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Hip Arthroscopy

Dr. Robert Afra is an expert in Hip Arthroscopy and provides expert diagnosis and arthroscopic surgery for hip conditions in San Diego and around. Orthopedic Surgery San Diego also provides highly specialised care during and after the surgery.

Hip arthroscopy is a surgical technique that employs minimally invasive methods for both diagnosing and addressing issues related to the hip joint and its adjacent soft tissues. During hip arthroscopy, a miniature camera known as an arthroscope is introduced into the hip joint by your surgeon. The camera projects images onto a video monitor, serving as a visual guide for your surgeon who employs miniature surgical instruments.

Due to the slender nature of the arthroscope and surgical instruments, the surgeon can make minimal incisions instead of the larger ones required in open surgery. This leads to reduced pain and joint stiffness for patients, and frequently accelerates the recovery process, enabling a quicker return to preferred activities.

In contrast to open surgery, which necessitates a sizable incision, arthroscopic surgery is characterized by its minimal invasiveness, typically requiring only a few small incisions. In many instances, patients are able to return home on the same day as the surgery, with recovery from arthroscopic procedures generally being swifter than that of open surgical interventions.

Conditions That Can Be Treated With Hip Arthroscopy

Hip arthroscopy is used to treat many types of hip problems. Some of these include:

  • Femoracetabular impingement (FAI) syndrome, also known as hip impingement. In FAI, bony growths arise on one or both bones of the hip joint. When the hip flexes, these bumps rub against one another, damaging the articular cartilage that covers the bones, as well as the labrum, a ring of cartilage that covers the outer rim of the acetabulum.
  • Labral tear. The labrum can tear or get damaged by falls, sports injuries, FAI, hip dysplasia, and degenerative conditions.
  • Hip Bursitis. Inflammation can form on the outside of the hip in a bursa—typically an area on the side of the hip that is painful to touch or lie on
  • Hip tendon tears. The hip abductor tendons are muscles that insert on the side of the hip. When they are torn, it can make walking difficult and cause weakness of the hip
  • Snapping hip syndrome. People with this syndrome may hear a snapping sound or feel a snapping sensation when moving their hip. It is often caused by a tendon sliding over bones in the hip joint.

Adolescent Groin Pulls

Overview of Adolescent Groin Pulls

Groin pulls or strains are common injuries in adolescent athletes, especially those playing sports requiring kicking, rapid changes in direction, and sprinting. The groin muscles span the hip joint and stabilize movements of the hip and pelvis. Sudden contractions or blows to the groin can cause strains or tears of the adductor muscles.

Epidemiology

Groin strains represent 2-5% of all sports injuries in adolescents . They are most frequent in sports like hockey, soccer, football, basketball, and track. Males have a higher rate than females. The injury typically occurs in adolescents during a growth spurt around ages 14-16 years old.

Mechanism of Injury

Excessive splits of the groin muscles during abrupt cutting motions often cause strains. Positions requiring forceful hip adduction, flexion, and internal rotation also pose risk. Fatigue and inadequate warm-up predispose to injury. Prior groin injury is a major risk factor for recurrence.

Clinical Presentation

Patients report acute onset of sharp groin pain during activity, often accompanied by an audible “pop“. Pain localizes to the inner thigh and increases with hip adduction against resistance. Ecchymosis, swelling, and tenderness may be present. Range of motion is limited by pain.

Diagnostic Imaging

Initial imaging like plain films or ultrasound can rule out avulsions or bone involvement. MRI gives the best visualization of muscle tears, localization, and severity. Grade 1 strains show stretching, grade 2 partial tears, and grade 3 complete tears with retraction.

Treatment

Acute management consists of rest, ice, compression, and elevation. Anti-inflammatories and analgesics help relieve pain. Stretching and strengthening of the groin, core, glutes and hamstrings are incorporated gradually. Physical therapy focusing on flexibility, neuromuscular control, and functional movement patterns helps prevent re-injury. Return to sport follows a progressive protocol over several weeks.

Prevention

A structured warm-up and conditioning program focusing on eccentric groin strengthening helps prevent strains. Proper technique, postural awareness, adequate rest and correction of muscle imbalances are key. Fair play rules in youth sports also reduce injury risk. Protective equipment like thigh pads provides no proven benefit.

Outcomes

With appropriate treatment, most grade 1-2 groin strains heal well over 2-6 weeks in adolescents. Higher grade strains take longer to rehabilitate and carry greater risk of prolonged symptoms or impairment. Education on modifiable risk factors empowers young athletes for prevention and safe return to activity.

Hip Femoroacetabular Impingement

Overview of Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain and impaired range of motion in young adults. It results from abnormal morphology of the hip joint that causes abnormal contact between the femoral head and acetabulum.

