1. Update on Hip Pain and Treatment
Todd Borus, MD

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

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

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

5. 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

6. 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

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

8. 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

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

10. 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

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

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

13. Treatment
NSAIDs
Tylenol
Weight loss
Activity modification

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

15. 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

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

17. 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?

18. 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

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

20. 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

21. Total Hip Replacement

22. Cautionary Tale -- MOM

23. 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)

24. Demographics

25. Direct Anterior Total Hip

26. 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

27. Robotic Assisted Total Hip

28. Robotic Assisted Total Hip

29. 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:

30. 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):
MGH surgeon missed “sweet spot” for acetabular component positioning more in than 50% of cases

31. Improved Accuracy

32. Thank You