Degenerative hoftelidelser og hoftedysplasi Flashcards
Ikke traumatiske hoftelidelser hos voksne
Degenerative / inflammatoriske lidelser *
Følger efter børnesygdomme
Medfødte lidelser *
Impingement tilstande - labrumskader *
Bløddelsproblemer: Bursitis trochanterica, springhofte *
Infektiøse lidelser
Knogle nekrose
Neurologiske lidelser: parese- spasticitet
Tumores
Symptomer ved hoftelidelser
Smerter / ømhed
Klik
Aflåsning, svigt
Udtrætning
Nedsat bevægelse
Nedsat funktion: ADL
Gang, løb, cykling,
svømning, golf,
anden sport, etc
Tab af arbejdsevne
Nedsat livskvalitet
- Anamnesen skal give anledning til tentative diagnoser, der afprøves ved den objektive undersøgelse
og ved parakliniske undersøgelser
Tænk på differentialdiagnoser im. hoftelidelser
Rygsygdomme
Arteriel insufficiens
Hernie
Abdominalt / Gynækologisk
Inflammatoriske lidelser
Symptomatologien ved hoftelidelser?
Hoftesmerter/ømhed
- Hvor er
hoftesmerter
lokaliseret ?
- Lyske
- Trochantor
major
- Sæde region
- Lår
- Knæ
- Crus
- Karakte?
- Pludselige uden
traume? - Natlige?
- Hvile eller
belastnings
relaterede
smerter? - Uprovokerede?
- Bedst i
bevægelse? - Smerte triade?
- Igangsætnings
smerter - Smertefri
periode - Tilbagevende
af smerter
- Igangsætnings
- Pludselige uden
Smerte score: VAS, Verbal rating scale (VRS)
Den objektive undersøgelse af hoften
Gangfunktion
Patienten stående
Patienten liggende
- Den objektive undersøgelse skal være fokuseret
Billeddiagnostiske undersøgelser af hofter
Rtg.
Forskellige projektioner
Kunstigt hofteled:
Total hoftealloplastik
Indikation
Billeddiagnostisk
udredning
Protesekoncepter
Komplikationer
Indikation total hoftealloplastik
Smerter
- Udbydes
Nedsat funktion
Nedsat livskvalitet
Ikke kirurgisk behandling
Behandling af hofter
Afhænger af smerteintensitet. Ved slemme smerter overvejer man superviseret kirurgi og non kirurgiske interventioner så som injektioner, NSAID, fysioterapi osv.
Hos de mere milde cases anbefaler man selvhjælp, simple analgesics, topicale agenser, livsstilintenvention og nutraceuticals og ellers information og råd, dannelse i god livsstil osv. Alle får sidstnævnte form for hjælp.
Ikke operativ behandling af hofte
Effekt af træning
- Artrose skole /
information
- Træning og
bevægeapparatslidelser - Træning og operation
Ændret fysisk aktivitet
Glucosamin til hoftelidelser
Glucosamin virker ikke ved smerter forårsaget af hofteartrose
Smertestillende medicin ved hoftelidelser
Paracetamol
Acetylsalicylsyre
NSAID
Morfica
Blokade behandling ved hoftelidelser
10 ml 2% lidocain intraartikulært
Depomedrol 40 mg
Adgang: lateral vejledt af ultralyd/røntgengennemlysning
Protesekoncepter til hoftelidelser
Ucementeret: < 70 år
Cementeret: > 70 år
Hybrid: Særlig indikation
Ucementeret:
- Umiddelbar
mekanisk
fiksation
- Efterfølgende
biologisk
forankring
Cementeret:
- Umiddelbar
fiksation ved
cementen
Komplikationer ved hoftealloplastik
Tidlige:
- Benlængde forskel
- Nervepåvirkning
(peroneus)
- Infektion
(overfladisk og
dyb): <1%
- Luksation (Bagud
og fremad): ca. 1-5
%
- Trombose - emboli
- Fraktur
(Peroperativ): ca. 1%
Sene:
- Aseptisk løsning
- Slid af
komponenter
- Infektion (Dyb)
- Luksation
- Fraktur
Causes for recurrent hip dislocation
Primary total hip alloplastia (THA)
Treatment of recurrent THA dislocation
Conservative procedures:
- Instructions in
relevant
precautions
- Aids and orthoses
Type B. Fracture around stem or just below the tip of the stem
B2: loose stem, adequate bone stock
B2: loose stem, adequate bone stock
Hoftedysplasi
Acetabular dysplasia
Acetabular hip dysplasi - definition?