Epidemiology

FAI has an estimated prevalence of 10-15% in the general population. Males and females are equally affected. Symptoms most commonly develop in adolescence and early adulthood. Athletes participating in sports requiring repetitive hip flexion are at increased risk.

Pathophysiology

Two types of impingement exist: cam impingement from asphericity of the femoral head, and pincer impingement from overcoverage of the acetabulum. These morphologies result in shearing forces during hip motion that damage the acetabular labrum and adjacent cartilage.

Clinical Presentation

Patients report insidious onset of anterior hip/groin pain and stiffness, worsened by activity and hip flexion. Pain may radiate to the back or inner thigh. Physical exam shows limited internal rotation and flexion of the affected hip.

Imaging Findings

Plain radiographs demonstrate cam or pincer deformities. MRI visualizes labral tears and articular damage. 3D CT provides detailed assessment of bony morphology. Radiographic signs are also seen in asymptomatic individuals, making correlation with symptoms essential.

Treatment

Conservative management focuses on activity modification, anti-inflammatories, and physical therapy. Intra-articular injections provide short term relief. Surgery is considered for recalcitrant cases, involving resection of bone (osteochondroplasty) and labral repair. Outcomes are generally good with 70-90% returning to sport.

Natural History

FAI may lead to progressive labral and cartilage injury. About half of patients develop osteoarthritis within 10-20 years. Thus early recognition and management aims to preserve the hip joint and prevent disability.

Prevention

There are no evidence-based guidelines for prevention. Maintaining appropriate strength, flexibility and sport-specific technique may be protective. Avoiding extreme hip motions also minimizes impingement. Prevention of slipped capital femoral epiphysis may reduce cam deformities.

Conclusions

In summary, FAI is a frequent cause of hip pain and dysfunction in active young adults. Increased awareness facilitates early diagnosis and intervention to improve symptoms and optimize long-term hip joint health.

Distinguishing Groin Pulls from Femoroacetabular Impingement in Adolescents

Introduction

Hip and groin pain are common complaints in adolescents, especially young athletes. The differential diagnosis includes both acute muscle strains and overuse hip conditions. Distinguishing characteristics help delineate groin pulls versus femoroacetabular impingement (FAI) as potential causes.

Differing Onset and Location

Groin pulls involve acute tearing of the adductor muscles, often with an audible “pop” during exertion. Pain and dysfunction occur suddenly during activity. FAI conversely develops insidiously over time. Symptoms are activity-related but not from a single event. Groin pulls cause well-localized pain at the adductor muscle origin. FAI pain is typically anterior in the hip or groin region.

Range of Motion Differences

Groin strains produce pain with resisted hip adduction and stretching of the muscle group. Passive range of motion is otherwise normal. FAI limits hip flexion and internal rotation due to mechanical impingement, with maximal discomfort at end range. Stiffness, reduced range of motion, and earlier compensations differentiate FAI.

Contribution of Imaging

Plain radiographs readily diagnose cam or pincer morphologies of FAI, along with secondary joint changes. They are unremarkable with groin pulls. MRI visualizes edema at the musculotendinous junction with strains, while showing labral pathology and early osteoarthritis in FAI.

Variation in Recovery

With proper rehabilitation, groin pull symptoms improve over several weeks as the muscle tissue heals. FAI often follows a more protracted course due to progressive joint damage. Night pain and loss of function over time are red flags for FAI over an isolated strain.

Impact on Activities

Acute groin injuries cause immediate disruption of sports participation. Activities requiring adduction and explosive starts are limited initially. Comparatively, FAI develops gradual activity restrictions due to recurrent pain with pivoting sports. Compensatory mechanisms eventually fail as hip damage advances.

Demographic Factors

Both conditions occur in adolescents, but FAI incidence peaks slightly later around skeletal maturity. There is a male predominance for FAI versus equal gender distribution of groin strains. Specific sports associations also exist like hockey and FAI versus soccer and strains.

Preventative Approaches

Targeted hip and groin strengthening helps prevent strains. No established protocols exist for FAI prevention, though maintaining flexibility and technique may be protective. Thigh pads are often used after groin injuries but do not prevent FAI.

Conclusions

In summary, a detailed history, physical exam, imaging, and understanding natural history distinguish FAI from acute groin pulls in adolescents. Awareness aids prompt diagnosis and management to optimize outcomes.

Hip Femoral Cam Lesions

Overview of Femoral Cam Lesions

A cam lesion, or cam deformity, is an aspherical contour of the femoral head-neck junction. It is a common cause of femoroacetabular impingement (FAI) and hip pain.

