Hip and Knee Anatomy
●● The hip joint is a ball and socket joint,
stabilised by static and
dynamic stabilisers
●● Static stabilisers include the capsule,
ligaments and labrum
●● Dynamic stabilisers consist of the muscles
acting across the
joint
●● Blood supply to the femoral head is mainly
derived from the
medial circumflex femoral artery
Complications of total hip replacement
Intraoperative complications
Nerve injury – sciatic, femoral and obturator
Vascular injury – femoral vein and artery
Femoral fracture
Fragments of cement left in joint
Postoperative complications
Deep vein thrombosis and pulmonary embolism
Leg length inequality
Dislocation
Infection
Aseptic loosening
Heterotopic ossification
Anatomy of the knee joint
● Complex synovial hinge joint
● The shape of the joint surfaces make it
inherently unstable
● The static stabilisers are the joint capsule,
menisci, cruciate and collateral ligaments
● The dynamic stabilisers are the quadriceps
and hamstrings muscles
Aetiology of osteoarthritis
Primary
Cause unknown, termed idiopathic
Associations: for example, genetics, gender, obesity
Secondary
Trauma
Avascular necrosis
Inflammatory arthropathy (e.g. rheumatoid arthritis)
Perthes’ disease
Developmental dysplasia of the hip
Slipped capital femoral epiphysis
Septic arthritis
Femoroacetabular impingement implicated as a possible cause
Osteoarthritis of the hip
● Osteoarthritis is a non-inflammatory and low-grade
inflammatory condition leading to progressive damage to the
articular cartilage and other joint structures
● The most consistent clinical features are groin pain and
limitation of movement
● Characteristic radiological findings include reduction of
joint space, subchondral sclerosis, subchondral cysts and
osteophyte formation
● Conservative treatment includes walking aids, non-steroidal
analgesics, physiotherapy and weight loss
● Surgical options include osteotomy, arthrodesis or a joint
replacement
Knee osteoarthritis
● More common in females
● Can be primary (idiopathic) or secondary (e.g. post
traumatic)
● The main symptom is pain made worse by use
● Examination reveals swelling, and reduced range of motion
with or without deformity
● The key radiographic features are joint space narrowing,
subchondral sclerosis and cysts, and osteophytes
● Treatment is non-operative initially. Knee replacement is
reserved for end-stage disease
Complications of total knee replacement
Intraoperative Risk factors for native joint septic arthritis.
Poor placement of implants leading to ● Extremes of age
instability or stiffness, ● Underlying joint abnormality, especially rheumatoid
or pain arthritis
Nerve or vessel injury including tourniquet ● Immunocompromise (e.g. diabetes mellitus, human
damage immunodeficiency virus infection, immunosuppressive
Fracture therapy)
Patellar tendon avulsion ● Joint instrumentation (e.g. steroid injection,
Malalignment arthroscopy)
Fat embolism ● Intravenous drug abuse
Postoperative ● Indwelling central venous catheter
Infection ● Bacteraemia (especially Staphylococcus aureus)
Deep vein thrombosis/pulmonary embolism
Pain/stiffness
Instability Diabetic foot infection
Osteolysis ● The most important risk factor for osteomyelitis is the
Component loosening presence of a foot ulcer
Dislocation ● Ulcer swabs are not reliable in determining the pathogens
responsible for osteomyelitis
● Bone biopsy for culture should be considered in extensive/
BONE TUMOURS complex infection, but may not be necessary in mild disease
● metastatic carcinomas – may show ●● In severe disease, surgical debridement of collections and/
histological features of or necrotic tissue is required, followed by antibiotics tailored
their tissue of origin; according to culture results
● haematopoietic tumours – e.g. myeloma;
● osteogenic tumours – e.g. osteosarcoma; ‘Red flags’
● chondrogenic tumours – e.g. ● Age <20 years or >50 years
chondrosarcoma; ● Recent significant trauma
● others – e.g. Ewing’s sarcoma. ● History of malignant disease
● Unexplained weight loss
Cauda equina syndrome presentation ● Constitutional symptoms (fever, chills)
● Low back pain ● Immunosuppression (intravenous drug abuse,
● Uni- or bilateral sciatica prolonged
● Saddle anaesthesia corticosteroid use)
● Motor weakness in the lower extremities ● Severe or progressive sensory alteration or motor
● Variable rectal and urinary symptoms weakness
● Commonest presenting symptoms: perineal ● Acute difficulty with micturition (painless
numbness, retention)
painless urinary retention and faecal ● Numbness in perineum or buttocks and/or faecal
incontinence incontinence
● Urgent investigation with MRI is required for
all suspected cases Non-spinal causes of low back pain:
● Confirmed CES requires surgical referred pain
decompression ● Respiratory, e.g. mesothelioma
● Vascular, e.g. abdominal aortic aneurysm
● Renal, e.g. pyelonephritis
Presentation of septic arthritis
● Gastrointestinal, e.g. peptic ulcer,
● Children may be toxic and febrile but adults
pancreatitis
may only have a low-grade fever
● Urogenital, e.g. testicular, ovarian or
● The joint is swollen and held in a
prostatic cancinoma
characteristic ‘position of comfort’
● Any movement causes extreme pain
Non-organic physical signs in low back pain
● Tenderness: superficial or non-anatomical
● Simulation tests: axial loading or rotation
● Distraction tests: variable straight leg raises
● Regional disturbances: non-anatomical sensory or motor loss
● Over-reaction: grimacing, muscle tremor, etc.

