Hip joint Rozkydal, Z. kyčel- anat Articulatio coxae Enarthrosis – Ball and socket type Concentric shape of femoral head Kyčel- rtg pánve Pelvis File:Hueftgelenk-gesund.jpg Img0193 3 D CT Os ilium Os pubis- ramus superior ramus inferior Os ischii Corpus ossis ischii Ramus ossis ischii- pars pubica pars acetabularis tuber ossis ischii Img0193 3D acetabulum Acetabulum facies lunata fossa acetabuli incisura acetabuli kyčel- femur celý Femur Anterior Linea intertrochanterica - Attachment of capsule Posterior Crista intertrochanterica - Attachment of quadratus femoris Anatomy http://upload.wikimedia.org/wikipedia/commons/thumb/a/a4/Coxa-valga-norma-vara-000.svg/250px-Coxa-v alga-norma-vara-000.svg.png File:Hip-sagittal-angle-000.svg File:Hip-transverse-angle-000.svg I:\Kyčel\anterverted.jpg CCD angle = 125±5° Anteversion neck 10-15° Anteversion of acetabulum = 35° Inclination of acetabulum 40 - 45 ° kyčel- Y chrupavka Boy, 6 years Triradiate cartilage kyčel- růst Chondroepiphysis Birth 6 months 3,5 years kyčel- růst Ossification of proximal femur Boy, 6 years old kyčel- růst Growth in length 30 % of the whole femur kyčel- změna CCD úhlu Change of CCD angle Change of anteversion of the neck Birth 40°, puberty 11° Kyčel-ligamenta Lig. iliofemorale Lig. pubofemorale Lig. ischiofemorale Joint capsule File:Gray339.png Ligaments of joint capsule File:Gray340.png File:Gray341.png File:Gray342.png kyčel- svaly zepředu Muscles kyčel- svaly zepředu 2 Muscles kyčel- svaly zepředu 3 Muscles kyčel- svaly zezadu 1 Muscles kyčel- svaly zboku Muscles kyčel- zev rotátory External rotators M. triceps coxae: m. obturatorius int. m. gemelus sup. m. gemelus inf. kyčel- n N. femoralis, a. v. femoralis n. obturatorius kyčel- n N. ischiadicus- sciatic nerve Vessels http://d3cgb598vs7bfg.cloudfront.net/images/upload-flashcards/back/5/0/34205418_m.jpg http://www.eorthopod.com/images/ContentImages/hip/hip_anatomy/hip_anatomy_arteries01.jpg kyčel- cévy 5 Vessels A. femoralis, a. profunda femoris a.circumflexa femoris medialis – posterior surface of neck a. circumflexa femoris lateralis – anterior surface of neck a.glutea superior et inferior, a. obturatoria a. capitis femoris kyčel- cévy 3 Vessels 1. Basal circle 3/4 a. CFM 1/4 a. CFL 2. Retinacular vessels - posterosuperior - posteroinferior - anterior 3. Hunter subsynovial circle Epiphyseal vessels kyčel- cévy 4 Terminal branches in femoral head Clinical examination •Gait, limping, sitting •Kinetic chain- L spine, SI joint, hip, knee, leg • •L spine –Hyperlordosis –Antalgic position of L spine –Scoliosis –Tilting of the pelvis – – – – – – – – – – – – – – – – – Trendelenburg sign •Stability of the hip • •Strength of abductors • •Negative •Positive • •Cause –Insuficiency of abductors –High position of greater trochanter • • I:\Kyčel\Trend1.png I:\Kyčel\Trend2.png •Movements, ROM • –Active – –Passive • S: extension - 0 - flexion 15 - 0 - 140 F: abduction- 0 - adduction 60 - 0 - 40 T: abduction - 0 - adduction 80 - 0 - 30 R: ER - 0 - IR 50 - 0 - 40 H:\Výuka\Nová složka\kyčel2.jpg H:\Výuka\Nová složka\kyčel4.jpg H:\Výuka\Nová složka\kyčel2.jpg H:\Výuka\Nová složka\kyčel3.jpg H:\Výuka\Nová složka\kyčel4.jpg H:\Výuka\Nová složka\kyčel2.jpg H:\Výuka\Nová složka\kyčel4.jpg •Contracture in hip joint –antalgic (semiflexion) –typical contracture