The Hip: Core Lecture

Class IC3 January 2016

Lecturers Iain Feeley

Richard Downey
Martin Kelly
Lauren Tiedt
 Learning Objectives
• After this lecture you should be able to:
– Obtain a structured musculoskeletal history from a patient
presenting with hip pain
– Demonstrate a structured comprehensive examination of the
hip joint
– Be able to explain aetiology; prognosis; treatment and
possible complications of treatment for common hip
pathologies
– Demonstrate a structured approach to the assessment of
radiographs of the hip
Anatomy – Femoral Head
• Lesser trochanter: Distal attachment of the iliopsoas.
• Greater trochanter: Attachment for gluteus medius and
minimus
• Trochantaric line: iliofemoral lig of hip attaches here
• Trochantaric fossa (b/w the GT and the femoral
neckpiriformis and both the obturator internus and
externus)
• Gluteal tuberosity posteriorly is where gluteus maximus
attaches.
• Linea aspera: adductors, vastus muscles and short
head of biceps femoris
• Adductor tubercle: adductors and vastus muscles
Anatomy - Acetabulum
• Deep
– Encompasses most of
femoral head
– Reduces risk of dislocation
• Horseshoe shaped
hyaline cartilage
– Acetabular notch inferiorly
• Acetabular Labrum is a
fibrocartilagenous rim
which deepens
acetabulum
 Anatomy - Capsule

Coxa vara is a deformity of the hip, whereby the

angle between the head and the shaft of the
femur is reduced to less than 120 degrees. This
results in the leg being shortened, and the
development of a limp. Coxa valga is a deformity
of the hip where the angle formed between the
head and neck of the femur and its shaft is
increased, usually above 135 degrees. It is
caused by a slipped epiphysis of the femoral
head.
 Anatomy - Muscles

• Hip Flexors
• Hip Extensors
• Hip Adductors
• Hip Abductors
• Hip External rotators
• Hip Internal rotators
 Anatomy - Muscles
• Hip Flexors

– Iliopsoas, sartorius, rectus femoris, tensor fascia lata,, pectineus adductor longus, brevis,
and magnus, gracilis
• Hip Extensors

– hamstrings, adductor magnus, gluteus maximus

• Hip Adductors
– adductor longus, brevis, and magnus, gracilis, pectineus
• Hip Abductors and internal rotators
– gluteus medius, minimus, tensor fascia lata
• Hip External rotators
– obturator externus, internus, piriformis, quadratus femoris, gluteus maximus
 Anatomy – Blood Supply
• 2 main suppliers
– Medial and lateral circumflex
arteries
• Medial > Lateral
• Ascending supply
• Profunda femoris
– Foveal artery
• Posterior division of obturator
artery

• Risk of AVN with intracapsular

#NoF
 Anatomy – Nerve Supply
• Femoral (L2,3,4)

• Obturator (L2, 3, 4)

• Sciatic (L4,5, S1, 2,)

• WHY ARE THESE

IMPORTANT???
- Referred pain to the knee can
hide hip pathology and vis versa
 History

•PAIN
• Stiffness
 History
• PAIN
 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
 Knee pain: 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
pathology....do not forget about referred pain from hernias, aortoiliac
vascular occlusive disease, ect
 History
• PAIN
 History
• PAIN
 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, ect.
 What does it feels like?
 Sharp: muscle strain/tear, fracture
 Dull: OA, RA
 Achy: OA, RA, AVN
 History
• What were they doing when the pain came on?
– Did they fall?
• fractures, muscle tears, haematomas, ect
– Playing sports?
• Muscle sprain, labral tear, ect
– Prolonged exercise?
• OA
– Gradual vs sudden?
• RA,OA vs. trauma
 History
• How bad is it and is it always there?
– Always ask the patient to score their pain based on
their pain threshold
– OA is worse as the day goes on
– RA present with morning stiffness and pain last
>30min, may be intermittent initially
– Muscle strain/tear may be a constant dull ache
– Bursitis may be intermittent
 History
• Do they have any aggravating or relieving
factors?
– OA gets worse as they day goes on and is relieved
by rest
– Bursitis/ muscle tear/sprain may be well controlled
with analgesia
– 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!
 History

