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Surgical Treatment of FAI
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Bill Bose, M.D.Advanced Orthopaedics, LLC
Providence Medical Park Plaza
Suite B 114
HIP INJURIES IN THE ATHELETE
ARTHROSCOPIC TREATMENT OF FAI
Life Story in 1 slide
College - LSUMedical School - LSUOrthopaedic Internship
and ResidencyFellowship –Univ. Florida
– “Adult Reconstruction” 1993
3 Years Practice – Faculty USA
13 years private practice
4 yr4 yr5 yr (1) yr
HIP AND PELVIS ANATOMY
• Ball-and-socket joint
• Femur – ball
• Acetabulum – socket
• Articular cartilage – surface material
• Labrum - cartilage around rim of acetabulum
©2008 Smith & Nephew, Inc. All rights reserved.
Femur
Acetabulum
Articular Cartilage
Labrum
HIP JOINT ANATOMY
Strength and Stability
Strength and Stability
TYPES OF HIP INJURIESTrauma
Contusionsfractures
Sports injuries or overuse injuriesstrainstendonitis
Developmental Things you are born withMay become symptomatic
by sports or excessive movements in sports
Contusions of Hip
“Hip Pointer”contusion of soft
tissue and bone where minimal soft tissue covering over the bone.
Iliac crestGreater trochanter
FRACTURES ABOUT THE HIP• FRACTURES• Iliac Wing
• Direct blow to side of Hip or fall onto the knee
MVA/Football/cyclingTYPES
Head/Neck/Proximal Femur
acetabulumPubic Rami
Elderly population with minor or even no trauma
Stress Fractures
“Micro-cracks”“Overuse”Pain with weightUsually no surgery
required.
TRAUMATIC DISLOCATION
BO JACKSONFemoral head comes
out of the socketAbrades of cartilage,
tears labrumLead to post-
traumatic arthritis or AVN
Shortened and IRSurgical emergency
HIP SOCKET FRACTURES
SPRAINS/STRAINSaround the hip
Sprain – tearing of some of the fibers of a ligament or tendon.
Strain – “muscle pull”
Tearing of some of the fibers of a muscle
Abdominal strain“Sports Hernia”
ACUTE MUSCLE STRAINSDiscrete event –
immediate painGroin Strain –
tearing of adductor muscles at attachment to pelvis
Hamstring Strain – tearing of posterior thigh muscles
Quad strainAbdominal strains
ACUTE MUSCLE STRAINS
Iliopsoas “hip flexor” strain
Can be acute due to explosive muscle
contraction of the Hip Flexor muscles
soccer
Overuse Injuries
Tendon injury due to repetitive micro trauma to the tendon - tendonitisIliopsoas tendonitis or “Snapping Hip
Syndrome”Rectus Femoris
tendonitis
Sprinters, kickers
Hip Overuse Syndromes
ITB friction syndrome or “Bursitis”CrestTrochanterTightness
Runners
Piriformis syndrome
Unusual cause of buttock pain
May irritate the sciatic nerve
Pain increased with activity
Piriformis stretchingMUST make sure
lumbar spine is not cause
SacroilitisInflammation of the
SI jointGradual onsetFigure of 4Buttock or lower
back
FAIFemoroacetabular Impingement
NON TRAUMATIC HIP PAIN7 million people visit the doctor for hip painClimbing stairs, or bending to tie shoes,
sports, ADLNormal x-ray and MRIthe determination of the cause of the pain
wasn’t clearPractical treatment NOT available30-50 with chronic hip pain “live with it until
you are an age when a THA is more feasible”
HIP ARTHROSCOPYTremendous
advancementhip
arthroscopy – 3-4 ½” incisions
Diagnose and treat hip pain
• Lack of room between femur and acetabulum
• Femur and acetabulum rub together
• More common in athletic men
• Strenuous activity aggravates pain
• Prolonged stationary seating may intensify pain
• Pincer – excessive growth around acetabulum
• Cam – neck of femur abnormally shaped
©2008 Smith & Nephew, Inc. All rights reserved.
