Surgical Treatment of Hip Arthritis: Reconstruction, Replacement, and Revision: Expert Consult - Online and Print with DVD

523 Pages·2009·71.52 MB·English

by  William J. Hozack

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SURGICAL TREATMENT OF HIP ARTHRITIS: RECONSTRUCTION, ISBN: 978-1-4160-5898-4
REPLACEMENT, AND REVISION
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Library of Congress Cataloging-in-Publication Data
Surgical treatment of hip arthritis : reconstruction, replacement, and revision / [edited by] William Hozack,
Javad Parvizi, and Benjamin Bender.—1 st ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4160-5898-4
1. Hip joint—Surgery. 2. Arthritis—Surgery. I. Hozack, William J. II. Parvizi, Javad. III. Bender,
Benjamin, M.D.
[DNLM: 1. Osteoarthritis, Hip—surgery. 2. Arthroplasty, Replacement, Hip—methods.
3. Reoperation—methods. WE 860 S9616 2010]
RD549.S867 2010
617.5′81059—dc22
2009027246
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Managing Developmental Editor: Cathy Carroll
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife, Vesna, for her love and my four kids for their understanding. To Richard Rothman, M.D.,
who sparked my interest in hip surgery and whose wisdom has helped me throughout my career.
W.H.
To my wife, Fariba, for her endless dedication to medicine and her eternal patience and love. To my patients
who willingly endure all hardships on the road to recovery.
J.P.
To my son Jonathan, his wonderful mother Korinna, my mother and father Hanna and Reuben,
my brother Guy, all my family, all my mentors, and all the great people along the way for their
consideration and support.
B.B.
Preface
This book is intended to be a comprehensive guide for sur- patients require hip implants that will last for decades. Hence,
geons performing primary and revision total hip arthroplasty. alternative bearing surfaces such as highly cross-linked poly-
The authors encompass a group of renowned experts from ethylene, ceramic-on-ceramic, and metal-on-metal are evalu-
around the world. Section I of this book deals with diagnostic ated in detail. For example, with progressive improvement in
evaluation of hip pain and imaging of the hip. Section II of mechanical properties of ceramics, fracture has become a
the book reviews in detail the reconstruction and replacement rarity. A new problem is has now been encountered with the
options for the diseased hip joint, and also alternative non- modern ceramic surfaces—squeaking. The availability of the
arthroplasty options. The latest developments such as incor- alternative bearing surface has allowed orthopedic surgeons
poration of computers and navigation into the procedure, the to perform total hip arthroplasty in younger patients who
use of minimally invasive techniques and specific instrumen- would have been deemed inappropriate candidates for hip
tations are described in detail. Section III of the book deals arthroplasty during the early era of joint replacement. Various
with perioperative management of the patient after hip complications related and unrelated to the procedure can
surgery. Section IV is dedicated to revision arthroplasty of the occur—infection, loosening, instability, wear—and methods
hip. Section V highlights a series of controversial issues associ- to minimize complications are discussed in detail.†
ated with hip arthroplasty. Hip resurfacing has enjoyed a renaissance in recent years.
Total hip arthroplasty is one of the most successful surgical There are several hip resurfacing devices available today, but
procedures as it relieves pain, restores mobility, and improves the most critical factors in resurfacing are the surgeon and
quality of life for patients with previous incapacitating arthri- proper patient selection. The main concern following hip resur-
tis. In the United States almost one quarter million total hip facing arthroplasty continues to be postoperative femoral
replacements are performed annually, and this number is neck fracture. Excessive varus or notching of the femoral neck
expected to rise to 572,000 (plus another 97,000 revisions) can result in early failure due to femoral neck fracture. In
by 2030. There are numerous causes of hip arthritis includ- addition female gender, poor bone quality, and femoral head
ing childhood disorders (such as DDH, Perthes disease, and cysts greater than 1cm in diameter are all associated with a
SCPE), inflammatory arthritis, osteonecrosis, trauma, and higher likelihood of postoperative femoral neck fracture.
