MINI MED SCHOOL UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE

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MINI MED SCHOOLUNIVERSITY OF MARYLAND
SCHOOL OF MEDICINE

• HIP DISEASE
• COMMON IMPEDIMENTS TO WALKING ERECT
• VINCENT D. PELLEGRINI, JR., M.D.
• JAMES L. KERNAN PROFESSOR AND CHAIR,
• DEPARTMENT OF ORTHOPAEDICS
• email vpellegrini_at_umoa.umm.edu

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HIP DISEASECOMMON IMPEDIMENTS TO WALKING
ERECT

• FRACTURE
• AVASCULAR NECROSIS
• HIP ATTACK
• ARTHRITIS

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HIP DISEASECOMMON IMPEDIMENTS TO WALKING
ERECT

• LEARNING OBJECTIVES
• EPIDEMIOLOGY
• CLINICAL SCENARIO
• PATHOANATOMY
• TREATMENT ALTERNATIVES

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HIP FRACTUREEPIDEMIOLOGY

• 250,000 HIP FRACTURES ANNUALLY IN USA
• DOUBLE BY 2040 COURTESY OF BABY BOOMERS
• 90 ARE LOW ENERGY
• SIMPLE FALL
• ELDERLY POPULATION
• WITH OTHER MEDICAL ILLNESSES

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HIP FRACTUREEPIDEMIOLOGY

• US BUREAU OF CENSUS
• 2030 ONE IN FIVE AMERICANS OVER 65
• 21 OF FEMALES 19 OF MALES
• HIP FRACTURE DOUBLES BY DECADE BEYOND 50
• 1/3 WOMEN AND 1/6 MEN HIP FX BY AGE 90
• CAUCASIAN FEMALES 2-3x gt HISPANIC AND A-A

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HIP FRACTURERISK FACTORS

• URBAN DWELLING
• ETOH OR CAFFEINE OR TOBACCO
• PHYSICAL INACTIVITY
• PRIOR HIP FRACTURE
• SENILE DEMENTIA
• CONCURRENT ARTHRITIC DISEASE IS RARE
• EXERTS A PROTECTIVE EFFECT !

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HIP FRACTURERISK FACTORS

• PSYCHOTROPIC MEDICATIONS
• HYPNOTICS, ANTIDEPRESSANTS, ANTIPSYCHOTICS
• BENZODIAZEPINES (VALIUM) -gt FALLS
• WEIGHT LOSS gt 10 WHITE FEMALES OVER 50
• IN NEED OF ASSISTIVE DEVICES FOR ADLs
• HOME BOUND AMBULATORS

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HIP FRACTURERELATED MORTALITY

• BELLWETHER OF IMPENDING PHYSIOLOGIC DECLINE
• INJURY - RELATED MORTALITY
• PERIOPERATIVE EVENTS
• ONE YEAR MORTALITY FOLLOWING HIP FX
• 12 - 36
• IN - HOSPITAL MORTALITY 1 - 2

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HIP FRACTURERELATED MORTALITY

• GREATEST RISK
• INITIAL 4 - 6 MONTHS POSTOPERATIVE
• MORTALITY RETURNS TO CONTROL AFTER 1 YEAR
• LOWEST IN THOSE SENIORS WHO ARE
• COGNITIVELY INTACT
• INDEPENDENT COMMUNITY DWELLING

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HIP FRACTURERELATED MORTALITY

• OPERATIVE DELAY gt 2 DAYS
• 2X RISK OF DEATH IN FIRST POSTOP YEAR
• OTHER PREDICTORS OF FIRST YEAR SURVIVAL
• NUTRITIONAL STATUS
• GENERAL HEALTH

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HIP FRACTURETREATMENT CONSIDERATIONS

• FOR AMBULATORS AND THOSE
• WITH REASONABLE AMBULATORY POTENTIAL
• HIP FRACTURE IS AN
• OPERATIVE DISEASE
• MINIMIZE MORBIDITY AND MORTALITY ASSOCIATED
• WITH BEDREST AND INACTIVITY
• PNEUMONIA / BLOOD CLOTS (DVT AND EMBOLISM)

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HIP FRACTURESPECIFIC TREATMENT GOALS

• AMBULATORS
• SOUND BONY UNION
• RESTORATION OF NORMAL ANATOMY
• NONAMBULATORS
• PAIN - FREE FRACTURE SITE

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HIP FRACTUREANATOMICAL TREATMENT DICTUM

• THE LOCATION OF THE FRACTURE
• RELATIVE TO THE CAPSULAR ATTACHMENTS
• DETERMINES THE THREAT OF INJURY
• TO THE BLOOD SUPPLY OF THE HIP,
• THE METHOD OF TREATMENT,
• AND ITS SUBSEQUENT LIKELIHOOD OF SUCCESS

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ANATOMICAL BASIS OF TREATMENTTHE HIP CAPSULE
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ANATOMICAL BASIS OF TREATMENTTHE HIP CAPSULE
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HIP FRACTUREVASCULAR SUPPLY TO THE HIP

