Orthopedics Hip

Question 1

Normal Anatomy Hip

Answer 1

Question 2

Hip Physical Exam Inspection

• Inspection
  
  • Both hips appear s______.
  • S____ is intact about both hips without erythema.
  • Leg-l______
    
    • ASIS → Medial malleolus
• Also screen for low back…
• LBP T _ _ ?
• S______ leg raise
• FABER =

Answer 2

• Inspection
  
  • Both hips appear symmetric.
  • Skin is intact about both hips without erythema.
  • Leg-lengths
    
    • ASIS (anterior superior iliac spine) → Medial malleolus (bump on inner side of ankle)
• Also screen for low back…
• LBP TTP?
• Straight leg raise
• FABER = used to identify the presence of hip pathology by attempting to reproduce pain in the hip, lumbar spine or sacroiliac region. examiner applies a posteriorly directed force against the medial knee of the bent leg towards the table top. A positive test occurs when groin pain or buttock pain is produced.

Question 3

Tenderness to palpation

• Greater tr_______?
• (or pain deepercentral/gr_____ → joint)

Range of Motion

• Look for sy_____
• _____ Extension → Flexion
• Internal Rotation / External Rotation
• Cr_____?
• St______?

Answer 3

• Greater trochanter?
• (or pain deeper/central/groin → joint)
• Look for symmetry
• Full Extension → Flexion
• Internal Rotation / External Rotation
• Crepitus?
• Stability?

Question 4

Strength/Sensation

• Compare bilaterally (flex/ext/IR/ER)
• Check distal
  
  • Ankle/toe d____ and p_____ flexion
  • Distal ___sation (generally DP/SP/TN)
• ________ nerve → branches into the tibial nerve and common peroneal nerve (which splits into DP/SP)

Answer 4

• Compare bilaterally (flex/ext/IR/ER)
• Check distal
  
  • Ankle/toe dorsi and plantar flexion
  • Distal sensation (generally deep peroneal/superficial peroneal/tibial nerve)
• Sciatic nerve → branches into the tibial nerve and common peroneal nerve (which splits into DP/SP)

Question 5

Common Conditions Hip

(5)

Answer 5

Trochanteric Bursitis / Iliotibial band syndrome

Snapping hip

Femoroacetabular impingement

Hip dysplasia

Hip arthritis

Question 6

Trochanteric Bursitis/Iliotibial Band Syndrome

• Pain at the “_____” of the hip
  
  • Usually extends to the outside of the thigh area.
    
    • Early stages, the pain is usually described as sh_____ and in_____.
    • Later, the pain may become more of an a____ and spread across a ______ area of the hip

Answer 6

• Pain at the “point” of the hip
  
  • Usually extends to the outside of the thigh area.
    
    • Early stages, the pain is usually described as sharp and intense.
    • Later, the pain may become more of an ache and spread across a larger area of the hip

Question 7

Trochanteric Bursitis / Iliotibial band syndrome

• Typically worse at _____ (lying on affected side), or after prolonged periods of activity and/or sitting on ______ surfaces.
• More common in gender (1) and _____-aged or ______ people.
• Causes
  
  • Repetitive ______secondary to iliotibial _____ tr_____ over the trochanteric _____.
• Bursa is superficial to the hip abductor muscles and deep to the iliotibial band

Answer 7

• Typically worse at night (lying on affected side), or after prolonged periods of activity and/or sitting on hard surfaces.
• More common in women and middle-aged or elderly people.
• Causes
  
  • Repetitive trauma secondary to iliotibial band tracking over the trochanteric bursa.
• Bursa is superficial to the hip abductor muscles and deep to the iliotibial band

Question 8

Trochanteric Bursitis / Iliotibial band syndrome: H&P

• History / Symptoms
  
  • ______ sided hip pain (_____ not involved)
• Physical Exam
  
  • Tenderness to palpation over greater _______
  • ____ /symmetric joint ROM
  • ______ neurovascular exam

Answer 8

• History / Symptoms
  
  • Lateral sided hip pain (joint not involved)
• Physical Exam
  
  • Tenderness to palpation over greater trochanter
  • Full / symmetric joint ROM
  • Normal neurovascular exam

Question 9

Trochanteric Bursitis Imaging

• XR/Imaging:
  
