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Hip Arthroscopy and Physical Therapy in Joint Preservation

Hip Arthroscopy and Physical Therapy in Joint Preservation. Daniel S. Lamar M.D. Hip Arthroscopy- Goals. Relieve Pain Improve function Improve Longevity???. Hip Preservation. Central premise- Improve the mechanical issues that predispose the joint to developing arthritis

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Hip Arthroscopy and Physical Therapy in Joint Preservation

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  1. Hip Arthroscopy and Physical Therapy in Joint Preservation • Daniel S. Lamar M.D.

  2. Hip Arthroscopy- Goals • Relieve Pain • Improve function • Improve Longevity???

  3. Hip Preservation • Central premise- Improve the mechanical issues that predispose the joint to developing arthritis • Essentially need to change the mechanics of the ball and socket in order to reduce continued injury

  4. Factors associated with Pathologic Mechanics • Dynamic • loss of offset and sphericity at HN junction (CAM) • Acetabular overcoverage, focal or global (Pincer) • Instability, posterior subluxation • Static • acetabular undercoverage (dysplasia)

  5. Hip Pathology and Treatment • CAM lesion- remove bump/ improve sphericity • Pincer lesion- Rim trimming vs femoral osteoplasty • Labral Tear- Repair vs debride vs reconstruct • Instability- Capsular plication vs PAO • Dysplasia- Debride vs PAO • Arthritis- Symptomatic relief/debride vs THA • Cartilage defects- Microfracture, OATS, Rim trim

  6. Diagnosis • Make the correct diagnosis! • Ensure that the hip is the source of pain • H+P (C sign) • Diagnostic injection • Then ID which structure/issue within the hip is the culprit and its source of origination

  7. Diagnosis • MRI can under appreciate severity of cartilage injury • MRA is better, but not perfect- great at demonstrating magnitude of labral pathology • CT scan with 3D recon is a great preop tool

  8. Labral Tear • Most common source of pain in non-arthritic hips • Associated with FAI 87% of the time (Wenger CORR 2004)

  9. FAI • CAM Pincer

  10. CAM/Pistol Grip • Overstuffing of anterolateral joint • Younger, athletic males • Short fem neck, SCFE • Usually see cartilage delamination with labral tear • Femoral cartilage usually spared until late

  11. Pincer • Pincer • tends to spare cartilage early • contra coup post cartilage wear • herniation pits femoral neck • local overgrowth vs global protrusio vs acetabular retroversion

  12. Treatment- Hip Preservation • Involves correctly identifying injury pattern • Removing bony overgrowth (3D CT scan) • Repairing labrum vs debride -suggestion that restoring the seal by repairing labrum if at all possible can decrease degenerative progression Larsen, Am J Sports Med 2012. • Treating established cartilage injury

  13. Outcomes • Gupta, Am J Sports Med. 2015, 2yr f/u results on primary hip arthroscopy • 595 pts • Improved HHS 61.29-82.02 • 7.7% revision scope, 9.2% conversion to THA • Linder, Arthroscopy. 2015, 2 yr f/u outcome on age-matched controls • Ave age 20.3 vs 54.8 • HHS 62.9-84.2 vs 61.2-82.2 • Survivorship 98% vs 82.7%

  14. Outcomes • Domb, Arthroscopy 2015, How much arthritis is too much? • reviewed 518 articles, 15 included,2,051 hips, age 40.2 • 1,195 had some sign of cartilage damage • 345 converted to THA (duration of f/u)

  15. Postop Rehab- Phase 1 0-3 weeks • Protect repair • Reduce pain • Avoid muscular inhibition • Foot down WB x 2 weeks • ROM limitations • ext-flex 0-90 degrees • IR- 0, ER 20-30 • Exercises • Isometrics, bike no resist,

  16. Phase 2 • 3-6 weeks • Goals • Protect repair • Restore FROM • Normalize gait • Begin strengthening • Balance progression • No forced stretching so avoid stress to repair

  17. Phase 3 • 6-10 weeks • Goals • Full hip ROM • Normal gait • Strengthening continued with emphasis on glut med • Step and squat progression

  18. Phase 4 • 10-12 weeks • Goals • Restore full muscle strength and endurance • Restore cardio • No contact activity • Avoid mobs and aggressive stretch

  19. Phase 5 • 12+ weeks • Sport specific training • Agility • Advance back to activities as tolerated

  20. Take Away Points • Making the correct diagnosis is not always easy, but critical • Our understanding of hip kinematics and the mechanics of pathologic progression has improved dramatically • Instrumentation and surgical technique are allowing us to tx and hopefully prevent more pathology than ever • The literature regarding disease progression and the effects of arthroscopy to modify that course is growing, but in its infancy.

  21. Take Away Points • Hip arthroscopist less excited about surgery with existing arthritis at any age • Hip Arthroscopy has excellent outcomes in the well selected patient • THA has excellent results, and seem to be improving in younger patients

  22. Thank You

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