Pathophysiology

In cam impingement, the non-spherical portion of the proximal femur abnormally contacts the acetabulum during hip flexion and internal rotation. This shearing force damages the acetabular labrum and adjacent cartilage, leading to pain and accelerated joint degeneration.

Epidemiology

The prevalence of cam lesions based on imaging is 10-15% in the general population. However, only a subset develops symptoms requiring treatment. Cam deformities are more frequent in young male athletes participating in sports requiring vigorous hip motion.

Etiology

The etiology is not fully understood but likely involves multiple factors. Cam lesions may arise during skeletal maturation due to high impact activities during the adolescent growth spurt. A genetic predisposition is also hypothesized based on heritability studies.

Diagnosis

Patients report hip/groin pain exacerbated by flexion activities like squatting or lunging. Physical exam shows limited internal rotation and flexion. Radiographs can measure the alpha angle to identify the cam, but MRI is more sensitive for detecting early changes. 3D CT provides the most detailed bony assessment.

Natural History

If left untreated, cam lesions can lead to worsening damage to the labrum and articular cartilage, resulting in early onset osteoarthritis. Chondral defects and joint space narrowing are seen 10-20 years after initial cam deformity. Patients younger than 40 years old at presentation have better outcomes.

Treatment

Nonsurgical treatment focuses on activity modifications and physical therapy. Intra-articular steroid injections provide short term relief. Arthroscopic osteochondroplasty effectively reshapes the femoral head-neck junction to remove impinging bone. This is frequently combined with labral repair with good return to function.

Prevention

No evidence-based guidelines exist for prevention. Encouraging hip stretching and avoiding excessive femoral loading during skeletal growth make intuitive sense. Early recognition facilitates intervention before irreversible joint degeneration.

Conclusions

In summary, cam deformities are a frequent cause of young adult hip pain that can lead to early osteoarthritis without treatment. Increased awareness aids prompt diagnosis and management.

Hip Acetabular Pincer Lesions

Overview of Pincer Lesions

A pincer lesion refers to focal or global overcoverage of the acetabulum resulting in abnormal contact with the femoral head. It is an important cause of hip pain and joint damage.

Pathophysiology

In pincer impingement, the excessive acetabular coverage impacts the femoral neck during hip motion, particularly flexion and internal rotation. This causes shearing forces that damage the acetabular labrum and adjacent cartilage, resulting in pain, limited motion, and accelerated degeneration.

Epidemiology

Pincer deformities have an estimated prevalence of 5-15% based on imaging studies. They are more common in middle-aged women compared to cam lesions that predominate in young males. Pincer lesions are also associated with acetabular retroversion.

Etiology

The cause of focal pincer lesions is often an osseous bump at the anterior acetabulum. Global pincer overcoverage develops from processes affecting acetabular shape and orientation like coxa profunda or protrusio. The etiology likely involves multiple factors including genetics.

Presentation

Patients report insidious onset of anterior hip/groin pain exacerbated by activity. Flexion and internal rotation are limited on exam. Labral tears manifest as sharp pains or catching. Early osteoarthritis symptoms may be present.

Diagnosis

Radiographs show overcoverage of the femoral head, cross-over sign, posterior wall sign, and other morphologic features. MRI confirms labral pathology and articular damage. 3D CT provides detailed visualization of bone anatomy.

Natural History

Left untreated, progressive joint damage occurs due to abnormal mechanics. Cartilage lesions expand and degeneration ensues. One study found over 50% of patients developing osteoarthritis at 12 year follow-up.

Treatment

Conservative management with activity modifications and anti-inflammatories provides temporary relief. Arthroscopic rim trimming effectively reshapes the acetabulum and removes impinging bone. Concomitant labral repair is frequently performed.

Prevention

No evidence-based guidelines exist for prevention. Maintaining appropriate hip flexibility and motion may be protective. Prompt diagnosis and treatment aim to intervene before irreversible arthritis develops.

Conclusions

In summary, pincer lesions can lead to debilitating hip pain and accelerated joint degeneration. Increased awareness facilitates diagnosis and management to optimize outcomes.

Mild Hip Acetabular Dysplasia

Overview of Mild Hip Dysplasia

Hip dysplasia refers to abnormal development of the acetabulum resulting in inadequate coverage of the femoral head. Mild dysplasia is a common cause of hip pain and osteoarthritis.

Definition

Hip dysplasia is radiographically defined as a lateral center-edge angle (CEA) less than 25 degrees. Mild dysplasia refers to CEAs between 20-25 degrees versus more severe subluxation below 20 degrees. The acetabular index and femoral head extrusion are also considered.

Prevalence

The prevalence of developmental dysplasia of the hip (DDH) ranges from 1-5%. However, mild acetabular dysplasia is much more common, affecting up to a quarter of the population. Women are affected more frequently than men.

