Hip Elective

Question 1

Examples of hip elective

Answer 1

-Osteoarthritis
-Greater trochanteric pain syndrome
-Dislocation

Question 2

What is OA?

Answer 2

-Progressive loss of the articular cartilage
-2nd most common site of OA (knee = 1st)

Question 3

Risk factors for OA

Answer 3

-Age
-Female (x2)
-Obesity
-Paediatric hip pathology (e.g., DDH, Perthes’, SCFE)

Question 4

Presentation of OA

Answer 4

-Pain (chronic history of groin ache following exercise and relieved by rest)
-Stiffness (Short duration, <2 hours)
-Late: deformity, laxity (instability)

-Look and feel normally NAD
-Reduced ROM
=Reduced IR
=Reduced extension (fixed flexion deformity)
-+/- Trendelenburg or antalgic gait

Question 5

Tonnis grading of radiological OA and Scoring systems

Answer 5

If features typical then clinical diagnosis made, plain x-rays otherwise first line

0: normal radiograph
1: mild sclerosis, mild joint space narrowing
2: moderate sclerosis and joint space narrowing, cysts in femoral head
3: obliteration of joint space, large cysts, loss of femoral head sphericity

LOSS: loss of joint space, osteophytes forming at joint margins, subchondral sclerosis, subchondral cysts

Oxford Hip Score for severity

Question 6

Management of OA

Answer 6

-Conservative: weight loss, exercise (local muscle strengthening, general aerobic fitness), physiotherapy, walking aids
-Medical: NSAIDs (topical first line, proton pump inhibitor with oral, and avoid if aspirin), opioids (if used infrequently for short-term relief), intra-articular steroid (short-term benefit 2-10 weeks)
-Surgical: total hip replacement (definitive)

Question 7

Describe greater trochanteric pain syndrome

Answer 7

-GTPS is a broad term used to describe
=Inflammation of the gluteal tendons insertion into the GT, and
=Inflammation of the trochanteric bursa

-A common cause of lateral ‘hip’ pain
-Commonly a sequalae of abnormal hip biomechanics
-Age 40-60* ♀»_space; ♂

Question 8

Presentation of greater trochanteric pain syndrome

Answer 8

-Lateral thigh pain
-Worse with exercise and lying on affected side

-Look: NAD
-Exquisitely tender over GT )jumps off bed)
-Move: pain with single leg stance, ROM normal (no stiffness) but may be painful

Question 9

Investigation of greater trochanteric pain syndrome

Answer 9

-Clinical
-However, the following may be useful:
=X/R – exclude OA
=MRI – diagnostic, but rarely required (gluteal muscles?)
=Diagnostic steroid injection into the hip (no benefit gained)

Question 10

Management of greater trochanteric pain syndrome

Answer 10

-90% recover
-Conservative: Weight loss, PT, treat the cause (i.e., optimise their biomechanics)
-Medical: NSAIDs, steroid injection (blind or USS-guided)
-Surgical: possible, but extremely rare

Question 11

Describe posterior hip dislocation

Answer 11

-Shortened, adducted, internal rotation
-In contrast to a #NOF when shortened and externally rotated
-Sciatic nerve injury common

Question 12

Describe native hip dislocation

Answer 12

-High risk of avascular necrosis(AVN) of the femoral head, sciatic nerve injury and associated femoral fracture
-Reduce hip asap

Question 13

Complications of total hip replacement

Answer 13

-Perioperative
=venous thromboembolism (4 weeks LMWH)
=intraoperative fracture
=nerve injury
=surgical site infection
-leg length discrepancy
-posterior dislocation
=may occur during extremes of hip flexion
=typically presents acutely with a ‘clunk’, pain and inability to weight bear
=on examination there is internal rotation and shortening of the affected leg
-aseptic loosening (most common reason for revision )
=prosthetic joint infection

Question 14

Types of hip replacement

Answer 14

1. Cemented hip replacement. A metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup
2. Uncemented hip replacements are becoming increasingly popular, particularly in younger more active patients. They are more expensive than conventional cemented hip replacements
3. Hip resurfacing is also sometimes used where a metal cap is attached over the femoral head. This is often used in younger patients and has the advantage that the femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life

Question 15

Minimising the risk of hip dislocation after surgery

Answer 15

-Avoiding flexing the hip > 90 degrees
-Avoid low chairs
-Do not cross your legs
-Sleep on your back for the first 6 weeks