Download Treatment of Femoroacetabular Impingement and other Hip

Diagnosis and Treatment of
Femoro-acetabular Impingement
and other Hip Conditions in the
Athlete
Thomas Brandon, MD
Peninsula Orthopaedic Associates
Salisbury University Sports
Medicine Symposium
January 2010
Overview
• Femoro-acetabular Impingement including
labral tears
• Ligamentum Teres injuries
• Snapping hip (coxa saltans)
• Instability
CLINICAL ANATOMY
• Femoral head/neck &
acetabulum ( nl
anteversion 15-20
degrees)
• Acetabular labrum &
cartilage
• Ligamentum teres
• Iliofemoral ligaments
CLINICAL ANATOMY
• Iliopsoas muscle
• Tensor fascia lata
• Trochanteric bursa
History & Examination of the Hip
• Onset: acute or
chronic, traumatic,
atraumatic
• Type of pain:
catching, locking,
aching, stiffness,
slipping
• Location of pain:
central of peripheral
History and Examination of the Hip
• Gait and posture
• Back exam
• Pelvic obliquity, LE
rotation and leg
length
• Atrophy & palpation
• Active and passive
ROM
• Neurovascular exam
Hip examination – Specific Tests
• Thomas test
• Ober’s test
Hip Examination – Specific Tests
• Faber’s test
• Anterior labral test
• Posterior labral test
Hip Examination – Special Tests
• Lateral compression test (osteitis pubis)
• Piriformis test
Imaging
Imaging
Femoro-acetabular Impingement
(FAI) - Ganz
• Abnormal contact of
femoral head and/or neck
on the acetabulum
• Creates either abnormal
shear forces on
acetabulum or direct
contact on the head or
neck causing damage to
the cartilage and labrum
Femoro-acetabular Impingment
• Congenital etiology:
abnl femoral and
acetabular anteversion
are caused by various
intrauterine position of
the fetal limbs
• Decrease in acetabular
+/- femoral anteversion
are a major cause of
hip pain and arthritis
(Tonnis et al, JBJS,
1999)
Femoro-acetabular Impingement
• Sub clinical SCFE or
growth disturbance of
proximal femur
produces nonspherical head (pistol
grip deformity)
• Coxa profunda (deep
acetabulum)
FAI
• 2 types – both cause abnormal forces: labral & cartilage
damage, ? Increased risk of OA
• Cam type
• Pincer type
• Combination of both
FAI – Cam Type
• Increased retroversion
of head/neck
(measured with CT)
• Decreased off set of
head neck ( <10mm)
and/or loss of sphericity
( alpha angle > 50 deg)
• More common in young
athletic malesretroversion of femur
more common
FAI-CAM TYPE
• Non-spherical head
creates shear forces
causing outside-in
abrasion
• Anterior superior
chondral damage first
then labral avulsion at
base and detachment
FAI – PINCER TYPE
• Anterior rim of
acetabulum contacts
the head or head/neck
junction
• Increased acetabular
retroversion (figure of 8
sign)
• Coxa profunda: center
of head is medial to
posterior acetabular
wall or medial wall of
acetabulum is medial to
ilioischial line
FAI – PINCER TYPE
• More common in
middle age athletic
women
• Direct contact of
acetabular rim on
femoral head neck
causing labral tear
FAI – SYMPTOMS & SIGNS
• Typically chronic onset
but can be acute
• Groin pain aggravated by
activities and sitting
• Night pain common
• Locking, catching , giving
way
• Limp, trendelenberg,
positive impingement sign
• Decreased flexion and
internal rotation
FAI TREATMENT
•
•
•
•
NSAID’s
Therapy
Steroid injection
Often not successful
FAI TREATMENT
• Open versus
arthroscopic versus
combined
• Goal is to address the
bony and/or labral
pathology
FAI – OPEN TREATMENT
• Surgical dislocation of the hip (Ganz, JBJS,
2006
OPEN TREATMENT RESULTS
• Depends on labral
debridement vs repair
(Espinosa et al.
JBJS,2007)
• Patients with labral
repair had superior
clinical and
radiographic results at
2 yrs
OPEN TREATMENT
DISADVANTAGES
• Large exposure
requiring trochanteric
osteotomy
• Theoretical increased
risk to blood supply
• Requires experienced
hip surgeon
• Prolonged recovery
FAI – ARTHROSCOPIC
TREATMENT
• Out patient procedure
• Can address central
and peripheral
compartments
treating intra- and
extra-articular
pathology
FAI – ARTHROSCOPIC
TREATMENT
•
•
•
•
Supine or lateral position
Distraction of hip joint
3-4 portals
Labral repair/
debridement + rim
trimming – pincer lesions
• Osteochondroplasty of
head/neck junction – cam
lesions
FAI – ARTHROSCOPIC
TREATMENT RESULTS
• Larson, et al.
