Hip Pathophysiology - Dr. Davies Flashcards
(108 cards)
1
Q
How many CT scans were taken in one surgery that Dr. Davies gave us as an example?
A
73
1
Q
Bracing for Labral tear surgery
A
Often use different types of braces, and limit motion in the hip.
This is pretty new, so we may not have seen these much in the clinic. One of our labs will actually be putting braces on.
Can dial in ROM limits. During surgery MD will do PROM and see where excessive strain is starting. They determine safe ROM, and then set the brace accordingly
90-0 is typically the safe range
Guideline is about 6 weeks MINIMUM.
Some motion is helpful to the joint, but the labrum must be protected!
2
Q
What are some scale components in the modified harris hip scoring system?
A
Gait: Limp, Support, Distance Walked
Functional: Stairs, socks/shoes, public transportation
2
Q
Hemiprosthesis for hip
A
Hemi means half, so this is when only half the joint is messed up.
Could be just the femoral prosthesis or the acetabular prosthesis
3
Q
Labral Repair Surgery
A
Will do if labrum looks salvagable on MRI/MRA
Lots of different ways to repair
Use suture anchors, which look like little barbs that go into the bone.
Sutures are then sewn around labrum to proximate it
5
Q
How does the press-fit prosthesis become secured?
A
it has rough edges and holes that bone tissue grows into
6
Q
What percentage of sciatic nerves pierce the piriformis muscle?
A
10-15%
6
Q
What is a hip structure that is more commonly being reconstructed now and has more to do with stability than originally thought?
A
Ligamentum teres
7
Q
Labral tear: Repair with graft
When is it appropriate (who gets one)?
Why would we go to that much trouble?
A
- Young person, macro-traumatic injury, MRA shows labrum tear
- We want to fix it and restore normal anatomy. The best is always to restore normal anatomy.
8
Q
should you be more careful during rehab of labral debriedment or repair?
A
Be more careful with Labrum repair
9
Q
what is an Awl?
A
a surgical tool used in microfracture procedures
10
Q
Is blood supply to the femoral head a large concern in hip resurfacing (since the ligamentum teres, the main source of nutrition for the femoral head, is severed)?
A
blood supply is already bad usually before resurfacing (usually performed in older adults) so the fact that it is now totally cut off is not as concerning.
11
Q
What are hip exam techniques predicated on? (4)
A
- Clusters of s/s
- Critical pathways
- Clinical Practice Guidelines
- Clinical decision making
12
Q
MOI for FAI
A
many different MOI possible
Example given was direct macrotraumatic (fall on greater trochanter, where femoral head is jammed into acetabulum)
Macrotraumatic contusions often lead to degeneration because the affect the chrondrocyte cells. Many people get degeneration because of this from surgery itself.
12
Q
Are MDs reccomending THA earlier or later than before? and why?
A
They are starting to do THA earlier because of concerns that pt waits so long that they are in such bad condition by the time it is done that recovery is extremely hard
13
Q
Definition of Extravigate
A
to go beyond proper limits
Source: http://www.merriam-webster.com/dictionary/extravagate
14
Q
What is something we should always use during post-op rehab?
A
Patient-reported outcomes (as opposed to just objective measurements we take with our physical tools)
15
Q
Three different THA surgical approaches:
A
- Posterior approach: traditional
- Lateral approach: less common
- Anterior approach: new & trendy
all relative to the greater trochanter landmark
16
Q
Occurance percentages of Isolated Cam, Isolated PIncer, and combined Cam-Pincer FAIs
A
Isolated CAM FAI: 17%
Isolated Pincer FAI: 11%
Combined Cam-Pincer FAI: 72%
KNOW THIS!
16
Q
Nine more complications of surgery
(the things that go wrong with the prosthesis)
A
- Component loosening
- Components breaking
- Associated bony fractures
- Osteolysis
- Osteonecrosis
- Heterotrophic ossification extra bone formation around surgery)
- Squeaky joints
- Debris buildup
- Components wearing out
17
Q
match FAI’s to location of labral tear, and why if applicable
A
CAM type involves Anteirior superior portion
Pincer translates force to the posterior part (contra-coup)
could effect anywhere along the labrum (not just in posterior part) but it shows up most often in the posterior part. Most commonly found in the posterior part.
