hip pathology - PDF document

1 hip pathology w mccormick 2017 mccormick
hip pathology w mccormick 2017 mccormickortho.com overview • classification • common hip pathologies • FAI • GT pain • snapping • workup • treatments • sample cas

2 es • rehabilitation • outcomes/compl
es • rehabilitation • outcomes/complications hip pathology classification • V – Vascular • I – Inflammatory • N – Neoplastic • D – Degenerative / Deficienc

3 y • I – Idiopathic • C – Conge
y • I – Idiopathic • C – Congenital • A – Autoimmune • T – Traumatic • E – Endocrine • mechanical • congenital • dysplasia • FAI • acquired •

4 trauma • FAI • non mechanical •
trauma • FAI • non mechanical • immune • infection • vascular (AVN) hip pathology classification - anatomic • groin • adductor muscle • anterior acetabular/labr

5 al • fascial disruption • flexion cr
al • fascial disruption • flexion crease • acetabular/labral • iliopsoas tendon • C - sign • lateral acetabular/labral • GT • abductor tendon • IT band (snappin

6 g) • buttock • posterior acetabular/
g) • buttock • posterior acetabular/labral • sciatic mechanical articular hip problems • single event trauma • dislocations/fractures/labral tears • think shoulder d

7 islocation • cumulative trauma • lab
islocation • cumulative trauma • labral tear • usually in setting of too much/too little bone • cartilage injury • point loading and shear mechanical non articular hip

8 problems • ischiofemoral impingement
problems • ischiofemoral impingement • sciatic entrapment • tendon tears • abductor • hamstring • fascial disruption (aka sports hernia etc ) onion layers • limpin

9 g • pain behavior • muscle activatio
g • pain behavior • muscle activation pattern changes • GT pain syndrome • narcotic use • mis - diagnoses *beware the young multiple comorbidity patient with sympt�

10 00;omsfindings* common hip pathologies â
00;omsfindings* common hip pathologies • labral tear • GT pain syndrome • snapping labral tear what? groin pain flexion rotation lock/catch why? labral tear – not enough

11 bone (dysplasia) • bone not providing
bone (dysplasia) • bone not providing enough coverage (support) for femoral head • labrum hypertrophies to provide that support labral tear – too much bone (FAI) • at ri

12 sk anatomy + at risk activity • wild c
sk anatomy + at risk activity • wild card • reparative capacity • young • active • at risk activities FAI – acetabular side (pincer impingement) • overcoverage F

13 AI – acetabular side too much bone
AI – acetabular side too much bone everywhere FAI - acetabular side too much bone in one area focal overcoverage FAI – femoral side – CAM impingement not enough cle

14 arance AIIS impingement ( subspine impin
arance AIIS impingement ( subspine impingement) • not enough clearance • possible history of AIIS avulsion **flexion crease pain with straight flexion • can be tough to diff

15 erentiate from anterior overcoverage /a
erentiate from anterior overcoverage /ant CAM/ant labral tear Image from Shibahara, healio 40(4):e725 - e728 fascial disruption/core muscle/FAI • the hip bone’s connected t

16 o the back bone… • restricted motion
o the back bone… • restricted motion in hip • demands more motion from low back, pubic symphysis • puts abdominal fascia/muscles in vulnerable position Image from Larson c

17 m. sports health 2014. 6(2):139 - 144 Pr
m. sports health 2014. 6(2):139 - 144 Prevalence • CT study of 100 joints (50 people) asymp • 39% of hips had at least 1 predisposing factor • M 48% � F 31% • 74% o

18 f hips aspherical GT pain syndrome • a
f hips aspherical GT pain syndrome • abductor tendon tendinopathy/tear • bursitis • idiopathic • **pain with resisted abduction is their usual pain** • pain with high f

19 lexion and IR is usually only at GT snap
lexion and IR is usually only at GT snapping - internal • iliopsoas over anterior acetabular rim • “I can hear it” • anatomy + movement • anatomy • overcoverage (p

20 ushes the labrum into the way) • can a
ushes the labrum into the way) • can also happen with THA • movement • repetitive high flexion with rotation • ?compensation for lack of mobility elsewhere? • iliopsoas

21 release??? • maybe in THA • better t
release??? • maybe in THA • better to treat underlying cause in native joint snapping external • “my hip dislocates” • ITB moving over GT • “I can see it” • I

22 TB fenestration??? • last resort Image
TB fenestration??? • last resort Image from aaos orthoinfo external snapping hip workup – history FAI Arthrosis Abductor Tear RED FLAGS episodic episodic but ache at night

