Understanding Hip ArthritisMichael J. Repine MDBoulder Medical Center Orthopedics(303) 647-5173
Your Treatment OptionsOptionsHip PainDoes this sound familiar?
“It would be embarrassing to get out of a car because everybody had to help me. Somebody would have to pull me up. I felt like this old woman.”
“My life got progressively less active, less fun, and less participative.”
“Just a day on my feet was exhausting and the pain became greater and greater until Advil and ibuprofen and all of those kinds of drugs couldn't numb it out. It just got worse and worse.”
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You’re Not Alone
More than 43 million people have some form of arthritis. It is estimated that the number of people affected by arthritis will increase to 60 million by 2020.
Source: CDC
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This program will touch upon the following topics:
Review of Hip AnatomyDiscussion of ArthritisLatest Treatment Options for Hip ArthritisExpectations/Outcomes
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About Myself
Oldest of sixIdentical twinColorado native Two young boys
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About MyselfOldest of sixIdentical twinColorado native Two boysI enjoy traveling and languages
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About My PracticeUndergraduate at CU BoulderUniversity of Colorado School of Medicine for medical school and residencyBoard certified in 2005, 2015Fourteen years at the Boulder Medical CenterIn addition to the management of arthritis, I enjoy trauma, sports-related, and hand injuries
Your Treatment OptionsOptionsHip PainANATOMY
Your Treatment OptionsOptionsHip PainNormal Hip
Bony Anatomy
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The Hip JointMusculature
Multiple muscles enveloping the hip jointProvide additional stability to the hip joint
Posterior
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The Hip JointMusculature
Multiple muscles enveloping the hip joint anteriorly as well
Anterior
Your Treatment OptionsOptionsHip PainThe Hip Joint
Ligaments
StabilityStabilityComplex array of ligamentsAugments stability to the ball and socket
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The Hip JointCartilage
Cartilage is critical in understanding arthritis
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The Hip JointCartilage
Transmits applied loads across mobile surfacesLines the ends of bones Surfaces roll or slide during motionHyaline cartilage is fluid-filled wear-resistant surfaceIt reduces friction coefficient to 0.0025.
“Like the frosting on a piece of cake”
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Normal Cartilage
Healthy, normal cartilage rolls easilySmooth motion
“Like the tires on your car”
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Damaged Cartilage
When the cartilage is thinned or absent, problems such as pain, instability, limited motion occur.
This mechanical wearing of the cartilage surface leads to deterioration in the joint or ARTHRITIS
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What is What is ARTHRITIS?
Definition: Inflammation of a joint, usuallyaccompanied by pain, swelling, andstiffness.
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What is What is ARTHRITIS?
Definition: The mechanical wearing of the cartilage surface resulting in pain and limited function.
Importantly, this mechanical change is accompanied by biochemical changes
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Normal Anatomy Normal XraysWhat is Normal AnatomyWhat is ARTHRITIS?
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Arthritis Anatomy Arthritic Xrays What is Arthritis AnatomyWhat is ARTHRITIS?
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Most Common Causes of Arthritis
Degenerative – “wear and tear”
Osteoarthritic – traumatic
Rheumatoid – inflammatory
Bacterial - infectious
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Evaluation of Hip Arthritis
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Diagnosing Hip Pain
Medical historyPhysical examinationX-rays, Radiographic StudiesOther tests
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SymptomsPAIN
Weight-bearing activitiesWhile sleeping at nightLocated over groin, lateral hip, sometimes buttock pain
*Important to evaluate for spinal source
Usually slow in onset
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Diagnosis
How and when did the pain start?If the pain has occurred before, how was it treated?What activities aggravate the pain?What activities relieve the pain?
