Agolley Young adult hip pain

www.davidagolley.com.au

Shooting From the Hip

Young Adult Hip pain and Fast Recovery Hip Preservation Surgery

Dr David Agolley Orthopaedic Hip and Knee Surgeon

Sports Surgery and Arthroplasty John Flynn Private Hospital

Institute of Sport and Exercise Health• State-of-the-art Facility

• 8 Consulting rooms

• 3T MR Imaging

• Ultrasound

• X-ray

• Interventional treatment rooms

• Well equipped physiotherapy gym

• Research

!


• Hip

• Young Adult Hip Pain

• Hip Preservation Surgery

• Hip impingement and labrum tears

• Hip Arthroscopy

• Periacetabular Osteotomy

• Hip Replacement young to old

My Scope of Practice

• Knee

• Preservation Surgery

• Knee Arthroscopy

• ACL / Ligament Reconstruction

• Knee Replacement


• 14+ (Skeletal Maturity)

• Spend long time consulting

• Thorough History and Examination

• Diagnosis

• Discuss non-surgical and surgical options

My Patients

www.davidagolley.com.au5

Cases


• 33yo male

• Left hip pain for a few months

• slight ache at night but not particularly bothersome

• Pain aggravated by walking and running

• Otherwise well

• No specific Injury

• No history of hip problems

Case 1

• Examination normal

• No swelling or skin changes

• No tenderness

• Normal range of motion

• No impingement


A. Refer Physiotherpy

B. Refer Specialist

C. Investigation

D. Review in 2 months

Case 1- 33yo Male

What Next?

= X-ray


Case 1- 33yo Male

Left proximal femur Osteosarcoma

Always get an X-ray


Case 2


• 25yo Female

• Bilateral Anterior Groin Pain

• Right worse than left

• No specific Injury

• First born female, Normal vaginal delivery

• No Childhood hip problems

• No family history of hip problems

Case 2 - 25yo female


• Pain

• Moderate to Severe 7/10

• anterior groin no radiation

• Aggravated by running more than 5 minutes and walking 3km

• Joint

• No clicking, catching or popping

• Function

• able to sleep well

• difficulty walking and standing for long periods

• unable to play hockey

• unable to stand in her retail job for more than 30 minutes

• Treatment

• Physio no help

• regular Paracetamol



• Examination

• Hip not irritable rolling on table

• Increased ROM

• ER 60 degrees

• IR 50 degrees

• Flex 130 degrees

• Impingement test positive



• Labral tear

• Loose bodies

• Ligamentum teres tear

• Inflammatory arthritis

• Osteoarthritis

• Internal snapping hip - Iliopsoas

• External snapping hip (ITB)

• Trochanteric bursitis

• Gluteal tendon tears

Groin Pain Differential Diagnoses

• Femoral neck stress #

• Adductor strain

• Osteitis Pubis

• Piriformis syndrome

• Sacro-iliac pain

• Sports Hernia (Gilmore’s groin)

• Inguinal or femoral hernia


Normal Values • Acetabular index 0-10 degrees • Centre to Edge Angle 25 - 40


Adult Acetabular Dysplasia

Normal Values • Acetabular index 0-10 degrees • Centre to Edge Angle 25 - 40


Periacetabular Osteotomy






Case 3


• 23yo male

• Right anterior groin pain

• Sudden onset doing power lift deep squat

• Felt a pop in the groin

• Pain aggravated by sitting in a chair, squatting, cycling

Case 3 - 23yo male


Case 3 - 23yo male

45 degrees


Case 3 - 23yo male

70 degrees

Modified Dunn



Femoroacetabular Impingement

normal pincer

cam combined

FAI


Cam and Pincer


Cam Impingement


Pincer Impingement


• Labral tear

• Cartilage delamination

• Subchondral bone injury due to stress

• Repetitive injury

• Location of Pain fibres

Why Pain?

Alzaharani et.al. 2014


• Labral tear

• Loose bodies

• Ligamentum teres tear

• Inflammatory arthritis

• Osteoarthritis

• Internal snapping hip - Iliopsoas

• External snapping hip (ITB)

• Trochanteric bursitis

• Gluteal tendon tears

Groin Pain Differential Diagnoses

• Femoral neck stress #

• Adductor strain

• Osteitis Pubis

• Piriformis syndrome

• Sacro-iliac pain

• Sports Hernia (Gilmore’s groin)

• Inguinal or femoral hernia


• Anterior groin pain in high hip flexion

• Age Group

• Young to middle age

• May not have an inciting injury

• C-sign

• Pain/click when standing from seated position

• Over use injuries : Hamstring, adductors

• Poor form in swinging and throwing sports

• ?Family history

FAI Clinical Presentation Pearls


• How are they seated in consult chair

• Gait - normal to antalgic

• Deep squat

• Range of motion

• Impingement tests

• Flex, ADd, IR (FADIR) most sensitive

FAI Examination Pearls


FAI Investigation Pearls


FAI Investigation Pearls - XRModified Dunn

Pistol Grip

Standing AP

Pre-op Post-op

pistol grip pic


FAI Investigation Pearls - CT


FAI Investigation Pearls - CT


FAI Investigation Pearls - MRI


• Lifestyle Modifications

• Training Modifications

• Physiotherapy is key BUT avoid provocative positions

• Pain relief

• Intra-articular LA steroid Injection

Non-Surgical Management

PRP


• For the Amateur Athlete, discuss change in sport

• Professional Athletes of different sports we treated on fellowship (pictured)

• Football (Soccer)

• Rugby

• Martial arts

• Ballet

• Horse riders

• Athletics

• Rowing

• Cycling

Non-Surgical Management


• Surgical Aims

• Correct the femoral head neck offset

• Remove pincer

• Treat associated pathology

• Cartilage damage : debride, repair, mircofrx

• Labral damage : debride, repair, reconstruct

• Open dislocation (Ganz)

• Arthroscopy

Surgical Management

Modified Dunn


• Open dislocation (Ganz)!

