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

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

3. UCLH, London, UK
UBC, Vancouver

4. Bermuda Triangle

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

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

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

8. 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

9. Inferior pubic rami fracture

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

13. 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

15. 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

16. Pain location

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

18. 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)

19. 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

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

21. Examination - trendelenberg

22. FADIR

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

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

25. 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

26. 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,

27. Labral repair

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

29. 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

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

32. CAM

33. 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%

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

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

37. 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

39. Pincer - retroversion

40. Notzli 2002

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

44. 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

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