This document discusses hip arthroscopy techniques and considerations in 2013. It begins with an overview of the goals of hip arthroscopy which are to relieve pain, improve function, and improve longevity by restoring hip anatomy. It then discusses various pathologies that may be addressed such as CAM lesions, pincer lesions, torn labrums, and cartilage defects. Approaches can be open or arthroscopic. The document emphasizes making the correct diagnosis and understanding concomitant issues. It provides guidance on evaluating patients through history, physical exam including various special tests, and diagnostic injections. Femoroacetabular impingement is discussed as a common cause of labral tears. Techniques for addressing pincer impingement including bony resection are outlined

1. Hip Arthroscopy in 2013
INOVA Annual Sports Medicine Program
2013
Andrew B. Wolff, M.D.
Washington OrthopaedicsWashington Orthopaedics
and Sports Medicineand Sports Medicine
Washington, DCWashington, DC
www.andrewwolffmd.comwww.andrewwolffmd.com

2. Hip Arthroscopy is a
Means, Not an End
• Restore anatomy to:
– Relieve pain
– Improve function
– Improve longevity?

3. CAM lesion Bump removal vs. Sphericity
Pincer lesion Rim Trimming vs. Femoral Osteoplasty
Torn labrum Repair vs. Debride vs. Reconstruct
Cartilage defects Microfracture, Repair, Rim Trim
Instability Plication, capsular shift
Dysplasia Arthroscopy vs. PAO
Approach Open vs. Arthroscopic
Early arthritis Symptomatic Relief vs. 2 Surgeries

4. What Should We Treat?
• Make the
correct
diagnosis!
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4

5. Date of download:
5/28/2013
Copyright © The Journal of Bone & Joint Surgery, Inc.
All rights reserved.
From: Femoroacetabular Impingement
J Bone Joint Surg Am. 2013;95(1):82-92. doi:10.2106/JBJS.K.01219
Fig. 1
A list of static and dynamic mechanical factors for prearthritic hip pain. AIIS = anterior inferior iliac spine, FAI = femoroacetabular impingement, SI = sacroiliac joint, and ITB = iliotibial band.
Figure legend:

6. • Make the correct diagnosis
• History and Physical are critical
• Understand concomitant disease (i.e.,
sports hernia, lumbar spine pathology,
etc.)
• Understand that there may be a mixed
picture of symptoms such as
sacroillitis, peri-pelvic tendinitis, ischial
or troch bursitis
What Should We Treat?
6

7. • Traumatic vs. Insidious
– Twisting or torqueing
– Subluxation
– Dislocation, associated fracture
• Congenital / Developmental
– DDH, Perthes, SCFE
• Other
– Infection, PVNS, Osteonecrosis, Synovial
Chondromatosis
History
7

8. Confirming the source of pain
• History
–Is it predominately
lateral or posterior?
–Or is it in the groin?
–Pain and/or
numbness going
down the leg?

9. Confirming the source of pain
• History
–Can you push on it
and make it hurt?
–Does your hip make
noise?
–When it pops, does it
hurt?

10. Confirming the source of pain
• History
–What causes the
pain?
–Twisting
–Running
–Prolonged sitting
– Plane rides/ long car
rides
–Walking uphill
–Getting in/out of car
–Achy night pain?

11. Confirming the source of pain
• Where does it hurt?
• C-sign

12. Confirming the source of pain
• Intra-articular etiologies
Acetabular labrum tears
Articular cartilage:
Defects
OA
Post-traumatic arthritis
Inflammatory arthritis
Joint capsule:
Laxity
Sprain
Tightness
Tear
Ligamentum teres tear
Internal impingement
Bony deformities:
FAI
DDH
SCFE
Perthes
Stress fx.
Osteonecrosis
Loose bodies
Transient synovitis
Infection

13. Confirming the source of pain
• Extra-articular etiologies
Bursitis:
Trochanteric
Psoas
Ischial
Muscular strain:
Iliopsoas
Gluteus medius
Hamstrings
Snapping hip:
ITB
Iliopsoas
Avulsion injuries
Stress fracture
SI pathology
Myositis ossificans
Hip pointer
Infection

14. Confirming the source of pain
• Many patients don’t
follow the textbook
–Combined back and
groin pain
–Troch and groin pain
–Butt and groin pain
–Groin pain but
negative anterior
impingement sign
–Achy night pain

15. Inspection: Postural
Analysis (Static)

16. Shoulder to Foot
Symmetry

17. Inspection: Dynamic
• Sport performance
• Standing single leg
squat
• Trendelenburg
• Standing single leg
raise
• Sit-up
• “Make it pop”

18. Palpation: Anterior
Checklist
• Rectus Abd
Insertion
• Pubic bone
• Ext inguinal ring
• Lower abd
quadrant
• AIIS: direct rectus
femoris
• ASIS
• Anterior 1/3

19. Palpation: Posterior
Checklist
• Paraspinous/axial
spine
• SI joints
• Ischial tuberosity
• Posterior Iliac
Crest
• Sciatic notch?

