Michael J. Sileo, MD, FAAOSSports Medicine Injuries

Arthroscopic Shoulder, Knee & Hip SurgeryDecember 7, 2018

NONE

Groin and hip pain is common in athletes Especially hockey, soccer, and

football 5% of all soccer injuries

Renstrom et al: Br J Sports Med 1980.

Complex anatomy and wide differential diagnoses that span multiple medical specialties make diagnosis difficult

Snapping hip Trochanteric bursitis Abductor tears Compression neuropathies LFCN (meralgia

paresthetica) Sciatic nerve (Piriformis

syndrome) Ilioinguinal,

iliohypogastric, or genitofemoral nerve

Muscle strain Adductor Iliopsoas Gluteus medius Hamstrings Gracilis

Avulsion injuries Sports Hernia Osteitis Pubis

• Extra-articular causes:

Intra-articular causes: Labral pathology Femoroacetabular impingement Chondral pathology Ligamentum teres injury Loose bodies Benign Intra-articular tumors PVNS Synovial chondromatosis

Capsular laxity Stress fracture Septic arthritis Adhesive capsulitis Osteonecrosis SCFE Transient synovitis

Soft-tissue injuries such as muscle strains and contusions are the most common causes of hip pain in the athlete

It is important to be aware and suspicious of intra-articular causes of hip pain

Up to 60% of athletes undergoing arthroscopy are initially misdiagnosed

Delay to diagnosis is typically 7 months Labral pathology may not be diagnosed for up to 21

monthsByrd et al: Clin Sports Med 2001.

Burnett et al: JBJS 2006.

Nature of discomfort Mechanical symptoms Stiffness Weakness Instability

Location of discomfort Onset of symptoms History of any trauma or developmental

abnormality

Assess gait, posture, limb-length inequality, and scoliosis

Complete neurovascular examination Active and passive hip range of motion Palpation for focal tenderness

Rare with intra-articular pathology

Full Lumbar spine, neuro exam!

“C-sign”: Hand cupped above

greater trochanter with thumb over posterior aspect of trochanter and fingers gripping into groin

Suggests intra-articular pathology

Log rolling: Pain suggests intra-articular pathology

Resisted Straight Leg Raise test (Stinchfield) Pain suggests intra-articular pathology

Thomas test: Hip flexion contracture

Patrick’s Test (FABER): Posterior pain suggests SI joint pathology Anterior pain suggests anterior capsule, labrum, or psoas

pathology

Anterosuperior Impingement Test (FADIR/Ganz): Hip is flexed, adducted,

and internally rotated Pain with most intra-

articular pathology Associated click may be

present Not specific for labral

pathology

Ganz: CORR 2003.

Fibrocartilaginous rim that overlies the articular cartilage and surrounds the perimeter of the acetabulum

Triangular in cross section Widest anteriorly and

superiorly; thickest superiorly

Bharam: Clin Sports Med 2006.

Contains free nerve endings May explain pain and decreased

proprioception

McCarthy: J Arthroplasty 2001.Kelly et al: Arthroscopy 2005.

Deepens acetabulum by approximately 21% Creates a seal of the hip joint

Maintains hydrostatic pressure enhancing lubrication Maintains negative pressure enhancing stability

Reinforces acetabular rim Contributes to containment of femoral head at extremes of motion Contributes to joint stability

Does NOT significantly participate in load transmission

Ferguson et al: J Biomech 2001

Trauma Injury or fall MVA Dislocation

Muscle weakness/imbalance FAI

Femoroacetabular impingement

Subtle osseous morphologic abnormalities result in abnormal contact between the femoral neck/head and the acetabular margin during terminal motion of the hip

Parvizi et al: JAAOS 2007.

Repetitive abnormal contact leads to labral and chondral damage

Continued progression leads to premature degenerative arthritis

Acetabular labral tears are frequently the manifestation of primary structural hip disease

Legg-Calve-Perthes disease Congenital hip dysplasia Slipped capital femoral ephiphysis Avascular necrosis Malunited fractures (acetabulum or femoral neck) Prior periacetabular or proximal femoral osteotomy Retroverted acetabulum Most patients lack a clear history for any predisposing

conditions

Parvizi et al: JAAOS 2007.