infection. For the majority of patients, however, a growing Minimally invasive surgical techniques continue to be an
body of evidence suggests that subtle morphological changes area of controversy in total hip replacement. Patient selection
in the hip, such as acetabular retroversion, mild acetabular and surgeon experience are clearly factors that influence the
dysplasia, and subtle forms of epiphyseal slippage are the degree of soft tissue trauma created during the hip replace-
underlying causes of hip arthritis. ment procedure. A variety of different techniques have been
Non-replacement options for hip arthritis will be covered offered as being minimally invasive, and this book will evalu-
in detail. Hip arthroscopy has evolved as a method to treat a ate them in detail.
variety of hip conditions, including intra-articular and extra- Total hip arthroplasty inevitably necessitates revision
articular pathology. Osteochondroplasty of the hip involves surgery. Multiple causes including aseptic loosening, infec-
resection of osteophytes, resection of a portion of the anterior tion, recurrent dislocation, implant failure, periprosthetic
femoral cortex to improve the femoral head and neck ratio, fracture, and leg length discrepancy necessitate hip revision.
debridement of damaged cartilage, and repair of the labrum. There may be considerable acetabular bone deficiency. Pre-
The indication for this procedure is usually femoroacetabular operative evaluation is critically important. Consensus has
impingement. Osteotomy of the adult hip is indicated for the developed regarding management of bone loss encountered
treatment of dysplasia, residual deformity from SCFE, cere- during total hip revision, but it still remains a challenging
bral palsy with hip instability and osteonecrosis. The choice problem.
of femoral or acetabular osteotomy is dictated by the type of The goal of this book is ambitious, but we feel that the
deformity present. challenge has been successfully met.
Implant material, design, and surgical techniques for total
hip arthroplasty are critically important for good functional William J. Hozack, MD
results and longevity. The average age of a primary total hip Javad Parvizi, MD
arthroplasty patient is decreasing,* and younger, more active Benjamin Bender, MD
*E. Dunstan, D. Ladon, and P. Whittingham-Jones, et al: Chromosomal aberrations
in the peripheral blood of patients with metal-on-metal bearing. J Bone Joint Surg †D.E. McCollum and W.J. Gray: Dislocation after total hip arthroplasty. Causes and
Am 90(3):517-22, 2008. prevention. Clin Orthop Relat Res 261:159-70, 1990.
vii
Contributors
Omar Abdul-Hadi, MD Keith R. Berend, MD Pablo Corona, MD
Rothman Institute of Orthopaedics Joint Implant Surgeons, Inc. Department of Orthopaedic Surgery
Thomas Jefferson University Hospital New Albany, OH Reconstructive and Septic Surgery Division
Philadelphia, PA Hospital Universitario Vall d’Hebron
Michael E. Berend, MD Barcelona, Spain
Ashutosh Acharya, FRCS Fellowship Director, Center for Hip and
Hip Fellow Knee Surgery Ross Crawford, DPhil, FRACS,
The Hip Unit St. Francis Hospital–Mooresville MBBS
Princess Elizabeth Orthopaedics Centre Mooresville, IN Institute of Health and Biomedical
Exeter, UK Innovation
Gurdeep S. Biring, MSc, FRCS School of Engineering Systems
Mir H. Ali, MD, PhD Clinical and Research Fellow Queensland University of Technology
Department of Orthopedic Surgery Department of Orthopaedics Brisbane, Queensland
Mayo Clinic Division of Adult Lower Limb Australia
Rochester, MN Reconstruction and Oncology
University of British Columbia J. de Beer, FRCSC
Carles Amat, MD Vancouver, British Columbia Assistant Clinical Professor
Department of Orthopaedic Surgery Canada McMaster University
Reconstructive and Septic Surgery Division Director of Hamilton Arthroplasty Group
