A. Normal Anatomy
The hip joint is composed of a ball and socket joint. The femoral head (ball) is the top of the femur (thigh bone) and the acetabulum (part of the pelvis) is the socket. These surfaces are both covered by articular cartilage, which is a specialized lining allowing smooth pain free motion of the joint. Damage to this lining result in arthritis.
The joint is lined by a specialized synovial layer, which secretes fluid helping with lubrication. Inflammation of this layer is called inflammatory arthritis the most common of which is rheumatoid arthritis.
The labrum is a specialized structure adding to stability of the joint. Damage to this structure can result in catching and pain in the joint. The capsule surrounds the synovium stabilizing the joint.
The hip joint is a ball and socket joint. The femoral head (ball) is the top of the femur (thigh bone) and the acetabulum (part of the pelvis) is the socket. These surfaces are both covered by articular cartilage, which is a specialized lining allowing smooth pain free motion of the joint.
II) A. What is the LABRUM?
1. Location & Function of the Labrum
The labrum is a ring of fibrocartilage (fibrous cartilage) that extends around the majority of the acetabulum, increasing its depth. The labrum acts as a suction seal around the femoral head maintaining the joint fluid within. The fluid protects the articular cartilage layers of the femur and acetabulum. The labrum does act as a stabilizer of the femoral head within the acetabulum as well.
2. Why does it tear?
Labral tears are typically the result of some underlying etiology.BONY , SOFT TISSUE, or TRAUMATIC
- Static Overload
- Femoral Anteversion
- Valgus Femoral Neck Orientation
- Acetabular Dysplasia (Anterior/Lateral)
- Dynamic Impingement
- Cam Impingement
- Femoral Retroversion
- Pincer Impingement
- PSOAS Impingement
- Laxity - Collagen Disorders
3. How does a labral tear present?
Labral tears most commonly result in "groin" pain. Most patients describe the pain as a sharp pain that is very deep. It tends to hurt more with increased activity, and is very easy to reproduce with high degrees of flexion and internal rotation of the hip joint. Prolonged periods of sitting will result in pain for patients with a condition known as femoroacetabular impingement.
Oftentimes, patients do not complain of a constant pain in the joint, but rather one that comes and goes without warning. Pain is usually located in the anterior region of the hip (groin area).
Less commonly, patients present with posterior (buttock area) or lateral (outside of the hip) pain.
Some complain of pain that wakes them up at night, or pain referred down the leg. These two symptoms tend to be more common in those with arthritis of the hip.
4. Why is it painful?
Patients with labral tear complain of hip pain because the labrum has nerve endings that can stimulate pain fibers, causing pain sensation in the hip region.
III) Causes of Hip Pain (Bony & Soft Tissue Abnormalities)
A. Bony Abnormalities
1. Femoroacetabular Impingement
Femoroacetabular impingement or FAI is a condition in which the femoral head, acetabulum, or both are shaped somewhat abnormally. Simply, the ball and socket do not fit perfectly, causing friction during hip movements, resulting in damage within the hip joint. The damage can occur to the articular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper that surrounds the socket).
Impingement can occur as a result of femoral sided impingement (Cam impingement), acetabular rim impingement (pincer impingement), or a combination of both which is the case in the majority of patients.
a. CAM Impingement
Femoral sided impingement got its name, CAM, from the Dutch word meaning "cog" describing the femoral head and neck relationship as aspherical or not perfectly round.
During motions such as hyperflexion and internal rotation of the hip, the Cam lesion is able to fully engage within the joint. This results in cartilage loss over the femoral head and corresponding dome (acetabulum), as well as labral tears. CAM lesions predominately affect the cartilage within the hip joint, resulting in a characteristic peeling of the cartilage off the bone. Cartilage wear is the definition of arthritis, therefore, this type of impingement is considered a pre arthritic condition.
The second category of femoroacetabular impingement is the "pincer" type lesion, referring to the "over coverage" of the acetabulum in respect to the ball (femoral head). Pincer comes from the French word meaning "to pinch". The "extra" bone of the acetabulum repetitively hits upon the femoral neck resulting in the pinching of the labrum in between.
