Hip Injuries In The Athelete+Arthroscopy Of The Hip


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Surgical Treatment of FAI

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  • Because FAI is such a devastating problem in young adults I have done this more and more past 5 yrs.
  • PELVIS DESIGNED TO PROTECT THE VITAL ORGANS INSIDE. BONY SHEILD. And connect the legs to the torso.***place for the muscles that control the leg to attach*****
  • Hip joint is made for strength and stability.To with stand the abuse we put on it.Landing, muscular contractionTorque forces
  • Powerful muscles use a fulcrum to exert tremendous force in order to control the legs and execute activities
  • Contusion – injury to soft tissue due to direct blowStrain – partial tearing of the muscle or tendon involvedFracture – broken bone.
  • Non surgical treatment
  • Land ball of feet with knees bent, roll to heels. Never run upright, plant with straight knee and hip and cut. Always small steps knee and hips flexed to cut.
  • The true abnormality of a sports hernia is thought to be a weakening or defect of the soft tissues such as the abdominal muscle fascia as they insert on the pubic bone of the pelvis.  This weakening can be associated with pain along the pubic bone termed “athletic pubalgia”.  Unlike other medical hernias, there is not typically a frank tissue opening with the associated bulge or passage of other organs or tissues.
  • Non surgical treatment
  • These muscles work together to help flex the hip, and to provide stability for the lower extremity.The most common cause of hip flexor injury is acute trauma. You may experience one specific instance when you felt your hip flexor pull. This may have been when you broke into a sprint, made a cut, or kicked a ball. Tight muscles and poor flexibility will contribute to hip flexor injury. When muscles are tight, there is an increased amount of tension on the tissues. When this increased tension is added to by an explosive movement, injury can occur. Hip flexor injury is very common in sports, especially soccer, football, and running. Caused by explosive movements, injury to these muscles can be painful, and cause all kinds of problems.
  • Muscle tightness is the most common cause of bursitis. The Iliotibial Band, or IT Band is a big culprit in trochanteric bursitis. The IT band runs along the outside of the hip, and the tendon actually moves over the greater trochanter everytime you lift your knee and flex your hip.Think about how many times you do this every time you play basketball, or go for a run. If the IT Band is tight, this increased friction will irritate the bursa, and may cause pain over time.Another cause is direct injury to the outside of the hip.
  • The most common cause of this injury is tightness of the piriformis muscle. Because of the close proximity of the sciatic nerve, tightness of the muscle can cause irritation and increased compression of the nerve, resulting in pain, numbness, and tingling. These symptoms are increased with activities, especially those that involve contraction of the muscles. They may also be increased by sitting for long periods of time. TreatmentWhether you are suffering from true piriformis problems, with numbness and tingling, or you are simply having hip pain in the back of your hip, stretching of the piriformis muscle can help reduce your pain. Piriformis stretching can effectively reduce the tension on the muscle and reduce the irritation of the nerve.
  • One of the biggest culprits for referring pain to the hip is the SI joint in the lower back. The SI joint is where your pelvis meets your sacrum. This joint can often be a problem with athletes, especially if they have core weakness or are overtraining. Pain that comes on gradually, or moves around from the front, back, and side may be referred pain.
  • Thanks to recent medical advances, patients with ongoing hip pain who don’t require a hip replacement may now be treated with minimally invasive surgery. The procedure, called hip arthroscopy, allows surgeons to diagnose and repair most injuries through tiny incisions in the hip instead of larger incisions like those needed for replacements. This less invasive approach usually means less pain and a quicker recovery for the patient. 
  • These days, people are staying active until much later in their lives, so it’s important to get them back on their feet and doing what they love quickly and with the smallest amount of pain possible,” said Dr. [insert doctor’s name here]. “In many cases, hip arthroscopy does this and more, because it’s treating an injury and at the same time diminishing the risk of arthritis and perhaps delaying the need for a hip replacement.”
  • Loss of femoro head offsetCrossover – retroversionA patient’s history will generally involve complaints of hip pain (front, side, or back) and loss of hip motion.  The physical exam will generally confirm the patient’s history and eliminate other causes of hip pain.
