Right Hip Pain. Timothy Pelkowski, MD Saint Vincent Family Medicine Residency

Transcription

1 Right Hip Pain Timothy Pelkowski, MD Saint Vincent Family Medicine Residency

2 The Case: 44 Year Old Male HPI: In August of 2015 was in the pool doing breast stroke kicking drills Noted the acute onset of pain over the right greater trochanteric region It was sharp, 9/10 intensity and initially not radiating anywhere NSAIDS helped a small amount Worse with walking, better with rest Stopped activities Eventually started to radiate to right groin area Seen by PCP and right hip radiographs ordered and negative Tried PT with no real help Seen by Ortho and right hip MRI arthrogram ordered Baseline physical activity is great; jogs miles per week and swam 3-4 times per week, weekly basketball and bowling NKDA Meds: Weekly immunotherapy for allergies PMH: Allergies PSH: Deviated septum repair, Benign Left Middle Finger Mass Removal SH: Never a smoker, ETOH 8-10 beers per week, BS in Electrical Engineering, Lighthouse Electrical Controls FH: Sister with idiopathic PE, MGF with h/o LE DVT and CA diagnosis ROS: Specifically no use of steroids, prior hip Fx or surgery, no radiation, no significant med use, no diving in years 2

3 The Case: Right Hip Radiograph HPI: In August of 2015 was in the pool doing breast stroke kicking drills Noted the acute onset of pain over the right greater trochanteric region It was sharp, 9/10 intensity and initially not radiating anywhere NSAIDS helped a small amount Worse with walking, better with rest Stopped activities Eventually started to radiate to right groin area Seen by PCP and right hip radiographs ordered and negative Tried PT with no real help Seen by Ortho and right hip MRI arthrogram ordered Baseline physical activity is great; jogs miles per week and swam 3-4 times per week, weekly basketball and bowling 3

4 The Case: Right Hip MRI Arthrogram HPI: In August of 2015 was in the pool doing breast stroke kicking drills Noted the acute onset of pain over the right greater trochanteric region It was sharp, 9/10 intensity and initially not radiating anywhere NSAIDS helped a small amount Worse with walking, better with rest Stopped activities Eventually started to radiate to right groin area Seen by PCP and right hip radiographs ordered and negative Tried PT with no real help Seen by Ortho and right hip MRI arthrogram ordered Baseline physical activity is great; jogs miles per week and swam 3-4 times per week, weekly basketball and bowling 4

5 Osteonecrosis of the Femoral Head Risk Factors Idiopathic Hip facture Hip dislocation Glucocorticoids Alcohol Fat emboli Gaucher s Sickle cell Decompression sickness Antiphospholipid antibodies Inheritied thrombophilia Hypofibrinolysis Drugs Radiation Toxins Classification Systems Ficat and Arlet Stage I Normal Stage II Sclerotic or cystic lesion Stage III Flattening of femoral head Stage IV OA with decreased joint space with articular collapse Steinberg University of Pennsylvania Takes into account percent involvement of the femoral head 5

6 Osteonecrosis of the Femoral Head Risk Factors Idiopathic Hip facture Hip dislocation Glucocorticoids Alcohol Fat emboli Gaucher s Sickle cell Decompression sickness Antiphospholipid antibodies Inheritied thrombophilia Hypofibrinolysis Drugs Radiation Toxins Classification Systems Ficat and Arlet Stage I Normal Stage II Sclerotic or cystic lesion Stage III Flattening of femoral head Stage IV OA with decreased joint space with articular collapse Steinberg University of Pennsylvania Takes into account percent involvement of the femoral head 6

7 Osteonecrosis of the Femoral Head Risk Factors Idiopathic Hip facture Hip dislocation Glucocorticoids Alcohol Fat emboli Gaucher s Sickle cell Decompression sickness Antiphospholipid antibodies Inheritied thrombophilia Hypofibrinolysis Drugs Radiation Toxins Classification Systems Ficat and Arlet Stage I Normal Stage II Sclerotic or cystic lesion Stage III Flattening of femoral head Stage IV OA with decreased joint space with articular collapse Steinberg University of Pennsylvania Takes into account percent involvement of the femoral head 7

8 Idiopathic Osteonecrosis of the Femoral Head Surgical Management Femoral Head Replacement Procedures Hemi-resurfacing arthroplasty Hemipolar/bipolar hip replacement Total hip arthroplasty Femoral Head Sparing Procedures Core decompression Bone grafting Tantalum implants Biological agents Osteotomies Nonsurgical Management Bisphosphonates Lipid lowering agents Anticoagulants Vasoactive substances Postoperative Course 8 Patient Perspective Anger Fear

9 Idiopathic Osteonecrosis of the Femoral Head Surgical Management Femoral Head Replacement Procedures Hemi-resurfacing arthroplasty Hemipolar/bipolar hip replacement Total hip arthroplasty Femoral Head Sparing Procedures Core decompression Bone grafting Tantalum implants Biological agents Osteotomies Nonsurgical Management Bisphosphonates Lipid lowering agents Anticoagulants Vasoactive substances Postoperative Course 9 Patient Perspective Anger Fear

10 References Amanatullah DF, Strauss EJ, Di Cesare PE. Current management options for osteonecrosis of the femoral head: part I, diagnosis and nonoperative management. Am J Orthop Sep;40(9):E Amanatullah DF, Strauss EJ, Di Cesare PE. Current management options for osteonecrosis of the femoral head: part II, operative management. Am J Orthop Oct;40(10):E Banerjee S, Issa K, Pivec R, Kapadia BH, Khanuja HS, Mont MA. Osteonecrosis of the hip: treatment options and outcomes. Orthop Clin North Am Oct;44(4): Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on osteonecrosis of the femoral head. World J Orthop Sep 18;6(8): Zalavras CG, Lieberman JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg Jul;22(7):