• EXTRACAPSULAR
• CIRCUMFERENTIAL RING OF VESSELS
• AT THE INTERTROCHANTERIC LINE
• MEDIAL AND LATERAL FEMORAL CIRCUMFLEX

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ANATOMICAL BASIS OF TREATMENTBLOOD SUPPLY
TO THE HIP
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HIP FRACTURETHE THREAT TO VASCULAR SUPPLY

• RETINACULAR VESSELS
• PRECARIOUS IN LOCATION ON THE FEMORAL NECK
• ARE SUBJECT TO INJURY / INTERRUPTION
• BY ANY INTRACAPSULAR HIP FRACTURE
• DISPLACEMENT -gt RISK OF DISRUPTION / TAMPONADE

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ANATOMICAL BASIS OF TREATMENTBLOOD SUPPLY
TO THE FEMORAL HEAD
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HIP FRACTURESPECIFIC TREATMENT CONSIDERATIONS

• EXTRACAPSULAR FRACTURE
• WILL HEAL WITH NONOPERATIVE RX
• CASTING OR TRACTION
• BUT, MORBIDITY AND MORTALITY
• ASSOCIATED WITH PROLONGED BEDREST
• IS UNACCEPTABLE

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HIP FRACTUREEXTRACAPSULAR - INTERTROCHANTERIC

• VASCULAR SUPPLY TO THE HIP IS PRESERVED
• GENERALLY TREATED BY INTERNAL FIXATION
  (REPAIR OF THE PARTS)
• FAILURE TO HEAL IS RARE (1-2)

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HIP FRACTURESPECIFIC TREATMENT CONSIDERATIONS

• INTRACAPSULAR FRACTURE
• HEAL ONLY INFREQUENTLY WITH NONOPERATIVE RX
• DISADVANTAGED BIOMECHANICS
• COMPROMISED VASCULAR SUPPLY
• NONDISPLACED FX
• TREAT BY REPAIR TO MOBILIZE THE PATIENT

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HIP FRACTUREINTRACAPSULAR - FEMORAL NECK

• NONDISPLACED FX
• TREAT BY REPAIR TO MOBILIZE THE PATIENT
• DISPLACED FX
• REPLACE THE HIP
• AVOID NONUNION / NECROSIS
• SINGLE OPERATION

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HIP FRACTUREDISPLACED INTRACAPSULAR

• THE UNSOLVED FRACTURE
• ?? REPAIR OR REPLACEMENT ??
• UNDER AGE 60
• REPAIR / PRESERVATION FEMORAL HEAD
• OVER 60 gt PROSTHETIC REPLACEMENT
• IN BETWEEN - CONTROVERSIAL

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HIP FRACTUREINTRACAPSULAR FX COMPLICATIONS

• VASCULAR SUPPLY TO THE HIP IS THREATENED
• ASEPTIC NECROSIS 15 - 33
• 1 IN 3 REQUIRE ADDITIONAL OPERATION
• NONUNION / FAILURE OF FIXATION 10 - 30
• VERTICAL FX PATTERN HIGH RISK
• 75 REQUIRE REOPERATION

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ASEPTIC NECROSIS OF THE HIP HIP ATTACK

• DEATH OF BONE IN THE FEMORAL HEAD
• SUPPORTING OVERLYING JOINT CARTILAGE
• REPAIR REPLACEMENT OF THE DEAD BONE
• TEMPORARY WEAKENED STATE
• UNDERLYING BONE COLLAPSES HEAD FLATTENS
• EVENTUAL ARTHRITIS

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ANATOMICAL BASIS OF TREATMENTBLOOD SUPPLY
TO THE HIP
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ASEPTIC NECROSIS OF THE HIP EPIDEMIOLOGY

• TYPICALLY YOUNG PATIENTS lt 50 YRS
• TWO THIRDS HAVE BOTH HIPS INVOLVED
• TREATMENT DILEMMA
• TOO YOUNG / WILL OUTLIVE HIP REPLACEMENT

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ASEPTIC NECROSIS OF THE HIP RISK FACTORS
DISRUPTION OF CIRCULATION

• FRACTURE
• STEROID EXPOSURE
• EXCESSIVE ALCOHOL CONSUMPTION
• CHEMOTHERAPY
• BONE MARROW DISORDERS
• SICKLE CELL DISEASE
• LUPUS
• DEEP SEA DIVING - THE BENDS

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ASEPTIC NECROSIS OF THE HIP PATHOANATOMY

• BLOOD SLUDGING IN SMALL VESSELS
• LOSS OF CIRCULATION ISCHEMIA
• EDEMA / TISSUE FLUID
• SWELLING IN SOFT TISSUES
• INCREASE IN PRESSURE WITHIN THE BONE
• PREVENTS BLOOD INFLOW VICIOUS CYCLE

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ANATOMICAL BASIS OF TREATMENTBLOOD SUPPLY
TO THE FEMORAL HEAD
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ASEPTIC NECROSIS OF THE HIP PATHOANATOMY

