Adult Hip Conditions and Surgery

Question 1

What occurs in femoroacetabular impingement syndrome (FAI)?

Answer 1

Altered morphology of the femoral neck and/or acetabulum

Causes abutment of the femoral neck on the edge of the acetabulum during movement (flexion, adduction, rotation)

Question 2

What are the two types of deformity that can occur in FAI?

Answer 2

CAM type impingement and pincer type impingement

Question 3

What are some features of CAM impingement in FAI?

Answer 3

Femoral deformity = asymmetrical femoral head with decreased head:neck ratio
Usually young athletic males
Can be related to previous SUFE

Question 4

What are some features of pincer type deformity in FAI?

Answer 4

Acetabular deformity = acetabular overhang

Usually seen in females

Question 5

What can both types of deformities present in FAI lead to?

Answer 5

Labrum damage and tears
Cartilage damage
Osteoarthritis in later life

Question 6

What is the presentation of FAI?

Answer 6

Activity related pain in groin (particularly in flexion and rotation)
Difficulty sitting
C positive sign
FADIR provocation test positive

Question 7

How may FAI be diagnosed?

Answer 7

Radiographs, CT, MRI (best for visualising damage to labrum and bony oedema)

Question 8

What are the management options for FAI?

Answer 8

Observation in asymptomatic patients
Arthroscopic or open surgery to remove CAM/debride labral tears
Peri-acetabular osteotomy/debride labral tears in pincer type impingement
Arthroplasty in older patients with secondary OA

Question 9

What is avascular necrosis?

Answer 9

Failure of the blood supply to the femoral head

Question 10

What causes most cases of avascular necrosis?

Answer 10

Most are idiopathic in origin

Question 11

What occurs in the pathogenesis of idiopathic avascular necrosis?

Answer 11

Coagulation of intraosseous microcirculation
Venous thrombosis causes retrograde arterial occlusion
Intraosseous hypertension reduces blood flow
Necrosis of femoral head causing chondral fracture and collapse

Question 12

What are some features of avascular necrosis?

Answer 12

More common in men, typical age is 35-50, 80% of cases are bilateral

Question 13

What causes avascular necrosis associated with trauma?

Answer 13

Injury to femoral head blood supply (medial femoral circulation)

Question 14

What are some risk factors for avascular necrosis?

Answer 14

Irradiation, trauma, haematological disease, hypercoagulable states, dysbaric disorders (Caisson disease), alcoholism, steroid use

Question 15

How do patients with avascular necrosis present?

Answer 15

Insidious onset groin pain, exacerbated by stairs/ impact, examination usually normal unless disease has progressed to collapse/OA

Question 16

How is avascular necrosis diagnosed?

Answer 16

Radiographs = often normal in early disease
MRI = best option

Question 17

How is avascular necrosis classed?

Answer 17

Reversible = Stage 0-II
Irreversible = Stage III-VI

Question 18

How is reversible avascular necrosis treated?

Answer 18

Bisphosphonates
Core decompression +/- bone grafting
Curettage and bone grafting
Vascularised fibular bone graft

Question 19

What are some treatments for irreversible avascular necrosis?

Answer 19

Rotational osteotomy

Total hip replacement

Question 20

What occurs in idiopathic transient osteonecrosis of the hip (ITOH)?

Answer 20

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

Question 21

What are the presentations of ITOH?

Answer 21

Progressive groin pain over several weeks, difficulty weight bearing, usually unilateral

Question 22

What are some features of ITOH?

Answer 22

More common in men overall

Two groups of common patients = middle aged men or pregnant women in the third trimester

Question 23

How do you diagnose ITOH?

Answer 23

Elevated ESR
MRI = gold standard
Bone scan
Radiographs = osteopenia of head and neck, thinning of cortices, preserved joint space

Question 24

How is ITOH managed?

Answer 24

Self limiting = resolves in 6-9 months

Analgesia and protected weight bearing to avoid stress fracture

Question 25

How does trochanteric bursitis arise?

Answer 25

Repetitive trauma caused by iliotibial band tracing over trochanteric bursa = causes inflammation of the bursa

Question 26

Who gets trochanteric bursitis?

Answer 26

Female patients, young runners, older patients (may be linked to gluteal cuff syndrome)

Question 27

How does trochanteric bursitis present?

Answer 27

Pain on lateral aspect of hip and on palpation of the greater trochanter

Question 28

What are some imaging techniques used to diagnose trochanteric bursitis?

Answer 28

``` Radiographs = usually unremarkable MRI = May be visible but not usually needed ```

Question 29

How is trochanteric bursitis treated?

Answer 29

Analgesia, NSAIDs, physio, steroid injection | No proven benefit from surgery

Question 30

What are some pathologies that cause secondary osteoarthritis?

Answer 30

DDH, SUFE, septic arthritis, AVN, FAI, trauma

Question 31

What is primary osteoarthritis?

Answer 31

Osteoarthritis with no precipitating cause

Question 32

What is osteoarthritis?

Answer 32

Degenerative disease of the synovial joints that causes progressive loss of articular cartilage

Question 33

What does inflammatory changes in osteoarthritis cause in the joint?

Answer 33

Thickening and tightness

Question 34

What is the epidemiology of osteoarthritis?

Answer 34

More common in females, usually older patients, has genetic element, common with pre-existing hip disease

Question 35

How may osteoarthritis present?

Answer 35

Groin pain, worse on activity, pain at night, stiff on testing ROM, start up pain

Question 36

What is assessed in a patient with suspected osteoarthritis?

Answer 36

Level of symptoms and impact on quality of life Medical comorbidities Social history Does the patient need surgery?

Question 37

What are some features of osteoarthritis radiographs?

Answer 37

Joint space narrowing, subchondral sclerosis, osteophytes, cysts

Question 38

What are some treatments for osteoarthritis?

Answer 38

Analgesia, weight loss, walking aids, physio if the patient has weakness, steroid injections, total hip arthroplasty

Question 39

What are some things that must be considered when planning osteoarthritis surgery?

Answer 39

Centre of rotation (low/high) Leg length discrepancy Offset Canal width

Question 40

What is the indication for a total hip arthroplasty in osteoarthritis, and what are some benefits of the surgery?

Answer 40

``` Indication = pain Benefits = pain relief and secondary improvement of function ```

Question 41

What are some risks associated with total hip arthroplasties?

Answer 41

Scarring, bleeding, neurovascular injury, fracture, clotting (DVT/PE), infection, dislocation, leg length discrepancy, loosening, ongoing symtpoms

Question 42

What are the different bearing choices and approaches for total hip arthroplasties?

Answer 42

Bearing choices = metal-on-poly, ceramic-on-poly, ceramic-on-ceramic Approaches = anterior, anterolateral, posterior

Question 43

What are the different choices of prostheses for total hip arthroplasties?

Answer 43

Hybrid, cemented and uncemented

Question 44

What are some features of a hybrid prosthesis in a total hip arthroplasty?

Answer 44

Uncemented cup = press fit, biological fixation Cemented stem = cone-in-a-cone Used in younger patients

Question 45

What are some features of a cemented prosthesis in a total hip arthroplasty?

Answer 45

Cemented cup = mechanical lock Cemented stem = cone-in-a-cone Bone cement = PMMA, works by interdigitation into bone surface Used in older patients