Hip Arthroscopy: Indications, Procedure, and Rehabilitation Hip Arthroscopy: Indications, Procedure, and Rehabilitation Laith A. Farjo, M.D. Community Orthopedic Surgery Ypsilanti / Howell / Saline Laith A. Farjo, M.D. Community Orthopedic Surgery Ypsilanti / Howell / Saline

Hip Arthroscopy: Overview Relatively new procedure –performed since the mid-1980’s Relatively rare procedure –few indications –few surgeons Relatively new procedure –performed since the mid-1980’s Relatively rare procedure –few indications –few surgeons

Indications Labral tears Loose bodies Synovitis Diagnostic ? Arthritis Labral tears Loose bodies Synovitis Diagnostic ? Arthritis

Technique Patient positioned supine or lateral position on a fracture table/traction table pounds of traction during the case Specialized long instruments 3 portal technique

Loose bodies Etiology: –Trauma, synovial chondromatosis, THA - cement Symptoms: –pain, clicking in hip Tests: –xray, CT, MRI - identify loose body Results: excellent! Etiology: –Trauma, synovial chondromatosis, THA - cement Symptoms: –pain, clicking in hip Tests: –xray, CT, MRI - identify loose body Results: excellent!

Loose bodies

Labral tears Etiology: unknown. ? Hypermobility. Symptoms: –painful clicking in groin or buttocks –unexplained hip pain in young adult Signs: –pain coming from hip joint –snapping from an intra-articular source Etiology: unknown. ? Hypermobility. Symptoms: –painful clicking in groin or buttocks –unexplained hip pain in young adult Signs: –pain coming from hip joint –snapping from an intra-articular source

Labral tears Tests: –x-rays rule out arthritis, dysplasia –MRI - not very helpful rule out AVN, other processes –gadolinium-MRI - ? More helpful –intra-articular injection Tests: –x-rays rule out arthritis, dysplasia –MRI - not very helpful rule out AVN, other processes –gadolinium-MRI - ? More helpful –intra-articular injection

Labral Tears

Labral Tear - Location

Labral tears Results: –70% good results in people with NO ARTHRITIS at two year follow-up »Farjo, Arthroscopy 1999 Results: –70% good results in people with NO ARTHRITIS at two year follow-up »Farjo, Arthroscopy 1999

Labral Tear Results No Arthritis on x-ray good result 71% poor result 29% 4 10 THA - 2 pts. 7, 96 mos post-op

Synovitis Types: –Rheumatoid synovitis –PVNS Symptoms: –hip pain Tests: –blood work, imaging Types: –Rheumatoid synovitis –PVNS Symptoms: –hip pain Tests: –blood work, imaging

Diagnostic Indication: –hip pain in a young adult with negative studies Findings: –labral tear –chondral lesion Indication: –hip pain in a young adult with negative studies Findings: –labral tear –chondral lesion

Arthritis Indication: –arthritis in a young adult –unresponsive to conservative treatment –attempt to delay total joint arthroplasty Results: –not very good compared to knee/elbow/ankle scopes for DJD Indication: –arthritis in a young adult –unresponsive to conservative treatment –attempt to delay total joint arthroplasty Results: –not very good compared to knee/elbow/ankle scopes for DJD

Arthritis

femur acetabulum abrasionchondroplasty

Arthritis - Outcome » Farjo, AANA, 1998

Other indications AVN (?) –chondral fragmentation –s/p fibula grafting with mechanical symptoms Dysplasia (?) –often get labral tears –most likely better to perform osteotomy to correct mechanical mismatch AVN (?) –chondral fragmentation –s/p fibula grafting with mechanical symptoms Dysplasia (?) –often get labral tears –most likely better to perform osteotomy to correct mechanical mismatch

Risks Nerve injury –Peroneal (sciatic branch) foot drop –Pudendal groin numbness –Lateral femoral cutaneous anterolateral thigh numbness

Risks Chondral injury Excessive fluid extravasation Loss of ROM Infection Failure to relieve pain

Immediate Post-Operative Instructions Dressing may be fluid/blood stained - reinforce prn Remove dressings in 48 hours Apply ice

Immediate Post-Operative instructions WBAT with crutches Exercise: –ankle pumping –knee, ankle ROM –isometric quad sets

Rehabilitation Not all patients will require physical therapy post-operatively Usually initiated 1-2 weeks post-operatively Rate of progression with PT variable

Goals of Rehabilitation Decrease swelling Decrease pain Gait training Improve function ROM is NOT a major concern

Gait training Usually weight bearing as tolerated Early: reflex inhibition Assistive device until patient stable –Although some patients might feel very well, I prefer at least 1 week of protected gait

Stretching Gentle Patient-based Hip flexion most important Most importantly: do not irritate a healing hip by over-exuberant stretching

Distraction therapy Need: –a compliant patient who is able to relax –a skilled therapist not afraid to get a work-out!

Distraction therapy - Types Straight plane –patient supine and “anchored” –patient must relax as much as possible –distraction applied by pulling on foot 0 degrees extension “natural” external rotation –duration: 5-10 seconds, 5 reps

Distraction therapy - Types Inferior glide –patient supine, relaxed –hip and knee flexed to 90 degrees - rest on therapists shoulder –therapist locks both hands around patient’s anterior thigh and pulls the thigh toward the therapists body –5-10 seconds, 5 reps

Strengthening Isometrics: –quads, hams, gluteal, adductor, abductors Avoid SLR Closed chain –eg single-legged stance

Functional Training Stationary bike –low resistance –seat raised Pool exercises Treadmill jogging Elliptical trainer –can occasionally irritate hip with poor extension

Hip Arthroscopy - Conclusions New, developing procedure Limited indications With good patient/disease selection, outcome is excellent P.T. - gentle, distraction, focus on functional outcome - not ROM