Adult Hip conditions - 26/10/18 Flashcards
What is the VITAMIN acronym for what causes things?
Vascular Infective/Inflammatory Traumatic Autoimmune Metabolic Iatrogenic/idiopathic Neoplastic
What are the three layers of the femoral head?
Hyaline articular cartilage
Subchondral bone
Cancellous bone
What is femeroacetabular inpingement syndrome?
Altered morphology of the femoral neck or acetabular
Causes abutment of the meoral neck on the edge of the acetabulum during movement
Fledxion adduction and intenal rotation
what s CAM type impingement?
Femoral deformity
Assymetic femoral head with decreased head:neck ratio
Who gets CAM impingement?
Usually young males
What can CAM impingement be related to?
SUFE
What is Pincer type impingement?
Acetabular deformity
Who gets pincer type impingement?
Usually seen in females
Acetabular overhang
What do CAM and Pincer impingement cause?
Damage to the labrum and tears
Damage to cartilage
Osteoarthritis in later life
What do patients with FAI present with?
Activity related pain in the groin Particular in flexion and rotation Difficulty sitting C sign positive FADIR provocation test +ve
How are FAIs diagnosed?
Radiographs
CT
MRI
How is FAI managed?
Observation in asymptomatic patients
Arthroscopic or open surgery to remove CAM
Peri-acetabular osteotomy remove labral tears
Arthroplasty in older patients with secondary OA
What causes Avascular necrosis (AVN)?
Failure of blood supply to the femoral head
What is the pathophysiology of AVN?
Idiopathic AVN
-Coagulation of the intraosseous microcirculation
-venous thrombosis causes retrograde arterial occlusion
-Intraosseous hypertension
-Decreased blood flow to femoral head
-Necrosis of femoral head
-chondral fracture and collapse
AVN associated with trauma
-Due to injury of the femoral head blood supply
Who gets AVN?
Males>Female
35-50
Bilateral
What are the risk factors for AVN?
Irradiation Trauma Haematologic diseases, sickle cell, leukaemia etc Dysbaric disorders Alcoholism Steroid use Idiopathic!
What do patients present with AVN?
Insidious onset of groin pain
Exacerbated by stairs or impact
Examination is usually normal unless disease has advances
How is AVN diagnosed?
Radiographs -hanging rope sign
MRI is most specific and sensitive
What is the staging for AVN?
Steinberg classification
What steinberg stages are reversible?
0,1,2
No permanent changes of the femoral head
Pre-subchondral collapse
What steinberg stages are irreversible?
3,4,5,6
Subchondral collapse
How are stages 0,1,2 steinberg treated?
Bisphosphonates
core decompression +/- bone grafting
curretage and bone grafting
Vascularised fibular bone graft
How are stages 3,4,5 and 6 steinbergs treated?
Rostational osteotomy for small bits
Total hip replacement
What is idiopathic transient osteonecrosis of the hip (ITOH)?
Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure
What do ITOH patients present with?
Progressive groin pain over several weeks
Difficulty weight bearing
Unilateral
Who gets ITOH?
Males>Females
Middle aged men
heavily pregnant women
How is ITOH diagnosed?
Elevated ESR Radiographs -Osteopaenia of head and neck Thinning of cortices Preserved joint space MRI (golden) Bone scan
How is ITOH treated?
Self-limiting
6-9 months to resolve
analgesia
Protected weight bearing to avoid stress fracture
What is Trochanteric bursitis?
Repetitive trauma caused by iliotibial band tracking over trochanteric bursa
Causes inflammation of the bursa
Who gets trochanteric bursitis?
Females
Young runners
Older patients
How does trochanteric bursitis present?
Pain on the lateral aspect of hip
Pain on palpation of greater trochanter
How is trochanteric bursitis?
Clinical diagnosis
Radiographs usually unremarkable
visible on MRI but not usually needed
how is trochanteric bursitis treated?
Analgesia NSAIDs Physiotherapy Steroid injection No proven benefit from surgery
What can cause OA?
DDH SUFE Septic arthrits AVN FAI Trauma
What is OA of the hip?
Degenerative disease of the synovial joints that cause progressive loss of articular cartilage
Inflammatory changes in the capsule leading to thickening and tightness
Who gets OA of the hip?
Females>Males
Older age
Genetics
Pre-existing hip disease
What does OA of the hip present with?
Groin pain Worse on activity Pain at night Start up pain Stiff on testing ROM
How is OA assessed?
Level of symptoms and impact on quality of life
Medical comorbidities
Social history
Do they want history
How is OA diagnosed?
Radiographs Loss of joint space Osteophyte formation Subchondral Cysts Subchondral sclerosis
How is OA managed?
Analgesia Weight loss Walking aids Physiotherapy if weakness identified ?Steroid injections Total hip arthroplasty
What surgical planning should be done for OA?
Centre of rotation -High or Low Leg length Offset - distance between centre of femoral head and the greater trochanter Canal width
What are the steps in the preparation of a total hip arthropasty?
Discussion of management with patients Indication - pain Consent - benefits/risks Approach - Posterior, Anterolateral, Anterior Prosthesis choice - Cemented Uncemented Hybrid Bearing choice - Metal on poly, Ceramic on poly, ceramic on ceramic
What are the benefits of a total hip arthroplasty?
Pain relief and secondary improvement of function
What are the risks of a total hip arthroplasty?
Scar, bleeding, neurovascular injury, fracture, clotting, infection, dislocation, leg length discrepancy, loosening
What is a hybrid THA and who is it used in?
Uncemented cup Press fit Biological fixation Cemented stem Cone-in-a-cone Younger patients
What is a cemented THA and who is it used in?
Cemented cup Mechanical look Cemented stem Cone-in-a-cone Older patients
What is bone cement and how does it work?
PMMA
Interdigitation into bone surface