  •   What are the central, peripheral, and lateral compartments of the hip?During a hip arthroscopy, the surgeon should visualize two compartments or spaces of the hip joint.  The first space is the central compartment.  The central compartment is composed of the surfaces of the ball (femoral head) and the socket (acetabulum) as well as the soft tissues (i.e., labrum).  Procedures performed within the central compartment include treatment of the cartilage and labrum.  The peripheral compartment is the remainder of the hip joint and refers to the area along the junction of the femoral head (ball) and femoral neck.  Procedures performed within the peripheral compartment include treatment of bone spurs and the joint capsule.  Both the central and peripheral compartments are within the hip joint capsule making them accessible with the arthroscope. The lateral or peritrochanteric compartment lies outside of the hip joint. The surgeon may enter the lateral compartment with the arthroscope to evaluate and treat disorders such as hip muscle/tendon tears, snapping hips, and hip inflammation (bursitis). 
  • Recovery time from most FAI surgical procedures is about 4 months to full, unrestricted activity.  Your postoperative activity level will depend on your surgeon’s recommendation, the type of surgery performed, and the condition of the hip joint at the time of surgery. Revision FAI surgery may involve a significantly longer recovery.
  • Hip Injuries In The Athelete+Arthroscopy Of The Hip

    1. 1. Bill Bose, M.D.<br />Advanced Orthopaedics, LLC<br />Providence Medical Park Plaza<br />Suite B 114<br />
    3. 3. Life Story in 1 slide<br />4 yr<br />4 yr<br />5 yr<br />(1) yr<br />College - LSU<br />Medical School - LSU<br />Orthopaedic Internship and Residency<br />Fellowship –Univ. Florida – “Adult Reconstruction” 1993<br />3Years Practice– Faculty USA<br />13 years private practice<br />
    4. 4.
    5. 5. HIP AND PELVIS ANATOMY<br />
    6. 6. <ul><li> Ball-and-socket joint
    7. 7. Femur – ball
    8. 8. Acetabulum – socket
    9. 9. Articular cartilage – surface material
    10. 10. Labrum - cartilage around rim of acetabulum</li></ul>Labrum<br />Articular Cartilage<br />Acetabulum<br />Femur<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    11. 11. HIP JOINT ANATOMY<br />
    12. 12. Strength and Stability<br />
    13. 13. Strength and Stability<br />
    14. 14. TYPES OF HIP INJURIES<br />Trauma<br />Contusions<br />fractures<br />Sports injuries or overuse injuries<br />strains<br />tendonitis<br />Developmental <br />Things you are born with<br />May become symptomatic by sports or excessive movements in sports<br />
    15. 15. Contusions of Hip<br />“Hip Pointer”<br />contusion of soft tissue and bone where minimal soft tissue covering over the bone.<br />Iliac crest<br />Greater trochanter<br />
    16. 16. FRACTURES ABOUT THE HIP<br /><ul><li>FRACTURES
    17. 17. Iliac Wing
    18. 18. Direct blow to side of Hip or fall onto the knee</li></ul>MVA/Football/cycling<br />TYPES<br />Head/Neck/Proximal Femur<br />acetabulum<br />Pubic Rami<br />Elderly population with minor or even no trauma<br />
    19. 19. Stress Fractures<br />“Micro-cracks”<br />“Overuse”<br />Pain with weight<br />Usually no surgery required.<br />
    20. 20. TRAUMATIC DISLOCATION<br />BO JACKSON<br />Femoral head comes out of the socket<br />Abrades of cartilage, tears labrum<br />Lead to post-traumatic arthritis or AVN<br />Shortened and IR<br />Surgical emergency<br />
    21. 21. HIP SOCKET FRACTURES<br />
    22. 22. Treatment – Surgical repair<br />
    23. 23. SPRAINS/STRAINSaround the hip<br />Sprain – tearing of some of the fibers of a ligament or tendon.<br />Strain – “muscle pull”<br />Tearing of some of the fibers of a muscle<br />Abdominal strain<br />“Sports Hernia”<br />
