Adult Hip Conditions and Surgery Flashcards
what is the VITAMIN acronym and what does it stand for?
types of causes of disease V- vascular I - infective/inflammatory T - traumatic A - autoimmune M - metabolic I - iatrogenic/idiopathic N - neoplastic
what are the 3 layers of the femoral head?
hyaline cartilage
subchondral bone
cancellous bone
why is damage to hyaline cartilage dangerous?
because you cant make more
can form new fibrocartilage but its not as effective
what is femoroacetabular impingement syndrome?
altered morphology of femoral head and/or acetabulum
what does FAI cause?
abutment of the femoral neck on the edge of the acetabulum during movement - flexion, adduction and internal rotation
damage to labrum and tears
damage to cartilage
OA later in life
what are the 3 types of FAI?
CAM impingement
Pincer impingement
Mixed
describe CAM impingement
femoral deformity causing asymmetrical femoral head with decreased head to neck ratio
who is CAM impingement more common in?
young athletic males
related to previous SUFE
describe pincer impingement
acetabular deformity causing acetabular overhang
who does pincer impingement usually affect?
females
how does FAI present?
activity related pain in groin, esp in flexion and rotation
difficulty sitting
C sign positive
FADIR provocation test positive
how is FAI diagnosed?
radiograph
CT
MRI (better for damage to labrum and bony oedema)
how is FAI managed?
observed if asymptomatic
if symptomatic
- arthroscopic/open surgery to remove CAM/debide labral tears
- peri-acetabular osteotomy/debride labral tears in pincer impingement
- arthroplasty in older patients with secondary OA
takes around 6 weeks to heal
what is avascular necrosis?
failure of the blood supply to the femoral head
how does idiopathic ecrosis occur?
idiopathic
- coagulation in intraosseous circulation > venous thrombosis causes retrograde arterial occlusion > intraosseous hypertension (due to back pressure) > decreased blood flow to femoral head > necrosis of femoral head > chondral fracture and collapse
how does trauma cause avascular necrosis?
due to injury of femoral head blood supply - medial femoral circumflex
what are the risk factors for avascular necrosis?
males 35-50 irradiation trauma haematological disease or hypercoagulable states dysbaric disease alcoholism steroid use however most are idiopathic
how does avascular necrosis present?
insidious onset of groin pain
exacerbated by stairs or impact
normal examination (unless disease advanced to collapse/OA)
how is avascular necrosis diagnosed?
radiographs (can be normal in early disease)
MRI scan is best
what can be seen in MRI in avascular necrosis?
oedema etc
what are the 2 overall groups of avascular necrosis?
reversible - stages 0-2 - pre-subchondral collapse irreversible - stages 3-6 - post-subchondral collapse
how is reversible avascular necrosis managed?
bisphosphonates core decompression +/- bone graft curettage and bone grafting vascularised fibular bone graft rotational osteotomy
how is irreversible avascular necrosis managed?
total hip replacement
rotational osteotomy
what is idiopathic osteonecrosis of the hip (ITOH)?
local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure
how does ITOH present?
progressive groin pain over several weeks
difficulty weight bearing
unilateral
what groups does ITOH affect?
pregnant women
middle aged men
how is ITOH diagnosed?
elevated ESR
radiograph - osteopenia of head and neck, thinning of cortices, preserved joint space
MRI (gold standard)
Bone scan
how is ITOH managed?
self limiting in 6-9 months
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 is trochanteric bursitis typically seen in?
young active women - due to shape of pelvis runners older patients can be linked to gluteal cuff syndrome
how does trochanteric bursitis present?
pain on lateral aspect of hip
pain on palpation of greater trochanter
how is trochanteric bursitis diagnosed?
clinically
visible on MRI but not usually needed
how is trochanteric bursitis managed?
analgesia NSAIDs physiotherapy steroid injection no surgical benefit
what can cause OA?
end point for many pathologies
- DDH
- SUFE
- septic arthritis
- AVN
- FAI
- trauma
- many more
is there always a cause for OA?
no
can be idiopathic
what is OA?
degenerative disease of synovial joints that causes progressive loss of articular cartilage
inflammatory changes in capsule lead to thickening and tightness
who does OA usually effect?
females
older age
genetic
pre-existing hip disease (can cause earlier onset)
how does OA of the hip present?
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 life
comorbidities (can they cope with surgery?)
social history
would they like surgery?
how is OA diagnosed?
radiographs
- loss of joint space
- osteophytes
- subchondral sclerosis
- subchondral cysts
how is OA managed?
analgesia weight loss walking aids physio if there's weakness steroid injections in some total hip arthroplasty
what must be considered when planning for total hip arthroplasty?
centre of rotation - high or low?
leg length discrepancy
offset (distance between centre of the femoral head and the greater trochanter)
canal width
what are the steps in a total hip arthroplasty?
discussion with patient (only used for pain, not stiffness etc)
obtain consent by giving benefits and risks
choose approach - anterior, posterior, anterolateral
prosthesis choice - cemented, uncemented, hybrid
bearing choice - metal on poly, ceramic on poly, ceramic on ceramic
what are the risks of total hip arthroplasty?
scars bleeding NV injury fracture clotting infection dislocation leg length discrepancy loosening ongoing symptoms
what is a hybrid total hip arthroplasty and when is it used?
uncemented cup(biological fixation) with cemented stem (cone in a cone) used in younger patients
what is a cemented total hip arthroplasty and when is it used?
cemented cup (mechanical lock) with cemented stem (cone in a cone) used in older patients
