Update on Hip Pain and Treatment Todd Borus, MD

Disclosure Stryker Orthopedics: educational consultant NextStep Arthropedix: consultant related to orthopedic implant design, royalties

Hip Anatomy Hip anatomy rather complex because it represents the intersection of bony, cartilage, musculotendinous and nervous structure. Oftentimes overlap, multiple issues

Source of Pain Often hard to determine History and physical exam Joint, soft tissue, or spine X-rays, advance imaging (MRI)

Sources of Pain From Buckland JAAOS 2017 Groin, anterior thigh, buttock --- hip joint. Less commonly below the knee. Burning pain, below the knee – spine. But an L1-L3 radiculopathy can also cause groin pain From Buckland JAAOS 2017

Greater Trochanteric Pain Syndrome Pain over lateral hip Positive Ober test Trendelenberg sign Beware of the “C-sign” Put in bursa pic From JAAOS april 2016 Can radiate down thigh. Really problematic, More than just trochanteric bursitis From Richmond JAAOS 2016

Treatment Paucity of literature Injection and PT Beware of refractory cases gluteus medial tendinopathy or tearing Advance imaging warranted in chronic situations

FAI and Labral Tearing Altered geometry between proximal femur and acetabulum, leads to conflict between the femoral neck and acetabular rim Can lead to acetabular labral tearing Sharp groin pain with hip flexion (>90 percent) Hot diagnosis in athletes

Osteoarthritis Pain (C-sign) – groin, thigh, buttock Stiffness – tying shoe laces Limp Physical exam Plain radiographs

Risk Factors Interestingly obesity plays less role in in hip arthritis than knee osteoarthritis. Familial clustering for genetics, genetics contributes 60% of risk to developing hip OA. Caucasions. Farmers, high impact athletes –repetitive load and high impact

Anatomic Risk Factors DDH Rise in young patients---find data FAI

Multifactorial From Sandell, Nat Rev Rheumatol 2012 Elucidation of exact genes and mutations may lead to better screening and potential treatments

Treatment NSAIDs Tylenol Weight loss Activity modification

Physical Therapy British Journal of Sports Med April 2016 Manual Therapy not effective in isolation or when combined with exercise program

Weight Loss and Exercise 8 month program exercise and weight loss BMI>30 32% improvement in self reported WOMAC function scores Improvements in pain and walking tests Average 5% reduction in BMI From Physical Therapy Feb 2013

Chondroitin/Glucosamine No reduction in joint pain or functional impairment at 6 mos

Is it Chondroprotective? Observational cohort study “moderate” OA – greater than 1mm joint space remaining MRI based study to assess cartilage volume C/G exposure led to less global articular cartilage loss Protective effect at early and mid stage?

Cortisone Injection Intra-articular injection effective at relieving pain and inflammation Effects usual moderate by 8 weeks Effective for diagnostic info May increase risk of infection in subsequent THA within one year

Other Injections Hyaluronic Acid (HA) injections – not approved and no efficacy demonstrated for hip OA Platelet Rich Plasma and Stem Cells – no clinical data

Total Hip Replacement Overall 1 million total hips performed globally annually, 90% for osteoarthritis Pain interfering with quality of life and activities of daily living, failed nonoperative treatment options

Total Hip Replacement

Cautionary Tale -- MOM

Total Hip Replacement Excellent survivorship – 95% at 10 years, 80% at 25 years Impact of new materials and implants Impact of higher level activity High Satisfaction – >90% expectations met with THA…Highest for higher functioning patients (Mancuso JBJS 2009)

Demographics

Direct Anterior Total Hip

Direct Anterior THA No difference in 10 meter walk test, EuroQuol, radiographic analysis Shorter hospital stay, less narcotic use with DA But, more blood loss, longer OR time, weaker hip flexion at 2 and 6 weeks No clear benefit to DA THA

Robotic Assisted Total Hip  

Robotic Assisted Total Hip

Does Component Position Matter? “Acetabular component malposition is a factor that contributes to increased dislocation rates, limb-length discrepancy, component impingement, bearing surface wear, pelvic osteolysis, and earlier revisions in the long term” Barrack RL, Krempec JA, Clohisy JC, McDonald DJ, Ricci WM, Ruh EL, Nunley RM. Accuracy of acetabular component position in hip arthroplasty. J Bone Joint Surg Am. 2013;95:1760-1768.

Clinical Problem Callanan MC, Jarrett B, Bragdon CR, Zurakowski D, Rubash HE, Freiberg AA, Malchau H. Risk factors for cup malpositioning: Quality improvement through a joint registry at a tertiary hospital. Clin Orthop Relat Res. 2011;469(2):319-329. MGH surgeon missed “sweet spot” for acetabular component positioning more in than 50% of cases

Improved Accuracy

Thank You