  • (1) (clinical diagnosis)
• But in cases of persistent pain, XRs can be useful to rule-out concomitant hip ______
• MRI can be helpful to confirm diagnosis and rule-out abductor t_____ (although treatment is rarely altered from the results of the imaging)

Answer 9

• XR/Imaging:
  
  • Not really necessary or helpful (clinical diagnosis)
• But in cases of persistent pain, XRs can be useful to rule-out concomitant hip arthritis
• MRI can be helpful to confirm diagnosis and rule-out abductor tears (although treatment is rarely altered from the results of the imaging)

Question 10

Trochanteric Bursitis Treatment

• Non-operative
  
  • N_____
  • Activity ______ / protection
    
    • Avoid / modify ag______ activities
  • P_ / home exercises / stretching
  • S_____ injections
    
    • If initial treatments are not helping
• Operative
  
  • Very ______
  • Often arthroscopic now, _____ectomy / debridement
• Refer
  
  • Symptoms not ________ to NSAIDs, PT, activity modification

Answer 10

• Non-operative
  
  • NSAIDs
  • Activity modification / protection
    
    • Avoid / modify aggravating activities
  • PT / home exercises / stretching
  • Steroid injections
    
    • If initial treatments are not helping
• Operative
  
  • Very rare
  • Often arthroscopic now, bursectomy / debridement
• Refer
  
  • Symptoms not responsive to NSAIDs, PT, activity modification

Question 11

Snapping Hip

• Snapping sensation in the hip that comprises of 3 entities:
  
  • _____ snapping hip (ITB/abductors)
  • ______ snapping hip (iliopsoas)
  • intra-_______ snapping hip (intra-articular)
• Diagnosis of external and internal snapping hip is generally made _______ with specific physical examination maneuvers.
  
  • Advanced imaging is generally required to diagnose _______ snapping hip.
• Usually h___less (and p___less), but can be annoying
  
  • And for external snapping, can be a precursor to b______
• More common in common in ath____ and da_____in their teens or twenties

Answer 11

• Snapping sensation in the hip that comprises of 3 entities:
  
  • external snapping hip (ITB/abductors)
  • internal snapping hip (iliopsoas)
  • intra-articular snapping hip (intra-articular)
• Diagnosis of external and internal snapping hip is generally made clinically with specific physical examination maneuvers.
  
  • Advanced imaging is generally required to diagnose intra-articular snapping hip.
• Usually harmless (and painless), but can be annoying
  
  • And for external snapping, can be a precursor to bursitis
• More common in common in athletes and dancers in their teens or twenties

Question 12

Snapping Hip History and Symptoms

• L_____ sided hip sn______ and/p____ (if external)
• Gr____/central (if internal or intra-articular)
• Patient is often able to re_____ the snapping
• Worse with ac______
• A cl_____ or lo______ sensation → more indicative of intra-________ pathology

Answer 12

• Lateral sided hip snapping and/pain (if external)
• Groin/central (if internal or intra-articular)
• Patient is often able to reproduce the snapping
• Worse with activity
• A clicking or locking sensation → more indicative of intra-articular pathology

Question 13

Snapping Hip Physical Exam

• Classical dogma (although not always easy to replicate…)
  
  • “External snapping one can ____ from across the room, while internal one may _____ from across the room”
• External: Palpate GT as hip is actively flexed; applying ______ likely stops the snapping, confirming diagnosis
• Internal: Snapping is reproduced by passively moving hip from a ______ and _______ rotated position to an _____ and ______ rotated position

Answer 13

• Classical dogma (although not always easy to replicate…)
  
  • “External snapping one can see from across the room, while internal one may hear from across the room”
• External: Palpate GT as hip is actively flexed; applying pressure likely stops the snapping, confirming diagnosis
• Internal: Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position

Question 14

Snapping Hip Imaging

• XR:
  
  • AP P_____, AP/lateral ____
  • Typically done but not really necessary (______ diagnosis)
  • Can rule-out radio-dense intra-articular _____ bo____, cal______, ar_____
• MRI:
  
  • Recal_____ cases only
  • Useful to rule-out intra-______ pathology
  • Often performed as an arthro_____ study
  • May show inflamed b_______

Answer 14

• XR:
  
  • AP Pelvis, AP/lateral hip
  • Typically done but not really necessary (clinical diagnosis)
  • Can rule-out radio-dense intra-articular loose bodies, calcifications, arthritis
• MRI:
  
  • Recalcitrant cases only
  • Useful to rule-out intra-articular pathology
  • Often performed as an arthrogram study
  • May show inflamed bursa

Question 15

Snapping Hip Imaging

• Ultrasound:
  
  • _____ done
  • Can be a dynamic study which may de______ the snapping band in either internal or external snapping
  • May be used to localize a diagnostic challenge ______ into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.