As mentioned previously, CAM lesions often coexist with pincer lesions. CAM lesions lead to articular cartilage injury first, whereas pincer lesions crush and tear the labrum first.
Dysplasia refers to the lack of coverage of the acetabulum over the femoral head. Dysplasia is congenital.
In the setting of dysplasia the body compensates for the loss of bony coverage and forms more soft tissue (labrum). A large labrum is called hypertrophic. Dysplastic patients typically present with a hypertrophic labrum. This tissue is overloaded and for this reason predisposed to tearing.
Dysplasia cannot be corrected arthroscopically. It requires an osteotomy. The arthroscopic procedure can address the torn tissue inside the joint, as a result of dysplasia.
Anterior acetabular dysplasia refers to the anterior (front of the hip) wall of the acetabulum, therefore anterior dysplasia is under coverage of the front of the femoral head. This is opposite to a pincer lesion where the anterior aspect of the femoral head is over covered by the acetabulum.
Lateral acetabular dysplasia is under coverage of the femoral head laterally (side of the hip). Similar to anterior dysplasia, the labrum is overloaded, resulting in tearing.
Version refers to the degree of the femoral neck relative to the shaft of the femur.
Version is an important variable when diagnosing and treating hip problems. Excessive version is not corrected with an arthroscopic surgery, but yet a much larger procedure called an osteotomy, in which the femur is broken and realigned.
a. Femoral Anteversion
Anteversion refers to how anterior (facing forward) the femoral neck is. A normal femur is 15 degrees anteverted.
Excessive anteversion overloads the anterior structures of the hip joint, including the labrum and capsule. It is common to see a patient with a snapping psoas over the femoral head in the setting of excessive anteversion.
b. Femoral Retroversion
Retroversion refers to how posterior (facing back) the femoral neck is.
Due to the anatomy of a retroverted femur, when the hip is internal rotated, the femoral neck hits the acetabular rim earlier than it would with a normal femoral neck. This results in crushing of the labrum, and many times more posterior (back) pathology in the joint.
B. Soft Tissue Abnormalities
Synovitis is inflammation of the capsular tissue. The capsule is the tissue surrounding the joint. Just about any hip condition can overload the capsule and result in inflammation. In the majority of hip arthroscopic procedures, synovitis, to some degree, is present.
2. Psoas Impingement
Interesting phenomenon in which a portion of the tendonous area of the psoas, running outside the joint (in the majority of cases), becomes symptomatic, in that it tightens causing it to snap (internal snapping hip) across either the rim of the acetabulum or the femoral head. The psoas itself can become painful from this repetitive motion. In other cases, the psoas compresses the labrum resulting in crushing and sometimes tearing of the labral tissue due to the close proximity of the two structures. Several patients do present with an internal snapping hip, over coverage of the acetabulum and labral tear, for which we have deemed the term "triple impingement."
3. Instability (Generalized ligamentous laxity/Collagen Disorders, i.e. Marfans, Ehlers-Danlos Syndromes)
4. External Snapping Hip Syndrome (Snapping ITB )
Iliotibial Band tightness sometimes results in snapping over the greater trochanter (external snapping hip). Patients will often come into the office thinking their "hip is dislocating," when in fact, it is the ITB snapping.
This patient population consists of females, predominately, similar to that of the internal snapping population. In many cases a snapping hip (internal and/or external) is a result of joint laxity. The laxity results in the tightening of muscles surrounding the joint, to stabilize the pelvis.
The pain felt from a snapping ITB is typically directly over the greater trochanter of the femur, located on the outside of the hip.
5. Trochanteric Bursitis
A bursa is a fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body.
The trochanteric bursa is located on the side of the hip over the greater trochanter of the femur. When this bursa becomes inflamed, it is called bursitis. Trochanteric bursitis causes pain on the outside of the hip and tenderness over the trochanter. It is commonly a result of a tight Iliotibial band, that also runs on the outside of the hip.
