Michael J. Sileo, MD, FAAOS Sports Medicine Arthroscopic Shoulder, & Surgery December 7, 2018  NONE  and 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  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   Ligamentum teres  Adhesive capsulitis  Loose bodies  Osteonecrosis  Benign Intra-articular tumors  SCFE  PVNS  Transient  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  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  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  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  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 (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  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.