8. fai approach to the failed hip procedure · 08.10.2015 · isha, aana, mash ... labral tears...
TRANSCRIPT
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FAI: Approach to the Failed Hip Procedure
Allston J. Stubbs, M.D., M.B.A.
Medical Director Hip Arthroscopy & Associate Professor
Department of Orthopaedic Surgery
August 16, 2015
HIP CENTER
2015 Chicago Sports Medicine Symposium Chicago, Illinois USA
• Consultant: Smith & Nephew
• Stock: Johnson & Johnson
• Research Support: Bauerfeind
• Department-‐Division Support: Smith & Nephew, DePuy-‐Mitek, Arthex
• Boards/Committees: AAOS, AOSSM, ISHA, AANA, MASH
Disclosure
Failed Hip Procedure Now What?!
• Incorrect Diagnosis
• Incorrect Procedure
• Insufficient Procedure
• Incorrect Rehabilitation
• Insufficient Biology
• New Problem/Pathology (includes iatrogenic)
Sometimes it was never an orthopaedic problem
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Hot Sexy Diagnoses
• Hip instability
• Chondrolabral dysfunction
• Gluteal tears
• Femoroacetabular impingement
• Atypical impingement: ischiofemoral/subspinous
Courtesy NBC-SNL
Hip Pain: 1990s
• Osteitis pubis
• Stress fracture
• Muscle strain/avulsion
• Sacroiliitis
• SCFE
• Arthritis
Most studies read as normal
Labral Tears are Traumatic in Origin
Hip Pain: 2010s
• Labral tear
• Femoroacetabular impingement
• Muscle strain/avulsion/core muscle injury
• Arthritis
• Cysts
• Stress fracture
Most studies read as abnormal
Labral Tears are Atraumatic in Origin
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Hip at Risk
• Contact athletes: Kinetic Chain Athlete
– Athlete’s Hip / Sports Hip
– FAI / Labral Tear / Borderline Dysplasia / Microinstability
• Extreme physiology athletes: Supraphysiologic Motion Athlete
– Dancers / Gymnasts / Acrobats / Swimmers / Cyclists / Figure Skaters / Martial Arts
– Dysplasia / Labral Tear / IFI / Macroinstability
• Special circumstances
– SCFE / LCP / Ehlers-‐Danlos
– Post-‐Traumatic: intraarticular (chondrolabral) and extraarticular (ex-‐avulsions)
– Baseball Catchers -‐ -‐> AIIS Subspinous Impingement
Sports Medicine is on front line of this epidemic
Modes of FAI Surgery Failure • Unstable chondrolabral interface
• Progressive hip OA
• Over or Under Resection Femoroplasty and Acetabuloplasty
• Iliopsoas complaints
• Capsulolabral adhesions
• Extraarticular impingement
• Instability
• Dysplasia: acetabular and femoral
• Extraarticular Other: CMI, Peritrochanteric, Sciatic, IF Space
• Autoimmune
• Neoplasm
• Rehabilitation
Modes of FAI Surgery Failure • Unstable chondrolabral interface
• Progressive hip OA
• Over or Under Resection Femoroplasty and Acetabuloplasty
• Iliopsoas complaints
• Capsulolabral adhesions
• Extraarticular impingement
• Instability
• Dysplasia: acetabular and femoral
• Extraarticular Other: CMI, Peritrochanteric, Sciatic, IF Space
• Autoimmune
• Neoplasm
• Rehabilitation
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Critical Questions
• Is the pain the same?
• Are you better or worse compared to preop?
• Response to diagnostic injections?
• What is patient expectation?
• What is surgeon expectation?
Timing of Outcomes: when to call it
History of Complaints
• Pain: Same or Different from Preop
– Same: CL interface, FAI, Extraarticular, OA
– Different: Adhesions, Rehab Related
• Mechanical Symptoms: Iliopsoas, OA
• Night pain: neoplasm, OA
• Weight bearing pain: OA, radiculopathy
Primary Decision Driver for Imaging
• History of Complaints
• Physical Examination Findings
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Nine Theories Why Does the Cartilage Tear?
Age
Dysplasia FAI SCFE
AVN
DDH
Trauma
IPI
AIIS
s/p PAO
s/p Osteotomy LCP
Inflammatory
Disease
IPI=Iliopsoas Impingement
Neoplasm
(PVNS)
s/p Instrumentation
LT Impingement
Instability
States
Clinical Evaluation of Hip
• History • Physical Examination • Plain X-‐Ray Films • MRI: dedicated hip • Diagnostic injections • Other
• CT/MRI: 3Dà4D Reconstruction • Lumbar spine work-‐up • Rheumatology work-‐up
Suspect Intraarticular Diagnosis
• Hip Pain: “C-‐sign” • Loss of range of motion: asymmetry
• Positive provocative tests
• Functional hemipelvic muscle
weakness/dysfunction
• Radiographic Findings
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Suspect Extraarticular Diagnosis
• Pelvis, Lumbar, Radiculopathic Pain
• Hip range of motion is symmetric
• Negative provocative tests
• Selective muscle weakness/dysfxn
• Soft Radiographic Findings
Physical Exam
• Inspection
– LLD
• Palpation
• Range of motion
– Symmetry
– Stress tests
• Ligament testing
• Functional Testing
• Gait
Physical Exam Keys
• Asymmetric range of motion
– Flexion
– Internal Rotation @ 90
– FABER Test
• Positive impingement test
“FADIR” Test
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Modified FABER Test
Vad et al. AJSM 2004
Imaging Tools
• Plain film
• MRI
• Fluoroscopy
• CT
• Ultrasound
Dynamic Software Analysis
Why I Avoid Contrast
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Intraarticular Failures
Capsulolabral Adhesions
Labrum
Capsule
Labral Tear s/p focal debridement
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Labral Deficiency s/p labral debridement
Capsular Defect
Subchondral Edema Consistent with Grade IV CM
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Contra-‐Coup Cyst Insidious Posteroinferior OA
RF Chondrolysis
Iliopsoas Impingement Cyst Suspect Iliopsoas Impingement
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Anchor Placement Assessment: OK Body Sagittal MRI
MRI Anchor Placement: OK
Anchor Erosion
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Anchor Cysts HA-‐PLLA anchors s/p two years labral repair
Inadequate Resection Mixed FAI
Inadequate Femoroplasty Preop
Postop #1
Postop #2
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3D CT
AFHN Jxn Edema MRI
Calcified Pincer
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Femoroplasty Over-‐resection Right Hip
Femoroplasty Over-‐resection Right Hip
Femoroplasty Over-‐resection Right Hip
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Femoroplasty Over-‐resection Right Hip
Femoroplasty Over-‐resection Left Hip
MRI Radial Reformat
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Extraarticular Failures
Left CMI on MRI
Right Inguinal Hernia
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AIIS Subspinous Impingement MRI
AIIS Subspinous Impingement
Acetabular Dysplasia False Profile
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Dysplasia Failure PRE OP POST OP
Pelvic Lymphoma
Excessive Femoral Antetorsion
+/- iliopsoas release
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Osteochondroma PreOp
PostOp
Osteochondroma
Inflammatory Arthropathy
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Role of Bone Scan
Osteoid Osteoma Spondylolysis
Summary
• History and Physical Exam still matter
• Utilize advanced imaging and analysis
• Patient risk assessment to avoid failed FAI
surgery
Thank You!
Cambridge September 2015 San Francisco September 2016
www.isha.net @ishanet