Hip Cases from Clinic: Refining your history and physical Alan - PDF document

11/20/2017 Hip Cases from Clinic: Refining your history and physical Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery 11/20/2017 Case #1  Healthy 21 M College Soccer Player  No specific injury but 4 years of ongoing L.Hip pain • Worse over last 6 mo. • PT for 6 mo. with no improvement  5/10 sharp groin pain, worse with prolonged sitting and running  Unable to continue playing soccer due to pain. 1

11/20/2017 History PMH: None Social:  Full time Student PSH: Wisdom Tooth  No Tobacco extraction FHx: None Allergies: NKDA Meds: None Physical Exam: Left Hip  Normal Gait  Non-tender to palpation  Flexion: 115 (120)  Extension: 10 (10)  IR: 20 (30)  ER: 50 (50)  5/5 strength throughout  + FADIR  -Ober’s, Log roll. 2

11/20/2017 Imaging 3

11/20/2017 FAI: Basics Clinical Question  What is the best surgical treatment for Cam predominant FAI in Athlete who fails non-operative management? 4

11/20/2017 Diagnosis and Treatment Options Diagnosis: Treatment Options:  Femoracetabular Non-Op Impingement: Cam  Physical Therapy lesion subtype  Activity Modification  Rest  Surgery Outcomes in Athletes  Byrd et al 2011 • 200 athletes with 2 year follow up after hip arthroscopy • 90% returned to sport (95% pro, 85% collegiate)  Nho et al. 2011- AJSM • 35 Athletes Varsity High School to Professional • Significant improvement in PRO • 79% return to play within 1 year 10 5

11/20/2017 Patient  Studies demonstrate: Arthroscopic femoroplasty with labral repair in athletes result in significant improvement in symptoms and return to play.  Taken to OR for Arthroscopic femoroplasty and labrum repair Labral Tear and Cartilage Injury 6

11/20/2017 Labral Repair Femoroplasty Images 7

11/20/2017 Removal of Cam lesion Case 2  CC: left hip pain  HPI: 64F geologist p/w 1 year left hip pain located on lateral aspect of hip. 4/10. No traumatic event. Insidious onset. • Initially improved and then worsened over the course of the year. • In 1/2015, she noticed pronounced weakness, which was new. • No improvement with PT. • Intra-articular corticosteroid injxn in 10/2015, which helped. • However, persistent weakness preventing her from working exercising at gym.  PMHx/PSHx: no previous hip injury or surgery  Meds: None 8

11/20/2017 Trendelenberg Gait 9

11/20/2017 Imaging Imaging 10

11/20/2017 Gluteus Medius Tears  Atraumatic, insidious onset of lateral-sided hip pain • Degenerative tear commonly in setting of chronic trochanteric bursitis • Most common  Acute traumatic injury  Iatrogenic • Avulsion after total hip replacement 11

11/20/2017 Anatomy Treatment Options? 12

11/20/2017 Operative Techniques  Approach • Open vs. Endoscopic  Repair • End-to-End • Suture anchors ‒ Partial-thickness  Transtendinous Repair ‒ Full thickness  Completion of tear and suture bridge repair Back to Our Case 1) Left hip endoscopic gluteus medius repair 2) Iliotibial band release (lengthening) 3) Bursectomy of trochanteric bursa 13

11/20/2017 Gluteus Medius Tear 14

11/20/2017 Repaired Gluteus medius 29 Case #3  HPI: • 63yo healthy man, h/o staged bilateral MoM THA (Oct/Dec 2010, OSH) via posterior approach • Persistent L groin pain post-operatively • Constitutional sx’s negative, R hip no symptoms • Attempted NSAIDs, PT  PMH: None significant  PSH: Bilateral THA (Left Oct 2010; Right Dec 2010) 30 15

11/20/2017  Hip range of motion Flex. Ext. IR ER Abd. Add. left 110 0 20 40 40 20 right 120 0 20 40 40 20  L leg- pain w/ aSLR and any rotation of hip referred to groin.  Hip strength Flexion Extension Abduction Adduction Left 4+ 5 5 5 Right 5 5 5 5  Provocative Tests: Flexion/Internal rotation for labral tear: negative Log roll test: negative FABER test: positive Ober’s test negative Straight leg raise: negative Positive Stinchfield- rested straight leg raise Case Presentation 16

11/20/2017 Imaging  MRI: • No evidence of pseudotumor/ AMR • Intact gluteus medius/ abductor complex Case Presentation  Outside Hospital Workup • Labs: ‒ ESR, CRP- wnl ‒ Serum Co, Cr - wnl • 3 Phase Bone Scan: ‒ Negative. No evidence of uptake c/w osteolysis/loosening, infection • MRI: ‒ Negative. No evidence of pseudotumor, adverse metal reaction (AMR)  Given constellation of symptoms, Left groin pain with aSLR, recommended guided CSI 17

11/20/2017 Case Presentation RT, 63yo M with L hip pain  Received fluoroscopic-guided corticosteroid injection, which provided complete, temporary relief Background  Anterior iliopsoas impingment (IPI) is a rare, poorly understood condition  Up to 4.3% of patients with persistent groin pain after THA 1  May be related to changes in hip biomechanics following THA  Or related to direct mechanical irritation 1. Lachiewicz and Kauk. JAAOS (2009) 18

11/20/2017 Background  Iliopsoas anatomy • Confluence of psoas and iliacus mm., insert to anteromedial lesser trochanter • Anatomic variation: iliacus length, separate/conjoined tendons, overlying bursa  Clinical Presentation • Persistent groin pain, activity-related/ transfers • Pain with resisted hip flexion (aSLR), little/no pain with passive leg raise • Often little/no pain with ambulation Lachiewicz and Kauk. JAAOS (2009)  Retrospective case series (2012)  10 cases of iliopsoas tendinitis  9 patients underwent guided tendon injection; 8/9 had relief  All underwent endoscopic iliopsoas release (at the level of the lesser trochanter)  Mean follow up: 20 months (12-60)  8/10 (80%) complete relief, 2/10 partial relief  Mean post-op WOMAC score 84 (60-95) from 34 (24-46)  Full (5/5) hip flexion strength obtained by 3 months post op (0.5-6)  No complications 19

11/20/2017 Our Case… 20

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11/20/2017 Thank You  Alan Zhang, MD  alan.zhang@ucsf.edu  415-353-4843 44 11/20/2017 22