Intra-Articular Disorders of the Hip

Question 1

What is the most common cause of hip pain in adults?

Answer 1

Hip Osteoarthritis

Question 2

What defines primary and secondary hip OA?

Answer 2

Primary: Idiopathic

Traumatic- Secondary: as a result of trauma or congenital abnormalities altering biomechanics

Question 3

What are some of the congenital abnormalities altering biomechanics of the hip?

Answer 3

• Hip Dysplasia
• Shape of the femoral head
• Leg-Calve-Perthes disease
• Congenital Dislocation
• Slipped Capital Femoral Epiphysis
• Leg Length Discrepancy

Question 4

What is the clinical presentation of hip OA?

Answer 4

Moderate- Lateral or Anterior hip pain with weight bearing.
Can progress to anterior thigh or knee region.
Adults greater than 50 years of age.
Limited passive ROM in at least 2 of 6 directions. Morning hip stiffness that improves in less than one hour.

Question 5

Hip Pain Referral Patterns

Answer 5

Hip joint innervation: obturator, femoral, sciatic nerves

Question 6

Intra articular hip disorders referred to where the most?

Answer 6

Buttocks then anterior thigh, then groin.

Question 7

Altman’s criteria for Hip OA Cluster 1 , Cluster 2

Answer 7

Cluster 1: Hip Pain, hip int rot 15 deg . –> Painful hip int rot, >50 years of age, hip stiffness

Question 8

Birrell’s Criteria for Hip OA:

Answer 8

ER

Question 9

Sutlive’s Criteria for hip OA- Unilateral hip pain

Answer 9

1) Self reported squatting aggravating factor
2) Active hip Flexion causing lateral hip pain
3) Scour test causing lateral hip or groin pain
4) Active hip extension causing pain
5) Passive hip internal rot

Question 10

Examination of Hip OA: What to look for in a gait analysis?

Answer 10

Antalgic Gait
Excessive lumbar lordosis in terminal stance
Lurching or leaning of trunk toward the affected side
Positive Trendelenberg

Question 11

HIP OA: What happens to their hip joint ROM?

Answer 11

Decreases particular the hip flexors. Assess mobility

Question 12

HIP OA: Decrease hip joint muscle strength and endurance

Answer 12

Measure hip abductors especially

Question 13

What are 2 self reported outcome measures to use?

Answer 13

WOMAC and LEFS

Question 14

LEFS?

Answer 14

Lower Extremity Function Scale. Score from 0-80

Question 15

WOMAC

Answer 15

24 question western ontario and McMaster OA Index. 5 pain , 2 stiffness, 17 physical function

Question 16

Functional Tests for HIP OA:

Answer 16

6 Minute Walk, TUG, Self Paced Walk Test

Question 17

Which bone is affected by Osteonecrosis?

Answer 17

Trabecular bone in the femoral head

Question 18

How can osteonecrosis occur?

Answer 18

Trauma to the femoral head.
Neck fracture. Femoral head dislocation.
Patients with history of alchohol abuse or corticosteroid abuse.
Sickle Cell Disease

Question 19

Vasculitis is what?

Answer 19

Inflammation of blood vessels

Question 20

What causes vasculitis?

Answer 20

Inflammatory arthropathy:

SLE, Rheumatoid Arthitis

Question 21

Osteonecrosis: is most common in which age range

Answer 21

30-50 years old.

Question 22

Clinical Presentation in History of Osteonecrosis:

Answer 22

Onset of pain gradual in onset and duration.
Can begin suddenly with collapse of femoral head.

Can report dullache of throbbing pain in groin, lateral to hip, or in buttock.

Pain can radiate into thigh and upper knee region.

Initially hip range of motion minimally effected although pain substantial.

Question 23

Management for Osteonecrosis:

Answer 23

NSAIDS= pain relief
Ambulation with an assistive device.
Total Hip Arthroplasty.

