1. Making the Right Diagnosis Symposium: Joint Preservation Hip Surgery – How to Avoid and Treat Complications and Failures Wednesday, February 16 th, 2011 Bryan T. Kelly, MD Co-Director Center for Hip Pain and Preservation

2. Bryan T. Kelly, MD Hospital for Special Surgery Disclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND DO NOT INTEND to discuss off label or investigational use of products or services.

3. Types of financial relationships and the companies with whom I have relationships are as follows: Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant A2 Surgical: Consultant

4. Diagnostic Dilemma Origin of hip pain can be difficult to identify MUST DISTINGUISH BETWEEN INTRA- AND EXTRA-ARTICULAR PAIN

5. “Intraarticular Disorders” Labral Tears –Hypertrophic tears (dysplasia) –Hypotrophic labra Chondral Injury –Focal chondral defects –AVN Ligamentum Teres Tears –Partial –Complete Femoroacetabular Impingement –CAM –Pincer Synovitis Loose Bodies Tumors –Synovial chondromatosis –PVNS

6. “Extraarticular Disorders” Capsular Problems –Hip Instability – Adhesive Capsulitis Snapping Hip –Internal Snapping Hip –External Snapping Hip Lateral Hip Pain –Recalcitrant Trochanteric Bursitis –Gluteus Medius / Minimus Tears Pubic Pain –Osteitis Pubis –Chronic adductor strain –Sports Hernia Tendonitis / Avulsion Injuries Nerve Compression Meralgia Paresthetica (LFCN) Piriformis Syndrome (Sciatic n.) Ilioinguinal n. Iliohypogastric n. Genitofemoral n.

7. History & Physical Exam

8. History Mechanism of Injury: Duration of Pain: –Location of pain: Primary Secondary Aggravating Activities –Sitting –Standing –Walking –Sports Clicking / Catching / Locking –Internal (Psoas) –External (ITB) –Intraarticular Previous Surgery: –Hip Arthroscopy –Pelvic Osteotomy –Open Hip Dislcoation –Hernia Surgery – Back Surgery – Others Physical Therapy: –Duration –Improvement ( Yes / No )

9. Minimum Clinical Exam Limp ( Yes No ) BMI ROM: –IR @ 90 degrees flexion –Flexion –External Rotation –Extension –Abduction in supine position –Craig’s Test Provocative Pain –Impingement (FADIR) –Sub-Spine Impingement Sign (Anterior Pain with Flexion) –Superolateral impingement (Anterolateral pain with flexion / ER) –Trochanteric Pain Sign (Posterolateral pain in FABER) –Lateral Rim Impingement (Pain with abduction) –Instability (Extension / ER with Anterior Pain) –Posterior Impingement (Extension / ER with Posterior Pain) –Ischio-Femoral Impingement Sign (Post pain with Ext / IR)

10. Normal Passive Hip ROM Adduction30 ˚ Abduction 45 ˚ Flexion 110 ˚ Extension 0 ˚ IR30 ˚ ER50 ˚

11. How do you assess ROM IR Block Test

12. Provocative Pain tests Impingement test Flexion, adduction, internal rotation Anterior or anteromedial pain with anterior and anterolateral impingement

13. Provocative Pain tests Subspine Impingement Sign Straight Flexion Anterior pain from inferior impingement or sub-spine impingement

14. Provocative Pain tests Superolateral Impingement Flexion, external rotation Anterolateral pain with superior or superolateral impingement

15. Provocative Pain tests Trochanteric Pain Test Flexion, abduction, external rotation Posterolateral pain from trochanteric irritation

16. Provocative Pain tests Lateral Rim Impingement Straight Abduction with neutral rotation Lateral pain from lateral rim impingement

17. Provocative Pain tests Instability Test Extension, external rotation Anterior hip pain

18. Provocative Pain tests Posterior Impingement Extension, external rotation Posterior hip pain

19. Minimum Clinical Exam Strength –Hip Flexion –Adduction –Abduction Palpation Pain –Central Pubic –Resisted Sit-Up –ASIS –Hip Flexors –Abductors –Adductors –Proximal Hamstrings –Ischium Peritrochanteric Space Exam –Pain over trochanter Anterior Lateral Posterior –Weakness in Abduction Knee Extended Knee Flexed –Snapping

20. COMPREHENSIVE EXAMINATION OF THE ADULT HIP Five points for five body positions –STANDING –SITTING –SUPINE –LATERAL –PRONE ADDITIONAL TESTS AS NEEDED

21. STANDING EXAMINATION General –Laxity, Body Habitus, Posture Gait –Swing, Stance, Foot Progression, Pelvis Spine –Lateral, Posterior, Scoliosis, Lordosis Pelvis –Shoulder height, Iliac Crest Trendelenburg Test –Positive, Shift or Weakness

22. STANDING EXAMINATION Gait a.Trendelenburg b.Abductor lurch c.Antalgic d.Foot progression angle a.Excessive External Rotation b.Excessive Internal Rotation e.Short Leg Limp

23. STANDING EXAMINATION Trendelenburg Test –Weak abductors lead to the pelvis dropping to the unsupported side With Compensation –Severe weakness the pt is unable to lift the opposite side without leaning toward the wt bearing limb to decrease the moment arm.

