The Athletic Hip - PDF document

The Athletic Hip : Common Diagnoses and Minimally Invasive Treatments Sanjeev Bhatia MD Orthopaedic Surgeon - Sports Medicine Co - Director, Hip & Knee Joint Preservation Center Northwestern Medicine West Region Team Phys

ician, Northern Illinois University Disclosures No Pertinent Disclosures to this Talk • Royalties with Nova Publishing - Ligamentous Injuries of the Knee , BMJ Publishing Group - “aedial Collateral Ligament Injuriesâ€

 • Stock and Ownership – Joint Preservation Innovations, LLC; Vericel ; Intuitive Surgical, EDGe Surgical • Consultant – EDGe Surgical Hip and Knee Joint Preservation: Because there is no substitute for yo

ur own joints Why Joint Replacements are not Good for Younger People Surgical Risks Infection Fracture Dislocation Blood clots Functional Limitations Permanently low demand Altered mechanics with any artificial joint N

eed for revision surgery Costs to Society Costs of Joint replacement surgery Costs of revision surgeries Costs of complications Economic loss of productivity “Nothing is as good as the original” Hip Pain is Common

Early Hip pain suffers a significant inequality!  400,000 Total Knee Replacements  600,000 Total Hip Replacements  Over 1 Million Knee Arthroscopies  Over 600,000 Shoulder Arthroscopies  70,000 Hip Arthrosc

opies 2013 Data Causes of Hip and Groin Pain – Anterior Hip Pain • Muscle strains • Contusion (hip pointer) • Avulsions and apophyseal injuries • Hip dislocation/subluxation • Acetabular labral tears and loose

bodies • Proximal femur fractures • Osteitis pubis • Iliopsoas bursitis • Stress syndrome • SCFE • Perthes disease • Developmental dysplasia • Osteoarthritis • Inflammatory Arthritis • Avascular Necrosis

• Femoro - acetabular Impingement – Lateral Hip Pain: • Greater trochanteric bursisits • Gluteus medius / minimus tear • ITB syndrome • Meralgia paresthetica – Posterior Hip Pain • Lumbar spine abnormalit

ies • Compression neuropathies • Piriformis syndrome • SI joint pathology • Ischial bursitis • Proximal hamstring strain/rupture – Other Causes of Hip Pain: • Abdominal (sports hernias and athletic pubalgia ,

inguinal hernias, appendicitis) • Gynecologic (ovarian cysts, PID, pregnancy) • Urologic (testicular, scrotal) • Genitourinary (kidney stone, nephritis) Burnett, Clohisy et al. JBJS 2006 • Average time from inju

ry to accurate diagnosis 21 months • Average of 3.3 providers seen before definitive treatment Diagnostic Approach  Many sources of potential pain – So, what is the best way to tackle hip pathology? 1. Know y

our anatomy! 2. Identify the Location or Area of Discomfort Intra - articular cause Extra - articular cause Microinstability Referred Pain Painful Hip AcePaNulum Up Flose…. Acetabular Labrum • Deepens the socket â€

¢ Provides a fluid seal • Injured at the chondro - labral junction • Critical for normal hip function Hip Capsule – Zona Orbicularis increases stability during extension Zona orbicularis (thick ring in capsule) tig

htens in extension Courtesy of Damian Griffin MD (United Kingdom) JBJS Am 2014 BMC Musculoskeletal Disorders 2014 Clinical & Radiographic Evaluation Diagnostic Approach  Many sources of potential pain – So, what is

the best way to tackle hip pathology? 1. Know your anatomy! 2. Identify the Location or Area of Discomfort Layered Understanding of the Hip Osteochondral Layer Femur/Acetabulum Dynamic Impingement (FAI) Static Overload

(Dysplasia) Inert Layer Labrum, Capsule, Ligaments Dynamic Layer All musculature Pain from entesopathies Neural Layer Nerve compression syndromes, referred pain Curr Rev Musc Med 2012 Posterior / Buttock Lateral Ant

erior / Groin Anterior Hip Pain Anterior Hip Pain • Extra - articular • Intra - articular Anterior Hip Pain • Extra - articular • Intra - articular Extra - Articular Anterior Hip Pain: Hip Flexor Strain / Iliopsoas

Tendinitis • Anterior hip or groin pain, F�M • Aggravated with activity, relieved with rest • Pain with rising from a seated position, walking up stairs or inclines, brisk walking • Pain may radiate down

the anterior thigh toward the knee. • Report an audible snap or click in hip or groin = Internal Snapping Hip Extra - articular Anterior Hip Pain: Hip Flexor Strain / Iliopsoas Tendinitis Internal Snapping Hip Iliopsoa

s Tendon snaps over Acetabular rim / AIIS “Can hear it” Treatment 1. Anti - inflammatories 2. Injections 3. Physical Therapy 4. Surgery rarely indicated 91% elite ballet dancers with painless snapping Anterior Hip Pain

