hip injuries in the athelete+arthroscopy of the hip

Bill Bose, M.D.Advanced Orthopaedics, LLC

Providence Medical Park Plaza

Suite B 114

HIP INJURIES IN THE ATHELETE

ARTHROSCOPIC TREATMENT OF FAI

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

HIP AND PELVIS ANATOMY

• 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

HIP JOINT ANATOMY

Strength and Stability

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

Contusions of Hip

“Hip Pointer”contusion of soft

tissue and bone where minimal soft tissue covering over the bone.

Iliac crestGreater trochanter

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

Stress Fractures

“Micro-cracks”“Overuse”Pain with weightUsually no surgery

required.

TRAUMATIC DISLOCATION

BO JACKSONFemoral head comes

out of the socketAbrades of cartilage,

tears labrumLead to post-

traumatic arthritis or AVN

Shortened and IRSurgical emergency

HIP SOCKET FRACTURES

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”

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

ACUTE MUSCLE STRAINS

Iliopsoas “hip flexor” strain

Can be acute due to explosive muscle

contraction of the Hip Flexor muscles

soccer

Overuse Injuries

Tendon injury due to repetitive micro trauma to the tendon - tendonitisIliopsoas tendonitis or “Snapping Hip

Syndrome”Rectus Femoris

tendonitis

Sprinters, kickers

Hip Overuse Syndromes

ITB friction syndrome or “Bursitis”CrestTrochanterTightness

Runners

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

SacroilitisInflammation of the

SI jointGradual onsetFigure of 4Buttock or lower

back

FAIFemoroacetabular Impingement

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”

HIP ARTHROSCOPYTremendous

advancementhip

arthroscopy – 3-4 ½” incisions

Diagnose and treat hip pain

• 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


Cam

Pincer

• 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


Femur Removed for Detail

• From trauma, degenerative disease

•or friction from torn labrum

• Cause “catching” in the joint

• Not easy to detect with x-ray


• 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


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??

FAIIntra articular

injection positiveMcCarthy’s sign C – signContrasted MRI –

30/40 false negativeOnly 60% positive

Young Patient (51)With Hip pain

???THA

NORMAL

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

Chondral Damage - Arthritis

Treatment is designed toDelay or Prevent OA and THA

SO WHAT ARE GOINGTO DO ABOUT IT???

treatment

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

ARTHROSCOPY OF THE HIP

8-10 yrs agoBegan using a tool

adapted from the knee and shoulder

3 or 4 small incisions

ARTHROSCOPY OF THE HIP

New techniqueMANY ADVANTAGES

– open techniqueOutpatient surgeryImproved resultsQuicker recoveryLess painMajor advancement :

Alex Rodriquez

Arthroscopy as toolAble to visualize

pathologyTreat pathology

Less spaceLonger distance

from the skinCurved joint surfaceTechnically difficult

HIP ARTHROSCOPY

Normal Articular Cartilage

VisualizeCartilage,FoveaLoose bodies

Labrum

Early Chondral Delamination

Chronic/Degenerative Tear90%

Labral Resection

Lateral and Medial limitsof the Resection

mediallateral

Resected Labrum

•• 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


Labral Repair

REPAIR OFTORN LABRUM

REPAIRED LABRUM

Peripheral Compartment

Femoral Osteochondroplasty

Re-establish Head-Neck Offset

FEMORAL OSTEOCHONDROPLASTY

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

• 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


Return to sportsIndividualize

3-4 mths

QUESTIONS???