1. Hip Arthroscopy and Physical Therapy in Joint Preservation
Daniel S. Lamar M.D.

2. Hip Arthroscopy- Goals
Relieve Pain
Improve function
Improve Longevity???

3. Hip Preservation
Central premise- Improve the mechanical issues that predispose the joint to developing arthritis
Essentially need to change the mechanics of the ball and socket in order to reduce continued injury

4. Factors associated with Pathologic Mechanics
Dynamic
loss of offset and sphericity at HN junction (CAM)
Acetabular overcoverage, focal or global (Pincer)
Instability, posterior subluxation
Static
acetabular undercoverage (dysplasia)

5. Hip Pathology and Treatment
CAM lesion- remove bump/ improve sphericity
Pincer lesion- Rim trimming vs femoral osteoplasty
Labral Tear- Repair vs debride vs reconstruct
Instability- Capsular plication vs PAO
Dysplasia- Debride vs PAO
Arthritis- Symptomatic relief/debride vs THA
Cartilage defects- Microfracture, OATS, Rim trim

6. Diagnosis Make the correct diagnosis!
Ensure that the hip is the source of pain
H+P (C sign)
Diagnostic injection
Then ID which structure/issue within the hip is the culprit and its source of origination

7. Diagnosis MRI can under appreciate severity of cartilage injury
MRA is better, but not perfect- great at demonstrating magnitude of labral pathology
CT scan with 3D recon is a great preop tool

8. Labral Tear Most common source of pain in non-arthritic hips
Associated with FAI 87% of the time (Wenger CORR 2004)

9. FAI
CAM Pincer

10. CAM/Pistol Grip Overstuffing of anterolateral joint
Younger, athletic males
Short fem neck, SCFE
Usually see cartilage delamination with labral tear
Femoral cartilage usually spared until late

11. Pincer Pincer tends to spare cartilage early
contra coup post cartilage wear
herniation pits femoral neck
local overgrowth vs global protrusio vs acetabular retroversion

12. Treatment- Hip Preservation
Involves correctly identifying injury pattern
Removing bony overgrowth (3D CT scan)
Repairing labrum vs debride -suggestion that restoring the seal by repairing labrum if at all possible can decrease degenerative progression Larsen, Am J Sports Med
Treating established cartilage injury

13. Outcomes
Gupta, Am J Sports Med. 2015, 2yr f/u results on primary hip arthroscopy
595 pts
Improved HHS
7.7% revision scope, 9.2% conversion to THA
Linder, Arthroscopy. 2015, 2 yr f/u outcome on age-matched controls
Ave age 20.3 vs 54.8
HHS vs
Survivorship 98% vs 82.7%

14. Outcomes Domb, Arthroscopy 2015, How much arthritis is too much?
reviewed 518 articles, 15 included,2,051 hips, age 40.2
1,195 had some sign of cartilage damage
345 converted to THA (duration of f/u)

15. Postop Rehab- Phase 1 0-3 weeks Protect repair Reduce pain
Avoid muscular inhibition
Foot down WB x 2 weeks
ROM limitations
ext-flex 0-90 degrees
IR- 0, ER 20-30
Exercises
Isometrics, bike no resist,

16. Phase 2 3-6 weeks Goals No forced stretching so avoid stress to repair
Protect repair
Restore FROM
Normalize gait
Begin strengthening
Balance progression
No forced stretching so avoid stress to repair

17. Phase 3
6-10 weeks
Goals
Full hip ROM
Normal gait
Strengthening continued with emphasis on glut med
Step and squat progression

18. Phase 4 10-12 weeks Goals No contact activity
Restore full muscle strength and endurance
Restore cardio
No contact activity
Avoid mobs and aggressive stretch

19. Phase 5 12+ weeks Sport specific training Agility
Advance back to activities as tolerated

20. Take Away Points
Making the correct diagnosis is not always easy, but critical
Our understanding of hip kinematics and the mechanics of pathologic progression has improved dramatically
Instrumentation and surgical technique are allowing us to tx and hopefully prevent more pathology than ever
The literature regarding disease progression and the effects of arthroscopy to modify that course is growing, but in its infancy.

21. Take Away Points
Hip arthroscopist less excited about surgery with existing arthritis at any age
Hip Arthroscopy has excellent outcomes in the well selected patient
THA has excellent results, and seem to be improving in younger patients

22. Thank You