18
Q
Hip labrum tear repair with graft: limitations
A
Limitations:
- Body might reject allograph
- Disease transmission from allograph (example, AIDS)
19
Q
What does inflow-outflow do during surgery
A
Constant flow of fluid
- keeps things visible
- Provides a bit of an abresement effect
20
Q
what does osteoplasty mean?
A
Oteoplasty = surgery to change the bone
21
Iliocapsularis muscle
a new muscle Dr. Davies has never heard of that was just reported in a JBJS Article
22
Does soft tissue or bone take longer to heal?
soft tissue
24
Two types of femoral stems
1. cemented
2. uncemented (press-fit)
25
How old is hip arthroscopy?
Has only been around the last 10 years
25
FAI Post-Op Recovery in Hip
* Rehab program is dependent on the exact surgical interventions
* Tx options for **lesions with FAI** indclude osteoplasty of the femoral neck and acetabular osteotomy
* Post-op rehab of these procedures typically involves **protected WB and ROM limitations for up to 8 Weeks**
* 4.7 yeasr post-op follow up: good to excellent results!
26
When is a labral resection performed?
Labrum is so macerated that it is not good quality tissue and it needs to be removed
(not fix-able for some reason)
Outcomes are not too great
26
What is a new technique that surgeons are using more in place of THA?
Hip Resurfacing
Instead of literally whacking off entire femoral head, they smooth down the femoral head and put a cap on it
It is sort of a stop-gap measure, so it is good for several years, but it doesn’t stop degeneration and eventually they still need THA. People can go back to a higher level of activity than if they had a THA
26
Eleven Complications of THA
1. Death from surgery (4% die from all surgeries)
2. Transfusions
3. PE (pulmonary embolism
4. DVT
5. Pain
6. Swelling
7. Chronic synovitis
8. Abscesses
9. Superficial infections
10. Deep infections
11. Dislocations (one of the most common)
27
Five general advangates to Anterior approach to THA
(don't worry about this as much)
1. Can split the muscles more than cut through the muscles.(Typically, the less cutting you can do, the quicker the recovery)
2. Pt is usually supine, easier to do C-Arm for radiographs and detect leg lenght differences
3. NO Hip precuations for anterior apporach (but many still use)
4. Shorter hpsital stay and
5. lower risk of dislocations
28
what test is very important to do before any labrum surgery
MRI or MRA
Don't want any surprises after surgery starts
30
What does surgical management of FAI in the hip focus on?
Surgical intervention has focused on improving the clearance of hip motion and alleviating femoral abutment against the acetabular rim, thus reieving pathologic changes in the labrum and articular cartilage.
Clearing stuff to improve motion
31
Draw a Labral tear
32
Hip Labral repair with graft: how to perform
1. Debride bad tissue first and burr the bone to create subchondral bleeding because it will facilitate healing
2. Will take some tissue (usually allograph), and put along periphery and sow it down.
3. “artificial” way to try to compensate for incompetent labrum in the hip.
34
In the hip, is loose pack position and max volume position the same?
yes
The position for both is:
30 degrees flexion
30 degrees of abduction
15 degrees of ER
35
Does Cam and Pincer type FAI's usually occur in isolation or together?
Most often together (72%)
36
Vascularity is important in labral surgery decisions because
It can tell you how likely a repair is to be successful. Better outcomes will happen in more vascularized areas. There is a test that can show vascularization and the sections of the labrum can be caterorized into areas that can be resected or repaired.
36
Which THA surgical approaches are the most common?
Posterior: less recently trained physicians
Anterior: more recently trained physicians (trend by far!)
38
What is the most up and coming Extra-articular hip arthroscopy surgery for and what it is anagolous to?
Gluteus Medius tendon repair
Anagolous to RTC repair
G. Medi is like supraspinatus
39
What is glute med injuries comparible to in the shoulder?
RTC tear
39
Log roll test
Roll leg back and forth when patient is supine and relaxed.
The single most specific test for **hip pathology** (no research to back that up). Dr. Byrd says to do it. It allows the articular surface of the femoral head in relation to the acetabulum but does not stress any of the surrounding extra-articular structures. Clinical experience of Dr. Byrd indicates we should do it.
