Kelechi R. Okoroha, M.D. , orthopedic surgeon and sports medicine specialist at Mayo Clinic in Minnesota, talks with Jonathan D. Barlow, M.D., an orthopedic surgeon at Mayo Clinic in Minnesota, about recent growth in the understanding of hip impingement — abnormal contact between the femoral head and the acetabulum — which has led to evolution of treatment algorithms. He indicates that hip impingement continues to be diagnosed at increasing rates.
To treat this condition, Mayo Clinic hip specialists may start with physical therapy, NSAIDs and injections to determine if surgery is necessary. If surgery is pursued, treatment involves comprehensive management of all hip-related structures whenever possible, including labral repair, femoral neck osteochondroplasty, acetabuloplasty and capsular closure. Dr. Okoroha also explains three potential categories of hip impingement origin as well as how treatment may at times differ by patient age.
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Mayo Clinic Medical Professionals — Orthopedic Surgery. Yeah, Welcome to the Mayo Clinic Orthopedic surgery podcast. A curated series of interviews and discussions highlighting the three shields of orthopedic surgery at Mayo Clinic clinical practice research and education. Mm hmm. Welcome back to the Mayo Clinic Orthopedic Surgery podcast. I'm really excited today to welcome colucci. A core. Aha. He's an outstanding sports medicine surgeon who joins us. He did undergrad at Xavier and played basketball there, did med school at Howard University and then did his residency training at Henry Ford. He's a fellowship trained sports surgeon. He trained at Rush University helps take care of the Minnesota Timberwolves with our sports medicine group. And we're really excited to have him join us today to tell us a little bit more about hip impingement. Thanks for joining Casey. Thanks for having me on john this is a topic that seems to just be continually changing. And I think it was really kind of knew when I was a resident. We started to talk about hip impingement. Maybe it was just new to me, but the field seems to continually slowly change. Can you talk to us about what the current thinking is about hip impingement? Is it congenital, is it developmental? Where does it come from? And How does it fit into the two hip pain and young athletes? Yeah, well, I think the understanding of hip and Benjamin has expanded quite a bit, you know, over the last 10 years. I mean, I think we know that hip and Benjamin is defined as a normal contact between the femoral head and massive Tabram and that continues to be diagnosed at increasing rates. So I think as we learn more about hip impingement. Ar treatment algorithms continue to evolve. So we first started with performing hip arthritis cities with labeled agreements, you know, then after we understand the importance of, you know correcting the bony abnormalities and preserving the labrum, surgeons started performing Aussies corrections, you know, and then they started performing labor repairs. And now we're finding that, you know, whereas initially capsule of closure was thought to be not so important. I think the current literature really demonstrates as patients that undergo hip arthroscopy without capsule of closure have decreased outcomes. So I think it's important to you know, perform capsule card, sir. So I think currently we have evolved into the surgical treatment and performing a comprehensive management of all the structures and that includes labor repair, Tamron nicasio Condra plasticky, ask the tableau plastic and then collapse or closure whenever possible. That's great. And it sounds like it's really adapted a lot. Since I was really learning about it a lot. Is it thought that this is congenital or is it thought its developmental or some combination of the two? How how are we? Um How is how are these bumps and and things forming? Yeah. So that's a great question. Um I like to put the hips at risk of impingement into three categories. So you can have abnormal anatomy and normal use that speaks to what you were talking about. That can be either congenital, you know such as the skiff e that could be hip dysplasia or even prior surgery. Then you can have normal anatomy and abnormal use. Where that use really exceeds the tolerance of the joint structures. Now that can be an acute injury and like a contact athlete or that can be a chronic injury you know involving either occupational or recreational use. And then that last category is a combination of abnormal anatomy and abnormal use which is really common as well. Got it. And it is the thought that um once once these changes develop or once you really start to use it in this way that this is actually rapidly or is moving you toward arthritis or is treatment geared at just symptomatic management? Yeah. So I think we do believe that hip impingement can lead to early arthritis. Um In fact if you look at the studies um studies have shown that up to 70 to 90% of all hip arthritis is caused by either F. I. A. Or hip dysplasia. Got it. So it seems to be a growing number. And and the I think the harder part that I also see is I see a lot of let's say middle aged or slightly older patients with hip pain. How do you sort of go about the work up and and thinking about if if they're a candidate for hip preservation or if they need to go down a different road let's say towards total hip replacement. Yeah. So I think that's the middle aged population is the most difficult population. I think the young patients are pretty you know, set forward. They have labeled here. They have a huge camp. Think those middle aged patients are similar to the degenerative meniscus here. So if you image Everybody over 40 and get a hip Mrr you're gonna find labral tears, you're gonna find Canada farmers. The question is who needs treatment? Right. So I think in those set of patients is important to exhaust your non operative management with physical therapy. You know your injections um and see who really needs surgery. Now we've done some studies to really evaluate what patient factors lead to increased success after hip arthroscopy. And some of those are lower B. M. I. Younger age especially under 45, decreased arthritis. And really getting to that treatment