Adult Hip Conditions and Surgery Flashcards
What occurs in femoroacetabular impingement syndrome (FAI)?
Altered morphology of the femoral neck and/or acetabulum
Causes abutment of the femoral neck on the edge of the acetabulum during movement (flexion, adduction, rotation)
What are the two types of deformity that can occur in FAI?
CAM type impingement and pincer type impingement
What are some features of CAM impingement in FAI?
Femoral deformity = asymmetrical femoral head with decreased head:neck ratio
Usually young athletic males
Can be related to previous SUFE
What are some features of pincer type deformity in FAI?
Acetabular deformity = acetabular overhang
Usually seen in females
What can both types of deformities present in FAI lead to?
Labrum damage and tears
Cartilage damage
Osteoarthritis in later life
What is the presentation of FAI?
Activity related pain in groin (particularly in flexion and rotation)
Difficulty sitting
C positive sign
FADIR provocation test positive
How may FAI be diagnosed?
Radiographs, CT, MRI (best for visualising damage to labrum and bony oedema)
What are the management options for FAI?
Observation in asymptomatic patients
Arthroscopic or open surgery to remove CAM/debride labral tears
Peri-acetabular osteotomy/debride labral tears in pincer type impingement
Arthroplasty in older patients with secondary OA
What is avascular necrosis?
Failure of the blood supply to the femoral head
What causes most cases of avascular necrosis?
Most are idiopathic in origin
What occurs in the pathogenesis of idiopathic avascular necrosis?
Coagulation of intraosseous microcirculation
Venous thrombosis causes retrograde arterial occlusion
Intraosseous hypertension reduces blood flow
Necrosis of femoral head causing chondral fracture and collapse
What are some features of avascular necrosis?
More common in men, typical age is 35-50, 80% of cases are bilateral
What causes avascular necrosis associated with trauma?
Injury to femoral head blood supply (medial femoral circulation)
What are some risk factors for avascular necrosis?
Irradiation, trauma, haematological disease, hypercoagulable states, dysbaric disorders (Caisson disease), alcoholism, steroid use
How do patients with avascular necrosis present?
Insidious onset groin pain, exacerbated by stairs/ impact, examination usually normal unless disease has progressed to collapse/OA
How is avascular necrosis diagnosed?
Radiographs = often normal in early disease MRI = best option
How is avascular necrosis classed?
Reversible = Stage 0-II Irreversible = Stage III-VI
How is reversible avascular necrosis treated?
Bisphosphonates
Core decompression +/- bone grafting
Curettage and bone grafting
Vascularised fibular bone graft
What are some treatments for irreversible avascular necrosis?
Rotational osteotomy
Total hip replacement
What occurs in idiopathic transient osteonecrosis of the hip (ITOH)?
Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure
What are the presentations of ITOH?
Progressive groin pain over several weeks, difficulty weight bearing, usually unilateral
What are some features of ITOH?
More common in men overall
Two groups of common patients = middle aged men or pregnant women in the third trimester
How do you diagnose ITOH?
Elevated ESR
MRI = gold standard
Bone scan
Radiographs = osteopenia of head and neck, thinning of cortices, preserved joint space
How is ITOH managed?
Self limiting = resolves in 6-9 months
Analgesia and protected weight bearing to avoid stress fracture
How does trochanteric bursitis arise?
Repetitive trauma caused by iliotibial band tracing over trochanteric bursa = causes inflammation of the bursa
Who gets trochanteric bursitis?
Female patients, young runners, older patients (may be linked to gluteal cuff syndrome)
How does trochanteric bursitis present?
Pain on lateral aspect of hip and on palpation of the greater trochanter
What are some imaging techniques used to diagnose trochanteric bursitis?
Radiographs = usually unremarkable MRI = May be visible but not usually needed
How is trochanteric bursitis treated?
Analgesia, NSAIDs, physio, steroid injection
No proven benefit from surgery
What are some pathologies that cause secondary osteoarthritis?
DDH, SUFE, septic arthritis, AVN, FAI, trauma
What is primary osteoarthritis?
Osteoarthritis with no precipitating cause
What is osteoarthritis?
Degenerative disease of the synovial joints that causes progressive loss of articular cartilage
What does inflammatory changes in osteoarthritis cause in the joint?
Thickening and tightness
What is the epidemiology of osteoarthritis?
More common in females, usually older patients, has genetic element, common with pre-existing hip disease
How may osteoarthritis present?
Groin pain, worse on activity, pain at night, stiff on testing ROM, start up pain
What is assessed in a patient with suspected osteoarthritis?
Level of symptoms and impact on quality of life
Medical comorbidities
Social history
Does the patient need surgery?
What are some features of osteoarthritis radiographs?
Joint space narrowing, subchondral sclerosis, osteophytes, cysts
What are some treatments for osteoarthritis?
Analgesia, weight loss, walking aids, physio if the patient has weakness, steroid injections, total hip arthroplasty
What are some things that must be considered when planning osteoarthritis surgery?
Centre of rotation (low/high)
Leg length discrepancy
Offset
Canal width
What is the indication for a total hip arthroplasty in osteoarthritis, and what are some benefits of the surgery?
Indication = pain Benefits = pain relief and secondary improvement of function
What are some risks associated with total hip arthroplasties?
Scarring, bleeding, neurovascular injury, fracture, clotting (DVT/PE), infection, dislocation, leg length discrepancy, loosening, ongoing symtpoms
What are the different bearing choices and approaches for total hip arthroplasties?
Bearing choices = metal-on-poly, ceramic-on-poly, ceramic-on-ceramic
Approaches = anterior, anterolateral, posterior
What are the different choices of prostheses for total hip arthroplasties?
Hybrid, cemented and uncemented
What are some features of a hybrid prosthesis in a total hip arthroplasty?
Uncemented cup = press fit, biological fixation
Cemented stem = cone-in-a-cone
Used in younger patients
What are some features of a cemented prosthesis in a total hip arthroplasty?
Cemented cup = mechanical lock
Cemented stem = cone-in-a-cone
Bone cement = PMMA, works by interdigitation into bone surface
Used in older patients