Hospital Universitario Vall d’Hebron Petros J. Boscainos, MD Chief of Orthopaedic Surgery
Barcelona, Spain Clinical Fellow Henderson Hospital
Division of Orthopaedic Surgery, Toronto Hamilton, Ontario
G. Rebecca Aspinall, MBChB, FRCS East General Hospital Canada
Orthopaedic Fellow University of Toronto
Division of Orthopaedics Research Fellow Ronald E. Delanois, MD
Dalhousie University Division of Orthopaedic Surgery Center for Joint Preservation and
Halifax, Nova Scotia Mount Sinai Hospital Reconstruction
Canada Toronto, Ontario Rubin Institute for Advanced Orthopedics
Canada Sinai Hospital of Baltimore
Matthew S. Austin, MD Baltimore, MD
Assistant Professor of Orthopaedic Surgery R. Stephen J. Burnett, MD, FRCS(C)
Rothman Institute of Orthopaedics Department of Orthopaedic Surgery Douglas A. Dennis, MD
Thomas Jefferson University Hospital Washington University School of Medicine Department of Biomedical Engineering
Philadelphia, PA St. Louis, MO University of Tennessee
Knoxville, TN
Khalid Azzam, MD William N. Capello, MD Rocky Mountain Musculoskeletal Research
Rothman Institute of Orthopaedics Department of Orthopaedic Surgery Laboratory
Thomas Jefferson University Hospital Indiana University School of Medicine Denver, CO
Philadelphia, PA Indianapolis, IN
Anthony M. DiGioia, III, MD
B. Sonny Bal, MD, MBA Isabelle Catelas, PhD Department of Orthopaedic Surgery
Department of Orthopaedic Surgery Associate Professor University of Pittsburgh Medical Center
University of Missouri School of Medicine Canada Research Chair–Tier II Magee-Women’s Hospital
Columbia, MO Mechanical Engineering and Department of Pittsburgh, PA
Surgery
Paul E. Beaulé, MD, FRCSC University of Ottawa Bill Donnelly, MB, BS, B Med Sci,
Associate Professor Ottawa, Ontario FRACS
University of Ottawa Canada Brisbane Orthopaedic Specialist Services
Head, Adult Reconstruction Service Ground Floor Medical Centre
The Ottawa Hospital John C. Clohisy, MD Holy Spirit Northside Private Hospital
Ottawa, Ontario Professor of Orthopaedic Surgery Chermside, Queensland
Canada Co-Chief Adult Reconstructive Surgery Australia
Director Adolescent and Young Adult
Benjamin Bender, MD Hip Service Lawrence D. Dorr, MD
Orthopaedic Surgeon Washington University Orthopaedics Arthritis Institute
Holon, Israel St. Louis, MO Inglewood, CA
ix
x Contributors
Gavan P. Duffy, MD Kevin L. Garvin, MD Ginger E. Holt, MD
Department of Orthopedics Professor and Chair Vanderbilt University Medical Center
Mayo Clinic Department of Orthopaedic Surgery Nashville, TN
Jacksonville, FL University of Nebraska Medical Center
Omaha, NE William J. Hozack, MD
John Dumbleton, PhD, DSc Professor of Orthopaedic Surgery
Consultancy in Medical Devices and G.A. Gie, MBBS, FRCS Ed Rothman Institute of Orthopaedics
Biomaterials Consultant Orthopaedic Surgeon Thomas Jefferson University Medical
Ridgewood, NJ Princess Elizabeth Orthopaedic Centre School
Exeter, UK Philadelphia, PA
Michael J. Dunbar, MD, FRCSC, PhD
Director of Orthopaedic Research Kenneth A. Greene, MD Bill K. Huang, MD
Clinical Research Scholar Associate Professor of Orthopaedics Everett Bone and Joint
Assistant Professor of Surgery Northeast Ohio Universities College of Adult Joint Reconstruction
Dalhousie University Medicine Everett, WA
Halifax, Nova Scotia Rootstown, OH
Canada Head of Adult Reconstructive Surgery B. Jaramaz, PhD
Summa Health System Institute for Computer Assisted Orthopaedic
Clive P. Duncan, MB, FRCSC Akron, OH Surgery
Professor and Chairman The Western Pennsylvania Hospital
Department of Orthopaedics Allan E. Gross, MD, FRCSC, O Ont Pittsburgh, PA
Division of Adult Lower Limb Professor of Surgery
Reconstruction and Oncology Faculty of Medicine Eric Jones, PhD
University of British Columbia University of Toronto Stryker Orthopaedics
Vancouver, British Columbia Bernard I. Ghert Family Foundation Chair Limerick, Ireland
