Scope on the hipLabrale letsesl

Zeist 24 april 2013

Dr J De SchepperAZ 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

• Activity related

• Normal X-rays

• All investigations negative

• Long conservative treatment

• Hernia repair

• Longterm absence on the field

Groin pain in athletes

Extra-articularCause for pain

Intra-articularCause 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

INDICATIES : LOOSE BODIES

Oorzaken:

• Posttraumatisch• Synoviale chondromatose• Andere kraakbeenaantastingen

Investigaties:CT – Arthro CT

Heup arthroscopie

Heup arthroscopie

Heup arthroscopie

INDICATIES : KRAAKBEENLETSELS

Traumatische letsels

Impactietrauma

Concept of femoro-acetabular impingement

FAIdynamic concept

Developed by R. Ganz (Bern)

1. cam - impingement

2. pincer - impingement

cam - impingement

Probleem situeert zich op de nek, gevolgen acetabulair

Anterior offset

Notzli’s angle

Concept of femoro-acetabular impingement

FAI

Notzli’s angle ????

cam - impingement

Consequences

labral tears

wave sign

delaminated cartilage

early arthritis

– Osseous bump• “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

cam - impingement

pincer - impingement

acetabular retroversion

cross-over sign

Concept of femoro-acetabular impingement

FAI

pincer - impingement

Pincer FAIPincer FAI

– Acetabular origin

– Acetabular overcoverage

– Coxa profunda

– Protrusio acetabuli

pincer - impingement

Consequences

Abutment nek tegen anterior wall

Mainly labral tears

Contre-coup lesions

Often combined impingement

Clinical features of FAI

• 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

• Testen– Faber

Clinical features of FAI

• Testen– Mc Carthy

Clinical features of FAI

Radiological findings of FAI

• Standard X-ray

• Arthro MRI

• 3D CT-scan

• In doubt : Injection of the joint

Standard X-Rays

- Comparison of contralateral Comparison of contralateral hiphip

- Leg lengthLeg length

- Pelvic rotationPelvic rotation

- Pelvic tiltPelvic tilt

- Correct evaluation Correct evaluation acetabular retroversionacetabular retroversion

- Coccyx must be centered over the pubic symphysis and should be not separated more than 2 cm

Standard radiography: standing AP pelvis

Standard X-rays

tilt

rotatie

Value of correct positioningValue of correct positioning

• 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 FAIPincer FAI

– Acetabular origin

– Acetabular overcoverage

– Coxo profunda

– Protrusio acetabuli

Standard X-rays

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 FAICAM FAI

– Bone Marrow Edema

– Labral tear

– Cartilage lesions

– Subchondral cyst formation

– (Bump-cyst complex; herniation pit)

Arthro-MRI findings

Pincer FAIPincer FAI

– Acetabular origin

- Acetabular depth

Distance ofcenter of the femoral neck toline that connected the

anterior and posterior acetabular rim

Pfirrmann C. et al. Radiology 2006;240:778.

Arthro-MRI findings

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

Treatment of FAI

COMPLICATIES

Villar, Clin Orthop, Jan 2003

1054 gevallen1,4 %

• Neuropraxie, skin necrosis• Bloeding portals of hematoomvorming• Trochanter bursitis• Breuk instrumentarium• Infectie

Heup arthroscopie

Scope on the hipScope in the hip