be a significant impediment to mobility and can greatly
impact quality of life
• In young patients FAI is a common cause of hip pain and can
decrease athletic performance
• Hip preservation procedures can improve function and prevent
early degeneration of the hip joint
• Hip resurfacing may provide a high performance option in arthritic
hips
• Alternate bearing surfaces may provide longevity in cases where
THA is the only option
hip joint anatomy
• Ball and socket joint
• femoral head - top of the
thigh bone
• acetabulum - hip socket
within the pelvis
• very stable and deep
articulation
• surrounded by ligaments and
capsule
smooth cartilage surface
smooth cartilage surface
so what?
• 64 million adults and 300,000 children
• between ages of 18-64 employed adults with
arthritis earned $3617.00 less per year vs healthy
adults
• in 1997 raw earnings losses totaled $108 Billion!
• 2003 Americans spent $80.8 Billion on healthcare
related to arthritis!
Differential Diagnosis• FAI
• Snapping hip (internal or external)
• Hip instability
• Trochanteric Pain Syndrome
• Lumbar pathology
• SI joint
• Sports hernia
• Inguinal hernia
Differential Diagnosis• FAI
• Snapping hip (internal or external)
• Hip instability
• Trochanteric Pain Syndrome
• Lumbar pathology
• SI joint
• Sports hernia
• Inguinal hernia
Femoroacetabular
Impingement (FAI)
• Abnormal contact between the
femoral head and acetabulum
• anatomical changes resulting in
altered hip mechanics
• CAM
• PINCER
FAI
• It has been seeing us longer than we have been seeing it!
• Not entirely new concept
• Stulberg et al 1975 - pistol grip deformity
• previously diagnosed primarily as a secondary condition
• SCFE - Slipped Capital Femoral Epiphysis
• LCP - Legg Calve Perthes
Normal Pincer
Cam Combined
Leunig et al. CORR2004;418:61-66
Cam Impingement
Cam Damage
Early delamination and labral tear
Late cartilage delamination
Pincer Impingement
Leunig, Ganz R. et al. Fibrocystic changes at anterosuperior femoral neck: Prevalence in hips with femoracetabular
impingement. Radiology 2005;236:237-246l
Natural History
• Developmental problem
• Often related to high intensity activity in adolescents
• Genetics? – associated in siblings, hard to separate from social
factor
• Moderate cam and Severe cam with 3.7 and 10 x’s greater
likelihood of developing OA in 5 years compared to controls
• Pincer lesions not as well correlated with OA but does cause
labral/chondral damage and pain.
Agricola R. Cam impingement causes OA of the hip: a nationwide prospective cohort study. Ann Rheum Dis 2013 72(6):918-23.
Nepple JJ. What is the association between sports participation and the development of proximal femoral cam deformity? AJSM2015 43(11):2833-40
Spectrum of Pathology: How do I work these up?
History
• Young and active (late teens to 40s)
• Insidious onset +/- mechanical sxs
• Pain is generally anterior groin (83%) but can be lateral or posterior. + C-sign.
• Pain in positions of hip flexion (sitting, squats)
• Childhood hip issues (dysplasia, SCFE, Perthes)?
• Back or SI joint issues?
Physical ExamThe Basics
• General exam of hip and back
• Hip motion – decreased IR
• Generalized laxity - Beighton’s
criteria
• Impingement test
*Exam maneuvers are sensitive
but not specific
Radiographic Assessment
Imaging findings ≠ Pain
• Review of 26 studies
• Looking at 2114 asymptomatic hips
• Athletes 37% cam, 60% pincer (variable definition)
• General population 10-20% have a cam
• Non-contrast MRI in asymptomatic patients• 43 - 68% labral tear
• 20% cam
• 24% chondral changes
Frank JM, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteeers: A Systematic Review Arthroscopy2015. 31(6):1199-
204
**Diagnostic Injection**
• 90% Accuracy of a + response
correlating with operative
findings.
• 100% Sensitive and >80%
Specific in differentiating hip
pathology from lumbar pathology.
treatment options
• Non Surgical Management
• medications
• physical therapy
• cortisone injections*
• helpful in diagnosis as well
• If all else fails hip preservation surgery may be an option
NSAIDS
• Cox 1 and 2 inhibitors (cyclo-oxygenase)
• Cox 2 may be easier on GI tract
• Cox 1 can be combined with GI protectives
• Caution with anticoagulants
• Caution with alcohol use
• Biologic Agents
physical therapy
• Many benefits
• increased joint stability
• increased flexibility
• posture
• improved strategies for
avoiding injury
• low risk!
activity modification
• FALL PREVENTION!!