Canada Lower Extremity Reconstructive Surgery
Mount Sinai Hospital Michael Kain, MD
Thomas A. Einhorn, MD Toronto, Ontario AO Hip Fellowship for
Professor and Chairman of Orthopaedic Canada Joint Reconstructive Surgery
Surgery Bern, Switzerland
Department of Orthopaedic Surgery Ernesto Guerra, MD
Boston University Medical Center Department of Orthopaedic Surgery Eoin C. Kavanagh, FFR RCSI
Boston, MA Reconstructive and Septic Surgery Divison Consultant Radiologist
Hospital Universitario Vall d’Hebron Mater Misericordiae Hospital
C. Anderson Engh, Jr, MD Barcelona, Spain Dublin, Ireland
Anderson Orthopaedic Research Institute
Alexandria, VA Mahmoud A. Hafez, MD, FRCS Ed Stephen Kearns, MD, FRCS (Tr &
Professor and Head—Orthopedic Unit Orth)
Xavier Flores, MD October 6 University Consultant Orthopaedic Surgeon
Department of Orthopaedic Surgery Cairo, Eygpt Galway Regional Hospitals
Chief of Reconstructive and Septic Surgery Professor Galway, Ireland
Division Institute for Computer Assisted Orthopaedic
Hospital Universitario Vall d’Hebron Surgery Catherine F. Kellett, BSc, BM, BCh,
Barcelona, Spain The Western Pennsylvania Hospital FRCS
Pittsburgh, PA
Clinical Fellow
Reinhold Ganz, MD University of Toronto
Consultant Department of Orthopedic Arlen D. Hanssen, MD Division of Orthopaedic Surgery
Surgery Professor of Orthopedics Mount Sinai Hospital
Balgrist University Hospital Mayo Clinic College of Medicine Toronto, Ontario
Zürich, Switzerland Mayo Clinic Canada
Rochester, MN
Donald S. Garbuz, MD, FRCSC Tracy L. Kinsey, RN
Assistant Professor Curtis W. Hartman, MD Athens Orthopedic Clinic
Department of Orthopaedics Department of Orthopaedic Surgery and Athens, Georgia
Division of Adult Lower Limb Rehabilitation
Reconstruction and Oncology University of Nebraska Medical Center Brian A. Klatt, MD
University of British Columbia Omaha, NE Assistant Professor
Vancouver, British Columbia Department of Orthopaedic Surgery
Canada James W. Heitz, MD University of Pittsburgh
Assistant Professor of Anesthesiology Pittsburgh, PA
J.W.M. Gardeniers, MD, PhD Jefferson Medical College
Orthopaedic Surgeon Thomas Jefferson University Gregg R. Klein, MD
University Medical Center St. Radboud Philadelphia, PA Rothman Institute of Orthopaedics
Radboud University Nijmegen Thomas Jefferson University
Heyendaal Kirby Hitt, MD Philadelphia, PA
Nijmegen, Netherlands Scott and White Clinic
Temple, TX
x
Contributors xi
Frank R. Kolisek, MD Aditya Vikram Maheshwari, MD Joseph P. Nessler, MD
Center for Joint Preservation and Arthritis Institute Director of Orthopedics
Reconstruction Inglewood, CA St. Cloud Hospital
Rubin Institute for Advanced Orthopedics Private Practice
Sinai Hospital of Baltimore Ormonde M. Mahoney, MD St. Cloud Orthopedics Associates
Baltimore, MD Athens Orthopedic Clinic St. Cloud, MN
Athens, Georgia
George Koulouris, MBBS, Michael Nogler, MD, MA, MAS, MSc
GrCertSpMed, MMed, FRANZCR Arthur L. Malkani, MD Associate Professor
Musculoskeletal Radiologist University of Louisville Vice Chairman, Department of Orthopaedic
Melbourne Radiology Clinic Department of Orthopaedic Surgery Surgery
East Melbourne, Australia Louisville, KY Medical University of Innsbruck
Innsbruck, Austria
Steven Kurtz, PhD W. James Malone, DO
Exponent, Inc. Chief of Musculoskeletal Radiology Michelle O’Neill, MD, FRCSC
Philadelphia, PA Department of Radiology Associate Professor
Drexel University Geisinger Medical Center University of Ottawa
Philadelphia, PA Danville, PA Adult Reconstruction Service
The Ottawa Hospital
Paul F. Lachiewicz, MD John Manfredi, MD Ottawa, Ontario
Professor of Orthopaedics Rothman Institute of Orthopaedics Canada
Department of Orthopaedics Thomas Jefferson University Hospital
University of North Carolina–Chapel Hill Philadelphia, PA Alvin Ong, MD
Chapel Hill, NC Rothman Institute of Orthopaedics
