Slipped Capital Femoral Epiphysis

This diagnosis occurs most commonly in boys between the ages of 10 and 17 who are commonly obese. Although typically of unknown cause, it has been associated with hormone abnormalities. 10 – 25% of cases are bilateral and trauma is associated with approximately 25% of cases. To make the diagnosis, X-rays typically are performed.

Signs and Symptoms
Groin pain may develop slowly or come on suddenly. The hip pain may extend to the knee or anterior thigh. Limited motion of the hip usually is present, with the leg being more comfortable in external rotation. Early in the process, plain films may reveal widening of the growth plate. More advanced changes result in slippage of the bone.

Differential Diagnosis
Other common causes of hip pain in this young patient population include muscle strain, avulsion fracture, or growth plate injuries in other areas around the hip.

Management
Surgical treatment consists of fixation when it presents initially. If symptoms occur later in life in patient who have been treated for this condition, the symptoms may be due to femoroacetabular impingement.

Femoroacetabular Impingement

Ganz and colleagues recently described the concept of femoroacetabular impingement (FAI) as a source of labrum (labral) tears and articular cartilage injury. Two bony abnormalities, CAM and pincer, frequently occur together. CAM impingement results from abnormal contact between an abnormally shaped femoral head and neck with a morphologically normal acetabulum. This type of impingement may be of unknown cause or may be associated with femoral neck fractures that have healed incorrectly, slipped femoral capital epiphysis, or Legg-Calve-Perthes disease. Pincer impingement results from abnormal contact between a normal femoral head with an abnormal acetabulum. This type of impingement is the result of focal (acetabular retroversion) or global (deep socket) over-coverage.

Because of its association with articular cartilage injuries and labral tears, there is considerable overlap in terms of presenting symptoms. Asymmetrical range of motion, especially into flexion-internal rotation or flexion–abduction–external rotation, may be noted. Radiographs and MRIs are the current standard to assess for FAI.

Open or arthroscopic surgical interventions include osteoplasty to reshape the head – neck junction of the femur or rim trimming to remove excessive bone from the acetabular rim.

Impingement is due to a bony abnormality and therefore no true preventative measure can be taken. Proper maintenance of core strength and muscle balance in and around the hip may help protect the soft tissues in the joint.

Degenerative arthritis

Degenerative arthritis refers to diffuse loss of normal articular cartilage in the joint and must be considered as the primary cause of hip pain, regardless of age. Osteoarthritis, traumatic arthritis, and rheumatoid arthritis are common causes of degenerative arthritis. Typically the presence and extent of arthritis tends to increase with age. Degenerative arthritis is the most common cause of hip pain in patients over fifty years of age.

Signs and Symptoms
Patients report progressively worsening pain, typically with a gradual onset. As activity increases, pain also tends to increase. A limp may develop, occasional sharp pains may be noted, and stiffness may be progressive. Radiographs reveal joint space narrowing, and possible cysts, spurs (also called osteophytes), and sclerosis (thickening of the bone adjacent to the joint). A decrease in range of motion may also be noted,

Differential Diagnosis
Differential diagnosis includes loose bodies, labral tears, ligamentum teres tears, and arthritis in the lumbar spine with radiating pains to the hip area.

Management
For patients with mild arthritis, nonoperative treatment may suffice. NSAIDS (non-steroidal anti0inflammatory medications), glucosamine and chondroitin sulfate, steroid injections, and hyaluronic acid injections may be effective. Activity modification is an option to minimize symptoms. Tylenol and the use of NSAIDS may be effective and should be discussed along with your primary care physician. There are concerns with the use of NSAIDS, particularly in the long term.

For patients who have failed nonoperative management, three surgical options exist:

1) For diffuse areas of articular cartilage injury, typically noted as joint space narrowing on plain x-rays, a total joint replacement is the best surgical treatment option.

2) For patients who have little to no joint space narrowing and who have localized or focal areas of articular cartilage injury:

2a) An open hip dislocation with treatment of the intra-articular abnormalities as well as any contributing abnormal bone alignment may be considered.

2b) An arthroscopic approach, through small incisions, may also be effective.

My approach to deciding which surgery is best is decided on an individual basis, with a number of factors taken into consideration, including but not limited to age and activity level.

Focal articular cartilage injuries

Causes include traumatic injury, e.g. from a direct blow to the greater trochanter or from femoroacetabular impingement. Xrays are very useful in determining the extent of articular damage and are routinely obrtained. In determining the presence of focal areas of chondral injury, MRIs have improved considerably in recent years and depend in part on the quality of the images and the experience of the reader. The presence of chondral lesions of the femoral head or the acetabulum has been shown to result in a poorer prognosis following arthroscopic treatment of a labral tear.

Signs and Symptoms
A deep ache in the joint may be reported by the patient, and the pain may be noted anteriorly, laterally, or posteriorly. A click or mechanical sensation in the joint will probably not be noted in the early stage of injury.

Differential Diagnosis
Differential diagnosis includes fractures, stress fractures, intra-articular derangement such as a labral tear, and degenerative joint disease.

