Purpose. Causes. Causes of Early Hip Disease. Causes. Clinical Evaluation 1/7/2010. Causes of early hip disease Femoral Acetabular Impingement (FAI)

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1 Purpose Henry R. Boucher, M.D. Union Memorial Hospital Baltimore, Maryland Causes of early hip disease Femoral Acetabular Impingement (FAI) Clinical and radiographic work up Treatment conservative and operative Hip resurfacing Emerging issues Relate to the athletic population Causes of Early Hip Disease Childhood disorders (up to early adult) Developmental dysplasia Infection Perthes disease Slipped capital femoral epiphysis Trauma Juvenile rheumatoid arthritis Causes Adult disorders (up to 50 s) Sequelae from childhood diseases Infection Trauma Osteonecrosis Medical steroid use Alcohol Inflammatory arthritis Idiopathic arthritic Femoral Acetabular Impingement (FAI) Causes Understand that the early degenerative hip may be a combination of causative factors with varying degrees of severity FAI has emerged as a leading cause of early degenerative hip disease FAI is due to abnormal anatomic and biomechanical function of the hip Those with childhood disorders at higher risk FAI is prevalent in both the athletic and nonathletic population as a cause of hip pain History Clinical Evaluation Acute versus chronic symptoms Location Groin Characterize pain Aggravating / Alleviating factors Mechanical symptoms Activity level 1

2 Clinical Evaluation Physical exam Hip range of motion Flex Adduct Internal Rotation Compare to other side Strength Flexion / Abduction / Ext rotators Palpate Trochanter / Symphysis/ Groin Other areas Spine Lower abdomen Unexplained knee pain look at the hip! Differential Diagnosis Intra articular Hip FAI / labral pathology Arthritis Osteochondral lesion Osteonecrosis Infection Inflammatory disease Gout Lyme Rheumatoid Benign process Synovial chondromatosis PVNS Tumor Malignant process Differential Diagnosis Extra articular hip Tendinopathy Hip flexor Psoas (lesser trochanter) ASIS (sartorius / TFL) AIIS (rectus) Abductors Adductors Rotators (piriformis) Extensors (hamstrings) Differential Diagnosis Extra articular hip Snapping syndromes Psoas IT band Pelvis Pubic Symphysis SI joint Other soft tissue Hernia Lateral femoral cutaneous nerve (meralgia paresthetica) Differential Diagnosis Referring sources Lumbar spine L2 L3 region Pelvic Abdominal Any process that irritates the iliopsoas Gynecologic (ovarian cyst) Bowel Hernia Genito urinary Inguinal, femoral, sports X rays Radiographic Evaluation AP pelvis, AP and lateral of the hip, false profile view MRI Arthrogram vs. Non arthrogram CT Bone architecture Intra pelvic, abdominal process Ultrasound Pelvic abdominal process 2

3 Bilateral Cam FAI / DJD False Profile View MRI MRI MRI Arthrogram 3

4 T2 weighted scan shows possible cartilage damage dgemric scan shows area of cartilage damage under the cyst Conservative Treatment Early degenerative disorders Activity modification Switch to low impact Physical therapy Hip range of motion and strengthening Core strengthening Medications NSAIDs Nutra ceuticals (glucosamine and chondroitin) Pain modalities Ice/Heat, U/S, iontophoresis, acupuncture Conservative Treatment Injections Fluoroscopic guided intra articular Cortisone and anesthetic Viscosupplements (non FDA) Diagnostic Help determine articular from non articular sources Therapeutic May provide months of pain relief Other areas to inject Trochanteric Psoas tendon sheath Pubic cleft Ischial bursa Piriformis region Surgical Treatment Joint preserving procedures (non arthroplasty) Arthroscopy Diagnostic Labral debridement / repair Osteochondroplasty for FAI Open hip surgery Surgical dislocation for full view of anatomy (Trochanteric osteotomy) Labral repair Osteochondroplasty for FAI PeriAcetabular Osteotomy (PAO) Correct dysplasia +/ labral repair and osteochondroplasty +/ femoral osteotomy Surgical Treatment Joint preserving procedures Technically challenging surgeries Need Hip specialist Targeted for patients typically under 50 Failure rates are high when there is articular cartilage loss 40 yr old runner Mild FAI, labral tear 4

