Hip Arthroscopy Christo phe r J. Utz, MD Assista nt Pro fe sso r o - PowerPoint PPT Presentation

Hip Arthroscopy Christo phe r J. Utz, MD Assista nt Pro fe sso r o f Ortho pa e dic Surg e ry Unive rsity o f Cinc inna ti

Disclosures • I ha ve no disc lo sure s re le va nt to this to pic .

Outline 1. Brie f Histo ry 2. Re vie w o f hip pa tho lo g y (F AI ) 1. Pa tho physio lo g y o f F AI 2. E va lua tio n 3. Ra dio g ra phs 3. T e c hnic a l c o nside ra tio ns

History of Hip Scope • F irst de sc rib e d b y Mic ha e l Burma n in 1931 E xpe rime nte d o n c a da ve rs to de te rmine fe a sib lity o I de ntifie d & de sc rib e d the a nte ro la te ra l po rta l o “Visua liza tio n o f the hip jo int is limite d to the intra c a psula r o pa rt o f the jo int. I t is ma nife stly impo ssib le to inse rt a ne e dle b e twe e n the he a d o f the fe mur a nd the a c e ta b ulum” • L ittle use until la te 70’ s Ric ha rd Gro ss – use in pe dia tric diso rde rs 1977 o Ja me s Glic k & T ho ma s Sa mpso n – de sc rib e d la te ra l o po sitio n a nd distra c tio n – 1980’ s T ho ma s Byrd – Re fine me nts to supine po sitio n, po rta l o a na to my, & using fluo ro sc o py fo r sa fe e ntry – 1990’ s

History of Hip Scope • F e w e a rly indic a tio ns Dia g no sis, Dx b io psie s, lo o se b o dy re mo va l o Sa mpso n 1996 – “pro c e dure lo o king fo r indic a tio ns” o • Re inho ld Ga nz, 2003 – de sc rib e s F AI “…in c e rta in a b e rra nt mo rpho lo g ic fe a ture s o f the o hip, a b no rma l c o nta c t b e twe e n the pro xima l fe mur a nd the a c e ta b ula r rim tha t o c c urs during te rmina l mo tio n o f the hip, le a ds to le sio ns o f the a c e ta b ula r la b rum a nd/ o r the a dja c e nt c a rtila g e .” De sc rib e surg ic a l dislo c a tio n to tre a t F AI o E a rly studie s sho we d c o uld tre a t the ma jo rity o f F AI o with a rthro sc o pic me tho ds Arthroscopic procedures grow exponentially!!!

Hip Scope Indications • F e mo ro a c e ta b ula r I mping e me nt • L a b ra l te a rs • L o o se Bo dy Re mo va l • Syno via l c ho ndro ma to sis • Sna pping Hip • Re c a lc itra nt tro c ha nte ric b ursitis • Glute a l te a rs • Hip insta b ility • I sc hio fe mo ra l imping e me nt • Pro xima l ha mstring te a rs

Pathophysiology of FAI • An abnormal bony morphology of the proximal femur and / or acetabulum o Retroversion, relative anterior overcoverage, coxa profunda, protrusio acetabuli, coxa vara, extreme coxa valga, subtle dysplasia, Perthes, SCFE, • Reduced joint clearance with physiologic terminal motion (flexion & IR) of the hip • Acetabular cartilage/labral lesions • Osteoarthrosis?

Labral Function • Provides mechanical stability o Substantial extension of acetabular rim • Contributes to load transmission

Labral Function • Seals pressurized fluid layer within joint o Lubricates, prevents direct cartilage contact • Slows rate of fluid expression from porous cartilage layers o Limits cartilage deformation and stress o Joint contact stresses 92% higher if resected

Pathophysiology of FAI • 2 Main types • Presentation w/ both more common than either alone • Beck et al in JBJS (Br) 2005 - analyzed 302 symptomatic hips w/ FAI o 86% had mixed impingement pattern o 26 pts isolated cam & 16 w/ isolated pincer

Pathophysiology of FAI • Non-spherical portion usually anterosuperior • Labrum displaced outward & superiorly – results in articular sided tear perpendicular to joint surface • Thought to cause Line drawing illustrating the delaminating effect on acetab pathomechanism of “ cam ” -type cartilage as “bump” impacts it impingement Espinosa N. et.al. J Bone Joint Surg 2006:88:925-935

Pathophysiology of FAI • Due to focal or global overcoverage • Labrum crushed against normal femoral neck • Focal area of cartilage behind incompetent labrum gets damaged • Thought that head starts to lever out of acetabulum creating counter- coup cartilage injury Line drawing illustrating the pathomechanism of “ pincer ” -type impingement, which is the result of contact between the acetabular rim and the femoral head-neck junction. Espinosa N. et.al. J Bone Joint Surg 2006:88:925-935