in cerebral palsy – (adduction, flexion, inner rotation – – illiopsoas, adductors, rectus femoris. –Thomas sign •Maximal flexion in contralateral hip – balanced hyperlordosis •Thigh goes into flexion I:\Kyčel\thomas.jpg I:\Kyčel\thomas.jpg – Duncan-Ely test •Contracture of rectus femoris •In prone position with flexion in the knee joint •Positive- lifting of the pelvis http://flipflashpages.uniflip.com/2/34834/92242/pub/html/index171.jpeg Imaging methods •X ray –AP –Axial –Lauenstein, frog leg position – – – •USG (children, effusion, bursitis) •Arthrography (children) •CT, MRI •Scintigraphy I:\Kyčel\frog1.JPEG I:\Kyčel\frog2.JPEG H RTG3 H RTG 1 AP view of the pelvis: centre umbiliculus- symphysis inner rotation H RTG4 AP view of the hip: centre over the hip in level of symphysis neutral rotation VDK a linie a Basic parameters Frequent pathology •Children –DDH –Perthes disease –Slipped upper femoral epiphysis –Coxitis –Non specific synovitis –Adults –O.A., R.A. –Necrosis of femoral head –FAI –Coxitis •Trauma, posttraumatic conditions •Tumors Frequent pathology •Entesopathies, bursitis • •Snapping hip • •Irradiation of the pain from L spine • Osteoarthritis •Degenerative, slow and progressive disease • of hyaline cartilage of synovial joint • •All conditions changing the structure and function of hyaline membrane and surrounding tissues lead to osteoarthritis Chrup Osteoarthrosis deformans •Primary (after 40 years of age ) • •Secondary – the cause is known • Osteoarthrosis 15 percent of the population 50 percent of people above 65 years 80 percent of people above 75 years Primary O.A. Begins over 40 y. Small joint in hands Cervical and lumbar spine Hip and knee joints Artroza 2 Hauser 15 Secondary O.A. 1. Mechanical factors (DDH, Perthes disease, aseptic necrosis, slipped femoral epiphysis, condition after fractures) 2. Metabolic disorders (ochronosis, gout, chondrocalcinosis, Gaucher disease) 3. Hormonal disorders (acromegaly, diabetes m.) 4. Inflamated disorders (septic artritis, R.A.) stková 10 DDH- developmental dysplasia of the hip joint Obr. 6 Condition after Perthes disease Obr. 8 O kočovský 1 Rheumatoid artritis CLS - R CLS- R Obr. 10 Weiterová 1 Ancylosing spondylitis Obr. 12 Septic arthritis Obr. 13 Gaža 15 Osteoarthrosis - symptoms •Pain •Tenderness •Limited movements •Muscle spasm, contracture •Limping •Gait- limited length, walking aids • Kellgren- Lawrence classification I- IV. O I. II. III. IV. O.A. management •Conservative • •Surgical treatment: • ASC, osteotomy, total hip replacement • Arthroscopy •Labral lesions •Osteochondral lesion •Loose bodies •Synovectomy •Transchondral fracture • Osteotomy of the pelvis •Capsular arthroplasty •Shelf procedure •Osteotomy- •Steel, Sutherland • Bernese Tectum Steel Femoral osteotomy •Varus •Valgus •Derotation •Angulation Osteotomie femuru THA Bártová 2 vdk27b Nik_0004 Cemented Hybrid Uncemented Kyčel-povrchová náhrada2 Resurfacing Kyčel-povrchová náhrada1 Ohnisková 4 Girdlestone procedure Idiopatic avascular necrosis of femoral head • •Male 20-40 years •Progressive pain • X-ray CT, MRI, scintigrafie •Etiology – unknown, coagulopathy, radiation, corticoids, alcoholic • AVN - hlavice fremuru Pain Limited movements Impaired gait Idiopatic avascular necrosis of femoral head AVN - nekróza hlavice