scope on the hip labrale letsesl zeist 24 april 2013 dr j de schepper az nikolaas – sint-niklaas
TRANSCRIPT
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Scope on the hipLabrale letsesl
Zeist 24 april 2013
Dr J De SchepperAZ Nikolaas – Sint-Niklaas
www.orthopedieregentie.be
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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
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Groin pain in athletes
• Activity related
• Normal X-rays
• All investigations negative
• Long conservative treatment
• Hernia repair
• Longterm absence on the field
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Groin pain in athletes
Extra-articularCause for pain
Intra-articularCause for pain
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Intra-articular causes for groin pain
• Acute injury
– Torn ligamentum teres– Loose body, cartilage lesion
• Gradual onset
– Concept of impingement
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Heup arthroscopie
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Anatomie
Centraal compartiment
Perifeer compartiment
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INDICATIES : LOOSE BODIES
Oorzaken:
• Posttraumatisch• Synoviale chondromatose• Andere kraakbeenaantastingen
Investigaties:CT – Arthro CT
Heup arthroscopie
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Heup arthroscopie
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Heup arthroscopie
INDICATIES : KRAAKBEENLETSELS
Traumatische letsels
Impactietrauma
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Concept of femoro-acetabular impingement
FAIdynamic concept
Developed by R. Ganz (Bern)
1. cam - impingement
2. pincer - impingement
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cam - impingement
Probleem situeert zich op de nek, gevolgen acetabulair
Anterior offset
Notzli’s angle
Concept of femoro-acetabular impingement
FAI
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Notzli’s angle ????
cam - impingement
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Consequences
labral tears
wave sign
delaminated cartilage
early arthritis
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– Osseous bump• “variant”• Idiopathic• old LCP• subclinical slipping
– Femoral retroversion
– Coxa vara
cam - impingement
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– Bone Marrow Edema
– Labral tear
– Cartilage lesions
– Subchondral cyst formation
– (Bump-cyst complex; herniation pit)
– Os acetabuli
cam - impingement
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CAM FAI: intact labrum + wave sign
cam - impingement
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cam - impingement
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pincer - impingement
acetabular retroversion
cross-over sign
Concept of femoro-acetabular impingement
FAI
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pincer - impingement
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Pincer FAIPincer FAI
– Acetabular origin
– Acetabular overcoverage
– Coxa profunda
– Protrusio acetabuli
pincer - impingement
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Consequences
Abutment nek tegen anterior wall
Mainly labral tears
Contre-coup lesions
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Often combined impingement
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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
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• Testen– Faber
Clinical features of FAI
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• Testen– Mc Carthy
Clinical features of FAI
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Radiological findings of FAI
• Standard X-ray
• Arthro MRI
• 3D CT-scan
• In doubt : Injection of the joint
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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
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Standard X-rays
tilt
rotatie
Value of correct positioningValue of correct positioning
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• Standard radiography: 3/4
– Lateral neck
Standard X-rays
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• Other valuable radiographs– Lequesne (faux
profile)• Profile of acetabulum:
anteversion, retroversion
– Dunn view• 90° flexion/ abduction
20°• Anterior femoral neck
Standard X-rays
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• Other valuable radiographs– Lequesne (faux
profile)• Profile of acetabulum:
anteversion, retroversion
– Dunn view• 90° flexion/ abduction
20°• Anterior femoral neck
Standard X-rays
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Pincer FAIPincer FAI
– Acetabular origin
– Acetabular overcoverage
– Coxo profunda
– Protrusio acetabuli
Standard X-rays
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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
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CAM FAICAM FAI
– Bone Marrow Edema
– Labral tear
– Cartilage lesions
– Subchondral cyst formation
– (Bump-cyst complex; herniation pit)
Arthro-MRI findings
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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
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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
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Resectie door surgical dislocation (Ganz)
Treatment of FAI
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Treatment of FAI
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COMPLICATIES
Villar, Clin Orthop, Jan 2003
1054 gevallen1,4 %
• Neuropraxie, skin necrosis• Bloeding portals of hematoomvorming• Trochanter bursitis• Breuk instrumentarium• Infectie
Heup arthroscopie
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Scope on the hipScope in the hip