Coxarthrosis: Degenerative Joint Disease

• COXARTROSE

Definition

• Chronic degenerative disease marked by cartilage deterioration and bone neoformation on the articular surface

Epidemiology

• More common in the elderly (5% of the population > 55 years)
• Incidence is increasing
• Higher prevalence in weightlifters and high-performance athletes
• More common in men < 55 years and women > 55 years
• More common in Caucasians
• Most common cause: secondary bone deformities

Physiopathology

• Change in the biochemistry of proteoglycans + presence of inflammatory mediators
• Cartilage degeneration with fibrillation, fissures, and erosions
• Synovial irritation secondary to cartilage destruction
• Decrease in chondroitin-6 and chondroitin 4
• Hyaline cartilage: collagen type 2 and proteoglycans
• Osteophytes occur by metaplasia of the articular capsule

Radiographic Signs

• Joint space narrowing
• Subchondral sclerosis (where there is more cartilage loss)
• Marginal osteophytes (bone neoformation in load-free zones)
• Cysts and geodes (late sign)
• A good incidence to assess osteoarthritis is the Lequesne profile, which shows the articular relationship well
• Narrowing starts in the inferointernal portion of the joint

Gothic Arch of Bombelli

• Base formed by the roof
• Medial wall formed by trabeculae of the quadrilateral lamina
• Lateral wall formed by the lateral rim of the acetabulum
• The apex of the arch should be over the center of the femoral head (normal)
• If the apex is not vertically over the center of the head there is mechanically at-risk hip, predisposing to arthritic hip
• CT scan - not very useful
• Useful for differential diagnosis with osteoid osteoma when necessary
• MRI scan: useful in osteonecrosis
• Arthroscopy: in cases of intra-articular loose bodies

Lawrence Classification

• Grade 0: Normal hip
• Grade 1: Joint space narrowing medially + possible marginal osteophytes
• Grade 2: Inferior joint space narrowing (joint space > 2 mm) + small well-defined osteophytes and sclerosis
• Grade 3: Significant narrowing (joint space < 2 mm) + osteophytes + cysts and sclerosis + deformity in the femur and acetabulum
• Grade 4: Joint space obliteration + significant sclerosis and cysts + significant deformity in the head and acetabulum + large osteophytes
• Cysts appear in grade 3 - a late sign

Wroblewski and Charnley Classification

• Incipient arthrosis
  • Superior pole (grades I, II, and III)
  • Medial pole
  • Acetabular protrusion
  • Concentric
  • Destructive

Clinical Presentation

• Typical pain
  • Continuous hip pain, on the inner face of the thigh and knee
  • Pain that worsens with movement, cold, and humidity
  • Typical: pain at the beginning of movement or when at rest, changes position
  • Night pain may occur
• Clinical-radiological dissociation
• Restricted range of motion (ROM)
• Joint stiffness after rest
• Crepitation
• Deformity
  • Remember the elderly in the hospital with the hip flexed, externally rotated, and adducted

Causes

• Primary: without apparent cause, population: > 50 years old, athletes, and obese individuals
• Secondary: due to a known or pre-existing cause - is the most common
  • Sequelae of Legg-Calvé/ Epiphysiolysis/ DDH/ Septic arthritis
  • Rheumatological diseases (Rheumatoid arthritis, Ankylosing spondylitis)
  • Diabetes Mellitus (main cause of neuroarthropathy in the hip)
  • Paget, Hemochromatosis, Alkaptonuria
  • Trauma
  • Repetitive trauma/ overuse
• Secondary due to pre-existing bone deformity is most common

Important Point

• Obesity does not cause osteoarthritis but accelerates its wear

Risk Factors

• Most important
  • Age (most important isolated factor)
  • Sex: Female
  • Caucasian
  • Hormonal: Estrogen
  • Nutritional: Hypovitaminosis D
  • Controversial: Osteoporosis
• Local factors
  • Anatomical changes
  • Obesity
  • Occupation: Repetitive tasks, lifting weight
  • Otto pelvis (bilateral in the primary form) - TEOT

Regarding Movement

• The first movement lost is internal rotation (IR), followed by External rotation (ER), abduction, adduction, flexion, and, lastly, extension

Bombelli Classification – "AMEBA"

• Amplitude of Movement - MORPHOLOGY , ETIOLOGY AND REACTION

Amplitude of Movement and rigid

• Flexion ≤ 30º
• Abduction 0º
• Adduction 0º
  • Rigid - External Superior
  • Cysts Superior External in the acetabulum
  • Disappearance Of The Joint Space Anterior Of the Femoral Head
  • Rigid/Mechanic - Defect Of The Shape Of the Head , Neck or acetabulum
    • Expl : Legg Calvé , Post Traumatic
  • Rigid/Atrophic
  • Elliptical Head
  • Femoral Head Reduces in Size Tends To Subluxate
  • Few Cysts

