Kennan Vance, DO Problem
On average, Pa ents with labral tears see an average of 4 physicians over a period of 2 years before the appropriate diagnosis is made
JBJS 2006; 88: 1448-57 Bony Anatomy
• Ball and Socket type synovial joint • Femoral Head and Neck • Acetabulum Labrum
• Horseshoe shaped fibrocar lage structure with a achments inferiorly to the transverse acetabular ligament • No intrinsic blood supply-comes from capsule and synovium • Mul ple nerve endings have been found within the labrum. (unlike the meniscus in the knee) Labrum Cross Sec on
• The Labrum and the Car lage on the Acetabulum run Car lage together. Thus a tear in the labrum, usually Labrum disrupts the car lage from the bone and causes a “delamina on” injury. • Watershed zone for blood supply
Arthroscopy 2005; 21: 6 Labral Func on
• Increases ar cular surface area 22% • Increases acetabular volume by 33% • Contributes to joint stability in extremes of mo on • Provides a “seal” to the central compartment Benefits of Labral Seal
• Resists distrac on of femoral head from socket due to nega ve intra-ar cular pressure • By maintaining fluid in central compartment, it allows more even distribu on of compressive forces • Provides nutri on to the ar cular car lage and allows for a smooth gliding surface • Allows for a low-fric on environment by sealing fluid in central compartment • With loss of “seal” it may increase joint compressive forces, increase joint fric on, and lead to earlier OA Labral Tear Mechanism
• Trauma c (<50%) – External force to extended and ER hip – Pivo ng sports • Degenera ve – 90% of atrauma c labral tears have bony abnormali es – Femero-Acetabular Impingement (FAI) – Dysplasia FemoroAcetabular Impingement (FAI) Cam lesion • Bony Mismatch of ball and socket joint • Cam Lesion is an oval shaped femoral head • Pincer is an overhang of the acetabulum • Mixed lesion most common • With hip rota on the ball Pincer and socket have abnormal contact pinching and tearing the labrum Consequences of FAI
• The abnormal contact leads to labral tears and car lage lesions; which contributes to the breakdown of the joint and arthri c changes Treatment of FAI
• Tradi onally done with an open surgical hip disloca on with osteotomies performed. • Arthroscopy has now replaced this method with less invasive approach, less damage to head blood supply, less infec on, etc. History
• Groin, Anterior, and • Extra-ar cular hip Thigh Pain complaints • Pain with hip flexed and – “hip dislocates” IR (impingement) – “pops or snaps really loud” • Pain with si ng – Pain on lateral side of • Pain and catching with hip; “can’t sleep on that stairs or rising from a side” seated posi on • Back and SI joint pain Physical Exam
• Difficult at best; an art in evolu on • Lots of overlap with SI joint, back, or extra- ar cular problems • Starts with inspec on, palpa on, ROM, and then special tests • FADIR or Impingement test is workhorse Physical Exam
• Resisted SLR or “Ac ve Compression Test” • FABER for SI joint and ght Iliopsoas • Dynamic Internal Rota on Impingement Test (DIRIT) • Dynamic External Rota on Impingement Test (DEXTRIT) • Intra-ar cular injec on – 87% sensi ve and 100% specific for hip OA vs LSD Imaging
• Xrays • MRI with intra-ar cular contrast is the best imaging we currently have • MRI can miss labral tears! • Not great for car lage lesions or “wave signs” • Arthroscopy is the gold standard for diagnosing tears and other lesions Arthroscopy
• First performed in the 1970’s. • Slow to catch on due to several factors including difficulty and instrumenta on • Now more widely accepted and be er understanding of hip pathology has progressed the art of hip arthroscopy • Surgeons are con nually pushing the spectrum of diseases that can be treated with arthroscopy. – Labral repairs and reconstruc ons, FAI resec on, Gluteus medius repairs, IT band releases, car lage disorders, etc. Who is a good candidate?
• Non-arthri c joint (>2mm joint space) – 43% underwent THA within 3 yrs with <2mm. (10 mes more likely than if >2mm) • No significant hip dysplasia • BMI less than 35 ideally but more important is body morphology • Non-osteoporo c • Reasonable expecta ons How is it Performed?
Surgery Demo
Wave Sign
Results
• Excision of labrum/car lage • Labral repair results are lesions without addressing slightly be er than bone yields 29-54% debridement in short term unsa sfactory results results • Meta-analysis in 2010 – We an cipate with longer indicates that addressing follow up the results will be more convincing bony impingement was – 15 studies showed good to most convincing indica on excellent results ranging from with good-excellent results 56-100% from 69-89% of pts. – Labral debridement pts not as good as repair CORR 2010;468:555-64 Complica ons
• Rate of 1.3-6.4% • Usually minor and transient – Trac on Neuropraxia to scia c and pudental nerve – Damage to LFC nerve • Intra-ar cular damage from surgery • Heterotopic Ossifica on – Naprosyn 500mg bid reduced incidence from 25% to 5.6% – No prophylaxis a er mixed resec ons were 16X’s more likely to develop HO AJSM 2014;42(6) 1359-64 Factors Associated with Failure
• Older age
• Presence of arthri c changes • Longer dura on of symptoms • Worse preopera ve pain and func onal scores Other Hip Condi ons Treated with Arthroscopy • Synovial Disease • Loose Bodies • Iliopsoas release – Internal Snapping hip • Adhesive Capsuli s • Chondral Lesions • Joint Sepsis • Ruptured Lig Teres • External Snapping Hip • Greater Trochanteric Pain Syndrome Thanks