40
The two Fitzgerald Tests
What we know as
1. Anterior Labral Tear test (FADDIR)
2. Posterior Labral Tear test
42
Barb Springer Study
what was it and what did we learn?
A study that tested the ability of clinical exams to detect labral tears (verified by hip arthroscopy).
Found that both were pretty close (and the PT had the highest rate of detection of the clinicians)
43
Hip Arthroscopy - multiple co-morbidities
often pt has comorbidities, so surgeon won’t do just one thing.
## Footnote
**Make sure you read the surgical notes, so you know what happened.**
45
Who are the three best hip MDs in the world?
Three best Hip MDs in the world:
1. Dr. Brian Kelly (one of the three best in world)
2. Dr. Philipon (more innovative one)
3. Dr. Thomas Byrd (probably the best scientist, has been doing longer - the other two trained with him)
46
The greatest change in orthopedics over the last few years has been in ________ (procedure).
Hip Arthroscopy (increase)
47
Four common lateral hip compartment pathologies:
1. External snapping hip
2. Trochanteric bursitis
3. Gluteus medius tendinopathy
4. TFL & ITB problems
48
What is a C-Arm
A CT device used during hip surgery.
It is easily positioned during hip surgery to be able to take radiographs during the procedure to make sure it is completed properly.
49
What is Hip Microfracture?
Becoming one of the most common procedures in the hip
Using more in the knee and ankle (talus) too
grade III or Grade IV. Almost down to the bone. A mess
Cartilage defect
Take out all the damaged cartalige
Take an Awl (surgical tool) and put poke-holes into the bone to stimulate stem cells to form a mesenchymal clot which creates fibrocartilage. Must do by hand, not a drill
TAKE HOME: it creates FIBROCARTILAGE (like the retread on your tires, it is not quite as good as hyaline. Better than none, but not as good as original)
50
Surgical Management of FAI: Three considerations
1. Presence of other related pathology should be considered and treated accordingly (very important to be extra-aware of co-morbidities)
2. FAI is a structureal deformity that appears to have a potential relationship with other hip intra-articular pathology
3. FAI is an underlying cause in 55% of patients with labral tears
50
Three complications of THA that particulary apply to metal on metal joints:
1. Metallosis
2. Cobalt Poisoning
3. Lawsuits
52
Is giving way in the hip always due to bony/connective tissue instability?
No
Giving way may not always be due to an unstable hip. Giving way here is a pain inhibition reflex (not under their control). Much more likely to be a pain inhibition than instability.
53
When and How do you perform a microfracture?
Perform when cartilage is all torn up and won't heal. Purpose is to stimulate formation of new cartilage (but it will be fibrocartilage)
1. Take out all the damaged cartalige (all the way back to the good cartilage - smooth it out)
2. Take an Awl (surgical tool) and put poke-holes into the bone to stimulate stem cells to form a mesenchymal clot which creates fibrocartilage. Must do by hand, not a drill
3. Allow to heal (hopefully will generate new (fibro)cartilage
55
## Footnote
Macrotraumatic contusions often lead to hip \_\_\_\_\_\_\_\_\_ because they affect \_\_\_\_\_\_\_\_\_\_\_\_\_.
degeneration
chrondrocyte cells
56
Three types THA component materials
Polyethelyene
Metal
Ceramic
56
If you use cemented prosthesis on one side of joint, must you use the same type on the other side?
Could be any combination of cemented or uncemented on acetabulation and femur. usually would go with same type in both areas unless there is a good clinical reason to do mixed.
57
Trendelenburg sign
One hip drops.
The contralateral hip (to the one that is dropping) that is having a problem here
58
Pincer-type impingement
* More common in middle aged athletic women
* Occurs when ther is an abnormal amount of increased coverage fromt he acetabulum (can be bony overgrowth). It sticks out further.
* Repeated contact between the femoral neck and the prominent anterior aspect of the acetabular rim leads to initial lamage of the labrum, and ofthen a contre-coup lesion leading to premautre wear of the posterior articular surface.
* Best detected by Posterior Labral Tear Test (Davies FABER)
60
what kind of cartilage does microfracture generate?
