ORTHOPAEDICS

1. HIP
OSTEOARTHROSIS
DR. PAWAN K. YADAV
D.ORTHO.,DNB(ORTHO)
BIRRD HOSPITAL, TIRUPATHI

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. OA hip
Primary
Rare in India
Bilateral
Secondary
Most common

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

7. 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

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

9. PATHOLOGY
&
PATHOGENESIS

10. 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, 20 damages to chondrocytes may cause
release of cell enzymes → Further matrix break down

12. • 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

13. • 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

14. • 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..

15. PATHOLOGY
Cardinal features are:
1. Progressive cartilage destruction
2. Subarticular cyst formation
3. Sclerosis of the surrounding bone
4. Osteophyte formation
5. Capsular fibrosis

16. • 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)..

17. Head In Osteoarthrosis

19. 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

20. A – Fissuring; B – Irregular Surface

21. Osteoarthrosis – Histology

22. 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

23. 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

24. Flexion, Adduction, External Rotation.

25. AMERICAN COLLEGE OF
RHEUMATOLOGY CLASSIFICATION (ACR)
CRITERIA FOR OSTEOARTHROSIS
• Hip pain and at least 2 of the following 3 items:
1. Erythrocyte sedimentation rate <20 mm/hour
2. Radiographic femoral or acetabular osteophytes
3. Radiographic joint space narrowing

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

27. Big osteophytes

28. 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

29. Articular
cartilage in
OA

30. TREATMENT
Treatment
Conservative Surgical

31. Principles of Treatment
1. Maintain movement & muscle
strength
2. Protect the joint from over load
3. Relieve pain
4. Modify daily activities

32. 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

33. 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)

34. 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

35. OA HIP
Osteotomy
Femoral
Mc Murray’s
Pauwel`s
Valgus osteotomy
Pelvic
Chiari
Ganz
Arthroplasty
GIRDLESTONE
(Excision) Interposition Replacement
Hemi replacement Total replacement Resurfacing
Arthrodesis Joint debridement
SURGERIES IN OA HIP

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

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

38. GIRDLESTONE
ARTHROPLASTY

39. GIRDLESTONE
ARTHROPLASTY

41. CUPARTHROPLASTY

43. TOTAL HIP
ARTHROPLASTY

44. TOTAL HIPARTHROPLASTY