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Orthopaedic Surgery - Humeral Shaft Fracture
Basics
A humeral shaft fracture is a fracture involving the diaphysis of the humerus, extending between the proximal and distal metaphyseal regions.
These fractures occur across all age groups and may result from low-energy or high-energy mechanisms depending on the patient.
Classification
Humeral shaft fractures can be described according to the AO classification, anatomic location, fracture pattern, soft-tissue status, and underlying bone quality.
Anatomic Location
Fractures may involve the:
Proximal one-third, middle one-third, or distal one-third of the humeral shaft.
Fracture Pattern
Common configurations include:
Transverse, oblique, spiral, comminuted, and segmental fractures.
Open Versus Closed
The skin and soft tissues should be examined carefully to determine whether the fracture is:
Closed or open.
An open fracture communicates with the external environment and requires urgent antibiotic administration, tetanus assessment, and operative debridement.
Pathologic Fracture
A fracture occurring through abnormal bone may represent an underlying:
Tumor, metastatic lesion, metabolic bone disease, or other pathologic process.
Holstein–Lewis Fracture
A spiral fracture involving the distal one-third of the humeral shaft is traditionally called a Holstein–Lewis fracture.
This pattern is clinically important because the radial nerve lies close to the distal humerus and may be injured or entrapped.
Epidemiology
Humeral shaft fractures are relatively uncommon.
Historical estimates place the annual incidence at approximately 0–2 per 10,000 people, with no major overall sex difference.
Distribution
Midshaft fractures account for approximately 40% of humeral fractures in some series.
Age Distribution
The incidence demonstrates a bimodal pattern.
A first peak occurs in younger adults, often related to high-energy trauma.
A second peak occurs in older adults, particularly women in approximately the seventh decade of life, where osteoporosis and low-energy falls become more important.
Pediatric Population
Humeral fractures represent an important proportion of pediatric fractures and have historically accounted for approximately 17% of fracture-related admissions in children in some series.
Risk Factors
Important risk factors include:
Osteoporosis in older adults, high-energy trauma in younger patients, falls from height, motor vehicle collisions, and sports involving strong torsional forces.
Sports
Rotational stresses generated during activities such as:
Wrestling, baseball, softball throwing, and similar sports
may occasionally produce spiral humeral shaft fractures.
Etiology
Most humeral shaft fractures are caused by a direct blow or substantial force applied to the upper extremity.
Direct Trauma
Direct impact commonly produces a transverse or comminuted fracture.
Twisting Injury
Torsional loading can produce spiral or oblique fracture patterns.
Violent Muscle Contraction
Rarely, forceful muscular contraction may generate enough torsional stress to fracture the humerus.
This has been described during throwing activities.
Pathologic Bone
Patients with abnormal or weakened bone may sustain a fracture after relatively minor trauma.
Associated Conditions
Because substantial trauma may be involved, the entire upper extremity should be examined for additional injuries.
Associated injuries may include fractures or soft-tissue damage involving the:
Shoulder, clavicle, elbow, forearm, wrist, or hand.
Neurovascular Injury
A careful neurovascular examination is essential.
The radial nerve deserves particular attention because of its close relationship to the humeral shaft.
Diagnosis
Signs and Symptoms
Typical findings include:
Pain, swelling, bruising, deformity, abnormal motion, and occasionally crepitus.
Patients usually support the injured arm with the opposite hand and avoid movement because of pain.
Physical Examination
Skin Integrity
The skin should be examined carefully for:
Open wounds, punctures, abrasions, tenting, threatened skin, or severe soft-tissue injury.
Any wound near the fracture should be assumed to represent a possible open fracture until proven otherwise.
Examination of Adjacent Joints
The shoulder and elbow should be assessed.
The clavicle, forearm, wrist, and hand should also be examined for associated trauma.
Neurologic Examination
Motor and sensory function of the:
Radial, median, and ulnar nerves
should be documented before and after any reduction or immobilization.
Radial Nerve Examination
The radial nerve is the nerve most commonly injured.
Motor testing should include:
Wrist extension, finger MCP extension, and thumb extension.
Sensory examination should include the dorsal first web space.
Median Nerve Examination
Median nerve function can be assessed through:
Thumb opposition, thumb IP flexion, index finger flexion, and sensation over the palmar radial digits.
Ulnar Nerve Examination
Ulnar nerve testing includes:
Finger abduction and adduction and sensation over the little finger.
Vascular Examination
The radial pulse should be palpated.
Capillary refill, skin temperature, and color should also be documented.
Any evidence of vascular compromise requires urgent evaluation.
Laboratory Tests
No laboratory test is diagnostic of an isolated humeral shaft fracture.
Laboratory studies are obtained when indicated by:
Trauma severity, suspected pathologic fracture, operative planning, or associated medical conditions.
Imaging
Plain Radiographs
Standard imaging includes:
AP and lateral views of the entire humerus.
The shoulder and elbow joints should be included to ensure that associated injuries are not missed.
Additional Imaging
CT or MRI is not routinely required for a straightforward shaft fracture.
Advanced imaging may be useful when evaluating:
Complex fracture extension, pathologic lesions, occult articular involvement, or associated soft-tissue abnormalities.
Differential Diagnosis
Important alternatives include:
Pathologic fracture through abnormal bone, muscular contusion, muscle strain or tear, and other upper-arm soft-tissue injuries.
Treatment
Most closed humeral shaft fractures can be treated successfully without surgery.
The humerus tolerates a moderate degree of shortening and angular deformity because shoulder and elbow motion compensate well.
Acceptable Alignment
Historical nonoperative guidelines have accepted approximately:
Up to 20–30° of angulation, up to 2–3 cm of shortening, and approximately 15° of rotational deformity, depending on fracture location and patient factors.
Greater deformity may require reduction or operative stabilization.
Initial Immobilization
Acute fractures are commonly immobilized initially with a coaptation or U-shaped splint.
U-Splint
The splint extends from the axilla, around the elbow, and upward along the lateral aspect of the arm toward the shoulder.
Its purpose is to provide circumferential support while allowing swelling.
Posterior Splint
A posterior slab may be added for additional stability.
The arm is then supported in a sling.
Functional Fracture Brace
After approximately 1–2 weeks, once swelling has decreased and pain is improving, many fractures can be transitioned to a functional humeral fracture brace.
Duration
Bracing is continued until there is adequate:
Clinical stability, absence of significant fracture-site pain, and radiographic evidence of healing.
This commonly requires at least 6–8 weeks, with some fractures taking longer.
Union Rate
Traditional functional bracing has produced union rates of approximately 90% in many series, although the risk varies with fracture pattern and patient characteristics.
Indications for Operative Treatment
Surgery may be considered for:
Open fractures, vascular injury, significant associated articular injury, ipsilateral forearm fracture, segmental fracture, multiple extremity injuries, inability to obtain or maintain acceptable alignment, certain pathologic fractures, and selected nerve injuries.
Floating Elbow
An ipsilateral humeral shaft and forearm fracture creates a floating elbow and often requires operative stabilization.
Secondary Radial Nerve Palsy
A radial nerve palsy that develops after manipulation or reduction raises concern for entrapment or iatrogenic injury and may warrant surgical exploration depending on the clinical situation.
Activity
The injured arm is supported in a sling initially.
The sling should be used for comfort rather than prolonged rigid immobilization once safe motion is permitted.
Nursing and Acute Care
Ice can be applied for approximately 15–20 minutes at a time during the acute phase to reduce pain and swelling.
The skin, particularly in the axilla beneath the splint or brace, should be kept clean and dry.
Fracture Motion
Patients may occasionally feel minor movement or clicking at the fracture site during the early healing period.
This can occur before callus formation but should be reassessed if associated with increasing pain, deformity, or loss of alignment.
Physical Therapy
Formal physical therapy is usually unnecessary during the earliest phase.
Once pain begins to settle, typically after approximately 1–2 weeks, gentle motion of the:
Shoulder, elbow, wrist, and hand
should begin as permitted.
Goals
Early controlled motion helps prevent:
Shoulder stiffness, elbow stiffness, muscle atrophy, and loss of hand function.
Medication
Analgesia is tailored to pain severity.
Short-term opioid medication may occasionally be required for severe acute pain.
Acetaminophen and other appropriate analgesics may also be used.
Surgery
Operative stabilization can be achieved by:
Plate-and-screw fixation, intramedullary nailing, or, rarely, external fixation.
Plate Fixation
Open reduction and internal fixation may use:
A 4.5-mm dynamic compression plate, locking compression plate, or other appropriate plate construct.
Plate fixation provides direct control of alignment and permits radial nerve exploration when necessary.
Intramedullary Nailing
An intramedullary nail may be inserted through either an antegrade or retrograde approach, depending on fracture anatomy and surgeon preference.
Antegrade Nailing
Antegrade insertion passes through the proximal humerus near the shoulder.
It may be associated with postoperative shoulder pain or rotator cuff irritation if the entry site or implant prominence affects the cuff.
Retrograde Nailing
Retrograde insertion avoids the proximal rotator cuff but has its own technical limitations and potential complications.
External Fixation
External fixation is rarely required but may be useful in situations involving:
Severe soft-tissue injury, major contamination, vascular reconstruction, damage-control orthopaedics, or selected open fractures.
Follow-Up
Prognosis
Most isolated closed humeral shaft fractures heal successfully.
Nonoperative treatment historically produces union in approximately 90% of cases.
Radial Nerve Injury
Radial nerve palsy is one of the most important complications.
It occurs in approximately 10–12% of humeral shaft fractures in historical series.
Timing
Radial nerve dysfunction may occur:
At the time of injury, during manipulation, or during operative treatment.
Primary Radial Nerve Palsy
A radial nerve palsy present at initial presentation in a closed fracture is commonly a neurapraxia or axonotmesis and often recovers spontaneously.
Observation is appropriate in many cases if there are no additional indications for exploration.
Secondary Radial Nerve Palsy
New radial nerve palsy developing after reduction or fixation raises greater concern for nerve entrapment, laceration, or implant-related injury and warrants prompt reassessment.
Recovery
Approximately 70% or more of radial nerve injuries associated with humeral shaft fractures are neurapraxic or otherwise recover without nerve repair.
Clinical recovery may take weeks to months.
Nonunion
Failure of the fracture to unite may occur, particularly with:
Marked distraction, transverse fracture patterns, proximal-third fractures, smoking, open injury, poor biology, or inadequate stability.
Historical literature suggested higher nonunion rates with certain intramedullary techniques, although outcomes depend heavily on modern implant design and patient selection.
Malunion
Mild angular deformity is often well tolerated because of the broad compensatory motion available at the shoulder and elbow.
More severe rotational or angular deformity may produce functional or cosmetic problems.
Shoulder Pain
Shoulder discomfort may develop after humeral shaft fracture because of:
Prolonged immobilization, altered mechanics, adhesive stiffness, or antegrade nail entry through the rotator cuff.
Elbow Stiffness
Elbow stiffness may result from prolonged immobilization and is minimized by beginning controlled motion as soon as fracture stability permits.
Patient Monitoring
Serial clinical and radiographic follow-up is necessary to confirm progressive healing.
Radiographic Follow-Up
Radiographs are commonly obtained every 4–6 weeks during early healing.
They should demonstrate:
Maintenance of acceptable alignment, increasing callus formation, and progressive union.
Range of Motion
Shoulder and elbow motion should be assessed at each follow-up visit.
If stiffness develops, the rehabilitation program should be adjusted.
Neurovascular Monitoring
Radial nerve function should be followed carefully, documenting recovery of:
Wrist extension, finger extension, thumb extension, and dorsal hand sensation.
Failure of neurologic recovery over an appropriate interval may warrant electrodiagnostic testing or further specialist evaluation.
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Orthopaedic Surgery - Hip Transient Synovitis
Basics
Transient synovitis of the hip is a self-limited inflammatory condition characterized by acute unilateral hip pain, limp, and temporary restriction of hip motion.
It is one of the most common causes of acute hip pain in children.
The most important diagnostic challenge is distinguishing it from septic arthritis, which requires urgent treatment.
Symptoms usually improve progressively over several days and resolve completely within a few weeks.
Synonyms
Transient synovitis is also known as:
Toxic synovitis or irritable hip.
Epidemiology
Transient synovitis is generally considered the most common cause of acute hip pain in children.
However, it remains a diagnosis of exclusion, meaning that infection and other important structural disorders must be ruled out before the diagnosis is accepted.
Age
The condition may occur from infancy through adolescence, but most cases occur between approximately 3 and 8 years of age.
Cases have been reported as early as about 9 months.
Lifetime Risk
The estimated probability that a child will experience at least one episode is approximately 1–3%.
Laterality
The right and left hips are affected with approximately equal frequency.
Symptoms are typically unilateral.
Sex
Boys are affected more frequently than girls, with a male-to-female ratio of approximately 2:1.
Incidence
Transient synovitis has historically accounted for approximately 0.5% of annual pediatric orthopaedic admissions in some series.
Reported incidence varies among populations.
Risk Factors
Recognized associations include:
Male sex and a recent upper respiratory or other minor infection.
Genetics
Transient synovitis is not considered an inherited disorder.
No consistent genetic predisposition has been established.
Etiology
The exact cause remains uncertain.
The condition is thought to represent a temporary, noninfectious inflammatory response of the hip synovium, possibly mediated by the immune system.
