Transcript Scope on the hip

Scope on the hip
Labrale letsesl
Zeist 24 april 2013
Dr J De Schepper
AZ Nikolaas – Sint-Niklaas
www.orthopedieregentie.be
Groin pain in athletes
• J Am Acad Orthop Surg. 2007
Aug;15(8):507-14
• Sports hernia
• Imbalance in trunk stabilizers and
adductor muscles
• Soccer, hockey, hurdling, running
Groin pain in athletes
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Activity related
Normal X-rays
All investigations negative
Long conservative treatment
Hernia repair
Longterm absence on the field
Groin pain in athletes
Extra-articular
Cause for pain
Intra-articular
Cause for pain
Intra-articular causes for groin pain
• Acute injury
– Torn ligamentum teres
– Loose body, cartilage lesion
• Gradual onset
– Concept of impingement
Heup arthroscopie
Anatomie
Centraal compartiment
Perifeer compartiment
Heup arthroscopie
INDICATIES : LOOSE BODIES
Oorzaken:
• Posttraumatisch
• Synoviale chondromatose
• Andere kraakbeenaantastingen
Investigaties:
CT – Arthro CT
Heup arthroscopie
Heup arthroscopie
INDICATIES : KRAAKBEENLETSELS
Traumatische letsels
Impactietrauma
Concept of femoro-acetabular
impingement
dynamic concept
FAI
Developed by R. Ganz (Bern)
1. cam - impingement
2. pincer - impingement
Concept of femoro-acetabular
impingement
FAI
cam - impingement
Probleem situeert zich op de nek, gevolgen acetabulair
Anterior offset
Notzli’s angle
cam - impingement
Notzli’s angle ????
Consequences
labral tears
wave sign
delaminated cartilage
early arthritis
cam - impingement
– Osseous bump
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“variant”
Idiopathic
old LCP
subclinical slipping
– Femoral retroversion
– Coxa vara
cam - impingement
– Bone Marrow Edema
– Labral tear
– Cartilage lesions
– Subchondral cyst formation
– (Bump-cyst complex;
herniation pit)
– Os acetabuli
cam - impingement
CAM FAI: intact labrum + wave sign
cam - impingement
Concept of femoro-acetabular
impingement
FAI
pincer - impingement
acetabular retroversion
cross-over sign
pincer - impingement
pincer - impingement
Pincer FAI
– Acetabular origin
– Acetabular
overcoverage
– Coxa profunda
– Protrusio acetabuli
Consequences
Abutment nek tegen anterior
wall
Mainly labral tears
Contre-coup lesions
Often combined
impingement
Clinical features of FAI
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Click, locking of the hip
Limited internal rotation
Pain in ADduction, Flexion and internal rotation
Gondolière sign +
McCarthy +
C-sign +
Pain during sport, may aggrevate afterwards
Clinical features of FAI
• Testen
– Faber
Clinical features of FAI
• Testen
– Mc Carthy
Radiological findings of FAI
• Standard X-ray
• Arthro MRI
• 3D CT-scan
• In doubt : Injection of the joint
Standard X-Rays
Standard radiography: standing AP pelvis
- Comparison of contralateral
hip
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Leg length
Pelvic rotation
Pelvic tilt
Correct evaluation
acetabular retroversion
- Coccyx must be centered
over the pubic symphysis
and should be not
separated more than 2 cm
Standard X-rays
Value of correct positioning
tilt
rotatie
Standard X-rays
• Standard radiography: 3/4
– Lateral neck
Standard X-rays
• Other valuable
radiographs
– Lequesne (faux
profile)
• Profile of acetabulum:
anteversion,
retroversion
– Dunn view
• 90° flexion/ abduction
20°
• Anterior femoral neck
Standard X-rays
• Other valuable
radiographs
– Lequesne (faux
profile)
• Profile of acetabulum:
anteversion,
retroversion
– Dunn view
• 90° flexion/ abduction
20°
• Anterior femoral neck
Standard X-rays
Pincer FAI
– Acetabular origin
– Acetabular overcoverage
– Coxo profunda
– Protrusio acetabuli
Arthro-MRI findings
MR Imaging
– Cor (FS)TSE pd/T2 both
hips
• Evaluation BME/
tumors…
– Direct MR arthrography
• Evaluation labrum,
cartilage, hip and
actebulum morphology
Arthro-MRI findings
CAM FAI
– Bone Marrow Edema
– Labral tear
– Cartilage lesions
– Subchondral cyst formation
– (Bump-cyst complex;
herniation pit)
Arthro-MRI findings
Pincer FAI
– Acetabular origin
- Acetabular depth
Distance of
center of the femoral neck to
line that connected the anterior
and posterior acetabular rim
Pfirrmann C. et al. Radiology 2006;240:778.
Treatment of FAI
Behandeling : ARTHROSCOPISCH
Philippon, Buly, Dienst
Centraal Compartiment :
- gevolgen van het impingement
- rimtrimming en labrumrefixatie
- resectie tot stabiele
kraakbeenrand
Perifeer Compartiment :
- Oorzaak wegnemen
Treatment of FAI
Resectie door surgical dislocation (Ganz)
Treatment of FAI
Heup arthroscopie
COMPLICATIES
Villar, Clin Orthop, Jan 2003
1054 gevallen
1,4 %
• Neuropraxie, skin necrosis
• Bloeding portals of hematoomvorming
• Trochanter bursitis
• Breuk instrumentarium
• Infectie
Scope
on
the
hip
Scope in the hip