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

• I

de ntifie d & de sc rib e d the a nte ro la te ra l po rta l

• “Visua liza tio n o f the hip jo int is limite d to the intra c a psula r

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
• Ja me s Glic k & T

ho ma s Sa mpso n – de sc rib e d la te ra l 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 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
• Sa mpso n 1996 – “pro c e dure lo o king fo r indic a tio ns”
• 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

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

• E

a rly studie s sho we d c o uld tre a t the ma jo rity o f F AI 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 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

• An abnormal bony morphology of the proximal

femur and / or acetabulum

• 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?

Pathophysiology of FAI

Labral Function

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

Labral Function

• Seals pressurized fluid layer within joint
• Lubricates, prevents direct cartilage contact
• Slows rate of fluid expression from porous

cartilage layers

• Limits cartilage deformation and stress
• Joint contact stresses 92% higher if resected

• 2 Main types
• Presentation w/ both more common than

either alone

• Beck et al in JBJS (Br) 2005 - analyzed

302 symptomatic hips w/ FAI

• 86% had mixed impingement pattern
• 26 pts isolated cam & 16 w/ isolated pincer

Pathophysiology of FAI

Line drawing illustrating the pathomechanism of “cam”-type impingement

Espinosa N. et.al. J Bone Joint Surg 2006:88:925-935

• Non-spherical portion usually

anterosuperior

• Labrum displaced outward &

superiorly – results in articular sided tear perpendicular to joint surface

• Thought to cause

delaminating effect on acetab cartilage as “bump” impacts it

Pathophysiology of FAI

Line drawing illustrating the pathomechanism

• f “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

• 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
• ut of acetabulum creating counter-

coup cartilage injury

Pathophysiology of FAI

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

• 3T

MRI pe rfo rme d o n 70 a sympto ma tic vo lunte e rs; me a n a g e 26

• 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

• Co mpa re d MRI

in 63 a sympto ma tic vo lunte e rs to 63 pts w/ sympto ma tic F AI

• 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!

• Pain
• Many patients will complain of insidious history of groin

pain, some may call it “stiffness”

• Pain mainly in groin. Also can have trochanteric or

buttock pain

• Initially during athletic activity but can progress to pain

w/ prolonged sitting

• Athletes – difficulty squatting, cutting, starting/stopping
• Demographics
• Predominantly cam – young athletic men
• Predominantly pincer – middle aged woman

Common Points in FAI History

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

Physical Examination

Physical Exam

• Hip Ra ng e o f Mo tio n
• L
• g ro ll te st while supine
• 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

• Ab duc tio n & Adduc tio n
• Ob e rT

e st

• Stre ng th T

e sting

• Ab duc to rs – T

re nde le nb e rg T e st

• Adduc to rs
• 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)

Peters C. L. et.al. J Bone Joint Surg 2006:88:1920-1926

Ischial Spine

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

Shindle M. K. et.al. J Bone Joint Surg 2007:89:29-43

General population avg 42 ° Cam impingement avg 74° 50-55° used as upper limit normal

T1-weighted magnetic resonance arthrographic image shows a lack of head- neck offset

Peters C. L., Erickson J. J Bone Joint Surg 2006:88:20-26

Full-thickness loss of articular cartilage (white arrow) is shown at labral-chondral transitional zone. Flap Tear of anterior- superior labrum

MRI Findings

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?

• Set-up
• Pt positioned on fracture table w/ well padded

perineal bolster.

• Traction applied to operative hip

using fluoroscopy to assess joint distraction – 8-12 mm

• Continuous traction time should

be limited to < 2 hrs

Arthroscopy

• Portal Placement
• Anterolateral portal – 1-2

cm anterior & proximal to greater troch

• Anterior – Directly distal

to ASIS – usually placed under direct visualization

• Mid Anterior– point distal

to AL & A portal creating equilateral triangle

Arthroscopic Approach

Arthroscopic Rim Trimming

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
• – cadaver study showing up to 30% of femoral neck can be resected before

compromising structural integrity

Arthroscopic Cam Resection

• 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

• Tonnis grade 2
• Outerbridge grade 3 or 4 at arthroscopy

Arthroscopic Treatment Results

• Be di e t a l. AJSM 2011
• Co mpa re d o pe n to a rthro sc o pic tre a tme nt fo r F

AI

• 30 pts tre a te d o pe n & 30 a rthro sc o pic a lly
• No sig nific a nt diffe re nc e in de fo rmity c o rre c tio n
• Bo tse r e t a l. Arthro sc o py 2011
• Syste ma tic lit re vie w c o mpa ring o pe n (O),

a rthro sc o pic (A) & c o mb ine d (C) tre a tme nt o f F AI

• Me a n impro ve me nt in Ha rris hip sc o re 26.4 (A), 20.5

(O), 12.3 (C)

• Co mplic a tio n ra te 1.7% (A), 9.2% (O), 16% (C)

Arthroscopic Treatment Results

• Athletes?
• Philippon et al. AJSM 2010
• 28 NHL players treated for symptomatic FAI
• Avg age 27; f/up 24 months
• 26 returned to play at avg 3.4 months
• Modified HHS improved from 70 to 95

Arthroscopic Treatment Results