Steep roof (sourcil):
AIA - angle
Abnormal: Steeper than 10 degrees
Reduced lateral coverage of the femoral head:
CE - angle
Abnormal: less than 20-25 degrees
Acetabular hip dysplasi - ætiologi?
Congenital genuin idiopathic dysplasia
Secundary
- Congenital hip
dislocation
- Calve-Legg-
Perthes
- Epiphysiolysis
- Fracture in child
- Other
Acetabular hip dysplasi - epidemiologi?
Radiological : CE<20
Prevalence:
App. 5 % in Denmark
Female / male = 1/1
Bilateral in 50 %
Prognosis for untreated acetabular hip
Patients with hip dysplasi has a know predictable risk of developing osteoarthritis untreated (CE<20)
Why should joint preserving surgery be
considered?
Total hip replacement is associated with increase risk of reoperation in younger patients
Total hip replacement is associated with increase risk of reoperation in younger patients: Danish Hip Arthroplasty Register
Hip survial ; 1. time revision all causes
Hip dysplasia: The diagnose
- Patient history
- Physical
examination - X-ray
Patient historie:
- Suspect hip
dysplasia in
younger patients
and patients without
osteoarthrosis
- Do not trust
radiologists or other
colleagues - You have to know
what you are
looking for
Hip dysplasia, typical patient history?
Debut: 30 (15-60) years of age
Pain
- Activity: Mild groin
pain; C-sign- later
severe pain- VRS
5-8 (0-10))
- Weakness in the
end of the day
- Sharp pain in the
groin (labrum)
- Later pain during
rest and night
Other symptoms:
- Click, locking or
sensation of giving
way (labrum)
Reduced level of activity:
- Jogging, hiking,
soccer, shopping
Sick leave
Reduced quality of life
Hip dysplasia - Physical examination
ROM: Normal or hyper-mobility
Apprehension: positive in some cases:
Apprehension
Extended hip-
external rotation
Impingement: low diagnostic validity:
Flexed – adducted
hip- internal
rotation
Hip dysplasia: X-ray
AP of the pelvis
Rule out for osteoarthrosis:
- AP of the hip
- False profile
- CT/MRI
Hip dysplasia - Treatment
Non-surgical
No validated exercise program Pain killers
Reduced activity level
Many patients say
“I can live with it”
Hofte dysplasi - Indication periacetabular osteotomy
Patient history:
- Pain: VRS score
- Reduced function
- Reduced quality
of life.
Physical examination:
- Free range of
motion
Radiology:
- Acetabular
dysplasia (CE < 25
and AA > 10)
- No osteoarthritis
- Joint congruency :
x-ray abduction
view
Age?
Periacetabular osteotomy?
Operationen: Røntgen-gennemlysning, snit i lysken
Standard osteotomy
Femuro-Acetabular Impingement definition
Impingement occurs between acetabulum/labrum and the femoral head-neck junction
Typer af impingement?
Normal
Pincer
CAM
CAM+pincer
CAM - Ætiologi? Og hvad står CAM for?
Dutch word meaning “cog” (tak på tandhjul))
- Abnormal femoral head radius
- Low head neck offset (predisposing)- Pistolgrip
Pincer (Knibtang/To pinch (knibe)), ætiologi?
Acetabular retroversion
Acetabular protrusion & profunda
Local increased anterior coverage
Acetabular retrovertion - definition og ætiologi?
Definition:
- Posterior oriented
opening of
acetabulum.
Ætiologi:
- Congenital and
developmental
dysplasia.