    24. 24. ACUTE MUSCLE STRAINS<br />Discrete event – immediate pain<br />Groin Strain – tearing of adductor muscles at attachment to pelvis<br />Hamstring Strain – tearing of posterior thigh muscles<br />Quad strain<br />Abdominal strains<br />
    25. 25. ACUTE MUSCLE STRAINS<br />Iliopsoas “hip flexor” strain<br />Can be acute due to<br /> explosive muscle contraction of the Hip Flexor muscles <br />soccer<br />
    26. 26. Overuse Injuries<br />Tendon injury due to repetitive micro trauma to the tendon - tendonitis<br />Iliopsoas tendonitis <br />or “Snapping Hip Syndrome”<br />Rectus Femoris tendonitis<br />Sprinters, kickers<br />
    27. 27. Hip Overuse Syndromes <br />ITB friction syndrome or “Bursitis”<br />Crest<br />Trochanter<br />Tightness<br />Runners<br />
    28. 28. Piriformis syndrome<br />Unusual cause of buttock pain<br />May irritate the sciatic nerve<br />Pain increased with activity<br />Piriformis stretching<br />MUST make sure lumbar spine is not cause<br />
    29. 29. Sacroilitis<br />Inflammation of the SI joint<br />Gradual onset<br />Figure of 4<br />Buttock or lower back<br />
    30. 30. FAI<br />Femoroacetabular Impingement<br />
    31. 31. NON TRAUMATIC HIP PAIN<br />7 million people visit the doctor for hip pain<br />Climbing stairs, or bending to tie shoes, sports, ADL<br />Normal x-ray and MRI<br />the determination of the cause of the pain wasn’t clear<br />Practical treatment NOT available<br />30-50 with chronic hip pain “live with it until you are an age when a THA is more feasible”<br />
    32. 32. HIP ARTHROSCOPY<br />Tremendous advancement<br />hip arthroscopy – 3-4 ½” incisions<br />Diagnose and treat hip pain<br />
    33. 33. Pincer<br />Cam<br />• Lack of room between femur and acetabulum<br />• Femur and acetabulum rub together<br />• More common in athletic men<br /><ul><li> Strenuous activity aggravates pain
    34. 34. Prolonged stationary seating may intensify pain
    35. 35. Pincer – excessive growth around acetabulum
    36. 36. Cam – neck of femur abnormally shaped</li></ul>©2008 Smith & Nephew, Inc. All rights reserved.<br />
    37. 37. FAI congenital or developmental<br />Repetitive collision of the femoral neck and the rim of the acetabulum<br />The labrum (gasket) is pinched, then tears causing pain<br />Articular cartilage damage and wear<br />lead to pain/arthritis later in life<br />
    38. 38. Things that you were born with (varying degrees)<br />Aggravated or irritated by sports events or movements <br />Or<br />Treating an injury<br />AND at the same time diminishing the risk of arthritis<br />
    39. 39. HIP ARTHROSCOPY<br />3-4 tiny incisions<br />Less pain and quicker recovery<br />More active less pain lifestyle<br />47 Y/O WF<br />
    40. 40. • Labrum - Layer of cartilage lining rim <br /> of socket<br />Rubbing of the bony impingement:<br />• causes injury or degeneration and tearing of this gasket<br />• Can cause locking or “catching” in joint<br />• MRI with dye injection needed to <br /> confirm diagnosis<br />Femur Removed for Detail<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    41. 41. • From trauma, degenerative disease<br /><ul><li>or friction from torn labrum</li></ul>• Cause “catching” in the joint<br />• Not easy to detect with x-ray<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    42. 42. • Articular cartilage - covers ball and socket<br />• Provides cushioning and protection<br />• over time with continued impingement, it can be torn or damaged by high impact sports, leading to degeneration<br />• Fragments can protrude into joint and <br /> cause pain – loose bodies<br />• Bone no longer protected from friction by the Cartilage and leads to arthritis and eventually a Hip Replacement<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    43. 43. FAI Patient History<br />Long duration hip/groin pain (2yrs)<br />Painful snapping<br />Normal x-ray (subtle clues)<br />Normal plain MRI of hip and or lumbar<br />No response L-esb<br />Not AVN<br />Not trochbursitis<br />ITB friction, psoas tendon or iliopsoas bursitis<br />Intra articular source?? <br />
