Update on Trauma and Orthopaedic Surgery Henley Management College 8th May 2008
Hip arthroscopy
Indications for hip arthroscopy Labral tears Loose bodies / foreign bodies Ligamentum teres tears Synovial chondromatosis Sepsis – diagnosis and treatment Assessment of painful hip Chondral lesions not seen on Xray / MRI
Pain C-sign distribution Groin Referred to L3 dermatome (Anteromedial thigh)
Characteristic Hip Symptoms Symptoms worse with activities: Twisting / turning /changing directions Rising from seated position (catching) Difficulty with stairs (up and down) Difficulty with getting in / out of cars Difficulty with socks / toe nails / shoes etc. Dyspareunia
Peripheral Compartment Anterior neck Medial neck Medial head Anterior head Lateral head Lateral neck Posterior Dienst et al (2001) Arthroscopy 17, 924
Central Compartment Articular cartilage Cotyloid fossa Acetabulum Femoral head Cotyloid fossa Ligamentum teres Labrum
So how do we do it…
Central Compartment Set - Up Problems Large distraction force required Specialist equipment Operative time limited by distraction time Complications
Complications Nerve traction injury Pudendal and sciatic nerves Direct nerve injury (portal placement) Femoral and sciatic nerves Perineal oedema / bruising / tears Chondral scuffing
Supine Position Patient positioned supine on fracture table Oversized padded perineal post 12cm outer diameter Positioned laterally against the thigh
Table Options S&N Hip Positioning System Maquet Fracture Table
Lateral Position
Working Portals
Establishing Portals - 1 Anterolateral portal first – (safe zone)
Establishing Portals - 2
Establishing Portals - 3 Subsequent portals under direct vision
Labral Tears
Loose Bodies
Femoroacetabular impingement Abutment of anterior femoral head-neck junction against anterior aspect of acetabular rim or labrum
Femoroacetabular impingement First recognised as consequence of PAO Dysplastic acetabulum repositioned in more anterior and lateral position Proximal femur (insufficient head-neck offset) abutted against newly positioned anterior aspect of the acetabular rim in flexion, IR and adduction
Femoroacetabular impingement Subsequently recognised in young active adults who presented with groin pain, and who had not had PAO Arthrotomies revealed damage to the anterior aspect of the acetabular labrum and articular cartilage Similar to what is seen in Perthes and SCFE All have reduction in femoral head-neck offset
Imaging of FAI Femoral neck bump on Xray or MRI Acetabular retroversion Coxa profunda Protrusio acetabuli Ossification of rim
Alpha angle – fat sat T1 MRI Kassarjlan et al: Radiology 2005; 236: 588-592 Abnormal if > 55 degrees
Cam and Pincer Impingement
Symptoms of FAI Slow onset of groin pain Pain after trivial traumatic incident Exacerbated by periods of activity Pain on prolonged sitting and walking Limited range of motion IR and adduction in flexion
Peripheral Compartment
Controversies Will hip arthroscopy delay onset of arthritis Is it better than mini-open procedures for FAI
www.readingorthopaediccentre.com Any questions…. Thank You! www.readingorthopaediccentre.com Any questions….