Answer 15

• Ultrasound:
  
  • Rarely done
  • Can be a dynamic study which may demonstrate the snapping band in either internal or external snapping
  • May be used to localize a diagnostic challenge injection into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.

Question 16

Snapping Hip Treatment

• Often painless and require no treatment (re______)
• Non-operative
  
  • A____ modification / protection
    
    • Avoid / modify aggravating activities
  • N______
  • P_ / home ex_____/ str_____
  • Steroid in_____
    
    • If initial treatments are not helping
• Operative
  
  • Very ____
    
    • External: ex_____ of GT bursa with __-plasty of ITB
    • Internal: r_______ of iliopsoas tendon
    • Intra-articular: hip _____scopy with removal of loose bo____, la_____ debridement/repair
• Refer
  
  • Symptoms ____ responsive to NSAIDs, PT, activity modification

Answer 16

• Often painless and require no treatment (reassurance)
• Non-operative
  
  • Activity modification / protection
    
    • Avoid / modify aggravating activities
  • NSAIDs
  • PT / home exercises / stretching
  • Steroid injections
    
    • If initial treatments are not helping
• Operative
  
  • Very rare
    
    • External: excision of GT bursa with z-plasty of ITB
    • Internal: release of iliopsoas tendon
    • Intra-articular: hip arthroscopy with removal of loose bodies, labral debridement/repair
• Refer
  
  • Symptoms not responsive to NSAIDs, PT, activity modification

Question 17

Femoroacetabular Impingement (FAI)

• FAI = abnormal contact between the _____ and ______ which may lead to l_____ damage, various degrees of chondral injury and progressive hip pain.
• Diagnosis: is made radiographically with hip radiographs showing an aspherical femoral (____ impingement) or anterosuperior acetabular overhang (_____ impingement), or a combination of both.
• Treatment: nonoperative or operative depending on the chronicity of sy____, patient a___, patient activity de_____, and development of secondary in____ to the hip joint (i.e. labral ____, secondary osteo_____).
• _____ in general population and often __symptomatic
• May become more apparent with participation in activities requiring ex______ range of motion (ballet, gymnastics, martial arts)

Answer 17

• FAI = abnormal contact between the femur and acetabulum which may lead to labral damage, various degrees of chondral injury and progressive hip pain.
• Diagnosis is made radiographically with hip radiographs showing an aspherical femoral (Cam impingement) or anterosuperior acetabular overhang (Pincer impingement), or a combination of both.
• Treatment: nonoperative or operative depending on the chronicity of symptoms, patient age, patient activity demands, and development of secondary insult to the hip joint (i.e. labral tear, secondary osteoarthritis).
• Common in general population and often asymptomatic
• May become more apparent with participation in activities requiring extreme range of motion (ballet, gymnastics, martial arts)

Question 18

Cam Vs. Pincer Impingement

Answer 18

Cam Impingement = Left pic

Pincer Impingement = Right pic

Question 19

Femoroacetabular Impingement H&P

• History / Symptoms
  
  • Activity related groin or hip p___, exacerbated by hip ____ion
  • Difficulty s______
  • Mechanical hip symptoms of cl____ or po_______
  • Can present with gl____ or trochanteric pain
    
    • Due to aberrant g____ mechanics
• Physical Exam
  
  • Motion
    
    • limited hip ____ion (<90 degrees), especially with _______ rotation (<5 degrees)
    • anterior impingement test =

Answer 19

• History / Symptoms
  
  • Activity related groin or hip pain, exacerbated by hip flexion
  • Difficulty sitting
  • Mechanical hip symptoms of clicking or popping
  • Can present with gluteal or trochanteric pain
    
