Hip Arthroscopy

1. Hip Arthroscopy Kennan Vance, DO

2. Disclosures

3. Road Map • Anatomy • Femoroacetabular Impingement • History • Hip-Spine Syndrome • Physical Exam • Treatment • Other Hip Disorders

4. Problem On average, Patients with labral tears see an average of 4 physicians over a period of 2 years before the appropriate diagnosis is made JBJS 2006; 88: 1448-57

5. Bony Anatomy • Ball and Socket type synovial joint • Femoral Head and Neck • Acetabulum

6. Labrum • Horseshoe shaped fibrocartilage structure with attachments inferiorly to the transverse acetabular ligament • No intrinsic blood supply-comes from capsule and synovium • Multiple nerve endings have been found within the labrum. (unlike the meniscus in the knee)

7. Labrum Cross Section • The Labrum and the Cartilage on the Acetabulum run together. Thus a tear in the labrum, usually disrupts the cartilage from the bone and causes a “delamination” injury. • Watershed zone for blood supply Cartilage Labrum Arthroscopy 2005; 21: 6

8. Labral Function • Increases articular surface area 22% • Increases acetabular volume by 33% • Contributes to joint stability in extremes of motion • Provides a “seal” to the central compartment

9. Benefits of Labral Seal • Resists distraction of femoral head from socket due to negative intra-articular pressure • By maintaining fluid in central compartment, it allows more even distribution of compressive forces • Provides nutrition to the articular cartilage and allows for a smooth gliding surface • Allows for a low-friction environment by sealing fluid in central compartment • With loss of “seal” it may increase joint compressive forces, increase joint friction, and lead to earlier OA

10. Labral Tear Mechanism • Traumatic (<50%) • External force to extended and ER hip • Pivoting sports • Degenerative • 90% of atraumatic labral tears have bony abnormalities • Femero-Acetabular Impingement (FAI) • Dysplasia

11. FemoroAcetabular Impingement(FAI) Cam lesion • Bony Mismatch of ball and socket joint • Cam Lesion is an oval shaped femoral head • Pincer is an overhang of the acetabulum • Mixed lesion most common • With hip rotation the ball and socket have abnormal contact pinching and tearing the labrum Pincer

12. Consequences of FAI • The abnormal contact leads to labral tears and cartilage lesions; which contributes to the breakdown of the joint and arthritic changes

13. Treatment of FAI • Traditionally done with an open surgical hip dislocation with osteotomies performed. • Arthroscopy has now replaced this method with less invasive approach, less damage to head blood supply, less infection, etc.

14. Road Map • Anatomy • Femoroacetabular Impingement • History • Hip-Spine Syndrome • Physical Exam • Treatment • Other Hip Disorders

15. History • Groin, Anterior, and Thigh Pain • Pain with hip flexed and IR (impingement) • Pain with sitting • Pain and catching with stairs or rising from a seated position • Back and SI joint pain • Extra-articular hip complaints • “hip dislocates” • “pops or snaps really loud” • Pain on lateral side of hip; “can’t sleep on that side”

16. Hip-Spine Syndrome • Term first used in 1983 to describe patients with coexisting hip arthrosis and Lumbar Spine Disease (LSD) • Many studies to support improvement in LSD after THA. • Paucity of research on implications for treatment of prearthritic hip disease • Recent systematic review found that pts with LSD frequently have decreased hip ROM and patients that undergo THA with concomitant LSD routinely improve postoperatively. • Many authors hypothesize that alterations in hip ROM lead to increased stress on SI joint and lumbar spine and development of pain. • Concluded that LSD is not a contraindication to THA. • Now we need to study effects of arthroscopy in presence of LSD Redmond et al, Arthroscopy 2014; (30) 872-81

