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Daniel Robin - Hip Pathology (Young Adults)

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Daniel Robin

on 21 October 2014

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Transcript of Daniel Robin - Hip Pathology (Young Adults)

Daniel Robin
Why Am I Here?
1) update on hip / groin pain patho-anatomy, diagnosis and treatment
"Hip" Pain
Age Group
Age Group
Paediatric - 4-16 yo
Hip Dysplasia
Perthes Disease
Slipped Upper/ Capital Femoral Epiphysis
Sepsis
Inflammatory - Juvenile Chronic Arthritis
Tumours
Referred from spine
Why the Interest in the Young Adult?
lifestyle + lifespan = ?higher incidence of hip pathology?

broader range of diagnostic imaging modalities available

broader range of procedural modalities available - THR is NOT the ONLY operation for hip pain anymore!

Greater opportunity to intervene earlier

significantly alter natural history
Location of "Hip Pain" = ?
Groin
Location of "Hip Pain"= ?
Location of "Hip Pain" = ?
What is Femoro-Acetabular Impingement?
What is Hip Dysplasia
Clinical Investigation of Hip Pain
History of Presenting Complaint
Paediatric Hip Diseases
Risk factors for AVN
Functional Limitation (Oxford Hip Score)
Imaging - XRay
Acetabular Retroversion and Impingement
Orthopaedic Surgeon
MBBS (hons) MS FRACS (Ortho)
2) tell you about myself
3) help you to get your patients up-to-date (and best available) treatment
Location
Geriatric - 60+ yo
Sequelae of Paediatric/ Young Adult disease
"Degenerative" = Osteoarthritis?
Inflammatory - joints or bursae
Traumatic - i.e. #'d NOF/GT
Tumour
Intra-articular
Extra-articular
Referred
chondral injury - FAI / dysplasia / hypermobility / all others
ligementum teres injury? - hypermobility
labral injury - FAI / dysplasia / hypermobility
effusion (blood/pus/tumour)
herniae / abdominal mischief
spinal pathology
testicular pathology
renal calculi
ilio-psoas tendinopathy/bursitis
adductor tendinopathy/enthesopathy
pelvic / proximal femoral tumours
stress fractures
Trochanteric
Intra-articular
Extra-articular
chondral injury - FAI / dysplasia / hypermobility / all others
trochanteric bursitis
Ilio-tibial band / tensor fascia lata tightness
"snapping hip syndrome = coxa saltans
Gluteal tendinopathy / enthesopathy
Buttock
Intra-articular
Extra-articular
Referred
chondral injury - FAI / dysplasia / hypermobility / all others
(labral injury - FAI / dysplasia / hypermobility)
effusion (blood/pus/tumour)
*spinal pathology*
piriformis tendinopathy
ischial bursitis
pelvic / proximal femoral tumours
Physical Examination - esp palpable tenderness
ROM and lower limb rotational profile
Special Tests
Anterior Impingement Test
Posterior Impingement Test
"F.Ab.ER" Test (SI Jt)
Obers Test (ITB/TFL)
Ludloff / Stinchfield Test (Psoas tendonopathy)
Hypermobility Testing
Xray
supine AP pelvis
lateral hip joint
45* Dunn view
CT scan
MRI
MR Arthrogram

Imaging - CT Scan
Imaging (FAI) - MRI / MRA
Treatment Modalities - FAI
Physio / Hydro
heat
stretching
muscle strengthening
gait / postural retraining
NSAIDs
Injections (Dxc / Txc)
Hip Arthroscopy
Cam Debridement
Pincer Debridement
Chondral flap debridement
Labral Repair / Debridement***
subchondral microfracture
removal of loose bodies
repair ligamentum teres?

Peri-Acetabular Osteotomy
Only for Acetabular Retroversion (i.e. focal overcoverage)

Total Hip Replacement
When chondral loss too severe and function significantly impaired
When the patient is too old/not functionally demanding and is still suitable for major procedure
Treatment Modalities - Hip Dysplasia
...
as above, but also
Pilates!
Treatment Modalities
Hip Arthroscopy
Diagnosis
Assess +/- Repair Labrum***
- DO NOT DEBRIDE LABRUM -

