Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique Cherry Blossom Seminar Sports Medicine and the Aging Athlete 2014 Andrew B. Wolff, MD Washington Orthopaedics and Sports Medicine Washington, DC
Jul 16, 2015
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
Cherry Blossom Seminar Sports Medicine and the Aging Athlete
2014
Andrew B. Wolff, MDWashington Orthopaedics and Sports Medicine
Washington, DC
Femoroacetabular Impingement
• Wenger et al. showed that 87% of patients with labral tears had underlying structural abnormalities (Wenger et al. CORR 2004)
• Ganz and colleagues introduced the concept of Femoroacetabular Impingement (FAI) as a cause of hip pain, labral tears, and early osteoarthritis(Ganz et al. CORR 2003)
CAM & PINCER ImpingementCAM & PINCER Impingement
PincerCAM
Espinosa et al J Bone Joint Surg 2006; 88-A: 225-239
Acetabular Labrum• Extends the
acetabulum beyond the bony socket
• Is present around the entire lunate surface of the acetabulum
• Is continuous with the transverse acetabular ligament inferiorly
Is my diagnosis correct?
• History and Physical are critical
• Understand concomitant disease (i.e., core muscle injury, lumbar spine pathology, muscle strains, etc.)
• Understand that there is often a mixed picture of symptoms such as sacroillitis, peri-pelvic tendinitis, ischial or troch bursitis
• Traumatic vs. Insidious– Twisting or torqueing
– Subluxation
– Dislocation, associated fracture
• Congenital / Developmental– DDH, Perthes, SCFE
• Other– Infection, PVNS, Osteonecrosis, Synovial
Chondromatosis
History
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Confirming the source of pain
• History
– Is it predominately lateral or posterior?
– Or is it in the groin?
– Pain and/or numbness going down the leg?
Confirming the source of pain
• History – What causes the pain?
• Twisting
• Running
• Prolonged sitting– Plane rides/ long car
rides
• Walking uphill
• Getting in/out of car
• Achy night pain?
Confirming the source of pain
• Many patients don’t follow the textbook– Combined back and
groin pain
– Troch and groin pain
– Butt and groin pain
– Groin pain but negative anterior impingement sign
– Achy night pain
“Anterior Impingement Test”Passive flexion to 90°
followed by forced adduction and IR
Leunig et al. Op Tech Orthop 2005
Confirming the source of pain
• Diagnostic injections
– Physical exam
– Inciting activities
– Pain diary
Indications
Is my diagnosis correct?
Do the patient’s current symptoms/limitations warrant surgical
intervention?
Do the patient’s current symptoms/limitations warrant
surgical intervention?
•If it doesn’t hurt, don’t operate
Do the patient’s current symptoms/limitations warrant
surgical intervention?
•No evidence for prophylactic FAI correction
•Possible exception of SCFE
Indications
Is my diagnosis correct?
Do the patient’s current symptoms/limitations warrant surgical
intervention?
Does this patient have osteoarthritis?
Osteoarthritis
• Cannot be cured with arthroscopy
• 2 mm rule (Philippon et al AJSM 2010)– Not applicable to women– Is it applicable at all?– High resolution MRI
• Role for chondral restorative procedures in chondral defects
Indications
Is my diagnosis correct?
Do the patient’s current symptoms/limitations warrant surgical
intervention?
Does this patient have osteoarthritis?
Does this patient have dysplasia?
Dysplasia
• Undercovered hips cannot be cured arthroscopically– Measure LCEA, ACEA, acetabular inclination
and femoral neck shaft angles on all patients • Consider acetabular and femoral version
– Definite role for arthroscopic treatment of borderline dysplastics
– How much dysplasia is too much?
Conclusions
• In 2014, much can be accomplished in the hip arthroscopically
• Not all FAI and labral tears need to be fixed
• With the right indications, modern techniques yield reproducibly good results
Conclusions
• In depth understanding of the hip joint is paramount
• Advanced imaging is very helpful
• Equally important: advanced history and physical
• Use diagnostic injections
• BEWARE osteoarthritis and dysplasia!