Arthroscopy,2008
• 96 pts 3 yr f/u cam
and pincer FAI
• Significant
improvement of pain,
function and alpha
angle
FAI – ARTHROSCOPIC
TREATMENT
• Technically difficult
• Amount of acetabular
version correction
limited?
• Obesity a relative
contra-indication
Complications
• Iatrogenic cartilage
injury
• Nerve or vessel injury:
direct or traction
• Fracture or
subluxation/dislocation
• Adhesions
• DVT/PE
• Progressive arthritis
• Infection
• Abdominal fluid
extravasation
FAI - Combined
• Arthroscopy +
limited open
approach (Hueter)
• Allows treatment of
intra-articular
pathology and
easier
contouring/bone
trimming +/- labral
fixation
(Arthroscopy 2009)
Post OP Management
• 20 lbs wt bearing &
cpm 4 hrs/d x 2 wks
• If microfx : pwb x 8
wks
• Rotation boots to
prevent ER x 14-21
days
• PT to restore passive
IR & hip pendulums
• Return to sports avg
3.4 mos (Phillipon
AJSM, 2009)
LIGAMENTUM TERES TEARS
• Diagnosis is increasing
• 3rd most common finding
at arthroscopy
• Symptoms include deep
anterior groin pain,
catching, locking, popping
and giving way
• Often occurs after a
injury: football, skiing,
gymnastics, MVA
• Exam is non-specific
groin pain with ROM
LIGAMENTUM TERES TEARS
• Imaging may be
diagnostic but
majority found at time
of arthroscopy
LIGAMENTUM TERES TEARS
• Treatment:
arthroscopic
debridement
• 96% improvement of
symptoms and return
to activity (Byrd,
Arthroscopy, 2004)
SNAPPING HIP – COXA
SALTANS
• External – snapping
of iliotibial band over
greater trochanter
• Internal – snapping of
iliopsoas tendon over
femoral head and/or
iliopectineal eminence
SNAPPING HIP - ETIOLOGY
• Direct injury – falls
and direct blows
• Training errors –
common in dancers,
gymnasts
• Mal-alignment of
lower extremities –
decreased head/neck
angle, varus knees,
pronated feet
SNAPPING HIP
• External – snapping
painful sensation
localized to greater
trochanter
• Internal – clicking
sensation rather than
snapping more
internal and central
SNAPPING HIP
• Internal occurs in
athletes who have
frequent rotation of
hip at high flexion
angles
• Click & pain with
flexion/abd of hip
followed by
ext/adduction
SNAPPING HIP
• External is usually
caused by abnormal
thickening of
posterior band of ITB
• Common in cyclists
and runners
• Athlete can often
demonstrate painful
snapping that is
palpable
SNAPPING HIP
• Internal: pain
reproduced by
flexion & abd
followed by ext &
adduction
• May have palpable
snap sometimes
reduced with finger
pressure
SNAPPING HIP
• Others causes :
trochanteric burstis,
loose bodies and labral
tears, gluteus medius
tears, ? instability
SNAPPING HIP
• Imaging: xrays and
CT to r/o other
pathology; MRI
occasionally helpful
• US and bursography
can be diagnostic with
experienced
radiologists
SNAPPING HIP
• Both usually respond
to rest, NSAID’s,
stretching and
strengthening
exercises
• Steroid injections
• Return to sports in 46 wks
SNAPPING HIP - Treatment
• External : open or
arthroscopic
iliotibial band
release and
bursectomy
• Excellent results in
small series;
Ilizalituri, et al,
Arthoscopy, 2006
SNAPPING HIP – Post-op
Rehab
• External release –
crutches wbat until
pain free;
stretch/strengthen
abd, etc; return to
sports when pain
free and strength
90%
SNAPPING HIP - Treatment
• Internal: open –
difficult dissection
• Complication rates
up to 50%: nerve
injury, hematoma,
infection, etc
SNAPPING HIP - Treatment
• Arthroscopic
release
• Successful in small
series; Flanum,
AJSM, 2007
• Few complications
• Return to sports at
~6 mos
SNAPPING HIP INTERNAL–
Post-op Rehab
• Wks 1-4: protected WB
until active hip flexion
regained and pain 3/10
• Wks 4-8: functional
gait, ROM and
strengthening to limits
of pain
• Return to sports when
strength 90%
HIP INSTABILITY
• Inherently stable joint
due to bony and soft
tissue constraints
• Acetabulum is
oriented 45 degrees
caudally and 15-20
degrees anteverted
HIP INSTABILITY
• Soft tissues provide