20. Range of Motion:
Supine/Prone
• Assess ranges:
– Flexion
– Extension
– ROTATION prone
and supine at 90
deg flexion
• Knee / Lumbar

21. Special Tests
• Sensitive NOT
specific
• Impingement
• Laxity / Instability
• SI joint
• Piriformis Syndrome
• ITB syndrome
• HNP lumbar spine
• Core Muscle Injury
(Sports Hernia)
• Standard hernia
(valsalva)

22. Anterior Impingement Test
Passive flexion to 90°
followed by forced
adduction and IR
Leunig et al. Op Tech Orthop 2005

23. FABER Test
Vad et al. Am J Sports Med 2004

24. Confirming the source of pain
• Diagnostic injections
–Can be very helpful
–Consider using
corticosteroid, not
just
lidocaine/marcaine

25. Confirming the source of pain
• Diagnostic
injections
– Inject other
potential sources of
pain if clinically
warranted
– Iliopsoas
– Troch bursa
– Piriformis
– SI joint
– Spine

26. Confirming the source of pain
•It’s the hip…now
what?
•In non-arthritic hips
most common
source of pain is
labral pathology
secondary to FAI

27. Acetabular Labrum
• Extends the
acetabulum beyond
the bony socket
• Is present around the
entire lunate surface
of the acetabulum
• Is continuous with
the transverse
acetabular ligament
inferiorly

28. Femoroacetabular Impingement
• Wenger et al. showed that
87% of patients with labral
tears had underlying
structural abnormalities
(Wenger et al. CORR 2004)
• Ganz and colleagues
introduced the concept of
Femoroacetabular
Impingement (FAI) as a cause
of hip pain, labral tears, and
early osteoarthritis
(Ganz et al. CORR 2003)

29. CAM & PINCER ImpingementCAM & PINCER Impingement
PincerCAM
Espinosa et al J Bone Joint Surg 2006; 88-A: 225-239

30. FAI:FAI: Pincer TypePincer Type

35. contre-coup

36. contre-coup

39. FAI:FAI: Cam TypeCam Type

54. Set Up - Initial position
• Complete Paralysis
• Perineal pad, padded boots, foot holder

55. Check Fluoroscopic Images

56. Applied Traction
Expect suction seal release when adducting

57. “Vacuum sign”

58. Portal Placement
ASIS
Greater Troch
45 degrees

60. Localize with
fluoroscopy

61. Localize with
fluoroscopy

62. Find the vessels

64. Final Dynamic Exam

65. Some are easier…
Pre-op Post-op

66. than others.
Pre-op Post-op

67. Pincer ImpingementPincer Impingement
• Overcoverage of the acetabulum on the femoral headOvercoverage of the acetabulum on the femoral head
• Global or localGlobal or local

68. Rationale
1. Directly address the
offending pathology
causing impingement in
pincer-type or mixed
pincer-cam-type FAI
2. Protect from further
impingement damaged
labrum which has been
repaired/reconstructed.
3. Resect areas of grade IV
chondral damage

69. Pincer ImpingementPincer Impingement
69
• Pre Operative PlanningPre Operative Planning
– Know your goalsKnow your goals
– Focal resection forFocal resection for
retroversion or generalretroversion or general
decompression for coxadecompression for coxa
profundaprofunda
– Measure LCEA, AcetabularMeasure LCEA, Acetabular
Inclination Angle and femoralInclination Angle and femoral
neck-shaft angle from AP pelvisneck-shaft angle from AP pelvis
– Measure ACEA from falseMeasure ACEA from false
profileprofile
– Be cognizant of significantBe cognizant of significant
femoral anteversionfemoral anteversion
Operative TreatmentOperative Treatment
• Pincer Bony ResectionPincer Bony Resection
– Philippon, Wolff et al.Philippon, Wolff et al. ArthroscopyArthroscopy
20102010
– Change in the CE angle could be
determined by the following formula:
Change in CE angle = 2.2 + (0.2 x [rim
reduction in millimeters]).
– General rule:General rule:
The CEA decreases 2 degrees forThe CEA decreases 2 degrees for
every mm of bone resectedevery mm of bone resected
– Bottom line:Bottom line:
– Don’t over-resect acetabular rimDon’t over-resect acetabular rim
– Be cautious if CEA<30Be cautious if CEA<30
– Especially if acetabularEspecially if acetabular
inclination level is >10inclination level is >10