within six months. Those are the facts respond to be most beneficial. That sounds great. So let's look at the younger population than let's say a more straightforward situation. May be abnormal anatomy. Maybe I would guess maybe the abnormal anatomy and abnormal use patients fall out a little bit earlier in in in this category. But uh do you go through the process of physical therapy and go through the process of an M. R. I. Or is or sorry? Of an injection? Or is this a situation where you say the anatomy is problematic enough that we're gonna we're gonna jump straight to surgery. How do you make that decision? Yeah that's a very great question because I actually treat patients differently by the age groups. So my younger patients are I still do a trial of physical therapy. I still get advanced imaging with M. R. I. Just to see what's going on. But in the younger pages once really, you know tell tale I don't inject them just because I'm worried about you know steroid in the joints and their cartilage being preserved. So in those patients after they fail physical therapy and they have labeled here and a huge camp I'll go straight to surgery. That makes sense. And and for the older patients even with very early arthritis or the patients that seem to fall into, let's say lower B. M. I. And a better candidate for hip arthroscopy. Even in the middle ages. There a role for hip arthroscopy or is it just kind of wait for a total hip replacement? How do you how do you decide to finally indicate somebody for that? Yeah there's there's definitely a role like you said in those ideal patients or they have a low B. M. I. Uh there you know, middle age but not too old and they don't have a lot of arthritis. What I'll do is I'll do an injection, okay like you said before and that injection does two things. It's diagnostic and it's therapeutic. So if I perform an injection in the hip and that patient gets pain relief. I know do defensively then that pain is coming from the hip. Okay. It's not coming from the back. You know the mussels come from inside the joint and then number two it gives them some therapeutic effect. So it gives them some pain relief, allows them to really do physical therapy and see if this is something we treat non operatively in those patients if they fail that. That's when I indicate them for hip arthroscopy. How does that make sense? And and thoughts about timeframe after injection to surgical management. Do you have a cut off that you like to go by? Yeah, usually three months. And I think the hip uh and me literature is similar. Yeah the shoulder literature has gone that way. Even for shoulder arthroscopy which is pretty low risk operation. Just like hip arthroscopy. But it's it's interesting because I see a lot of patients who I have almost a reflex injection into into something let's say. And probably it's more common in your young patients where they go in and somebody's giving them an injection and now you've really lost three months of luncheon time. But in the older patient obviously a little less critical especially in terms of that decision making that makes sense. Right. I mean that is a hard number but I'm less worried about infection and our theosophy. So you know it's not that hard. Can you talk a little bit more about the steps of the procedure. So I know that or my understanding is that there's portions of the procedure that you do on the tabular side, portions on the femoral side. Do you do all of the procedures? And then you talked a little bit about labor repair versus debridement capsule closure. Do you do all the procedures on every patient or um or as by and large or or is it really individualized based on what their deformity looks like and and um and how they got the tear? Yeah. So I really try to treat patients in the a la carte manner based on the pathology present. You know? So if there's a label repair, I try to preserve labeled tissue. So I'm trying to do a label repair whenever possible. And then you start looking at the femoral cam or the pencil deformity. Now most patients have a combination of both. But I only treat what I see, You know? So if they have a cam deformity, I'm gonna do osteo Condra plastic and get that alpha angle under 55. You know, if they have a large center edge angle and they have a large pencil for me, then I'm doing a statistical plastic and then all my patients get a capsule of closure. That's great. And is the is that an interpretive decision most of those steps or is it more based on the radio radio radiographs and the M. R. I. Scan about the femoral side and the as tabular side. I think for the most part you can see that on on an M. R. I. I do get CT scans on some of my patients, especially patients that I'm concerned with some version issues of the femur of the established. So that really allows you to assess that bony abnormality. Perfect. And um one of the things I sometimes read about is the thought of labor or reconstruction as opposed to labor repair thoughts about that in in the current age. Yeah so labor reconstruction is a great tool to have. Those are gonna be the patients where they have a real diminutive labor. Um or they've had previous procedures and don't have a lot of labor. Um So the labor reconstruction is a procedure we can do where you take either an autographed or an autograph tissue and really form a new labor for that patient. And I think this you know kind of kicked off you know 5 to 10 years ago. But we've done some recent research in at rush and um evaluating augmentation versus reconstruction. So augmentation is a little bit different in that you don't take down the whole labor room and put a new tissue. You really just augment your new labor on top of that old tissue. And what we think is because the labor provides a suction seal effect to the hips. So think about if you have a suction cup on something, If you do a 360° reception And then fix it down by eight points, you still have some space in between those, you know, repairs for air. Whereas if you augment your putting new tissue on top of that and you really don't lose as much of that section steel. So I'm more of a fan of augmentation whenever a candidate reconstruction that makes a lot of sense and and um going the opposite direction. Do you think