Adult Hip Conditions & Surgery Flashcards
What is the surgical sieve?
V: vascular I: infective/inflammatory T: traumatic A: autoimmune M: metabolic I: iatrogenic/idiopathic N: neoplastic
Name the layers of cartilage and bone usually found in the head of the femur
Hyaline cartilage
Subchondral Bone
Cancellous Bone
What condition is characterised by altered morphology of the femoral neck and/or acetabulum causing them to rub together on movement?
Femoroacetabular Impingement Syndrome
FAI
What movements does FAI specifically affect?
F - Flexion of hip
A - Adduction of hip
I - Internal Rotation of hip
remember this as its also FAI
What is the difference between a CAM femoroacetabular impingement and a Pincer impingement?
CAM = neck of femur has extra bone growing on outside causing deformity
Pincer = acetabulum has extra bone growing down towards femur causing the deformity
What type of FAI is most common?
Mixed CAM and Pincer Impingement
=> deformity in both femoral neck and the acetabulum
What type of FAI is more common in males?
CAM
Usually young athletic males
What can a CAM deformity in the femoral neck be related to in a patients history?
Previous Slipped Upper Femoral Epiphysis (SUFE)
What type of FAI is more common in females and why could this be?
Pincer Impingement
this is due to acetabular overhang/ an excessively deep acetabulum
=> females have wider hips and suffer from this deformity more
What do both types of FAI cause?
damage/ tears the labrum
damage to cartilage
osteoarthritis in later life
How do patients with femoroacetabular impingement usually present?
Activity related pain in the groin (especially on flexion and rotation) Difficulty sitting C sign positive FADIR provocation test positive
What methods of imaging are used in the diagnosis of FAI?
Radiographs
CT
MRI (better for visualising damage to labrum and bony oedema)
How is FAI managed?
Observation if asymptomatic
CAM and Pincer:
Remove excess bone deformity and debride labral tears
Joint replacement in Secondary OA
What is Avascular Necrosis (AVN) in the head of the femur?
Failure of the blood supply to the femoral head
What are the two types of AVN?
Idiopathic
Trauma-related
Describe the pathophysiology of idiopathic AVN
- coagulation of intraosseous microcirculation
- venous thrombosis causes retrograde arterial occlusion
=> intraosseous hypertension - decreased blood flow to femoral head
=> necrosis - chondral fracture and collapse
In traumatic AVN, what artery is usually compromised?
Medial Femoral Circumflex artery
How do patients with AVN often present?
- Insidious onset groin pain
- Exacerbated by stairs or impact
- Examination = usually normal
- *unless disease has advanced to collapse/OA**
What imaging methods are used in AVN, and what do they show?
Radiographs
(ALTHOUGH these = often normal in early disease)
MRI scan is most sensitive/specific
What sign of AVN in children (Perthe’s disease) can be seen on X-Ray ?
Hanging rope sign
Thin sclerotic line across femoral neck
How many stages of AVN have been identified? What range of these stages are reversible and irreversible?
Stages 0-VI
Stages 0-II = Reversible
Stages III-VI = Irreversible
How is AVN commonly treated?
Drilling into the femoral head to relieve pressure and restore blood flow
Bone grafting
Rotational osteotomy
Total Hip Replacement (THR)
What is Idiopathic Transient Osteonecrosis of the Hip (ITOH)?
- Local hyperaemia (excess blood in vessels)
- impaired venous return
- marrow oedema
- increased intramedullary pressure
How do patients with ITOH usually present?
- Progressive groin pain over several weeks
- Difficulty weight bearing
- Usually unilateral
Who is most likely to get ITOH?
Males > Females
2 groups:
- Middle aged men
- Pregnant women in third trimester
What investigations are used to diagnose ITOH?
Elevated ESR
Radiographs:
Lucent bone on X-Ray
Joint space = preserved
MRI (gold standard)
Bone scan
How is ITOH managed?
- Self-limiting condition that resolves in 6-9 months
- Analgesia
- Protected weight bearing to avoid stress fracture
What is trochanteric bursitis?
Repetitive trauma caused by IT band tracking over trochanteric bursa
=> causes inflammation
What type of patients usually present with trochanteric bursitis?
Female patients
Young runners and older patients
may be linked to gluteal cuff syndrome
How do patients with Trochanteric bursitis present?
Pain on the LATERAL ASPECT of the hip
Pain on palpation of greater trochanter
What imaging modalities are used in trochanteric bursitis?
Clinical diagnosis!!!
=> Radiographs usually unremarkable
Visible on MRI but not usually needed (expensive)
How is trochanteric bursitis usually treated?
Analgesia
NSAIDs
Physiotherapy
Steroid injection
No proven benefit from surgery!
What conditions can lead to potential secondary OA?
DDH SUFE Septic arthritis AVN FAI Trauma
What is osteoarthritis (OA)?
Degenerative disease of synovial joints
=> progressive loss of articular cartilage
Inflammatory changes in capsule lead to:
- thickening
- tightness
What type of people usually get osteoarthritis?
Female > Males
- older age
- Genetic element
- Pre-existing hip disease
How do patients with OA tend to present?
Groin pain Worse on activity Pain at night Start up pain Stiff on testing ROM
What should you asses
Level of symptoms and impact on quality of life
Medical comorbidities
Social history
WOULD THE PATIENT LIKE SURGERY?!
What is the management of osteoarthritis?
Analgesia Weight loss (decrease joint reaction force) Walking aids Physiotherapy if weakness identified Steroid injections THR