FIBROCARTILAGE
61
Glute Med Tendon Repair
Greater trochanteric rupture of the tendon.
Put sutures there and pull that down and repair that to the greater trochanter. Just like a supraspinatus tear
62
Extra-Articular Hip Arthroscopy
Funny name since
It is not in the joint, so it is really ENDOscopic (outside the joint)
Main example: Glute Med tendon repair
63
Non surgical managment of FAI
Has been suggested to have little place because it cannot eliminate hte hpathomechanics of structural deformities
We might do some modalities.
Maybe 1-2 grade mobs
Some flexibility exercises
But ALWAYS follow up with therapeutic exercise
But because it is a bony problem PTs are not effective.
64
CAM-type Impingement
1. More common in young athletic men
2. Occurs most commonly with flexion and IR.
3. Femoral head/neck abnormality leads to jamming of the head-neck junction causes an outside-in intra-substance avulsion of the labrum (loosening) from the adjoining acetabular cartilage.
4. Best detected by Anterior Labral Tear Test (Davies FADIR/FAIR)
65
how does the artificial femoral head affect a THA
The bigger the ball used, the more stable it can be
66
draw the three THA approaches
67
What is an FAI?
Femoral Acetabular Impingement:
An abnormal abutment between the femoral head and the pelvic acetabulum
68
What is probably one of the mosr demanding clinical procedures that surgeons do?
Hip Arthroscopy
69
What is done first when performing a hip arthroplasty?
Draw on the patient
KNOW YOUR ANATOMY!
70
Vascularity of periphery of labrum
If the top areas were named IIB and IB from left to right
&
If the bottom areas were named IIA & IA from left to right
IA IIA areas has more vascularity (better outcome)
IIB & IB has less vascularity (worse outcome)
72
FAI: Clusters of s/s (7)
Subjective (All of these could be potential indications of labral tears or something going on intraarticularly):
1. Gradual onset of sharp groin pain
2. Worsens with athletic activities requiring an excessive demand on hip flexion (91%)
3. Patient experiences night pain (71%)
4. Pt may report mechanical symptoms (locking, catching, giving -way [due to pain inhibition of muscle]) indicative of labral tear or injury of articular cartilage.
Objective:
1. Limp (39%)
2. + Trendelenburg sign (38%)
3. Positive impingement sign (95%)
73
Abresement definition
injecting fluid into a joint capsule to stretch it from the inside
73
How many types of THA replacement devices are there?
Lots and lots!
75
APTA Patient Management Model (8)
1. Examination
2. Evaluation
3. Diagnosis
4. Prognosis
5. Interventions
6. (re-evaluation)
7. Outcomes
8. (long term outcomes, i.e. 2 years)
76
Five types of hip replacement joints
77
General THA Precautions for Anterior approach
1. No extension past 0 degrees
2. No Abduction past 0 degrees
3. No ER past 0 degrees
Follow for at least 6 weeks
78
What is a typical posture of a patient when we go out to meet them (if they are sitting or standing)?
Sitting: trying to get into hip extension because flexion hurts because it compresses hip into acetabulum.
Standing: standing on contralateral leg with affected hip slightly flexed and non-weight bearing. (loose pack position feels better and non-weight bearing prevents compression of femoral head into acetabulam)
79
Hip FAI
Femoral Acetabular Impingement
Somewhat similar to rotator cuff impingement
Many different types
80
The most common hip Patient Reported outcomes that we could use in rehab
1. Harris-Hip Scale (scoring system)
2. Modified Harris Scale
81
What is the main difference between Cam FAI and Pincer FAI
CAM is an abnormality on femoral head (abnormally large radius)
Pincer is abnormality on acetabulum
83
Three hip compartments:
1. Anterior
2. Lateral
3. Posterior
83
What is the best imaging technique to detect a labral tear?
How does it work to detect labral tear?
MRA with Gallium dye
Inject Gallium dye into joint. If there is a defect in the labrum, it leaks (exravigates) out and shows on MRA
85
How cemented type of femoral stem works
methylmethacilate is the bone cement. Put that into the femoral shaft, then push stem down into that.