    • Due to aberrant gait mechanics
• Physical Exam
  
  • Motion
    
    • limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees)
    • anterior impingement test (flexion, adduction, internal rotation) elicits pain

Question 20

Femoroacetablur Impingment Inspection

• _______ rotated extremity
  
  • Can be due to post S _ _ _ deformity

Answer 20

• Externally rotated extremity
  
  • post SCFE

Question 21

Femoroacetabular Impingement: Studies

• XR:
  
  • Recommended views
    
    • _ _ with true _____ view (hip placed in 15 degrees of internal rotation)
  • Optional views
    
    • _____ or modified Dunn view, False profile view to assess _______ coverage of the femoral head
• CT
  
  • Provides _____ detail of bony structural abnormalities
  • Surgical pl______
• MRI:
  
  • Best modality to assess l_____ and ar_____ pathology

Answer 21

• XR:
  
  • Recommended views
    
    • AP with true lateral view (hip placed in 15 degrees of internal rotation)
  • Optional views
    
    • Dunn or modified Dunn view, False profile view to assess anterior coverage of the femoral head
• CT
  
  • Provides more detail of bony structural abnormalities
  • Surgical planning
• MRI:
  
  • Best modality to assess labral and articular pathology

Question 22

Femoroacetabular Impingement Treatment

• Often pain____ and require __ treatment (reassurance)
• Non-operative
  
  • Activity m______ / pr_____
    
    • Avoid / modify ag______ activities
  • Rx (1)
  • _ _ / home ex_____ / st_____
  • (1)
    
    • If initial treatments are not helping
• Operative
  
  • Symptomatic mechanical symptoms / failure of non-op treatments
  • ___ (or minimal) arthritis
  • Typically addressed ______scopically (although recent data shows open and arthroscopic procedures have similar outcomes)
  • Goals: sh_____ down cam and pincer lesions, debride or repair l______
• Refer
  
  • Symptoms not responsive to (3)

Answer 22

• Often painless and require no treatment (reassurance)
• Non-operative
  
  • Activity modification / protection
    
    • Avoid / modify aggravating activities
  • NSAIDs
  • PT / home exercises / stretching
  • Steroid injections
    
    • If initial treatments are not helping
• Operative
  
  • Symptomatic mechanical symptoms / failure of non-op treatments
  • No (or minimal) arthritis
  • Typically addressed arthroscopically (although recent data shows open and arthroscopic procedures have similar outcomes)
  • Goals: shave down cam and pincer lesions, debride or repair labrum
• Refer
  
  • Symptoms not responsive to NSAIDs, PT, activity modification

Question 23

Hip Dysplasia

• Developmental Dysplasia of the Hip is a disorder of abnormal ______ resulting in dysplasia, sub____, and possible dis_____ of the hip secondary to capsular ____ity and mechanical in_______.
• What does dysplasia mean?
  
  • Greek root “plasis” meaning molding/con_______
  • So → abnormal mol____ or development of the hip

Answer 23

• Developmental Dysplasia of the Hip is a disorder of abnormal development resulting in dysplasia, subluxation, and possible dislocation of the hip secondary to capsular laxity and mechanical instability.
• What does dysplasia mean?
  
  • Greek root “plasis” meaning molding/conformation
  • So → abnormal molding or development of the hip

Question 24

Hip Dysplasia

• Diagnosis can be confirmed with (1) in the first __ months and then with (1) after femoral head ___ification occurs (~ _-_ months).
• Treatment varies from Pavlik _______ to surgical re_____ and ____teotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.

Answer 24

• Diagnosis can be confirmed with ultrasonography in the first 4 months and then with radiographs after femoral head ossification occurs (~ 4-6 months).
• Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.

