Hip Osteoarthrosis -PAWAN

ORTHOPAEDICS

1. hip OSTEOARTHRosiS Dr. Pawan K. Yadav D.ORTHO.,DNB(ORTHO) BIRRD HOSPITAL, TIRUPATHI

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3. DEFINITION Chronic disease, Degenerative changes in Articular Cartilage & subsequent new Bone Formation Results from, Rate of Degeneration being greater than Rate of repair &/or Regeneration of articular cartilage

4. OSTEOARTHROSIS is the preferred term than OSTEOARTHRITIS No evidence of Synovial Thickening / Inflammatory infiltrate..

5. PRIMARY OA Idiopathic Causative Factor Suspected are: ↑ ed Anteversion Trabecular micro# causing Stiffening of the Subchondral Bone

6. SECONDARY OA Incongruity :- Causes abnormal friction Perthe`s d/s, #s of Articular surface Instability :- Causes abnormal mechanical friction Dysplasia of hip, DDH AVN :- If femoral head is not protected agaist load bearing stress while repair is taking place # N.O.F , Drugs, Idiopathic, Radiation, Chronic alcoholism, Sickle cell d/s

7. Concentration of pressure load :- Coxa vara, Increased Anteversion Direct injury to cartilage :- Infection, Rheumatoid Arthritis, Missile Injury Constitutional causes :- Obesity, Menopause, Hypothyroidism, Pituitary Dysfunction

8. PATHOLOGY & PATHOGENESIS

9. PATHOGENESIS Role of Art: Cartilage – Distributing & Dissipating the forces associated with Jt: loading Earliest Changes (while the cartilage is still morphologically intact) – An ↑ in water content of the Cartilage & easier extractability of the matrix Proteoglycan At a later stage – Loss of Proteoglycan & Defect appear in cartilage As the cartilage become less stiff, 2 damages to chondrocytes may cause release of cell enzymes → Further matrix break down

10. Cartilage deformation – stress on the Collagen network…. Amplifying the changes in a cycle that leads to tissue break down When it loses its integrity, these forces are ↑ ngly concentrated in the Subchondral Bone Results in focal Trabecular Degeneration & Cyst formation Also an ↑ ed vascularity & Reactive Sclerosis in the zone of maximal loading

11. In normal mech: of standing, the hip is stable in EXTENSION, slight ABDUCTION & slight INTERNAL ROTATION This permits opp: pelvis to be elevated in next forward step with the opp: limb The Anterior & Inferior Capsule is taut in this position When fibrosis has caused thickening, shortening & loss of elasticity of the Inf: Capsule, the Femur is pulled into opposite deformity of FLEXION, ADDUCTION & EXTERNAL ROTATION

12. External pressure is absent at the infero-medial aspect of head & extreme outer margin – Ossfication proceed Unopposed… Supero-lateral aspect – Pressure is greatest – suffer minute trabecular #s. Concentration of compressed bone appear to be dense & eburnated suggesting Aseptic Necrosis. But actually this is dense vascular bone..

13. PATHOLOGY Cardinal features are: Progressive cartilage destruction Subarticular cyst formation Sclerosis of the surrounding bone Osteophyte formation Capsular fibrosis

14. With progression of the disease, there will be continous loss of articular cartilage leads to exposure of subchondral bone – which appears as shiny foci on the articular surface (known as EBURNATION )..

15. Head In Osteoarthrosis

16. MICROSCOPY Early stages: Cartilage show small irregularities / splits in the surface Deeper layer – Patchy loss of metachromasia Increased cellularity Appearance of clusters / clones of chondrocytes Late stages Cleft – More extensive Areas of cartilage loss

17. A – Fissuring; B – Irregular Surface

18. Osteoarthrosis – Histology

19. Slight pain lasting only 1 or 2 days, after a Twisting Strain / Misstep Sensation of stiffness appearing after Rest & Free Movement obtained after Activity Protective limp due to muscle spasm Pain becomes Progressively Worse in Degree & Duration Stiffness becomes More & Pain lessened because of severe restriction of movement

20. Pain is located about the hip Anteriorly / Laterally / Posteriorly & is referred to Medial aspect of Thigh & Knee Joint Tenderness over capsular inflammation – Scarpa’s Triangle Flexion , Adduction , External Rotation Deformity FABER test ( Figure of ‘4’ test / Patrick’s test) – ‘+’ve Limitations of movements in all direction

21. Flexion, Adduction, External Rotation.

22. American College of Rheumatology Classification (ACR) Criteria for Osteoarthrosis Hip pain and at least 2 of the following 3 items: Erythrocyte sedimentation rate <20 mm/hour Radiographic femoral or acetabular osteophytes Radiographic joint space narrowing

23. ROENTGENOGRAPHIC FINDINGS Joint Space Narrowing Sub-Chondral sclerosis under cartilage damage Osteophytes at the margins of bone Subchondral cyst formation at maximum cartilage damage Concurrent similar changes takes place in Acetabulum

24. Big osteophytes

25. STAGING – Kallegran & Lawrence Stage I - Doubtful O.A. Minute Osteophytes of doubtful importance Stage II - Minimal O.A. Definite Osteophytes without reduction of the joint space Stage III - Moderate O.A. Osteophytes & moderate diminution of joint space Stage IV -Severe O.A. Greatly Reduced Joint Space & Sclerosis of Sub-chondral Bone

26. Articular cartilage in OA

27. TREATMENT

28. Principles of Treatment Maintain movement & muscle strength Protect the joint from over load Relieve pain Modify daily activities

29. CONSERVATIVE Rest Heat and Massage to overcome Muscle Spasm Traction in abduction to Stretch the Capsule Range of motion exercises Manipulation restricted to gentle stretching of anterior & inferior capsule Reduction of wt: bearing loads - Cane (Support) on opposite hand, Crutches & Weight reduction measures Non-Steroidal-Anti-Inflammatory Drugs Intra-articular Steroid to relieve pain

30. Medical Management of Patients with Osteoarthrosis of the Hip Non Pharmacologic therapy Patient education Self-management programs (e.g., Arthritis Self-Help Course) Health professional social support via telephone contact Weight loss (if overweight) Physical therapy Range of motion exercises Strengthening exercises Assistive devices for ambulation Occupational therapy Joint protection and energy conservation Assistive devices for ADLs Aerobic aquatic exercise programs Pharmacologic therapy Non-opioid analgesics (e.g., acetaminophen) Non-steroidal anti inflammatory drugs Opioid analgesics (e.g., propoxyphene, codeine, oxycodone)

31. SURGICAL Indication Pain unrelieved by Conservative Rx Both hips with gross restriction of Movement Severe Flexion, Adduction Deformity on one side with Pelvic Tilt & Secondary Degenerative Spondylosis producing pain

32. SURGERIES IN OA HIP

33. Varus Osteotomy – Increase weight bearing area of femoral head & relaxes all muscles

34. Valgus Osteotomy – Increase weight bearing area of head doesn’t produce muscle relaxation

35. GIRDLESTONE ARTHROPLASTY

36. GIRDLESTONE ARTHROPLASTY

37. CUP ARTHROPLASTY

38. TOTAL HIP ARTHROPLASTY

39. TOTAL HIP ARTHROPLASTY

40. THANQ