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

8/10/2016 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 1

8/10/2016 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 2

8/10/2016 Diagnostic injection • Clinical and x-ray findings unreliable predictors of 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 3

8/10/2016 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% 4

8/10/2016 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 5

8/10/2016 Patient selection • Non-surgical management – Rest, activity modification – Oral NSAIDs – Intra-articular injection – PT However, none of these change the morphology or 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) 6

8/10/2016 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 2 nd opinion – open or arthroscopic colleague – Careful EUA – Carefully evaluate articular cartilage (long-term outcome) Sport-specific 7

8/10/2016 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 8