Question 25

Hip Dysplasia Incidence and Demographics * Incidence: * Most common orthopaedic disorder in \_\_\_\_\_\_\_ * Dysplasia is 1:1\_\_\_\_ * Dislocation is 1:1\_\_\_\_\_ * Demographics * More common in _______ (6:1) * More commonly seen in ______ Americans and Laplanders * Due to cultural traditions such as sw\_\_\_\_\_\_ with hips together in extension * ______ seen in African Americans

Answer 25

* Incidence: * Most common orthopaedic disorder in newborns * Dysplasia is 1:100 * Dislocation is 1:1000 * Demographics * More common in females (6:1) * More commonly seen in Native Americans and Laplanders * Due to cultural traditions such as swaddling with hips together in extension * Rarely seen in African Americans

Question 26

Hip Dysplasia Anatomic Location * ___ \> ___ (60% / 40%) * due to the most common intra\_\_\_\_\_ position being left occiput anterior (left hip is adducted against the mother's lumbosacral spine) * bilateral in 20%

Answer 26

* L \> R (60% / 40%) * due to the most common intrauterine position being left occiput anterior (left hip is adducted against the mother's lumbosacral spine) * bilateral in 20%

Question 27

Hip Dysplasia Risk Factors * \_\_\_\_\_born * Due to unstretched uterus and tight abdominal structures compressing the uterus * ______ gender * Due to increased ligamentous laxity that transiently exists as the result of circulating maternal hormones and the estrogens produced by the fetal uterus * ______ position * More commonly seen in female children, firstborn children, and pregnancies complicated by \_\_\_\_\_hydramnios * Higher risk of DDH with f\_\_\_\_/single breech position compared to f\_\_\_\_\_\_ breech position * Other: family \_\_\_\_\_, oligohydramnios, m\_\_\_\_somia

Answer 27

* Firstborn * Due to unstretched uterus and tight abdominal structures compressing the uterus * Female * Due to increased ligamentous laxity that transiently exists as the result of circulating maternal hormones and the estrogens produced by the fetal uterus * Breech * More commonly seen in female children, firstborn children, and pregnancies complicated by oligohydramnios * Higher risk of DDH with frank/single breech position compared to footling breech position * Other: family history, oligohydramnios, macrosomia *(large babies)*

Question 28

Hip Dysplasia PE \<3 Months ## Footnote **(2) Tests**

Answer 28

**Barlow/Ortolani** **Galeazzi Sign (or Allis sign)**

Question 29

Barlow and Ortolani ## Footnote * **(1)**: dislocates a dislocatable hip by adduction and depression of flexed femur * “Click of exit” * **(1)**: reduces a dislocated hip by elevation and abduction of the flexed femur * "Click of entry” * **_NOTE_**: Be very \_\_\_\_\_\_. * Hold the legs as if they are a “ripe tomato” * Barlow and Ortolani are rarely positive after 3-months due to the soft-tissue _______ that form around the hip

Answer 29

* **Barlow**: dislocates a dislocatable hip by adduction and depression of flexed femur * “Click of exit” * **Ortolani (Legs Out)**: reduces a dislocated hip by elevation and abduction of the flexed femur * “Click of entry” * **_NOTE_**: Be very gentle. * Hold the legs as if they are a “ripe tomato” * Barlow and Ortolani are rarely positive after 3-months due to the soft-tissue contractures that form around the hip

Question 30

Galeazzi Sign (or Allis sign) ## Footnote * Apparent limb _____ \_\_\_\_\_\_\_ due to a unilateral dislocated hip with hip flexed at ___ degrees and ____ on the table * Femur appears ________ on dislocated side

Answer 30

* Apparent limb length discrepancy due to a unilateral dislocated hip with hip flexed at 90 degrees and feet on the table * Femur appears shortened on dislocated side

Question 31

Hip Dysplasia \>3m-1y ## Footnote 1. Limitation of \_\_\_\_\_\_\_ * Most sensitive test once contractures have begun 2. Leg-length discrepancy (\_\_\_\_\_\_\_)

Answer 31

1. Limitation of abduction * Most sensitive test once contractures have begun 2. Leg-length discrepancy (Galeazzi)

Question 32

Hip Dysplasia \>1 year - Walking Child ## Footnote * Pelvic \_\_\_\_\_uity * Lumbar _______ (in response to hip contractures, more typically seen with bilateral dislocations) * _______ gait * Abductor insufficiency * \_\_\_\_\_-walking * An attempt to compensate for relative shortening of the affected side

Answer 32

* Pelvic obliquity * Lumbar lordosis (in response to hip contractures, more typically seen with bilateral dislocations) * Trendelenburg gait * Abductor insufficiency * Toe-walking * An attempt to compensate for relative shortening of the affected side