6. Gluteus Medius/Minimus Tears
Both the Gluteus Medius and Minimus act as abductors of the hip and are located on the outer aspect of the hip. Abductor muscles allow for you to pull your leg to the outside.
The muscles of the medius and minimus join and turn to tendon, inserting on the greater trochanter of the femur bone. A tear of the tendon typically results in pain over the lateral aspect of the hip, but more so, results in weakness. A tear does frequently result in gait disturbances.
7. Loose Bodies/Tumors
- Synovial Chondromatosis
8. Chondral Defect
9. Osteoarthritis (OA)
Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the articular cartilage of the hip. Cartilage is a protein substance that serves as a "cushion" between the bones of joints. Both the acetabulum and femoral head are lined with cartilage.
The most common symptom of osteoarthritis is pain in the hip joint. Stiffness of the hip joint is also very typical. This may or may not be associated with swelling of the joint. It is common for patients to describe pain radiating down the leg, and pain at rest, even waking them up at night.
10. Inflammatory Disorders
a. Rheumatoid Arthritis (RA)
Rheumatoid arthritis is an inflammatory form of arthritis that can result in a great deal of joint pain. Rheumatoid arthritis attacks the lining of the capsule of the joint (synovium) causing swelling that can result in aching and throbbing. RA often occurs in multiple joints, where osteoarthritis tends not to.
Rheumatoid arthritis is more common in women with a general age being between 40-60. RA, however, does occur in all ages.
Often times, RA affected joints do result in swelling and are tender to touch.
Lupus is a chronic, autoimmune disease.
With lupus, the immune system attacks healthy cells and tissues by mistake. This can damage your joints, skin, blood vessels and organs. Several types of Lupus exist but the most common type is called systemic lupus erythematosus and can affect many parts of the body.
The most common symptoms of lupus in the hip are joint swelling and/or pain and muscular pain.
IV) Diagnostic Studies - Role of X-Ray, MRI/MRA, & CT Scan
An x-ray is a 2 dimensional view of a bone(s). Patients will often show up the day of their appointment without the x-rays, explaining that the previous doctor said, "they were normal." However, this is not always the case. There is a lot of information to be gained from an xray; much different than that of an MRI or CT scan. PLEASE BRING ALL STUDIES TO THE APPOINTMENT.
X-Rays obtained at the time of visit:
- AP PELVIS - SUPINE
- ELONGATED NECK LATERAL (DUNN VIEW) [90 DEG FLEXION/ 20 DEG ABDUCTED]
- FALSE PROFILE VIEW (IF APPLICABLE)
Although the gold standard for diagnosing a labral tear is an MR Arthrogram, we are able to use an MRI at our facility to collect the appropriate data. An MRI does not require an injection with contrast, whereas an MRA does.
These studies look at the soft tissue, including labral tears, muscular tears, ligament tears, arthritis, cartilage defects, etc.
C. CT Scan
A CT scan is a study we commonly prescribe to obtain additional information on the bony anatomy. This study differs from MRI and MRA scan, in that the focus is on the bone, not soft tissue.
CT scans define and outline impingement lesions as well as provide femoral version angles.
V) Treatment Options
A. Physical Therapy
P.T. is an extremely important component to managing hip pain. The hip joint is a very deep joint surrounded by almost 30 muscles! Physical therapy aims at strengthening these muscles, increasing flexibility, maintaining the range of motion of the joint, and decreasing the inflammation associated.
Joint injuries (i.e. labral tear) result in secondary muscular issues (strains, snapping hips - internal and external, bursitis, tendonitis, etc.)
1. Will PT heal/fix my labral tear?
This is a question asked of us all the time, and the simple answer is no. However, it is possible for a tear to become asymptomatic with appropriate muscular training and activity modification and therefore not require surgery.
2. PRE SURGERY PT PROTOCOL
Pre surgery physical therapy is very important for those who present with extreme weakness or stiffness.
Anti inflammatories are used primarily to treat mild to moderate pain associated with inflammation. Inflammation is associated with muscular tears, bursitis, tendonitis, arthritis, labral tears, and synovitis.