Michael Manley, PhD Thomas Jefferson University Hospital
Jo-Ann Lee, MS Homer Stryker Center for Orthopaedic Philadelphia, PA
New England Baptist Hospital Education
Boston, MA Mahwah, NJ Fabio R. Orozco, MD
Rothman Institute of Orthopaedics
P.D. Michael Leunig, MD Bassam A. Masri, MD, FRCSC Thomas Jefferson University Hospital
Lower Extremity/Hip Specialist Professor and Head Philadelphia, PA
Schulthess Klinik Department of Orthopaedics
Zürich, Switzerland University of British Columbia and Mark W. Pagnano, MD
Vancouver Acute HSOA Department of Orthopedic Surgery
David G. Lewallen, MD Vancouver, British Columbia Mayo Clinic
Department of Orthopedic Surgery Canada Rochester, MN
Mayo Clinic/Mayo Foundation
Rochester, MN James P. McAuley, MD Panayiotis J. Papagelopoulos, MD,
Anderson Orthopaedic Clinic DSc
Jay R. Lieberman, MD Alexandria, VA Associate Professor of Orthopaedics
The Musculoskeletal Institute Athens University Medical School
Department of Orthopaedic Surgery Joseph C. McCarthy, MD Athens, Greece
University of Connecticut School of Clinical Professor of Orthopedic Surgery Consultant, First Department of
Medicine New England Baptist Hospital Orthopaedics
Farmington, CT Boston, MA ATTIKON University General Hospital
Athens, Greece
Adolph V. Lombardi, Jr, MD, FACS John B. Medley, PhD, PEng
Joint Implant Surgeons, Inc. Professor and Associate Chair for Graduate Wayne G. Paprosky, MD, FACS
New Albany, OH Studies Associate Professor Orthopaedic Surgery
Department of Mechanical and Chicago, IL
William T. Long, MD Mechatronics Engineering Attending Physician
Arthritis Institute University of Waterloo Central Dupage Hospital
Inglewood, CA Waterloo, Ontario Winfield, IL
Canada
P.J. Lusty, FRCS Javad Parvizi, MD, FRCS
Orthopaedic Fellow Michael A. Mont, MD Professor of Orthopaedic Surgery
Sydney Hip and Knee Surgeons Center for Joint Preservation and Rothman Institute of Orthopaedics
Sydney, Australia Reconstruction Thomas Jefferson University Hospital
Rubin Institute for Advanced Orthopedics Philadelphia, PA
Steven J. MacDonald, MD, FRCSC Sinai Hospital of Baltimore
Orthopaedic Surgeon Baltimore, MD Frank A. Petrigliano, MD
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
London Health Sciences Centre William Morrison, MD David Geffen School of Medicine
University Campus Professor of Radiology University of California–Los Angeles
Ontario, Canada Department of Radiology Los Angeles, CA
Thomas Jefferson University Hospital
Philadelphia, PA
xi
xii Contributors
Simon Pickering, BSc, MB ChB, Rafael J. Sierra, MD Slif D. Ulrich, MD
FRCS, MD Assistant Professor Fellow
Consultant Orthopaedic Surgeon Department of Orthopedic Surgery Center for Joint Preservation and
The Royal Derby Hospital Mayo Clinic Reconstruction
Derby, UK Mayo College of Medicine Rubin Institute for Advanced Orthopedics
Rochester, MN Sinai Hospital of Baltimore
James Purtill, MD Baltimore, MD
Assistant Professor of Orthopaedic Surgery Franklin H. Sim, MD
Rothman Institute of Orthopaedics Department of Orthopedics Thomas Parker Vail, MD
Thomas Jefferson University Hospital Mayo Clinic Professor and Chairman
Philadelphia, PA Rochester, MN Department of Orthopaedic Surgery
University of California–San Francisco
Amar S. Ranawat, MD Mark J. Spangehl, MD San Francisco, CA
Attending Surgeon Assistant Professor of Orthopaedics
Department of Orthopaedic Surgery Mayo Clinic College of Medicine Eugene R. Viscusi, MD
Lenox Hill Hospital Mayo Clinic–Arizona Director, Acute Pain Management Service
New York, NY Phoenix, AZ Jefferson Medical College
Thomas Jefferson University
Chitranjan S. Ranawat, MD Scott M. Sporer, MD, MS Philadelphia, PA
The James A. Nicholas Chairman Assistant Professor Orthopaedic Surgery
Department of Orthopaedic Surgery Rush University Medical Center W.L. Walter, MBBS, FRACS,
Lenox Hill Hospital Chicago, IL FAOrthA
