update on trauma and orthopaedic surgery henley management college 8 th may 2008
TRANSCRIPT
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Update on Trauma and Orthopaedic Surgery
Henley Management College8th May 2008
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Hip arthroscopy
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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
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Pain
• C-sign distribution• Groin• Referred to L3
dermatome– (Anteromedial thigh)
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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
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Peripheral Compartment
1. Anterior neck2. Medial neck3. Medial head4. Anterior head5. Lateral head6. Lateral neck7. Posterior
Dienst et al (2001) Arthroscopy 17, 924
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Central Compartment
• Articular cartilage– Acetabulum– Femoral head
• Cotyloid fossa• Ligamentum teres• Labrum
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So how do we do it…
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Central Compartment Set - Up
Problems• Large distraction force
required• Specialist equipment• Operative time limited
by distraction time• Complications
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Complications
• Nerve traction injury– Pudendal and sciatic nerves
• Direct nerve injury (portal placement)– Femoral and sciatic nerves
• Perineal oedema / bruising / tears• Chondral scuffing
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Supine Position
• Patient positioned supine on fracture table
• Oversized padded perineal post– 12cm outer diameter– Positioned laterally
against the thigh
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Table Options
Maquet Fracture TableS&N Hip Positioning System
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Lateral Position
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Working Portals
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Establishing Portals - 1Anterolateral portal first – (safe zone)
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Establishing Portals - 2
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Establishing Portals - 3Subsequent portals under direct vision
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Labral Tears
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Loose Bodies
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Femoroacetabular impingement
Abutment of anterior femoral head-neck junction against anterior aspect of acetabular rim or labrum
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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
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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
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Imaging of FAI
• Femoral neck bump on Xray or MRI
• Acetabular retroversion• Coxa profunda• Protrusio acetabuli• Ossification of rim
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Alpha angle – fat sat T1 MRIKassarjlan et al: Radiology 2005; 236: 588-592
Abnormal if > 55 degrees
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Cam and Pincer Impingement
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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
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Peripheral Compartment
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Controversies
• Will hip arthroscopy delay onset of arthritis
• Is it better than mini-open procedures for FAI
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Thank You!
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Any questions….