Etiology

The etiology is multifactorial, involving genetic and environmental influences. Shallow acetabula likely result from abnormal growth and modeling. Laxity, breech position, and swaddling increase risk. Delayed diagnosis of infantile DDH predisposes to later dysplasia.

Natural History

Mild dysplasia is relatively asymptomatic in childhood but leads to gradual onset of pain and stiffness by early adulthood. If untreated, osteoarthritis develops in over a third of dysplastic hips by 60 years old. Higher grades of dysplasia portend worse outcomes.

Presentation

Patients with mild dysplasia typically present between ages 20-40 with insidious onset hip or groin pain. Mechanical symptoms like clicking, catching, or giving way may be present from labral tears. Range of motion and strength are reduced.

Evaluation

Weightbearing radiographs (false profile view) establish the diagnosis. MRI evaluates for cartilage loss and labral pathology. CT scans characterize bony anatomy. The contralateral hip should also be imaged given the risk of bilateral disease.

Management

Treatment is initially conservative focused on activity modifications, anti-inflammatories, and physical therapy. Intra-articular injections can provide short term relief. Surgery is considered for refractory cases, including peri-acetabular osteotomy and/or arthroscopy.

Prevention

Early treatment of infantile hip dysplasia prevents sequelae. Maintaining appropriate strength and flexibility may be protective. However, mild acetabular dysplasia may be an inevitable anatomic variant in some individuals.

Conclusions

In summary, mild acetabular dysplasia is a common condition that can lead to early hip arthritis. Increased awareness facilitates diagnosis and treatment to optimize long-term hip function.

Hip Laberal Tears

Overview of Hip Labral Tears

The acetabular labrum is a fibrocartilaginous structure that provides stability and lubrication to the hip joint. Tears are a common cause of hip pain and dysfunction.

Anatomy and Function

The labrum is a ring of tissue attached to the rim of the acetabulum, sealing the joint space. It helps distribute synovial fluid for lubrication and nutrition. The labrum also provides proprioceptive nerve endings and stability against distraction forces across the hip.

Pathophysiology

Abnormal hip mechanics from underlying disorders like FAI or dysplasia cause shear stresses on the labrum leading to tears. Degeneration from aging or capsular laxity can also contribute. This causes pain and instability, while removing the labrum’s protective effects.

Presentation

Patients typically report insidious onset hip/groin pain worsened by activity. Catching, locking, stiffness, and reduced range of motion are common. Exam shows a positive impingement sign and limited internal rotation.

Imaging

MRI with intraarticular contrast (MRA) provides optimal visualization of labral tears. Plain radiographs assess bony morphology for underlying etiologies. CT can better characterize certain osseous abnormalities.

Treatment

Conservative measures like activity modifications, anti-inflammatories, and physical therapy provide temporary relief. Surgery, either arthroscopic debridement or repair, is often required for definitive treatment and to address underlying structural deformities.

Natural History

Leaving labral tears untreated risks progression to early osteoarthritis, especially when associated with FAI or dysplasia. Articular cartilage damage accelerates in the absence of the labrum’s protective effects. Treatment aims to preserve the native hip joint.

Outcomes

Studies show arthroscopic labral surgery significantly improves pain and function in appropriately selected patients. Results are best for mild disease without advanced arthritis. Addressing underlying bony pathology like CAM or pincer lesions optimizes outcomes.

Conclusions

In summary, labral tears are a common cause of non-arthritic hip pain that warrant further evaluation. Prompt diagnosis and management aim to alleviate symptoms and slow progression to osteoarthritis.

Nonoperative Management of Hip FAI with Directed Core Strengthening and Physical Therapy

Introduction to Nonoperative Management of FAI

Femoroacetabular impingement (FAI) is a common cause of hip pain treated with both conservative measures and surgery. Nonoperative management with physical therapy aims to improve strength and neuromuscular control to minimize symptoms.

Rationale for Nonoperative Treatment

FAI is a mechanical hip disorder caused by abnormal morphology leading to labral and cartilage damage. Nonoperative treatment cannot alter the underlying structure. However, it can help address muscular impairments and dynamic instability that also contribute to the condition. This option is typically pursued initially before considering surgery.

Physical Therapy Protocol

A thorough evaluation identifies functional limitations in range of motion, strength, coordination, and movement patterns. Typical findings include poor core control, hip flexor/quadriceps tightness, weak gluteal stabilizers, and impaired motor control. An individualized rehabilitation program is developed targeting these areas.

Initial Phase

The early phase focuses on pain modulation, correcting muscle imbalances, and improving neuromuscular control. Manual therapy, stretching, gentle strengthening, postural correction, activity modification, and anti-inflammatory modalities help control symptoms.

