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Agolley Young adult hip pain
- 1. www.davidagolley.com.au Shooting From the Hip Young Adult Hip pain and Fast Recovery Hip Preservation Surgery Dr David Agolley Orthopaedic Hip and Knee Surgeon Sports Surgery and Arthroplasty John Flynn Private Hospital
- 2. Institute of Sport and Exercise Health • State-of-the-art Facility • 8 Consulting rooms • 3T MR Imaging • Ultrasound • X-ray • Interventional treatment rooms • Well equipped physiotherapy gym • Research !
- 3. www.davidagolley.com.au • Hip • Young Adult Hip Pain • Hip Preservation Surgery • Hip impingement and labrum tears • Hip Arthroscopy • Periacetabular Osteotomy • Hip Replacement young to old My Scope of Practice • Knee • Preservation Surgery • Knee Arthroscopy • ACL / Ligament Reconstruction • Knee Replacement
- 4. www.davidagolley.com.au • 14+ (Skeletal Maturity) • Spend long time consulting • Thorough History and Examination • Diagnosis • Discuss non-surgical and surgical options My Patients
- 6. www.davidagolley.com.au • 33yo male • Left hip pain for a few months • slight ache at night but not particularly bothersome • Pain aggravated by walking and running • Otherwise well • No specific Injury • No history of hip problems Case 1 • Examination normal • No swelling or skin changes • No tenderness • Normal range of motion • No impingement
- 7. www.davidagolley.com.au A. Refer Physiotherpy B. Refer Specialist C. Investigation D. Review in 2 months Case 1- 33yo Male What Next? = X-ray
- 8. www.davidagolley.com.au Case 1- 33yo Male Left proximal femur Osteosarcoma Always get an X-ray
- 10. www.davidagolley.com.au • 25yo Female • Bilateral Anterior Groin Pain • Right worse than left • No specific Injury • First born female, Normal vaginal delivery • No Childhood hip problems • No family history of hip problems Case 2 - 25yo female
- 11. www.davidagolley.com.au • Pain • Moderate to Severe 7/10 • anterior groin no radiation • Aggravated by running more than 5 minutes and walking 3km • Joint • No clicking, catching or popping • Function • able to sleep well • difficulty walking and standing for long periods • unable to play hockey • unable to stand in her retail job for more than 30 minutes • Treatment • Physio no help • regular Paracetamol Case 2 - 25yo female
- 12. www.davidagolley.com.au • Examination • Hip not irritable rolling on table • Increased ROM • ER 60 degrees • IR 50 degrees • Flex 130 degrees • Impingement test positive Case 2 - 25yo female
- 13. www.davidagolley.com.au • Labral tear • Loose bodies • Ligamentum teres tear • Inflammatory arthritis • Osteoarthritis • Internal snapping hip - Iliopsoas • External snapping hip (ITB) • Trochanteric bursitis • Gluteal tendon tears Groin Pain Differential Diagnoses • Femoral neck stress # • Adductor strain • Osteitis Pubis • Piriformis syndrome • Sacro-iliac pain • Sports Hernia (Gilmore’s groin) • Inguinal or femoral hernia
- 14. www.davidagolley.com.au Normal Values • Acetabular index 0-10 degrees • Centre to Edge Angle 25 - 40
- 15. www.davidagolley.com.au Adult Acetabular Dysplasia Normal Values • Acetabular index 0-10 degrees • Centre to Edge Angle 25 - 40
- 20. www.davidagolley.com.au • 23yo male • Right anterior groin pain • Sudden onset doing power lift deep squat • Felt a pop in the groin • Pain aggravated by sitting in a chair, squatting, cycling Case 3 - 23yo male
- 21. www.davidagolley.com.au Case 3 - 23yo male 45 degrees
- 22. www.davidagolley.com.au Case 3 - 23yo male 70 degrees Modified Dunn
- 28. www.davidagolley.com.au • Labral tear • Cartilage delamination • Subchondral bone injury due to stress • Repetitive injury • Location of Pain fibres Why Pain? Alzaharani et.al. 2014
- 29. www.davidagolley.com.au • Labral tear • Loose bodies • Ligamentum teres tear • Inflammatory arthritis • Osteoarthritis • Internal snapping hip - Iliopsoas • External snapping hip (ITB) • Trochanteric bursitis • Gluteal tendon tears Groin Pain Differential Diagnoses • Femoral neck stress # • Adductor strain • Osteitis Pubis • Piriformis syndrome • Sacro-iliac pain • Sports Hernia (Gilmore’s groin) • Inguinal or femoral hernia
- 30. www.davidagolley.com.au • Anterior groin pain in high hip flexion • Age Group • Young to middle age • May not have an inciting injury • C-sign • Pain/click when standing from seated position • Over use injuries : Hamstring, adductors • Poor form in swinging and throwing sports • ?Family history FAI Clinical Presentation Pearls
- 31. www.davidagolley.com.au • How are they seated in consult chair • Gait - normal to antalgic • Deep squat • Range of motion • Impingement tests • Flex, ADd, IR (FADIR) most sensitive FAI Examination Pearls
- 33. www.davidagolley.com.au FAI Investigation Pearls - XR Modified Dunn Pistol Grip Standing AP Pre-op Post-op pistol grip pic
- 37. www.davidagolley.com.au • Lifestyle Modifications • Training Modifications • Physiotherapy is key BUT avoid provocative positions • Pain relief • Intra-articular LA steroid Injection Non-Surgical Management PRP
- 38. www.davidagolley.com.au • For the Amateur Athlete, discuss change in sport • Professional Athletes of different sports we treated on fellowship (pictured) • Football (Soccer) • Rugby • Martial arts • Ballet • Horse riders • Athletics • Rowing • Cycling Non-Surgical Management