Upper motor neurone lesions Lower motor neurone lesions

● Increased tone – spastic ● Decreased tone – flaccid
● Hyper-reflexia ● Hyporeflexia
● Muscle spasms ● Denervation fasciculations
● Motor weakness ● Motor weakness
● Disuse atrophy ● Sensory loss
● Positive Hoffman’s sign ● Severe atrophy
● Ankle and patellar clonus ● Downgoing plantar response
● Upgoing plantar response

Spinal stenosis Forces going through the hip joint

● Extremely common condition in the 50–70-year age group ● Lifting leg from bed – one and a half times
● Classic symptoms: back, buttock, thigh and calf pain body weight
● Provoked by walking and extended posture ● Standing on one leg – three times body
● Relieved by flexed posture weight
● Symptoms progress in up to one-third of untreated patients ● Running and jumping – ten times body
weight

Spondylolysis
● Incidence in general population 6% by 14 years Carpal tunnel syndrome
● Incidence in athletic population 15–47% ● Night pain is common and relieved by
● May be completely asymptomatic/incidental finding on shaking the hand
radiograph ● Thenar wasting is an advanced sign
● Difficult to image, but MRI proving more useful ● Tinel’s, Phalen’s and Durkin’s tests are
● Conservative treatment: activity modification, antilordotic useful
brace ● Treatment includes splints and surgical
● Surgical treatment: direct repair preserving motion or spinal decompression
fusion if associated disc degeneration

Rheumatoid arthritis Osteoarthritis

Periarticular osteoporosis/subchondral Subchondral sclerosis and cysts
erosions
Periarticular soft-tissue swelling Less pronounced swelling
Joint space narrowing Joint space narrowing
Marginal erosions Marginal osteophytes
Joint deformity/malalignment Less pronounced deformities
Ankylosis Less common ankylosis
Chronic osteomyelitis
● Chronic disease requires specialist surgery with
excision,stabilisation and reconstruction
● Host status should be optimised before surgery
● Following surgery, antibiotic therapy is typically continued for
at least 6 weeks
Congenital and developmental abnormalities Congenital Causes of avascular necrosis of the femoral head
of the skeleton ● Steroids
● Achondroplasia affects enchondral ● Infection/surgery/previous injury or fracture
ossification and presents ● Perthes’ disease
with disproportionate short stature ● Sickle cell disease
● Exostoses may cause functional and/or ● Hypothyroidism
cosmetic problems ● Skeletal dysplasia – classically multiple epiphyseal dysplasia
● Patients with Ollier’s disease (multiple
enchondromatosis) often have lesions in the
hands and feet

Common causes of rickets Complications of bone and joint

1.Nutritional-Reduced intake of vitamin D and Infection
calcium Sepsis
2.Environmental-Inadequate exposure to sunlight Meningococcal sepsis
3.Gastrointestinaldisease-Crohn’s disease, gluten- TB
sensitive enteropathy Chronic relapsing/recurrent
4.Genetic-X-linked hypophosphataemia multifocal osteomyelitis
5.Renal disease-End-stage renal failure, renal Discitis
tubularanomalies; changes related to secondary Brodies’s abscess
hyperparathyroidism may be present