Advanced Phase

Progressive strengthening targets the core, gluteals, quadriceps, and hip external rotators to enhance stability in affected movement planes. Dynamic exercises improve proprioception, movement patterning, and muscle reactions. Sport-specific training prepares patients for return to activity.

Outcomes

Evidence demonstrates modest benefits from physical therapy for FAI symptoms, but high quality studies are limited. Success varies based on age, baseline function, and severity. Surgery may still be warranted if conservative management fails.

Conclusions

A trial of nonoperative treatment is reasonable for select FAI patients with mild symptoms and muscle impairments. However, underlying structural deformities often necessitate surgery for definitive treatment. Physical therapy plays an important post-op role as well.

Hip Arthroscopy Labral Repair

Overview of Hip Arthroscopy Labral Repair

Hip arthroscopy allows for minimally invasive access to diagnose and treat intraarticular hip pathology. Labral repair is commonly performed arthroscopically to preserve the native labrum.

Indications

Arthroscopic labral repair is indicated for symptomatic labral tears not responding to conservative measures. Typical indications include FAI, mild dysplasia, capsular laxity, and traumatic tears in active patients. The procedure addresses labral pathology and associated lesions.

Contraindications

Contraindications include advanced osteoarthritis, joint space narrowing, severe dysplasia, and extensive cartilage damage. Labral debridement rather than repair may be performed in these settings. Medical comorbidities, arthrofibrosis, and poor rehabilitation potential are also considered.

Surgical Technique

Using fluoroscopic guidance, anterolateral and mid anterior portals are established. Diagnostic arthroscopy evaluates the labrum, cartilage, and ligamentum teres. Acetabuloplasty is performed for pincer impingement if indicated. The torn labrum is mobilized, trimmed, and refixed to the acetabular rim using suture anchors. Capsular plication helps stabilize the repair.

Rehabilitation

Postoperative guidelines initially restrict weightbearing and hip motion to protect the repaired labrum. Physical therapy focusing on core strength and restoring range of motion begins around 6 weeks. Impact activities are avoided for 3-4 months. Full return to sports occurs by 9-12 months for most patients.

Outcomes

Multiple studies show significant improvement in pain, function, and quality of life scores after hip arthroscopy and labral repair. Success rates over 80% have been reported at 2-3 year follow-up. Younger age, lower BMI, and shorter symptom duration correlate with better outcomes.

Complications

Reported complications include temporary neuropraxias (1-2%), deep vein thrombosis (<1%), and heterotopic ossification (2-4%) .Re-tear rates for repaired labra range from 6-30% but many remain asymptomatic. Progression to hip replacement is under 10% within 5 years.

Conclusions

In summary, arthroscopic hip labral repair offers a minimally invasive approach to preserve the native labrum and improve hip function with favorable outcomes when appropriate indications are met. Further studies will continue to refine techniques and optimize patient selection.

Hip Arthroscopy Cam Osteoplasty

Overview of Arthroscopic Cam Osteoplasty

Cam osteoplasty refers to reshapement of an aspherical femoral head-neck junction to remove abnormal bone causing femoroacetabular impingement (FAI). It is commonly performed during hip arthroscopy.

Indications

Cam osteoplasty is indicated for symptomatic cam-type FAI not responsive to conservative measures. Candidates have clear cam morphology on imaging correlating with clinical findings of FAI. The goal is to restore normal head-neck contour and address associated lesions.

Surgical Technique

With the patient supine, anterolateral and mid anterior portals are established. The cam lesion is visualized and probed to mark the areas of resection. A motorized burr is used to contour the head-neck junction to a more anatomic morphology. Fluoroscopy assists with assessing resection adequacy.

Pearls

The focus is smoothing the transition zone while preserving the femoral neck circumference and offset. Over-resection risks iatrogenic injury. Leaving residual deformity leads to continued impingement. The articular cartilage should be viable for repair if damaged.

Rehabilitation

Postoperative guidelines initially restrict weightbearing and range of motion to protect repaired tissue. Around 6 weeks, physical therapy focuses on restoring mobility and core strength. Impact activities are limited for 3-4 months. Full return to sports typically occurs between 9-12 months.

Outcomes

Multiple studies show arthroscopic cam osteoplasty significantly improves pain, function, and quality of life in appropriately selected FAI patients. Success rates over 80% have been reported at 2-3 year follow-up. Milder disease and shorter duration of symptoms portend better outcomes.

Complications

Risks include those of hip arthroscopy such as neurovascular injury (1-2%), thromboembolism (<1%), and heterotopic ossification (2-4%). Under-resection may fail to resolve impingement. Specific risks of cam osteoplasty include femoral neck fracture and avascular necrosis, but these are very rare.