Recent Infection
A preceding or concurrent illness is commonly reported.
Associated conditions have included:
Upper respiratory infection, pharyngitis, and otitis media.
Older studies reported a recent nonspecific infectious illness in as many as 70% of affected children.
Importantly, the hip itself is not infected in uncomplicated transient synovitis.
Minor Trauma
Minor trauma has been reported in up to approximately 30% of cases.
It is uncertain whether trauma directly causes the synovitis or merely draws attention to an already-irritable hip.
Allergic Predisposition
A history of allergic or hypersensitivity tendencies has been described in a minority of patients, historically up to approximately 25%.
Associated Conditions
The most commonly associated clinical history is a recent upper respiratory tract infection.
Diagnosis
Signs and Symptoms
The classic presentation is the acute onset of unilateral hip pain in an otherwise well child.
Pain Location
Pain is usually felt in the:
Groin or hip, but may be referred to the anterior thigh or knee.
Because pediatric hip pathology commonly presents as knee pain, the hip should always be examined in a child with unexplained knee discomfort or limp.
Limp
A limp or antalgic gait is common.
Some children refuse to bear weight on the affected side because of pain.
Resting Position
The child may hold the hip in slight:
Flexion and external rotation, which reduces capsular tension and may be more comfortable.
Range of Motion
Hip motion is painful and restricted, particularly:
Internal rotation, abduction, and extension.
Despite discomfort, the hip often retains a substantial portion of its normal passive range when examined slowly and gently.
Fever
A low-grade temperature may occasionally occur.
High fever should increase concern for septic arthritis or another infection.
Physical Examination
The child usually appears less toxic and less distressed than a patient with septic arthritis.
Nevertheless, substantial overlap may occur, and clinical appearance alone cannot reliably exclude infection.
Kocher Criteria
The Kocher criteria were developed to estimate the likelihood of septic arthritis rather than transient synovitis in a child with an irritable hip.
The classic criteria are:
Refusal to bear weight
Temperature greater than 38.5°C
Peripheral white blood cell count greater than 12,000/mm³
ESR greater than 40 mm/hr
A subsequently described modification also incorporates C-reactive protein, particularly a substantially elevated CRP.
The greater the number of concerning findings, the greater the suspicion for septic arthritis.
These criteria support clinical judgment but should not be used as an absolute rule.
Hip Examination
The child usually localizes discomfort to the:
Groin, anterior thigh, hip, or knee.
Passive range of motion is typically painful and somewhat restricted.
Compared with septic arthritis, however, the child with transient synovitis generally has less severe pain with gentle passive motion.
Preserved Motion
When examined slowly, many patients retain at least approximately 50% of normal hip motion.
Severe pain with nearly all passive movement should raise concern for infection.
Gait
When the child can walk, an antalgic limp is common.
Some children refuse to walk entirely during the acute phase.
Muscle Atrophy
Ipsilateral thigh or gluteal muscle atrophy is unusual.
If present, it suggests that symptoms have existed longer than expected and should prompt consideration of an alternative diagnosis such as:
Legg–Calvé–Perthes disease, chronic infection, neuromuscular disease, or other longstanding pathology.
Laboratory Tests
Laboratory results in transient synovitis are generally normal or only mildly abnormal.
Their principal value is helping to exclude infection and other diagnoses.
White Blood Cell Count
The peripheral leukocyte count is usually normal or only mildly elevated.
ESR
The ESR may be normal or mildly elevated.
Older series reported average values around 20 mm/hr.
A marked elevation raises greater concern for infection or inflammatory disease.
C-Reactive Protein
CRP is typically normal or only minimally elevated.
A substantial elevation should prompt careful reconsideration of septic arthritis or osteomyelitis.
Additional Tests
Other studies such as:
Urinalysis, blood cultures, rheumatoid testing, Lyme serology, or tuberculosis testing
are generally normal in transient synovitis and should be ordered only when the clinical context suggests another diagnosis.
Joint Aspiration
Routine aspiration is not required when the clinical picture strongly favors transient synovitis and infection is unlikely.
However, aspiration should be considered when septic arthritis cannot be excluded.
Synovial Fluid
When aspirated, the joint usually contains a small sterile effusion, historically around 1–5 mL, with negative bacterial cultures.
Synovial-fluid testing is nonspecific except that it helps exclude infection.
Imaging
Plain Radiographs
AP and lateral radiographs of the hip or pelvis may be obtained.
In uncomplicated transient synovitis, radiographs are typically normal or nonspecific.
Their principal purpose is to exclude other pathology such as:
Legg–Calvé–Perthes disease, fracture, or SCFE in older children.
Ultrasound
Ultrasound is useful for detecting a hip joint effusion.
It can also guide diagnostic aspiration when infection remains a concern.
However, the presence of an effusion alone does not distinguish transient synovitis from septic arthritis.
MRI
MRI is not routinely required.
It may be useful when:
Pain persists longer than expected, symptoms recur, radiographs are unrevealing, or infection and other serious diagnoses have been excluded but uncertainty remains.
MRI can assess the femoral head, bone marrow, joint, and surrounding soft tissues.
Pathological Findings
Synovial biopsy, when historically performed, demonstrates nonspecific nonpyogenic synovial hypertrophy and inflammation.
No characteristic bacterial process is present.
Differential Diagnosis
Transient synovitis should only be diagnosed after clinically important alternative disorders have been considered.
Septic Arthritis
This is the most important diagnosis to exclude.
Septic arthritis often presents with:
More severe pain, fever, refusal to bear weight, marked restriction of passive motion, and elevated inflammatory markers.
Urgent aspiration and surgical management may be necessary.
Osteomyelitis
Infection of the proximal femur or pelvis may mimic an irritable hip and should be considered in children with persistent pain or systemic features.
Tuberculous Arthritis
Chronic tuberculous infection may cause prolonged hip pain, stiffness, and constitutional symptoms.
Psoas Abscess
An iliopsoas abscess can cause hip flexion posture, pain with extension, fever, and limp.
Pyomyositis
Infection of muscles around the hip may produce pain, swelling, fever, and restricted movement.
Juvenile Idiopathic Arthritis
Inflammatory arthritis should be considered when symptoms are prolonged, recurrent, bilateral, or associated with other involved joints.
Acute Rheumatic Fever
Migratory joint symptoms in the appropriate systemic context may suggest rheumatic fever.
Legg–Calvé–Perthes Disease
Perthes disease can initially resemble transient synovitis, especially during early stages when radiographs may still be subtle or normal.
Persistent or recurrent symptoms should raise suspicion.
Tumor
Bone or soft-tissue tumors should be considered when pain is persistent, progressive, nocturnal, or associated with systemic symptoms.
Slipped Capital Femoral Epiphysis
SCFE should be considered especially in an older, overweight child or adolescent with hip, thigh, or knee pain and obligatory external rotation during hip flexion.
Hip Dislocation
Traumatic dislocation is generally apparent from the mechanism, deformity, and imaging.
Sacroiliac Joint Infection
Septic sacroiliitis may cause buttock or hip-region pain and gait disturbance.
Treatment
General Principles
Transient synovitis is usually self-limited and requires primarily rest, symptom control, and close observation until infection is confidently excluded.
Natural History
Symptoms commonly improve substantially within several days.
The average symptomatic period is often less than 1 week, although mild discomfort or stiffness may occasionally persist longer.
Most children recover completely without clinical or radiographic sequelae.
Rest
During the painful phase, the child should reduce activity.
Short-term bed rest or relative rest may be appropriate until:
Pain decreases and comfortable hip motion returns.
Weight Bearing
Weight bearing should be limited while significant pain is present.
Normal walking can gradually resume once the child is comfortable and has regained near-full range of motion.
Strenuous activity should be delayed somewhat longer.
Traction
Routine traction is not necessary.
Historically, traction has been used for comfort in particularly painful cases.
If used, the hip may be positioned in approximately 30° of flexion to reduce intra-articular pressure and improve comfort.
Joint Aspiration
Routine aspiration is unnecessary in a typical low-risk presentation.
It becomes appropriate when the possibility of septic arthritis remains significant.
NSAIDs
NSAIDs may be used to reduce pain and inflammation.
Some clinicians historically avoided early anti-inflammatory medication out of concern that symptom improvement might mask infection.
In practice, NSAID response alone should never be used to distinguish transient synovitis from septic arthritis.
Physical Therapy
Formal physical therapy is usually unnecessary.
Parents can generally supervise gradual return to normal activity once symptoms resolve.
Persistent stiffness or weakness should prompt reevaluation rather than routine prolonged therapy.
Follow-Up
Prognosis
The prognosis is excellent.
Transient synovitis is usually self-limiting and resolves without clinically important long-term consequences.
Relationship to Perthes Disease
Some older studies reported subsequent diagnosis of Legg–Calvé–Perthes disease or femoral-head osteonecrosis after an apparent episode of transient synovitis.
This probably reflects, at least in some cases, early Perthes disease initially being mistaken for transient synovitis rather than transient synovitis causing osteonecrosis.
Persistent or recurrent symptoms therefore warrant repeat evaluation.
Complications
True complications are uncommon.
The principal clinical risk is misdiagnosing septic arthritis, osteomyelitis, Perthes disease, or another significant disorder as transient synovitis.
Patient Monitoring
The child should remain under observation until infection and other urgent causes are considered sufficiently unlikely.
Re-Examination
Follow-up examination within approximately 1–2 weeks is appropriate to confirm:
Resolution of pain, return of normal hip motion, and normalization of gait.
Return to Activity
Full activity should resume only after:
Pain has resolved, gait is normal, and hip range of motion has returned.
Return Precautions
Parents should seek prompt reassessment if the child develops:
Increasing pain, high fever, persistent refusal to bear weight, worsening limp, recurrent symptoms, new systemic illness, or failure to improve as expected.
These findings should prompt reconsideration of diagnoses such as septic arthritis, osteomyelitis, or Legg–Calvé–Perthes disease.
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Orthopaedic Surgery - Hip Replacement
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Basics
Total hip arthroplasty, commonly called hip replacement, is a reconstructive procedure used to treat advanced destruction of the hip joint.
Many forms of arthritis and other hip disorders can lead to progressive loss of articular cartilage, resulting in pain, stiffness, impaired walking, and loss of function.
When symptoms become severe and nonoperative treatment no longer provides adequate relief, the damaged joint can be replaced surgically with prosthetic components.
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Age Considerations
Hip replacement is most commonly performed in older adults, although it is increasingly used in younger patients when symptoms are severe.
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Older Patients
Older patients may have a greater burden of medical comorbidity and may therefore have increased perioperative risk from conditions such as:
Cardiovascular disease, pulmonary disease, renal dysfunction, frailty, or osteoporosis.
Preoperative medical optimization is especially important in this population.
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Younger Patients
Patients younger than approximately 50 years have a higher lifetime probability of requiring revision surgery because their expected lifespan may exceed the longevity of the prosthesis.
Their generally higher activity levels may also increase cumulative implant wear.
For this reason, joint-preserving or other alternative strategies should be considered when appropriate.
These may include:
Continued medical management, corrective osteotomy, selected hip-preserving procedures, or, rarely, hip arthrodesis.
Nevertheless, age alone is not an absolute contraindication to total hip arthroplasty when arthritis is severe and disabling.
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Implant Fixation
Hip components may be secured to bone with either:
Cemented fixation or uncemented biologic fixation.
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Cemented Fixation
Bone cement provides immediate mechanical fixation between the implant and bone.
It remains useful in selected patients, particularly those with poor bone quality or certain fracture patterns.
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Uncemented Fixation
Uncemented components have porous or roughened surfaces that permit bone ongrowth or ingrowth.
Over time, biologic fixation develops as host bone integrates with the implant surface.
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Prevention and Delay of Surgery
Progression to hip replacement cannot always be prevented.
However, symptoms and joint loading may sometimes be reduced by:
Weight reduction, low-impact exercise, activity modification, physical therapy, and appropriate treatment of the underlying hip disorder.
These measures may postpone surgery in selected patients.
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Epidemiology
Most hip replacements have historically been performed in patients older than 65 years, although the procedure is now increasingly common in younger adults.
The overall number of total hip arthroplasties continues to increase because of population aging, expanding indications, and favorable long-term outcomes.
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Risk Factors for Hip Disease Requiring Replacement
The risk factors depend on the underlying diagnosis.
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Primary Osteoarthritis
Factors associated with hip osteoarthritis include:
Age, obesity, abnormal hip morphology, previous trauma, and high cumulative mechanical loading.
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Osteonecrosis
Osteonecrosis of the femoral head may be associated with:
Prolonged systemic corticosteroid use, heavy alcohol use, trauma, radiation exposure, and certain hematologic or systemic diseases.
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Femoral Neck Fracture
Osteoporosis predisposes older adults to femoral neck fractures, some of which are treated with hemiarthroplasty or total hip replacement.
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Genetics
Primary hip osteoarthritis appears to have a familial component.
However, there is no simple Mendelian inheritance pattern.
Multiple genetic and environmental factors probably contribute.
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Pathophysiology
Regardless of the underlying cause, end-stage degenerative hip disease shares several important features.
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Cartilage Degeneration
The articular cartilage progressively loses:
Proteoglycans, normal matrix architecture, and mechanical resilience.
This leads to cartilage thinning, fissuring, and eventual loss.
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Subchondral Bone
As cartilage disappears, the underlying bone is subjected to abnormal loading.