femuru 2 ON4 X ray MRI Excised head ON5 Subchondral fracture http://www.nw-hip-knee-clinic.com/hip-clinical-cases/hip-cases-im%20/Avascular-necrosis-(AVN)2.jpg MRI- idiopatic avascular necrosis of femoral head Idiopatic necrosis of the femoral head CLS - necrosis Jelínek Obr. 7 Olšová 15 Necrosis after femoral neck fracture Obr. 9 Management Non weight bearing Forrage Curretage , bone grafting Fibular graft Graft from greater trochanter Osteotomy Tantal rods Hyperbaric chamber THR ON9 Vascular fibular graft, 5 y. postop. ON8 Preop. ON8 Tantal rods , 4 y. postop. ON7 Vascular fibular graft 11 y. postop. refuses THA 10 y. postop. Asymptomatic. ON6 LED, percutaneous drilling with Steinman pin Synovitis •Overloading • •Decompansated O.A. • •R.A. • •During or after infection disease Idiopatic protrusion of the acetabulum •X ray changes in childhood •Slowly limited movements •Several synovitis •Secondary O.A. • •Therapy: conservative, THR Kyčel-protruze Bursitis •Greater trochanter bursitis •Iliopectineal bursitis •Ischial bursitis •Dg.- clinical, USG, X.ray •Th.- NSAID, local corticoids, surgery Kyčel-cévy,burzy1 Bursa ileopectinea Entesopathies •Adductors •Abductors •Spina iliaca ant. inf. •Hamstrings - tuber ossis ischii •Iliopsoas – lesser trochanter •Painful groin- gracilis syndrom Snapping hip •Pain during gait •Snapping of the hip •Thickening of tensor fascia lata •Surgery: Z- plasty •Diff. dg.- FAI, osteochondroma.. http://www.arthros.pl/public/images/fck/image/przeskakujace.jpg Snapping hip •surgery http://ajs.sagepub.com/content/32/2/470/F1.large.jpg Perthes disease Ischemia of the whole epiphysis Articular cartilage continues to grow Bone is resorbed and replaced by wowen bone The bone is soft and vulnerable Subchondral fracture - showes the extent of damage New bone is gradualy revascularised New bone is plastic- can be deformed AVN subchondr Subchondral fracture of femoral epiphysis AVN M. Perthes 1. Ischemic stage: avascular necrosis growth arrest of epiphysis revascularisation from periphery ossification 2. Ischemic stage: trauma, subchondral fracture resorption under the fracture replacement by plastic woven bone subluxation, deformity Catterall classification AVN Caterall I. 25 % II. 50 % med.- lateral column III. 75 % IV. 100 % Obr. 7 Necro- caterall 1 necro- caterall2 Catterall I Catterall II Obr. 9 Obr. 8 Necro- caterall3 Necro- caterall 4 Catterall III Catterall IV Obr. 10 Obr. 11 A Caterall Stage Subchondral fx –Herring classification •Prognosis according lateral column •Typ A – normal lateral column, 100% good results •Typ B – more than 50 % of lateral column, 70% good • results •Typ C – less than 50 % of lateral column • 30% good results http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/751-3-iline_default.gif http://ars.els-cdn.com/content/image/1-s2.0-S0268089004000659-gr5.jpg Salter classification A Catterall I. a II. less then one half of the epiphysis short subchondral fracture lateral column intact conservative treatment Necro- caterall 1 necro- caterall2 Obr. 12 Obr. 13 B Caterall III. a IV. more then one half of the epiphysis long subchondral fracture lateral column is absent operative treatment Salter classification Necro- caterall3 Necro- caterall 4 Obr. 14 Obr. 15 •X-ray http://easypediatrics.com/wp-content/uploads/2012/09/Legg-calve-perthes-disease.jpg