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Acetabular Labral Tears and Femoroacetabular Impingement

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Acetabular Labral Tears and Femoroacetabular Impingement Michael J. Sileo, MD, FAAOS Sports Medicine Injuries Arthroscopic Shoulder, Knee & Hip Surgery December 7, 2018 NONE Groin and hip pain is common in athletes Especially hockey, soccer, and football 5% of all soccer injuries Renstrom et al: Br J Sports Med 1980. Complex anatomy and wide differential diagnoses that span multiple medical specialties make diagnosis difficult • Extra-articular causes: Muscle strain Snapping hip Adductor Trochanteric bursitis Iliopsoas Abductor tears Gluteus medius Compression neuropathies Hamstrings LFCN (meralgia paresthetica) Gracilis Sciatic nerve (Piriformis Avulsion injuries syndrome) Sports Hernia Ilioinguinal, Osteitis Pubis iliohypogastric, or genitofemoral nerve Intra-articular causes: Labral pathology Capsular laxity Femoroacetabular impingement Stress fracture Chondral pathology Septic arthritis Ligamentum teres injury Adhesive capsulitis Loose bodies Osteonecrosis Benign Intra-articular tumors SCFE PVNS Transient synovitis Synovial chondromatosis Soft-tissue injuries such as muscle strains and contusions are the most common causes of hip pain in the athlete It is important to be aware and suspicious of intra- articular causes of hip pain Up to 60% of athletes undergoing arthroscopy are initially misdiagnosed Delay to diagnosis is typically 7 months Labral pathology may not be diagnosed for up to 21 months Byrd et al: Clin Sports Med 2001. Burnett et al: JBJS 2006. Nature of discomfort Mechanical symptoms Stiffness Weakness Instability Location of discomfort Onset of symptoms History of any trauma or developmental abnormality Assess gait, posture, limb-length inequality, and scoliosis Complete neurovascular examination Active and passive hip range of motion Palpation for focal tenderness Rare with intra-articular pathology Full Lumbar spine, neuro exam! “C-sign”: Hand cupped above greater trochanter with thumb over posterior aspect of trochanter and fingers gripping into groin Suggests intra-articular pathology Log rolling: Pain suggests intra-articular pathology Resisted Straight Leg Raise test (Stinchfield) Pain suggests intra-articular pathology Thomas test: Hip flexion contracture Patrick’s Test (FABER): Posterior pain suggests SI joint pathology Anterior pain suggests anterior capsule, labrum, or psoas pathology Anterosuperior Impingement Test (FADIR/Ganz): Hip is flexed, adducted, and internally rotated Pain with most intra- articular pathology Associated click may be present Not specific for labral pathology Ganz: CORR 2003. Fibrocartilaginous rim that overlies the articular cartilage and surrounds the perimeter of the acetabulum Triangular in cross section Widest anteriorly and superiorly; thickest superiorly Bharam: Clin Sports Med 2006. Contains free nerve endings May explain pain and decreased proprioception McCarthy: J Arthroplasty 2001. Kelly et al: Arthroscopy 2005. Deepens acetabulum by approximately 21% Creates a seal of the hip joint Maintains hydrostatic pressure enhancing lubrication Maintains negative pressure enhancing stability Reinforces acetabular rim Contributes to containment of femoral head at extremes of motion Contributes to joint stability Does NOT significantly participate in load transmission Ferguson et al: J Biomech 2001 Trauma Injury or fall MVA Dislocation Muscle weakness/imbalance FAI Femoroacetabular impingement Subtle osseous morphologic abnormalities result in abnormal contact between the femoral neck/head and the acetabular margin during terminal motion of the hip Parvizi et al: JAAOS 2007. Repetitive abnormal contact leads to labral and chondral damage Continued progression leads to premature degenerative arthritis Acetabular labral tears are frequently the manifestation of primary structural hip disease Legg-Calve-Perthes disease Congenital hip dysplasia Slipped capital femoral ephiphysis Avascular necrosis Malunited fractures (acetabulum or femoral neck) Prior periacetabular