Orthopaedic Hip Conditions

Question 1

Describe the blood supply to the femoral head?

Answer 1

Femoral head has limited blood supply:

• Profunda femoris
  
  • Branches medial and lateral circumflex arteries
  • MFCA (main supply)
    
    • 2 branches
      
      • Ascends to head
      • Transverse to form cruciate anastomosis
  • LFCA
    
    • 3 branches
      
      • Ascending branch to joint capsule
      • Transverse branch to cruciate anastomosis
      • Descending branch
• Minor contributors
  
  • Artery of ligamentum teres
  • Nutrient arteries of bone

Question 2

What is the main blood supply to the femoral head?

Answer 2

• Profunda femoris
  
  • Branches medial and lateral circumflex arteries
  • MFCA (main supply)
    
    • 2 branches
      
      • Ascends to head
      • Transverse to form cruciate anastomosis
  • LFCA
    
    • 3 branches
      
      • Ascending branch to joint capsule
      • Transverse branch to cruciate anastomosis
      • Descending branch

Question 3

What are the branches of the MFCA?

Answer 3

• 2 branches
  
  • Ascends to head
  • Transverse to form cruciate anastomosis

Question 4

What are the branches of the LFCA?

Answer 4

• 3 branches
  
  • Ascending branch to joint capsule
  • Transverse branch to cruciate anastomosis
  • Descending branch

Question 5

Describe the blood supply to the femoral neck?

Answer 5

• Primary blood supply enters via capsule
  
  • Significant because fracture of neck of femur disrupts supply (intracapsular)
  • Extracapsular fractures blood supply maintained

Question 6

What is osteoarthritis?

Answer 6

Osteoarthritis = degenerative change of synovial joint, causing progressive loss of articular cartilage and secondary bony changes

Question 7

What is osteoarthritis characterised by?

Answer 7

Characterised by worsening pain and stiffness of affected joint

Question 8

What is the main treatment of osteoarthritis of the hip?

Answer 8

• Hip replacement

Question 9

What is trochanteric bursitis?

Answer 9

Trochanteric bursa = fluid filled sac sandwiched between hip abductors and ITB

Question 10

What is bursitis?

Answer 10

Bursitis = inflammation of bursa

Question 11

Describe the epidemiology of trochanteric bursitis in terms of sex?

Answer 11

• F>M

Question 12

What are some causes of trochanteric bursitis?

Answer 12

• Trauma
• Over-use
  
  • Athletes, often runners
• Abnormal movements
  
  • Distinct problem
    
    • Scoloiosis
  • Local problems
    
    • Muscle wasting following surgery
    • Total hip replacement
    • Osteoarthritis

Question 13

What are the clinical features of trochanteric bursitis?

Answer 13

• Pain
  
  • Worse lying on side and walking
• Swelling

Question 14

What investigations are done for trochanteric bursitis?

Answer 14

• X-rays
  
  • Exclude arthritis
• MRI
  
  • Shows soft tissues and fluid
• Ultrasound

Question 15

What is the treatment of trochanteric bursitis?

Answer 15

• NSAIDs
• Relative rest/activity modifications
• Physiotherapy
  
  • Correct posture
  • Stretching
  • Strengthen muscles around joint
• Injection
  
  • Corticosteroids
• Surgery
  
  • Bursectomy

Question 16

What is avascular necrosis?

Answer 16

Is death of the bone due to loss of bony supply

Question 17

Describe the epidemiology of avascular necrosis in terms of sex and age?

Answer 17

• M>F
• Average age 35-50

Question 18

What are risk factors for avascular necrosis?

Answer 18

• Trauma
  
  • Irradiation
  • Fracture
    
    • Injury to femoral head
  • Dislocation
  • Iatrogenic
• Systemic
  
  • Idiopathic
  • Hypercoagulable states
  • Steroids
  • Haematologica
    
    • Sickle cell disease
    • Lymphoma
    • Leukaemia
  • Caisson’s disease
  • Alcoholism

Question 19

Describe the pathophysiology of avascular necrosis?

