Hip Impingement and Osteoarthritis. Hip Arthroscopy, Resurfacing, or Replacement: Is it Time for Surgery?

Bryan Whitfield, MDBryan.j.whitfield@emory.edu

Hip Operations• Background of hip diagnoses• Treatment of hip pathology• Surgery candidates• Time for surgery?• Cases

Intra-articular hip pain - diagnoses• FAI (femoroacetabular impingement) / acetabular labrum tear

• Neck of the femur and rim of the socket run into each other• Tear the labrum.• Articular cartilage damage possible• Labrum: fluid management, stability, and seal of the joint

• Osteoarthritis• Socket and ball both coated in a layer of cartilage• Arthritis is the wearing away, loss of or damage to the cartilage

coating (articular cartilage)

Intra-articular hip pain - diagnoses• FAI (femoroacetabular impingement) / acetabular labrum tear

• Neck of the femur and rim of the socket run into each other• Tear the labrum.• Articular cartilage damage possible• Labrum: fluid management, stability, and seal of the joint

• Osteoarthritis• Socket and ball both coated in a layer of cartilage• Arthritis is the wearing away, loss of or damage to the cartilage

coating (articular cartilage)

Intra-articular hip pain - diagnoses• FAI (femoroacetabular impingement) / acetabular labrum tear

• Neck of the femur and rim of the socket run into each other• Tear the labrum.• Articular cartilage damage possible• Labrum: fluid management, stability, and seal of the joint

• Osteoarthritis• Socket and ball both coated in a layer of cartilage• Arthritis is the wearing away, loss of or damage to the

cartilage coating (articular cartilage)

Intra-articular hip pain - presentation• Groin (sometimes side, buttock, or less often “hip”)

• “C-sign”• Worse with sitting for a while then standing• Sore for 1-2 days after activity• Difficulty with donning or doffing shoes• Impact and cutting activities difficult

Intra-articular hip pain – physical exam• Impingement sign• Decreased range of motion• Pain not recreated by examination of spine or other places

Intra-articular hip pain – imaging• X-rays

• Joint space• Cam lesion• Pincer lesion

• MRI• If arthritis severe, unnecessary• Arthrogram helps diagnose labrum tear• Cartilage damage/absence• Bone changes: cysts, edema

Intra-articular hip pain – treatment• Medications• Rest• Activity modification• PT• Benign neglect (living with it)• Injections

• Cortisone• Biologics

• Surgery

Intra-articular hip pain – SURGERY?!• Goals• Severity• Limitations

• Are you living your own life or your hip’s life?• It is easier to fix your hip than your heart and your mind

Intra-articular hip pain – SURGERY!• Scope

• ≤ mild OA• Replace with resurfacing

• Moderate to Severe OA• Age < 60• Activity demands beyond limitations of replacement• Appropriate bone density• Males preferred (metal on metal reaction)

• Replace with replacement• Severe OA• 60+• No impact, cutting, running, jumping• AVN

Intra-articular hip pain – SURGERY!•Scope•≤ mild OA

• Replace with resurfacing• Moderate to Severe OA• Age < 60• Activity demands beyond limitations of replacement• Appropriate bone density• Males preferred (metal on metal reaction)

• Replace with replacement• Severe OA• 60+• No impact, cutting, running, jumping• AVN

Intra-articular hip pain – SURGERY!• Scope

• ≤ mild OA

• Replace with resurfacing• Moderate to Severe OA• Age < 60• Activity demands beyond limitations of

replacement• Appropriate bone density• Males preferred (metal on metal reaction)

• Replace with replacement• Severe OA• 60+• No impact, cutting, running, jumping• AVN

Intra-articular hip pain – SURGERY!• Scope

• ≤ mild OA• Replace with resurfacing

• Moderate to Severe OA• Age < 60• Activity demands beyond limitations of replacement• Appropriate bone density• Males preferred (metal on metal reaction)

•Replace with replacement•Severe OA•60+•No impact, cutting, running, jumping•AVN

Time for Surgery?

• If scope is an option – sometimes treating earlier leads to better results (6 months to 1 year is ideal)

• OA / articular cartilage damage• Outcomes• Secondary pain from biomechanical compensation

• If replacement/resurfacing is the consideration – put off as long as possible

• Younger, more active patients will likely wear out their replacement faster

• 43 y/o male • Avid tennis player• Hip pain x 3 years

– Injured while hitting a backhand • Cortisone injection x 2

– Just a few days of relief

Time for surgery?Case 1

• MRI shows some mild narrowing of the cartilage and an acetabular labral tear with morphology consistent with both cam and pincer. The cysts in the acetabulum are just on the margin consistent with impingement and not osteoarthritis.

Case 1

Hip Arthroscopy• Procedures performed

– Femoroplasty– Acetabuloplasty – Acetabular labral tear repair– Microfracture of the right acetabulum

Hip Arthroscopy• 1 year postop: Back to full activities • Continues to do PT for hip and back

– Works with tennis-specific PT • Very pleased with results

• 63 y/o male • Insidious onset, exacerbated with

tennis• Buttock pain with serving• Despite

• Physical therapy • Cortisone injection (intra-

articular)• NSAIDS

Time for surgery?Case 2

MRI1.Severe osteoarthritis with multiple

loose bodies 2.Diffuse labral tear with maceration 3.Tendinosis and partial-thickness tear

of hamstring and glute tendons

Case 2

Case 2

Underwent left hip resurfacing

emoryhealthcare.org/sports

Hip ResurfacingAndy Murray (31 years old): Hip Arthroscopy -> Resurfacing

Bob Bryan (40 years old): Hip Resurfacing

emoryhealthcare.org/sports

Thank you• Bryan Whitfield, MD

• Emory Sports Medicine specialist• Hip arthroscopy• Hip replacement• Bryan.j.whitfield@emory.edu

• George Guild, MD • Emory arthroplasty specialist (resurfacing)