or proximal femoral osteotomy Retroverted acetabulum Most patients lack a clear history for any predisposing conditions Parvizi et al: JAAOS 2007. Patients typically 25-40 years of age Mean delay in diagnosis: 7-21 months Groin pain is most common complaint Anterior groin: 92% Lateral hip: 59% Deep within the buttocks: 38% Worse with activity, especially repetitive twisting and pivoting motions Pain with prolonged hip flexion (sitting) Pain with rising from a seated position McCarthy et al: CORR 2003. Burnett et al: JBJS 2006. Byrd: ICL 2007. AP Pelvis Acetabular Characteristics: Center edge angle Acetabular inclination Acetabular version Crossover sign Presence of Osteoarthritis Femoral Characteristics: Head sphericity Head-neck offset Neck-shaft angle Trochanteric height Dunn lateral Obtained in 90° flexion and 20° abduction Useful for evaluating: Femoral head-neck junction Femoral head sphericity Alpha angle Congruency Normal acetabular labrum has uniformly low signal intensity and a sharp triangular morphology Sofka et al: Op Tech Sport Med 2007. Sensitivity increased compared to MRI, but false- positive rate also increases Sensitivity: 57-95% Specificity: 75% False-Positive rate: 20% Byrd et al: AJSM 2004. Burnett et al: JBJS 2006. Radiologically-guided intra-articular local anesthetic injections (easily performed in conjunction with MR arthrography) are useful to assess whether pain is intra-articular **Transient pain relief is a 90% reliable indication of intra-articular pathology Byrd et al: AJSM 2004. Initial trial of non-surgical treatment Activity modification including restriction of athletic activities NSAIDs Usually fails to control the symptoms In an attempt to prevent progression of arthritis, surgery is recommended if non-surgical treatment fails Fitzgerald: CORR 1995. Byrd: Arthroscopy 1996. Kelly et al: Arthroscopy 2005 Post LABRAL TEAR LABRAL REPAIR 52 patients underwent arthroscopic labral repair Mean follow-up: 9 months – overall improvement in HHS Long term follow up needed Hines et al: Arthroscopy 2007. 158 patients underwent arthroscopic surgery for FAI 50% pain resolution by 3 months 95% pain resolution by 1 year Sampson: Tech Orthop 2005. 45 professional athletes with FAI 49% Cam lesions 7% Pincer lesions 44% Combined Cam and Pincer 42 athletes (93%) returned to professional competition 3 athletes who did not return to play all had diffuse osteoarthritis 35 athletes (78%) remain active in professional sport at an average follow-up of 1.6 years Philippon et al: KSSTA 2007. 100 hips (mean age 34.7 years) with FAI treated with arthroscopic management Follow-up at mean 9.9 months 75% good/excellent results 3 patients required total hip arthroplasty All had grade 4 chondral injuries > 2 cm on acetabulum Larson et al: Arthroscopy 2008. Long term studies are needed to see if alteration in the natural progression to osteoarthritis and sustained pain relief can be achieved with arthroscopic management of FAI CPM immediately post op 30-70 deg hip flexion (debateable) Immediate PWB with crutches x 2-4 weeks Start PT immediately for AA/PROM, Strengthening Indocin 75 mg PO daily 10-14 days Decreased incidence of HO Baby ASA, chemical DVT prophylaxis Patients with previous history of DVT OCPs Minimization of hip flexor inflammation Labral repair/Osteoplasty/Chondroplasty Flexion 0-90, abd 0-25, ER 0-25 x 2 weeks (avoid labral stress) CPM x 4 weeks (4 hours/day) Isometrics/Core Advanced strengthening once FWB 3-6weeks Single leg stance Advanced bridging Single knee bends Sidestepping w/ resistance Stalzer et al., Operative Tech Orthopaedics, 2005 Acetabular labral tears are a common cause of hip pain. Acetabular labral tears rarely occur as isolated pathology. FAI is a common cause of acetabular labral tears in the athlete. To optimize results, surgical treatment should address not only the acetabular labral tear, but also the associated pathology Chonral injury Underlying impingement Long-term studies are needed to see if these results are durable and delay or prevent the onset of osteoarthritis. .
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