MD Hip and Pelvis Lecture PDF

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** *Italics* -- fyi or review **[Hip and Pelvis]** I. [Hip Disorders in Adults] A. [Hip Fractures:] 1. High Energy (Young) a. MVC/Fall from height b. Unstable fracture 2. Low Energy (Elder...

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** *Italics* -- fyi or review **[Hip and Pelvis]** I. [Hip Disorders in Adults] A. [Hip Fractures:] 1. High Energy (Young) a. MVC/Fall from height b. Unstable fracture 2. Low Energy (Elderly) c. 90 % result from fall; present to Emer. Room with extremity shortened & externally rotated d. Impacted fracture (stable) e. Displaced fracture (unstable) 3. Risk Factors for low energy fracture: Weak bone, unstable gait f. Increased age, female gender, urban\>rural, prior hip fracture, alcohol/caffeine, dementia/delirium, medications 4. Hip Fractures Anatomic Location g. Femoral Neck Fracture h. Intertrochanteric Fracture i. Sub trochanteric Fractures 5. Mortality = 14-36% within 1 year of hip fracture. j. Risk factors for mortality [after] fracture include age, systemic disease, male sex, institutionalized living, dementia, and poor nutrition. k. Only \~30-50%% return to their former level of independence. 6. Hip Fractures Management Principles l. In general: fix young, replace old m. Non-op only for sick patients with stable impacted fractures or unfit for surgery n. Evaluate and correct medical conditions o. Early mobilization post-op, i.e. transfers, ambulation, etc. Image from OrthoBullets B. [Specific treatment of hip fractures] -- 1. **Femoral Neck Fractures**: - Nondisplaced *(Garden types I and II)* - Displaced *(Garden types III and IV)* a. i. ii. iii. b. i. a. - b. - - c. ii. Young (\ 12-24 hrs after fracture due to risk of osteonecrosis - Complications: AVN, nonunion 2. **[Intertrochanteric] fractures**: a. Same frequency/population as neck fracture; *males \> females* b. Less risk of AVN than with neck fracture c. d. Surgical Treatment (preferred) - Stabilize and compress facture - Dynamic hip screw in most cases -- *allows for controlled fx compression* - Intramedullary Nail (IMN) e. Post-op i. Stable fracture pattern -- WBAT ii. Unstable fracture pattern(posterior comminution)-- protected WB iii. No hip precautions b/c capsule intact, no ROM restrictions iv. Strengthening after healing initiated usually 6 weeks d. Complications -- 4-12% loss of fixation, less complications than neck fx, malunion, hardware complications (lateral screw irritation) 3. **[Subtrochanteric] fractures** a. Fracture at or below lesser trochanter; femoral shaft fracture b. High stress region of the femur- fx maybe relatively unstable due to muscle attachments in this region c. Higher incidence of delayed union and malunion d. Young pts usually high energy injury, older - m*ore common in women on osteoporosis meds* e. Surgical Treatment i. *Standard IM nail: often with open reduction* ii. *Fixed angle plate devices* f. Post-op i. a. Usually protected WB 6-12 weeks b. Strengthening after healing under way c. No hip precautions g. Complications -- few b/c supply intact; generally heal better than neck fx - loss of fixation, nonunion C. [Osteonecrosis] 1. Ischemia of the femoral head (vascular insult or high pressure) which results in bone edema, decreased flow leading to bone necrosis, 2. Ineffective healing process with bone resorption\>bone formation(structural weakness) 3. Cartilage collapse and joint destruction 4. Etiology (associated conditions) a. Corticosteroids b. Alcohol c. Trauma -- femur fracture, dislocation d. Not as common: Sickle cell anemia, transient osteoporosis, 5. Staging -- Ficat and Arlet (symptoms and positive biopsy)- you need to know that osteonecrosis is staged and the basic staging because it directs treatment. (no need to know all the details of staging) a. Stage 0 -- normal MRI in asymptomatic