Amplitude of Movement and hipomobile

• Flexion 30-60°
• Abduction ≤ 15º
• Adduction < 15º
  • Hipomobile/Concentric
  • Uniform Loss Of Cartilage Joint Of The Head And Of Acetabulum
    • (Explained Ar) - Sclerosis In The Superior Part Of The Head
  • Hipomobile/Metabolic - Alteration In The Matrix Oshea With Deformity
    • Expl . Gout - Normotrophic -
  • Osteophytes In The Acetabulum And Head Deformed Femoral Head
  • Sclerosis Oshea external
  • Osteophytes Inferiors In The Femoral Head And Inferior Acetabular

Amplitude of Movement and mobile

• Flexion > 60º
• Abduction > 15º
• Adduction > 15º
  • Mobile and Internal
  • Decrease The Space In The Internal Portion Of The Head That puts it in Contact With Bottom Acetabular it Can Evolve to protrusion

Inferointerna

• Rare Inferior Waste Big Osteophytes
  • Elevator Trunk -Superior Space Increased
  • Mobile/ Combined
  • Mechanic + Metabolic - Hypertrophic - Mega Deformed Head Many Osteophytes

Important point

• Secondary arthropies of rheumatic diseases are
  • Generally Precocious (2nd and 3th decades of life) -Highly painful and Imepairing -Bilateral

Tonnis classification

• Grade 0: No signs of Osteoarthritis
• Grade 1: mild. with increase of sclerosis narrowing articular minimal , abscense of minimal losing of the sphericity
• Grade 2: moderate, with little cysts moderate narrowing and waste of the sphericity
• Grade 3: severe with largest cysts , severe narrowing and waste of articular severely deformity in head

Management

• The goal of treatment is to improve pain and function
• The first line is always conservative treatment
• Response to NSAIDs and Corticoids in acute crises
• Physical Exercise - (No Impact - Strength the Musculature Periarticular)
  • Use can reduce load 20-30 in the hip -Lost Weight the most Effort to Stop the Evolution - There are no medicines to modify the actual illness
  • Supplemantacion of controitina and glysacosamina can help in the algic control , however Without Proof Scientific
  • Inside Us of the Articular acid Yaluronic doesn´t have proof - Surgical treatment

Considerations Before Management

• Assess Functionality and Demand then start the management

Osteotomies

• Surgery preservative search medializes head and improve distribution of in the femoral head

Requirements To Osteotomia

• Flexion minima 60-70º Some Literature >60 to valgus >50 to variz
  • Rarely Brings Benefits To Rheumatics Hips
    • Adduction Fixed Contraindicates Osteotomy Varizante -Abduction Fixed Contraindicates Osteotomy Valguizante
    • No medialize the Diaphise more that 50% Of Diameter of the Diaphise -Osteotomies Variants < 100º and Valguizantes > 160º Are Subject To Fracasso -Recurrent Pain After Osteotomia is due to Material of Synthesis. -Reconstructiva x Salvamento

Reconstructiva and Salvamento

• Reconstructiva – Hip With Box mild or Normal Prevents to retardarthrose The same one
• Indicado en <25 Years with minimal symtoms And Good Funcion
• Articulation Congruent , More Bad Aligned
• Salvamento – Box Moderate - Improve The Funcion and retardate the indication of Totalarthoplastia - Indicado en <50 Years

Important Points Before Surgery

-Always Do Rx en abduccion e adduccion Maxima– If The centralizacion Is Better in adduction- Do osteotomi varizante Advantages: Increasing the area Of Discharge and the Contact of Area and promotes effect Relax the flexors Abductors and Flexors

Important points About Surgical Treatment

• Disadvantage: Encurtamento Of Limb
• InferOperated (1-2cm) and tredelemburg March osteotomi valguizante(Más indicada)Indications Deformity en adduccion March of tredelemburg adduccion dolorosa
• Lateral Wedge Of Resection (Increase Angle CervicoDiaphisário) - The Transfer of the Center of Rotation medially CAN BE done by way biplanar VALGOEXTENSORA - Advantages Increasing the power DeAbudctor/ tensiona e allonga the limb - Secundarily Relax

Arthroplastias - Most Effective Isolated Treatment

• Choosing a suitable patient is the most important factor
• Indication
• Arthroplasties. arthrose with impairing pain refractory with Conservative treatment Bilateral that's greatest indication patients with systemic disease such as rheumatoid artithries spondylitis and quilozante In preference
• Contraindications

