ARTHRITIC HIP -EXAMINATIONdr vaibhav bagaria

joint replacement surgeonsir h n reliance foundation hospital

girgaum, mumbai, india

‘A CASE OF IDENTITY’Watson: You appeared to read a good deal upon [your client] which was quite invisible to me.

Holmes: Not Invisible but unnoticed, Watson

USUAL SEQUENCEHistory

Look

Feel

Move

Special tests

PAINDuration

Onset

Progress

Site

Severity

Character

Radiation

Aggravating and Relieving factors

Diurnal variation

Associated Symptoms

DEFORMITYHow Long has ist been present?

Didi it Progress?

What initiated it?

What other symptoms accompany it?

Any History of trauma/ Infection?

FUNCTION ASSESSMENT & SCORING

Walking ability/ Aids

Ability to Squat/ Sit cross legged

Drive

Tie Shoes

Expectations from treatment

PAST HISTORYHT

DM

Sepsis

TB

Prolonged IV infusion as child

Bleeding episodes

Prior Trauma Surgery

Allergies

OTHER HISTORYSporting History

Drug Abuse/ Alchol/ Smoking

Occupational History

Treatment History

Family History

INSPECTIONAttitude

Deformity

Landmarks - Bone & Soft tissue

Swelling/ Wasting/ Skin

LLD

DEFORMITY/ CONTRACTURES

ATTITUDE

FEEL - PALPATION

Systematic

Anterior

Lateral

Posterior

MOVE

MEASURE

SPECIAL TESTSTests for deformity assessment

Tests for LLD

Tests for stability

Tests for impingement

Tests for muscle contracture

SINGLE MOST IMP TEST???

GAIT

Normal Gait is rhythmical bipedal biphasic walking in which the lumbar spine, hip and legs move in unison

LIMPING

Any abnormality of normal rhythmic biphasic walking

ARTHRITIC HIPOsteoarthritis: Wear & Tear

FAI: Mechanical cause

DDH: Late Presentation

Post Traumatic

Osteonecrosis & 2ry Arthritis

Inflammatory Arthritis

Septic Arthritis/ TB Arthritis

Pagets; Gauchers; Sickle: SLE; Hemophilia;

WHY?Reconfirming that this is cause!

Decide Surgical vs Non Surgical Management

Plan for your Surgery; Possible detours

Take care of associated things!

Decide Unilateral vs Bilateral

Re examination of the hip: Otto Aufranc noted that “more is missed by not looking than by not knowing.”Aufranc OE. The patient with a hip problem. In Aufranc OE, editor. (ed):

Constructive Surgery of the Hip. St. Louis, CV Mosby, 1962;15–49

COMMON PRESENTATIONJoint Stiffness and pain often Groin, in front of hip, occasionally thigh

Start up pain and stiffness

Aching that increases with weather change

Loss of ROM

Limping

Weakness esp getting up

CO - FACTORS

Obesity

Professional sports

Injury

Risk factors for AVN

INFLAMMATORY ARTHRITISPrevious steroid treatment

Skin condition - dermatitis/ Prone to Infection

Osteoporosis

Choice of anaesthesia

Other Joint Evaluation: Muscle Wasting

Post op Complications: Myositis, Sp Physio needs

DRUG HISTORY

Important in Inflammatory Arthritis

Specifically ask for steroids and Biologicals

Ayurvedic/ Alternate medicine

What to stop?

DO NOT FORGETWhich joint to do first?

Uni vs Bilateral

contractures

protrusion

LLD

Implant Choice

ANKYLOSING SPONDYLITIS

Younger

Stiffness is a bigger issue

Spine and Chest examination

Positioning / Cup Placements/ landmarks

WHAT TO REMEMBERModified New York criteria

When to stop Biologicals?

Anaesthesia Issues

What to do: Spine Vs Hip

Approach - Landmarks

FAI

FAIAnterolateral Hip Pain, Typical C shaped fashion

Flexion, Adduction and Internal Rotation is the most sensitive test ( FADIR)

Compare the contralateral side

Dunn view radiography, in which the hip is flexed 90 degrees and abducted 20 degrees

FAI

OSTEOARTHRITIS

Usually Straight Forward

Ensure that this is the main cause of symptoms

LLD

Flexion/ ER/ adduction - Apparent Shortening

AVN

Cause

Reconfirm the stage on examination

Loss of IR

Obligatory ER

OBLIGATORY ER

CONCLUSIONSystematic Approach

Know what you are looking for !

In Clinical Setting: Focussed Assessment is Key.

The clues are endless, and the game is played by everyone ( qualified or lay) at each new encounter throughout life.

THANK YOU

Questions?