This contributes to:
Subchondral sclerosis, cyst formation, osteophytes, deformity, pain, and progressive limitation of motion.
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Etiology
Primary osteoarthritis remains one of the most common indications for total hip arthroplasty.
Other causes of severe hip destruction include:
Post-traumatic arthritis, osteonecrosis, rheumatoid arthritis, sickle cell disease, recurrent hemarthrosis, Paget disease, ankylosing spondylitis, and other inflammatory arthropathies.
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Developmental Causes
Childhood and adolescent hip disorders can produce secondary osteoarthritis years later.
Examples include:
Slipped capital femoral epiphysis, developmental dysplasia of the hip, and Legg–Calvé–Perthes disease.
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Acute Fracture
Some acute displaced femoral neck fractures, particularly in older adults, may be treated directly with:
Hemiarthroplasty or total hip arthroplasty.
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Associated Conditions
Patients requiring hip replacement often have degenerative disease at other sites, including:
The opposite hip, knees, lumbar spine, shoulders, or other upper-extremity joints.
Coexisting musculoskeletal disease may influence rehabilitation and perceived outcome.
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Diagnosis
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Symptoms of Advanced Hip Arthritis
Pain from hip arthritis is classically felt in the:
Groin, anterior thigh, lateral hip, or knee.
Groin pain is particularly characteristic of intra-articular hip disease.
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Activity-Related Pain
Early symptoms are usually aggravated by:
Walking, standing, stair climbing, and other weight-bearing activity.
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Rest and Night Pain
As arthritis becomes advanced, pain may become present:
At rest, during the night, and with minimal activity.
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Walking Limitation
Severe disease may restrict walking to only a few blocks or even less before the patient must stop because of pain.
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Functional Disability
Patients may report difficulty with activities of daily living such as:
Putting on socks or shoes, dressing, grooming, climbing stairs, getting into a car, rising from a chair, and walking outdoors.
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Range of Motion
Advanced disease commonly causes progressive loss of:
Internal rotation, flexion, extension, and abduction.
Internal rotation is often one of the first movements to become painful and restricted.
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Gait
A painful or weak hip may produce:
Antalgic gait, abductor lurch, shortened stance time, or Trendelenburg gait.
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Indications for Considering Hip Replacement
Typical features include:
Severe pain and functional limitation consistent with physical and radiographic findings, failure of appropriate nonoperative treatment, substantial limitation of walking, and difficulty performing daily activities.
The decision to proceed with surgery is based primarily on the patient’s symptoms and functional impairment rather than radiographic severity alone.
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Physical Examination
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Neurovascular Examination
A complete neurologic and vascular assessment of the affected extremity should be documented before surgery.
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Range of Motion
Hip motion should be recorded, including:
Flexion, extension, internal rotation, external rotation, abduction, and adduction.
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Contractures
Fixed flexion or rotational contractures should be identified because they may affect:
Gait, pelvic position, leg length, and surgical planning.
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Leg-Length Discrepancy
True and apparent leg-length discrepancy should be assessed.
Patients should be informed that perfect equalization of leg length cannot always be achieved because joint stability and soft-tissue tension may take priority.
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Gluteal Strength
Hip abductor strength should be assessed, especially the gluteus medius and minimus.
Preexisting abductor weakness can contribute to postoperative limp.
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Gait Examination
The patient’s gait should be observed for:
Antalgia, Trendelenburg pattern, shortening, stiffness, and use of assistive devices.
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Pain With Motion
Advanced arthritis commonly causes pain at the extremes of hip motion.
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Trendelenburg Test
A positive Trendelenburg sign indicates inadequate hip abductor function or painful hip mechanics.
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Stinchfield Test
A resisted straight-leg raise may reproduce groin or anterior thigh pain from an intra-articular hip disorder.
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Laboratory Evaluation Before Surgery
Preoperative testing is individualized according to patient age, health status, and institutional protocol.
Common studies may include:
Complete blood count, electrolytes and renal function, coagulation testing when indicated, and other targeted laboratory studies.
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Additional Preoperative Testing
An electrocardiogram, chest imaging, or urinalysis may be obtained when clinically appropriate rather than routinely in every patient.
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Blood Management
Routine preoperative autologous blood donation is now uncommon.
Modern blood-management strategies may instead include:
Treatment of preoperative anemia, tranexamic acid, careful surgical hemostasis, and restrictive transfusion protocols.
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Imaging
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Plain Radiographs
Standard evaluation generally includes:
AP pelvis and lateral views of the affected hip.
These studies demonstrate:
Joint-space narrowing, osteophytes, subchondral sclerosis, cyst formation, deformity, and bone loss.
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Additional Views
Standing long-leg or other specialized radiographs may be useful when evaluating:
Limb-length discrepancy, deformity, prior osteotomy, complex anatomy, or alignment concerns.
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Differential Diagnosis
Not all hip-region pain is caused by the hip joint.
Important alternative diagnoses include:
Lumbar spinal stenosis, lumbar disc herniation, radiculopathy, greater trochanteric pain syndrome, occult stress fracture, and neoplasm.
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Neoplasm
Occult malignant disorders that may mimic degenerative hip pain include:
Metastatic bone disease, multiple myeloma, and primary bone or soft-tissue tumors.
Atypical pain, particularly severe night pain or systemic symptoms, should prompt further evaluation.
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Nonoperative Treatment Before Surgery
Total hip replacement is usually considered only after reasonable nonoperative measures have failed or become inadequate.
These may include:
Activity modification, weight reduction, NSAIDs, acetaminophen, physical therapy, walking aids, and selected intra-articular corticosteroid injections.
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Physical Therapy
Physical therapy has important roles both before and after arthroplasty.
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Preoperative Therapy
Prehabilitation may improve:
Strength, gait mechanics, familiarity with assistive devices, and postoperative expectations.
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Postoperative Therapy
Rehabilitation emphasizes:
Walking, transfers, hip and lower-extremity strengthening, progressive mobility, balance, and restoration of independence.
Particular attention is given to the:
Hip abductors, flexors, and extensors.
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Assistive Devices
Patients are taught safe use of:
A walker, crutches, or cane, depending on mobility and postoperative instructions.
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Medication
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Postoperative Analgesia
Pain control is generally multimodal and may include:
Acetaminophen, NSAIDs when appropriate, regional anesthesia techniques, and limited opioid medication for breakthrough pain.
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Venous Thromboembolism Prophylaxis
Patients undergoing total hip arthroplasty require prophylaxis against deep venous thrombosis and pulmonary embolism.
Options may include:
Aspirin, low-molecular-weight heparin, direct oral anticoagulants, or other anticoagulants, depending on individual thrombotic and bleeding risk.
Early mobilization and mechanical compression devices are also important.
Routine use of warfarin for every patient is no longer standard practice.
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Surgery
Total hip arthroplasty replaces both the femoral and acetabular sides of the joint.
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Femoral Component
The femoral head and part of the femoral neck are removed.
A prosthetic stem is inserted into the femoral canal and supports a modular head.
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Acetabular Component
The acetabulum is prepared and typically reconstructed with a metal shell.
A bearing liner, usually highly cross-linked polyethylene or ceramic, is inserted into the shell.
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Fixation
Both femoral and acetabular components may be:
Cemented, uncemented, or combined in a hybrid construct.
Fixation choice depends on:
Bone quality, age, anatomy, fracture pattern, and surgeon preference.
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Surgical Approaches
Several approaches may be used successfully.
No single approach is universally superior for every patient.
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Direct Anterior Approach
The direct anterior approach uses an internervous plane near the interval between the sartorius and tensor fascia lata superficially, with deeper dissection toward the anterior hip capsule.
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Structures at Risk
The lateral femoral cutaneous nerve is particularly susceptible to traction or injury and may produce numbness or dysesthesia over the anterolateral thigh.
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Anterolateral Approach
The Watson-Jones approach uses the interval between the:
Tensor fascia lata and gluteus medius.
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Direct Lateral Approach
In the direct lateral or Hardinge approach, part of the anterior abductor mechanism is elevated from the greater trochanter.
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Potential Concerns
Postoperative abductor weakness and limp may occur if healing is incomplete.
The superior gluteal nerve is vulnerable if the dissection extends too proximally.
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Posterior Approach
The posterior approach splits the gluteus maximus and releases the short external rotators to expose the capsule.
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Sciatic Nerve
The sciatic nerve lies near the operative field and must be protected.
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Dislocation
Historically, the posterior approach was associated with a higher dislocation rate.
Modern repair of the posterior capsule and external rotators, larger femoral heads, improved implant positioning, and contemporary techniques have reduced this difference substantially.
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Bearing Surfaces
The bearing surface is formed by the femoral head articulating against the acetabular liner.
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Ceramic or Metal on Polyethylene
A ceramic or metal femoral head articulating with highly cross-linked polyethylene is one of the most widely used modern combinations.
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Polyethylene Wear
Older conventional polyethylene could produce substantial wear debris, leading to:
Osteolysis and implant loosening.
Highly cross-linked polyethylene has substantially reduced wear.
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Metal-on-Metal Bearings
Metal-on-metal total hip bearings are rarely used in contemporary practice because of problems including:
Metal ion release, adverse local tissue reactions, pseudotumor formation, and high failure rates in some implant designs.
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Ceramic-on-Ceramic Bearings
Ceramic-on-ceramic bearings have very low wear.
Potential concerns include:
Noise or squeaking and rare ceramic fracture, although modern ceramics have markedly improved strength.
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Femoral Head Size
Larger femoral heads can increase:
Jump distance, stability, and impingement-free range of motion.
However, head size must be balanced against liner thickness, component design, and bearing mechanics.
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Minimally Invasive and Rapid-Recovery Techniques
Smaller incisions alone do not necessarily explain faster recovery.
Modern recovery has improved largely because of:
Refined surgical techniques, multimodal analgesia, tranexamic acid, early mobilization, standardized rehabilitation, and enhanced-recovery pathways.
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Follow-Up
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Prognosis
Total hip arthroplasty has excellent long-term outcomes.
Most patients experience:
Major pain relief, substantial improvement in walking ability, increased range of motion, and improved quality of life.
Many return to activities that had previously become impossible because of arthritis.
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Implant Longevity
Older studies demonstrated that approximately 85% of some cemented prostheses remained functional at 20 years.
Modern cemented and uncemented implants can both provide excellent long-term survivorship, with outcome strongly influenced by patient age, activity level, implant design, bearing surface, and surgical technique.
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Complications
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Medical Complications
Potential perioperative medical complications include:
Myocardial infarction, pneumonia, urinary retention, ileus, venous thromboembolism, and, rarely, death.
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Leg-Length Discrepancy
A perceived or true limb-length difference may occur after surgery.
Small discrepancies are often tolerated, but larger differences may cause gait disturbance or dissatisfaction.
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Deep Venous Thrombosis and Pulmonary Embolism
DVT and PE remain important complications, although routine chemical prophylaxis, mechanical compression, and early mobilization have greatly reduced risk.
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Infection
Periprosthetic joint infection is a serious complication that may require:
Antibiotic treatment, surgical debridement, implant exchange, or staged revision surgery.
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Dislocation
Dislocation may occur because of:
Component malposition, soft-tissue insufficiency, impingement, neurologic disease, or high-risk movement.
Risk is generally higher after revision arthroplasty than uncomplicated primary surgery.
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Periprosthetic Fracture
Fractures may occur around the femoral or acetabular components either during surgery or later after trauma.
Treatment depends on implant stability and fracture pattern.
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Heterotopic Ossification
Ectopic bone formation around the hip may restrict motion.
Most cases are mild, but severe cases can cause substantial stiffness.
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Implant Loosening
Components may loosen over time because of:
Wear, osteolysis, inadequate initial fixation, infection, or mechanical failure.
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Osteolysis
Particle-induced bone loss may develop around implants, historically most often from polyethylene wear debris.
Modern bearing surfaces have reduced but not eliminated this problem.
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Nerve Injury
Nerve palsy is uncommon.
The sciatic nerve is most frequently involved, although the femoral, obturator, superior gluteal, or lateral femoral cutaneous nerves may also be affected depending on the surgical approach.
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Revision Surgery
Revision may eventually be necessary because of:
Aseptic loosening, infection, recurrent dislocation, fracture, wear, osteolysis, instability, or component failure.
Revision surgery is generally more complex than primary arthroplasty.
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Patient Monitoring
Long-term clinical and radiographic follow-up is important even in patients who feel well.
Radiographs can detect:
Component migration, polyethylene wear, osteolysis, loosening, fracture, and other asymptomatic changes.
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Follow-Up Interval
Periodic radiographic assessment, often every 1–2 years after the early postoperative period, may be appropriate, with timing individualized according to implant age, symptoms, and surgeon preference.
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Dental Procedures and Antibiotic Prophylaxis
Routine antibiotic prophylaxis before dental procedures is not universally recommended for every patient with a total hip replacement.
The decision should be individualized according to current dental and orthopaedic guidance, especially in patients with:
Previous prosthetic joint infection, major immunocompromise, complex revision arthroplasty, or other specific high-risk circumstances.
Good dental hygiene and prompt treatment of active oral infection remain important.
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Orthopaedic Surgery - Hip Pain in the Child
Basics
Hip pain in a child usually refers to discomfort arising from structures around the hip and commonly perceived in the groin, lateral hip, anterolateral thigh, or even the knee.