• 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?
 History
When deciding on treatment

– Always opt for conservative measures over surgical

ones

– Use analgesia and physiotherapy/ OT when and

where appropriate

– When necessary offer surgical treatment (if

appropriate)
 History
• PMHx:
– Have they had any childhood hip disease?
• Perthes, Slipped Upper Femoral Epiphysis , CDH, ect. Predisopse to
OA
– Have they previously injured their hip or had problems with
their hip?
• Previous hip fractures may lead to OA
• Previous bursitis may become aggravated
– Any other illnesses?
• Is the patient fit for surgery if they need it?
• Do they need to be reviewed by respiratory, cardiology, ect
• Will they be at risk of infection? DM, PVD, ect
 History
• Sx
– Who will take care of them when they go home post
operatively?
– Will they need to go to a step down facility?
– Does OT need to asses their home?
• Stairs, bathroom access
• Are they liable to fall at home???
– Do they smoke?
• If so they are at a higher risk of infection, wound
breakdown
 Examination
– Inspection (Look)

– Palpation (Feel)

– Movement (Move)

– Measurement

– Special Tests
 Look
• Involves a general
inspection of the patient
• Gait
– Antalgic
– Trendelenberg
– Waddling
– Circumduction: make circ
– Short limb gait
 Look
• Standing
– Adequate exposure
– Pelvic obliquity
– Scars, swellings, symmetry
 Feel
• Mid point of inguinal ligament
– hip joint and iliopectinal bursa
• Lateral aspect of thigh
– trochanteric bursa
• Place thumbs on ASIS while finger are placed
on tips of greater trochanter
– if abnormal usually higher one is the abnormal one
 Movement
• Test flexion (135 deg):

• Flex knee and move it

towards the chest without
moving the opposite leg

• If opposite side moves

apply THOMAS TEST
(tests for fixed flexion
deformity)
 Movement
• Rotation (45 deg)
-With hip and knee flexed move the foot medially (ext rotation of hip) and laterally (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 adduction
• Extension (30 deg):
- ask the patient to roll onto their stomach
- place one hand over the sacroiliac joint while the other elevate each leg
Measure
 Special 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 sympathy 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

Distal Pulses
 Common causes of hip pain

– Osteoarthritis
– Rheumatoid arthritis
– Labral tear/Soft tissue pathology
– Osteonecrosis
– Femoroacetabular impingement syndrome
– Paediatric conditions presenting in early adulthood
– Trauma
 Osteoarthritis
What is it?
A degenerative joint disease that causes
stiffness, pain, and reduction in
movement

Who are the two types?

Primary OA: middle aged/ elderly,
aetiology unknown

Secondary OA: anyone with predisposing

factors such as SUFE; DDH; Perthes
disease; FAI
 Osteoarthritis
-Affects weight bearing joints
-Prevalence increases with age
-Disease accelerated by mechanical instability/ stress on
joint/increased stress on joint surface
- initial changes in articular cartilage  fibrillation of
cartilage vertical clefts  exposure of subchondral
bone
- with continuous pressure this leads to sclerosis of
subcondral bone (eburnation)
- bone degeneration under stress creates cysts
-At joint margins new bone forms resulting in spurs