86
Super cool name for scar tissue
Angiofibroplastic hyperplasia
(this is often found in glute medius tears too)
87
Information from Dr. Davies about THA that I didn't figure out how to put into a question
THA, recent study
Prehab with PT , performed before joint replacement surgery can diminish the need for post op care by nearly 30%, saving an average of $1, 215 per patient in post op care
Millions performed world wide
Do the math
88
relationships between FAI, Labral Tear, OA, & THA
FAI --\> degenerative changes--\> labral tear --\> more degeneration --\> OA --\> THA
89
What do the best surgeries do?
Fix what is broken
90
T/F: Many people get hip degeneration because of this from surgery itself.
true
91
What are the main componenets of a normal hip prosthesis for THA?
* Acetabular component
* Plastic liner
* Femoral head
* Femoral stem
or (can be problems at each of these components)
* Cup
* Head
* Neck
* Stem
92
Ng, et. al. study of Efficacy of surgery for FAI. A systematic review from AJSM
High points
* pt dissatisfaction rates were high (30%)
* pretty high percentage of athletes returned to sports (93%)
* Repairs were better than resection (micromotion in the joint becasue of absent labrum caused problems)
93
Eight Common Hip Surgeries
Five Arthroscopic:
1. Hip Arthroscopy - FAI
2. Hip Arthroscopy - labrum resection
3. Hip arthroscopy - labrum repair
4. Hip Arthroscopy microfracture
5. Hip Arthroscopy - extra-articular treatments and repairs
Three Others:
1. Hip Osteoplasty
2. THA
3. Hip resurfacing
94
Who is Dr. Mark Philippon?
A leading Hip Surgeon (info from his bio online):
* Managing Partner of the Steadman Clinic
* Sports Medicine and Hip Disorders Specialist
* Co-chair and Board Member at the Steadman Philippon Research Institute
* Associate Clinical Professor at McMaster University in Hamilton, Ontario
* Adjunct Associate Professor of Orthopaedic Surgery at the University of Pittsburgh School of Medicine
http://drmarcphilipponmd.com/
95
Four-Five anterior Hip compartment pathologies (2-3)
1. Lateral snapping hip & psoas impingement
2. Anteroinferior iliac spine impingement.
3. ASIS avulsion
4. AIIS avulsion
96
General THA Precautions for Posterior approach
1. no Hip flexion past 90 degrees
2. No horizontal adduction past 0 degrees
3. No IR past 0 degrees
97
What are two special pieces of equipment that are used during hip surgery?
Specialty hip table
C-Arm
98
C-Sign
This is a pathopneumonic sign for hip problems.
If pt displays the sign when you ask where they have pain, it is pretty certain there is something going on in the hip joint.
Person makes C shape with thumb and index finger and grabs hip with index finger in front.
99
What is the single most popular hip surgery that is being done right now?
Repair of the labrum
100
Hip Arthroscopy: Osteoplasty for FAI
For FAI it is to trim femoral head, femoral neck, and/or acetabulum
Use a bone burr
For example to make one side of femoral neck look the same as the other side
Use C-Arm to make sure things look ok
101
MIS
Minimally invasie surgery
(use this)
I think it was the small incision for anterior approach
102
What is Hip-Resurfacing?
not a THA
## Footnote
Instead of literally whacking off entire femoral head, they smooth down the femoral head and put a cap on it
It is sort of a stop-gap measure, so it is good for several years, but it doesn’t stop degeneration and eventually they still need THA. People can go back to a higher level of activity than if they had a THA
103
Two options for labral tear surgery
1. Resecton (remove it)
2. Repair or Fixation (re-attach it)
3. Repair with Graft (rebuild it)
104
What is nano-fracture?
it is like microfracture, but goes deeper into pleuri-potential cells
It has not been fully tested yet, but there are claims that it stimulates more healing cells than microfrature.
105
Draw the differnt types of FAIs
could be on different parts (I don't think it always has to be posterior)
106
do labral tears lead to degenerative changes in the joint?
yes.
This is different from the shoulder because the shoulder is not a weight-bearing joint
107
You made it!
108
The difference between
debridement
and
brisement
Debridement: clearling debris
Brisement: tearing. When fluid is injected into a joint capsule and stretches the capsule from within