• DEAD BONE MARROW FAT
• EARLIEST DETECTION BY MRI
• ANTERIOR, SUPERIOR AND LATERAL HEAD
• OPPOSITE THE SITE OF ENTRY
• OF PRIMARY BLOOD VESSELS TO HEAD

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ASEPTIC NECROSIS OF THE HIP STEROIDS /
ASTHMA MRI
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ASEPTIC NECROSIS OF THE HIP SYMPTOMS

• PAIN
• INCREASED PRESSURE IN BONE
• DEAD BONE WEAK COLLAPSES WITH OVERLYING
  CARTILAGE
• LATE ARTHRITIC DISEASE

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ASEPTIC NECROSIS OF THE HIP TREATMENT
CONSIDERATIONS

• GOALS
• RELIEF OF PAIN
• ENHANCE REPAIR / REVASCULARIZATION DEAD BONE
• PREVENTION OF LATE ARTHRITIS

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ASEPTIC NECROSIS OF THE HIP CLASSICAL
TREATMENT

• CORE DECOMPRESSION
• DRILL A HOLE IN FEMUR TO RELIEVE PRESSURE
• RELIABLE RELIEF OF PAIN
• UNCHANGED PROGRESSION OF DISEASE
• EVENTUAL COLLAPSE OF DEAD BONE
• LATE ARTHRITIS AND HIP REPLACEMENT
• 10 - 30 RETENTION OF NORMAL HIP AT 5 YRS

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ASEPTIC NECROSIS OF THE HIP CONTEMPORARY
TREATMENT

• VASCULARIZED BONE GRAFT (FIBULA)
• RELIEVE PRESSURE IN FEMUR
• REDIRECT NEW CIRCULATION
• PROVIDE SUPPORT TO PREVENT COLLAPSE
• TWO SURGICAL TEAMS
• ONE HARVEST FIBULA FROM SAME SIDE LEG
• ONE PREPARE HIP AND MICROSURGERY

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ASEPTIC NECROSIS OF THE HIP VASCULARIZED
FIBULA GRAFT
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ASEPTIC NECROSIS OF THE HIP VASCULARIZED
FIBULA GRAFT
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ASEPTIC NECROSIS OF THE HIP VASCULARIZED
FIBULA GRAFT
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VASCULARIZED FIBULA FOR HIP AVN STEROIDS / MS
- 8 WEEKS
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VASCULARIZED FIBULA FOR HIP AVN STEROIDS / MS
- 6 YEARS
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ASEPTIC NECROSIS OF THE HIP TREATMENT
RESULTS

• IF OPERATION BEFORE COLLAPSE OF HEAD
• VASCULARIZED BONE GRAFT (FIBULA)
• 80 - 85 RETENTION OF NORMAL HIP AT 5 YRS
• 15 CONVERSION TO TOTAL HIP REPLACEMENT

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VASCULARIZED FIBULA FOR HIP AVNMECHANISM OF
FAILURE
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ARTHRITIS OF THE HIP EPIDEMIOLOGY

• MANY DIFFERENT CAUSES
• POST TRAUMA
• OSTEOARTHRITIS (WEAR AND TEAR)
• RHEUMATOID ARTHRITIS (INFLAMMATORY)
• ASEPTIC NECROSIS
• DEVELOPMENTAL / ADOLESCENT
• CONGENITAL

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ARTHRITIS OF THE HIP PRESENTATION

• GROIN PAIN
• REFERRED PAIN TO THIGH AND KNEE
• UNABLE TO FULLY STRAIGHTEN / EXTEND
• STOOPED PAINFUL GAIT
• STIFFNESS / PARTICULARLY LOSS OF ROTATION
• CONSTANT PAIN AT REST NIGHT

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ARTHRITIS OF THE HIP TREATMENT

• ANALGESIC MEDICATION
• ANTI-INFLAMMATORY MEDICATION
• CANE (OPPOSITE HAND)
• WEIGHT LOSS
• OSTEOTOMY (CUT REPOSITION HIP)
• FUSION (STIFFENING)
• TOTAL HIP REPLACEMENT

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ANATOMICAL BASIS OF TREATMENTINSIDE THE HIP
JOINT - CARTILAGE WEAR
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ARTHRITIS OF THE HIP XRAYS - LOSS OF
CARTILAGE SPACE
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TOTAL HIP REPLACEMENT OUTCOMES
CEMENTLESS FIXATION LOOSENING RARE 90
SURVIVE 15 YRS MOST REVISIONS FOR SOCKET
WEAR
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PROSTHETIC HIP REPLACEMENT MECHANISMS OF
FAILURE
INSTABILITY INFECTION WEAR OF THE BEARING
SURFACES BONE RESORPTION
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PROSTHETIC HIP REPLACEMENT THE FUTURE
IMPROVED BEARING SURFACES NEWER
MATERIALS CERAMIC / METAL / PLASTIC REDUCED
REACTION TO WEAR DEBRIS PREVENT BONE
RESORPTION RESPONSE ? MINI INCISIONS ? NOT
LIKELY THE ANSWER