When all else
fails…
Treatment Options
• Surgical Treatment
• Hip Arthroscopy
• Mini Open with Arthroscopy
• Surgical Hip Dislocation
Hip Arthroscopy: Indications
• Symptomatic labral tears and FAI treatment
• Some chondral lesions – Microfracture +/-
augment
• Instability – capsular plication
• Snapping hip – ITB/iliopsoas
• Trochanteric “bursitis” and abductor repairs
• Endoscopic hamstring repair
• Sciatic neurolysis/piriformis release
• Infection
McCarthy JC, Day B, Busconi B. Hip arthroscopy: applications and technique. JAAOS. 1995;3(3):115-122.Mason JB, McCarthy JC, O’Donnell J, etal. Hip Arthrocsopy: surgical approach, positioning, distraction. Clin Orthop
2003;1(406):29-37.
Hip Arthroscopy: Contra-indications
• Advanced degenerative joint
disease• Joint space <2mm
• Age?
• Dysplasia (LCE<20)
• Severe deformity (relative)
32yo Ranger
FAI Surgical Outcomes
• 16 Studies – 9 open (600hips), 7 Scope (1484 hips)
• Survivorship @ 8 yrs: 93%open, 91% scope
• VAS (Visual Analog Pain Score) 6.4 → 2.1
• mHHS (Harris Hip Score)59.6 → 83.0
• NAHS (non-arthritic hip score) 55.3 → 78.2
• HOS (Hip outcome score –sports specific) 45.3 → 77.5
• Improves function and pain
• Saves the hip?
Nwachukwu BU. Arthroscopic versus open treatment of FAI a systematic review of medium and longterm outcomes. AJSM2015.
hip resurfacing
• Designed for patients who have
end stage hip arthritis but wish
to maintain an athletic lifestyle
• limited by the patients bone
quality and size
• fewer limitations on activity
once healing is complete
hip resurfacing
• FDA approved in 2006
• large diameter metal head in
metal cup
• bigger surgical insult in order to
preserve bone
hip resurfacing
• designed to conserve patient’s
own bone
• important in younger patents
• designed to allow return to
impact activities
hip resurfacing outcomes
• single surgeon series of 1000 hips
• mean 13.7 years follow up
• 97% implant survival rate at 10 years and 95%
at 15 years
• questionable return to full athletics for some
patients
Results of Birmingham hip resurfacing at 12 to 15 years
a single-surgeon seriesJ. Daniel, C. Pradhan, H. Ziaee, P. B. Pynsent, D. J. W. McMinn
Published Online:1 Oct 2014https://doi.org/10.1302/0301-620X.96B10.33695
Colby Lewis
The Undertaker
Ed Jovanovski
hip replacement
• one of the most successful
surgical procedures
• non cemented fixation
• alternative bearing surfaces
may improve longevity in
younger active patients.
Summary
• Hip pain in the young active patient is a significant source of
dysfunction and lost quality of life
• FAI is evolving to be a primary source of hip dysfunction and if
recognized and treated can result in prolonged high level
function of the native hip
• In cases where hip preservation is not possible HRA may
provide an option that allows continued athletic performance
• In cases of deformity and advanced arthritis hip replacements
with alternative bearing surfaces can be an option
thank you
hip replacement
• Acetabulum
• usually consist of 2 parts
• metal socket
• liner - plastic, ceramic,
metal
hip replacement
• Femoral stem
• designed to sit within the
femur bone and support the
ball
• coated for ingrowth
• can be cemented into place
anterior?
posterior?
which way do
we go?
posterior
• Approach from the back of the
hip
• traditional
• extensile
• excellent exposure
• cutting through and detaching
muscles
posterior
• Problems
• slower recovery
• limitations of motion initially
• higher risk of dislocation
• more reliant on cane or walker intially
posterior
• Tried and true method
• Can be done through small
incisions
• New technology and
refinements have decreased
dislocation dramatically
Anterior approach
• Not really that new!
• Carl Heuter - 1881
• Smith-Petersen - 1917
• Robert Judet MD - 1950’s
Anterior approach
• Approach Hip from Front
• Muscle sparing
• move muscles rather than
cutting them
• internervous
Anterior approach
• Approach Hip from Front
• hip is closer to the front of the
body
• no muscles detached from
bone
anterior approach
• So why did we get away from it?
• Technically difficult
• development of special tools and instruments
• evolution of hip implants
Anterior approach
• Approach is made easier by the
use of a special operating table
• Can be done without
Anterior approach
• Advantages
• ability to get live X-ray during
surgery to assess leg length,
offset and mechanical
parameters
anterior approach
• Advantages
• no limitations on mobility
post op
• less reliance on devices
• lower risk of dislocation*
• faster initial recovery
Summary
• Hip arthritis is a debilitating condition
• Hip Replacement is an excellent treatment option
when non surgical methods have failed
• Anterior hip replacement provides faster recovery
and less tissue damage
• Hip resurfacing may be a great option for select
patients who want to maintain an athletic lifestyle.
hip arthritis
• affects hundreds of thousands of patients every year
• results in pain, stiffness, and decreased motion at the
hip joint
• often occurs in conjunction with arthritis at other joints
• knees
• lower back
hip arthritis
• inflammation of the hip joint
• wear and tear
• loss of cartilage
• trauma
• infection
• other disease processes
• rheumatoid, psoriasis