Orthopaedic Hip Conditions Flashcards by Robbie Pollock

what are some common conditions of the hip?

Osteoarthritis

Bursitis (causes lateral hip pain) - Gluteal tendinopathy (differential diagnosis)

Avascular Necrosis (AVN)

Impingement

Labral Tear

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what make sup the pelvis?

Each hemipelvis = fusion of 3 bones (Ischium, Ileum and Pubis)

joined by Sacrum posteriorly and pubic symphysis anteriorly

Acetabulum - Socket

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Femur is long bone, what is its high clinical significance?

NoF

Bleeding

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what are the different parts of the femur and their function?

Head - Articulates with Acetabulum, Head covered in smooth hyaline cartilage and if damaged wont regenerate and beginning of arthritis

Neck - Blood supply

Greater Trochanter - Attachment for Abductors and Rotators (external)

Lesser trochanter - Attachment for Psoas

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what is the acetabulum?

Part of Pelvis

Cup-shape socket

Ligamentum teres in middle

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what is the labrum and its function?

Fibrocartilagious lining of acetabulum

Deepen socket

Add stability

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what is the blood supply?

Profunda femoris (branch of femoral)

Branches medial and lateral circumflex arteries

MFCA (Major contributor to femoral head) - 2 branches - Ascend to head and Transverse to form cruciate anastomosis

LFCA (lateral femoral circumflex artery) - 3 branches - Ascending branch to joint capsule, Transverse branch to cruciate anastomosis, Descending branch

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hwat are other minor contributors to the blood supply?

Artery of Ligamentum Teres

Nutrient Arteries of Bone (vessels in the femur so when fractured blood supply to head is disrupted

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where does the blood supply to the neck of the femur enter and what is its clinical significance?

Neck Of Femur - Primary blood supply enters via Capsule

Clinical Significance - Fracture Neck of Femur

Intracapsular Fracture = Blood supply disrupted

Extracapsular Fracture = Blood supply maintained

Anastomosis on the neck of femur and ascend to the head

Fractures out of the capsule don’t have risk of avascular necrosis

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13 muscles around the hip joint which do what actions?

Flexors

Extensors

Abductors

Adductors

Rotators

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what are bursae?

Fluid-filled sacs

Reduce friction between tissues

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what is osteoarthritis?

Degenerative change of synovial joints

Progressive loss of articular cartilage

Secondary bony changes

Can be primary or secondary (a pathology that’s caused damage)

Hip replacement is main treatment for people with bad arthritis

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how does osteoarthritis present?

Characterised by worsening pain and stiffness of the affected joint

Limiting everyday life

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what is Trochanteric Bursitis?

Trochanteric Bursa is a Fluid-filled sac that is Sandwiched between hip abductors and ITB

Bursitis - Inflammation of the bursa, Swelling

Epidemiology - Females > Males

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what are the causes of trochanteric bursitis?

Trauma

Over-use - Athletes, often runners, Repetitive movements

Abnormal movements:

Distant problem, e.g. Scoliosis
Local problem - Muscle wasting following surgery (so have to tense harder), Total Hip Replacement, Osteoarthritis

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what is the presentation of trochanteric bursitis?

Pain (well localised)

Point tenderness

Lateral hip

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what would be found on examination of trochanteric bursitis?

LOOK:

May have scars from previous surgery
May have muscle wasting - Gluteals

FEEL:

Tenderness at Greater Tuberosity

MOVE:

Worst pain in active abduction

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how do you investigate trochanteric bursitis?

X-ray - May be normal, OA, THR, Spine abnormalities

MRI - Shows soft tissues and fluid

Ultrasound - Can be therapeutic as well as diagnostic, Guided injection

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what is the treatment of trochanteric bursitis?

NSAIDs

Relative rest / Activity modification

Physiotherapy:

Correct posture, abnormal movements
Stretching
Strengthen muscles around joint

Injection - Corticosteroids

Surgery - Bursectomy (leaves scar which may be painful and not helpful, divide ITB aswell), Rarely required

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what is avascular necrosis?

Death of bone due to loss of blood supply

onset of hip pain

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what is the epidemiology of avascular necrosis?

Males > Females

Average age 35-50 years old

80% = bilateral (May be offset in time)

3% = multifocal (3 or more joints)

what are the risk factos for avascular necrosis? (trauma)

Irradiation

Fracture

Dislocation

Iatrogenic

what are the risk factos for avascular necrosis? (systemic)

Idiopathic

Hypercoaguable states

Steroids

Haematological - Sickle Cell Disease, Lymphoma, Leukaemia

Caisson’s disease (divers)

Alcoholism (commonest risk factor)

avascular necrosis can be caused by trauma to what area?

Injury to femoral head blood supply

Intracapsular fracture

Anastomosis of blood vessels around neck of femur

what is the process of avascular necrosis being caused by idiopathic?

Intravascular coagulation is the final common pathway Pathoanatomic cascade: Coagulation of intraosseous microcirculation = Venous thrombosis = Retrograde arterial occlusion = Intraosseous hypertension = Reduced blood flow to head = Cell death = Chondral fracture and collapse =

what ar ethe symptoms of avascular necrosis?

Insidious onset of groin pain Pain with stairs, walking uphill and impact activities Limp

what would be seen on examination of avascular necrosis?

Largely normal May replicate early arthritis: - Reduced range of motion (partic internal rotation) - Stiff joint

what imaging would be done for avascular necrosis?

X-Ray MRI: - 99% sensitive and specific - Will identify earliest changes - MRI shows where bone is affected so can help to plan treatment

what is the non-operative treatment of avascular necrosis? (First make diagnosis, then stop cause if possible)

Reduce weight-bearing NSAIDs Bisphosphonates - Early AVN, controversial Anticoagulants Physiotherapy - Maintain range of motion, Keep the ball round!

what is the surgical treatment of avascular necrosis?

Restore blood supply ## Footnote - Core decompression (drill hole in head to avascular area to reduce venous hypertension and to allow new blood supply to grow in and restore bone strength) - Core decompression and vascularised graft Move the lesion away from the weight-bearing area - Rotational Osteotomy (osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment) Total Hip Replacement

what is Femoroacetabular Impingement (FAI)?

Femoroacetabular impingement (FAI) is a condition in which extra bone grows along one or both of the bones that form the hip joint — giving the bones an irregular shape. Because they do not fit together perfectly, the bones rub against each other during movement 2 surfaces hitting together

what is the commonest cause of FAI?

Hip pathology in younger patient Secondary osteoarthritis

what are the different types of FAI?

Broadly divided into 2 categories: - Cam lesion - Pincer Results in impingement of femoral neck against anterior edge of acetabulum

FAI - what is a Cam lesion?

Femoral-based impingement Usually in young athletic males - Rowers Excess bone leading to Decreased head to neck ratio and Aspherical head Abutment of lesion on edge of acetabulum - Flexion

what is shown here?

FAI cam lesion Slight bump Easier to see on 3D imaging

what is a FAI pincer?

Acetabulum-based impingement Usually in active females Abnormal acetabulum leading to: - Anterosuperior acetabular rim overhang - Acetabular protrusion Abutment of lesion on edge of acetabulum More prominence of the edge of the acetabulum

what is shown here?

FAI - Pincer

what are associated injuries of FAI?

labral degeneration and tears cartilage damage and flap tears secondary hip osteoarthritis

what is the presentation of FAI?

Groin pain - Worse with flexion Mechanical symptoms: - Block to movement - Pain with certain manoeuvres - Getting out of a chair, Squatting, Lunging

what would be seen on examination of FAI?

Reduced flexion and internal rotation Positive FADIR test - Flexion, ADduction, Internal Rotation

what investigations would be used in FAI?

X-ray - Identify the bony pathology MRI - Useful for assessing associated conditions: - Labral tears - Articular cartilage damage

what is the non-operative treatment of FAI?

Activity modification NSAIDs Physiotherapy: - Correct posture - Strengthen muscles around joint

whatis the operative surgery of FAI?

Arthroscopy: - Shave down the defect - Deal with labral tears - Resect artic cartilage flaps Open Surgery: - Resection - Periacetabular Osteotomy - Hip Arthroplasty - Resurfacing - Replacement

what is a Labral Tear?

A hip labral tear is an injury to the labrum, the soft tissue that covers the acetabulum (socket) of the hip. A hip labral tear can be caused by injury, structural problems, or degenerative issues. Symptoms include pain in the hip or stiffness Most commonly anterosuperior tear

what is the epidemiology of a labral tear?

All age groups Commonly active females: - Pincer - More flexible In older age group often degenerative changes

what are the cuases of a labral tear?

FAI Trauma OA Dysplasia Collagen diseases – Ehlers-Danlos

what is the presentation of a labral tear?

Groin or Hip Pain - Intermittent pain that comes on on certain movements of the hip and not a constant pain Snapping sensation Jamming or locking

what would the examination of a labral tear be like?

can be normal Positive FABER test - Flexion, ABduction, External Rotation Anterior tears

what investigationg would be used for a labral tear?

Ensure adequate imaging so identify any root causes of pathology X-ray - OA, Dysplasia MRI Arthrogram - 92% sensitive Diagnostic injection - Local anaesthetic

what is the non-opertative treatment of a labral tear?

Activity modification, NSAIDs, Physiotherapy Injection of Steroids

what is the operative treatment of a labral tear?

Arthroscopy (more of a role in younger people) Repair Resection