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1 The Hip Andrew Pearse Consultant Trauma and Orthopaedics Worcestershire Acute Hospitals NHS Trust Introduction Brief anatomy and topography History & examination Osteoarthritis Investigations Referral Oxford Hip Score Ball and socket joint Movement Flexion Extension Abduction Adduction Rotation Internal External Anatomy 1

2 Hip Topography Buttock pain -?back Deep groin pain hip joint Trochantric bursitis Meralgia parasthetica LOOK FEEL MOVE Special tests LOOK Walk limp Position of hip when lying on couch flexed / externally rotated Short leg Scars / erythema / sinuses / swellings 2

3 FEEL Get patient to POINT to tender bit Groin (tends to be hip joint pain) Greater trochanter bursitis / meralgia parasthetica Buttocks referred from back MOVE Take it through range of motion and. ASK WHEN IT HURTS OA is often painful in internal rotation Back problems usually don t affect hip movements when lying down Special tests Trendelenburg test Thomas test? 3

4 Osteoarthritis Osteoarthritis Osteoarthritis (OA) is a disorder of synovial joints: Focal areas of damage to the articular cartilage Remodelling of underlying bone Mild synovitis Osteoarthritis (OA) is the most common form of arthritis Post-mortem studies show that most people over the age of 65 years have OA in at least one joint X-ray studies show that at least 50% of people over the age of 65 years have evidence of OA. However, only 30% of people with X-ray evidence of OA have pain at the relevant site Symptomatic OA (pain with X-ray changes) is found in 6% of people over the age of 30 years OA Hip The Patient History Pain When? How fardo you walk? Have you tried using a stick? Is your distance limited by hip pain or other medical conditions? Does it wake you? Function Can you tie your shoe laces / clip your toenails? Analgesia Which and how often? Would you consider a hip replacement if appropriate? 4

5 OA Hip The Patient LOOK Limp - antalgic / short leg / Trendelenburg gait Use of a stick (in opposite hand) Shortened leg FEEL Groin pain MOVE Stiff particularly internal rotation OA Hip The Patient +ve Trendelenburg test: Failure of hip abductors or pelvic elevators Swung weight over bad leg OA Hip The Patient Think about the back Referred pain to thigh / buttocks / greater trochanter Distal neurology REMEMBER knee pain can be a presenting complaint of HIP OA 5

6 Management XR AP hips Bloods inflammatory markers Review analgesia and walking aids Physio is there a role? CKS* recommended despite weak evidence Weight loss * Current Evidence Exercise / physio? TENS? Avocado soybean? Steroid injections? Chondroitin? Topical NSAIDs? Magnetic braces? Yes limited evidence No evidence Yes Under X-ray not in 1 care No lack of evidence Flare-ups only Yes -?how they work Referral Recommendation Pain Not controlled by appropriate analgesia Waking at night Severe restriction of quality of life Hobbies Walking distance They want to be considered for surgery Oxford Hip Score 6

7 Oxford Hip Score Recent greater focus on patient-based outcome scores OHS Validated + Disease specific Highly reliable + Broadly used and accepted in peer-review literature - including national joint registries* + J Bone Joint Surg Br 1996, 78: *NJR / NZJR Oxford Hip Score 12 point questionnaire Designed for patients to fill out without aid of a doctor Pre-op and post-op measure Patient gets to tell the surgeon how good his hip is rather than the other way around! Oxford Hip Score Score severe OA moderate to severe OA mild to moderate OA satisfactory joint function Referral* An Oxford Hip or Knee Assessment has been undertaken and a score of less than 30 has been identified as an indicator for possible surgery. Whilst specifying an Oxford Hip or Knee score of less than 30, this is only a guide and if considered clinically necessary onward referral with a score of more than 30 * NHSW Commissioning will be accepted Policy 7

8 Oxford Hip Score Score severe OA moderate to severe OA mild to moderate OA satisfactory joint function Referral* An Oxford Hip or Knee Assessment has been undertaken and a score of less than 30 has been identified as an indicator for possible surgery. Whilst specifying an Oxford Hip or Knee score of less than 30, this is only a guide and if considered clinically necessary onward referral with a score of more than 30 * NHSW Commissioning will be accepted Policy Summary Anatomy History Look, Feel, Move Osteoarthritis Oxford Hip Score Any Questions? 8