- Alone or in
combination with
general hip
dysplasia - Posttraumatic
CAM - epidemiologi?
Overall prevalence approximately 17 % in men and 4 % in women
Epidemiology: Retroverted acetabulum
Of the 201 hips with a cam-impingement deformity, 42% (84) had also a
pincer deformity (retroverted acetabulum)
Significance of impingement
Increased risk of osteoarthrosis.
“The role of acetabulum geometry and femoral head-neck ratio in the development of osteoarthritis in young men”
femuro-acetabular impingement - symptomer?
Symptoms, slow onset:
- Pain
- Reduced level of
activity
- Reduced quality
of life
femuro-acetabular impingement - symptoms, pain?
Groin pain
Greater trochantor
Gluteal region
Pain following physical activity
Pain following or during sports
Pain at rest
Pain at stair climbing
Pain when sitting in deep/low chairs
femuro-acetabular impingement - symptoms, Reduced level of activity
Fittness
Running
Handball
Soccer
Tennis
Etc.
femuro-acetabular impingement - symptoms, Reduced quality of life
EQ-5D
Self reported health-related quality of life
Five dimensions:
1. mobility
2. self-care
3. usual activities
4. pain/discomfort
5. anxiety/depression
Femuro-acetabular impingement - Clinical findings
Positive impingement test
Reduced range of motion: flexion
Asymmetry
Radiological evaluation: CAM
Alm. rtg.us:
Bækken og hofte incl. axial(lat.)opt.
Lauenstein
The retroverted acetabulum in femoro-acetabular impingement
Radiological findings?
Cross-over / figure of eight sign
Posterior wall sign
Ischial spine sign
–> CT-scanning
Opening
posterior
Treatment Impingement
Non-surgical:
- Patient information
and education
- Modification of
activity
- Avoidance of
symptomatic
motion
- Exercise
Surgical:
Surgical treatment
Impingement - indikation?
Persistent pain
Reduced range of motion
Positive impingement test
No or slight osteoarthrosis
Clear radiologic diagnose
Willingness to undergo surgery
Treatment CAM
Open
Arthroscopically
Periacetabular osteotomy of the retroverted acetabulum in femoro- acetabular impingement
Standard osteotomy
+ wedge osteotomy on illium
Reorientation
- Flexion
- Internal rotation
Klik / spring ved hofteleddet - årsager?
Externe :
- tractus iliotibialis :
coxa saltans
- bursitis
trochanterica
- gluteus maximus
Interne:
- iliopsoas senen
- tenosynovitis
- caput longum
biceps
Intraarticulære:
- Labrum
- mus
- synovitis
- chondromatose
- lig. iliofemorale
Instabilitet:
idiopatisk dynamisk subluksation
DIAGNOSE: COXA SALTANS OG STRAM TRACTUS
KLINISKE BILLEDE
Obers test for stram tractus iliotibialis
1) Sidelejr
2) Flektion
3) Abduktion
4) Ekstension
5) Adduktion
Test positiv:
Syge side kan ikke adduceres til lejet,
men forbliver passivt abduceret
BEHANDLING COXA SALTANS OG STRAM TRACTUS - ikke operativ
Fjerne udløsende faktorer
Udstrækningsøvelser
Smertestillende medicin
Steroid-Blokade
BEHANDLING COXA SALTANS OG STRAM TRACTUS - operativ
Z- plastik
Fjernelse af bursa
Procedure: Z-plastik
1) Longitudinel hud incision
2) Longitudinel incision i tractus iliotibialis
3) Z:
Proximale ben af z: distalt anteriort
Distale ben af z: proximalt posteriort
4) Lapperne løsnes, mobiliseres og sutureres
Procedure Z-plastik - Efterbehandling?
Mobilisering med to krykkestokke med fuld
belastning
Ingen aktiv abduktions træning i 6 uger
Sport og evt. udstrækning efter ca. 3 måneder
Operation for intern springhofte
Tenotomi af psoassenen
Postoperativt:
- Fuld belastning
- Fri bevægelighed
- Træning gradvis
øget aktivitet og
styrke over 6 mdr.