23 episodic +/ - ache “ all the time ”
episodic +/ - ache “ all the time ” groin / Csign buttock GT rad below knee worse with flexion rotation “ loosens up ” worse at night worse with standing/walking wors

24 e with any movement better with NSAID
e with any movement better with NSAIDs better with rest NSAIDs better with rest nothing improves it Image from Dooley Can Fam physician 2008.54(1)42 - 47 workup – exam FAI

25 Arthrosis Abductor Tear RED FLAGS gait
Arthrosis Abductor Tear RED FLAGS gait normal only limp when flared normal to antalgic limp walking aids with little demonstrable pathology n to low abd . strength normal +/

26 - pain inhibition decreased abd stren
- pain inhibition decreased abd strength unable to selectively activate glutei worse with flexion rotation straight flexion may be painless pain at GT with resisted abd

27 unable to flex � 90 GT tendernes
unable to flex � 90 GT tenderness is not the usual pain GT tenderness not common GT tenderness may be the usual pain tenderness everywhere Image from Dooley Can Fam ph

28 ysician 2008.54(1)42 - 47 workup - test
ysician 2008.54(1)42 - 47 workup - tests routine • screen for bony pathology • xray (AP pelvis, 45 degree Dunn view, false profile) FAI • CT with 3D reformats • screen fo

29 r occult arthrosis • preop planning â€
r occult arthrosis • preop planning • MRI only if diagnosis uncertain AND your radiologists are experienced • joint injection if multiple pain generators • caution false

30 negatives abductor tear • MRI fascial
negatives abductor tear • MRI fascial disruption/core muscle injury • MRI treatment – non operative/preoperative • mechanism dependent • abductor and core strengthenin

31 g • NSAIDs • activity modification â
g • NSAIDs • activity modification • normalize gait/strength • teach muscle control (vital for postop) • not everyone with pathology is a surgical candidate • arthro

32 sis may be too advanced • ability to s
sis may be too advanced • ability to successfully rehab is critical treatment - operative • address the underlying cause • undercoverage – PAO • overcoverage – acetab

33 uloplasty • AIIS – recession • CA
uloplasty • AIIS – recession • CAM – resection • tendon tear – repair • fascial disruption – repair rehabilitation • phase 1 • manage inflammation • r

34 egain motor control iliopsoas tendoniti
egain motor control iliopsoas tendonitis raw bone surfaces • phase 2 • gait • strength emphasis on coordination, proprioception, balance • phase 3 • non - sagittal plan

35 e • endurance ROM? internal ok many ar
e • endurance ROM? internal ok many are delayed arthroscopy for FAI - outcomes • mHHS 62 – 82 • 8 yr survival – 82.6% - �MF, y�oungold, BMI lo�

36 ;whigh • Revision – 5% at 2 yrs â€
;whigh • Revision – 5% at 2 yrs • BMI, age, sex arthroscopy for FAI - complications 8% • DVT/PE – 0.1% • Infection – deep 0.04%, superficial 1% • femoral neck

37 stress fracture – 0.1% • heterotop
stress fracture – 0.1% • heterotopic ossification 0.8% • traction related • perineal numbness 1.4% • ankle/foot pain 0.8% • lateral thigh numbness - common postop,

38 1.6% beyond 6mo • iatrogenic chondral/
1.6% beyond 6mo • iatrogenic chondral/labral injury 2% complications - avoidable • wrong diagnosis • radiculopathy • missed secondary diagnosis • fascial disruption com

39 plications - avoidable • residual def
plications - avoidable • residual deformity/pathology complications - avoidable • rehab • too fast • too slow • just plain wrong • unknown • capsular stiffness and

40 inflammation • poor response to NSAI
inflammation • poor response to NSAIDs, injections • adhesions less common hip pathologies • ischiofemoral impingement • sciatic entrapment • hamstring avulsions sampl

41 e case 1 – CAM FAI sample case 2 - o
e case 1 – CAM FAI sample case 2 - overcoverage sample case 3 – mixed FAI • dancer • postop where is all this going? • we have been here before • shoulder • pick

42 up new diagnoses • treat them in less
up new diagnoses • treat them in less invasive ways • not everything is understood…so not everything has a name/treatment yet • subacromial impingement vs GT pain syndrom

43 e • history and physical are paramount
e • history and physical are paramount • imaging can lead you astray • “what can I do?” vs “what should I do?” • rehab focuses on muscular control • despite