• Extra - articular • Intra - articular  “C” sign  Groin – 75%  Worse with: • start - up activities • prolonged sitting • prolonged activity or sports • uphill, putting on shoes • getting in a

nd out of car  Can be ATYPICAL! • Associated symptoms  Catching or locking  Instability  Stiffness Intra - Articular Hip Pain Most Common Causes of Intra - Articular Hip Pain If the age of the patient is:

• �50 years, think: – Osteoarthritis • years, think: – Femoroacetabular Impingement (FAI) – Labral Tear  Anterior Hip Pain  Muscle strains  Contusion (hip pointer)  Avulsions and apophyseal inj

uries  Hip dislocation/subluxation  Acetabular labral tears and loose bodies  Proximal femur fractures  Osteitis pubis  Iliopsoas bursitis  Stress syndrome  SCFE  Perthes disease  Developmental d

ysplasia  Osteoarthritis  Inflammatory Arthritis  Avascular Necrosis  Femoroacetabular Impingement Why do young patients (ages 20 - 50) with apparently normal anatomy develop arthritis of the hip? • Hip cond

itions, in most cases, can be though of as being on a spectrum • Conditions range from preclinical disorders with early symptoms and radiographic findings to those that result or have led to clear degeneration of the hip

Normal Hip • Good cartilage and labrum Preclinical Hip problems • Femoroacetabular impingement (FAI) with Labral Tear • Acetabular Dysplasia End stage arthritis • Complete loss of joint space • "Bone on Bo

ne" arthritis Cam Dominant Femoroacetabular Impingement (FAI)       ”Pistol Grip” Femur - Stulberg and Harris 1975 • Stulberg SD , Cordell LD, Harris WH, Ramsey PL, MacEwen GD. Unrecognized ch

ildhood hip disease: a major cause of idiopathic osteoarthritis of the hip. In: The hip: proceedings of the third meeting of the Hip Society. St. Louis, MO: Mosby, 1975:212 – 228. • FAI occurs when the femoral nec

k and acetabular rim abut at the extremes of motion due to deformity of the femoral neck (CAM), acetabulum (pincer), or both • FAI leads to early OA • Prevalence of FAI = 15% • Up to 70 - 90% of ALL hip arthri

tis cases thought to be caused by FAI or hip dysplasia British J Sports Med 2016 - Best summary on FAI syndrome for patients, healthcare providers - International consensus statement British J Sports Med 2016 What is FAI

syndrome? • A motion - related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. • It represents symptomatic premature contact between the proximal femur and the acetabul

um Femoroacetabular Impingement  Due to a mismatch between ball (femoral head) and cup (acetabulum) CAM Lesion Femoroacetabular Impingement • Due to a overcoverage of the acetabulum with a normal femoral head/

neck Pincer Lesion Etiology of FAI  Genetic / Inherited ➢ Siblings of patients with CAM deformity have 2.8x RR of having same deformity ➢ Siblings of patients with Pincer deformity have 2.2x RR of having same defor

mity (Pollard JBJS Br 2010) • Acquired • Athletes with Open physes  increased risk of CAM lesion compared to non - athletes  85% of patients with sxatic FAI have bilateral bone abnormalities, 25% symptomatic

on other side Femoroacetabular Impingement  Typical patient: ➢ Young Active Adults ➢ Athletes ➢ Runners ➢ Dancers Symptoms  Anterior Hip

/ Groin Pain  Worse with flexion activities, sitting for long periods of time  Limited motion (flexion, IR)  Clicking or locking of the hip or a feeling of hip suddenly “giving out.” British J Sports M

ed 2016 Clinical Signs • Hip impingement tests usually reproduce pain • The most commonly used test, FADIR test, is sensitive but not specific • There is typically restricted internal rotation in flexion. Clinical

Exam British J Sports Med 2016 Diagnostic imaging • An AP pelvis and a lateral femoral neck view • Can quickly review joint space, identify cam or pincer morphologies • Advanced imaging shows cartilage, labral le

sions, and bone pathology Always Assess Joint Space on a Standing AP Radiograph – Make sure arthritis not already advanced! Measure this space Ideally wan�t 3mm Joint space with no subchondral cysts CAM Deform

ity  On plain AP radiographs, this pathology may easily be missed. CAM Deformity • Alpha angle on Dunn lateral radiograph . – Normal = 42º – �CAM 50º • Alpha angle = Poor interobserver reliability (0.

