6-5 update on hip arthroscopy korcek · bone/joint femoroacetabularimpingement (fai) acetabular...

$: 6-5 Update on Hip Arthroscopy Korcek · Bone/joint Femoroacetabularimpingement (FAI) Acetabular labral tears Osteitis pubis Stress fractures: Pubic ramus/femoral neck Degenerative$
10/30/19

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OAOS 2019 ● Portland, Oregon

Update on Hip ArthroscopyOAOS 2019

Lucas Korcek, MDEugene, Oregon

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DisclosuresI have nothing to disclose

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BackgroundHip arthroscopy continues to expand as a tool to address multiple hip pathologies

Many current practitioners were not exposed to hip arthroscopy in their formal training

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Purpose• Overview: Many applications of hip arthroscopy in orthopedic surgery

• Focus: Femoral acetabular impingement (FAI) and labral tear treatment

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Hip / Pelvic Pain: Diagnosis

Burnett JBJS 2006

21 months:Average time from injury

to accurate diagnosis

3.3:Average number of

providers seen before definitive treatment

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Orthopaedic causes Bone/jointFemoroacetabular impingement (FAI) Acetabular labral tearsOsteitis pubisStress fractures: Pubic ramus/femoral neck Degenerative hip joint diseaseAvascular necrosis of the femoral head Slipped capital femoral epiphysisAvulsion fracture: ASIS/AIIS/Ischium

MuscleAthletic pubalgiaHockey player’s syndromeRectus femoris strain/tearAdductor strain/tendonitis/tearIliopsoas strain/tearRectus abdominis strain/tearMuscle contusion Gracilis syndromeSnapping hip syndrome NeurologicNerve entrapment: Ilioinguinal/obturator neuropathy Lumbar radiculopathy

Other orthopaedicBursitis Bone/soft tissue neoplasm of hip/pelvis Herniated nucleus pulposus Seronegative spondyloarthropathy

Non-orthopaedic causes

Hernia: Inguinal/femoral

GynecologicEndometriosisPelvic inflammatory disease Ovarian cyst

GastrointestinalRectal/colon neoplasm Inflammatory bowel disease Diverticulitis

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Arthroscopic indications described for growing number of pathologies

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Arthroscopic indications described for growing number of pathologies

FAI and labral tears are most common arthroscopically treated conditions

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What is FAIThe impingement of the femoral neck on the anterior acetabular margin

Smith-Petersen JBJS 1936

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Source of FAI• Femur

• Cam (Abnormal femoral head-neck offset)• Retroversion• Coxa Vara

• Acetabulum• Pincer (Over-coverage by acetabular rim)

• Coxa Profunda• Retroversion• AIIS subspine prominence

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EtiologyIdiopathic• Some evidence of adolescent sport activity as a risk factor• Femoral head-neck malformation may be a response to repetitive

stress at the the open proximal femoral physis

Childhood disease• DDH, epiphyseal dysplasia, SCFE, Legg-Calvé-Perthes

Inflammatory disease• RA

Post-traumatic

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SequelaeShort term

Labral tear and articular damage

Strength deficits and reduced athletic performance

Long termHip arthritis

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Labrum Anatomy

Surrounds periphery of acetabulum

22% of articular surface

Seldes. CORR 2001

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Labrum Biomechanics

Hlavácek Biomechanics 2002

“Suction seal” of femoral head in acetabulum

Preserves synovial fluid interface between articularsurfaces

Near frictionless articulation

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Labrum Biomechanics

Ferguson Biomechanics 2002

Removal of the labrum:

92% increase in contact stress between cartilage layers

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Patient evaluation

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History• Symptoms

• Pain is the most common complaint• Insidious onset• Groin is most common location

• Sometime associated:• Mechanical symptoms• Instability sensation• Lateral hip, buttock, thigh, and low-back pain

Philippon KSSTA 2007

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Clinical Exam

• Goal: distinguish intraarticular from extraarticular causes of pain

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Clinical Exam

• Anterior impingement test • (Flexion-Adduction-Internal

Rotation)

• Nearly always positive in FAI

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Imaging

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X-ray: AP view

Pistol grip femurAcetabular coverage and versionJoint space preservation

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X-ray: False profile

Anterior coverage of the femoral head

Posterior joint congruity

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X-ray: Lateral view

45˚ Dunn view: Alpha Angle

Alpha >50˚ is abnormal head-neck offset

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MRI vs MRADetect Labral Tear

• 3.0 Tesla MRI is as good as MRA

Crespo-Rodriguez Radiol 2017Magee Br Radiol 2015

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Intra-articular injection

Limited therapeutic efficacy for definitive treatment

Excellent diagnostic tool in surgical candidates with FAI

37% prevalence of cam deformity in asymptomatic individuals

Frank. Arthroscopy 2015

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Conservative Treatment

Improve femoroacetabularmechanics

Reduce repetitive impingement and inflammation

• Activity modification• NSAIDS• Core and abductor strengthening• Hip motion exercises

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Surgical treatmentAddress osseous deformity and labral-chondral injury

Goal: Improve clearance for hip motion between femur and

acetabular rimMaintain labral seal

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Labral tear

Repair is superior to debridement

Suction seal restored

Greater joint volume and surface area

Consistently better outcome scores

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Labral deficiency

Labral deficiencyLoss of suction sealInstability

Reconstruction Allograft vs. autograft

Short term follow-up promisingLong-term follow-up with higher quality studies lacking

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Osteoplasty of Femur and/or Acetabulum

Treat bony morphology of FAI

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Outcomes

Labral repair improves pain and function

mHSS, HOS-SSS, VAS

Hevesi AJSM 2018

Poor outcome associated with:Age > 35 yearsTönnis grade 2+BMI > 30 m/kg2

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Societal Costs $$$

Mather AJSM 2018

Arthroscopy vs. non-opCheaperHigher quality of life

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AnecdotallyTechnically challenging

Very rewarding with incredibly grateful patients

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Lucas Korcek, MDSlocum Center for Orthopedics & Sports [email protected]

Thank You

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mailto:[email protected]

6-5 update on hip arthroscopy korcek · bone/joint femoroacetabularimpingement (fai) acetabular...

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