Cam and pincer impingement with the hip in extension (A) and flexion (B) Peters C. L., Erickson J. A. J Bone Joint Surg 2006:88:1735-1741

Patient Evaluation

Labral Tear Prevalence • L e e e t a l. Bo ne & Jo int J 2015 o 3T MRI pe rfo rme d o n 70 a sympto ma tic vo lunte e rs; me a n a g e 26 o 27 (38%) ha d la b ra l te a rs o n MRI • T re sc h e t a l. J Ma g n Re so n I ma g ing 2016 o Co mpa re d MRI in 63 a sympto ma tic vo lunte e rs to 63 pts w/ sympto ma tic F AI o 44% o f vo lunte e rs ha d la b ra l te a rs vs 61% o f pa tie nts Not all labral tears are symptomatic!

Common Points in FAI History • Pain o Many patients will complain of insidious history of groin pain, some may call it “stiffness” o Pain mainly in groin. Also can have trochanteric or buttock pain o Initially during athletic activity but can progress to pain w/ prolonged sitting o Athletes – difficulty squatting, cutting, starting/stopping • Demographics o Predominantly cam – young athletic men o Predominantly pincer – middle aged woman

Physical Examination o Gait evaluation • Trendelenburg or antalgic gait o Palpation • Adductor tendons • Symphysis pubis • SI joints • Greater trochanter o Spine, neuro and abdominal exam

Physical Exam • Hip Ra ng e o f Mo tio n o L o g ro ll te st while supine o F le xio n, e xte nsio n, inte rna l & e xte rna l ro ta tio n • F le xio n & I R o fte n de c re a se d o Ab duc tio n & Adduc tio n o Ob e rT e st • Stre ng th T e sting o Ab duc to rs – T re nde le nb e rg T e st o Adduc to rs o I lio pso a s

The impingement test is performed with the hip in 90 ° of flexion with additional internal rotation and adduction of the femur. Peters C. L., Erickson J. J Bone Joint Surg 2006:88:20-26

Radiographic Assessment

Line drawing representing an anteroposterior radiograph showing the pistol-grip deformity (arrow). Maheshwari A. V. et.al. J Bone Joint Surg 2007:89:2508- 2518

Schematic drawing of an anteroposterior radiograph of the hip, showing an anteverted acetabulum (A) and retroverted acetabulum (B) Ischial Spine Peters C. L. et.al. J Bone Joint Surg 2006:88:1920-1926

A retroverted hip is demonstrated on a coned-down anteroposterior pelvic radiograph Peters C. L., Erickson J. J Bone Joint Surg 2006:88:20-26

In a patient with a positive impingement test, decreased internal rotation of the hip, and groin pain, an abnormal alpha angle of 74 ° is measured on an axial oblique fast-spin-echo magnetic resonance imaging scan General population avg 42 ° Cam impingement avg 74 ° 50-55 ° used as upper limit normal Shindle M. K. et.al. J Bone Joint Surg 2007:89:29-43

MRI Findings T1-weighted magnetic resonance Full-thickness loss of arthrographic image shows a lack of head- articular cartilage neck offset Flap Tear of anterior- ( white arrow ) is shown superior labrum at labral-chondral Peters C. L., Erickson J. J Bone Joint Surg 2006:88:20-26 transitional zone.

FAI Treatment Non-operative • Rest & activity restriction • Minimal literature available to support effectiveness Operative • Optimal timing unknown • If pt has both cam & pincer – treat both or is treating one component enough?

Arthroscopy • Set-up o Pt positioned on fracture table w/ well padded perineal bolster. o Traction applied to operative hip using fluoroscopy to assess joint distraction – 8-12 mm o Continuous traction time should be limited to < 2 hrs

Arthroscopic Approach • Portal Placement o Anterolateral portal – 1-2 cm anterior & proximal to greater troch o Anterior – Directly distal to ASIS – usually placed under direct visualization o Mid Anterior– point distal to AL & A portal creating equilateral triangle

Arthroscopic Rim Trimming

Arthroscopic Cam Resection

Arthroscopic Cam Resection • Area of cam impingement – identified by location, color changes, & texture • Know location of retinacular vessels • Resect only what is necessary to relieve impingement Mardones et al. JBJS 2006 o • – cadaver study showing up to 30% of femoral neck can be resected before compromising structural integrity

Arthroscopic Treatment Results • Several outcome studies exist showing good to excellent results in 67-96% of patients • Most studies only have short term follow-up (avg 2 yrs) • Increased articular cartilage damage consistently correlated with poor outcome o Tonnis grade 2 o Outerbridge grade 3 or 4 at arthroscopy