40) Nepple , Philippon AJSM 2014 a Nötzli , H et al. JBJS, 84 - B :556, 2002. MRA and CT • MRI: – Labral tears – Articular cartilage lesions – Herniation pits – Sensitive + Specific for Chondral Lesions but

not labral pathology • CT (Preoperative Planning): – Detailed bony anatomy – Acetabular and femoral neck road map Treatment British J Sports Med 2016 What is the appropriate treatment of FAI syndrome? • Activity

modification, rehabilitation or surgery • Rehabilitation aims to improve hip stability, neuromuscular control, strength, ROM and movement patterns • Surgery, usually arthroscopic, aims to improve the hip morphology

and repair damaged tissue Griffin DR. British J Sports Med 2016 Treatment – My Initial Approach  Conservative, non - surgical treatment is ALWAYS the first course of action in treating hip pain.  This includes a

nti - inflammatories, physical therapy, chiropractic therapy and injections. ➢ Diagnostic/Therapeutic Injections • Huge part of my decision - making and treatment protocol • Intra - articular U/S guided lidocaine /

cortisone injection • 90% accuracy for determining intra - articular pathology Non - operative Treatment 1. Treat inflammation ➢ Oral NSAIDS, steroids ➢ Injections 2. Address functional deficits ➢ Physical therapy

➢ Chiropractic therapy 3. Reduce aggravating factors ➢ Sitting ➢ Running Intra - articular Hip Injections Indications FAI Syndrome Osteoarthritis Diagnostics Injection types Steroid + Numbing agent PRP Visco off l

abel  Cost Effective  Real Time Diagnostics and Therapeutic in office Ultrasound Guided Hip Intra - articular Injections Fluid Success Rates of Nonoperative Tx Intra - Articular Labral tears/FAI/OA • Less than

50% success • PT alone often worsens symptoms • Maximum one intra - articular injection • Careful about prolonged pain and dysfunction Extra - Articular Muscle strain/snapping hip • � 90% success • PT is

hallmark of treatment • Focus on strengthening and stretching of opposing muscle groups • Pelvic tilt / balance re - training “ Hey Doc, I have FAI and a labral tear but therapy has made it worse! What’s the ne

xt step??? Treatment  If fail to improve with nonoperative treatment modalities, consider surgery Hip Arthroscopy vs Open Hip Surgery Hip Arthroscopy Indications Who is the Ideal Patient for Isolated Hip Arthroscop

y?  Greater than 2mm (Ideally � 3mm) of joint space on standing AP Pelvis radiographs  Tonnis Grade 0 or 1  Intra - articular symptomatic FAI syndrome ➢ Hip and groin pain with symptoms that occur during

hip flexion and/or internal rotation ➢ Limitations in ROM compared to c/l side  Failed physical therapy +/ - injection  No dysplasia or severe hip instability Hip Arthroscopy – What Can I Treat?  FAI  La

bral Tears  Cartilage Defects  Loose Bodies  Septic Joint  Abductor Tears  Iliopsoas tendon release  Trochanteric Bursectomy and IT band resection Hip Arthroscopy - Portals Portal Placement  Typical

ly use 2 - 3 Portals Hip Arthroscopy - Access AL Portal least traumatic way to access central compartment Spinal needle  Nitinol Wire  4.5mm Cannula  Scope Avoid piercing labrum and hitting femoral head Hip Ar

throscopy – Capsulotomy Basic Technique  Cut the capsule to allow intra - articular mobility and visualization Hip Arthroscopy - Technique  Expose the anterior and superior labrum.  Necessary for labral

repair or removal of bone Hip Arthroscopy - Technique  Remove bone from anterior superior acetabulum  Repair labrum Labral Treatment Algorithm During Hip Arthroscopy Address FAI • Very important to concomitantl

y address • 96% labral tears due to FAI Labral Repair • Most cases labrum torn • Usually use 3 - 4 anchors • Preservation of labrum truly joint protective Labral Debridement • Done in situations of labr

al degeneration when suction seal intact Labral Reconstruction • Rarely needed • Mostly for revision cases • Can use allograft or autograft • Kite Technique Hip Arthroscopy - Technique  Remove the imping

ing CAM lesion • No guidelines to define CAM correction goal • Excessive bone resection can compromise suction seal or structural integrity of femoral neck • Can be difficult to translate 2D perspectives seen on p

reoperative AA assessment to 3D FAI assessment • Intra - op assessment may be easier and more fruitful in guiding resection Preoperative Dynamic Exam Postoperative Dynamic Exam (same patient) Intra - op Dynamic Exam to

Guide Cam Resection What Works? • Early PROM and Hip Arthroscopy Specific Rehab WhaP Goesn’P Work? • Limited Rehab without PROM Hip Arthroscopy • 1264 hip arthroscopy surgeries • Patients undergoing rehab

without circumduction were 4.2x more likely to have symptomatic intra - articular adhesions seen during revision arthroscopy KSSTA 2014 40F with capsulolabral adhesions 4 Phases of PT Protocol 1. Protection = Weeks 0