there's a role for debridement and any patients or is that something that sort of has gone by the wayside for the most part? Yeah. I think the debris mints are going to be more on your older, you know, patients that have a degenerative labral tear. There's not really much tissue to repair. Those are still good candidates for, you know, debris mint. But most and large we try to repair it whenever we can. Right? And I my understanding is that the learning curve for hip arthroscopy is fairly steep and obviously the costs are high if you don't get it quite right in terms of either cartilage defects or heaven forbid femoral neck fractures or otherwise. Can you talk about some of the key components and maybe talk a little bit about the learning curve about um sort of frequency of use or somebody thoughts about low volume hip arthroscopy surgeons. Yeah. So hip arthroscopy is not as common as shoulder arthroscopy. And so it requires some, you know, additional expertise or training, you know, So one thing that's not as common as they used a 70° scope, you know, so that is a little bit difficult, especially for residents and fellows and therefore they don't get as much practice in training, you know? So the key to a really successful hip arthroscopy is performing the procedure in a traumatic nature. So you're not damaging any cartilage or any labrum on the way in. And so it's harder to teach that because coming in the, you know, hip is not is not easy. And so as a resident or a fellow, if you're doing that, you're demolition cartilage or labor when you already send yourself back, you know, So I just think it's something that needs a little bit more practice in detail in the lab And a little more familiarity with that 70° scope. Got it. And it sure sounds, oh, go ahead. Mhm. I was gonna say it sure sounds like with the the indications the way that they are, it's it's um, there's a challenges within the, it's a it's a sort of a complex indications game, but then also a complex surgical game and probably seems like something best done by people who are doing a relatively high volume. Yeah, I'd agree. It's best done by people that are doing a high degree of volume. I think when we look at what's the most common reason for re operation, it's inadequate bone resection, you know, so I think you know you have to have an experience and really respecting that camp to the proper level. And then the second reason is probably capsule er closure. Um So we know that the iliac femoral ligament is the strongest looking everybody. It's a key hip stabilizer and so back in the day, nobody used to repair the capsule a lot of times just because it's too difficult to do, you know your end of the procedure, you're two hours, 30 minutes, three hours. Some people just you know, bailed. What we're finding is that those patients that didn't have capsule closure are doing worse than patients that do. So capsule closure is a key component as well. That's interesting. And and can you talk about sort of the technique around that capsule closure and then tie into that any emerging technologies that you see over the next few months or years that will come out that you think will dramatically change this game again. Yeah, so just a little bit about the capsule of closure, it depends on what you do. So some people just make a straight incision in the capsule and some people perform a T in the capsule. But what you really want to do is make sure that you have a sutra not every 1-2 cm of capsule of closure you do to make sure you have a tight repair. Um So that's about capsule closure and then emerging techniques. Um, there's a lot of current technologies that are current coming out. Um There's one that's used to map the bony deformities pre operatively and then you can correlate that inter operatively to kind of check your reception. Um So these are techniques that are useful to really check your bony reception and they're really useful when, you know, surgeons that haven't done a lot of hip arthroscopy. That's super helpful. I'm gonna try and summarize what this shoulder surgeon learned about hip arthroscopy and then you can update what I got wrong and have any final comments for our listeners who, I'm sure excited about continuing to move this ball forward. So it sounds like obviously hip arthroscopy is is here to stay in the early concerns about not exactly finding out who should have it or when should have it are dying down as the indications really tightened down. Sounds like there's sort of a combination of some congenital factors or abnormal growth patterns. But then there's clearly some use issues in association with this and and that combination or overplay seems to be really important in terms of making decisions. Sounds like we've gotten confident enough about the procedure that in young athletes with pretty clear an atomic deformities going straight to surgery as a reasonable option as opposed to nursing things along with injections, which potentially could have some risk of complications, But in the older population, um, it's where there's a few more pain generators that could be in play. An injection for diagnostic and therapeutic reasons can be really helpful. And then finally the tech, it's a very technical operation. It sounds like with a number of different steps that that really need to be done to give the patient the best chance at a good outcome, particularly addressing the bony abnormality, sufficiently sufficiently repairing or reconstructing the tabular labrum. And then obviously capsule closure, which you mentioned a few times. Any other thoughts that you'd like to add for people who are either interested in hip impingement or surgeons who want to maybe add it to their to their game or residents who are interested in it. Yeah, I know that that's a really great summary of hip and Benjamin and where we are. I would just say, you know, if you wanna do hip arthroscopy and make sure you go somewhere. Either fellowship that has somebody doing it in high volume or make sure you get a lot of practice. But I don't think, you know, people should give up. I think if you want to do it, you know, there's plenty of opportunities to get it done right. Beautiful. Thanks so much for joining us. Alright, thanks for having me mm hmm