Adult Hip Conditions and Surgery

Question 1

what is the VITAMIN acronym and what does it stand for?

Answer 1

types of causes of disease
V- vascular
I - infective/inflammatory
T - traumatic
A - autoimmune
M - metabolic
I - iatrogenic/idiopathic
N - neoplastic

Question 2

what are the 3 layers of the femoral head?

Answer 2

hyaline cartilage
subchondral bone
cancellous bone

Question 3

why is damage to hyaline cartilage dangerous?

Answer 3

because you cant make more

can form new fibrocartilage but its not as effective

Question 4

what is femoroacetabular impingement syndrome?

Answer 4

altered morphology of femoral head and/or acetabulum

Question 5

what does FAI cause?

Answer 5

abutment of the femoral neck on the edge of the acetabulum during movement - flexion, adduction and internal rotation
damage to labrum and tears
damage to cartilage
OA later in life

Question 6

what are the 3 types of FAI?

Answer 6

CAM impingement
Pincer impingement
Mixed

Question 7

describe CAM impingement

Answer 7

femoral deformity causing asymmetrical femoral head with decreased head to neck ratio

Question 8

who is CAM impingement more common in?

Answer 8

young athletic males

related to previous SUFE

Question 9

describe pincer impingement

Answer 9

acetabular deformity causing acetabular overhang

Question 10

who does pincer impingement usually affect?

Answer 10

females

Question 11

how does FAI present?

Answer 11

activity related pain in groin, esp in flexion and rotation
difficulty sitting
C sign positive
FADIR provocation test positive

Question 12

how is FAI diagnosed?

Answer 12

radiograph
CT
MRI (better for damage to labrum and bony oedema)

Question 13

how is FAI managed?

Answer 13

observed if asymptomatic
if symptomatic
- arthroscopic/open surgery to remove CAM/debide labral tears
- peri-acetabular osteotomy/debride labral tears in pincer impingement
- arthroplasty in older patients with secondary OA
takes around 6 weeks to heal

Question 14

what is avascular necrosis?

Answer 14

failure of the blood supply to the femoral head

Question 15

how does idiopathic ecrosis occur?

Answer 15

idiopathic
- coagulation in intraosseous circulation > venous thrombosis causes retrograde arterial occlusion > intraosseous hypertension (due to back pressure) > decreased blood flow to femoral head > necrosis of femoral head > chondral fracture and collapse

Question 16

how does trauma cause avascular necrosis?

Answer 16

due to injury of femoral head blood supply - medial femoral circumflex

Question 17

what are the risk factors for avascular necrosis?

Answer 17

males
35-50
irradiation
trauma
haematological disease or hypercoagulable states
dysbaric disease
alcoholism
steroid use
however most are idiopathic

Question 18

how does avascular necrosis present?

Answer 18

insidious onset of groin pain
exacerbated by stairs or impact
normal examination (unless disease advanced to collapse/OA)

Question 19

how is avascular necrosis diagnosed?

Answer 19

radiographs (can be normal in early disease)

MRI scan is best

Question 20

what can be seen in MRI in avascular necrosis?

Answer 20

oedema etc

Question 21

what are the 2 overall groups of avascular necrosis?

Answer 21

reversible 
- stages 0-2
- pre-subchondral collapse
irreversible
- stages 3-6
- post-subchondral collapse

Question 22

how is reversible avascular necrosis managed?

Answer 22

bisphosphonates
core decompression +/- bone graft
curettage and bone grafting
vascularised fibular bone graft
rotational osteotomy

Question 23

how is irreversible avascular necrosis managed?

Answer 23

total hip replacement

rotational osteotomy

Question 24

what is idiopathic osteonecrosis of the hip (ITOH)?

Answer 24

local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure

Question 25

how does ITOH present?

Answer 25

progressive groin pain over several weeks difficulty weight bearing unilateral

Question 26

what groups does ITOH affect?

Answer 26

pregnant women | middle aged men

Question 27

how is ITOH diagnosed?

Answer 27

elevated ESR radiograph - osteopenia of head and neck, thinning of cortices, preserved joint space MRI (gold standard) Bone scan

Question 28

how is ITOH managed?

Answer 28

self limiting in 6-9 months analgesia protected weight bearing to avoid stress fracture

Question 29

what is trochanteric bursitis?

Answer 29

repetitive trauma caused by iliotibial band tracking over trochanteric bursa causes inflammation of the bursa

Question 30

who is trochanteric bursitis typically seen in?

Answer 30

``` young active women - due to shape of pelvis runners older patients can be linked to gluteal cuff syndrome ```

Question 31

how does trochanteric bursitis present?

Answer 31

pain on lateral aspect of hip | pain on palpation of greater trochanter

Question 32

how is trochanteric bursitis diagnosed?

Answer 32

clinically | visible on MRI but not usually needed

Question 33

how is trochanteric bursitis managed?

Answer 33

``` analgesia NSAIDs physiotherapy steroid injection no surgical benefit ```

Question 34

what can cause OA?

Answer 34

end point for many pathologies - DDH - SUFE - septic arthritis - AVN - FAI - trauma - many more

Question 35

is there always a cause for OA?

Answer 35

no | can be idiopathic

Question 36

what is OA?

Answer 36

degenerative disease of synovial joints that causes progressive loss of articular cartilage inflammatory changes in capsule lead to thickening and tightness

Question 37

who does OA usually effect?

Answer 37

females older age genetic pre-existing hip disease (can cause earlier onset)

Question 38

how does OA of the hip present?

Answer 38

``` groin pain worse on activity pain at night start up pain stiff on testing ROM ```

Question 39

how is OA assessed?

Answer 39

level of symptoms and impact on life comorbidities (can they cope with surgery?) social history would they like surgery?

Question 40

how is OA diagnosed?

Answer 40

radiographs - loss of joint space - osteophytes - subchondral sclerosis - subchondral cysts

Question 41

how is OA managed?

Answer 41

``` analgesia weight loss walking aids physio if there's weakness steroid injections in some total hip arthroplasty ```

Question 42

what must be considered when planning for total hip arthroplasty?

Answer 42

centre of rotation - high or low? leg length discrepancy offset (distance between centre of the femoral head and the greater trochanter) canal width

Question 43

what are the steps in a total hip arthroplasty?

Answer 43

discussion with patient (only used for pain, not stiffness etc) obtain consent by giving benefits and risks choose approach - anterior, posterior, anterolateral prosthesis choice - cemented, uncemented, hybrid bearing choice - metal on poly, ceramic on poly, ceramic on ceramic

Question 44

what are the risks of total hip arthroplasty?

Answer 44

``` scars bleeding NV injury fracture clotting infection dislocation leg length discrepancy loosening ongoing symptoms ```

Question 45

what is a hybrid total hip arthroplasty and when is it used?

Answer 45

``` uncemented cup(biological fixation) with cemented stem (cone in a cone) used in younger patients ```

Question 46

what is a cemented total hip arthroplasty and when is it used?

Answer 46

``` cemented cup (mechanical lock) with cemented stem (cone in a cone) used in older patients ```