Regarding Anquiloses

• Anquiloses: ABSOLUTE articula neuropatica and Recent Septic or in Course
• Absoluta : Immaturity esquiletical neurological Illnesses progressed
• Absolutta /Relativa deficit in muscular abdductr Contraindications

arthroscopia

indicacion Removing Loose Bodies -Inside Articular Surgical Debridement In Impact Relatieve Ankylose Quadril - Injuries in soft parts - OSTEONECROSE stable No progressing OBESITY QUADRIL ARTHRODESE -

Quadrik Arthodese

indicate pacient young <40

• Year old activetrail- with artrhrose Unilateral Post traumatic arthrite POST infectious contra

arthodesse

Absolut Contraiindications and absolute septic arte. of quadril Post traumatic Bilaterall side affectIn Knee ipsilateral In Contralaterall and lumbal pain POSICIONAMENTO: flexao between 20-30 abduccion tendency to leave neutral

• Principal complicacion dor lombar

osteocondrosis Especifcas

• General - Alterations Degeneratives in joints next to artehodesse se tornar symptomatic in a year

Specific Arthrose

• Sequelas de legg- calve - Artrrtrose Precoce -Osteotomias para tempo - ATQ se nescessari
• Artrirtes Rheumatoides - Bilateralidad freuqente- melhor indicacao _ATQ otto pelve primarialy women benificality

Specific Arthrose

girdlestione: sequela piroartrites/ eliminates pression Trocanterica - BENEFICALITY ARTILAGE- INDICATED : QUADRIL DISPLASIA - ANGLE WIDEBERG <20 CABEÇA ESQUEFERICA - IT"s INDICATED PERIACETABULAR

• COMPILACATION : COUMM OF FEMORAL RECUPERACION NECROSAL

Important point

• ATENÇÃO : SEMRPE ATQ >O MESMO PROCEDIMENTO
• DIMINUI CUSTO EM - > AUMENTA COMPLICAES Locas ou Sistemas -+ DIMIMUI O GERAL 30%

Osteonecrosis of the femoral head

• Also known as aseptic necrosis of the femoral head, avascular necrosis of the femoral head
• More common in men
• Occurs between 30-50 years of age
• 35%-80% are bilateral (asymmetric when bilateral)
• More common in Caucasians
• More common in males in a 4:1 ratio
• Etiology - Idiopathic (25%+)
  • Traumatic
  • Atraumatic
    • Corticosteroid use
    • Alcoholism
    • Lupus
    • Rheumatoid Arthritis
    • Sickle Cell Anemia
    • Gaucher's Disease
    • Hemoglobinopathies
    • Pancreatitis
    • Radiation
    • Dysbarism(Decompression sickness)
    • Hyperuricemia
    • Chemotherapy
    • Hypertriglyceridemia
    • HIV

Risk Factors For Osteonecrosis of the Femoral Head

• Trauma
• Corticosteroid use/ Hyperlipidemia
• HIV
• Pregnancy
• Smoking/ Alcoholism
• Renal Failure
• Gaucher’s Disease
• Coagulation Disorders
• Hemoglobinopathies
• Diabetes is not a risk factor

Pathophysiology

• Disruption of normal blood flow caused by – Direct Cellular Injury (Cytotoxicity) • Chemotherapy • Radiotherapy • Corticosteroid use • Alcohol • Nicotine – Extraosseous Arterial Factors • Displaced Fractures of the Femoral Neck (80%) • Traumatic Hip Dislocation (20-40%), Femoral Head Fracture (75-100%) – Extraosseous Venous Factors • Venous Stasis / Increased Intracapsular Pressure • Intra and Extravascular Factors • Increased Intraosseous Pressure from Edema • Increase of Lipids/Corticosteroid/Gaucher’s • Intravascular Embolism (Diving/Hypertriglyceridemia/Coagulation Disorder

Clinical Appearance

• Diagnosis in early stages yields better outcomes
• 58% in corticosteroid using individuals
  • Insidious pain with intermittent episodes
  • Pain can be inguinal (most common), gluteal, knee, or trochanteric
  • If Bilateral - Asymmetric
  • 5-25% Corticoterapia

Tests and procedures: of Osteonecrosis of the Femoral Head

• Normal on early stages
  • Normal On early stages
• Sclerosis: mainly anterior-superior on the head/ Early Stage (starting from stage 2)
• Subchondral Fracture - Crescent Sign (starting from stage 2B/3) Better Viewed in Profile - Pathogmonomic
• Femoral Head Collapse -> Acetabular Changes -> Arthrosis

In hip fractures and injuries- Radiograpy CINTILIGRAFIA INICIALMENTE:

