Hip pain and Hip arthroscopy Matt Wilkinson Orthopaedic surgeon Sports and Arthroplasty

Hip surgery 1990’s Total hip replacement 2010’s Arthroscopy, Capsular Repairs/stabilisation Pelvic osteotomy Tendon releases/repairs - endoscopic Hernia repairs Neurolysis

UCLH, London, UK UBC, Vancouver

Bermuda Triangle

Cases Causes of hip pain Clinical examination and investigations Role of hip arthroscopy and FAI

“Groin Strain” Evolving pathology Muscular strain Osteitis pubis/OM Sportsman hernia (inguinal disruption) FAI/labral tears

Hip pain? Intra-articular pathology/FAI Sportsman’s hernia Osteitis Pubis Adductor tendinitis Psoas tendinitis Trochanteric bursitis Referred pain – lumbar/pelvis Meralgia paraesthetica

R Hip pain ? THJR 67y/o female Severe R hip pain, acute onset, nil trauma Irritable hip joint, reduced flexion and IR, FADIR strongly +ve

Inferior pubic rami fracture

L hip pain 14y/o male Playing soccer Felt “pop” L groin Painful walking and hip flexing

R hip pain ? Labral tear 20y/o Long distance runner Progressive buttock and R hip pain Nil specific trauma Difficulty weight bearing R leg End range of flexion and rotation of hip painful

Evaluating hip pain Age Skeletally immature – apophyseal injuries, avulsion injuries, congenital, transient synovitis Mature – musculotendinous sprain, FAI, bursitis, tendintis Old – Arthritis, fractures, trochanteric bursitis History of trauma/athletic pursuits, pain characteristics Location of pain Anterior, lateral, posterior

Pain location

Anterior hip pain C sign Hip joint OA Labral tears Iliopsoas bursitis Stress fracture AVN Transient synovitis/septic arthritis Adductor tendinitis

Lateral hip pain Trochanteric pain syndrome 10-25% pop Atraumatic onset ITB, bursitis, Gluteus minimus/medius tears Non-op, physio, HCLA, TFL release (endoscopic vs open)

Posterior hip pain Hip joint Piriformis syndrome Ischio-femoral impingement Hamstring – insertional pain/tendintis Back/SIJ/sacrum Pain with ER of hip will exacerbate piriformis syndrome/ischiofemoral impingement

Examination Gait Leg length discrepancy Trendelenberg sign Palpation Adductor pathology, trochanteric bursitis, meralgia paraesthetica, ROM Provocative tests - impingement (FADIR),SLR, FABER

Examination - trendelenberg

FADIR

Imaging XR (AP, lateral) US MRI/MRA (90% sensitivity)

US guided LA or HCLA Adductor tendon Psoas Bursa Intra-articular Trochanteric bursa Lateral femoral cutaneous nerve

Hip arthroscopy First Hip scope 1931 – cadaver 80’s and 90’s hip arthroscopy began in American and UK Central compartment arthroscopy – loose bodies, biopsies Peripheral compartment arthroscopy – developed afterwards – loose bodies, osteoplasty

Simple debridements CAM/Pincer osteoplasties FAI Labral reconstructions/repairs Ligamentum teres pathology and reconstruction Iliopsoas lengthening Gluteus medius tears/trochanteric bursitis Femoro-ischial impingement, sciatic nerve decompression,

Labral repair

FAI Pathomechanical process Abnormal contact between fem head and acetabulum Damage to labrum and cartilage Precursor to OA

History of FAI OA –secondary to SCFE, assoc with pistol grip deformity, acet dysplasia Unclear why some young people develop hip OA – not explained by mechanical factors, trauma, previously understood predisposing factors 1990’s – FAI described Ganz – open dislocation

Two types CAM – malshaped proximal femur Pincer – excessive acet coverage

CAM

Incidence JBJS 2010, Hack et al. MRI – 200 asymptomatic individuals age 29 14% pop – CAM deformity (3.5% bilateral) 79% men, 21% female Male incidence – 24%, female 5%

History Groin pain Insidious, may be history of trauma Worse with activity, prolonged sitting “C sign”

Examination Loss of rotation – IR and adduction Impingement test nearly always positive FADIR

Imaging Pelvis AP XR Well centered – tip of coccyx 1-2cm above symphysis to assess version Most CAM lesions – anterolateral – may be missed on AP – cross table lateral, frog leg 3D CT High resolution MR arthrogram with radial sequences

Pincer - retroversion

Notzli 2002

Surgery Open dislocations – ganz Arthroscopic labral debridement Arthroscopic bony resection Labral refixation Rim recessing

What we know Review of literature – 70% success with arthroscopic hip surgery Worse results with pre-existing OA Better long term results with labral refixation vs debridement Cadaveric studies indicate arthroscopic resection accomplishes adequate osteoplasty

Summary Location of pain “C sign” good indicator of hip joint pathology US guided injections useful in differentiating origin of pain