- 39. www.davidagolley.com.au • Surgical Aims • Correct the femoral head neck offset • Remove pincer • Treat associated pathology • Cartilage damage : debride, repair, mircofrx • Labral damage : debride, repair, reconstruct • Open dislocation (Ganz) • Arthroscopy Surgical Management Modified Dunn
- 40. www.davidagolley.com.au • Open dislocation (Ganz)! • major op • scar • hospital 3-5 days • long rehab • risks - AVN • uncommon indication Surgical Management pic scar
- 41. www.davidagolley.com.au • Arthroscopy! • min invasive • same/next day d/c • FWB Crutches day 1 • Pain relief protocol • Accelerated rehab • limitations • risks Surgical Management
- 43. www.davidagolley.com.au • Indications for hip arthroscopy • FAI • removal loose bodies • Ligamentum teres injury • Internal snapping hip • external snapping hip • Gluteus medius tendon repair • Biopsy • Diagnostic Surgical Management
- 44. www.davidagolley.com.au • PWB to FWB crutches 4-6 weeks • Early motion within comfort • Avoid inflammation • Protect labral repair 8 weeks • Core and hip strength • Maintain ROM • Wean off crutches and gait retrain (avoid limp) • Jog to Run 8-10 weeks Rehab Pearls
- 45. www.davidagolley.com.au • Set up • Land marks • view • capsulotomy • view • findings • scoring system • Treatment of labral tears, degen, partial, full • treatment of pincer • treatment of cartilage damage, partial, full thickness, delimitation • treatment of cam • iliopsoas Hip Arthroscopy
- 46. www.davidagolley.com.au • Case Series, 53 patients (41m, 21f) • Avg age 42. Mean f.u 2.4 yrs • 45 regularly sport prior to first incident of hip pain • Only 4 still played at accustomed level of sport • All arthroscopic osteoplasty Outcomes FAI surgery
- 47. www.davidagolley.com.au • At final follow-up • 31 patients returned to full accustomed level of sport • mean VAS pain score improved mean 5.6 to 1.5 (0-9) (sig) • Non-arthritic hip score improve 54.4 to 85.7 (max 100) (sig) • Sports Frequency score increased from 0.78 to 1.84 (0-5) (sig) Outcomes FAI surgery
- 48. www.davidagolley.com.au • Systematic Review • min 6 months follow-up (1.36 - 3.76 years), FAI only • Athletes - ice-hockey, golf, football, soccer, dancing, horse riding, bull riding, lacrosse, tennis, martial arts, baseball • 9 Clinical studies (Case series Level IV), 418 athletes, mean age 25.4 • 2 Studies open surgical dislocation, 7 arthroscopy only • 249 cam, 36 pincer, 138 mixed Outcomes
- 49. www.davidagolley.com.au • 92% return to sport (95%CI, 87% - 96%) • 88% return previous level competition (95% CI 80%-94%) • Comparison to non-athletic populations is similar Outcomes
- 50. www.davidagolley.com.au • Do we need to repair the labrum? • Not all the time • Can we prevent arthritis? • Probably, but yet to be proven • Should we prophylactically operate on asymptomatic hips with incidental findings of morphological problems? • Probably not ?Need Answers
- 52. www.davidagolley.com.au • 39yo male, builder • Right groin pain increasing over last 2 years • No injury • Enjoys surfing, but now v.painful • Pain aggravated by sitting, driving, squatting, surfing • Recently walk limit 300m in sand due to groin pain Case 4 - 39yo male
- 53. www.davidagolley.com.au • Examination • Rolling the hip causes pain • In flexion obligatory external rotation 20 degrees, no further IR but can ER 45 degrees • Impingement test positive • Diagnosis? Case 4 - 39yo male
- 54. www.davidagolley.com.au Case 4 - 39yo male
- 55. www.davidagolley.com.au • Non-operative • Hip Arthroscopy • Hip fusion • Arthroplasty • Resurfacing • THR Case 4 - 39yo male Treatment Options
- 56. www.davidagolley.com.au Case 4 - 39yo male
- 57. www.davidagolley.com.au Case 4 - 39yo male
- 58. www.davidagolley.com.au • How long does the average THR last A. 10-15 years B. 15-20 years C. 20+ years Age Old Adage THR Only Last 10-15 years
- 61. www.davidagolley.com.au • Exploits intermuscular interval • No cutting of muscle and tendon • Faster recovery and rehabilitation • Stable joint • ?Long term benefit over other approaches Direct Anterior Approach
- 62. www.davidagolley.com.au Least Wearing Bearing Surfaces
- 63. www.davidagolley.com.au Least Wearing Bearing Surfaces
- 64. www.davidagolley.com.au • Young to elderly patients • Offer the complete surgical solution for hip pathology in both • hip preserving and • arthroplasty options • Appropriate approach for the patient • Use proven lowest wearing and lowest revision rate implants to provide best longevity THR My hip Practice
- 65. www.davidagolley.com.au • Groin Pain in the young adult can be a diagnostic dilemma • Be aware of Femoroacetabular impingement • Be concerned about the groin pain that is not improving • X-ray is the main primary investigation • standing AP pelvis, lateral and Modified Dunn • First Line Rx - Non-operative management • Second Line Rx - Refer on to someone you know • Hip preservation and arthroscopy are highly specialised techniques • Hip arthroscopy has excellent outcomes in well selected patients Conclusion
- 66. Questions? P : (07) 5598 0530 F : (07) 5598 0539 E : reception@davidagolley.com.au! www.davidagolley.com.au ! Suite 4F Level 4 John Flynn Medical Centre John Flynn Private Hospital 42 Inland Dr, Tugun QLD 4224 ! ! www.davidagolley.com.au