Conclusions

In summary, arthroscopic cam osteoplasty has become the gold standard treatment for symptomatic cam-type FAI with favorable outcomes when performed well in indicated patients. Further studies continue to refine techniques and patient selection criteria.

Hip Arthroscopy Pincer Osteoplasty

Overview of Arthroscopic Pincer Osteoplasty

Pincer osteoplasty involves reshaping the acetabulum to reduce overcoverage causing femoroacetabular impingement (FAI). It can be performed arthroscopically for symptomatic pincer-type FAI.

Indications

Pincer osteoplasty is indicated for focal or global pincer lesions with clinical correlation not responding to conservative measures. Candidates have clear pincer morphology on imaging and no advanced arthritic changes. The aim is to restore normal acetabular anatomy.

Surgical Technique

With the patient supine, anterolateral and mid anterior portals are established. The pincer lesion and labrum are inspected. Using a motorized burr the acetabular rim is contoured, reducing overcoverage while preserving the labrum. Fluoroscopy helps assess resection adequacy. Capsular plication may help stabilize the repair.

Key Principles

The goal is smooth, circumferential rim trimming without violating the weightbearing zone. Over-resection medializes the joint center. Leaving residual deformity continues impingement. Preserving the labrum is preferable, but partial resection may be required.

Rehabilitation

Postoperative guidelines initially restrict hip range of motion and weightbearing. Around 6 weeks, physical therapy focuses on core strength, flexibility and neuromuscular control. Impact activities are limited for 3-4 months. Full return to sports typically occurs between 9-12 months.

Outcomes

Multiple studies show pincer osteoplasty significantly improves symptoms and function in appropriately selected FAI patients. Success rates over 75% have been demonstrated at 2-3 year follow-up. Milder disease severity and younger age portend better outcomes.

Complications

Risks include those of hip arthroscopy such as neurovascular injury (1-2%), DVT (<1%), and heterotopic ossification (2-4%). Under-resection may fail to resolve impingement. Specific risks include joint instability and iatrogenic cartilage damage.

Conclusions

In summary, arthroscopic pincer osteoplasty has become an effective treatment for symptomatic pincer-type FAI with favorable outcomes. Further studies will continue to optimize patient selection and refine surgical techniques.

Hip Arthroscopy Labral Reconstruction

Overview of Hip Labral Reconstruction

Labral reconstruction is an emerging technique to restore the native labrum using autograft or allograft tissue when repair is not possible. It can be performed arthroscopically in indicated cases.

Rationale

The acetabular labrum provides essential stability and lubrication to the hip joint. However, severe damage or absence limits repair options. Labral reconstruction aims to restore these functions in patients with irreparable labral pathology and preserve the native joint.

Indications

Candidates include those with severe labral deficiency and functional impairments unresponsive to conservative measures. Associated disorders like FAI must be corrected. The hip cartilage should be in relatively good condition without arthritis. Patient factors impacting graft incorporation are considered.

Surgical Technique

Graft choice is either iliotibial band or tensor fascia lata allograft or autograft. Using arthroscopic portals, the acetabular rim is prepared and the graft is fixed with suture anchors mimicking the native labral shape and dimensions. Capsular repair helps stabilize the reconstruction.

Rehabilitation

Postoperative guidelines restrict hip range of motion and weightbearing initially. Around 6 weeks, physical therapy focuses on core strength, flexibility and neuromuscular control. Impact activities are limited for 6 months. Return to sports criteria are gradually met over 9-12 months.

Outcomes

Emerging evidence shows significant improvement in pain, function and quality of life after labral reconstruction at early term follow-up. Graft hypertrophy and incorporation occur by 1 year. Success rates over 80% have been reported in appropriately chosen surgical candidates. Longer term data is still needed.

Complications

Risks include those of hip arthroscopy such as neurovascular injury (1-2%), DVT (<1%), and heterotopic ossification (2-4%). Specific risks include delayed graft incorporation, poor healing, and reconstruction failure. Secondary procedures may be required in 5-10% of patients.

Conclusions

In summary, arthroscopic labral reconstruction shows promise for restoring labral function when repair is not feasible. However, appropriate patient selection criteria are still being defined as longer term outcomes remain unknown.

Adolescent Athlete Return to Sport After Hip Arthroscopy Labral Repair

Introduction

Hip arthroscopy has become a common procedure to address hip pain and dysfunction in adolescent athletes. Labral tears are a frequent finding during hip arthroscopy in this population. After labral repair, appropriate return to sport (RTS) progressions are important to ensure athletes can successfully resume their prior level of competition. This statement will review considerations for RTS after hip arthroscopy labral repair in adolescent athletes.