patient, look for "bone marrow edema" in MRI b. Stage I -- normal radiographs with symptoms, positive MRI c. Stage II -- normal femoral head contour, mixed lysis and sclerosis d. Stage III -- subchondral collapse, flattening of head e. Stage IV -- narrowed joint space, head collapse, degenerative on acetabular side f. Stage V -- narrowing of joint g. State VI -- advanced OA 6. Treatment- dictated by location & size of lesion, age of pt, underlying dz, worse on weight bearing if lesion is lateral a. Nonoperative- for stages I & II i. Protected WB ii. Electrical stimulation to the bone (not FDA approved) iii. Short term phosomax (bisphosphonate) iv. Hyperbaric oxygen chamber -- questionable efficacy b. Operative- Stage III and up i. [Core decompression] (grafting, e-stim) a. Decompress intermedullary cavity - get new vascularization to the femoral head b. Rehab concern -- must protect against fracture secondary to hole made in femoral neck so 30-50% wt bearing status; protected wt bearing status for 4-6 mos ii. [Osteotomy ] iii. iv. v. [Arthroplasty] D. [Hip Dislocations] 1. **Unstable Total Hip-** a. **Incidence: (know- - revisions have higher incidence)** 1. **Primary THA -- 1-5%** 2. **revision and some complex primary THA are at increased risk for dislocation *(7-15%)*** b. **Factors: Component position** a. ***Acetabular alignment*** b. ***Femoral offset*** c. ***Femoral length*** d. ***Combined rotation*** e. ***Soft tissue tension*** c. **Decreasing Incidence** 3. **Femoral components that match patient anatomy** 4. **Larger femoral heads = dual mobility** 5. **Soft tissue management** d. **Timing and Treatment** 6. **Acute dislocations** f. **Most occur within 3 months of THA. Breach of restrictions** g. **Initial treatment: reduction and bracing. Most have no further issues** h. **Revisions: recurrent dislocation with components are malpositioned** 7. **Chronic dislocations** i. **Generally occurring years after THA** j. **More prone to recurrence** k. **Initial treatment: reduction and bracing** l. **Revision: if components are malpositioned** e. **abduction brace holds the hip in a safe position while healing *(allows 30-60 flex, 15 abd and neutral rotation)*** - **primary THA often only use abduction pillow only in hospital** - **revision THA use brace for 6 wks to 6 mos** f. ***constrained ("locked") acetabular component can be used for recurrent dislocations or instability situation(often wears out faster).*** 1. Traumatic dislocations (Native hip) a. Usually high energy trauma, usually MVA, 85% are posterior dislocation 8. Loading on flexed hip - Posterior dislocation - Acetabular wall fracture- if less than 60 y.o. then it is repaired - Femoral head fracture b. Poor prognosis if: - - - e. - - - f. i. [Prompt] reduction is paramount in preserving good hip function - watch for vascular disruption, sciatic nerve injury, knee -- PCL injury ii. Traction used by physicians to reduce the dislocation iii. Return to ambulation with weight bearing precautions iv. Exercise within precautions E. [Stress Fracture of Hip] - Femoral neck, found in military recruits, ammenorheic women and long distance runners. Repeated trauma/increased activity relative to baseline - "dreaded black line" on radiographs or MRI - Bone scan -- increased activity - X-rays - No abnormality - Mild increase in bone density - Linear radiolucency - Treatment- initially limit wt bearing, surgery as last resort (ORIF) - Prognosis is less optimal if on tensile side of bone - If fracture goes all the way across -- requires surgery F. [Infection of Hip Joint] -- surgical emergency a. b. c. d. DX - Laboratory studies: ESR, CRP, CBC - Joint Aspiration: cell count, culture e. Treatment: - I & D - [Hip Girdlestone]- procedure done for infected THA a. If infection caught within 1^st^ 24-48 hrs 75% chance of salvage with emergent I & D and months of antibiotics b. If \> few