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    06-Dr. Bajammal Hip Disorders 2017

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    Muath
    The document discusses common hip disorders including their presentation, causes, and management principles. It covers topics like avascular necrosis, osteoarthritis, hip replacements, fractures, and trauma. Case examples are provided to demonstrate clinical scenarios and treatment decisions for various hip conditions.

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    06-Dr. Bajammal Hip Disorders 2017

    Uploaded by

    Muath
    33 views48 pages
    The document discusses common hip disorders including their presentation, causes, and management principles. It covers topics like avascular necrosis, osteoarthritis, hip replacements, fractures, and trauma. Case examples are provided to demonstrate clinical scenarios and treatment decisions for various hip conditions.

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    © © All Rights Reserved

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    The document discusses common hip disorders including their presentation, causes, and management principles. It covers topics like avascular necrosis, osteoarthritis, hip replacements, fractures, and trauma. Case examples are provided to demonstrate clinical scenarios and treatment decisions for various hip conditions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    33 views48 pages

    06-Dr. Bajammal Hip Disorders 2017

    Uploaded by

    Muath
    The document discusses common hip disorders including their presentation, causes, and management principles. It covers topics like avascular necrosis, osteoarthritis, hip replacements, fractures, and trauma. Case examples are provided to demonstrate clinical scenarios and treatment decisions for various hip conditions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 48

    Hip Disorders

    Sohail Bajammal, MBChB, MSc, FRCSC

    September 25, 2017


    Learning Objectives
    • Recognize the significance of femoral blood supply
    anatomy and its implication on management

    • Recognize common diseases of the hip, their


    clinical presentation & principles of management

    • Identify the principles of managing fractures


    around the hip according to their classification
    Case

    • 30-year-old male
    • PMH: sickle cell
    anemia
    • Bilateral hip pain for 6
    months
    • X-ray was seen by his
    brother (a new med
    graduate). Given
    NSAIDs.
    • Given steroids by GP
    for better pain control
    Hip Anatomy
    • Ball-and-Socket joint
    • Femoral head
    • Acetabulum

    • Blood supply to femoral head


    • Importance for AVN & femoral neck fracture

    • Muscle groups
    • Flexors: iliopsoas, others
    • Abductors: Gluteus medius, minimus & TFL
    • Adductors
    • External rotators: Gluteus maximus & others
    Common Diseases of the Hip in Adults
    • Hip Arthritis:
    • Primary Osteoarthritis
    • Secondary: trauma, infection, AVN, DDH

    • Avascular necrosis (AVN)

    • Trochanteric bursitis

    • Others: stress fracture, transient osteoporosis of


    the hip
    Back to the case

    • 30-year-old male
    • PMH: sickle cell
    anemia
    • Bilateral hip pain for 6
    months
    • X-ray was seen by his
    brother (a new med
    graduate). Given
    NSAIDs.
    • Given steroids by GP
    for better pain control
    • Describe the X-ray
    Avascular Necrosis (Osteonecrosis) of
    The Femoral Head
    • Can be symptomatic (pain, limitation of movement) or
    asymptomatic
    • 85% of symptomatic AVN  collapse  osteoarthritis

    • Causes/Risk Factors (long list)


    • Trauma: Femoral neck fracture, Posterior hip dislocation
    • Steroids, Alcohol
    • Coagulopathy
    • Sickle Cell Anemia
    • Decompression sickness
    • SCFE, Perthes Disease
    • Pregnancy

    • MRI is the most sensitive diagnostic tool

    • Treatment:
    • Early stages: anticoagulant, bisphosphonates, core decompression
    • Late stages: resurfacing, total hip replacement, fusion
    3 years later
    Hip Osteoarthritis
    Hip Osteoarthritis
    • Symptoms:
    • Groin pain: radiating to thigh, or buttock
    • Referred knee pain
    • Stiffness
    • Antalgic gait

    • On examination:
    • Pain & limitation of internal rotation of the hip early
    • Late: fixed flexion & external rotation

    • Must rule out other pathologies


    • Lumbar degenerative disc disease
    • Sacroiliac joint arthritis
    Etiology of Hip Arthritis
    • Primary: idiopathic osteoarthritis