The groin receives sensory innervation largely through branches of the femoral and obturator nerves, which helps explain why pathology within the hip joint is frequently perceived anteriorly.
Pain may originate from numerous structures, including:
The joint capsule and synovium, pelvis, proximal femur, surrounding muscles and tendons, peripheral nerves, blood vessels, buttock, groin, and pelvic structures.
Because several causes of pediatric hip pain require urgent treatment and may cause permanent disability if diagnosis is delayed, every child with significant hip pain or unexplained limp requires a careful evaluation.
Epidemiology
Transient synovitis is commonly reported as the most frequent cause of acute hip pain in children.
Several important pediatric hip disorders show a male predominance.
Historical male-to-female ratios include approximately:
Transient synovitis: 2:1
SCFE: approximately 2.5:1
Osteomyelitis: approximately 4:1
Legg–Calvé–Perthes disease: approximately 6:1
Septic arthritis also demonstrates a slight male predominance.
Incidence
Transient Synovitis
The lifetime risk of at least one episode of transient synovitis during childhood has been estimated at approximately 3%.
Legg–Calvé–Perthes Disease
Peak incidence occurs at approximately 6 years of age.
Historical incidence is approximately 1 per 1,500 children, although rates vary among populations.
Slipped Capital Femoral Epiphysis
SCFE occurs almost exclusively during preadolescence and adolescence.
Its incidence has historically been estimated at approximately 1 per 10,000 children, although prevalence varies substantially with age, sex, ethnicity, and obesity.
Risk Factors
Risk factors depend on the underlying diagnosis.
Important examples include:
Juvenile inflammatory arthritis, trauma, impaired immune function, obesity, and age.
Obesity, adolescence, and mechanical stress are particularly associated with SCFE.
Genetics
Most causes of pediatric hip pain do not follow a simple hereditary pattern.
A minority of patients with SCFE have a positive family history, historically reported in approximately 4% of cases.
Etiology
The two most common acute causes of hip pain in children are transient synovitis and septic arthritis, but the differential diagnosis is broad.
Transient Synovitis
Transient synovitis is a self-limited inflammatory process involving the hip joint.
Age
The average age at presentation is approximately 6 years, with most cases occurring between 3 and 8 years.
Associations
The disorder may follow:
A recent viral illness, minor trauma, or an allergic or inflammatory stimulus.
In many children, no clear precipitating cause is identified.
Septic Arthritis
Septic arthritis is a bacterial infection of the hip joint and represents an orthopaedic emergency.
Approximately two-thirds of cases historically occur in children younger than 3 years.
Mechanism
Infection may reach the hip by:
Hematogenous spread through the synovial blood supply or direct extension from adjacent osteomyelitis.
Infants
During approximately the first 12–18 months of life, transphyseal vascular channels may permit infection to spread from the proximal femoral metaphysis into the epiphysis and hip joint.
For this reason, concomitant proximal femoral osteomyelitis and septic arthritis are particularly important in infants.
Organisms
The causative organism varies with age and immunization history.
Staphylococcus aureus remains a major pathogen across pediatric age groups.
Historically, neonatal infections were also associated with streptococci and other organisms, while Haemophilus influenzae type b was an important cause before widespread vaccination.
Sexually active adolescents may rarely develop gonococcal septic arthritis.
Legg–Calvé–Perthes Disease
Perthes disease is an idiopathic osteonecrosis of the developing femoral head.
Its exact cause remains unknown.
Proposed contributing mechanisms include:
Vascular interruption, thrombosis, hypercoagulability, repetitive trauma, and other disturbances of femoral-head perfusion.
Slipped Capital Femoral Epiphysis
SCFE results from failure of the proximal femoral physis during adolescent growth.
Potential contributing factors include:
Mechanical stress, physeal weakness during rapid growth, obesity, trauma, and hormonal or metabolic influences.
Approximately 80% of affected patients have historically been described as overweight or obese.
Other Causes of Pediatric Hip Pain
Other etiologic categories include:
Infectious, traumatic, neoplastic, inflammatory, hematologic, developmental, and idiopathic conditions.
Associated Conditions
Transient synovitis may occur in association with:
Current or recent viral illness, minor trauma, or an allergic-type inflammatory event.
Diagnosis
Signs and Symptoms
Hip pathology may produce pain in several locations.
Common sites include:
The groin, greater trochanter, anterolateral thigh, medial thigh, or knee.
An important principle is that knee pain in a child may originate from the hip.
Muscle Guarding
Inflammation or pain within the hip frequently causes involuntary muscle spasm or guarding.
The child may hold the hip in a position that maximizes capsular volume and minimizes discomfort.
Loss of Motion
Both active and passive hip motion may become restricted.
The pattern of restriction can provide diagnostic clues.
Perthes Disease and Hip Dysplasia
Loss of abduction and internal rotation is characteristic.
SCFE
A particularly important finding is obligatory external rotation of the hip during attempted flexion.
As the hip is flexed, the thigh progressively rotates outward.
This finding strongly suggests SCFE.
Weight Bearing
Refusal or inability to bear weight is an important red flag.
Possible causes include:
Septic arthritis, osteomyelitis, fracture, severe transient synovitis, or unstable SCFE.
Limp
The child may have either:
An antalgic painful limp or a relatively painless chronic limp, depending on the disorder.
Muscle Atrophy
Long-standing disease may cause wasting of the:
Thigh, gluteal, or other periarticular musculature.
This finding suggests a more chronic process.
Fever
Fever should raise concern for infection, especially:
Septic arthritis or osteomyelitis.
Absence of fever does not completely exclude infection.
Physical Examination
Inspection
Inspect the child at rest and, when possible, during standing and walking.
Look for:
Abnormal limb position, swelling, erythema, bruising, muscle wasting, limb-length discrepancy, or deformity.
Palpation
Palpate the:
Hip, groin, greater trochanter, buttock, lower back, pelvis, and thigh.
Assess for:
Warmth, focal tenderness, swelling, fluctuance, or tenderness over a bursa or bone.
Resting Position
Document the spontaneous position of the limb.
A child with an irritable hip may hold it in slight flexion, abduction, and external rotation to reduce capsular pressure.
Range of Motion
Active and passive range of motion of both the hip and knee should be examined and compared with the opposite side.
Particular attention should be given to:
Internal rotation, external rotation, abduction, and flexion.
Loss of internal rotation is often one of the earliest findings in many intra-articular hip disorders.
Neurovascular Examination
A complete distal motor, sensory, and vascular examination should be documented.
Weakness, numbness, abnormal reflexes, or poor perfusion may point toward neurologic, spinal, or vascular pathology rather than an isolated joint disorder.
Gait Examination
If the child is able to walk safely, observe the gait.
Assessment may include:
Normal walking, toe walking, heel walking, stride length, stance duration, trunk position, and symmetry.
An antalgic gait is characterized by decreased stance time on the painful side.
Hip Aspiration
If septic arthritis is suspected, urgent aspiration of the hip joint should be considered.
Because the hip is deep, aspiration is usually performed with ultrasound or fluoroscopic guidance.
Fluid should be sent for appropriate microbiologic and laboratory analysis.
Laboratory Tests
Routine blood studies may be normal in:
Transient synovitis, Perthes disease, SCFE, and developmental hip dysplasia.
However, laboratory testing is important when infection is part of the differential diagnosis.
Septic Arthritis Laboratory Findings
Common abnormalities include:
Elevated leukocyte count, neutrophilia or left shift, elevated ESR, and elevated C-reactive protein.
No single blood test confirms or excludes septic arthritis.
Synovial Fluid
The synovial white blood cell count is an important diagnostic measure.
A value greater than approximately 50,000 cells/mm³, particularly with a high neutrophil percentage, strongly raises concern for septic arthritis, although lower counts can still occur with infection.
Blood Cultures
Blood cultures should be obtained early when septic arthritis or osteomyelitis is suspected.
Historically, blood cultures have been positive in approximately 40% of children with septic arthritis or osteomyelitis.
Imaging
Plain Radiographs
Radiographs are commonly the first imaging study for persistent or significant hip pain.
Typical views include an AP pelvis and appropriate lateral hip view, depending on the suspected disorder.
Septic Arthritis
Early plain radiographs may show:
Soft-tissue swelling, capsular distension, or displacement of normal fat planes.
They can also help exclude fracture, SCFE, Perthes disease, or advanced osteomyelitis.
Osteomyelitis
Early radiographs can be normal.
As infection progresses, findings may include:
Loss of normal bone density, cortical or medullary lucency, periosteal reaction, sclerosis, and progressive osseous destruction.
Untreated proximal femoral infection may ultimately damage the femoral head.
Transient Synovitis
AP and lateral radiographs are typically normal or nonspecific.
Their main purpose is to exclude other structural disease.
Ultrasound may demonstrate an effusion but cannot reliably distinguish transient synovitis from septic arthritis.
Legg–Calvé–Perthes Disease
Radiographic abnormalities evolve over time.
Early Findings
Early findings may include:
Failure of expected epiphyseal growth, increased density or sclerosis of the femoral head, and subtle loss of normal contour.
Later Findings
Progressive disease may produce:
Subchondral fracture, fragmentation, femoral-neck shortening, flattening, extrusion, and eventual enlargement or deformity of the femoral head.
Slipped Capital Femoral Epiphysis
Radiographs may show:
Physeal widening or irregularity, osteopenia around the physis, and displacement of the proximal femoral epiphysis relative to the metaphysis.
Both hips should generally be evaluated because bilateral disease is not uncommon.
When an unstable SCFE is suspected, forceful frog-leg positioning should be avoided.
Pathological Findings
Septic Arthritis
Early disease causes synovial inflammation and hypertrophy.
Without rapid treatment, bacterial enzymes and inflammatory mediators can destroy the articular cartilage.
SCFE
The femoral head remains seated within the acetabulum while the proximal femoral metaphysis displaces relative to the epiphysis.
The epiphysis is therefore effectively positioned posteriorly and inferiorly relative to the metaphysis.
Perthes Disease
Progressive femoral-head osteonecrosis can result in:
Flattening, extrusion, fragmentation, and deformity of the capital femoral epiphysis.
Differential Diagnosis
Transient synovitis is common but should remain a diagnosis of exclusion, particularly until infection and other serious conditions have been considered.
Infectious Causes
Important infectious conditions include:
Septic arthritis of the hip, proximal femoral osteomyelitis, pelvic osteomyelitis, sacroiliac septic arthritis, discitis, pyomyositis, and psoas infection or abscess.
Developmental and Mechanical Causes
These include:
Legg–Calvé–Perthes disease, SCFE, developmental hip dysplasia, and early degenerative or chondral disease.
Inflammatory Causes
Consider:
Juvenile idiopathic arthritis and other inflammatory arthropathies.
Neoplastic Causes
Tumors involving the:
Pelvis, spine, proximal femur, or surrounding soft tissues may present with hip or referred knee pain.
Hematologic and Malignant Disorders
Consider:
Sickle cell crisis, leukemia, and lymphoma.
Extra-Articular Causes
Other possibilities include:
Iliopsoas bursitis, greater trochanteric bursitis, pyomyositis, referred lumbar or sacroiliac pain, and other nonarticular disorders.
Treatment
Management depends entirely on the underlying diagnosis.
Transient Synovitis
Transient synovitis is usually self-limited.
Treatment focuses on symptom relief.
Rest
Relative rest and temporary reduction in weight bearing are appropriate until pain improves and a normal or near-normal range of motion returns.
NSAIDs
Anti-inflammatory medication may reduce pain and synovial irritation.
Natural History
Symptoms usually resolve spontaneously.
Failure to improve as expected should prompt reassessment of the diagnosis.
Septic Arthritis
Septic arthritis requires urgent treatment because irreversible cartilage injury can occur rapidly.
Drainage
The infected joint should be aspirated and, when indicated, surgically irrigated and debrided.
Antibiotics
Empiric broad-spectrum intravenous antibiotics are started after appropriate cultures are obtained whenever feasible, then narrowed according to culture and susceptibility results.
The route and total duration of treatment depend on:
The organism, clinical response, inflammatory markers, presence of adjacent osteomyelitis, and local infectious-disease protocols.
Rigid historical treatment durations should not replace clinical and laboratory response.
Positioning
When severe capsular distension has occurred, the hip may temporarily be positioned to reduce discomfort, historically including mild abduction.
Range of Motion
After infection is controlled and drainage is no longer required, gentle range-of-motion exercises are begun to minimize stiffness.
Osteomyelitis
Antibiotic therapy is the primary treatment.
Surgical drainage or debridement may be required when there is:
Abscess formation, necrotic bone, failure of medical treatment, or need for diagnostic tissue sampling.
Legg–Calvé–Perthes Disease
Treatment aims to preserve:
Femoral-head containment, hip range of motion, and the most spherical possible femoral-head shape during healing.
Nonoperative Care
Measures may include:
Activity modification, maintenance of hip motion, treatment of synovitis, and temporary reduction in weight bearing when symptoms are severe.
Traction or bed rest has historically been used during painful episodes, although prolonged immobilization is generally avoided.
Surgery
Selected patients with more extensive disease may require femoral or pelvic reconstruction to improve containment of the femoral head within the acetabulum.
Slipped Capital Femoral Epiphysis
SCFE requires prompt stabilization to prevent further displacement.