- 4 ➢ PRICE ➢ CPM, FFWB 20# x 2 - 3 wks , Hip Brace ➢ Avoid Hip Flexor Irritation 2. Initial Strengthening = Weeks 4 - 10 ➢ Non - compensatory gait and progressions ➢ Aquatic program if possible 3. Advanced Str

engthening ➢ Week 10 – Sports Test Completion ➢ Return to Pre - Injury Level of Function 4. Return to Sport ➢ Usually at 5 - 7 months ➢ Safe and Successful RTP is Main Goal Previous patient: 21 year old female

college soccer player Outcomes Surgical Outcomes following hip arthroscopy for FAI • 85 - 90% good to excellent results in our hands • Durable at 5 years • Evolving techniques and understanding • Outcomes depend

on Indications! AJSM 2010  28 NHL Hockey players undergoing hip arthroscopy with labral repair ➢ 3.4 months was avg time to return to skating ➢ All players returned to sport ➢ mHHS 70  95 AJSM 2017  87% (

52/60) returned to play professional football after hip arthroscopy ➢ Athletes who returned went on to play an average of 3.2 seasons after surgery • 21yo Div 1 collegiate basketball player planning to play profess

ionally • 6 mo right hip pain • Failed 6 mo of PT, injections, cessation of sports Case 1 Large cam lesion Labral tear • Labral repair • Femoral osteoplasty Surgery Labrum being repaired Labral tear with Grade

III chondromalacia • Labral repair • Femoral osteoplasty Surgery Femoral osteoplasty Focal cam lesion Outcome – 1.5 years post - op  Preoperative sharp pain gone within first 2 weeks  Back to dunking and cu

tting  Playing basketball professionally overseas Instrument Preop 3 mo postop 12 mo postop mHHS 67 91 100 Vai l Hip Score 53 89 100 HOS - ADL 81 99 100 HOS - Sport 78 100 100 • 42yo male with 2 years of hip pain a

nd severe mechanical symptoms • Diagnosis of synovial chondomatosis (loose bodies) on MRI Case 2 Large loose bodies – synovial chondromatosis • Labral repair • Femoral osteoplasty • Microfracture of acetabu

lar cartilage defect • 35 Loose bodies removed (synovial chondromatosis ) Surgery 10x10 loose bodies throughout joint Labral tear with Grade IV chondromalacia • Labral repair • Femoral osteoplasty • Microfracture

of acetabular cartilage defect • 35 large loose bodies removed (synovial chondromatosis ) Surgery 35 loose bodies Labral repair Summary  Hip pain is common and commonly missed ➢ C - sign or groin = intra - articul

ar, but can be atypical  Location, location, location ➢ Anterior/Groin with C - sign – Intra - articular ➢ Lateral – Trochanteric Bursitis/Gluteus medius tendinopathy ➢ Posterior/Buttock – Lumbar spine pa

thology/SI joint Summary  Physical Therapy always first line treatment ➢ Injections PRN - can be used diagnostically and therapeutically ➢ PT Protocol depends on location/cause: • FAI/Arthritis/Intra - articular p

ain – Posterior pelvic muscle strengthening • Lateral hip pain/Troch Bursitis – IT band stretching, gluteus medius strengthening, soft tissue mobs Summary  Treatments ➢ Non - operative treatment • Greater

than 90% success for extra - articular causes • Only 50% success for intra - articular causes (FAI/OA) ➢ Surgery has excellent results in right hands (90% good to excellent) • Hip Arthroscopy • PAO indicated

when dysplasia +/ - Microinstability Hip Preservation: A Team Approach! Orthopaedic Sports Medicine Athletic Training Treatment Physical Therapy Joint Replacement NM West Region Hip & Knee Joint Preservation Center at

CDH • NM West Region Hip & Knee Joint Preservation Center aims to provide patients from the Midwest region and beyond with a cutting edge, multidisciplinary approach to optimizing joint function • Goal is to prov

ide patients with the best evidence - based non - arthroplasty treatment for relieving hip and knee pain, especially those experiencing accelerated progression towards end stage arthritis NM West Region Hip & Knee Joint

Preservation Center at CDH • A true multidisciplinary approach to optimizing joint function  - MSK Radiology  - PM&R  - PT  - Chiropractic Care  - Primary Care Sports Medicine  - Ortho Sports Medicin

e  - Rheumatology  - Adult Reconstruction Current Research Initiatives • Create a robust database with computerized patient reported outcomes collection and surgical procedure data Outcomes Registry Creation â€

¢ Registry will facilitate research • Clinical studies can then be developed Clinical Trials and Studies NM West Region Hip & Knee Joint Preservation Center at CDH • Mission:  To provide patients with the best ev

idence - based non - arthroplasty treatment for relieving hip and knee pain, especially those experiencing accelerated progression towards end stage arthritis Sanjeev Bhatia MD Orthopaedic Surgeon, Sports Medicine Sanjee