17. Its not the Back • Groin pain often distinguishes btwn 2 causes • Khan et al report 84% sensitivity and 70% specificity for hip etiology and groin pain • Pts with groin pain are 7times more likely to have hip disorder only or hip/spine disorder than just a spine disorder • Pain radiating down the thigh is classic for hip pathology • Pain radiating below is usually considered spine in origin, they found 47% of hip pts demonstrated this • Lateral hip pain presents a problem and can be both Ann R Coll Surg Engl2004;86(2):119-121

18. Physical Exam • Difficult at best; an art in evolution • Lots of overlap with SI joint, back, or extra-articular problems • Starts with inspection, palpation, ROM, and then special tests • FADIR or Impingement test is workhorse

19. Physical Exam • Resisted SLR or “Active Compression Test” • FABER for SI joint and tight Iliopsoas • Dynamic Internal Rotation Impingement Test (DIRIT) • Dynamic External Rotation Impingement Test (DEXTRIT) • Intra-articular injection • 87% sensitive and 100% specific for hip OA vs LSD

20. Imaging • Xrays • MRI with intra-articular contrast is the best imaging we currently have • MRI can miss labral tears! • Not great for cartilage lesions or “wave signs” • Arthroscopy is the gold standard for diagnosing tears and other lesions

21. Road Map • Anatomy • Femoroacetabular Impingement • History • Hip-Spine Syndrome • Physical Exam • Treatment • Other Hip Disorders

22. Arthroscopy • First performed in the 1970’s. • Slow to catch on due to several factors including difficulty and instrumentation • Now more widely accepted and better understanding of hip pathology has progressed the art of hip arthroscopy • Surgeons are continually pushing the spectrum of diseases that can be treated with arthroscopy. • Labral repairs and reconstructions, FAI resection, Gluteus medius repairs, IT band releases, cartilage disorders, etc.

23. Who is a good candidate? • Non-arthritic joint (>2mm joint space) • 43% underwent THA within 3 yrs with <2mm. (10 times more likely than if >2mm) • No significant hip dysplasia • BMI less than 35 ideally but more important is body morphology • Non-osteoporotic • Reasonable expectations

24. Post-op Xrays

25. Results • SR and MA in 2018 • 1981 hios in 1911 pts with FAI • Reoperation rate of 5.5% with 29mos (+/-14) Follow-up • 87.7% return to sport • 1.7% complication rate • All PRO scores improved significantly (AJSM Jan 26, 2018) • When do they improve? • Majority improve within 3 months, but QoL, RTS, and pain can improve up to 2 years (AJSM Sept 2018)

26. Return to Play • No Peer reviewed and tested RTP guidelines. Left up to discretion of rehab team and physician • 84% RTP at avg 7.4 months with mean f/u of 24 months (AJSM March 2018) • Another study showed only 57% RTP at preinjury level. • Only 1/3 of these reported their performance as optimal (AJSM Aug 2018)

27. Complications • Rate of 1.3-6.4% • Usually minor and transient • Traction Neuropraxia to sciatic and pudental nerve • Damage to LFC nerve • Intra-articular damage from surgery • Heterotopic Ossification • Naprosyn 500mg bid reduced incidence from 25% to 5.6% • No prophylaxis after mixed resections were 16X’s more likely to develop HO AJSM 2014;42(6) 1359-64

28. Factors Associated with Failure • Older age • Presence of arthritic changes • Longer duration of symptoms • Worse preoperative pain and functional scores • History of smoking • Mental illness

29. Other Hip Conditions Treated with Arthroscopy • Synovial Disease • Loose Bodies • Iliopsoas release • Internal Snapping hip • Adhesive Capsulitis • Chondral Lesions • Joint Sepsis • Ruptured Lig Teres • External Snapping Hip • Greater Trochanteric Pain Syndrome

30. Greater Trochanteric Pain Syndrome • Pain on lateral aspect • Can be first symptom of arthritis or other hip problems • Bursitis • Gluteus Medius/Minimus Tears • Calcific Tendinitis

31. Thanks