**Peri - Acetabular Osteotomy**

Total Hip Replacement
end stage symptoms with degenerative changes on X-rays / post arthroscopy
Peri-Acetabular Osteotomy
Total Hip Replacement / Resurfacing
Hip Arthroscopy
Surgical Hip Dislocation
Total Hip Replacement / Hip Resurfacing
Hip Arthroscopy
Treatment Modalities - Soft Tissue Issue
Trochanteric Bursitis / Abductor Enthesopathy / Tears
U/S guided injection of local & steroid into trochanteric bursa
Arthroscopic (open) Bursectomy +/- ITB cruciform release
Open Debridement / Repair / Reconstruct Abductors

Psoas Tendinopathy
Dx/Tx injection of tendon sheath with local/steroid
Arthroscopic release through hip joint / open release at lesser trochanter

"Sporting Injuries"
multimodal - but usually responds to non-operative treatment
rest
gait/postural retraining
graduated return to training
sport-specific exercise programme
injections (local + steroid / prolotherapy?)
Rarely surgical intervention
Non-operative
Operative
Operative
Non - operative
Periacetabular Osteotomy
Controversial, or... "A Brave New World"...
Who Am I?
Update on Hip Pathology and Treatment
DANIEL ROBIN
Diagnostic Imaging
Young Adult Hip Pathology
Suggested Treatment Options
Established Public Hospital Consulations at Maroondah Hospital, Ringwood
Flexible with arrangements for private patients with financial hardship
Availability
Affability
Ability
Affordability
Post Fellowship Training in all the mentioned diagnostic and procedural aspects of young adult hip pathology
Discussion of cases with:
Patients,
Physios,
Sporting Coaches,
GPs & Sports Med Physicians,
Orthopaedic Colleagues
Timely Appointments for Patients
Establishment of Private Consultation Suites and operating at Masada Medical Centre, East St Kilda
Also consulting at Epworth Eastern (Box Hill), The Valley Private Hospital (Mulgrave ) and surgical privileges at Cabrini Health
How Can I Help Your Patients?
MBBS (Hons)
Monash University
1998
2006-2009
Master of Surgery
(orthopaedics)
St Vincent's Hospital, University of Melbourne
FRACS (Ortho)
2003
Consultant Orthopaedic Surgeon
The Northern Hospital
Maroondah Hospital
2010
Post Fellowship Training
2011-2012
2011 - University College Hospital London
Johan Witt & Prof. Fares Haddad
Hip Arthroscopy
Peri Acetabular Osteotomies
Total Hip Replacement
Revision Total Hip Replacement
(Total Knee Replacement)
2012 - Avon Orthopaedic Centre, Bristol
Prof. Ashley Blom, Robert Spencer, Stephen Eastaugh-Waring, Jason Webb, (Andrew Porteous & Jonathan Eldridge - Knees)
Hip Arthroscopy
(Peri Acetabular Osteotomies)
Total Hip Replacement
Revision Total Hip Replacement
Total Knee Replacement
Revison Total Knee Replacement
ACL Reconstruction
Unicompartmental Knee Replacement
Patello-Femoral Stabilisation / Realignment
Extra-articular impingement ( ischio-femoral / subspinous impingement)
?extra-articular arthroscopic debridement?

Hip arthroscopy for evaluation of painful THR / drainage of septic arthritis
So What Are the Take-Home Messages?
Beware the young adult with "pulled groin" or "buttock ache" for >6/52
Opportunity to significantly delay (?prevent?) the onset of hip OA?
Low threshold for plain X-rays of the pelvis
(but a "normal" X-ray isn't always reassuring)
refer early if any abnormality
Leave the MRI to the discretion of the treating physician
Find a surgeon who understands the breadth and complexity of hip pathology
Ultrasound...?
Young Adult - 15-55 yo
Femoro-Acetabular Impingement (FAI)
Focal Acetabular Overcoverage - "Retroversion"
Subtle Hip Dysplasia
Hypermobility syndromes
Sporting/Muscular
osteitis pubis / rectus - adductor strains / psoas tendinopathy / Inguinal Canal Insufficiency ("sports herniae") / stress fractures (pelvis / femur)
Avascular Necrosis (AVN) femoral head
Sequelae of Paediatric Diseases
Post-traumatic
Etc...
Anteverting Periacetabular Osteotomy for Acetabular Retroversion... watch this space
CONSULTANT ORTHOPAEDIC SURGEON

MASADA MEDICAL CENTRE - EAST ST KILDA

EPWORTH EASTERN HOSPITAL - BOX HILL

THE VALLEY PRIVATE HOSPITAL - MULGRAVE

CABRINI HEALTH - BRIGHTON / MALVERN

EASTERN HEALTH - MAROONDAH HOSPITAL
Full transcript