Initial Management
Once SCFE is suspected, the child should generally be made non–weight bearing until definitive treatment.
Surgery
The standard treatment for most stable slips is in situ percutaneous screw fixation.
Forceful reduction should be avoided because vascular injury to the femoral head can cause osteonecrosis.
Physical Therapy
Formal physical therapy is not routinely needed for every child with hip pain.
Its role depends on the diagnosis and may include:
Gait retraining, maintenance of range of motion, strengthening, and postoperative rehabilitation.
Medication
Septic Arthritis and Osteomyelitis
Appropriate antimicrobial therapy is essential.
Treatment should be tailored to the likely organism initially and then adjusted to culture results.
Transient Synovitis
NSAIDs may be used for symptomatic relief.
Surgery
Septic Arthritis
Surgical treatment may involve:
Irrigation, debridement, and drainage of the hip joint.
An anterior or other suitable approach may be chosen according to surgeon preference and clinical circumstances.
Osteomyelitis
If operative drainage is necessary, a cortical window may be created to permit:
Culture, curettage, and decompression of infected bone.
Chronic osteomyelitis, although uncommon in children with modern treatment, may require more extensive debridement.
Perthes Disease
Severe disease may require reconstructive surgery involving either the:
Proximal femur, acetabulum, or both to improve containment.
SCFE
Percutaneous in situ fixation is performed to prevent progression of the slip and reduce the risk of additional deformity.
Follow-Up
Prognosis of Septic Arthritis and Osteomyelitis
Early diagnosis and treatment can produce a good outcome.
Delayed or chronic infection may result in permanent deformity.
Prognosis of Perthes Disease
Outcome generally improves when:
The child is younger at disease onset, the necrotic segment is smaller, femoral-head extrusion is minimal, and hip range of motion remains good.
Some residual radiographic deformity may persist even when clinical function is satisfactory.
Prognosis of SCFE
Long-term outcome depends substantially on the severity of the slip and development of complications.
More severe deformity is associated with a greater risk of later femoroacetabular impingement and degenerative arthritis.
Complications
Septic Arthritis and Osteomyelitis
Untreated infection can be devastating in a growing child.
Potential consequences include:
Femoral-head or physeal destruction, limb shortening, joint incongruity, stiffness, deformity, growth disturbance, and early degenerative arthritis.
Cartilage injury can begin very early in the course of untreated bacterial arthritis, reinforcing the need for urgent treatment.
SCFE Complications
Major complications include:
Osteonecrosis and chondrolysis.
Osteonecrosis
Disruption of the femoral-head blood supply may occur as a consequence of the unstable slip or overly aggressive reduction.
Chondrolysis
Chondrolysis is rapid loss of articular cartilage and produces:
Joint-space narrowing, stiffness, contracture, pain, and limp.
Degenerative Arthritis
Patients with SCFE have an increased long-term risk of premature hip osteoarthritis, particularly when residual deformity is substantial.
Patient Monitoring
Septic Arthritis and Osteomyelitis
Clinical recovery should be followed together with inflammatory markers such as:
C-reactive protein and ESR.
A downward trend toward normal supports successful treatment.
Antibiotic duration should be guided by the overall clinical course, inflammatory markers, microbiology, and presence or absence of associated osteomyelitis.
Transient Synovitis
Observation is appropriate when symptoms improve predictably and serious alternative diagnoses have been excluded.
Persistent, recurrent, or worsening symptoms require reevaluation.
Legg–Calvé–Perthes Disease
Children with limited femoral-head involvement may be managed with observation and serial clinical and radiographic assessment.
Historically, involvement of less than approximately 50% of the femoral head has been associated with a more favorable course.
Important Clinical Red Flags
Urgent evaluation is particularly important in a child with:
Fever, inability to bear weight, severe pain with passive hip motion, rapidly progressive symptoms, night pain, systemic illness, significant trauma, or suspected unstable SCFE.
These findings may indicate a condition in which delayed treatment risks permanent damage to the hip.
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Orthopaedic Surgery - Hip Fracture in the Child
Basics
Pediatric hip fractures include fractures of the femoral neck, intertrochanteric region, and subtrochanteric proximal femur.
Femoral-neck fractures in children are rare but serious injuries because disruption of the blood supply to the femoral head can lead to osteonecrosis, nonunion, growth disturbance, coxa vara, and later degenerative arthritis.
Classification
The most commonly used system for pediatric femoral-neck fractures is the Delbet classification, as popularized by Colonna.
Delbet Type I
Type I is a transphyseal separation in which the femoral head separates from the neck through the proximal femoral physis.
It is the least common type and is generally seen in younger children.
A substantial proportion of these injuries are associated with dislocation of the femoral head from the acetabulum.
Delbet Type II
Type II is a transcervical fracture through the middle portion of the femoral neck.
This is the most common pediatric femoral-neck fracture pattern.
Delbet Type III
Type III is a cervicotrochanteric or basicervical fracture occurring near the base of the femoral neck.
It is the second most common pattern.
Delbet Type IV
Type IV is an intertrochanteric fracture, located between the greater and lesser trochanters.
This fracture generally carries a lower risk of osteonecrosis than the more proximal intracapsular types.
Importance of Initial Displacement
The degree of displacement at the time of injury is one of the most important predictors of femoral-head osteonecrosis.
More displaced fractures are more likely to disrupt the vulnerable vascular supply.
Anatomy and Blood Supply
The blood supply of the pediatric femoral head changes substantially during growth.
Early Childhood
At birth, vascular channels arising from the femoral circumflex system travel toward the femoral head through the proximal femoral neck.
The proximal femoral physis acts as a barrier to direct metaphyseal blood vessels entering the epiphysis.
After Approximately 4 Years of Age
By about 4 years of age, the medial femoral circumflex artery, particularly its retinacular branches, provides the dominant blood supply to the femoral head.
These vessels travel along the femoral neck and are vulnerable to injury during fracture or dislocation.
Ligamentum Teres
The artery within the ligamentum teres contributes only a relatively small portion of the total femoral-head blood supply and generally cannot compensate for major disruption of the retinacular vessels.
Surgical Relevance
Capsulotomy itself does not usually compromise the femoral-head circulation provided the important posterosuperior and posteroinferior retinacular vessels along the femoral neck are protected.
Fracture Stability
Approximately half of pediatric hip fractures are initially nondisplaced.
Once displacement occurs, the fracture is generally considered mechanically unstable.
Epidemiology
Pediatric hip fractures account for less than 1% of all fractures in children.
They are far less common than adult hip fractures because healthy pediatric bone is strong and usually requires substantial force to fracture.
Etiology
Approximately 75% of pediatric hip fractures are caused by major trauma.
Typical mechanisms include:
Motor vehicle collisions, pedestrian trauma, falls from significant height, and other high-energy injuries.
Pathologic Fractures
The remaining cases may occur through abnormal bone weakened by disorders such as:
Unicameral bone cyst, aneurysmal bone cyst, fibrous dysplasia, or other osseous lesions.
Nonaccidental Injury
In infants and young children, particularly when the history is inconsistent with the child’s developmental abilities, nonaccidental trauma must be considered.
Associated Conditions
Infants
A hip fracture in an infant should prompt careful assessment for possible nonaccidental injury unless there is a convincing high-energy mechanism.
Children
Because substantial force is usually necessary to fracture the pediatric femoral neck, other associated injuries should be actively sought.
Adolescents
In adolescents, proximal femoral physeal injury may resemble or overlap with slipped capital femoral epiphysis.
Atypical or pathologic slips should raise concern for underlying metabolic or endocrine disease, including:
Hypothyroidism and renal osteodystrophy.
Diagnosis
Signs and Symptoms
The usual presentation is sudden severe hip pain following trauma.
The child may be unable to stand, walk, or move the hip.
Swelling
Swelling may be visible in the:
Inguinal region, proximal thigh, or gluteal area.
Resting Position
The limb is often held in a position of:
External rotation, flexion, and adduction, which may reduce capsular tension and pain.
Motion
With displaced fractures, active hip movement is usually impossible.
Passive movement is markedly painful and restricted, particularly:
Flexion, abduction, and internal rotation.
Crepitus
Pain and occasionally crepitus may be produced with hip motion.
Forceful examination should be avoided.
Infants
Infants may present with pseudoparalysis, refusing to move the involved extremity.
Limb Shortening
The affected leg may appear shortened by approximately 1–2 cm, particularly with a displaced fracture.
External rotation is common.
Physical Examination
Most children with a complete femoral-neck fracture are in substantial pain.
The examination should be gentle and should include assessment for associated injuries.
Incomplete or Nondisplaced Fracture
In patients without an obvious complete fracture, pain may be particularly evident with:
Internal rotation, abduction, and flexion of the hip.
Neurovascular Examination
Distal pulses, capillary refill, motor function, and sensation should be documented before and after reduction or operative treatment.
Imaging
Plain Radiographs
Initial imaging generally includes:
AP pelvis or AP hip and lateral views of the affected hip.
Radiographs may show superior and lateral displacement of the femoral shaft relative to the femoral head.
CT
CT may be helpful for:
Defining fracture comminution, assessing complex fracture geometry, evaluating associated acetabular injury, and determining the direction of femoral-head dislocation.
It is not necessary in every case.
Ultrasound
In newborns and very young infants, ultrasound may be useful because much of the proximal femur remains cartilaginous and therefore poorly visualized on radiographs.
Differential Diagnosis
Important alternatives include:
Slipped capital femoral epiphysis and developmental coxa vara.
Developmental Coxa Vara
Developmental coxa vara may demonstrate a characteristic vertical defect or cleft near the femoral neck and should not be mistaken for an acute fracture.
Treatment
General Principles
Treatment aims to obtain and maintain an anatomic or near-anatomic reduction with stable fixation while minimizing additional injury to the femoral-head blood supply.
Because displaced pediatric femoral-neck fractures are unstable and have a high complication rate, operative fixation is commonly required.
Reduction
Either closed or open reduction may be used.
Reduction should be:
Gentle, accurate, and performed without repeated forceful manipulation.
Residual translation or varus should be avoided because imperfect reduction substantially increases the risk of nonunion and deformity.
Fixation by Age
Implant choice depends on patient age and the size of the femoral neck.
Young Children
In children approximately 2–6 years old, fixation may use:
Smooth pins or small cannulated screws, typically around 4.0–4.5 mm when anatomy permits.
Older Children
In children approximately 7 years and older, larger cannulated screws, historically around 6.5–7.3 mm, may be used when appropriate.
Modern implant size should be individualized to the child’s anatomy.
Spica Casting
A hip spica cast is often added in younger children because the small femoral neck may limit the number or size of implants that can safely be inserted.
The cast provides additional protection against displacement.
Physeal Crossing
Type I
When fixation of a Type I transphyseal injury requires crossing the growth plate, smooth pins are generally preferred, often followed by a spica cast.
Types II–IV
For Types II–IV, implants should ideally avoid crossing the proximal femoral physis when stable fixation can still be achieved.
However, secure fixation takes priority over physeal preservation.
The proximal femoral physis contributes only about 3 mm of longitudinal growth per year, so inadequate fixation should not be accepted merely to avoid crossing it.
Associated Hip Dislocation
When femoral-head dislocation accompanies the fracture, only a gentle attempt at closed reduction should be made.
Repeated manipulations increase the risk of further vascular and physeal injury.
If reduction is unsuccessful, open reduction is indicated.
Surgical Approach
The open approach should generally correspond to the direction of dislocation:
Posterior approach for posterior dislocation and anterior approach for anterior dislocation.
Treatment by Delbet Type
Type I Without Dislocation
A gentle closed or open reduction is followed by fixation with a pin or screw as appropriate for age and anatomy.
Type I With Dislocation
This is one of the highest-risk pediatric hip injuries.
Historical series report osteonecrosis rates approaching 100% in some displaced Type I injuries with dislocation and a very high incidence of later degenerative arthritis.
Reduction
A gentle attempt at closed reduction may use:
Longitudinal traction, abduction, and internal rotation.
If this fails, open reduction and fixation are required.
Type II
Type II transcervical fractures are the most common pediatric femoral-neck fractures.
Most are displaced.
Osteonecrosis Risk
Historical osteonecrosis rates are approximately 50%, with displaced fractures carrying substantially greater risk than nondisplaced injuries.
Treatment
Both displaced and nondisplaced Type II fractures are generally treated with:
Reduction and internal fixation using screws or pins.
Type III
Type III fractures are the second most common pattern.
Historical osteonecrosis rates are approximately 25%.
Displaced Type III
Treatment consists of:
Gentle closed reduction or open reduction followed by internal fixation.
Nondisplaced Type III
Prophylactic screw fixation is commonly recommended because late displacement can occur.
In selected children younger than approximately 8 years, an abduction spica cast may occasionally be considered, but close monitoring is essential because of the risk of:
Late displacement and coxa vara.
Type IV
Intertrochanteric fractures are generally treated with stable fixation appropriate to the child’s size and fracture pattern.
A pediatric hip compression screw or similar fixed-angle device may be used.
Surgical Technique
Imaging
A radiolucent or fracture table with fluoroscopic image intensification is typically used.
Reduction Maneuver
Common reduction principles include:
Longitudinal traction and correction of external rotation, usually with internal rotation.
Acceptable Reduction
No significant translation across the width of the femoral neck should be accepted.
Residual displacement predisposes to progressive varus and nonunion.
