Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique

Cherry Blossom Seminar Sports Medicine and the Aging Athlete

2014

Andrew B. Wolff, MDWashington Orthopaedics and Sports Medicine

Washington, DC

Femoroacetabular Impingement: a risk factor for hip pathology and pain

Femoroacetabular Impingement

• Wenger et al. showed that 87% of patients with labral tears had underlying structural abnormalities (Wenger et al. CORR 2004)

• Ganz and colleagues introduced the concept of Femoroacetabular Impingement (FAI) as a cause of hip pain, labral tears, and early osteoarthritis(Ganz et al. CORR 2003)

CAM & PINCER ImpingementCAM & PINCER Impingement

PincerCAM

Espinosa et al J Bone Joint Surg 2006; 88-A: 225-239

Acetabular Labrum• Extends the

acetabulum beyond the bony socket

• Is present around the entire lunate surface of the acetabulum

• Is continuous with the transverse acetabular ligament inferiorly

FAI: FAI: Pincer TypePincer Type

contre-coup

contre-coup

FAI: FAI: Cam TypeCam Type

Indications

Is my diagnosis correct?

Is my diagnosis correct?

• History and Physical are critical

• Understand concomitant disease (i.e., core muscle injury, lumbar spine pathology, muscle strains, etc.)

• Understand that there is often a mixed picture of symptoms such as sacroillitis, peri-pelvic tendinitis, ischial or troch bursitis

• Traumatic vs. Insidious– Twisting or torqueing

– Subluxation

– Dislocation, associated fracture

• Congenital / Developmental– DDH, Perthes, SCFE

• Other– Infection, PVNS, Osteonecrosis, Synovial

Chondromatosis

History

32

Confirming the source of pain

• History

– Is it predominately lateral or posterior?

– Or is it in the groin?

– Pain and/or numbness going down the leg?

“C” Sign

Confirming the source of pain

• History – What causes the pain?

• Twisting

• Running

• Prolonged sitting– Plane rides/ long car

rides

• Walking uphill

• Getting in/out of car

• Achy night pain?

Confirming the source of pain

• Many patients don’t follow the textbook– Combined back and

groin pain

– Troch and groin pain

– Butt and groin pain

– Groin pain but negative anterior impingement sign

– Achy night pain

“Anterior Impingement Test”Passive flexion to 90°

followed by forced adduction and IR

Leunig et al. Op Tech Orthop 2005

FABER Test

Vad et al. Am J Sports Med 2004

Confirming the source of pain

• Diagnostic injections

– Physical exam

– Inciting activities

– Pain diary

Indications

Is my diagnosis correct?

Do the patient’s current symptoms/limitations warrant surgical

intervention?

Do the patient’s current symptoms/limitations warrant

surgical intervention?

•If it doesn’t hurt, don’t operate

Do the patient’s current symptoms/limitations warrant

surgical intervention?

•No evidence for prophylactic FAI correction

•Possible exception of SCFE

Indications

Is my diagnosis correct?

Do the patient’s current symptoms/limitations warrant surgical

intervention?

Does this patient have osteoarthritis?

Osteoarthritis

• Cannot be cured with arthroscopy

• 2 mm rule (Philippon et al AJSM 2010)– Not applicable to women– Is it applicable at all?– High resolution MRI

• Role for chondral restorative procedures in chondral defects

Indications

Is my diagnosis correct?

Do the patient’s current symptoms/limitations warrant surgical

intervention?

Does this patient have osteoarthritis?

Does this patient have dysplasia?

Dysplasia

• Undercovered hips cannot be cured arthroscopically– Measure LCEA, ACEA, acetabular inclination

and femoral neck shaft angles on all patients • Consider acetabular and femoral version

– Definite role for arthroscopic treatment of borderline dysplastics

– How much dysplasia is too much?

Pincer correction with labral repair

Correction of cam type FAI

Some are easier…

Pre-op Post-op

…than others

Pre-op Post-op

Conclusions

• In 2014, much can be accomplished in the hip arthroscopically

• Not all FAI and labral tears need to be fixed

• With the right indications, modern techniques yield reproducibly good results

Conclusions

• In depth understanding of the hip joint is paramount

• Advanced imaging is very helpful

• Equally important: advanced history and physical

• Use diagnostic injections

• BEWARE osteoarthritis and dysplasia!

Thank You!

andywolffmd@gmail.comcell: 202-276-9834

www.andrewwolffmd.comwww.wosm.com