Hip orthopaedics and trauma Flashcards
What can cause secondary osteoarthritis in the hip?
Trauma
AVN
DDH
Perthes disease
SUFE
Where might hip pain present?
Pain in groin, anterior or lateral thigh
Referred pain in the knee
Pain at night
Limp
Stiffness (morning - RA)
Reduced walking distance
For most patients, what are the indications for total hip replacement?
Severe pain and disability usually with accompanying radiological changes at the hip, in patients where non-operative treatment has failed or is futile
Why is total hip replacement not favoured in younger patients?
Increased risk of loosening
Increased risk of osteolysis
What other treatments might be considered in place of total hip replacement in a younger patient?
Osteotomies of pelvis and/or femur
Hip resurfacing
Arthrodesis (with ORIF)
Vascularized fibular graft in early AVN
What are some of the symptoms of hip osteoarthritis?
Pain in the hip joint that may include pain in the groin, outer thigh, or buttocks
Difficulty walking or walking with a limp
Pain that worsens with vigorous or extended activity
Stiffness in the hip or limited range of motion
What are some of the symptoms of hip rheumatoid arthritis?
Pain in the hip joint that may include pain in the groin, outer thigh, or buttocks
Difficulty walking or walking with a limp
Stiffness in the hip or limited range of motion
Bilateral involvement
Small joints (hands, cervical spine) involvement
How do patients with avascular necrosis tend to present?
Groin pain
What can avascular necrosis of the femoral head be secondary to?
Alcohol abuse
Hyperlipidaemia
Thrombophilia
Which form of imaging might be required to show early changes due to avascular necrosis?
MRI
What does this image show?
Femoral head removed during total hip replacement with a loose flap of cartilidge (osteochondritis dessicans) due to avascular necrosis
What are the two main causes of hip impingement?
Deformity of head of femur
Deformity of acetabulum
What are the symptoms of hip impingement?
Stiffness in groin or front of thigh
Loss of full range of motion of hip
Pain near limit of movement of hip
What is bone marrow oedema syndrome?
Transient osteoporosis
How might bone marrow oedema syndrome of the hip present?
Worsening hip pain - worse on exercise
Usually unilateral
What radiological changes occur in bone marrow oedema syndrome?
Osteoporotic changes on Xray
Bone inflammation on MRI
Which patients tend to be affected by bone marrow oedema syndrome?
Middle aged men
Women in third trimester of pregnancy
What is the treatment for transient osteoporosis?
Painkillers
Bisphosphonates
(Self-limiting)
What kinds of hip impingement are there?
What is trochanteric bursitis?
Painful inflammation of the bursa just superficial to the greater trochanter
What is snapping hip syndrome?
A condition characterized by a snapping sensation felt when the hip is flexed and extended, which may be associated with an audible snap or pain
Which type of snapping hip syndrome is more common?
Lateral extra-articular, involving the snapping of the iliotibial band, the tensor fascia lata or the tendon of the gluteus medius sliding back and forth over the greater trochanter
What can untreated snapping hip syndome lead to?
Bursitis
Effusion/inflammation of the area
Muscle trauma
What is the pain associated with trochanteric bursitis/gluteal cuff syndrome?
Patients have pain and tenderness in the region of the greater trochanter with pain on resisted abduction
What is gluteal cuff syndrome?
Tearing, inflammation and degradation of the tendons of the abductor muscles, particularly gluteus medius, due to the immense strain they are under
What are the treatments avaliable for trochanteric bursitis/gluteal cuff syndrome?
Anti-inflammatories
Analgesia
Physiotherapy
Steroid injection
What is the treatment for avascular nercosis?
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
Post-collapse: total hip replacement
What is the difference between total hip arthroplasty (THA) and total hip replacement (THR)
THA encompasses procedures such as hip resurfacing
Which total hip replacement is the ‘gold standard’ to which all other results must be compared?
Cemented metal/polyethylene THR
How long are hip replacements expected to last in a low demand older patient?
Cup - 15 years
Stem - 20 years
Why does loosening of hip replacements occur?
Wear particles from the bearing surface cause an inflammatory response at the implant-bone/cement-bone interface
Macrophages ingest microscopic wear particles and release inflammatory mediators resulting in osteoclastic bone resorption
Why are ceramic hip replacements widely used?
Favourable friction properties
What problem was caused in a small number of metal-on-metal hip replacements?
There was a reaction to metal debris resulting in the formation of an inflammatory pseudotumour which can cause necrosis of muscle and bone
What are the early local complications of hip replacement?
Infection
Dislocation
Nerve injury (sciatic nerve)
Leg length discrepancy
What are the late complications of a total hip replacement?
Early loosening
Late infection (haematogenous spread from a distant site)
Late dislocation (due to component wear).
What are the extra risks associated with a revision hip replacement?
Bigger, more complex surgery
Substantial blood lose
Double the complication rate as primary procedure
Poor functional outcome
Which acetabulum fracture is associated with hip dislocation?
Posterior wall - this is fractured as the head of the femur is pushed through the wall
What kind of injury in which patient is the most common for acetabulum fractures?
High energy injury, young patients
Can be low energy injury in older patients
What radiological investigations should be requested for an acetabulum fracture?
X-rays - oblique view may help as fracture can be hard to see on AP
CT scan - essential for surgical planning
How is acetabulum fracture treated?
Undisplaced or small wall fractures can be treated conservitively
Displaced or unstable fractures must be treated with anatomic reduction and rigid fixation to prevent development of OA in a younger patient
THR can be considered in older patients
Which condition are hip fractures generally associated with in the aging population?
Osteoporosis
Which is the most common kind of patient to present with hip fracture?
Over 80 years old
Female
Co-morbidities (cerebrovascular insufficiency, cardiac arrhythmias, postural hypotension etc.) which contribute to falls
Which complications are common following surgical fixation of a fractured hip?
Chest infections
Respiratory failure
MI
Acute renal failure
DVT
What is the mortality rate one year after fixation of a hip fracture?
30%
What are the two broad classifications of hip fracture and what is the relevance of this classification?
Intracapsular
Extracapsular
Related to the blood supply: describes the liklihood of disruption to the femoral blood supply
Which kind of hip fracture can disrupt the arterial supply of the femoral head?
Intra-capsular
What is the best treatment for intracapsular hip fractures?
Femoral head replacement due to disruption to the arterial supply: either hemi-arthroplasty (replacing just the femoral head) or THR
In which patients is an intracapsular hip fracture best treated with a hemi-arthroplasty?
Impaired cognitive function
Restricted mobility
This is due to greater risk of dislocation with THR
What is the best treatment for extracapsular hip fracture?
Internal fixation: compression or dynamic hip screw
What is a dynamic hip screw?
This consists of a large screw, inserted into the femoral head across the fracture line, and a plate with a barrel which engages with the lateral end of the screw and is fixed to the femoral shaft
As the patient weight bears, the screw is allowed to slide in the barrel of the plate, which results in compression at the fracture site which promotes fracture healing
What are the associated complications with intracapsular fracture?
Avascular necrosis
Non-union
What is the best treatment for subtrochanteris proximal femoral fractures?
Intramedullary nail - avoids further disruption to blood supply