HIPOCAPTANTE/ - NECROSE - subsequente area quente / Increase of metabolismi no differentiate of inflammatorys

Hip Fracture MRI/ PADRON OURO :

• Start in 72 Double Line high dens low in t2 alterations serpentine CLASSIFICATION:

Ficat and Arlet Classification

Stage 0-1 Absent or Leve - Absent or Aumentante Leve

• Sypmtoms NORMAL

• radiografies and cintilographies show Normal

• biópsi: infart of load AREA Stage 1-2 Modered aumentante a esclerose cisto:

    Aea Fria na cabeca  -REPARACION Spontaneous
  

1.3 - A grave - Sinal Do crescente colapso

• biopsi Fractura subcondral Colapso compacto fragment
• NCONGRUENCIA surfaces cartilaginous -degeneração Alteracoea Acetabular -

ATTETNTIN

• ATENÇAO MUDANCA CAMPBELL No DIVIDE MAIS 2 a E 2b sinal de crescente tipo 3 ESTEIMBERG: IDENTICO mas,DIVIDE STAGE 3 steimberg.
• A FASE há imposicao Nas TRABECUAS(taro)
• CLASSIFICAIÇAO antigua : 2A ESCLEROSE ; 2B CRESCENTE

Primary hip arthroplasty

APPLIED BIOMECHANICS Forces that Update On the quadrilateral Weight of the body From center gravity of the body strength to center of rotation of the femoral Body Body : lever of the Face Laterall Of the Trolcanter major Lever of the weight of Body And 30° Angle Lever force Weight Force force must be the same is same as weight to level the pelvis =2.5-3 *

hip Arthoplsty

Desing CHARNLEY medialize the Femoral Face decreasing the lever power weigth BUT fell Into Disuse PRESEVATION subchondra minimum proxima LATER power Subing 3-4 forca deflexadora TRANSFER TENSIN forca para o osSo to good

Type's of Osteomoy

• Type A funnel or cup of champagne- cortical thickened a p profile channel medial narrow connection metaphysis disphase more

Dor

• TYPe b Waste Bone Cortical medial and posterior Chanel - Intramedullar a little more width Formacore do femur is affectes implant Fixaction Is not a problem
• TYPe C "in chimene / cylindrical
• Corticals thins Medullar chanel large Connecxian Matta phisise to low low quaility bone mulherest and favoresfixan - Good tension
• Waste BONE is DERSIRABLE it AVOISS osteopenia b blindegm meta equilibre Evitar rebabsorpttion
• Depends

Hips

• low modullly and stimulation bone deponds bone material diameter more load by the HIPP
• HIGH CargA bone generate -bone SHILEDING REABSORCION Proximo.

Type's Of Implant

FUNCTION: to Substitute The Face And Neck GOAL: articulation Stable With BIOMECHANICSOffset FEMORAL -Altura : influence Amount of Face - OFFSET : Distancia Of Center Of Diaphise VERTICAL OFFSET :

Type Of Implante

LENGTH : COLOS EXISTENTES - Colos : between 25-50 , TheOffset

• Short Abductors , aumentar força diminuir force reactio

• Long : o AUMENTA the COMPRIMENTO , 0 4cm with colos

• Versican Femoral Is important for The Estabilidade Protesica normal 10-15 °

• Face Greater -ADM

Cimenent not Cimented Bone

• Itanium Is masbioprobabil Maspensa A TRAVANCAL Materiak Cromo coball altareistencia more Redruz .Estrelles
• PONTO ChAvis Uniao face cementi Face Redruz and 109 Ciment - Formas Nao melhlres and A stabilidiad

Tips of Femoral Cimentation

• A Limentr homogeneous A Zona and - Face to great
• The Cement face - Bone , stability is greater to central zona The greaztest

Componentes of arthoplsty

FUNCITION SUBSTITUTE To Stabilshe THE BIO

• Types with cistoses is
• Small greates Diminhu the Waste 12% Of Years a good . Is more dura then other is greates To arranhoes . - Menor the 10 Microns
• Ceramica Crokslinked melhor

INIDCADO The Bone is

Hip Indications To be to a

• Anteversican : 1.15 -4 20 to º LATTO : 45°A3k CONCEITO 1.4 : The Bone Femoral -
• Inidacões Osteoarticular -
• Causa Unilatereal / - Anvaliar Bilatearel / funcinal / -
• Bone - The Win a Life ,

The bone

• Dour and The Limmitacoaes Are Main Bone With - The bone a 7 with Comorbiddidades

Compilicadies - The bone is

• And I : 024 The Bone And -++ A
• Falla By :