Hip Flashcards
Hip pathology
typically produces pain in the groin which may radiate to the knee (due to the obturator nerve supplying both joints and referred pain).
may also result in buttock pain however lumbar spine and SI joint problems can also give rise to buttock pain.
can also present purely with knee pain, particularly in SUFE.
Hip examination
Examination may reveal a reduced range of motion with loss of internal rotation usually the first sign.
Pain may be exacerbated by rotational movements.
positive Trendellenburg sign/ Trendellenburg gait.
may manifest as altered hip biomechanics or weakness from chronic disuse, abductor weakness (gluteus medius & minimus)
Shortening of the lower limb
seen in severe OA, Perthes, SUFE or AVN (or fracture).
Groin pain
due to a hernia (inguinal or femoral)
tendonitis (especially adductor tendoinitis)
pubic symphysis dysfunction
a high lumbar disc prolapse (with L1/2 radiculopathy but this is very rare).
Total Hip Replacement (THR)
“low friction arthroplasty” used a stainless steel stem with a small head (to reduce wear) and a high density polyethylene cup with both components being cemented in place using a bone (PMMA)
THR remains the “gold standard” against which all other THA results must be compared.
implications of performing THR in younger patients
higher risk of requiring revision surgery later in life as they will put more demand on their prosthetic hip than an elderly patient and they have a longer life expectancy.
This is the rationale behind delaying surgery for as long as possible however if the patient’s pain and disability is severe, hip replacement in the younger patient may be justified.
Total Hip Arthroplasty (THA)
THA will ultimately fail as a result of loosening of one or both of the prosthetic components.
In a low demand older patient, one can expect the cup of a hip replacement to last around 15 years and the stem to last over 20 years before failure from wear or loosening.
Less than 5% of implants loosen before ten years.
THA descion & conservative measures
The decision to undergo THA is dependent on the level of pain and disability which the patient experiences.
Conservative measures include simple analgesics, physiotherapy, use of a stick (which reduces the joint force by 15%), weight reduction and modification of activities.
If conservative measures are failing to control symptoms, THA may be considered.
Early complications
infection, dislocation, nerve injury (sciatic nerve) and leg length discrepancy.
Early general complications include medical complications from surgery (MI, chest infection, UTI, blood loss & hypovolaemia) as well as deep vein thrombosis and pulmonary embolism (around 0.5% incidence).
Revision hip replacement
hip replacement has failed, it can be re‐done (known as a revision hip replacement) however this involves bigger and more complex surgery than a first time (primary) procedure with often substantial blood loss, around twice the complication rates and often poorer functional outcome.
Tend not to last as long as primary hip replacements.
Late complications
early loosening, late infection (haematogenous spread from a distant site) and late dislocation (due to component wear).
AVN
hip joint is one of the commonest sites of AVN which as previously discussed may be primary / idiopathic or secondary to alcohol abuse, steroids, hyperlipidaemia or thrombophilia.
AVN symptoms & investigation
patients tend to present with groin pain.
Early cases may only show changes on MRI (pre‐radiographic AVN) whilst later cases show patchy sclerosis of the weight bearing area of the femoral head with a lytic zone underneath formed by granulation tissue from attempted repair.
The lytic zone gives rise to the classic “hanging rope sign” on Xray.
The femoral head may then collapse with irregularity of the articular surface and subsequent secondary OA.
AVN treatment
If the condition is detected early enough (pre‐collapse), drill holes can be made up the femoral neck and into the abnormal area in the head in an attempt to relieve pressure (decompression), promote healing and prevent collapse.
Once collapse has occurred, the only surgical option is THR.
Trochanteric bursitis / gluteal cuff syndrome
The broad tendinous insertion of the abductor muscles (predominantly the gluteus medius) is under considerable strain and is subject to tendonitis and degeneration leading to tendon tears.
The trochanteric bursa can also become inflamed. The condition is similar to rotator cuff problems of the shoulder.
Trochanteric bursitis / gluteal cuff syndrome Symptoms
Patients have pain and tenderness in the region of the greater trochanter with pain on resisted abduction.
Trochanteric bursitis / gluteal cuff syndrome Treatment
analgesic, anti‐inflammatories, physiotherapy (to strengthen other muscles and avoid abductor weakness) and steroid injection.
No surgical treatment has a proven benefit.
