The Hip by 7ODBPL


									The Hip

Joint meeting IBEC & RCSI.
Cappagh National Orthopaedic Hospital.

Dr. Aamir Shaikh.
Clinical Lecturer of Orthopedics RCSI &

15th December 2010.
 1: Anatomy
 2: Clinical features.
 3: Examination.
 4: Pathology.
 5: Treatment.

Ball and socket joint of synovial joint.

Connects the pelvic girdle to the lower limb

Made up of femoral head and acetabulum

Designed for stability and wide range of

Covered with a thin layer of hyaline
                                    More Anatomy

The articular surface of is horse-
shoe shaped and is deficient
inferiorly- acetabular notch

Has a labrum
-is a circular layer of cartilage
which surrounds the outer part of
the acetabulum making the socket
deeper and so helping provide
more stability

-Acetabular labral tears are a
common injury from major or
repeated minor trauma
                             Iliofemoral Ligament

This is a strong ligament which
   connects the pelvis to the femur
at the front of the joint

It resembles a Y in shape

Stabilises the hip by limiting
 Pubofemoral ligament
   The pubofemoral ligament attaches the part of the pelvis known
    as the pubis (most forward part, either side of the pubic
    symphysis) to the femur.
 Ischiofemoral ligament:
   This is a ligament which reinforces the posterior aspect of the
   attaches the ischium to the two trochanters of the femur.
 Transverse acetabular Ligament:
   Bridges acetabular notch.
 Ligament of head of femur: flat and triangular in shape
     Lies within joint, ensheathed by synovium

Gluteus Maximus, Gluteus
Minimus and Gluteus Medius

Attach to the Ilium and travel laterally
to insert into the greater trochanter
of the femur

 Medius and Minimus abduct and
medially rotate the hip joint, as well
as stabilising the pelvis

Gluteus maximus extends and
laterally rotates the hip joint
                                      More Muscles

The four Quadricep muscles are Vastus
lateralis, medialis, intermedius and
Rectus femoris

All attach inferiorly to the tibial

Rectus femoris originates at the
Anterior Inferior Iliac Spine and acts to
flex the hip

The 3 other Quad muscles do not cross
the hip joint, and attach around the
greater trochanter and just below it.
Still More Muscles:


The is the primary hip flexor muscle
which consists of 2 parts

Attaches superiorly to the lower part of
the spine and the inside of the ilium

Cross the hip joint and insert to the
lesser trochanter of the femur

The hamstrings are three muscles which
form the back of the thigh

Attach superiorly to the ischial tuberosity

Cause hip extension
Functional Group of Muscles Acting on the Hip
        Iliopsoas, sartorius, tensor fascia lata, rectus femorus, pectineus, adductor
         longus, brevis, and magnus, gracilis
      - hamstrings, addcutor magnus, gluteus maximus
      - adductor longus, brevis, and magnus, gracilis, pectineus
      - gluteus medius, minimus, tensor fascia lata
    External rotators:
      - obturator externus, internus, piriformis, quadratus femoris, gluteus maximus
    Internal Rotators:
      - gluteus medius, minimus, tensor fascia lata.

Femoral (L2,3,4)

Obturator (L2, 3, 4)

Sciatic (L4,5, S1, 2,)

-Referred pain to the knee can
hide hip pathology and vis
Blood Supply
     Clinical features of Hip Pathology:
 Pain.
 Stiffness.
 Loss of function.
 Crepitations.
 Leg length
 Most important reported symptom.
   Site:       Where?
     Anterior hip pain DDx: arthritis, hip flexor strain, iliopsoas bursitis,
       labral tear
     Lateral hip pain DDx: greater trochanteric bursitis, gluteus medius tear,
       iliotibial band syndrome (athletes), meralgia paresthetica (an entrapment
       syndrome of the lateral femoral cutaneous nerve syndrome)
     Posterior hip pain DDx: hip extensor and external rotator pathology,
       degenerative disc disease, spinal stenosis
     REFERED PAIN: to knee. hip pathology can be referred to the knee as
       they share the same nerves!!!!
     Just because your patient has hip pain does not mean they have hip not forget about referred pain from hernias, aorto-iliac
       vascular occlusive disease, etc.
The Pain Continues...
 Timing: When did it start?
   Hours, days, weeks, years
 Does it radiate?
   Sciatica can run from the hip, down the back of the thigh, into
    the foot
   Radiates to the groin can imply inguinal hernia, groin strain,
 What does it feels like?
   Sharp: muscle strain/tear, fracture
   Dull: OA, RA
   Achy: OA, RA, AVN
 What were they doing when the pain came on?
   Did they fall?
     fractures, muscle tears, haematomas, etc
   Playing sports?
     Muscle sprain, labral tear, etc
   Prolonged exercise?
     OA
   Gradual vs sudden?
     RA,OA vs. trauma
 Do they have any aggravating or relieving factors?
   OA gets worse as they day goes on and is relieved by rest
   Muscle tears/sprains may be exacerbated by certain positions
   RA is worse after prolonged periods of rest
   If analgesia works, find out what they take and how often!
 How does the pain affect their daily life?
   How far can they walk?
   Difficulty walking up/down stairs?
   Are they still able to do their favourite hobbies?
   Has their partner noticed their pain limiting them?
   Are they taking regular analgesia?
If the pain is manageable
   this effects your
   management plan