New York, NY Attending Physician Consultant Orthopaedic Surgeon
Central Dupage Hospital Sydney Hip and Knee Surgeons
Camilo Restrepo, MD Winfield, IL Sydney, Australia
Rothman Institute of Orthopaedics
Thomas Jefferson University Hospital R.G. Steele, MBBS, FRACS Aiguo Wang, PhD
Philadelphia, PA Consultant Orthopaedic Surgeon Stryker Orthopaedics
Dandenong Hospital Mahwah, NJ
Raymond R. Ropiak, MD Melbourne, Australia
Fellow Madhusudhan R. Yakkanti, MD
Department of Orthopaedic Surgery Kate Sutton, MA, ELS University of Louisville
Thomas Jefferson University Hospital Homer Stryker Center for Orthopaedic Department of Orthopaedic Surgery
Philadelphia, PA Education Louisville, KY
Mahwah, NJ
Richard H. Rothman, MD, PhD D. Young, MBBS, FRACS, FAOrthA
Rothman Institute of Orthopaedics Moritz Tannast, MD Consultant Orthopaedic Surgeon
Thomas Jefferson University Hospital Resident in Orthopaedic Surgery Melbourne Orthopaedic Group
Philadelphia, PA Department of Orthopaedic Surgery Victoria, Australia
Inselspital, University of Bern
B.W. Schreurs, MD, PhD Bern, Switzerland Eric J. Yue, MD
University Medical Center St. Radboud Department of Orthopedics
Radboud University Nijmegen Marco Teloken, MD Mayo Clinic–Jacksonville
Heyendaal Rothman Institute of Orthopaedics Jacksonville, FL
Nijmegen, Netherlands Thomas Jefferson University Hospital
Philadelphia, PA Adam C. Zoga, MD
Peter F. Sharkey, MD Assistant Professor of Radiology
Rothman Institute of Orthopaedics Andrew John Timperley, MB, ChB, Director of Musculoskeletal MRI
Thomas Jefferson University FRCS Ed, DPhil Musculoskeletal Fellowship Program
Philadelphia, PA Consultant Orthopaedic Surgeon Director
The Hip Unit Department of Radiology
Klaus A. Siebenrock, MD Princess Elizabeth Orthopaedic Centre Thomas Jefferson University Hospital
Department of Orthopaedic Surgery Exeter, UK Philadelphia, PA
University of Bern
Bern, Switzerland
xii
Evaluation of Hip Pain in Adults 3
1
C H A P T E R

Evaluation of Hip
Pain in Adults
Gregg R. Klein and Peter F. Sharkey
CHAPTER OUTLINE
History 3 Ober Test 5 Bone Marrow Edema Syndrome (Transient
Physical Examination 4 Specific Diagnoses 5 Osteoporosis of the Hip) 7
General Tests 5 Stress Fractures 5 Nerve Entrapment Syndromes 7
Leg Length Measurement 5 Snapping Hip 6 Athletic Pubalgia 7
Thomas Test 5 Acetabular Labral Tears 6 Inflammatory Arthritis 7
Trendelenburg Test 5 Femoroacetabular Impingement 6 Osteoarthritis 7
Patrick Test (FABER [Flexion, ABduction, Osteonecrosis 6 Other Causes of Hip Pain 8
External Rotation]) 5 Osteitis Pubis (Pubic Symphysitis) 7
Resisted Straight Leg Raise 5 Bursitis 7
So-called hip pain in an adult can originate from the hip joint, C—Congenital (dysplasia)
may be referred from another location (i.e., pelvis, lumbar T—Traumatic (stress fracture, fracture)
spine, or sacroiliac joints), or may be the result of a systemic V—Vascular (avascular necrosis)
process. Evaluation of this pain requires a careful and thor- M—Metabolic (osteoporosis)
ough history and physical examination. The evaluation should I—Inflammatory, Infection, Impingement
include orthopedic and nonorthopedic components because N—Neoplasia
many nonorthopedic conditions may manifest as hip pain. D—Degenerative, Drugs
Evaluation of a patient with hip pain requires an understand-
ing of musculoskeletal disorders related to the hip and a vast
array of nonorthopedic diagnoses distant from the hip region. HISTORY
As with all organ systems, evaluation begins with a thor-
ough history and physical examination. Most of the time, the The location, frequency, chronicity, and modifying pain factors
etiology of pain may be determined by using the history and all are important to consider when evaluating a patient with
physical examination, and then may be confirmed by imaging hip discomfort. Many patients lump all pain in the lower