Anti inflammatories are used as a first line treatment in conjunction with a strengthening program. Post operatively, they are prescribed them as well.
We do not recommend taking anti inflammatories for long periods of time and require blood work to be done every 3-6 months if anti inflammatories are being used daily for this extended period of time.
2. Commonly used drugs
Injections are commonly prescribed to either assist in confirming the diagnosis or act as therapeutic treatment. The injection is a scheduled appointment. Hip injections are not done at the time of the appointment, unless our radiologist happens to have an open slot for that day.
The scheduled injection takes approximately 40 minutes. It is best to bring someone with you for the injection, but this is not completely necessary.
Following an injection, patients tend to feel better immediately; however, this is not always the case. Some patients get more of a reaction from the injection, resulting in more pain for about 3 days, before they feel relief. In this case, rest, ice and an anti inflammatory such as motrin, advil, or aleve is recommended, assuming your body tolerates such drugs.
Anti inflammatories are permitted after the injections. It is recommended that you avoid impact activities for the first couple days, following an injection. A pain log is provided at the time of the injection, to document pain related to specific movements of the hip.
In most cases, we will prescribe an injection into the joint to confirm that the pathology is in fact coming from inside the joint. For instance, if a labral tear is truly symptomatic, an injection inside the joint (where the labrum is located), will result in pain relief. If the problem is coming from outside of the joint, ( i.e. back, muscles), the pain will not resolve with an intra articular injection.
Intra articular injections are typically performed under fluoroscopy. Fluoroscopy is commonly used in hip joint injections for guidance in properly targeting and placing the needle, and for avoiding nerve or other injury. Intra-articular injections are sometimes performed under ultra sound as well.
Pain relief after a hip joint injection varies from patient to patient. Patients may or may not obtain pain relief immediately or the next few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient's pain. Occasionally, the patient may feel numb or experience a slightly weak or odd feeling in the leg for a few hours after the injection. The patient will discuss with the doctor any immediate relief of pain, and will then record the levels of pain relief during the next week. A pain log is helpful to clearly inform Dr. Kelly of the injection results and in planning future treatment. Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and the cortisone is just starting to take effect. If the injection site is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief and appear more beneficial than applying heat.
If the hip joint that was injected is the source of the pain, the patient may begin to notice pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient's hip pain.
The psoas muscle runs outside of the hip joint. Psoas injections are performed under ultrasound. These injections are often prescribed when the diagnosis is thought to be a symptomatic psoas tendon. In some cases, this diagnosis is difficult to make, as a painful psoas tendon often results in compression and tears of the labrum. In this case, being the labrum is inside the joint and the psoas is outside, the injection may not result in 100% pain relief.
3. Trochanteric Bursa
A trochanteric bursal injection is prescribed for those that present clinically with bursitis on the outside of their hip. Our first line treatment is physical therapy along with an anti inflammatory. Should this not alter any of the symptoms, an injection would be performed.
This type of injection is easier to perform in the office, as compared to a joint or psoas injection, using the maximum point of tenderness as the targeted area, however, using an ultrasound machine is much more accurate.
D. Active Release Therapy (ART)
1. What is ART?
"ART is a patented, state of the art soft tissue system/movement based massage technique that treats problems with muscles, tendons, ligaments, fascia and nerves.
Over-used muscles (and other soft tissues) change in three important ways:
- acute conditions (pulls, tears, collisions, etc),
- accumulation of small tears (micro-trauma)
- not getting enough oxygen (hypoxia).
Each of these factors can cause your body to produce tough, dense scar tissue in the affected area. This scar tissue binds up and ties down tissues that need to move freely. As scar tissue builds up, muscles become shorter and weaker, tension on tendons causing tendonitis, and nerves can become trapped. This can cause reduced range of motion, loss of strength, and pain. If a nerve is trapped you may also feel tingling, numbness, and weakness." www.activerelease.com
2. Why do we use ART?
Hip injuries occur in the hip joint but often times result in secondary muscular injuries over time ( i.e. flexor tendonitis, trochanteric bursitis, lower back pain, hamstring pulls). ART has been very successful in decreasing pain associated to these muscular injuries. We have found that patients do much better post operatively if the muscular pathology is addressed prior to surgery.