Surgical Approaches
For intracapsular reduction of Type II and III fractures, exposure may be obtained through a proximal extension of the tensor fascia lata–gluteal interval or another suitable approach.
Type I and very proximal Type II injuries may require an anterior iliofemoral approach.
Instrumentation
Types I–III
Fixation often uses 2–3 cannulated screws or smooth pins, sized appropriately for the child’s age and anatomy.
Type IV
A pediatric hip compression screw with side plate or other fixed-angle construct may be used.
Age-Specific Management
Ages 7–12 Years
Pediatric hip screw fixation may be combined with a hip spica cast for approximately 8–12 weeks, depending on stability.
Age 13 Years and Older
Older adolescents may often be treated similarly to adults.
A hip screw and side plate or other adult-type fixation may cross the physis if required for stability.
Postoperative casting is usually unnecessary when fixation is secure.
Timing of Surgery
Operative management should generally be performed urgently, usually within 24 hours.
Type I With Dislocation
A Type I injury accompanied by hip dislocation requires immediate treatment because of the extreme risk to femoral-head vascularity.
Osteonecrosis and Timing
Although early reduction is strongly favored, studies have not demonstrated a perfectly consistent relationship between exact operative timing and osteonecrosis.
Initial vascular injury and fracture displacement appear to be major determinants.
Implant Removal
There is no universally mandatory time for implant removal.
When removal is planned, it is commonly performed after solid healing, often within approximately 12–18 months.
Potential reasons include prevention of bony overgrowth around the implant or later stress concentration and refracture.
Neonatal Epiphysiolysis
Neonatal proximal femoral epiphyseal separation is a special injury pattern.
Acute Recognition
If diagnosed before callus forms, gentle skin traction may be used to restore alignment.
Delayed Recognition
If callus is already visible, simple immobilization and observation are usually preferred.
Open reduction is generally avoided because neonatal hips have substantial remodeling potential if the physis remains viable.
Follow-Up
Close monitoring is necessary for growth disturbance and osteonecrosis, although the incidence of osteonecrosis in this particular neonatal pattern may be relatively low.
Follow-Up
The long-term outcome is largely determined by the degree of injury to the femoral-head blood supply.
These patients require prolonged follow-up because major complications may not become apparent for months or years.
Prognosis
The prognosis depends on:
Delbet type, initial displacement, patient age, quality of reduction, vascular injury, development of osteonecrosis, and occurrence of growth arrest.
Complications
Complications occur in as many as approximately 60% of pediatric femoral-neck fractures in some historical series.
The unique and changing blood supply of the developing proximal femur is responsible for many of these problems.
Osteonecrosis
Osteonecrosis is the most common and most devastating complication.
It may involve:
The epiphysis alone, both epiphysis and metaphysis, or the metaphysis with relative sparing of the femoral head.
Incidence
Historical series report osteonecrosis in approximately 42% of pediatric femoral-neck fractures overall, usually becoming apparent within about 9–12 months.
Approximate rates by Delbet type have been reported as:
Type I: nearly 100%
Type II: approximately 52%
Type III: approximately 27%
Type IV: approximately 14%
Rates vary among modern series.
Risk Factors for Osteonecrosis
Factors associated with greater risk include:
Initial fracture displacement, Delbet Types I and II, associated dislocation, and age greater than approximately 10 years.
Ratliff Classification of Osteonecrosis
Ratliff Type I
There is total involvement and collapse of the femoral head.
This carries the worst prognosis and historically represents the most common pattern.
It reflects widespread injury to the lateral epiphyseal blood supply.
Ratliff Type II
Only part of the epiphysis is involved, with limited or minimal collapse.
This may reflect more localized vascular injury, often affecting the anterolateral femoral head.
Ratliff Type III
There is increased sclerosis of the femoral neck from the fracture line to the physis, while the femoral head itself is relatively spared.
This pattern is associated with metaphyseal vascular injury.
Treatment of Osteonecrosis
The goals are to preserve:
Hip motion, femoral-head containment, and joint congruity.
Selected patients may benefit from corrective osteotomy that rotates a less-deformed portion of the femoral head into the weight-bearing zone.
Nonunion
Nonunion occurs in approximately 5–8% of pediatric femoral-neck fractures.
Risk Factors
Closed treatment of displaced Types II and III has historically been associated with higher rates of:
Nonunion, late displacement, and coxa vara.
Stable internal fixation after accurate reduction lowers the risk by preventing varus collapse.
Coxa Vara
Coxa vara may develop because of:
Malunion or growth arrest of the proximal femoral physis.
Remodeling
If the femoral neck-shaft angle is less than approximately 110°, spontaneous remodeling is unlikely to provide adequate correction.
Treatment
In the absence of severe osteonecrosis, a subtrochanteric valgus osteotomy with internal fixation, sometimes combined with bone grafting, can provide good long-term correction.
Premature Physeal Closure
Premature closure of the proximal femoral physis may occur even when implants do not cross the growth plate.
It is often related to the original injury or associated osteonecrosis.
Limb-Length Discrepancy
The proximal femoral physis contributes approximately 3 mm of longitudinal growth per year, representing about 15% of total lower-extremity length growth.
Isolated closure may therefore cause only modest shortening, but combined osteonecrosis and growth disturbance can result in a more substantial limb-length discrepancy.
Growth Monitoring
Children with premature physeal closure should be followed with serial assessment of limb length.
Long-standing monitoring may include:
Standing limb-length imaging or scanograms and bone-age assessment using hand and wrist radiographs.
Contralateral Epiphysiodesis
If a clinically significant projected limb-length inequality develops, contralateral epiphysiodesis may be considered at the appropriate time.
Trochanteric Overgrowth
Growth disturbance can occasionally produce symptomatic relative overgrowth of the greater trochanter.
In selected children older than approximately 8 years, trochanteric advancement or transfer may be considered if abductor mechanics are substantially impaired.
Patient Monitoring
Children with proximal femoral fractures require long-term surveillance for:
Osteonecrosis, nonunion, coxa vara, physeal arrest, limb-length discrepancy, trochanteric overgrowth, deformity, loss of hip motion, and secondary degenerative arthritis.
Follow-up should include serial physical examination and radiographs, particularly throughout the first year, when osteonecrosis often first becomes evident, and subsequently through skeletal growth when significant physeal injury has occurred.
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Orthopaedic Surgery - Traumatic Hip Dislocation
Basics
Traumatic hip dislocation is an orthopaedic emergency in which the femoral head is completely displaced from the acetabulum.
These injuries usually result from high-energy trauma and may occur as an isolated dislocation or as a fracture-dislocation involving the acetabulum, femoral head, or femoral neck.
Because the mechanism is often severe, a complete trauma assessment is essential.
Associated Trauma
Up to approximately 50% of patients may have additional fractures or other major injuries at the time of presentation.
Associated acetabular, femoral head, femoral neck, knee, foot, spinal, thoracic, and abdominal injuries should be actively sought.
Classification
Traumatic hip dislocations are classified primarily according to the direction of displacement.
They may be:
Posterior or anterior, with further description according to associated fractures of the femoral head, femoral neck, or acetabulum.
Prevention
Seat-belt use together with appropriate air-bag protection reduces the risk and severity of injuries sustained in motor vehicle collisions.
Epidemiology
Traumatic hip dislocation is most commonly encountered in young adults exposed to high-energy trauma.
Males are affected more frequently than females.
Posterior Dislocation
Posterior dislocations account for approximately 85–90% of traumatic hip dislocations.
Anterior Dislocation
Anterior dislocations represent approximately 10–15% of cases.
Risk Factors
Major risk factors include:
Motor vehicle collisions, falls from substantial height, pedestrian-versus-vehicle injuries, industrial trauma, and high-energy sports accidents.
Etiology
Approximately 70–90% of traumatic hip dislocations have historically been associated with motor vehicle collisions.
Dashboard Injury
A classic mechanism for posterior dislocation occurs when the patient is seated with the hip and knee flexed.
During rapid deceleration, the knee strikes the dashboard, transmitting an axial force through the femur.
This drives the femoral head posteriorly out of the acetabulum.
Other Mechanisms
Other causes include:
Falls from height, industrial accidents, pedestrian injuries, motorcycle trauma, and sporting injuries.
The direction of force and position of the hip at impact determine whether the femoral head dislocates anteriorly or posteriorly.
Associated Conditions
Because traumatic hip dislocations usually result from high-energy injury, associated abnormalities are common.
Sciatic Nerve Injury
The sciatic nerve is particularly vulnerable in posterior dislocation.
Sciatic nerve dysfunction has been reported in approximately 10–20% of posterior dislocations.
The peroneal division is affected most commonly.
Relationship to Reduction Delay
Prolonged dislocation may increase the likelihood of neurologic injury and other complications.
Musculoskeletal Injuries
Common associated injuries include:
Femoral head fracture, femoral neck fracture, acetabular fracture, ipsilateral knee injury, and foot or ankle injury.
Other Trauma
Chest, abdominal, spinal, and head injuries may also occur and can take priority during initial resuscitation.
Diagnosis
Signs and Symptoms
Patients usually have severe hip pain and inability to move or bear weight on the affected extremity.
Numbness or paresthesias may occur when the sciatic nerve is injured.
Posterior Dislocation Position
The classic posture of a posteriorly dislocated hip is:
Flexion, adduction, and internal rotation.
The affected extremity also typically appears shortened.
Anterior Dislocation Position
An anteriorly dislocated hip usually rests in:
Abduction and marked external rotation, often with some degree of flexion or extension depending on the subtype.
Altered Mental Status
Some patients are obtunded or unconscious because of associated trauma, intoxication, or head injury.
The diagnosis therefore cannot depend solely on patient-reported symptoms.
Careful inspection of limb position and systematic trauma imaging are essential.
Physical Examination
Trauma Survey
A full primary and secondary trauma survey should be performed because associated injuries are common and may be life-threatening.
Limb Position
The position, shortening, and rotational alignment of the lower extremity should be documented before reduction.
Neurovascular Examination
Motor, sensory, and vascular findings should be documented before and after reduction.
Sciatic Nerve
Particular attention should be given to sciatic nerve function.
Motor testing should include:
Ankle dorsiflexion, plantarflexion, great-toe extension, and ankle eversion.
Sensory testing should include the dorsum and plantar aspects of the foot according to tibial and peroneal nerve distribution.
Vascular Status
Distal pulses, capillary refill, skin temperature, and overall limb perfusion should be assessed.
Laboratory Tests
Laboratory studies are directed by the overall trauma evaluation rather than the hip dislocation itself.
A standard trauma panel may be obtained according to injury severity and anticipated operative management.
Imaging
Initial Trauma Radiographs
Imaging commonly includes an AP pelvis as part of the initial trauma evaluation.
Additional imaging is determined by associated injuries.
Hip Radiographs
Dedicated radiographs may include AP and cross-table lateral views.
A cross-table lateral can help establish whether the dislocation is anterior or posterior.
Radiographic Appearance
In a posterior dislocation, projection may make the displaced femoral head appear relatively smaller than the opposite side.
In an anterior dislocation, it may appear somewhat larger.
These findings are secondary to projection and should not replace assessment of the actual displacement pattern.
Associated Acetabular Injury
The acetabulum should be inspected carefully for fracture fragments, wall disruption, or joint incongruity.
When an acetabular fracture is suspected, Judet oblique views may provide additional information, although CT now plays the major role in defining fracture anatomy.
Femoral Neck
The femoral neck must be scrutinized for associated fracture.
An unrecognized femoral neck fracture can be displaced or worsened by forceful reduction.
Intra-Articular Fragments
The joint should be evaluated for:
Osteochondral fragments, femoral-head fractures, acetabular fragments, and asymmetric joint-space widening suggesting an incarcerated fragment.
CT
CT is routinely obtained after reduction in many modern trauma protocols, particularly when there is concern for associated fracture or nonconcentric reduction.
Post-Reduction CT
CT can demonstrate:
Small intra-articular fragments, femoral-head fractures, acetabular fractures, subtle femoral-neck injury, joint congruity, and incarcerated osteochondral material.
Before Open Reduction
If closed reduction fails and open reduction is required, CT may help define fracture anatomy when this can be obtained without creating an unsafe delay.
MRI
MRI is not routinely required during the acute reduction phase.
It may later be useful for evaluating:
Osteonecrosis, cartilage injury, labral injury, occult fracture, or persistent unexplained symptoms.
Differential Diagnosis
Important competing or associated diagnoses include:
Femoral neck fracture, femoral head fracture, acetabular fracture, pelvic fracture, and severe proximal femoral trauma without dislocation.
Treatment
Initial Stabilization
Initial management follows standard trauma principles.
Life-threatening injuries are addressed first.
Once the patient is sufficiently stable, the dislocated hip should be reduced urgently.
Orthopaedic Emergency
Traumatic hip dislocation requires emergent orthopaedic reduction because prolonged displacement increases the risk of femoral-head osteonecrosis and other complications.
Timing
Reduction should be performed as soon as safely possible, ideally within approximately 6 hours of injury when circumstances permit.
Closed Reduction
Closed reduction is the preferred initial treatment when there is no contraindication.
Sedation or Anesthesia
Adequate muscle relaxation is essential.
Reduction may be performed under:
Procedural sedation, regional anesthesia in selected circumstances, or general anesthesia with muscle relaxation.