Patients typically 25-40 years of age Mean delay in diagnosis: 7-21 months Groin pain is most common complaint

Anterior groin: 92% Lateral hip: 59% Deep within the buttocks: 38%

Worse with activity, especially repetitive twisting and pivoting motions Pain with prolonged hip flexion (sitting) Pain with rising from a seated position

McCarthy et al: CORR 2003.Burnett et al: JBJS 2006.

Byrd: ICL 2007.

AP Pelvis Acetabular

Characteristics: Center edge angle Acetabular inclination Acetabular version Crossover sign

Presence of Osteoarthritis

Femoral Characteristics: Head sphericity Head-neck offset Neck-shaft angle Trochanteric height

Dunn lateral Obtained in 90° flexion

and 20° abduction Useful for evaluating: Femoral head-neck

junction Femoral head sphericity Alpha angle Congruency

Normal acetabular labrum has uniformly low signal intensity and a sharp triangular morphology

Sofka et al: Op Tech Sport Med 2007.

Sensitivity increased compared to MRI, but false-positive rate also increases Sensitivity: 57-95% Specificity: 75% False-Positive rate: 20%

Byrd et al: AJSM 2004.

Burnett et al: JBJS 2006.

Radiologically-guided intra-articular local anesthetic injections (easily performed in conjunction with MR arthrography) are useful to assess whether pain is intra-articular

**Transient pain relief is a 90% reliable indication of intra-articular pathology

Byrd et al: AJSM 2004.

Initial trial of non-surgical treatment Activity modification including restriction of athletic

activities NSAIDs Usually fails to control the symptoms

In an attempt to prevent progression of arthritis, surgery is recommended if non-surgical treatment fails

Fitzgerald: CORR 1995.Byrd: Arthroscopy 1996.

Kelly et al: Arthroscopy 2005

Post

LABRAL TEAR LABRAL REPAIR

52 patients underwent arthroscopic labral repair Mean follow-up: 9 months – overall improvement in HHS Long term follow up needed

Hines et al: Arthroscopy 2007.

158 patients underwent arthroscopic surgery for FAI 50% pain resolution by 3 months 95% pain resolution by 1 year

Sampson: Tech Orthop 2005.

45 professional athletes with FAI 49% Cam lesions 7% Pincer lesions 44% Combined Cam and Pincer

42 athletes (93%) returned to professional competition 3 athletes who did not return to play all had diffuse

osteoarthritis 35 athletes (78%) remain active in professional

sport at an average follow-up of 1.6 years

Philippon et al: KSSTA 2007.

100 hips (mean age 34.7 years) with FAI treated with arthroscopic management

Follow-up at mean 9.9 months 75% good/excellent results 3 patients required total hip arthroplasty

All had grade 4 chondral injuries > 2 cm on acetabulum

Larson et al: Arthroscopy 2008.

Long term studies are needed to see if alteration in the natural progression to osteoarthritis and sustained pain relief can be achieved with arthroscopic management of FAI

CPM immediately post op 30-70 deg hip flexion (debateable)

Immediate PWB with crutches x 2-4 weeks Start PT immediately for AA/PROM, Strengthening

Indocin 75 mg PO daily 10-14 days Decreased incidence of HO

Baby ASA, chemical DVT prophylaxis Patients with previous history of DVT OCPs

Minimization of hip flexor inflammation

Labral repair/Osteoplasty/Chondroplasty Flexion 0-90, abd 0-25, ER 0-25 x 2 weeks (avoid labral stress) CPM x 4 weeks (4 hours/day) Isometrics/Core Advanced strengthening once FWB 3-6weeks Single leg stance Advanced bridging Single knee bends Sidestepping w/ resistance

Stalzer et al., Operative Tech Orthopaedics, 2005

Acetabular labral tears are a common cause of hip pain.

Acetabular labral tears rarely occur as isolated pathology.

FAI is a common cause of acetabular labral tears in the athlete.

To optimize results, surgical treatment should address not only the acetabular labral tear, but also the associated pathology Chonral injury Underlying impingement

Long-term studies are needed to see if these results are durable and delay or prevent the onset of osteoarthritis.