Monday, December 11, 2017
Isaiah Thomas, Labral Tearing, and Femoroacetabular Impingement
The Celtics issued the following statement related to the hip injury during the 2016 playoffs: “Isaiah Thomas will miss the remainder of this year's postseason following re-aggravation of a right femoral-acetabular impingement with labral tear during Game 2 of the Eastern Conference Finals against Cleveland. Thomas initially injured the hip during the third quarter of the Celtics' March 15 game against Minnesota, forcing him to miss the next two regular season contests. The injury was further aggravated during Game 6 of the Eastern Conference Semifinals at Washington on May 12." In this case, the diagnosis appears clear in terms of the injury. Femoral acetabular impingement (FAI) is an abnormal alignment of bone either on the acetabular (cup side of the joint) and/or on the femoral side (ball side of the joint) that causes abnormal mechanics of the joint, particularly in positions of extremes of motion (most often flexion). FAI is correlated with hip injury, although there is not a direct cause and effect association. In other words, patients with femoral acetabular impingement (FAI) do not necessarily develop tears or need treatment for the impingement.Femoral acetabular impingement alone is not a reason for surgical treatment, although in the setting of hip injuries and labral tears, surgical treatment may be appropriate. In those cases in which surgical treatment of the labral tear is performed, the femoral acetabular impingement is treated at the same time, with the goal of removing any abnormal shear forces on the repaired joint and thereby prevent further future injury. Labral tears can be present in patients who have no symptoms. This has been shown in several studies, including studies performed in the NHL, in which players who had no symptoms were noted to have labral tears on MRI. Especially in patients who have a very recent onset of symptoms (< 3 months), a trial of nonoperative treatment in the setting of labral tears is a reasonable option. However, labral tears generally are not thought to repair themselves and subsequent imaging will oftentimes continue to show tears. For these reasons, in patients who have persistent symptoms with labral tears and femoral acetabular impingement, it is reasonable to consider surgical treatment. When considering surgery, factors that should be evaluated are the extent of symptoms, the condition of the joint in terms of potential articular cartilage injury, and whether improvement is ongoing. As the duration of symptoms becomes longer, the likelihood of pain resolving and function improving becomes even lower. The decision for surgical treatment is complex and many patient specific factors should be taken into account. Hip arthroscopy is a treatment for hip preservation, and the condition of the joint is very important in terms of predicting success. I like to use the analogy of a “broken car”. When taking a car to the mechanic, the likelihood of getting a 1990 car to run well and function well into the future is lower than fixing a 2016 car with minor damage. Similarly, the extent of injury to the labrum and articular cartilage is an important factor in predicting success. MRI scanning, x-rays, physical examination, and previous surgeries are all important factors to determine the extent of the problem and all may help to predict success.