• major op

• scar

• hospital 3-5 days

• long rehab

• risks - AVN

• uncommon indication

Surgical Management

pic scar


• Arthroscopy!

• min invasive

• same/next day d/c

• FWB Crutches day 1

• Pain relief protocol

• Accelerated rehab

• limitations

• risks

Surgical Management



• Indications for hip arthroscopy

• FAI

• removal loose bodies

• Ligamentum teres injury

• Internal snapping hip

• external snapping hip

• Gluteus medius tendon repair

• Biopsy

• Diagnostic

Surgical Management


• PWB to FWB crutches 4-6 weeks

• Early motion within comfort

• Avoid inflammation

• Protect labral repair 8 weeks

• Core and hip strength

• Maintain ROM

• Wean off crutches and gait retrain (avoid limp)

• Jog to Run 8-10 weeks

Rehab Pearls


• Set up

• Land marks

• view

• capsulotomy

• view

• findings

• scoring system

• Treatment of labral tears, degen, partial, full

• treatment of pincer

• treatment of cartilage damage, partial, full thickness, delimitation

• treatment of cam

• iliopsoas

Hip Arthroscopy


• Case Series, 53 patients (41m, 21f)

• Avg age 42. Mean f.u 2.4 yrs

• 45 regularly sport prior to first incident of hip pain

• Only 4 still played at accustomed level of sport

• All arthroscopic osteoplasty

Outcomes FAI surgery


• At final follow-up

• 31 patients returned to full accustomed level of sport

• mean VAS pain score improved mean 5.6 to 1.5 (0-9) (sig)

• Non-arthritic hip score improve 54.4 to 85.7 (max 100) (sig)

• Sports Frequency score increased from 0.78 to 1.84 (0-5) (sig)

Outcomes FAI surgery


• Systematic Review

• min 6 months follow-up (1.36 - 3.76 years), FAI only

• Athletes - ice-hockey, golf, football, soccer, dancing, horse riding, bull riding, lacrosse, tennis, martial arts, baseball

• 9 Clinical studies (Case series Level IV), 418 athletes, mean age 25.4

• 2 Studies open surgical dislocation, 7 arthroscopy only

• 249 cam, 36 pincer, 138 mixed

Outcomes


• 92% return to sport (95%CI, 87% - 96%)

• 88% return previous level competition (95% CI 80%-94%)

• Comparison to non-athletic populations is similar

Outcomes


• Do we need to repair the labrum?

• Not all the time

• Can we prevent arthritis?

• Probably, but yet to be proven

• Should we prophylactically operate on asymptomatic hips with incidental findings of morphological problems?

• Probably not

?Need Answers


Case 4


• 39yo male, builder

• Right groin pain increasing over last 2 years

• No injury

• Enjoys surfing, but now v.painful

• Pain aggravated by sitting, driving, squatting, surfing

• Recently walk limit 300m in sand due to groin pain

Case 4 - 39yo male


• Examination

• Rolling the hip causes pain

• In flexion obligatory external rotation 20 degrees, no further IR but can ER 45 degrees

• Impingement test positive

• Diagnosis?

Case 4 - 39yo male


Case 4 - 39yo male


• Non-operative

• Hip Arthroscopy

• Hip fusion

• Arthroplasty

• Resurfacing

• THR

Case 4 - 39yo maleTreatment Options


Case 4 - 39yo male


Case 4 - 39yo male


• How long does the average THR last

A. 10-15 years

B. 15-20 years

C. 20+ years

Age Old Adage THR Only Last 10-15 years


Successful THR in Young


Successful THR in Young


• Exploits intermuscular interval

• No cutting of muscle and tendon

• Faster recovery and rehabilitation

• Stable joint

• ?Long term benefit over other approaches

Direct Anterior Approach


Least Wearing Bearing Surfaces


Least Wearing Bearing Surfaces


• Young to elderly patients

• Offer the complete surgical solution for hip pathology in both

• hip preserving and

• arthroplasty options

• Appropriate approach for the patient

• Use proven lowest wearing and lowest revision rate implants to provide best longevity THR

My hip Practice


• Groin Pain in the young adult can be a diagnostic dilemma

• Be aware of Femoroacetabular impingement

• Be concerned about the groin pain that is not improving

• X-ray is the main primary investigation

• standing AP pelvis, lateral and Modified Dunn

• First Line Rx - Non-operative management

• Second Line Rx - Refer on to someone you know

• Hip preservation and arthroscopy are highly specialised techniques

• Hip arthroscopy has excellent outcomes in well selected patients

Conclusion

Questions?

P : (07) 5598 0530 F : (07) 5598 0539 E : [email protected]! www.davidagolley.com.au !

Suite 4F Level 4 John Flynn Medical Centre John Flynn Private Hospital 42 Inland Dr, Tugun QLD 4224 !!


Date post:	16-Jul-2015
Category:	Health & Medicine
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Agolley Young adult hip pain

Health & Medicine