1. 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

2. 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

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

4. Technique Patient positioned supine or lateral position on a fracture table/traction table 40-50 pounds of traction during the case Specialized long instruments 3 portal technique

5. 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!

6. Loose bodies

7. 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

8. 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

9. Labral Tears

11. Labral Tear - Location

12. 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

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

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

15. 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

16. 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

17. Arthritis

18. femur acetabulum abrasionchondroplasty

19. Arthritis - Outcome » Farjo, AANA, 1998

20. 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

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

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

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

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

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

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

27. 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

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

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

30. 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

31. 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

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

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

34. 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