Reduction Technique
Most techniques use longitudinal or inline traction combined with controlled manipulation of the hip.
The specific maneuver depends on the direction of dislocation and surgeon preference.
Forceful repeated attempts should be avoided.
Contraindications to Forceful Closed Reduction
Reduction should be approached cautiously when there is concern for:
Associated femoral neck fracture, large displaced fracture fragment, or other injury in which manipulation could worsen the fracture.
Stability Assessment
After reduction, the hip should be gently assessed for stability through a safe range of motion.
Instability may suggest an associated acetabular wall fracture, capsular injury, or intra-articular fragment.
Post-Reduction Examination
The neurovascular examination must be repeated immediately after reduction.
Any new deficit should be documented and urgently evaluated.
Post-Reduction Radiographs
Plain radiographs should confirm:
Reduction of the femoral head, restoration of joint congruity, and absence of obvious new fracture displacement.
Post-Reduction CT
CT is then used to assess the congruity of the reduction and to identify occult fracture fragments or intra-articular debris.
Traction
Routine prolonged traction is not required for most simple, stable hip dislocations after successful concentric reduction.
Temporary traction may be considered in selected unstable injuries, painful fracture-dislocations, or situations awaiting definitive fixation.
Definitive Management
After the hip is reduced, management becomes focused on:
Associated fractures, joint stability, intra-articular fragments, cartilage injury, and the patient’s overall trauma condition.
Indications for Surgery
Operative treatment may be required for:
Irreducible dislocation, nonconcentric reduction, incarcerated intra-articular fragments, associated femoral-head fracture requiring fixation or excision, acetabular fracture requiring stabilization, femoral-neck fracture, or persistent post-reduction instability.
Open Reduction
If a satisfactory closed reduction cannot be achieved, open reduction is indicated.
The surgical approach depends on the direction of dislocation, associated fracture pattern, and surgeon preference.
Associated Acetabular Fracture
Acetabular fractures are treated according to displacement, stability, articular congruity, and fracture pattern.
Some require open reduction and internal fixation.
Associated Femoral-Head Fracture
Treatment depends on fragment size, location, displacement, and whether the fragment contributes to the weight-bearing surface.
Options may include:
Fixation, excision of a small nonessential fragment, or more extensive reconstruction.
Activity
Weight-bearing recommendations depend on whether the injury is a simple dislocation or a fracture-dislocation.
Simple Stable Dislocation
After a concentric stable reduction without significant fracture, early protected mobilization and range of motion are generally encouraged.
Weight bearing may be advanced according to the injury pattern and treating surgeon’s protocol.
Fracture-Dislocation
Associated femoral-head or acetabular fractures often require more prolonged protected or restricted weight bearing.
Physical Therapy
Physical therapy commonly includes:
Gait training, protected weight bearing when required, progressive hip range of motion, and later strengthening.
Early controlled motion helps reduce stiffness.
Medication
Analgesics are required during the acute phase.
Opioid medications may be necessary initially because traumatic hip dislocation is extremely painful.
Venous thromboembolism prophylaxis should be considered according to the patient’s overall trauma burden, mobility, and associated injuries.
Follow-Up
Prognosis of Simple Posterior Dislocation
Approximately 70–80% of uncomplicated posterior hip dislocations without associated fracture have historically achieved good or excellent long-term outcomes.
Fracture-Dislocation
Outcome is less favorable when posterior dislocation is associated with acetabular or femoral-head fracture because cartilage injury, instability, and post-traumatic arthritis are more common.
Anterior Dislocation
Anterior dislocations may be associated with substantial femoral-head impaction or cartilage injury.
Long-term outcome depends largely on the degree of articular damage and associated fracture.
Effect of Delayed Reduction
Prognosis worsens as the duration of dislocation increases.
Reduction delayed beyond several hours, particularly beyond approximately 6–12 hours, is associated with greater concern for femoral-head osteonecrosis.
Complications
Post-Traumatic Arthritis
Post-traumatic osteoarthritis is the most common major long-term complication.
Risk is highest in patients with:
Acetabular fractures, femoral-head fractures, chondral injury, nonconcentric reduction, or osteonecrosis.
Osteonecrosis
Avascular necrosis of the femoral head may occur because the injury disrupts its blood supply.
Reported rates vary widely, historically ranging from approximately 1–17% or more depending on injury severity and delay to reduction.
Timing of Reduction
The risk of osteonecrosis increases with prolonged dislocation.
Even prompt reduction cannot eliminate the risk completely because vascular damage may occur at the moment of injury.
Sciatic Nerve Injury
Sciatic nerve palsy occurs most often with posterior dislocation.
Reported rates are approximately 8–20%.
Peroneal Division
The common peroneal component of the sciatic nerve is affected more frequently than the tibial component.
Patients may develop weakness of ankle dorsiflexion and great-toe extension together with sensory loss over the dorsum of the foot.
Electrodiagnostic Testing
If neurologic deficits persist, electromyography and nerve-conduction studies may be obtained after several weeks, often around 3–4 weeks or later, to establish a baseline and aid prognosis.
Recovery
Neurologic recovery is variable.
Some patients recover completely, whereas others have persistent weakness or sensory loss.
Recurrent Dislocation
Recurrent traumatic hip dislocation is uncommon, historically occurring in fewer than approximately 2% of patients.
Heterotopic Ossification
Heterotopic ossification may develop after severe hip trauma or surgery, although it is less common after uncomplicated dislocation alone.
Chondral and Labral Injury
Damage to the acetabular labrum and articular cartilage may occur at the time of dislocation and can contribute to persistent pain and later arthritis even after successful reduction.
Patient Monitoring
Patients require long-term follow-up because osteonecrosis and post-traumatic arthritis may appear months or years after the original injury.
First Year
Clinical examination and serial radiographs may be obtained approximately every 3–4 months during the first year, depending on injury severity.
MRI for Osteonecrosis
MRI is more sensitive than radiographs for early detection of femoral-head osteonecrosis and may be used when symptoms, examination, or radiographs raise concern.
Long-Term Surveillance
Follow-up should assess:
Pain, gait, hip range of motion, neurologic function, femoral-head contour, joint congruity, osteonecrosis, and development of post-traumatic arthritis.
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Orthopaedic Surgery - Hip Avascular Necrosis
Basics
Hip avascular necrosis, also called osteonecrosis of the femoral head, is a condition in which the bone and marrow of the femoral head die because of compromised blood supply.
As the necrotic subchondral bone loses structural strength, the femoral head may collapse. Once collapse occurs, the articular surface becomes incongruent and secondary degenerative arthritis commonly develops.
Classification
Several staging systems are used to describe the extent and progression of femoral-head osteonecrosis.
Ficat and Arlet Classification
Stage I
Plain radiographs are normal, but MRI or other advanced imaging demonstrates osteonecrosis.
There is no collapse of the femoral head.
Stage II
Radiographs show sclerotic or cystic changes within the femoral head, but the articular surface remains intact without subchondral collapse.
Stage III
A subchondral fracture develops beneath the articular surface.
This may appear radiographically as the characteristic crescent sign.
Femoral-head collapse is beginning.
Stage IV
The femoral head has collapsed sufficiently to produce secondary degenerative changes of the hip joint, including joint-space narrowing and acetabular involvement.
Steinberg Classification
The Steinberg system expands on the Ficat and Arlet classification by incorporating lesion size and more detailed stages.
Stage 0
Plain radiographs and bone scintigraphy are normal.
Stage I
Plain radiographs remain normal, but bone scintigraphy or MRI demonstrates osteonecrosis.
Stage II
Radiographs demonstrate sclerosis or cyst formation without subchondral collapse.
Severity can be estimated according to the percentage of the femoral head involved:
A: mild, less than approximately 20%.
B: moderate, approximately 20–40%.
C: severe, greater than approximately 40%.
Stage III
A subchondral fracture or crescent sign is present without substantial flattening of the femoral head.
Extent may be described as:
A: mild, less than approximately 15%.
B: moderate, approximately 15–30%.
C: severe, greater than approximately 30%.
Stage IV
Flattening of the femoral head has occurred, but there is not yet major joint-space narrowing or acetabular involvement.
Severity is based on the amount of surface involvement and depression.
Stage V
Femoral-head flattening is accompanied by joint-space narrowing or acetabular involvement, indicating secondary degenerative arthritis.
Lesion Size
One of the most important prognostic findings on MRI or radiographs is the size and location of the necrotic segment.
Small lesions located away from the primary weight-bearing surface are less likely to collapse than large lesions involving the superior weight-bearing portion of the femoral head.
Prevention
When possible, modifiable risk factors should be addressed.
Corticosteroids
Systemic corticosteroids should be used only when the anticipated benefit for the underlying medical condition outweighs the risk of treatment-related complications.
When long-term corticosteroid therapy is necessary, the lowest effective dose should be used under the direction of the treating medical team.
Alcohol
Heavy alcohol consumption is an important risk factor and should be avoided.
Tobacco
Smoking may adversely affect bone and vascular health and should be discontinued.
Epidemiology
Osteonecrosis of the femoral head occurs more commonly in younger and middle-aged adults than typical primary hip osteoarthritis.
Males are affected more frequently in many series.
Arthroplasty Burden
Osteonecrosis accounts for a meaningful proportion of hip arthroplasties, historically estimated at approximately 5–10% in some series.
Risk Factors
Important risk factors include:
Systemic corticosteroid use, heavy alcohol consumption, hip dislocation, displaced femoral neck fracture, previous surgical disruption of the hip blood supply, decompression sickness, thrombophilic disorders, antiphospholipid syndrome, systemic lupus erythematosus, sickle cell disease, HIV infection, and certain abnormalities of coagulation.
Trauma
Traumatic interruption of the blood supply to the femoral head is a major cause.
Important mechanisms include:
Hip dislocation, displaced femoral neck fracture, and surgical injury to femoral-head vascularity.
Hypercoagulable States
Abnormalities that promote thrombosis may compromise the femoral-head microcirculation.
Examples include:
Protein C or protein S deficiency, activated protein C resistance, antiphospholipid syndrome, and other thrombophilic disorders.
Hematologic Disease
Sickle cell disease is an important cause because repeated vascular occlusion can impair femoral-head perfusion.
Decompression Sickness
Caisson disease or decompression sickness in divers can lead to intravascular gas formation and compromise of osseous blood flow.
Genetics
There is no single inherited pattern for most cases of femoral-head osteonecrosis.
However, inherited thrombophilic disorders may predispose certain patients.
Etiology
The final common mechanism is interruption or compromise of blood flow to the femoral head, followed by ischemia and death of bone and marrow elements.
Corticosteroid-Associated Osteonecrosis
High cumulative exposure to systemic corticosteroids is a well-recognized nontraumatic cause.
The exact mechanism is multifactorial and may involve lipid metabolism, marrow pressure, vascular compromise, and altered bone-cell function.
Alcohol-Associated Osteonecrosis
Heavy alcohol consumption may contribute through lipid abnormalities, marrow changes, and impaired microvascular blood flow.
Gaucher Disease
Marrow infiltration and increased intraosseous pressure can impair circulation in disorders such as Gaucher disease.
Systemic Lupus Erythematosus
Patients with lupus have increased risk related to both the disease process and frequent corticosteroid exposure.
Associated Conditions
HIV infection has been associated with an increased risk of osteonecrosis, potentially related to multiple factors including medication exposure, metabolic abnormalities, and thrombophilia.
Diagnosis
Signs and Symptoms
Some patients are initially asymptomatic, especially in the early pre-collapse stages.
When symptoms develop, they usually reflect irritation or structural failure of the femoral head.
Groin Pain
The most common symptom is deep groin pain.
Pain may radiate into the buttock, thigh, or knee.
Limp
A limp is common as pain increases.
Functional Limitation
Patients may have difficulty walking, running, climbing stairs, or participating in sports.
Advanced disease can substantially impair normal ambulation.
History
Before femoral-head collapse, patients may report gradually increasing atraumatic hip pain.
The history should specifically address corticosteroid exposure, alcohol use, trauma, hematologic disease, autoimmune disease, diving history, and thrombophilic conditions.
After Collapse
Once collapse occurs, the symptoms increasingly resemble those of hip osteoarthritis, including persistent groin pain, stiffness, reduced walking tolerance, and progressive loss of motion.
Physical Examination
Gait
An antalgic limp is common.
Advanced disease may produce compensatory gait changes related to pain, weakness, or loss of hip motion.
Range of Motion
Hip range of motion should be compared with the contralateral side.
Internal Rotation
Painful and reduced internal rotation is a common finding, although it is not specific to osteonecrosis and may occur with many intra-articular hip disorders.
Flexion and Abduction
Flexion and abduction may also become limited as the disease progresses.
Laboratory Tests
There is no serum laboratory test that confirms osteonecrosis.
Coagulation Evaluation
In patients with unexplained or idiopathic osteonecrosis, especially when bilateral or multifocal, evaluation for an underlying thrombophilic disorder may be considered.
Imaging
Plain Radiographs
Initial imaging should include AP and lateral views of the affected hip, usually with an AP pelvis.
Radiographs are particularly useful for detecting:
Subchondral sclerosis, cysts, crescent sign, femoral-head flattening, and secondary arthritis.
Early Disease
Radiographs can remain normal in early osteonecrosis.
A normal radiograph does not exclude the diagnosis when clinical suspicion is high.