Treatment
If nonoperative treatment consisting of activity modification, physical therapy, NSAIDS, and glucosamine chondroitin fail, treatment may consist of arthroscopic microfracture versus total joint replacement, depending on patient specific factors and the extent of articular cartilage injury.

Groin Strain

The most common acute injuries about the hip and pelvis from athletic competition are muscle strains. The musculature of the groin most often affected includes the adductor group (gracilis, pectineus, adductor brevis, adductor longus, and adductor magnus). The rectus abdominus, rectus femoris, and iliopsoas are also common muscles that can be affected. The mechanism of injury can be overuse causing microtears or a sudden forceful movement. A position of external rotation and eccentric forces often cause flexor / adductor strains, and the injury most typically occurs at the myotendonous junction or the tendonous insertion.

Signs and Symptoms
A strain can be felt as a sudden sensation of tearing or twinge while playing or may not be noticed until after the activity. Symptoms include pain and swelling. Focal areas of tenderness and swelling are often detected. With more severe injuries, a defect may be palpable. The history of injury, localized tenderness, and pain with resistance are the most notable measures for diagnosis.

Differential Diagnosis
Avulsions should be ruled out with an AP pelvis radiograph. Differential diagnosis also includes hernia, internal derangement of the hip (e.g. labral tears and chondral injuries), nerve entrapments, osteitis pubis, fractures and stress fractures.

Treatments
Strains should be treated with RICE and analgesics as needed for a minimum of 2 to 3 days. Range of motion exercises should be initiated early. As pain resolves, gentle isometric exercise progressing to more dynamic resisted exercise can be performed using pain as a guide. The athlete can gradually return to play when pain-free. A protective spica bandage may assist in the early phase of return to sport for flexor / adductor strains. The most common complication is recurring symptoms and in chronic cases, surgery may be indicated but is rare.

Prevention
Training programs should be specific for the level of athlete, timing during the season, and goals of the athlete. It is important to focus on general conditioning, specifically strength, endurance, and flexibility. Programs should include warm-ups and cool downs for training and matches.

Hip labral (labrum) tears

Patients with hip pain may end up getting an MRI which shows a labral (labrum) tear. Inevitably I get asked "What is that? I've never heard of it before."

Most labral tears are not associated with a traumatic onset. Running, sprinting, and frequent rotation of the hip while playing sports is thought to result in tears of the labrum. Bony structural risk factors include hip dysplasia and femoroacetabular impingement (FAI). Clinical assessment including history, physical, and radiographic analysis is 98% accurate in determining the presence of an abnormality within the hip joint. MRI with contrast injected into the hip joint(arthrography) is 65-90% sensitive for detecting labral tears. Relief of pain (lidocaine pain test) from an intraarticular anesthetic injection at the time of arthrography is very suggestive of intraarticular abnormalities and is useful in predicting improvement with arthroscopic intervention, particularly in patients with normal imaging exams.


Signs and Symptoms
In greater than 90% of patients with labral tears, pain is reported in the anterior hip or groin region. Less often pain occurs in the lateral or posterior hip region. Patients may also report clicking, catching, locking, or giving away. Range of motion restrictions in flexion, internal rotation, and/or figure four position may be noted. Provocative tests include the anterior impingement test of flexion, internal rotation, and adduction. A positive test causes pain in the groin and restricted motion. Pain in the joint with a resisted straight leg raise may be indicative of a labral tear.

Treatment
Unfortunately the labrum does not heal on its own if it is torn. The goak of non-operative treatment is to reduce the symptoms. If non-operative methods fail, surgical intervention of labral tears may be performed open or arthroscopically. The labrum can be debrided (cleaned-up) and/or repaired with suture anchors. Histologic studies have shown potential for labral healing. Conservative treatment may include limited weight bearing, NSAIDS, and avoidance of pivoting motions on the hip. Physical therapy can improve muscle recruitment to control hip motion.

Why the hype about minimally invasive surgery?

I commonly have been asked by family members and friends about minimally invasive techniques, as they are increasing advertised for a variety of different surgical procedures. The questions can best be summarized by “should I have my surgery done that way?”

The goals of minimally invasive surgery are much the same as for the traditional “open” surgeries of the past. The difference is that the incisions are smaller, and in general, there is less dissection, less bleeding, and less pain, and thereby quicker rehabilitation. But these less invasive procedures must be considered with caution, as the visualization during surgery is oftentimes decreased. Less invasive does not necessarily result in better outcomes, particularly when considered in the long term. And certain procedures, such as bunion surgery, have been shown to have worse results when performed in a less invasive manner.

One such type of minimally invasive surgery is arthroscopic surgery. Arthroscopy utilizes small portals (1 to 2 cm incisions) to pass cameras and instruments to perform the surgery. Saline water is used to fill the joint and to view the procedure. This type of surgery has become a standard of care for certain injuries such as anterior cruciate ligament (ACL) surgery, and has become more popular not only in the knee, but also in the shoulder, hip, and foot and ankle. Training programs in sports medicine traditionally have provided extensive training in arthroscopic procedures. The risk of infection is decreased because of the continuous use of water in arthroscopy.