24. SEATED EXAMINATION Neurologic –DTRS, Sensory, Motor, Straight Leg Raise Circulation –DP, PT, Popliteal Skin Lymphatic IR/ER

25. SUPINE EXAMINATION Passive ROM –Flexion, Abduction, Adduction, IR, ER Strength Testing –Flexion, Adduction, Abduction Provocative Pain Test Pubalgia Testing Special Tests –Thomas Test –Patrick / Faber’s –Instability Test (extension / ER)

26. LATERAL EXAMINATION Palpation GT, ABDUCTORS, SI, ISCHIAL BURSAE Obers Test FLEXION, EXTENSION Passive / Active ROM MEDIUS / MAX FADDIR IMPINGEMENT Lateral Rim Impingement

27. Palpation 1 SI 2 Greater Trochanter Medius, Minimus Maximus origin 3 Ischial Tuberosity 4 Piriformis

28. Lateral Hip Anatomy Gluteus MediusGluteus Minimus

29. Dwek J. Pfirrmann C. Stanley A. Pathria M. Chung CB. MR imaging of the hip abductors: normal anatomy and commonly encountered pathology at the greater trochanter. Magnetic Resonance Imaging Clinics of North America. 13(4):691-704, vii, 2005 Nov 4 facets, 3 have distinct insertions

30. OBERS TEST ILIOTIBIAL BAND IN EXTENSION

31. Touch the table o/3 3=above neutral Obers in Flexion Tight Maximus contribution

32. Grade 0/5

33. Active ABD Medius vs Max Strength

34. PRONE EXAMINATION Craig’s Test –Femoral anteversion Ely’s –Rectus Femoris Contracture Hyperextension –Lumbar Spine Palpation –Paravertebral muscles, spinous process

35. Anteverted 82.6% Retroverted 17.2% Retroverted 17.2% Elys Craigs Test

36. Anatomic Approach to Evaluation of the Non- Arthritic Hip History Clinical Exam Radiographic / Mechanical Diagnosis Intra-articular Damage Pattern –MRI / Arthrogram –Intra-operative findings

37. Layer 1: Osteochondral Layer Structures: Femur, Pelvis, Acetabulum Purpose: Joint congruence and normal osteo / arthro kinematics Dynamic Impingement –Cam Impingement –Rim Impingement –Femoral Retroversion –Femoral Varus Static Overload –Acetabular Dysplasia –Femoral Anteversion –Femoral Valgus

38. Radiographic Indices: Mechanical Diagnosis >15 o [nml <10 o ] Retroversion (15-20 o anteversion) <15 o [nml >25 o ] >140 or <120 7.2mm Nml=11.6 Alpha Angle >50 o

39. CT-Scan: Mechanical Diagnosis

40. Layer 2: Inert Layer Structures: Labrum, joint capsule, ligamentous complex, ligamentum teres Purpose: Static stability of the joint Labral Injury Cartilage Injury Capsular Injury –Instability –Adhesive capsulitis

41. MRI

42. Layer 3: Contractile Layer Structures: All musculature including lumbosacral musculature Purpose: Dynamic stability Athletic Pubalgia Abductor Failure / Pain/ ITB Proximal Hamstring Syndrome Hip flexor tendonitis Psoas dysfunction Paraspinal dysfunction

43. Layer 4: Neuromechanical Layer Structures: TLS Plexus, Lumbopelvic structures, LE structures Purpose: Neuromuscular linking and functional control of the entire segment as it functions within its environment Nerve compression syndromes Pain syndromes Neuromuscular dysfunction Spine referral patterns

44. Patient Selection Hip loaded pelvis usually rotates over fixed femur creating anterior and medial forces with rotary moments Neuromuscular Research Laboratory University of Pittsburgh

45. LABRAL TEARS Combine these forces with dynamic or static overload to the joint…

46. Treatment Plan The location and quality of the pain should correspond to the mechanical diagnosis and primary and secondary injury patterns. If they do, then correcting the mechanical problems and primary and secondary injuries should lead to a good outcome….

47. Thank You