studies such as plain radiography, MRI, and CT. Common extremity into their description of “hip pain.” It is important
diagnoses causing hip pain include stress fractures, avascular to elicit a clear location of pain. Patients report that they have
necrosis, snapping hip disorders, labral tears, bursitis, syno- “hip pain,” but with careful questioning this pain is discov-
vitis, fractures, muscle strains, osteitis pubis, compression ered to be in the posterior buttocks, lateral thigh, groin,
neuropathies, femoral acetabular impingement, dysplasia, anterior thigh, or low back. Pain in the buttocks or lateral
osteoporosis, and arthritis (osteoarthritis and inflammatory thigh may be related to pathology in the lumbar spine or
arthritis). Although beyond the scope of this chapter, acute sometimes the thigh musculature.
hip pathologies such as infection, contusions, fractures, and Radiation of the pain can help determine its etiology.
dislocations, must always be considered if suggested by the Pain originating in the posterior buttocks and radiating
history and physical examination. A simple mnemonic that down the lateral thigh and leg into the foot is often spine
can be helpful for assessment of the painful hip is CTV MIND: related. Groin or thigh pain with radiation to the knee is
3
4 Surgical Treatment of Hip Arthritis
often the result of pathology of the joint capsule or synovial may originate from abdominal or pelvic pathology. Nausea,
lining.1 vomiting, constipation, diarrhea, and gastrointestinal bleed-
The timing of onset and duration of the pain are important ing can indicate a gastrointestinal cause of pain such as
in differentiating the various pathologies. Acute sudden onset inflammatory bowel disease, diverticulosis, diverticulitis,
of pain is usually related to trauma or sports injuries. Trau- abdominal aortic aneurysm, or appendicitis. Urinary symp-
matic etiologies such as acute fractures and dislocations are toms such as frequency, polyuria, nocturia, or hematuria may
readily diagnosed and should be addressed immediately. suggest a urinary tract infection or nephrolithiasis.
Patients with nontraumatic acute injuries may experience dis- The male and female reproductive systems should be
ability only in their hobby or activity of interest. Labral tears addressed to rule out pathology that might be causing the
may occur after a sudden twisting motion during routine pain. Prostatitis, epididymitis, hydroceles, varicoceles, testicu-
sports activity and cause significant disability. The patient may lar torsions, and testicular neoplasms all have been known to
be asymptomatic at rest but unable to participate in his or her cause groin pain in men. Women of childbearing age should
activity. More chronic symptoms also may characterize a labral be asked about their menstrual history to determine if an
tear and can develop over years and be accompanied by ectopic pregnancy, dysmenorrhea, or endometriosis is a cause
limited range of motion and declining function. of their pain. Women also should be asked if they have had
Many other questions should be asked about the pain any signs or a history of sexually transmitted diseases that
characteristics. Is the condition improving, worsening, or may have resulted in pelvic inflammatory disease. Very active
staying the same? Does this pain awaken the patient at women with eating disorders, amenorrhea, and osteoporosis
night? What (e.g., position, medication) makes the symptoms (the so-called female athlete triad) have a very high rate of
better? What makes the symptoms worse? Are there any stress fractures.8 Finally, musculoskeletal causes not related to
activities or positions unique to the patient that exacerbate the hip, such as back pain, history of herniated disks, and
the symptoms? sacroiliac injuries, must be considered.
