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

Pincer Damage

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