days then have girdlestone procedure in which all components are removed and antibiotic spacer placed i. Abduction brace used ii. Protected wt bearing iii. Antibiotics IV for 6 wks to 6 mos then oral for life iv. May be able to have reimplantation later - Presents 6-12 mos afterward 4\. Treatment: - Prevention - Indocin has been shown to lower incidence as has reduction. - Surgical excision with post-op radiation - p/o AAROM only - No PROM **[Pelvic fractures]** - Usually due to high energy trauma. - Frequently have multiple other injuries - occasionally life-threatening such as intra abdominal bleeding, urologic, colorectal, chest. - Complex fractures usually requiring CT scan for evaluation. Divided into fractures of pelvic ring and acetabular fractures. Every injury to the pelvis may have ligamentous injuries at the SI joint. Need to get pelvic inlet view, outlet view and AP of pelvis. A. [Pelvic Ring Fractures] \- Lateral compression -- hit by car \- SI joint \- Vertical sheer - always unstable [Treatment] Restoration of stability of the pelvic ring 1\. NWB if unstable, if stable can be WBAT-TTWB 2\. Traction/pelvic sling - unusual - only if medically unstable 3\. External fixation/Planting -- Anterior 4\. ORIF -- Posterior SI joint B. [Acetabular Fractures] - Intra-articular fractures that demand [anatomic reduction]. - Frequently associated with hip dislocation and/or femoral neck/shaft fracture. - Damage to joint cartilage occurs with injury - Post-traumatic arthritis regardless of how it is treated because cartilage is sheared off [Treatment] -- watch for Pulmonary Embolism 1\. NWB or TTWB for non-displaced & stable fractures for 12 weeks 2\. Unstable or displaced fx- ORIF followed by TTWB for 10-12 weeks - May have skeletal traction short term while awaiting surgery C. [Pelvic Stress Fracture] \- Older patient without significant injury history ie low energy \- Ossification around area of stress fracture/bone scan \- WBAT - with or without assistive device **Hip Part 2** I. Non-prosthetic Surgery of the Skeletally Mature Hip A. young adult patients with pre-arthritic or early arthritic hip pain can be treated by deformity correction (CDH, Perthe's, SCFE) to relieve pain & preserve the joint. B. Intra-articular and peri-articular pathology = persistent cause of hip pain, restriction of function and predispose to secondary OA. C. a variety of disorders of the adult hip joint can be effectively managed with nonprosthetic surgical techniques. - Post-traumatic hip disorders (malunion, nonunion, OA) - [Pre-arthritic and early arthritic diseases] (DDH, SCFE, Perthe's, AVN) - [Intra-articular and periarticular lesions] (impingement syndromes, labral pathology, loose bodies) - II. Patient Evaluation A. History B. Physical Exam 1. Gait, leg lengths, hip strength, Trendelenburg, range of motion 2. Motion (limits, arc), strength (abductors) 3. Signs a. Impingement test- flexion/ADD/IR; groin pain indicates intra-articular problem b. Apprehension- hip extended with ER; tests for dysplasia (shallow acetabulum) c. bicycle test- test abductor function; pt in sidelying 4. Position of comfort (supine and weightbearing) C. Imaging- 1. Plain radiographs - weight bearing pelvis, false profile (dysplasia), frog leg view or cross-table, *functional views* (congruency, joint space, comfort) 2. MRI (ON/AVN)- 85% 3. [MRI arthrogram] (intraarticular pathology, labral tear)- \>85% 4. CT scan-bony detail (ON, congruency, osteophytes) III. Post-traumatic Hip Disorders - - - A. Proximal Femoral Malunion 1. Very good indication for proximal femoral osteotomy (from varus to valgus alignment of head and neck) 2. Define components of malunion 3. Goal is to restore normal anatomic relationships of hip (length, offset, rotation, varus/valgus) 4. Usually no wedge technique B. Femoral Neck Non-union 1. Very good indication for proximal femoral osteotomy 2. No head collapse, established nonunion, good joint space 3. Change shear/tension force into compressive force across nonunion 4. Pauwel's valgus osteotomy C. Rehab after Proximal Femoral Osteotomy- 1. Priority is to get bone healing before beginning aggressive rehab 2. Emphasis on healing first 3. TTWB 6 wks, passive, active-assisted ROM 4. 