A past medical history should be obtained from all patients.
It is important to determine if the patient has a history of hip
disease during childhood (e.g., developmental dysplasia of PHYSICAL EXAMINATION
the hip, slipped capital femoral epiphysis, Legg-Calvé-Perthes
disease) or has had previous surgery on the hip. Systemic The physical examination begins long before the examiner’s
diseases that may be related to hip disease include coagulopa- hands are placed on the patient. When the patient first walks
thies, collagen vascular diseases, and malignancies. A history into the examination room or the waiting area, the examiner
of asthma or skin disorder that has been treated with oral or should evaluate the patient’s gait and stance. Does the patient
intravenous steroids may suggest avascular necrosis as the have an antalgic gait? What is the patient’s standing posture?
cause of the pain. A social history also is important; avascular Does the patient walk with ambulatory aids? The patient
necrosis should be suspected in patients with a history of should be specifically asked to walk for the examiner. On the
alcoholism. affected side, the patient may have a shortened stance phase
The patient should be asked about social and recreational or stride length to limit the amount of time weight is loaded
interests. Soccer, rugby, and marathon running all have been on the affected extremity. If the patient has weak abductors,
shown to be associated with an increased incidence of degen- he or she may walk with a Trendelenburg lurch. With this
erative arthritis of the hip.2-6 Runners who have drastically type of gait, the patient compensates for abductor weakness
increased their mileage and military recruits have a high pro- by leaning over the painful hip in an attempt to shift the
pensity for stress fractures around the hip. A family history center of gravity to the affected side. With the patient
also should be evaluated; osteoarthritis of the hip and hand undressed, the examiner should evaluate for skin lesions,
are associated with a high genetic influence.7 obvious deformities, or surgical scars.
A thorough review of systems is important in the patient A complete set of vital signs including temperature is
with hip pain. The differential diagnosis of hip and groin pain important to attain if infection is suspected. An elevated
includes many nonmusculoskeletal disorders. If the source temperature may clue the examiner into the diagnosis of
of the groin pain is obviously not the hip, and the review septic arthritis or non–hip-related sepsis, such as prostatitis,
of systems reveals another potential source of the pathology, urinary tract infection, pelvic inflammatory disease, or psoas
appropriate referrals to primary care physicians, surgeons, abscess.9 A thorough examination of areas distant to the hip
urologists, and gynecologists may be appropriate. Questions should be done for non–hip-related causes of pain. The
that are related to the patient’s general health and that probe lumbar spine, sacroiliac joints, abdomen, inguinal region and
topics such as weight loss, fevers, chills, and malaise should groin (for femoral and inguinal hernias), and knee should be
be asked. Unexplained weight loss may indicate a malignancy, evaluated. A femoral pulse should be taken to rule out femoral
and fevers and chills may guide the examiner toward a diag- aneurysms or pseudoaneurysms, which can manifest as a
nosis of infection. palpable pulsatile masses. Active and passive range of motion
Disorders of the abdominal wall, such as inguinal hernias of the affected hip and unaffected side should be performed
or rectus abdominis strains, may cause hip pain. Patients for comparison. The strength of the major muscle groups of
should be questioned to determine whether they have any the hip in flexion, extension, abduction, adduction, external
bulges or palpable masses in the groin that might represent a rotation, and internal rotation should be tested. Muscle
hernia. Hernias are often more pronounced with coughing or testing is performed on the classic scale of 0 to 5. A score of
other Valsalva maneuvers. 5 indicates full strength against gravity and resistance; 4, full
It is important to perform a through review of the gastroin- range of motion against some resistance; 3, motion against
testinal and genitourinary systems because hip and groin pain gravity with no resistance; 2, motion with gravity eliminated;
4