Patient Presentation and Selection Joshua Harris, MD August 7, 2016 - - PDF document

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Patient Presentation and Selection

Joshua Harris, MD August 7, 2016

Disclosures

Research support: Smith & Nephew, Depuy Synthes, Ossur; Consultant: Smith & Nephew, NIA Magellan; Royalties: SLACK, Inc.; Editorial board: Arthroscopy, Arthritis Research UK; Committees: AANA, AOSSM, AAOS

Goals

• Patient presentation

– Subjective – Objective (physical exam)

• Patient selection

– Athletes – Arthritis – Dysplasia

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History for “hip” pain

• Intra-articular problem:

– Deep anterior groin – Sitting > standing – Socks, shoes – Log-roll (sleeping covers) – “C” sign – “Between the fingers” sign

• Extra-articular problem:

– Back, butt, lateral hip (i.e. everywhere else)

• Remember, both….

History for “hip” pain

• Pain location – intra-articular problems:

– Deep anterior (70%)

• Inquire “coughing” or “sneezing” or “Valsalva” pain

– Deep lateral (20%) – pitfall “abductor fatigue”

• Check limp, abductor tendon pathology

– Deep posterior (10%)

• Check stride length (ischiofemoral impingement, DGS, PHS)
• If unsure, inject local anesthetic

Diagnostic injection

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Diagnostic injection

• Clinical and x-ray findings unreliable predictors
• f injection response
• Negative injection response strong negative

predictor of FAI surgical outcome

• Positive injection response is poor predictor of

FAI surgical outcome

• Amount of relief:

– 93% acetabular chondral injury – 83% labral injury – 82% FAI

“Snapping”

• If you can see it:

– ITB/TFL – lateral – It’s not the “hip dislocating”

• If you can hear it:

– Iliopsoas – deep anterior

• If you can feel it:

– ITB/TFL – Iliopsoas – Labral tear – Knee

Physical Exam for “Hip”

• Based on the subjective history
• Should confirm suspected intra-articular vs extra-

articular source of pain

– Could be both

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Physical Exam for “Hip”

• Inspection (including gait)
• Palpation
• Motion
• Strength
• Special testing

– Impingement (subspine, anterior, lateral, posterior, TP, IFI) – Instability (extension ER, ER recoil, dial, distraction, hip pivot shift) – Snapping (iliopsoas [Ludloff, iliopsoas test], Ober) – Stress fracture (Log roll, axial load, hop)

B.A.R.F. = Blind Application of Radiographic Findings

Asymptomatic

• 26 studies; 2,114 hips – ALL asymptomatic

– 57% male, 43% female – Cam: 37% – Pincer: 67%

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Asymptomatic

• 1,081 hips (55%M, 45%F; mean 67 y/o)
• 83% FAI; 10% dysplasia

– Neither predictive of OA

• Increased FAI morphology in:

– 18-35 y/o competitive athletes

• Increased OA risk in:

– Lifetime competitive athletes

Advanced imaging - MRI

• Prefer non-arthrogram

– Assess effusion – Risks (infection, LFCN, capsular damage) – Cost, time/scheduling – May confound future injection outcome

Advanced imaging - CT

• Radiation exposure
• Cost
• Optimal osseous evaluation

– Version – Coverage – Morphology

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Patient selection

• Non-surgical management

– Rest, activity modification – Oral NSAIDs – Intra-articular injection – PT

However, none of these change the morphology

• r heal the labrum

Patient selection

• Possible utility of PT evaluated via x-ray:
• “Glute max squeeze” view

Patient selection

• Surgical indications:

– Failed non-surgical measures – FAI, labral injury, +/- chondral injury – Extra-articular impingement (AIIS, iliopsoas, PF, IFI)

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Patient selection

• Surgical contra-indications:

– Dysplasia

• LCEA or ACEA <20°, Tonnis >15°, extrusion index >25%

– OA

• <2 mm joint space
• Tonnis 2 or 3

– Asymptomatic

Surgical considerations

• Pearls:

– Set realistic expectations with patients

• Especially rehab duration, RTS timing
• MCID, MDC, PASS

– Evaluate soft tissues

• Beighton, Brighton, EDS, CTD, genetics work-up

– Get 2nd opinion – open or arthroscopic colleague – Careful EUA – Carefully evaluate articular cartilage (long-term outcome)

Sport-specific

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Sport-specific

• At time of hip arthroscopy for FAI, high-level versus

recreational athletes:

– Younger (20 versus 33 years old) – Male more (62% vs 54%) – Bilateral more (28% vs 16%)

Conclusions

• Good history and physical examination

– “Whenever you are having your anatomy sessions, pay particular attention, because Orthopedics is all anatomy, plus a little common sense” – Intra- vs extra-articular

• Treat patients, not x-rays
• Respect indications, contra-indications
• Address expectations
• Everyone is unique – tailor your treatment

– Hip – Sport