Question 24

Conservative management outcomes are very ____

Answer 24

Poor; unless it is Legg-Perthes disease in children. Leading to better outcomes with the younger the child.

Question 25

Hip Fractures: How many percent die in the following year? What is the cost per episode? In adults 85 or older, what percent will fracture hip? Twice as many fractures occur in _____ .

Answer 25

30% 40k$ 43.3% Twice

Question 26

Mechanism of hip fracture injury?

Answer 26

Caused by balance loss and twisting of LE on a fixated foot. High torque between femoral shaft and head leading to neck fracture.

Question 27

Femoral head can also be affected as a result of ________.

Answer 27

Osteoporosis.

Question 28

Clinical Presentation of hip fracture?

Answer 28

``` Inability to move after a fall. Severe pain in hip or groin. Inability to weight bear. Stiffness, bruising and swelling around hip. Apparent shortening of the LE. ```

Question 29

What examination would be ideal for a hip fracture test?

Answer 29

Patella-Pubic Compression Test

Question 30

Treatment options for hip fracture?

Answer 30

ORIF.

Question 31

Mortality rate for ORIF?

Answer 31

20-25%, up to 40-50%. Rehab needs to take place early.

Question 32

Subtrochanteric and intertrochanteric fractures have ____ prognosis compared to femoral neck fractures

Answer 32

Better

Question 33

Complications following ORIF?

Answer 33

``` Avascular Necrosis Infection Arthritis Dislocation Coxa Vara/Valgus Nail Penetration. ```

Question 34

THA incision length?

Answer 34

>10cm

Question 35

THA Anterolateral approach, between what 2 muscles and how is the hip dislocated?

Answer 35

Between TFL, Glute Med. Hip ABD released from greater Tro, hip dislocated anteriorly ( extension and ER)

Question 36

Posterolateral approach, how is hip disloacted.

Answer 36

Split Glute Max Short EXT ROT are cut and Glut Med retracted anteriorly. Hip dislocated posteriorly (flex, adducting, INT rot)

Question 37

Which THA procedure is best?

Answer 37

Doesnt matter. Evidence inconclusive.

Question 38

Cemented vs Cementless Fixation. Cemented survivorship. Cementless?

Answer 38

98% at 10 years, 93% 25 years Similiar to above numbers for femoral component but better prognosis with acetabular component at 15 years.

Question 39

Which THA technique is preferred? In younger.

Answer 39

Cementless. You can weight bear earlier in cementless. WBAT/FWB with assistive device.

Question 40

Which post THA complication is most worrisome?

Answer 40

DVT. 50-75% risk of DVT without action taken to prevent.

Question 41

Clinical detection of DVT:

Answer 41

Wells Criteria.

Question 42

Wells Criteria :

Answer 42

``` Localized tenderness along venous system. Entire LE swelling Calf Swelling > cm Pitting Edema Collateral superficial veins ```

Question 43

Prevention of DVT

Answer 43

Compressive Devices, TED HOSE, Anti coagulants. Ankle Pumps. Early mobilization.

Question 44

THA Precautions: Posterior Lateral

Answer 44

No hip flexion over 90. No hip IR past neutral No hip adduction past neutral

Question 45

THA precaution lateral

Answer 45

Varies by surgeon but avoid ER and extension.

Question 46

THA procedure?

Answer 46

Hip joint removed during surgery. Ligaments resected. Supporting musculature has trauma, after surgery joint very unstable.

Question 47

How long for a patient can maintain THA precautions.

Answer 47

6-12 weeks. Incidence of dislocation is reduced by 95% after 12 weeks.

Question 48

Long term impairments after THA (3 month mark)

Answer 48

``` Ant hip, groin pain, back pain. Decreases in endurance, strength, ROM/ flexibility Gait deviations Decrease balance Activity limitations. Leg Length Discrepancy ```

Question 49

What are some causes of leg length discrepancy

Answer 49

Improper stem length, hip muscle imbalance, muscle contracture, capsular tightness.