Post operatively, hip arthroscopic patients sometimes complain of muscular stiffness, tightness, and associated discomfort. Patients have great success with ART, breaking up this post operative scar tissue.
E. Hip Arthroscopy
1. What is a hip arthroscopy?
Arthroscopy refers to a procedure done within a joint through small incisions, using an arthroscope (camera) to visualize the structures within. Arthroscopic procedures are commonly done on an outpatient basis.
Hip arthroscopic surgeries are performed to mainly address pathology within the joint, however, there are some procedures outside of the joint (i.e. gluteus medius tear, trochanteric bursitis, internal/external snapping hip) that we are able to address arthroscopically as well. We have detailed some of the more common hip arthroscopic procedures performed in a later section.
2. Set up
The set up for the hip arthroscopy differs greatly from other orthopaedic procedures, due to the anatomy of the hip joint. The patients are placed supine (on the back). Being that the hip is such a confined joint, traction must be applied under the guidance of fluoroscopy to allow for the placement of instruments. The amount force needed to distract the hip varies from patient to patient. We try to minimize the amount of traction to under 90 minutes. Minimizing the length of traction time will decrease the amount of neuropraxias that develop post operatively.
Incisions are made on the lateral aspect of the hip. The number of incisions varies from patient to patient depending upon their pathology. Each incision is approx 2cm long and is closed with either two or three sutures. These sutures are not dissolvable.
As Dr. Kelly enters the joint, he will address labral pathology by either repairing or debriding the labrum. The decision to repair or remove is based on the quality of the tissue upon viewing it with the camera.
There are two options for anesthesia: General or Regional. We prefer the use of a spinal (regional), as it allows for pain control immediately post op, and tends to minimize anesthetic side effects including, but not limited to, nausea, vomiting, pain at the site of insertion, spinal headache, etc. Some patients that have spine pathology, or bleeding disorders may not be candidates for the regional block. In this case, general anesthesia will be used.
Spinal vs. Epidural:
In the majority of cases, a spinal block is sufficient as opposed to an epidural. The two blocks differ in the location of the medication into the spine and an epidural is convenient for long cases, where the anesthesiologist can continually dose, according to the time. A spinal block is typically adequate for our procedure as surgical time is rarely over three hours. The anesthesiologist will speak with each patient prior to the procedure to go over the pros and cons. Ultimately, the decision is made by the patient.
One of the most frequently asked questions is, "Will I be awake for the procedure if I use a spinal?" This decision is also made by the patient. Prior to the block, the patient is sedated so they feel very sleepy and unaware of the injection. In most cases, the patient prefers to sleep during the procedure, so after the regional block is completed, additional sedation will be given so the patient can sleep during the surgery. This should also be discussed with the anesthesiologist the day of surgery.
4. Common HIP ARTHROSCOPY procedures
A synovectomy is performed using radio frequency probes that are able to, with a controlled amount of heat, rid the capsule of inflamed tissue.
Treatment of Labral Tears:
The decision to remove labral tissue is based upon the location, chronicity, and vascularity of the injured fibrocartilage. Attempts are made to preserve as much healthy labral tissue as possible.
a. Labral Debridement:
If the quality of the labral tissue is poor (crushed, erythematous, ossified) we perform a debridement of the labrum. This is done by using a rotating shaver in the joint that is able to "shave" the beat up labrum and with the use of a suction, remove the fragments from the joint.
b. Labral Refixation:
If the quality of the labral tissue is adequate, an anchor is placed into the bone (acetabular rim). The suture attached to the anchor is then fed around the labral tissue and tied down to the acetabulum. We do use a bioabsorbable suture anchor as compared to metal for this repair. The goal of this refixation procedure is for the once torn labrum to scar down the acetabulum and remain there once the suture dissolves.