Answer 19

Question 20

What are the clinical features of avascular necrosis?

Answer 20

• 80% of time bilateral
• 3% of time multifocal
• Insidious onset of groin pain
• Limp
• Reduced range of motion
• Stiff joint

Question 21

What investigations are done for avascular necrosis?

Answer 21

• X-ray
• MRI
  
  • Will identify earliest changes

Question 22

What is the treatment of avascular necrosis?

Answer 22

• Non-operative
  
  • Reduced weight bearing
  • NSAIDs
  • Bisphosphonates
  • Anticoagulants
  • Physiotherapy
• Surgical
  
  • Restore blood supply
    
    • Core decompression
    • Core decompression and vascularised graft
  • Move lesion away from weight bearing area
    
    • Rotational osteotomy
  • Total hip replacement

Question 23

What does FAI stand for?

Answer 23

Femoroacetabular impingement

Question 24

What is impingement?

Answer 24

Impingement is two surfaces hitting together

Question 25

FAI is a common cause of what?

Answer 25

* Hip pathology in younger patient * Secondary osteoarthritis

Question 26

What are the 2 categories of femoroacetabular impingement?

Answer 26

* **Cam lesion** * Femoral-based impingement * Usually young athletic mnales * Excess bone leading to * Decreased head to neck ratio * Aspherical head * **Pincer** * Acetabulum based impingement * Usually in active females * Abnormal acetabulum leading to * Anteriosuperior acetabular rim overhang * Acetabular protrusion

Question 27

Cam lesion is a what based impingment?

Answer 27

Femoral based impingement

Question 28

Pincer is a what based impingement?

Answer 28

Acetabulum based impingement

Question 29

Which of cam lesion and pincer FAI affect males more than females?

Answer 29

Cam lesion - males Pincer - females

Question 30

What bony changes does cam lesion FAI cause?

Answer 30

* Excess bone leading to * Decreased head to neck ratio * Aspherical head

Question 31

What bony changes does pincer FAI cause?

Answer 31

* Abnormal acetabulum leading to * Anteriosuperior acetabular rim overhang * Acetabular protrusion

Question 32

What are associated injuries to FAI?

Answer 32

* Labral degeneration and tears * Cartilage damage and flap tears * Secondary hip osteoarthritis

Question 33

What is the presentation of FAI?

Answer 33

* Groin pain * Mechanical symptoms * Block to movement * Pain with certain movements * Reduced range of motion * Flexion and internal rotation

Question 34

What investigations are done for FAI?

Answer 34

* FADIR test * X-ray * Identify bony pathology * MRI * Assesses associated conditions like labral tears and articular cartilage damage

Question 35

What is the treatment of FAI?

Answer 35

* Non-operative * Activity modification * NSAIDs * Physiotherapy * Correct posture * Strengthen muscles around joint * Operative * Arthroscopy * Shave down defect * Deal with labral tears * Resect articular cartilage flaps * Open surgery * Resection * Periacetabular osteotomy * Hip arthroplasty * Resurfacing * Replacement

Question 36

What is the most common kind of labral tear?

Answer 36

Most commonly is an anterosuperior tear

Question 37

Describe the epidemiology of labral tear in terms of age and sex?

Answer 37

* All age groups * Commonly active females

Question 38

What are causes of labral tear?

Answer 38

* FAI * Trauma * OA * Dysplasia * Collagen disease * Ehler’s-Danlos

Question 39

What is the presentation of labral tear?

Answer 39

* Groin or hip pain * Snapping sensation * Jamming or locking * Positive FEBER test

Question 40

What investigations are done for labral tear?

Answer 40

* X-ray * MRI * Diagnostic injection (contrast)

Question 41

What is the treatment of labral tear?

Answer 41

* Non-operative * Activity modification * NSAIDs * Physiotherapy * Injection of steroids * Operative * Arthroscopy * Repair * Resection

Question 42

What is arthroscopy?

Answer 42

A minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision