COVER FEATURE
Femoroacetabular Impingement and
Hip Arthroscopy Hip Arthroscopy Evolution In the past decades there has been a steady transition from open to arthroscopic surgery and although its use is now widespread for most large joints, the hip was the last one to join the list. Whilst complex arthroscopic treatment is well established in joints like the knee, shoulder and ankle, complex reconstructive hip arthroscopy is relatively new and therefore it is still a much subspecialised area. New techniques allow us to preserve the hip anatomy with the potential to delay or even prevent the evolution to osteoarthritis. For many years the deep, tight nature of the joint meant that more complex therapeutic hip arthroscopy was not possible. Replacement hip joints were the only real surgical option for painful joints. Over the last few years arthroscopic technology and techniques have evolved tremendously. Because nowadays, young and middle aged patients wish to remain active and practise sports for longer, hip arthroscopy is a welcome option, being a less invasive form of treatment, which usually offers a faster recovery. Hip Arthroscopy Today In 2003 the ‘discovery’ of the problem of ‘femoro-acetabular impingement’ (FAI) or hip
impingement unleashed hip arthroscopy’s true potential. We now know that hip impingement is the cause of arthritis in many patients, and there is hope that treatment of this condition at an early stage will potentially lessen the impact of osteoarthritis in the older population. For patients who have advanced osteoarthritis of the hip (which usually affects patients over 55) hip replacement remains the standard treatment. In patients with minimal or no degenerative changes, we can correct the bony abnormality responsible for the impingement. During the procedure the surgeon also addresses the articular cartilage and labral tears. History and clinical examination Patients usually present with groin and trochanter pain, some also with adductor or buttock pain. More than 50% of the patients have a limp and report a reduced walking distance. Half the patients also report pain with sitting. The pain initially tends to be intermittent. Your patient might have had a laparoscopy and still have symptoms. The pain might affect the more active and sportive patient earlier. Conservative management such as NSAIDs can help to take the edge off the pain, but doesn’t cure the condition. Patients also report
increasing stiffness of the hip and a reduced range of motion: e.g. they have difficulty putting on their socks and shoes in the morning. On clinical examination the GP can use two simple tests to diagnose hip impingement. The hip impingement test (fig 1a and 1b) and measurement of the Faber distance. The Faber distance is measured between the lateral joint line of the knee and the examination table and is increased in patients with FAI and reflects a reduced ROM of the hip. Figure 1a Hip X rays can be used to demonstrate bony abnormalities associated with FAI and to define the type. Patients usually become symptomatic with FAI when they have a labral tear or acetabular articular cartilage lesion and this can be demonstrated with an MRI of the hip. Procedure Hip arthroscopy is performed under a general anaesthesia and can be done as a day case or over night stay. In the majority of the cases two portals (small stab incisions) are used. There are two mechanisms of impingement: cam and pincer (fig 2). In cam there is an increased offset of bone at the head neck junction of the femur.
FAI in primary care: key points Professor Ernest Schilders is a Consultant Orthopaedic Surgeon, specialising in Hip Arthroscopy at Bradford Teaching Hospitals and The London Hip Arthroscopy Centre at The Wellington Hospital.
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practicematters winter 2011
n FAI is (10-15% of the population),
n Early referral is indicated
but relatively unknown n Young adults (15-55) with groin pain may have FAI or labral damage n Extensive investigations in primary care are neither necessary nor helpful
guide for referral n A plain x-ray true pelvis can be performed to rule out significant arthritis
n A positive impingement test is a simple
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