http://t0.gstatic.com/images?q=tbn:ANd9GcTCVcy4mRCyy8pZRaeujLitrxPQnR6MgBCi3akXPQsSG68RF9781w Examination X-ray Artrography CT - 3 D reconstruction MRI Scintigraphy Ultrasonography Prognosis I. a II. stage good prognosis III. a IV. stage wrong prognosis Risk factors: Older age Loss of containment, subluxation Large extent Limited movements A Perthes 1 Types of deformity in Perthes disesase Management -containment of the head in the acetabulum -good range of motion - Conservative methods - Atlanta orthesis - Operative methods Osteotomy of the pelvis (Salter, Steel, Sutherland, Dungl) Osteotomy of the femur Conservative methods Rest in bed Nonweight bearing Crutches Atlanta orthesis Necro-Atlanta Atlanta orthesis Operative methods Salter pelvic osteotomy Varus osteotomy of the femur Necro- Salter op Necro- varisace u Perthesu Obr. 17 Obr. 18 AVN-Salter AVN Salter osteotomy Obr. 19 Obr. 20 A perthes 3 Perthes disease on the right hip after Salter osteotomy Almost normal hip in 18 years of age Perthes disease on the right hip after Salter osteotomy Almost normal hip in 18 years of age A perthes 3 Consequences of Perthes disease Coxa plana Shortening of the leg Limited movements Early osteoarthritis Better prognosis Younger age Less extent of danage No subluxation AVN Obr. 21 Condition after Perthes disease O kočovský 1 Slipped upper femoral epiphysis http://raymondliumd.com/images/SCFE%20illustrated%20and%20cropped.jpg •Etiology –Obesity –Hormonal changes –Habitus adiposogenital, eunuchoid – http://www.orthopediatrics.com/binary/org/ORTHOPEDIATRICS/images/hipimages/child_hip_slipped_cfe_in tro01.jpg H:\Výuka\somatotyp\1658-0550x0475[1].jpg Slipped upper femoral epiphysis Growth plate of proximal epiphysis of the femur is weak and soft AVN-CVA 4 AVN- CVA3 Slipping of epiphysis down and backwards to varus and to retroversion Metaphysis goes proximaly and to external rotation Slipped upper femoral epiphysis Symptoms Pain in groin and in the thigh Limping Shortening of the leg Limited abduction and external rotation Positive Trendelenburg sign Types 1. Preslip (6%) 2. Acute slip (11%) 3. Chronic slip (after two weeks, 60 %) 4. Acute slip on chronic sliping (23%) AVN-CVA 4 http://img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1248422-1509.jpg Stages 1. 2. 3. CVA 10 kopie Slight: slip up to 30% 2. Moderate : slip 30-60 % 3. Severe: slip above 60 % Management Fixation in situ (K wires, Knowles pins) Closed reduction and K wires Open reduction Osteotomy of proximal femur - Southwick, Imhäuser-Weber –Acute slip –up to 30º– in situ pinning / epiphyseodesis –over 30º– reduction, in situ pinning / epiphyseodesis http://www.bjj.boneandjoint.org.uk/content/93-B/6/833/F4/graphic-5.large.jpg http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/757-4_default.jpg –Chronic slip •Up to 30º – epiphyseodesis •Over 30º – corrective OT –Subcapital (Dunn) –Basicervical (Krämer) – Intertrochanteric (Immhäuser – Weber) –Subtrochanteric (Southwick) • http://www.mysportphysio.com/media/img/343444/surgery03.jpg http://www.clohisyhipsurgeon.com/wp-content/uploads/Pre-OP1-1024x563.jpg AVN- CVA1 Fixation in situ Necro- CVA2 Obr. 31 Obr. 32 AVN Open reduction Obr. 33 Southwick osteotomy AVN- CVA southwick2 AVN- CVA Southwick3 Obr. 34 