Partial Psoas Release:
After entering the joint, the psoas tendon is visualized by making a small window in the capsule and then releasing the tight tendon by cutting it. After being cut, the tendon separates and eventually fills in with scar tissue, resting in a lengthened position.
a. Acetabuloplasty (Rim Trimming/Decompression):
Anterior over coverage secondary to a pincer lesion can be treated arthroscopically. This lesion is usually associated with a flattened, degenerative or cystic labrum. Pincer lesions require bony resection which can be performed using a motorized burr. Resection of the rim lesion oftentimes leads to destabilization or requires detachment of the labrum in order to fully visualize the extra bone. Following the rim resection, unstable but healthy residual labral tissue is refixed to the acetabular rim using arthroscopic suture anchoring techniques.
b. Osteochondroplasty (CAM decompression):
With visualization of the Cam lesion, a motorized burr is introduced and the removal of the Cam lesion is performed to recreate a spherical femoral head. A resection of less than 30% of the head neck junction is recommended because this has shown to preserve the load bearing capacity of the femoral neck, thus decreasing the risk of stress fracture. Fluoroscopy is often time used to assist in determining the amount of bone in which to resect.
Iliotibial Band Release:
An ITB release is performed in patients with symptomatic (painful) snaps. This is performed by accessing the lateral space in the hip. Traction is not needed for this portion of the procedure. Once the ITB is visualized, a cut is made to lengthen the tissue.
A trochanteric bursectomy is a simple procedure in which a motorized shaver is placed in the peritrochanteric space (outside of the hip) to debride the inflamed bursal tissue. To access this area of the hip, the same portals that are used to access the inside of the hip joint are used. Traction is not needed for the bursectomy portion of the hip arthroscopy.
Gluteus Medius Repair:
Repair of the Gluteus Medius/Minimus tendon(s) is done in the lateral space, where traction is not needed. In the majority of cases, the procedure is completed arthroscopically, however, the size and/or location of the tear may warrant an open technique to be used. The Tendons are visualized and an anchor(s) is placed into the greater trochanter of the femur while a suture is passed around the tendon. The tendon is then pulled down to its normal anatomic position and tied over the bone. For this procedure, a metal anchor is more commonly used as opposed to a bioabsorbable one. The procedure is very similar to that of a rotator cuff in the shoulder.
Removal of Loose Bodies/Tumors: (include PVNS/Synovial Chondromatosis)
Performing a chondroplasty consists of removing loose fragments of cartilage. This is common in the setting of some arthritis.
The cartilage is taken out of the joint by a motorized shaver or a grasper depending upon the size of the fragments.
5. Post-Operative management
Post operative equipment
The weight bearing status following all hip procedures is 20 lbs foot flat (partial weight bearing). Crutch time is dependant upon the type of surgery, but is usually anywhere from 2-4 weeks. Gluteus medius repairs require 6 weeks of crutches, as does a microfracture procedure.
b. Continuous Passive Motion (CPM) Machine
The CPM machine is used for 4 hours/day for 4 weeks, typically. It is a rental so must be returned. Our office will order the machine and have it delivered to the hospital the day of surgery.
The brace is to be worn for 2 weeks following surgery, mainly to prevent extreme flexion and extension of the hip. It is only to be worn while weight bearing with crutches. Due to the configuration of the brace, it must be worn over clothes. The brace is bought through insurance, ordered by our office and delivered to the hospital the day of surgery.
d. Ice machine
The ice machine is a rental ice colling system that is ordered by the office and delivered to the hospital the day of surgery with the other equipment. It is to be used 4-6 times a day for 20-30 minutes at a time.
Post-Operative Physical Therapy Protocols
6. Follow Up Visits
10-14 days following surgery for suture removal
6 weeks from the date of surgery
3 months from the date of surgery
6 months from the date of surgery
1 year from the date of surgery (x-rays will be obtained)
2 years from the date of surgery (x-rays will be obtained)
5 years from the date of surgery (x-rays will be obtained)