Cam
Pincer
• Labrum - Layer of cartilage lining rim of socket
Rubbing of the bony impingement:
• causes injury or degeneration and tearing of this gasket
• Can cause locking or “catching” in joint
• MRI with dye injection needed to confirm diagnosis
©2008 Smith & Nephew, Inc. All rights reserved.
Femur Removed for Detail
• From trauma, degenerative disease
•or friction from torn labrum
• Cause “catching” in the joint
• Not easy to detect with x-ray
©2008 Smith & Nephew, Inc. All rights reserved.
• Articular cartilage - covers ball and socket
• Provides cushioning and protection
• over time with continued impingement, it can be torn or damaged by high impact sports, leading to degeneration
• Fragments can protrude into joint and cause pain – loose bodies
• Bone no longer protected from friction by the Cartilage and leads to arthritis and eventually a Hip Replacement
©2008 Smith & Nephew, Inc. All rights reserved.
FAI Patient HistoryLong duration
hip/groin pain (2yrs)Painful snappingNormal x-ray
(subtle clues)Normal plain MRI
of hip and or lumbarNo response L-esb
Not AVNNot troch bursitisITB friction, psoas
tendon or iliopsoas bursitis
Intra articular source??
FAIIntra articular
injection positiveMcCarthy’s sign C – signContrasted MRI –
30/40 false negativeOnly 60% positive
FAI
FAI
Young Patient (51)With Hip pain
???THA
NORMAL
FAILead to cartilage
wear arthritisArrest or stop the
impingement process
goal is to preserve the native hip joint as long as possible
Postpone or avoid THA
Chondral Damage - Arthritis
Treatment is designed toDelay or Prevent OA and THA
SO WHAT ARE GOINGTO DO ABOUT IT???
treatment
OPEN PROCEDURE FOR FAI10 yrs agoAnterior incisionAvoid nerves and arteryCut through muscles8-12 inch incision3-4 days in hospitalRisk of AVNLarge blood lossLong recovery 6-12 mthsStiffnessResults mediocre
ARTHROSCOPY OF THE HIP
8-10 yrs agoBegan using a tool
adapted from the knee and shoulder
3 or 4 small incisions
ARTHROSCOPY OF THE HIP
New techniqueMANY ADVANTAGES
– open techniqueOutpatient surgeryImproved resultsQuicker recoveryLess painMajor advancement :
Alex Rodriquez
Arthroscopy as toolAble to visualize
pathologyTreat pathology
Less spaceLonger distance
from the skinCurved joint surfaceTechnically difficult
HIP ARTHROSCOPY
Normal Articular Cartilage
VisualizeCartilage,FoveaLoose bodies
Labrum
Early Chondral Delamination
Chronic/Degenerative Tear90%
Labral Resection
Labral Resection
Lateral and Medial limitsof the Resection
mediallateral
Resected Labrum
•• 10% tears are repairable
•THE Labrum may be repaired - anchors and sutures
•Smooth edges of labrum - shaver blades or RF energy
•Remove torn tissue
•Repair with suture anchors
©2008 Smith & Nephew, Inc. All rights reserved.
Labral Repair
REPAIR OFTORN LABRUM
REPAIRED LABRUM
Peripheral Compartment
Femoral Osteochondroplasty
Re-establish Head-Neck Offset
FEMORAL OSTEOCHONDROPLASTY
PostopResection Crutches x 72 – One Crutch X 4
weekscycling at pod 2Full ROM pod 2Quad and Abductor
@ one weekSports 2 mths
Labral Repair – crutches TTWB 4-6
weeksNo ER – damage
repairFlexion on cycle ok
one week6 weeks begin
rotationSports 3-4 mths
• Relieve pain
• Improve joint stability
• Remove loose bodies
• Repair tears and damage
• May delay onset of osteoarthritis
• May delay need for total hip replacement
• Improve quality of life
• Optimize activities of daily living
©2008 Smith & Nephew, Inc. All rights reserved.
Return to sportsIndividualize
3-4 mths
QUESTIONS???