AVN- CVA 5 Pertrochanteric osteotomy Obr. 35 Complication of slipped upper femoral epiphysis Avascular necrosis of the femoral head Chondrolysis of the femoral head Osteoarthritis of the hip Femoroacetabular impingement FAI •Pathological contact between femoral head • and the acetabulum • •Changes of the shape and orientation of the acetabulum and the femoral head • •Damage to the labrum and cartilage • •Limited movements, pain, progression into O.A. •Classification • •CAM type – femur •PINCER type – acetabulum – C:\Users\Lukas\Desktop\X\impimgement.jpg http://www.londonhiparthroscopycentre.com/images/3-stages-colour-final.jpg •Tests – •Imaging methods –X ray, CT, MRI http://t0.gstatic.com/images?q=tbn:ANd9GcQtZiHzIcjt7B3b5U8DiodflMRJKnjH7Gmcia72sFE2ro-eGdmKXQ http://www.ernestschilders.com/userfiles/image/pelvic-xray.jpg •Therapy –Labrum, cartilage, remodelation of the femoral head 1.Open surgery with dislocation of the head 2.Arthroscopy http://www.phongtran.com.au/images/anatomy/hip/ar-cam-300-01.jpg http://t0.gstatic.com/images?q=tbn:ANd9GcRFhGSCLn5HrQjB1Kma0nRTbglUkuxIOuQ_Qry9x8LQcZkhPl6w Cerebral palsy Spastic paralysis 50 % Athetosis 25 % Ataxia 7 % Tremor 1 % Rigidity 7 % Combinations 10 % http://www.wheelessonline.com/images/arthrg1.jpg Hemiparesis 30 % of all cases ½ normal intelligence Good walking ability N diparesis 1 Diparesis Both lower extremities are involved more than upper extremities Retarded motoric and psychologic development Strabismus Scissors gait Flexion and adduction contracture in hip Flexion contraction of the knee Equinosity of the feet, tip toe walking N diparesis spastica 1 Quadruparesis, triparesis Severe paralysis of both extremities Head nerves involvement, debilitated patients N quadruparesis 1 Orthopaedic procedures in the hip joint Adductos tenotomy Transposition of adductor of the hip Iliopsoas recession Open reduction of dislocated hip Varus osteotomy of the femur Acetabuloplasty, shelf procedures Osteotomy of the pelvis Girdlestone Schanz THA N tenotomie add 1 Adductor tenotomy N atlanta 1 N tenotom 2 Flexion contracture of the hip and knee joints Before surgery, after surgery Pyogenic coxitis •Clinical symptoms •Laboratory tests •Aspiration •Bacteriology, PCR, cytology • • Management •Admission to the hospital •ATB, revision, lavage •Girdlestone, synovectomy Ohnisková 3 F, 50 y., O.A. of the right hip, Infection of the big toe CLS coxitis Ohnisková CT 2 CLS coxitis Ohnisková CT 4 F, 50 y. Intrapelvic absces Pyogenic coxitis, Staphylococcus aureus F, 50 y. chronic synovitis, erosion of the head and the edges Ohnisková 4 Op. sec. Girdlestone CLS coxitis Ohnisková CT 6 CLS coxitis Ohnisková CT 7 F, 50 y., after one year, Girdlestone situation, deep scar tissue, osteopenia, resorbed edges of the acetabulum, thin medial wall. CT reconstruction, width 51,7 mm CLS coxitis - Ohnisková CT 1 CLS coxitis Ohnisková CT 6 CT scan at the onset of symptoms, normal shape of the edges After one year, resorbed edges of the acetabulum Ohnisková 10 HHS 95 points, 2 y. after surgery Other diagnoses •Osteopathies •Stress fractures of the femoral neck •Fractures, nonunion, necrosis •Tumors •Osteomyelitis •TB •Neurological disorders Irradiated pain •Lumbar spine • •Pelvis- GI, urogenital • •Pain from the knee to the thigh and hip joint