secondary restraints
• Capsuloligamentous
structures
• Labrum
• Cartilage
• Ligamentum teres
• Transverse
acetabular ligament
HIP INSTABILITY
• Traumatic: acute
defined event
resulting in
subluxation or
dislocation
• Atraumatic: subtle,
not well defined, can
be overuse or due to
congenital
abnormality
TRAUMATIC HIP INSTABILITY
• Obvious or subtle
minimal trauma
• Most common
mechanism is MVA
• Athletics: fall on
knee with hip flexed
or blow from behind
• Reported in almost
all sports: football,
rugby, gymnastics,
soccer, etc
TRAUMATIC HIP INSTABILITYDISLOCATION
• Acute injury: usually
posterior
• Hip held in flexion, IR
and adduction
• Xrays show
dislocation +/-fx
TRAUMATIC HIP DISLOCATION
• Management: closed
reduction within 6 hrs to
reduce AVN
• CT to confirm reduction
• Surgery if loose body or
fx
• Crutches TTWB x 6 wks
• MRI @ 6 wks to R/O
AVN
• Return to play depends
on imaging results and
exam
TRAUMATIC HIP SUBLUXATION
• Misdiagnosed as
sprain or strain
• Same mechanism as
dislocation
• Usually less energy
involved
• Have high index of
suspicion
TRAUMATIC HIP SUBLUXATION
• PE: pain with rom and
may have loss of
motion
• Xrays usually
negative but oblique
may show post lip fx
(bankart- like lesion)
TRAUMATIC HIP SUBLUXATON
• MRI- characteristic triad: posterior lip fx, iliofemoral ligament
disruption, hemarthrosis (Moorman, JBJS,2003)
• Can also show marrow edema, chondral injury, loose bodies
TRAUMATIC HIP SUBLUXATION
• Consider fluoroscopic
aspiration if large
hemarthrosis
• MRI @ 6wks to r/o
avn – hip arthroscopy
if indicated
• Repeat MRI at 12
wks to r/o AVN
MANAGEMENT OVERVIEW
Shindle,et alClin sports med2006
TRAUMATIC HIP INSTABILITY
PROGNOSIS
• Traumatic dislocationavn reported in 117%, increased risk of
late OA up to 30%
• Traumatic subluxation
–risks unknown; avn
in 2/8 pro football
players (Moorman,
JBJS,2003)
ATRAUMATIC HIP INSTABILITY
• No discrete event
• Difficult diagnosis
• Symptoms include leg giving out, pain when
rising from a chair or getting in or out of a car,
painful clicking or catching
• Broad DDX: labral tear, FAI, dysplasia, AVN,
loose bodies, osteitis pubis, GU, spine, hernia,
GYN, PVD, infection, tumors, stress fx,
inflammatory arthritis, etc
ATRAUMATIC HIP INSTABILITY
• Overuse or repetitive
motion injury involving
hip rotation with axial
loading: hockey,
gymnastics, golf,
ballet
• Hip dysplasia
• Congenital conditions:
Ehlers-Danlos,
Marfan’s
ATRAUMATIC HIP INSTABILITY
• Athlete can often
describe motion that
reproduces pain: driving
ball in golf and sideline
throws in FB
• Over time can lead to
coxa saltans due to
overcompensation of
iliopsoas ( flexion
contracture & back pain)
ATRAUMATIC HIP INSTABILITY
• Evaluate other joints for
laxity
• Positive dial test
• Axial
distraction/apprehension
test
• Prone extension-external
rotation test produces
anterior hip pain
• Increased prom
• Pt may voluntarily sublux
hip
ATRAUMATIC HIP INSTABILITYIMAGING
• CE angle of Wiberg: nl greater than 25 degrees
• Tonnis angle: nl less than 10 degrees
• Sharp’s angle greater than 45 degrees is abnl
ATRAUMATIC INSTABILITY IMAGING
• MRA – capsule
appears thickened at
lateral margin of
anterior capsule with
increased signal
intensity
• Local anesthetic
injection at time of
MRA can confirm pain
is intra-articular
ATRAUMATIC INSTABLILITY
MANAGEMENT
• Modification of activity, nsaid’s, therapy
• Arthroscopy to reduce volume of hip capsule
• Byrd (Arthroscopy,2003); Philippon, Knee Surg Sports
Trauma, 2007) report significant improvement and return
to sports.
ATRAUMATIC HIP INSTABILITY
MANAGEMENT
• Open osteotomy for
dysplastic hips
• Prognosis for return
to sports?
SUMMARY
• Hip pain in athlete is multi-factorial
• Diagnosis can be difficult
• Must have a high index of suspicion as
misdiagnosis can have poor prognosis
• Hip arthroscopy is becoming an important
diagnostic and therapeutic technique in
the treatment