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

11/20/2017 1

Hip Cases from Clinic: Refining your history and physical

11/20/2017

Alan Zhang MD

Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery

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.

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History

PMH: None PSH: Wisdom Tooth extraction Allergies: NKDA Meds: None Social:

• Full time Student
• No Tobacco

FHx: 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.

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Imaging

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FAI: Basics Clinical Question

• What is the best surgical treatment for Cam predominant FAI in

Athlete who fails non-operative management?

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Diagnosis and Treatment Options

Diagnosis:

• Femoracetabular

Impingement: Cam lesion subtype Treatment Options: Non-Op

• Physical Therapy
• 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

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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

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Labral Repair Femoroplasty Images

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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

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Trendelenberg Gait

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Imaging Imaging

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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

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Anatomy Treatment Options?

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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

1) Left hip endoscopic gluteus medius repair 2) Iliotibial band release (lengthening) 3) Bursectomy of trochanteric bursa

Back to Our Case

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Gluteus Medius Tear

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Repaired Gluteus medius

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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

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• Hip range of motion

Flex. Ext. IR ER Abd. Add. left 110 20 40 40 20 right 120 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

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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

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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 THA1
• May be related to changes in hip biomechanics following THA
• Or related to direct mechanical irritation
• 1. Lachiewicz and Kauk. JAAOS (2009)

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Background

• Iliopsoas anatomy
• Confluence of psoas and iliacus mm.,

insert to anteromedial lesser trochanter

• Anatomic variation: iliacus length,

separate/conjoined tendons,

• verlying 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

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Our Case…

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Thank You

• Alan Zhang, MD
• alan.zhang@ucsf.edu
• 415-353-4843

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