5 Arthroplasty options Surgical Treatment Total Hip Replacement (THR) Alternative to total hip replacement Metal cap of the acetabulum and femoral head Bone conserving (femur) Modern metal on metal bearing Meant for the younger patient, less than Currently <10% of all hip arthroplasty worldwide History (Jiranek AAOS 2008) Hemi resurfacing ( ) Articular wear Femoral loosening Total Resurfacing ( ) Metal cap on cemented poly acetabular component High wear rates/osteolysis Femoral neck fracture Femoral loosening Acetabular loosening Metal on Metal Total Resurfacing (1991?) Many designs (McMinn, Wagner, Amstutz) Femoral loosening Femoral neck fracture Acetabular loosening ALVAL Metal ion release BHR (Smith and Nephew) FDA clearance in 2006 Cormet (Stryker) FDA clearance in 2007 Conserve (Wright Medical) FDA clearance in 2009 Why is it needed? Younger patient population Demand for higher activity Bone conservation Better bearings Biomechanics Ease of revision procedure Total Hip vs. Resurfacing Conventional hip replacement 5

6 Total Hip vs. Resurfacing Pros Bone sparing Less activity restrictions Better biomechanics More stable Advanced bearing Ease of revision Helpful with retained hardware or proximal femoral deformity 42 yr old, FAI and degenerative changes Retained Hardware Femoral Deformity and Hardware 6

7 Femoral Deformity and Hardware Cons Femoral neck fracture Femoral loosening Metal ion release (Cobalt and Chromium) ALVAL (aseptic lymphocyte mediated vasculitis associated lesion) Long term exposure to ions Component position related Nerve injury Hip impingement FAI Learning curve Added time and difficulty vs. THA Larger skin incision Candidate Active patient usually less than 60 Degenerative OA or AVN Failed Fild conservative measures Appropriate anatomy and bone stock No contraindication to metal on metal Renal disease Nickel, cobalt, chromium allergy Non childbearing female Exposures Posterior G. Maximus sling Flap of SERs and capsule Full capsulotomy Lateral Trochanteric Anterior Surgical Approach Posterior Surgical Approach Posterior 7

8 After surgery Patients undergo a rehabilitation protocol similar to total hip replacement patients Weight bearing as tolerated with crutches/walker May do active abduction Posterior P i hip precautions (Flex < 70, avoid flex/add/int rotation) for 6 weeks Routine DVT prophylaxis During 1 st six months: Low impact activities as bone and muscles adjust to the new stresses (swimming, walking, bicycling) After 6 months: Higher impact physical activity possible (singles tennis, jogging) Resurfacing Results Worldwide results >90% survival at ten years Patients can have a high activity level Good results depend on proper implant placement and patient selection Some prosthetics performing better than others 1 yr My experience >200 cases since 2006 Safe procedure Recovery is rapid even with larger incision Faster return to normal gait Patients seem to be happy Complications can be avoided by proper planning and technique Caveats Osteopenia Females > 55 AVN Deformity Leg length difference > 1cm Metal allergy Renal disease Women of childbearing age 49 year old 8

9 Total Hip Replacement Considerations for younger active patients Bone sparing (implant choice) Muscle sparing (incision choice) Bearing options Polyethylene Metal (cobalt chromium) Ceramics Long term activity restrictions Avoidance of high impact sports Potential need for further surgery Total Hip Replacement Emerging Issues Better diagnostic tools to direct best treatment Longer term follow up of procedures Longer follow up on resurfacing and bearings in hip replacement Track activity levels Henry R. Boucher, M.D. Union Memorial Hospital Baltimore MD 9