Medical History
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Diagnosis
Tenderness to the touchWeakness in the musclesExtent of passive and active range of motionCrepitation
Physical Examination
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Diagnosis
X-rays of an arthritic hip:narrowing of the joint spacecystic changes in the boneformation of bone spurs (osteophytes)
X-ray Evaluation
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Diagnosis
Blood testsComputerized Topography (CT) scansMagnetic Resonance Imaging (MRI) scans
– Best non-surgical modality to identify focal cartilage defects
– RARELY NECESSARY FOR HIP ARTHRITIS
Arthroscopy– Small areas of traumatic arthritis, loose
bodies
Additional Tests
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Non-Surgical Treatment Options for Arthritis
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Nonsurgical treatment optionsPhysical Therapy
Almost always start with physical therapy
– Improve range of motion– Improve strength– Decreases pain
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Nonsurgical treatment options
Medications
NSAIDS– Decreases inflammation– Decreases pain
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Nonsurgical treatment options
Supplements
Lots of claims
NONE have passed FDA testing as provenPersonal trials
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Nonsurgical treatment options
Cortisone injectionPROS
Relatively easy procedure under fluoroscopyExcellent diagnostic toolWell-toleratedVery predictable reduction in pain
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Nonsurgical treatment options
Cortisone injectionCONS
Must be placed carefullyMasks symptomsCan soften cartilageUsed to “buy” time
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Nonsurgical treatment options
Viscosupplement
Purify Hylauronic acid from rooster combs or bacterial growth“Oil-additive” to joint fluid
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Nonsurgical treatment options
ViscosupplementPROS
Protects remaining cartilaageImproves biochemical environment of jointReliable reduction in pain
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Nonsurgical treatment options
ViscosupplementCONS
“Off label use”
Currently, approved for knees onlyCurrently being studied
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Nonsurgical treatment optionsStem Cell Therapy
Great claims of what can be treatedPromising early anecdotal reportsExpensiveLikely the best future option for moderate arthritis
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Surgical Treatment Options for Arthritis
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Decision Variables
Moderate or
extensive arthritis
Age, strength, range of motion
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Decision VariablesYour Treatment OptionsOptions
Hip PainSurgical Treatment
Moderate Cartilage Damage
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Surgical treatment
Moderate cartilage damage
Must catch damage earlyBest treated before secondary changes occur within the hip
“Pothole”
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Surgical treatment
Focal cartilage damageMicrofracture
Largely treated arthroscopically
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Surgical treatmentFocal cartilage damageCartilage Transplantation
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Surgical treatment
Focal cartilage damage
Partial replacementResurfacing
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Advanced Arthritis
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Advanced ArthritisBecause hip replacement is predictably so good in restoring function and pain relief, the choice is really replacement or not.
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Advanced ArthritisPatient determines the appropriate time for surgical interventionNot determined by X-ray Can’t really “miss the boat”
with hip arthritis
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Surgical TreatmentAdvanced Arthritis
ANTERIOR ANTERIOR HIP REPLACEMENT
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Anterior Hip ReplacementWhat is it?– The DIRECT ANTERIOR
approach
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Anterior Hip ReplacementAdvantage(s)– True intermuscular
approach to the hip joint
– Originally described in 1883
– Regained popularity
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Anterior Hip ReplacementAdvantage(s)– Patient is positioned
supine (on their back)– Sometimes use
specialized leg holder– Easier for patient,
surgeon and anesthesia
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Anterior Hip ReplacementAdvantage(s)– Intermuscular– Limited trauma to
muscles and tissue– Anterior capsular
incision– No disruption of the
posterior structures to the hip at all
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Anterior Hip ReplacementAdvantage(s)– Allows excellent
visualization– With more limited
surgical dissection– Faster recovery– Less pain
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Anterior Hip ReplacementAdvantage(s)– Patients are up walking
on the hip the same day– Most patients go home
after just one night in the hospital
– No pillows between legs– Minimal positional
precautions
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Surgical TreatmentAdvanced Arthritis
COMPUTER COMPUTER ASSISTED ASSISTED
HIP REPLACEMENT
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Computer Assisted Hip ReplacementMakoplasty
Rationale:– Allows extreme
precision when performing hip replacement surgery
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Computer Assisted Hip ReplacementMakoplasty
Rationale:– Correct positioning of
the components leads to lower wear rates and reduced risk of dislocation
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Computer Assisted Hip ReplacementMakoplasty
Technique:– Preoperative CT scan
data is synced to intraoperative data with a probe
– Implant positioning and surgical resection can be planned before any cuts are actually made
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Computer Assisted Hip ReplacementMakoplasty
Technique:– Robotic arm assists
with controlled resection of bone
– Real-time evaluation
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Computer Assisted Hip ReplacementMakoplasty
Technique:– Allows single stage
reaming– Solid, stable fit of the
acetabular component
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Recovery
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Recovery
Begins immediatelyImprovements in anesthesia also facilitate immediate mobilityStart working with therapy to get out of bedWBATAnterior hip precautions
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Summary
You choose the time to intervene for hip replacementGold Standard of all joint replacementsVery predictable outcome with a painless and fully functional hip joint
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Summary
Combining techniques of computer assistance with an anterior hip surgical approach utilize the best of current technologies to maximize your recovery and outcome
Your Treatment OptionsOptionsHip PainThank You
Michael J. Repine MDBoulder Medical Center Orthopedics
(303) 647-5173
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Replaced Hip X-ray