Question 33

Hip Dysplasia Imaging ## Footnote **(1)** Primary modality 4-6 mo after the femoral head begins to ossify (~6-8 months old) * **_\_\_\_\_\_\_\_\_\_ line_** * Horizontal line through the right and left triradiate cartilage * Femoral head ossification should be inferior to this line * **_\_\_\_\_\_\_\_ line_** * Line perpendicular to Hilgenreiner's line through a point at the lateral margin of the acetabulum * Femoral head ossification should be medial to this line * **_\_\_\_\_\_\_\_\_ line_** * Arc along the inferior border of the femoral neck and the superior margin of the obturator foramen * Arc line should be continuous

Answer 33

* **X-ray =** Primary modality 4-6 mo after the femoral head begins to ossify (~6-8 months old) * **_Hilgenreiner's line_** * Horizontal line through the right and left triradiate cartilage * Femoral head ossification should be inferior to this line * **_Perkin's line_** * Line perpendicular to Hilgenreiner's line through a point at the lateral margin of the acetabulum * Femoral head ossification should be medial to this line * **_Shenton's line_** * Arc along the inferior border of the femoral neck and the superior margin of the obturator foramen * Arc line should be continuous

Question 34

Hip Dysplasia Imaging ## Footnote **(1)** Primary imaging modality from birth to 4 months * May produce false results if performed before 4-6 ______ of age * Indications: * + Physical examination * AAP recommends an **US study at __ weeks** in patients who are considered **\_\_\_\_\_ risk** (family history or breech presentation) despite normal exam * Most studies show it is not cost effective for _______ screening

Answer 34

**Ultrasound =** primary imaging modality birth - 4m * May produce false results if performed before 4-6 weeks of age * Indications: * + Physical examination * AAP recommends an **US study at 6 weeks** in patients who are considered **high risk** (family history or breech presentation) despite normal exam * Most studies show it is not cost effective for routine screening

Question 35

Hip Dysplasia Imaging ## Footnote Arhtrogram/CT/MRI Usually as part of \_\_\_\_\_\_/ _____ planning

Answer 35

Usually as part of treatment/surgical planning

Question 36

Hip Dysplasia Non-Op Treatment ## Footnote 1. **\_\_\_duction splinting/bracing (1)\*** * Indications * \< __ months old and red\_\_\_\_\_\_ hip * Contraindicated in \_\_\_\_\_tologic (irreducible) hip dislocations and patients with sp\_\_\_ bi\_\_\_\_\_ or sp\_\_\_\_\_\_\_ * Requires normal _______ function for successful outcome 2. **\_\_\_\_\_\_\_\_\_ reduction and spica \_\_\_\_\_\_\_** * Indications * 6-18 months old * Failure of Pavlik treatment * Trivia: Definition of spica: a bandage that is applied in successive V-shaped crossings and is used to immobilize a limb especially at a joint

Answer 36

* **Abduction splinting/bracing (Pavlik harness)** * Indications * \< 6 months old and reducible hip * Contraindicated in teratologic (irreducible) hip dislocations and patients with spina bifida or spasticity * Requires normal muscle function for successful outcomes * **Closed reduction and spica casting** * Indications * 6-18 months old * Failure of Pavlik treatment * Trivia: Definition of spica: a bandage that is applied in successive V-shaped crossings and is used to immobilize a limb especially at a joint

Question 37

Hip Dysplasia Operative Treatment ## Footnote * Usually after \_\_\_-months when ______ treatments have failed * Options * _____ reduction and (1) * _____ reduction and ______ osteotomy * ______ reduction and _______ osteotomy * When to refer? * All cases of suspected hip \_\_\_\_\_\_\_\_

Answer 37

* Usually **after 18-months when closed treatments have failed** * Options * Open reduction and spica casting * Open reduction and femoral osteotomy * Open reduction and pelvic osteotomy * Refer * All cases of suspected hip **dislocation**

Question 38

Hip Arthritis ## Footnote **Hip Osteoarthritis is ______ disease of the hip joint that causes progressive loss of articular _______ of the (1) and (1).** * _Diagnosis_ can be made with plain (1) of the hip. * _Treatment_ * **Observation, NSAIDs, and corticosteroids** for **m\_\_\_\_\_\_** disease / symptoms patients. * **Hip \_\_\_\_\_\_** is indicated for progressive symptoms with **s\_\_\_\_\_\_** degenerative disease.