Surgical Technique and Rehabilitation

Current techniques allow labral repair rather than debridement in most adolescent athletes undergoing hip arthroscopy. Surgical goals include restoring labral suction seal and acetabular coverage. Post-operative rehabilitation progresses from protected weightbearing to restoration of range of motion, strength, neuromuscular control, and sport-specific activities. Rehabilitation should last around 4-6 months before cleared for full sports participation.

Return to Sport Decision Making

The decision to clear adolescent athletes for unrestricted return to sport should involve both objective and subjective criteria. Objective measures include hip strength and range of motion comparable to the nonoperative side. Subjective measures include resolution of pain with sport-specific movements, high-level dynamic neuromuscular control, and psychological readiness to resume full competition. Input from surgeons, physical therapists, athletic trainers, coaches, and parents should factor into the RTS decision.

Timing of Return to Sport

Average time for RTS after hip arthroscopy varies from 4-6 months but depends on many individual factors. A primary consideration is the type and level of sport participation. Non-impact endurance sports such as swimming or cycling can be resumed earlier than cutting/pivoting field sports or high impact sports. Elite adolescent athletes also require longer recovery periods compared to recreational athletes before RTS. Other factors influencing timing include tissue healing, rehabilitation progress, and whether any complications occurred.

Re-injury Concerns

A systematic review found an overall reoperation rate of 6.3% in patients under 20 years old within 2 years after hip arthroscopy. However, studies have found low rates of recurrent labral tearing after repair in adolescent athletes with appropriate surgical technique and rehabilitation. Still, youth athletes should be counseled on activity modification to limit hip flexor strain and adverse or uneven hip loading after RTS. Continued neuromuscular retraining helps ensure dynamic hip control and stability.

Conclusion

Hip labral repair in adolescent athletes aims to eliminate mechanical symptoms and restore function. Appropriate surgical technique and compliance with rehabilitation helps enable a successful return to sport. However, RTS timelines and activity modification should be individualized. Continued assessment and training can help reduce injury recurrence and optimize outcomes. With coordinated management, most adolescent athletes can achieve lasting relief from hip pain and return to their pre-injury activity level.

Effect of Age on Outcomes After Hip Arthroscopic Labral Repair

Introduction

Hip arthroscopy with labral repair has become a common technique to address labral tears in active patients. However, outcomes may differ based on patient age. This statement will review the current evidence on the impact of age on outcomes after hip arthroscopic labral repair.

Older Patients

In patients over 50 years old undergoing hip arthroscopy with labral repair, high satisfaction rates around 80% have been reported at 2 years follow-up. However, older patients have shown slightly lower outcome scores and higher revision rates compared to younger patients. Predictors of poorer outcomes in older patients include greater pre-operative arthritis, chondral damage, and limb length discrepancy. Thus, appropriate patient selection is important when considering hip arthroscopy with labral repair in older patients.

Middle-Aged Patients

Patients between 40-60 years old can still have favorable outcomes from hip labral repair. In a study of patients with an average age of 45 years, modified Harris hip scores improved from 61 preoperatively to 83 at 2 years after surgery. Satisfaction rates exceeded 90% in another study of patients between 40-60 years old. Outcomes are optimized if pre-operative joint space is preserved and appropriate rehabilitation is completed.

Adolescent/Young Adult Patients

Patients under 20 years old have shown excellent outcomes after hip labral repair, with modified Harris hip scores improving from 67 preoperatively to 94 at 1 year follow-up. High return to sport rates around 80-90% have been reported in adolescent athletes after hip arthroscopy. However, young patients that resume cutting/pivoting sports may have a higher risk of recurrence requiring revision surgery compared to low-impact athletes.

Middle-Aged versus Young Patients

A retrospective matched-cohort analysis compared outcomes of hip labral repair in patients aged 15-25 years and 40-60 years. At 1 year follow-up, both groups showed significant improvement in modified Harris hip scores without a significant difference between age groups. However, adolescent/young adult patients were 3.6 times more likely to require revision hip arthroscopy within 3 years of surgery compared to middle-aged patients.

Factors Affecting Outcomes

Outcomes after hip labral repair appear to be influenced more by intra-articular findings and procedures performed rather than age alone. Patients with greater pre-operative arthritis or cartilage damage have shown less optimal outcomes regardless of age group. Recent studies have not found a significant independent association between age and outcomes if other confounding variables are controlled. Appropriate surgical indications and rehabilitation remain essential for a successful outcome across age groups undergoing hip labral repair.

Conclusion

Patients from adolescence through the mid-60s can have significant improvement in pain and function after hip labral repair. However, outcomes may decline with advanced age and arthritis. Surgical indications should be carefully considered in older patients to optimize results. Young active patients can return to high level sports after surgery but have a higher risk of recurrence. Continued research is needed to better define age-related factors affecting outcomes after hip labral repair.