71. • If you take it off .
. .
– PUT IT BACK
• Beware small
labrum (anterior
zone)
• Beware
DYSPLASIA!
• If it’s torn
traumatically . . .
– More rare
– Fix when you can
– Remove what you
must
– Think “hoop fibers”
– No segmental
resection

72. Post-op care
• Crutch-aided walking
for 2-3 weeks
• PT x approx 12 weeks
• Return to full activities
3-6 months

73. Post-operative
Principles
• Properly done post-operative rehab
is crucial

74. Post-operative
Principles
• Commonly seen problems
– Hip flexor tendonitis
– Avoid active hip flexion and hip flexor
strengthening for as long as possible
– Anterior hip capsule contracture
– Early stretching gentle stretching can help
– At 6 week mark, if motion not progressing
will have patients spend minimum of 10
minutes daily in prone FABER position getly
pressing pelvis to floor

75. Post-operative
Principles
• Commonly seen problems
– Limp
– Patients should remain on crutches until
they are able to walk with normal gait
– Emphasize normal gait pattern – heel to toe
with achievement of terminal stance and hip
extension for toe off of involved.

76. Post-operative
Principles
• Soft tissue mobilization and
stretching
– Scar massage at week 2
– Initial soft tissue massage gently at
weeks 1-2-- iliopsoas, rectus femoris,
adductors gluteus medius and
piriformis.
– Progress to more aggressive soft tissue
work at week 4 if needed
– active release, dry needling, Graston

77. Post-operative
Principles
• Aquatic Therapy
– Can be a very useful adjunct
– Not mandatory
– Can begin at 2 weeks post-op

78. Post-operative
Principles
• Can see full post-op protocol and
aquatic therapy protocol at:
www.andrewwolffmd.com
• Protocol is in evolution.
Suggestions welcome.
• andywolffmd@gmail.com

79. What does the literature say?What does the literature say?
Asheesh Bedi, MD ; Bryan T. Kelly, MD
MedSport, University of Michigan Orthopaedics, Domino’s Farms, Lobby A, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106. E-mail address:
abedi@umich.edu
Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71st Street, New York, NY 10021
Disclosure statement for author(s): PDF
Investigation performed at the University of Michigan, Ann Arbor, Michigan, and the Center for Hip Pain and Preservation, Hospital for Special
Surgery, New York, NY
Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jan 02;95(1):82-92. doi: 10.2106/JBJS.K.01219
TABLE I Grades of Recommendation for Femoroacetabular Impingement (FAI)
Grade*
Pathophysiology B
Injury patterns B
Etiology C
Nonoperative treatment I
Surgical treatment B
Open versus arthroscopic approach I
Improvement in hip kinematics C
Prevention of osteoarthritis I
*A = good evidence (level-I studies with consistent findings) for or against recommending intervention, B = fair evidence (level-II or level-III studies
with consistent findings) for or against recommending intervention, C = poor-quality evidence (level-IV or level-V studies with consistent findings)
for or against recommending intervention, and I = insufficient or conflicting evidence, therefore not allowing a recommendation for or against
intervention.
The Journal of Bone and Joint Surgery
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Needham, MA 02492 USA
Copyright © 2013. All Rights Reserved.
The Journal of Bone and Joint Surgery, Inc.
STRIATUS Orthopaedic Communications
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80. What’s coming? / HotWhat’s coming? / Hot
TopicsTopics
•Better global
understanding of hip
pathology
–3D imaging and modeling
–Image guided bony resection
–Improved coordination with
osteotomy surgeons
•Capsuloligamentous
management
•Articular cartilage mgmt
•Labral reconstruction

81. Labral Reconstruction
Indications
• Revision
– Previous labral resection/ aggressive
debridement with persistent pain and
no arthritis
• Primary
– “Hip at risk” with irreparable labrum

82. Revision

83. Primary: “Hip at risk”
25 yo, 12 yrs s/p SCFE pinning in
situ

84. Primary: “Hip at risk”
27 yo former NCAA basketball
player 8 yrs of hip pain

85. Labral recon case
• 38 year old female triathlete
• 3 yrs s/p labral repair with persistent
pain
• Referred for worsened symptoms and
inability to return to running

87. Articular cartilage

88. Thank You
88