    • Secondary:
    • Vascular: Avascular Necrosis
    • Inflammatory: reactive arthritis
    • Traumatic: intra-articular fractures, instability, cartilage
    damage
    • Autoimmune: rheumatoid arthritis
    • Metabolic
    • Infection
    • Developmental: DDH
    Factors leading to osteoarthritis

    Figure 15.2, Textbook of Orthopaedics, Trauma & Rheumatology


    What can we do to any joint pathology?
    e.g., Hip Joint
    1. Don’t touch it: non-surgical management
    According to pathology, life style modification, weight loss,
    activity modification, physiotherapy, pain medications
    2. Inject it: steroids
    3. Look inside it & fix: arthroscopy
    4. Re-align it: osteotomy
    5. Resurface it: resurfacing arthroplasty
    6. Replace it: partial (hemi) or total joint arthroplasty
    7. Fuse it: arthrodesis
    8. Resect (excise) it: excision (resection) arthroplasty
    9. Resect the limb: amputation
    Total Hip Replacement
    (Arthroplasty)
    Total Hip Replacement
    • Very common procedures
    • 400,000 every year in the US

    • Excellent results & improvement in quality of life


    • >90% excellent function after 10 years

    • Complications (Immediate vs Delayed)”


    • DVT
    • Leg Length Discrepancy
    • Neurovascular Injury
    • Fracture
    • Infection
    • Dislocation
    • Loosening
    Hip Hemiarthroplasty Total Hip Arthroplasty
    Total Hip Arthroplasty Hip Resurfacing
    Hip Fusion (Arthrodesis) Total Hip Arthroplasty
    Girdlestone Excision Arthroplasty
    More patients
    Neglected DDH
    Patient #1
    • 79-year-old female
    • Asymptomatic hip
    • Known DDH when she
    was a kid
    Neglected DDH
    Patient #2
    • 73-year-old female
    • Severe pain left hip
    • Disabling her activities
    • Exhausted non-
    operative treatment
    Hip Trauma
    Injuries around the hip joint
    • Ligamentous injuries

    • Hip Dislocation
    • Anterior vs Posterior
    • Central with Acetabulum Fracture Dislocation

    • Fractures around the hip:


    • Acetabulum fracture
    • Femoral head fracture
    • Femoral neck fracture
    • Intertrochanteric fracture
    • Subtrochanteric fracture
    Posterior Hip Dislocation
    • More common than anterior

    • Mechanism: dashboard

    • Flexed, Adducted, Internally


    Rotated & Shortened

    • Complications:
    • Sciatic nerve injury  Foot Drop
    • AVN of Femoral Head
    Femoral Neck Fractures
    • Differences between young & old

    • Mechanism differs according to age

    • Clinically, leg is shortened & externally rotated.

    • Complications:
    • Avascular necrosis
    • Non-union
    • Malunion
    • Implant-related complications
    Femoral Neck Fractures
    Patient #1
    • 31-year-old lady
    • Motor Vehicle Crash
    • 9 hours ago
    • Isolated injury
    • What to do?
    “Open” reduction & internal fixation
    “Closed” reduction & internal fixation
    Non-union

    6 months later
    Femoral Neck Fractures
    Patient #2

    • 80-year-old lady
    • Fell at home
    • What to do next?
    What to do next for an elderly with
    femoral neck fracture?
    1. Primary Survey of ATLS if not done
    2. Detailed History:
    • Reason of fall: Dehydration? Hypothension? Angina? MI? CVA?
    • Mechanism?
    • Other injuries?
    • Any loss of consciousness (transient)?

    3. Physical Exam: Secondary Survey


    4. Any medical comorbidities?  optimize first
    5. DVT Prophylaxis before & after
    6. Osteoporosis workup & management upon discharge
    7. Social issues, Fall Prevention
    Hip Hemiarthroplasty Total Hip Arthroplasty

    Option 1 Option 2
    1 year later
    Intertrochanteric Fractures
    • 80-year-old lady
    • Fell at home
    • What to do?
    Options for intertrochanteric #
    Nail DHS
    Complications do happen
    Complications do happen
    Many options for subtrochanteric
    Acetabulum Fractures
    Pelvic Injuries
    What can you do
    now or when you graduate
    to have a positive impact
    on hip fractures?
    Summary
    • Recognize the significance of femoral blood supply
    anatomy and its implication on management

    • Recognize common diseases of the hip, their


    clinical presentation & principles of management

    • Identify the principles of managing fractures


    around the hip according to their classification

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