Hip Arthroscopy Labral Repair to Total Hip Arthroplasty for Patients Over 50 Years Old

Introduction

Labral tears are a common cause of hip pain and mechanical symptoms in active patients over 50 years old. Treatment options include hip arthroscopy with labral repair or total hip arthroplasty (THA). This statement compares outcomes of these procedures for older patients with hip labral tears.

Hip Arthroscopy Labral Repair

In patients over 50 with minimal arthritis, hip arthroscopy with labral repair may relieve pain and improve function. In a systematic review, patients over 50 reported high satisfaction rates of 78-89% at 2 years after hip arthroscopy. Advantages of labral repair include less surgical morbidity, faster recovery, and retention of the native hip joint. However, outcomes decline with advancing age, severity of cartilage damage, and progression of arthritis. The re-operation rate is estimated around 10% at 5-10 years after hip arthroscopy in this population.

Total Hip Arthroplasty

For patients over 50 with end-stage hip arthritis or joint space <2mm, THA is the standard treatment to relieve pain and restore function. Numerous studies show excellent pain relief, functionality, and survivorship at over 90% with modern THA implants and techniques. THA has more surgical morbidity but provides more reliable long-term outcomes compared to hip arthroscopy. However, activity is still restricted after THA and risks include dislocation, infection, and eventual prosthetic loosening.

Comparative Outcomes

There are limited direct comparisons of hip arthroscopy versus THA for labral tears in older patients. One study matched 45 patients over 50 treated with hip arthroscopy to patients who underwent THA. At 1 year follow-up, THA patients had better outcomes scores and greater improvement in pain and function compared to the hip arthroscopy group. However, arthroscopic patients still reported good satisfaction rates of 80% despite inferior outcomes versus THA.

Treatment Selection Factors

The choice between arthroscopic labral repair versus THA depends on several factors in individual patients over 50 years old. Joint space width, arthritis severity, activity demands, and patient age are considered. In general, hip arthroscopy may be appropriate for patients 50-65 with Tönnis grade 0-1 arthritis and joint space ≥2mm. However, patients with more advanced arthritis often have better outcomes with THA. Patient expectations and desires must also be incorporated into shared decision making about surgery.

Conclusion

For older patients, hip arthroscopy provides symptomatic relief and delay of arthroplasty in appropriately selected individuals. However, THA remains the gold standard for end-stage arthritis. Further study is needed to refine criteria for hip preservation versus joint replacement in patients over 50 with labral pathology. Open discussion and shared decision making with patients over 50 is necessary to determine the optimal surgical treatment strategy.

Periacetabular Osteotomy (PAO) for Developmental Dysplasia of the Hip (DDH):

Introduction

Periacetabular osteotomy (PAO) is an established joint-preserving procedure for young patients with developmental dysplasia of the hip (DDH). PAO aims to provide mechanical stability and delay the onset of osteoarthritis. This statement will review indications, surgical technique, outcomes, and complications of PAO for DDH.

Indications

PAO is typically indicated for patients between ages 15-50 years with symptomatic DDH. Ideal indications include Tönnis grade 0-1 osteoarthritis, lateral center edge angle <25 degrees, and adequate hip joint congruency. PAO can provide symptomatic relief and functional improvement in this population by correcting acetabular undercoverage and abnormal mechanics associated with DDH.

Surgical Technique

During PAO, precise osteotomies are made around the acetabulum through a modified Smith-Peterson approach.3 The acetabular fragment is then reoriented laterally and anteriorly to improve coverage. Correction of femoral version or osteochondroplasty may also be performed. Stabilization is achieved with internal fixation plates and screws. Precise execution adhering to detailed surgical principles is imperative for success.

Clinical Outcomes

Multiple studies show PAO provides significant improvement in pain, function, and activity levels for most patients with DDH. One systematic review reported modified Harris hip scores improved from 52 preoperatively to 84 at 5 years after PAO. Up to 90% patient satisfaction has been reported as well. However, minor residual symptoms may persist, and activity modification is still required after PAO.

Complications

Reported complication rates range from 10-30% after PAO. Major complications are rare but include deep infection, vascular injury, and nerve palsies. More common complications include fracture, heterotopic ossification, and lateral femoral cutaneous nerve injuries. Appropriate surgical techniques and structured physical therapy can help reduce complications.

Conclusions

PAO is an effective hip preservation strategy for symptomatic DDH in appropriately selected patients. Successful PAO can provide durable improvement in pain, function, mechanics, and joint congruency. However, PAO remains a technically demanding procedure with a notable complication rate. Patient reported outcomes and survivorship after PAO are generally favorable at mid-term but long-term follow-up is still needed.

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