Always opt for
  conservative measures
  over surgical ones

Use analgesia and
 physiotherapy/ OT
 when and where

When necessary offer
 surgical treatment if
The Always Daunting Physical Exam
Watch the patient walk into the room and sit down
        - walking aid, limp, uncomfortable gait
Inspect hips for scars, swelling, obvious deformity
Assess leg length for any true leg length discrepancy (measure
  from ASIS medial malleolus) and apparent leg length
  (umbilicus  medial malleolus)
        - a difference in true leg length indicates hip disease on
  the shorter side
        - a difference in apparent leg length are due to tilting of
  the pelvis
 Mid point of inguinal ligament
   hip joint and iliopectinal bursa
 Lateral aspect of thigh
   trochanteric bursa
 Feel for crepitations while hip is moved in I.R / E.R

Test flexion (135 deg):

flex knee and move it
towards the chest without
moving the opposite leg

 if opposite side moves
(tests for fixed flexion
                              More Movement
 Rotation (45 deg)
   -With hip and knee flexed move the foot outward (ext rotation of hip) and inward (int
     rotation of hip
 Abduction (50 deg)       Adduction (45 deg):
   - stand on the same side of the bed as the leg being tested
   - put your hand over the ASIS of the side not being tested to stabilize the pelvis
   - with your other hand grasp the heel of the leg being tested and move it outwards as far
   as possible
   - then bring the leg across to the opposite side to test
 Extension (30 deg):
   - ask the patient to roll onto their stomach
   - place one hand over the sacroiliac joint while the other elevate each leg
And the Extra Tests
Trendelenburg test:
- ask the patient to stand first on one leg
then the other
- normally the non weight bearing hip
rises or stays level
- with proximal myopathy or hip joint
disease the non weight bearing side sags

Neurological exam:
-power, tone, sensation
Know your nerve supply!!!
           flexion: L2/3
           extension: L5, S½
           abduction: L4/5, S1
           adduction: L2/3/4
Trendelenberg Test:
HIP Pathology.
   A degenerative joint
       disease that causes
       stiffness, pain, and
       reduction in

What are the two types?
  Primary OA: middle
     aged/ elderly,
     aetiology unknown

    Secondary OA: anyone
      with predisposing
      factors such as SUFE,
      CDH, DDH, Perthes,
      or early onset trauma/
      fracture to hip joint etc
                     OA Pathogenesis
-Affects weight bearing joint.
-Prevalence increases with age
-Disease accelerated by mechanical
instability/ stress on jt/increased
stress on jt surface
- initial changes in articular cartilage
 fibrillation of cartilage vertical
clefts  exposure of subchondral
- with continuous pressure this leads
to sclerosis of subchondral bone
- bone degeneration under stress
creates cysts
-At joint margins new bone forms
resulting in spurs/ osteophytes.
   Radiological manifestations:
Subchondral Sclerosis.
And this?
Spur/ osteophytes.
This one?
Sub periosteal Cyst

And finally.

Bone on bone
surface contact.
                OA Presentation
   Pain: relieved by rest
   Stiffness: typically lasting 15-20min then disappears
   Joints show reduced movement and is associated with crepitus
   Joint swelling/ deformity
   Usually affects weight bearing joint
     Hip: pain in buttock/upper thigh, limited movement resulting in
        antalgic gait, hesitant gait to avoid pain
       Knee: pain/crepitus at joint surface, deformity results in bow legs/
        knock knees
       Spine: usually C/L spine, stiffness, radicular pain from compression
        of spinal nerves
       Hands: Heberden’s node, Bouchard’s nodes
       Feet: deformity of 1st MT bunion
What to look for on X-rays ?
1. Narrowing of jt
2. Sclerosis of
   subcondral bone
3. Cystic bone
4. Osteophytes
Osteoarthritis model:
 Conservative
     Weight loss
     Modify daily activities, walking aids
     Physiotherapy
     Analgesia: aspirin, paracetamol , NSAIDS + other opioid.
 Surgical
   Arthroplasty
     When patients have severe pain, nocturnal pain, pain at rest, and severely
      restricted mobility & functional in-capacity.
   Arthrodesis
     Rarely used in OA, sometimes used in pt too young for hip replacement
   Osteotomy
     Utilised to realign deformities and spread the transmitted loads more evenly
      in younger pts
              Rheumatoid Arthritis
Is a chronic systemic disease
of unknown aetiology
Characterized by chronic
symmetric inflammation of
the joints
Variable extra articular
F>M 4:1
Genetic prediposition with
RA Pathogenesis

