Orthopaedic Hip Conditions

Question 1

OA: pathophysiology

Answer 1

• DEGENERATIVE CHANGE of SYNOVIAL JOINTS

	○ PROGRESSIVE LOSS of ARTICULAR CARTILAGE
	○ 2ndary BONY CHANGES

Can FOLLOW AVN & PAEDIATRIC DISEASE; BMI DOESN’T INCREASE RISK of HIP OA

Question 2

OA: investigations/diagnosis

Answer 2

ON/E:

* ANTALGIC GAIT & +VE TRENDELENBURG SIGN
* REDUCED ROM esp. on INTERNAL ROTATION

IMAGING: X-RAYS

Question 3

OA: management

Answer 3

• HIP REPLACEMENT

Question 4

Trochanteric bursitis: epidemiology

Answer 4

F > M

Question 5

Trochanteric bursitis: pathophysiology

Answer 5

• BURSA THICKENS + CREATES MORE FLUID when it becomes INFLAMED
  
  • CYTOKINES RELEASED = INTERPRETED by BODY as PAIN
  • PRESSURE EFFECT of BURSA

Question 6

Trochanteric bursitis: presentation

Answer 6

• BURSITIS = INFLAMMATION of BURSA = PAIN + SWELLING OVER GREATER TROCHANTER

	○ PAIN = POINT TENDERNESS - V. LOCALISED PAIN on LOWER LATERAL HIP - WILL POINT TO WHERE IT HURTS

Question 7

Trochanteric bursitis: aetiology

Answer 7

• TRAUMA
  
  • OVER-USE = ATHLETES, often RUNNERS; REPETITIVE MOVEMENTS
  • ABNORMAL MOVEMENTS = DISTANT PROBLEM e.g. SCOLIOSIS; LOCAL PROBLEM e.g. MUSCLE WASTING AFTER SURGERY, TOTAL HIP REPLACEMENT, OSTEOARTHRITIS

Question 8

Trochanteric bursitis: investigations/diagnosis

Answer 8

ON/E:

LOOK - scars, muscle wasting e.g. gluteals
FEEL - tenderness at greater trochanter/tuberosity
MOVE - worst pain in active abduction

IMAGING:

X-RAY - normal, OA, THR, spine abnormalities
MRI - soft tissue, fluids
USS - therapeutic, diagnostic

Question 9

Trochanteric bursitis: management

Answer 9

• NSAIDs
  
  • RELATIVE REST/ACTIVITY MODIFICATION - may not have to stop causative activity, just alter it
  • PHYSIOTHERAPY = CORRECT POSTURE, ABNORMAL MOVEMENTS, STRETCHING, STRENGTHEN MUSCLES ~ JOINT
  • CORTICOSTEROID INJECTION
  • SURGERY - BURSECTOMY○ RARELY REQ.
    ○ EVEN IF SMALL BIT LEFT - INFLAMMATORY PROCESS RESTARTED (bursitis again); it’ll TRACK THROUGH PATH of LEAST RESISTANCE (the WOUND) - can get CHRONICALLY DISCHARGING SINUS

Question 10

Femoacetabular impingement: complications

Answer 10

• LABRAL DEGENERATION & TEARS
  
  • CARTILAGE DAMAGE & FLAP TEARS
  • 2ndary HIP OA

Question 11

AVN: definition

Answer 11

• BONE DEATH due to LOSS of BLOOD SUPPLY

Question 12

AVN: epidemiology

Answer 12

M > F

• AVERAGE AGE ~ 35 - 50yrs

80% - bilateral; 3% - multifocal i.e. 3/more joints

Question 13

AVN: presentation

Answer 13

• PAIN
○ In GROIN; occurs w/ STAIRS, WALKING UPHILL & IMPACT ACTIVITIES

• LIMP

Question 14

AVN: risk factors

Answer 14

Trauma:
• IRRADIATION esp. BONY METS ~ PELVIS - CAREFUL when doing RT ~ HEAD of FEMUR

• FRACTURE
• DISLOCATION
• IATROGENIC

Causes INJURY to FEMORAL HEAD BLOOD SUPPLY e.g. INTRACAPSULAR #

Systemic:

• IDIOPATHIC - INTRAVASCULAR COAGULATION is FINAL COMMON PATHWAY

○ MICROTRABECULAR NETWORK DAMAGED = HEAD COLLAPSES = NOT REPLENISHED as OSTEOCLASTS are DEAD

PATHOANATOMIC CASCADE
• HYPERCOAGULABLE STATES

• STEROIDS esp. SYSTEMIC
• HAEMATOLOGICAL○ SICKLE CELL DISEASE
  ○ KAYSON’S DISEASE
  ○ LYMPHOMA
  ○ LEUKAEMIA
• CAISSON’S DISEASE
• ALCOHOLISM (alcohol/lack of nutrition & exercise etc.)

Question 15

AVN: investigations

Answer 15

ON/E:

* Mainly NORMAL
* May REPLICATE EARLY ARTHRITIS = REDUCED ROM esp. INTERNAL ROTATION, STIFF JOINT

• CLINICALLY VAGUE, EXCEPT RLLY STRUGGLES w/ INTERNAL ROTATION

IMAGING:

* X-RAY
* MRI = 99% SENSITIVE & SPECIFIC, IDENTIFIES EARLIEST CHANGES

Question 16

AVN: management

Answer 16

Non-operative:
• REDUCE WGT.-BEARING/IMMOBILISATION
• NSAIDs
• BISPHOSPHONATES - DEACTIVATE OSTEOCLASTS (controversial)

• ANTICOAGULANTS - THIN BLOOD to IMPROVE FLOW
• PHYSIOTHERAPY - MAINTAIN ROM, KEEP BALL/HEAD ROUND (otherwise, lack of movement & pressure on femur = flattens head)

Operative:
• RESTORE BLOOD SUPPLY = CORE DECOMPRESSION ± VASCULARISED GRAFT

• MOVE LESION AWAY FROM WGT.-BEARING AREA = ROTATIONAL OSTEOTOMY
• TOTAL HIP REPLACEMENT

Question 17

Labral tear: management

Answer 17

Non-operative:
• ACTIVITY MODIFICATION
• NSAIDs
• PHYSIOTHERAPY

STEROID INJECTION

Operative:
• ARTHROSCOPY = REPAIR (w/ SUTURES + SCREW IT DOWN)/RESECTION

Question 18

Labral tear: pathology

Answer 18

ANTEROSUPERIOR TEAR

Question 19

Labral tear: presentation

Answer 19

• PAIN = GROIN/HIP
  
  • SNAPPING SENSATION = ELASTIC BAND GOING OFF IN HIP
  • JAMMING/LOCKING = can be EXTREMELY PAINFUL

Question 20

Labral tear: epidemiology

Answer 20

• ALL AGE GROUPS

* COMMONLY ACTIVE FEMALES = PINCER, MORE FLEXIBLE

Question 21

Labral tear: aetiology

Answer 21

• FAI
  
  • TRAUMA
  • OA
  • DYSPLASIA = DEGENERATIVE PROBLEMS e.g. DDH
  • COLLAGEN DISEASES = e.g. EHLERS-DANLOS

Question 22

Labral tear: investigations/diagnosis

Answer 22

ON/E:

* Can be NORMAL
* PRESSING DOWN ON KNEE = causes PAIN
* +VE FABER TEST = put hip in FLEXION, ABDUCTION, EXTERNAL ROTATION, for ANTERIOR TEARS

IMAGING: ENSURE ADEQUATE IMAGING to INDENTIFY ANY ROOT CAUSES of PATHOLOGY

* X-RAY = OA, DYSPLASIA
* MRI ARTHROGRAM = 92% SENSITIVE, CONTRAST DYE into JOINT - FILLS GAPS
* DIAGNOSTIC INJECTION = under LOCAL ANAESTHETIC - gives COMPLETE PAIN RELIEF/NO PAIN RELIEF (if CANNOT do MRI ARTHROGRAM or it's NOT +VE)