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    8 Pearls for Success with Hip Arthroscopy

    At ICJR’s 13th Annual Winter Hip & Knee Course, Marc J. Philippon, MD, provided his top tips, tricks, and techniques to help surgeons set themselves up for success with hip arthroscopy for femoroacetabular impingement (FAI) and labral pathology.

    The patient should always be at the center of the decision-making process. The decision on whether to operate should be based on the evidence and the individual patient’s needs, Dr. Philippon said. Knowing when not to perform hip arthroscopy is important, too.

    Establish a standardized screening and clinical evaluation protocol. Doing so will help with patient selection, Dr. Philippon said. His protocol includes a combination of physical exam, history, imaging (ultrasound and MRI), and clinical testing/observation. The tests he uses are:

    • FABER distance test
    • Anterior and posterior impingement test
    • Internal rotation evaluation
    • Hip range of motion
    • Hip strength
    • Dial (log roll) test
    • Pelvic tilt observation
    • Gait observation
    • Sports test

    It’s not just FAI: Take a global hip approach. When a patient presents with hip pain, keep in mind that it can be caused by more than impingement and that there are multiple pain generators in the hip. To determine the origin of the pain, the surgeon should evaluate:

    • Cam
    • Pincer/subspine
    • Labrum
    • Balance of the periarticular muscles
    • Capsule
    • Chondral surface

    Evidence leads to consensus. Treatment for labral pathology has evolved over the past decade, Dr. Philippon said, with research from his group helping to predict the best candidates for hip arthroscopy to treat FAI with labral pathology [1] and parameters for various surgical techniques. [2] This research has led to an algorithm for labral defects:

    • A tear with healthy volume of more than 6 mm can be repaired with 2 or 3 sutures.
    • Repair of a degenerative tear with decreased volume (less than 6 mm) should be augmented with an iliotibial band (ITB) autograft.
    • A tear with an absent or calcified section should be reconstructed with an ITB autograft.

    Use biologics to improve the joint environment and cartilage healing. Dr. Philippon has been using platelet-rich plasma (PRP) and bone marrow concentrate (BMC) since the early 2000s, and he has most recently been investigating the addition of losartan, a TGF-b1 blocker, to the PRP or BMC regimen to promote healing and reduce fibrosis formation. [3] He and his colleagues are now involved in multiple clinical trials to validate their bench research involving a rabbit osteochondral defect model. [3]

    Great surgery will not be successful without appropriate rehabilitation. Dr. Philippon and his colleagues use the same protocol for labral augmentation and labral reconstruction to rebalance the musculature, and it includes:

    • Protected weight-bearing for 10 to 21 days, followed by 1 week of weaning off crutches
    • Continuous passive motion 6 to 8 hours a day for 4 weeks (non-microfracture patients only)
    • Anti-rotation bolster for 3 weeks to prevent external rotation of the hip
    • Hip brace for 17 days to restrict extension and external rotation
    • Progression from passive motion to active motion to strengthening exercises in physical therapy

    Identify problem areas to improve outcomes. It is important to review current practice to fine-tune techniques, Dr. Philippon said, such as the angle of the anchors and the amount of rim that should be trimmed. It is also important to prevent revisions, as patients who undergo revision procedures have worse outcomes that patients who do not require a revision. [4,5] Adhesions are the most common indication for a revision procedure, [6] and they can be prevented with a good rehab program and possibly with the use of losartan, Dr. Philippon said.

    Collaboration between specialists and integration of various modalities of research leads to innovation. For example, Dr. Philippon and his colleagues collaborate with biomechanical engineers to conduct biomechanical studies that evaluate labral and capsular reconstructions. They also conduct outcomes-based research to better understand short-term, mid-term, and long-term results of hip arthroscopy for FAI and labral pathology.

    Click the image above to watch Dr. Philippon’s presentation from ICJR’s 13th Annual Winter Hip & Knee Course.

    Faculty Bio

    Marc J. Philippon, MD, is the Managing Partner of The Steadman Clinic in Vail, Colorado, where he specializes in sports medicine, hip disorders, and hip arthroscopy. He is also Co-Chairman and Co-Director of the Sports Medicine Fellowship at the Steadman Philippon Research Institute.

    Disclosures: Dr. Philippon has disclosed that he receives royalties from Arthrex Inc., Arthrosurface, Bledsoe, ConMed Linvatec, Don Joy, and Smith & Nephew; that he has stock or stock options in Arthrosurface, MIS, MJP Innovations LLC, Vail Valley Surgery Center, EffRx, Proofpoint Biologics, TSC DME, and TSC Imaging; that he is a paid consultant for Smith & Nephew and MIS; and that he receives research or other financial or material support from Smith & Nephew, Ossur, Arthrex Inc., Siemens, and Vail Valley Medical Center.

    References

    1. Menge TJ, Briggs KK, Dornan GJ, McNamara SC, Philippon MJ. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: labral debridement compared with labral repair. J Bone Joint Surg Am. 2017 Jun 21;99(12):997-1004. doi: 10.2106/JBJS.16.01060.
    2. Philippon MJ, Arner JW, Crawford MD, Bolia IK, Briggs KK. Acetabular labral reconstruction with iliotibial band autograft: outcome and survivorship at a minimum 10-year follow-up. J Bone Joint Surg Am. 2020 Sep 16;102(18):1581-1587. doi: 10.2106/JBJS.19.01499.
    3. Nakama GY, Gonzalez S, Matre P, et al. Effect of oral losartan on orthobiologics: implications for platelet-rich plasma and bone marrow concentrate-a rabbit study. Int J Mol Sci. 2020 Oct 6;21(19):7374. doi: 10.3390/ijms21197374.
    4. Newman JT, Briggs KK, McNamara SC, Philippon MJ.Outcomes after revision hip arthroscopic surgery in adolescent patients compared with a matched cohort undergoing primary arthroscopic surgery. Am J Sports Med. 2016 Dec;44(12):3063-3069. doi: 10.1177/0363546516659656. Epub 2016 Aug 11.
    5. Newman JT, Briggs KK, McNamara SC, Philippon MJ. Revision hip arthroscopy: a matched-cohort study comparing revision to primary arthroscopy patients. Am J Sports Med. 2016 Oct;44(10):2499-2504. doi: 10.1177/0363546516650888. Epub 2016 Jun 15.
    6. Locks R, Bolia IK, Utsunomiya H, Briggs KK, Philippon MJ. Revision hip arthroscopy after labral reconstruction using iliotibial band autograft: surgical findings and comparison of outcomes with labral reconstructions not requiring revision. Arthroscopy. 2018 Apr;34(4):1244-1250. doi: 10.1016/j.arthro.2017.10.054. Epub 2018 Feb 15.