 Primarily involve synovial joint
 Inflammation synovitis  exudation of fluid and
  inflammatory cells into joint cavity
 Inflammation stimulates ingrowth of vessles and proliferation
  of synovial cells  pannus
 Pannus secretes lytic enzymes and mediators of
  inflammation destroys cartilage and erodes underlying
              RA Presentation
 Often insidious but may present with a sudden onset of joint pain, swelling,
 Early morning stiffness
 Symmetrical involvement of small jts
 Joint deformity and contracture
    Hands: z-deformity, Swan Neck, Boutonnierre, ulnar deviator, subluxation of
 a/w low grade fever, loss of appetite, malaise, fatigue
 Extra articular manifestation:
   Lymphadenopathy
   Splenomegaly
   Subcutaneous nodules
   Eyes: scleritis, keratoconjunctivitis sicca, Sjogrens syndrome
   Lungs: serositis, fibrosis
   CVS: pericarditis, pericardial effusion
Hands Deformities:
 History and Physical Exams
 Bloods: FBC (check for anaemia from chronic
  disease/methotrexate /vit def), ESR, CRP, Rheumatoid
   Check uric acid levels to outrule gout
 X-rays
    What to look for on X-rays
Soft tissue swelling

Juxta-articular osteopaenia

Marginal erosions

Joint space narrowing

   Hands are often affected
American College of Rheumatology
   morning stiffness
   arthritis of 3 or more joint areas
   arthritis of hand joints
   symmetric arthritis
   subcutaneous rheumatoid nodules
   serum rheumatoid factor
   x-ray finding — periarticular erosions, osteopenia, loss of joint
 A patient has RA if at least 4 criteria are present and the first
  four for 6 weeks
 Medical:
   NSAIDs
     Reduce stiffness and synovitis, improve mobility
     do not change outcome
   Second Line Tx
     Gold salts, penicillamine, immunosuppressants (methotrexate)
      infliximab (anti tnf-α)
     Known as the DMARDs (Disease modifying antirheumatic drugs)
   Third Line Tx
     Corticosteroids (prednisolone) – lowest dose to control symptoms and
      minimize side effects
     Intra-articular steroids may be utilised in accessible joints
 Surgical
   Early in disease process before significant radiographic
    changes – synovectomy
      Can be performed arthroscopically
   Advanced disease
      Joint replacement (Arthroplasty) – particularly hip
       and knee
        Restores pain free function
   Joint fusion (arthrodesis) – now confined to digital
    joints, ankle and wrist
         Total Hip Replacement:
 Prosthetic replacement of arthritic hip joint with metal.
 Two components acetabular & Femoral.
 Acetabulum shell is either made from poly, X3 or metal with
  or without option for securing with cancellous screws.
 Bearing surface acetabular: UHMW Polyethylene.
                              X3 Poly. With or without 10 deg
                                       posterior lip.
                              Ceramic or metal.
 Stem use is metal with polish coat or porous coat finish of
  different offset.
 Either cement use on both sides or no cement use sometimes
  hybrid system is used.
         Bone cement : PALACOS-R
 Constituents:  1: 40.8 gm of powder (polymer) with:
Gentamicin 0.5 gm as Gentamicin sulphate.
Methyl- methacrylate- methyl acrylate co-polymer
Benzoyl peroxide.
Zirconium dioxide.
                2. 18.8 gm of liquid in amber glass ampoule.
Methyl methacrylate (stablised with hydroquinone)
N-N –dimethyl-p-toluidine
Chlorophyll – copper-complex.
What does a hip replacement look like?
What do they look like on x-ray?
Complications of hip replacement
 GA/ spinal anaesthetic risk
 Need for blood transfusion
 Infection
 Loosening of replacement
 Altered leg length
 Mechanical failure
 Dislocation of Total hip replacement.
 Hip Abductor muscle weakness.
What does an Arthodesis Look Like?
Total Hip Replacement:
           Arthroscopic Hip Procedure:
 Minimally invasive hip procedure designed to carry out on
    selected patients for diagnostic or therapeutic purpose.
   Indications: for identifying and treating labral tear.
                 for debridement of loose cartilaginous fragment.
                 Proceed for core decompression in selected pt.
                 arthroscopic washout for infected hip.
Arthroscopic Approach to Hip joint:
Hip arthroscopic procedure:
Which is which....

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