–LOSS
 Osteoarthritis
Pain: relieved by rest
Stiffness: typically lasting 15-20min then
disappears
Joints show reduced movement and is
associated with crepitus
Joint swelling/ deformity
 Osteoarthritis
 Conservative Treatment
 Weight loss
 Modify daily activities, walking aids
 Exercising within the limits of pain should be encouraged
 Physiotherapy
 Analgesia: aspirin, paracetamol NSAIDS
 Surgical Treatment
 Arthroplasty
 When patients have severe pain, nocturnal pain, pain at rest, and
severely restricted mobility
 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
 What is arthroplasty?
 Surgical replacement of all/part of a
joint with a prosthesis
 Hip arthroplasty is one of the most
common operations performed
(over 70,000 per year in the UK),
and demand projected to increase
by >40% over the next 3 decades
(increasingly aged population,
increasing obesity, etc.)
 One of the most important
advances in modern medicine
 Fixation Methods
Cemented
 Polymethylmethacrylate (PMMA) forms a grout with limited remodelling
potential (hard within 10 minutes)
 Smooth metal femoral stem (usually cobalt chrome)
 Plastic acetabular cup
 Preferred for irradiated bone
Uncemented
 Porous metal vs. bone => Must have rigid fixation and intimate contact
(<50μm)
Hybrid
 (cemented stem and uncemented cup)
 Bearing surfaces
Metal-on-Polyethylene
 Most frequently used but has highest wear rate (75-250μm per year) and
highest risk of dislocation
Metal-on-metal
 Uncommonly used in THRs but used in Hip Resurfacing prostheses.
 Larger heads allow greater ROM
 Main problem: metal ion toxicity
Ceramic-on-ceramic
 Lowest wear rates (0.5-2.5μm per year) but problems include: limited
modularity, brittle (may break), and squeaking
 COMPLICATIONS OF
ARTHROPLASTY
 Infection
 Leg length discrepancy
 Aseptic loosening
 Dislocation
 Periprosthetic fracture
 Particle disease
 Heterotopic ossification
 Component wear/fracture
 Nerve injury
 Infection
 Common reason for revision
 Approx 1% of cases. Risk factors:
 Prolonged operative time
 Poor tissue handling
 Co-morbid (diabetes, immunosuppressed, etc.)
 Very strict infection control precautions perioperatively (e.g. design of
theatre, Charnley/Stryker suits)
 Suspect if:
 Mechanical loosening after short time
 Raised CRP
 +ve joint aspirate (commensals => false +ve)
 Flagrant signs of infection - rare!
 Irregular lucency and periosteal
reaction are signs on X-ray
 Bone scintigraphy is useful (high
negative predictive value)
 Options:
 Single stage revision with
prolonged course of antibx
 Two stage revision (e.g.
PROSTALAC spacer) – 95%
successful
 Long term antibx
 Girdlestone/excision
arthroplasty
 Dislocation
 1-3% of arthroplasty patients will experience a dislocation. Vast majority
occur within first month post-op
 Usually posterior
 Risk factors:
 Female
 Revision
 Small femoral head
 Malposition
 Posterior approach to hip
 Wear
 Pt not obeying instructions to avoid risky postures
 Closed reduction will usually suffice, but recurrent dislocations may require
revision
 Labral Tear
Risk Factors:
• FAI
• Hip dysplasia
• Trauma
• Capsular laxity
• Joint degeneration
Presentation
• Mechanical pain, hip snapping
• Vague groin pain
• Sensation of locking
Investigation
• MRI arthrogram
Treatment
• Operative
• Non operative
 Osteonecrosis of Femoral Head
Risk factors
• Direct: irradiation; trauma; dysbaric disorders; marrow replacing disease
(Gaucher’s disease)
• Indirect: steroids; alcoholism; SLE; transplant patients; HAART therapy
Classified by the Steinberg classification (I – VII)
Presentation
• Insidious onset hip pain
• Physical exam can be normal initially, advanced disease similar to OA
Imaging
• Plain film AP; lateral and frog lateral
• MRI
Treatment
• Non operative: Bisphosphonates
• Operative: Core decompression; bone grafting; rotational osteotomy; THA
Osteonecrosis of Femoral Head
 Femoroacetabular Impingement
Cause of
•Early onset hip dysfunction
•Secondary OA
Types
•Cam
•Pincer
•Combined
Presentation
•Activity related groin or hip pain
•Sitting difficulties
•Anterior impingement test (flexion,
adduction, internal rotation)
Treatment
•Operative
•Nonoperative
 Hip Fractures
• Orthopaedic emergency
• High level morbidity and mortality
– 14-36% mortality at one year
• Risk factors: female; age; poor health;
alcohol; previous fracture; falls history
• Presentation
– non weightbearing
– history of trauma
– shortened, externally rotated
– High energy trauma: ATLS

• History important
– Cause of fall
– Background medical history
– Warfarin/other anticoagulant
Anatomical Classification
Garden Classification
Evans Classification
Operative Interventions