Occurence and treatment principles for bone and soft tissue infection
● Occurs by haematogenous spread, enhanced by microtrauma
● In untreated and/or chronic osteomyelitis, new involucrum
envelops dead sequestrum
● In addition to antibiotics, treatment consists of:
● Rest/splintage of affected limb
● Analgesia
● A joint effusion may be sympathetic or caused by direct
spread from the adjacent metaphysis
● Treatment involves drainage of pus when present
● Appropriate and often prolonged antibiotic therapy: parenteral
and then oral
● Treatment of the underlying condition, e.g. nutritional
deficiency, sickle cell disease

UROLOGY
Lower urinary tract symptoms (LUTS)
● Are classified as storage, voiding or post-micturitional
● Storage LUTS are frequency, nocturia, urgency and urge
incontinence
● Storage LUTS are typical of an overactive bladder
● Voiding LUTS are hesitancy, a reduced stream and
straining
● Voiding LUTS are typical of bladder outlet obstruction
● Some patients may have storage and voiding LUTS in
combination
● Are often investigated with urodynamics
Pyelonephritis
● More common in women
● Can be associated with septicaemia
● Associated with pyuria
● Should be treated initially with broad-spectrum antibiotics
● Is potentially fatal, especially if associated with obstruction of
the urinary tract
Autosomal dominant polycystic kidney disease
● Autosomal dominant condition
● Cysts may also occur in liver, pancreas and arachnoid
membrane
● Usually does not manifest before 30 years of age
● Clinical manifestations are divided into renal and extrarenal
● Hypertension is the most common clinical manifestation
● Renal function declines after the 4th to 6th decade of life
● Men tend to progress to renal failure more rapidly than women

Genitourinary tuberculosis (TB)

● Is always either re-infection or reactivation of old TB
● Is a cause of sterile pyuria
● Spreads from the kidney to involve the distal ureters
and
bladder around the ureteric orifices
● Treatment involves short-course therapy
● Surgery is increasing for this condition

STONES
Aetiology
● idiopathic calcium urolithiasis
● hypercalcaemic disorders-
1. primary hyperparathyroidism 2.Sarcoidosis 3.prolong immobilization 4.Milk alkali
syndrome
● renal tubular syndromes-
1.Renal TB 2.Cystinuria
● uric acid lithiasis
● enzyme disorders-
1.Primary hyperoxaluria 2. xanthinuria 3. 2, 8-dihydroadeninuria
● secondary urolithiasis-
1. SECONDARY HYPEROXALURIA 2. DIETARY EXCESS 3. INFECTION 4.
OBSTRUCTION AND STASIS 5. MEDULLARY SPONGE KIDNEY 5. URINARY
DIVERSION 6. DRUGS (Acetazolamide, Thiazide, Allopurinol)
● other factors-
geography,climatic and seasonal factors,water intake;diet,occupation, especially sedentary
jobs in hot environments.

Urinary stones
● The commonest urinary tract stones are calcium
oxalate
● Stones are best diagnosed on a non-contrast computed
tomography kidney–ureter–bladder (KUB)
● Most stones <5 mm will pass spontaneously
● Medical expulsive therapy remains controversial
● Indications for surgical intervention are persistent pain,
obstruction and infection
Extracorporeal shockwave lithotripsy Renal cell carcinoma (RCC)
● Is the commonest method of treating urinary tract ● Arises from epithelium of the proximal
stones convoluted tubule
nowadays ● Frequently detected coincidentally
● Several sessions of ESWL may be needed for ● Has a male preponderance
complete stone ● Major subtypes are clear-cell, papillary and
fragmentation chromophobe RCC
● Stone fragments collecting in the distal ureter post ● Surgery is the mainstay of treatment for organ-
ESWL are confined disease
called Steinstrasse ● Metastatic disease is treated with tyrosine kinase
inhibitors
Benign tumours of Kidney (TKIs) or mTOR inhibitors
Adenoma
Angioma
Angiomyolipoma