    44. 44. FAI<br />Intra articular injection positive<br />McCarthy’s sign<br /> C – sign<br />Contrasted MRI – 30/40 false negative<br />Only 60% positive<br />
    45. 45. FAI<br />
    46. 46. FAI<br />
    47. 47. Young Patient (51)With Hip pain<br />???THA<br />
    48. 48. NORMAL <br />
    49. 49. FAI<br />Lead to cartilage wear arthritis<br />Arrest or stop the impingement process<br />goal is to preserve the native hip joint as long as possible<br />Postpone or avoid THA<br />
    50. 50. Chondral Damage - Arthritis<br />
    51. 51. Treatment is designed toDelay or Prevent OA and THA<br />
    52. 52. FAI Pincer vs. CAM<br />Cam<br />Due to loss of femoral offset <br />Treatment is capsulotomy and a proximal femoral osteochondroplasty<br />Pincer<br />Due to overcoverage of anterior acetabulum<br />Treatment is rim trimming and refixation of labrum if possible<br />
    53. 53. SO WHAT ARE GOINGTO DO ABOUT IT???<br />treatment<br />
    54. 54. OPEN PROCEDURE FOR FAI<br />10 yrs ago<br />Anterior incision<br />Avoid nerves and artery<br />Cut through muscles<br />8-12 inch incision<br />3-4 days in hospital<br />Risk of AVN<br />Large blood loss<br />Long recovery 6-12 mths<br />Stiffness<br />Results mediocre<br />
    55. 55. ARTHROSCOPY OF THE HIP<br />8-10 yrs ago<br />Began using a tool adapted from the knee and shoulder<br />3 or 4 small incisions<br />
    56. 56. ARTHROSCOPY OF THE HIP<br />New technique<br />MANY ADVANTAGES – open technique<br />Outpatient surgery<br />Improved results<br />Quicker recovery<br />Less pain<br />Major advancement : Alex Rodriquez<br />
    57. 57. Arthroscopy as tool<br />Able to visualize pathology<br />Treat pathology<br />Less space<br />Longer distance from the skin<br />Curved joint surface<br />Technically difficult<br />
    58. 58.
    59. 59.
    60. 60. HIP ARTHROSCOPY<br />
    61. 61.
    62. 62. Normal Articular Cartilage<br />Visualize<br />Cartilage,<br />Fovea<br />Loose bodies<br />
    63. 63. Labrum<br />
    64. 64. Early Chondral Delamination<br />
    65. 65. Chronic/Degenerative Tear90%<br />
    66. 66. Labral Resection<br />
    67. 67. Labral Resection<br />
    68. 68. Lateral and Medial limitsof the Resection<br />lateral<br />medial<br />
    69. 69. Resected Labrum<br />
    70. 70. <ul><li>• 10% tears are repairable
    71. 71. THE Labrum may be repaired - anchors and sutures
    72. 72. Smooth edges of labrum - shaver blades or RF energy
    73. 73. Remove torn tissue
    74. 74. Repair with suture anchors</li></ul>©2008 Smith & Nephew, Inc. All rights reserved.<br />
    75. 75. Labral Repair<br />
    76. 76. REPAIR OFTORN LABRUM<br />
    77. 77. REPAIRED LABRUM<br />
    78. 78. Peripheral Compartment<br />
    79. 79. Femoral Osteochondroplasty<br />
    80. 80. Re-establish Head-Neck Offset<br />
    82. 82. Platelet Rich Plasma<br />
    83. 83. • Recovery room for observation<br />• Discuss use of crutches with physician<br />• Request information regarding postoperative plan<br />• Rehabilitation - consult physician<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    84. 84. Postop<br /> Resection <br />Crutches x 72 – <br />One Crutch X 4 weeks<br />cycling at pod 2<br />Full ROM pod 2<br />Quad and Abductor @ one week<br />Sports 2 mths<br />Labral Repair – <br />crutches TTWB 4-6 weeks<br />No ER – damage repair<br />Flexion on cycle ok one week<br />6 weeks begin rotation<br />Sports 3-4 mths<br />
    85. 85. • Relieve pain<br />• Improve joint stability<br />• Remove loose bodies<br />• Repair tears and damage<br />• May delay onset of osteoarthritis<br />• May delay need for total hip replacement<br />• Improve quality of life<br />• Optimize activities of daily living<br />©2008 Smith & Nephew, Inc. All rights reserved.<br />
    86. 86. Return to sportsIndividualize3-4 mths<br />
    87. 87. QUESTIONS???<br />