50% WB 6-12 wks, active ROM, gentle strengthening 5. Full WB at 3mos, wean off assist as tolerated, aggressive strengthening especially abductors 6. Avoid sports for one year or longer D. Arthodesis= hip fusion 1. Rarely done 2. Usually only done in young (15-30 yrs), active patient 3. Male, manual laborer 4. Indications: Post-traumatic, infection, takedown of THA - Normal back, bilateral knees 5. Careful patient counseling 6. Anterior approach, hip screws, anterior plate, abductors/trochanter intact - 15-30 degrees flexion, neutral abduction, 10-15 degrees external rotation 7. Long-term: 20 year survival excellent, adequate pain relief - Complications: lumbar spine and ipsilateral knee/ankle, contralateral hip IV. Pre-arthritic/early arthritic hip diseases - Femoroacetabular impingement, DDH, SCFE, Perthe's - 60-90% of patients undergoing THA have an underlying deformity; some think that true idiopathic OA in hip is uncommon - A. Femoral-acetabular Impingement 9. Pincer- too much bone on acetabulum, deep acetabulum 10. CAM- femoral neck is enlarged; can sublux inferior posterior 11. May have both B. Slipped Capital Femoral Epiphysis (SCFE)- This will be covered in Pediatric orthopedic lecture; 1. Symptoms secondary to impingement, (anterolateral osteophyte) & secondary OA 2. 3. Flexion IT osteotomy a. Anterior capsule release b. Derotation (internal rotation) c. Valgus correction?- controversial d. Results- \>80% good/excellent results at long term follow-up (Imhauser, 1977) C. Developmental Dysplasia of Hip- most common; often bilateral 1. - Deficient femoral head coverage (lateral and anterior) - Hyperplastic Labrum 2. 3. 4. 5. 6. - Usually done on young pts a. Goals - Regain femoral head coverage - Medialize hip center of rotation b. 18 year old female with 2 year history of left hip (Perthe's deformity) c. False profile (anterior coverage) d. Flexion/abduction view (check congruence) e. 10 months postop, no pain full activities D. PAO rehab 1. Healing as priority, very painful procedure 2. Initial \~48hrs- on epidural 3. 0-6 weeks- partial WB (30lbs), passive, A/A ROM, no active hip flexion if rectus femoris resected during surgery 4. 6-12 weeks: partial or 50% wt bearing, active ROM 5. 12- 16 weeks: full WB with assist, active strengthening (may be earlier if RF is was not transected) 6. \> 16 weeks, wean off support, aggressive strengthening 7. Full recovery 6-12 months V. Hip Arthroscopy for Intra-articular and peri-articular lesions B. Labral Tear Clinical Presentation 1. Adolescent, adult patient, occasionally elderly 2. Groin pain, activity/position related, frequently worse with flex/IR (sitting) 3. Catching, locking 4. Insidious or traumatic event 5. Associated with DDH (more load on labrum secondary to shallow acetabulum), previous fracture 6. Differential diagnosis - Snapping psoas, often symptomatic when pt walking or actively flex hip C. Non-operative treatment for labral tears 1. Activity restriction 2. NSAID's, pain meds - Occasionally will use steroid injection 3. Physical therapy 4. 6-12 wk trial 5. Efficacy? D. Operative treatment for labral tears 1. Open labral debridement- assoc with osteotomy, joint debridement procedures 2. Arthroscopic debridement a. Avoid major open surgery b. Same day surgery, overnight c. Minimally invasive d. Better visualization of joint (diagnostic) 3. Correct FAI -- osteochondroplasty E. Rehab after arthroscope for labral tear 1. Emphasize ROM within comfort limits, CPM for 1^st^ few days 2. Immediate ROM, passive/active - for 1 mo restrict flex \