Renal trauma
● 10% of trauma cases involve the genitourinary tract
● Blunt trauma is much more common than penetrating trauma
● Most cases of blunt trauma are treated conservatively
● Most penetrating injuries require renal exploration
Treatments for incontinence can be summarised as follows-
1. Conservative measures: lifestyle interventions, pelvic floor muscle and bladder
training.
2. Devices: external penile condom or an indwelling urethral or suprapubic catheter.
3. Drugs: adrenergic blockers, TCA, anticholinergic drugs, Botulinum toxin A, Duloxetine
4. Intermittent self-catheterisation: to improve emptying.
5. Increasing outlet: pelvic floor physiotherapy
6. Denervation of bladder: S3 sacral nerve blockade
7. Sacral nerve stimulation device
8. Augmentation of bladder
9. Urinary diversion

Urinary tract infections ( UTIs) in adults

● Isolated UTIs in adults are not infrequent and are more common in women
● Recurrent or complicated infection (haematuria, rigors) warrants appropriate
antimicrobial therapy and investigation
● Investigation to exclude a predisposing cause includes urinalysis, microscopy and
culture, upper tract imaging and cystoscopy
● Mycobacterium tuberculosis, Neisseria gonorrhoeae or Mycoplasma genitalium should
be suspected if pus cells are present but urine culture is negative
● Cancer, especially CIS, masquerading as infection may be diagnosed as a bacterial
cystitis
Urothelial cell carcinoma of the bladder
● The fourth most common non-dermatological malignancy inmen (male:female ratio 3:1)
● Strongly associated with smoking and chemical exposure inwestern societies
● Strongly associated with Schistosoma haematobium infection(bilharzial bladder cancer)
in regions where the parasite isendemic
● Reducing in incidence in countries where smoking isdecreasing
BENIGN PROSTATIC HYPERPLASIA
Serum testosterone levels slowly but significantly decrease with advancing age; however,
levels of oestrogenic steroidsare not decreased equally. According to this theory, the
prostateenlarges because of increased oestrogenic effects. It is likely that the secretion of
intermediate peptide growth factors plays a part in the development of BPH.

Benign prostatic hyperplasia (BPH)

● Occurs in men over 50 years of age; by the age of 60 years, 50% of men have
histological evidence of BPH
● Is a common cause of significant lower urinary tractsymptoms in men and is the most
common cause of bladder outflow obstruction in men >70 years of age
Consequences of benign prostatic hyperplasia
● No symptoms, no bladder outflow obstruction (BOO)
● No symptoms, but urodynamic evidence of BOO
● Lower urinary tract symptoms, no evidence of BOO
● Lower urinary tract symptoms and BOO
● Others (acute/chronic retention, haematuria, urinary infectionand stone formation)

BOO may result from: common causes of urethral stricture are:

● BPH;
● bladder neck stenosis;
● bladder neck hypertrophy;
● prostate cancer;
● urethral strictures;
● functional obstruction due to neuropathic conditions
Varicocoele
● Varicocoele is a common condition and 90% are
left sided
● Development of a left-sided varicocoele in later life
may indicate the presence of a renal tumour
● They are usually asymptomatic and as such rarely
need treatment
● First-line treatment is embolisation in symptomatic
cases
● Varicocoeles often recur, even after surgical
treatment
● The association of varicocoeles with subfertility is
controversia
Acute epididymo-orchitis
● In young men usually arises secondary to a
sexually transmitted genital infection
● In older men usually arises secondary to
urinary infection
● May be a complication of catheterisation or
instrumentation of the urinary tract
● May need aggressive treatment with parenteral
antibiotics
● Inflammatory
● Secondary to urethritis
● Secondary to balanitis xerotica obliterans (BXO)
● Traumatic
● Bulbar urethral injury
● Pelvic fracture urethral disruption injury
● Iatrogenic
● Secondary to urethral instrumentation including
catheterisation
and transurethral prostatectomy
● Secondary to radical prostatectomy
● Secondary to radiotherapy for prostate cancer
● Idiopathic
Hydrocoele
● A hydrocoele is a collection of fluid within the
tunica vaginalis
● Primary hydrocoeles surround the testis and
transilluminate brightly
● Ultrasound examination is valuable, especially
when the testis and epididymis are impalpable
● Hydrocoeles can be treated conservatively unless
they are large and symptomatic
● Surgery is the mainstay of treatment
● Testicular malignancy is an uncommon cause of
hydrocele that can be excluded by ultrasound
examination