Hip Arthroscopy Kennan Vance, DO Problem On average, Paents 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 aachments 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 “delaminaon” 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 moon • Provides a “seal” to the central compartment Benefits of Labral Seal • Resists distrac;on of femoral head from socket due to negave 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 • Traumac (<50%) – External force to extended and ER hip – Pivo;ng sports • Degenerave – 90% of atraumac 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 rotaon 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 dislocaon 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 sing – 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 evoluon • Lots of overlap with SI joint, back, or extra- ar;cular problems • Starts with inspec;on, palpaon, 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 Rotaon Impingement Test (DIRIT) • Dynamic External Rotaon 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 instrumentaon • Now more widely accepted and beTer 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 expectaons How is it Performed? Surgery Demo Wave Sign Results • Excision of labrum/car;lage • Labral repair results are lesions without addressing slightly beTer than bone yields 29-54% debridement in short term unsasfactory 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 indicaon 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 Complicaons • Rate of 1.3-6.4% • Usually minor and transient – Trac;on Neuropraxia to sciac and pudental nerve – Damage to LFC nerve • Intra-ar;cular damage from surgery • Heterotopic Ossificaon – Naprosyn 500mg bid reduced incidence from 25% to 5.6% – No prophylaxis aer 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 duraon of symptoms • Worse preoperave 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 .