Answer 38

**Hip Osteoarthritis is degenerative disease of the hip joint that causes progressive loss of articular cartilage of the femoral head and acetabulum.** * _Diagnosis_ can be made with plain radiographs of the hip. * _Treatment_ * **Observation, NSAIDs, and corticosteroids** for **minimally** disease / symptoms patients. * **Hip arthroplasty** is indicated for progressive symptoms with **severe** degenerative disease.

Question 39

Hip Arthritis Risk Factors ## Footnote * Modifiable * Tr\_\_\_\_\_ * Heavy ph\_\_\_\_\_ work * High-impact sp\_\_\_\_\_ * Non-modifiable * Gender (\_+\>\_\_) * A\_\_\_ * Ge\_\_\_\_\_\_\_ * De\_\_\_\_\_\_\_ or acquired deformities * DDH * SCFE * Legg-Calve-Perthes disease * FAI * Etiology: Controversial → regardless of the cause, the end-result is the same ( w\_\_\_ and deg\_\_\_\_\_ of the cartilage)

Answer 39

* Modifiable * Trauma * Heavy physical work * High-impact sports * Non-modifiable * Gender (F\>M) * Age * Genetics * Developmental or acquired deformities * DDH * SCFE * Legg-Calve-Perthes disease * FAI * Etiology: Controversial → regardless of the cause, the end-result is the same (wearing and degeneration of the cartilage)

Question 40

Hip Arthritis History and Symptoms ## Footnote * Identify a\_\_, f\_\_\_\_\_\_ activity, pa\_\_\_\_\_ of arthritic involvement, overall h\_\_\_\_\_ and du\_\_\_\_ of symptoms * Pain in the hip / groin area (\_\_\_\_\_ with rest, ____ with activity) * Hip st\_\_\_\_ness / decreased R _ \_ * Cr\_\_\_\_\_\_\_ / Mechanical symptoms

Answer 40

* Identify age, functional activity, pattern of arthritic involvement, overall health and duration of symptoms * Pain in the hip / groin area (better with rest, worse with activity) * Hip stiffness / decreased ROM * Crepitus / Mechanical symptoms

Question 41

Hip Arthritis PE ## Footnote * Physical Exam * Inspection * Body ha\_\_\_\_, g\_\_\_\_, leg-length \_\_\_\_\_\_\_\_\_\_, s\_\_\_ (scars?) * Motion * Lack of full extension (\>\_\_\_ degrees flexion contracture) * Lack of full flexion (flexion \< \_\_\_-100 degrees) * **_Limited ________ rotation\*_** (compare to other side)

Answer 41

* Physical Exam * Inspection * Body habitus, gait, leg-length discrepancy, skin (scars?) * Motion * Lack of full extension (\>5 degrees flexion contracture) * Lack of full flexion (flexion \< 90-100 degrees) * **_Limited internal rotation\*_** (compare to other side)

Question 42

Hip Arthritis Imaging ## Footnote * (1) * Recommended views * St\_\_\_\_\_\_ AP pelvis * (1) + (1) * Look for: * Joint space \_\_\_\_\_\_ * Osteo\_\_\_\_\_ * Subchondral sc\_\_\_\_\_ * Subchondral c\_\_\_\_\_

Answer 42

* XR: * Recommended views * Standing AP pelvis * AP + lateral hip * Look for: * Joint space narrowing * Osteophytes * Subchondral sclerosis * Subchondral cysts

Question 43

Hip Arthritis Non-Op Treatment =

Answer 43

* Activity modification / protection / walking aid * Avoid / modify aggravating activities * Weight loss * NSAIDs * PT / home exercises / stretching * Steroid injections * If initial treatments are not helping

Question 44

Hip Arthritis Operative Treatment ## Footnote * Younger patients / less severe DJD * **(1)**, **(1)** (rare) * Older patients / more severe disease * **(1)\*** / resurfacing * When to refer?

Answer 44

* Younger patients / less severe DJD * Arthroscopy, Osteotomy (rare) * Older patients / more severe disease * Total hip replacement / resurfacing * Refer * Symptoms not responsive to NSAIDs, PT, activity modification