Update on Trauma and Orthopaedic Surgery

Henley Management College8th 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

1. Anterior neck2. Medial neck3. Medial head4. Anterior head5. Lateral head6. Lateral neck7. Posterior

Dienst et al (2001) Arthroscopy 17, 924

Central Compartment

• Articular cartilage– 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

Maquet Fracture TableS&N Hip Positioning System

Lateral Position

Working Portals

Establishing Portals - 1Anterolateral portal first – (safe zone)

Establishing Portals - 2

Establishing Portals - 3Subsequent 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 MRIKassarjlan 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

Thank You!

www.readingorthopaediccentre.com

Any questions….