MRI
MRI is the most sensitive imaging study for detecting early femoral-head osteonecrosis.
It can identify disease before structural changes appear on radiographs.
T1-Weighted Imaging
On T1-weighted sequences, osteonecrosis often appears as a geographic or wedge-shaped area of low signal intensity.
T2-Weighted Imaging
Fluid-sensitive sequences may demonstrate surrounding high signal related to reactive change or bone marrow edema.
Double-Line Sign
A characteristic MRI finding is the double-line sign, in which a low-signal rim is bordered by a relatively high-signal inner line on T2-weighted images.
Bilateral Imaging
Because nontraumatic osteonecrosis can affect both hips, MRI evaluation of the contralateral femoral head may be appropriate when risk factors are substantial.
Pathological Findings
The final pathologic feature is necrosis of both the osseous trabeculae and marrow elements.
As healing attempts occur at the margin of the lesion, structurally weakened necrotic bone may fail under repetitive weight bearing.
This leads to subchondral fracture and eventual collapse.
Differential Diagnosis
Any process that produces hip pain can mimic osteonecrosis.
Important alternatives include:
Septic arthritis, proximal femoral osteomyelitis, soft-tissue abscess, femoral-neck or femoral-shaft stress fracture, early osteoarthritis, femoroacetabular impingement, and chondrolysis.
Treatment
General Principles
Treatment depends on:
Patient age, symptoms, lesion size, location, cause, degree of femoral-head collapse, and presence of secondary arthritis.
The major distinction is between pre-collapse disease, in which hip-preserving treatment may still be possible, and post-collapse disease, in which arthroplasty is often required.
Remove or Modify the Cause
Whenever possible, reversible risk factors should be addressed.
Corticosteroids
Unnecessary corticosteroid exposure should be reduced or discontinued under the supervision of the physician treating the underlying disease.
Alcohol
Heavy alcohol intake should be stopped.
Tobacco
Smoking cessation should be encouraged.
Activity Modification
Reducing repetitive impact loading may decrease symptoms during early disease.
However, activity modification alone generally does not reliably prevent progression of a large necrotic lesion.
Cane or Crutches
A cane held in the opposite hand can reduce load across the affected hip.
Two crutches may be used temporarily for greater unloading.
Physical Therapy
Physical therapy is useful primarily for:
Gait training, maintenance of motion, strengthening of surrounding musculature, and instruction in assistive-device use.
Forceful weight-bearing exercise over a symptomatic necrotic femoral head should be avoided.
Medication
There is no universally effective medication that reliably reverses established osteonecrosis.
Anticoagulation
Anticoagulation may be considered in carefully selected patients with a documented thrombophilic disorder and early-stage disease, under specialist supervision.
It is not routine treatment for all cases.
Surgery
Surgical treatment is tailored to the stage of disease and the patient’s age and functional demands.
In younger patients with pre-collapse disease, preservation of the native femoral head is emphasized whenever feasible.
Once substantial collapse and arthritis are present, total hip arthroplasty becomes the most reliable treatment.
Core Decompression
Core decompression involves drilling one or more channels into the necrotic area of the femoral head.
The procedure is intended to reduce intraosseous pressure, stimulate vascular ingrowth, and promote healing.
Indications
Core decompression is most effective in early pre-collapse disease with relatively small lesions.
Outcomes are less favorable once substantial subchondral collapse has occurred.
Success
Older series reported success rates of roughly 50–60%, although results vary considerably according to lesion size, stage, and patient selection.
Bone-Grafting Procedures
Various procedures have been developed to support the necrotic femoral head and introduce biologically active bone.
Vascularized Fibular Graft
A vascularized fibular graft may be used in selected young patients with pre-collapse or early-collapse disease.
The operation is technically demanding, and indications vary among centers.
Nonvascularized Bone Grafting
Other techniques include bone grafting through a core tract or through a limited opening in the femoral head or neck.
Trapdoor Procedure
The so-called trapdoor procedure provides direct access to the necrotic segment for removal of dead bone and grafting.
It is used selectively and is not a routine treatment.
Total Hip Arthroplasty
Total hip arthroplasty is the standard treatment for advanced femoral-head collapse with secondary arthritis and disabling symptoms.
Components
Modern total hip replacement typically uses a metal or ceramic femoral head articulating against a highly cross-linked polyethylene or ceramic bearing surface.
Metal-on-metal bearings are generally avoided in contemporary practice because of concerns regarding metal wear debris and adverse local tissue reactions.
Hip Resurfacing
Hip resurfacing has been used in selected younger patients, but indications are limited and the procedure is far less commonly performed than conventional total hip arthroplasty.
Follow-Up
Prognosis
The prognosis depends heavily on whether the femoral head has already collapsed.
Pre-Collapse Disease
Small lesions detected early may remain stable or respond to hip-preserving treatment.
Large lesions involving the weight-bearing dome have a substantially greater risk of progression.
Post-Collapse Disease
Once structural collapse is present, progression toward secondary arthritis is common.
Many symptomatic patients eventually require total hip arthroplasty.
Nonoperative Treatment
Nonoperative management alone frequently fails to prevent progression in symptomatic, structurally significant disease.
It may nevertheless be appropriate for small asymptomatic lesions or patients who are poor surgical candidates.
Complications of Hip-Preserving Procedures
Potential complications include:
Failure of the lesion to heal, continued femoral-head collapse, progression to arthritis, fracture, infection, and need for later arthroplasty.
Complications of Hip Surgery
General operative risks include:
Wound-healing problems, infection, blood loss, neurovascular injury, deep venous thrombosis, and pulmonary embolism.
Complications of Total Hip Arthroplasty
Potential complications include:
Dislocation, infection, periprosthetic fracture, nerve injury, venous thromboembolism, implant wear, osteolysis, and aseptic loosening.
Modern complication rates vary substantially according to patient factors, implant type, and length of follow-up.
Patient Monitoring
Patients with early-stage osteonecrosis should be followed clinically and radiographically for evidence of femoral-head collapse.
An initial follow-up interval of approximately 3–4 months during the first year may be appropriate in higher-risk lesions.
Thereafter, annual or symptom-driven follow-up may be used depending on stability.
Monitoring should assess:
Pain, gait, hip range of motion, lesion size, development of the crescent sign, femoral-head contour, and progression to secondary arthritis.
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Orthopaedic Surgery - Hip Arthritis
Basics
Hip arthritis results from progressive loss of the articular cartilage covering the femoral head and acetabulum.
As cartilage deteriorates, the underlying subchondral bone is increasingly exposed to abnormal mechanical loading. This produces pain with weight bearing, progressive restriction of motion, gait disturbance, and eventually substantial functional disability.
Prevention and Risk Reduction
Although not all hip arthritis can be prevented, symptoms and mechanical stress may be reduced through:
Low-impact exercise, activity modification, maintenance of healthy body weight, and avoidance of repetitive high-impact loading when symptoms are present.
Suitable activities often include swimming, cycling, and walking within a tolerable range.
Epidemiology
Hip arthritis is a common cause of pain and disability in adults.
Some hips appear particularly susceptible because of subtle or overt abnormalities of joint anatomy, including developmental dysplasia and femoroacetabular impingement.
Prevalence
Arthritis overall affects a substantial proportion of the population, with older estimates suggesting that approximately 12% of the U.S. population has some form of arthritis.
The prevalence of symptomatic hip osteoarthritis increases with age.
Risk Factors
Important risk factors and underlying conditions include:
Previous trauma, osteonecrosis, infection, hemophilia, developmental hip dysplasia, femoroacetabular impingement, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, and inflammatory arthritides.
Inflammatory Arthritis
Inflammatory disorders that may involve the hip include:
Rheumatoid arthritis, systemic lupus erythematosus, and psoriatic arthritis.
Etiology
The exact cause of primary osteoarthritis is multifactorial and incompletely understood.
Contributing factors probably include differences in cartilage biology, genetics, aging, loading patterns, and joint morphology.
Mechanical Factors
Abnormal hip alignment can increase focal contact stress.
Important examples include acetabular dysplasia and femoroacetabular impingement, both of which can lead to premature cartilage and labral damage.
Classification
Hip arthritis can be broadly divided into:
Primary osteoarthritis, inflammatory arthritis, and secondary osteoarthritis.
Primary Osteoarthritis
Primary osteoarthritis develops without a single clearly identifiable initiating disorder, although subtle structural abnormalities may still contribute.
Secondary Osteoarthritis
Secondary osteoarthritis results from an underlying condition such as:
Trauma, dysplasia, osteonecrosis, Perthes disease, slipped capital femoral epiphysis, infection, or femoroacetabular impingement.
Associated Conditions
Patients may also have degenerative disease elsewhere in the musculoskeletal system, particularly:
Lumbar degenerative disc disease and knee osteoarthritis.
These conditions may complicate localization of the primary source of pain.
Diagnosis
Signs and Symptoms
Patients usually present with a deep, diffuse ache around the hip.
The classic location is the anterior groin.
Pain Distribution
Pain may radiate into the:
Buttock, thigh, or knee, often along the medial side of the thigh.
In some patients, knee pain is the predominant complaint despite the underlying pathology being located in the hip.
Gait Symptoms
Patients frequently report:
Limping, fatigue with walking, reduced walking distance, and difficulty with prolonged standing.
Functional Limitation
As hip motion decreases, patients may have difficulty:
Tying shoes, putting on socks, cutting toenails, getting into or out of a car, climbing stairs, or rising from a low chair.
History
The pain of osteoarthritis usually develops gradually over months or years.
It is generally aggravated by activity and relieved by rest, particularly early in the disease.
Activity-Related Pain
Pain with walking, prolonged standing, or other weight-bearing activity is characteristic of hip arthritis.
Night Pain
Advanced osteoarthritis may produce pain at rest or at night.
However, new severe constant pain, especially with systemic symptoms or an atypical clinical pattern, should prompt consideration of infection, tumor, occult fracture, or another diagnosis.
Age
Primary osteoarthritis is most commonly encountered in adults older than approximately 50 years.
Hip arthritis in a younger patient should prompt evaluation for a secondary cause such as trauma, dysplasia, osteonecrosis, Perthes disease, SCFE, or femoroacetabular impingement.
Physical Examination
Range of Motion
Hip range of motion should be measured and compared with the opposite side.
Internal Rotation
Loss of internal rotation is one of the earliest and most characteristic findings of hip osteoarthritis.
Pain with internal rotation is also common.
Flexion
Hip flexion gradually becomes restricted as arthritis progresses.
Flexion Contracture
A fixed flexion contracture should be assessed because it can alter standing posture, pelvic tilt, and lumbar mechanics.
Gait
The patient should be observed for:
Antalgic gait, Trendelenburg pattern, reduced stance time, short stride, or other compensatory abnormalities.
Leg-Length Discrepancy
True and apparent leg lengths should be assessed.
Progressive joint-space loss, deformity, contracture, or pelvic tilt may create actual or functional limb shortening.
Muscle Strength
Hip abductor and flexor strength should be assessed.
Chronic pain and disuse can produce substantial muscle weakness.
Stinchfield Test
A resisted straight-leg raise, commonly called the Stinchfield test, places load across the hip joint.
Reproduction of groin or deep hip pain supports an intra-articular source.
Greater Trochanter Examination
The greater trochanter should be palpated for tenderness.
Localized lateral tenderness suggests greater trochanteric pain syndrome or trochanteric bursitis rather than isolated intra-articular arthritis.
Neurologic Examination
A careful neurologic examination is necessary because lumbar radiculopathy may mimic hip disease.
Straight-Leg Raise
The straight-leg raise test can help identify radicular symptoms, particularly those arising from the lumbar spine.
Spine and Pelvis
The lumbar spine should be examined for:
Tenderness, restricted motion, scoliosis, or radicular signs.
Pelvic tilt should also be assessed because it can affect apparent limb length and hip mechanics.
Laboratory Tests
Routine laboratory studies are generally unnecessary for uncomplicated osteoarthritis.
If inflammatory arthritis is suspected, appropriate rheumatologic testing should be obtained.
Inflammatory Arthritis Evaluation
Depending on the clinical context, studies may include:
ESR, C-reactive protein, rheumatoid factor, anti-CCP antibodies, and other disease-specific tests.
Imaging
Plain Radiographs
Plain radiographs are the first-line imaging study.
A typical evaluation includes an AP pelvis and dedicated AP and lateral views of the involved hip.
Radiographic Features
Characteristic findings include:
Joint-space narrowing, osteophyte formation, subchondral sclerosis, and subchondral cyst formation.
Advanced disease may also produce femoral head deformity and acetabular remodeling.
Lumbar Spine Radiographs
If radiculopathy or substantial spinal pathology is suspected, AP and lateral radiographs of the lumbosacral spine may be useful.
Bone Scintigraphy
Technetium bone scanning can occasionally help identify occult skeletal disease when the patient has severe unexplained pain and the source remains unclear.
Its use has decreased as MRI has become more widely available.
MRI
MRI is useful for evaluating disorders that may not be visible on plain radiographs.
It is particularly effective for detecting:
Osteonecrosis, occult fracture, bone marrow abnormalities, soft-tissue disease, labral pathology, and neoplasm.
The suspected region must be adequately included within the imaging field.
Diagnostic Injection
An intra-articular hip injection containing local anesthetic can be used diagnostically when the source of pain is uncertain.
Substantial temporary pain relief after injection supports the hip joint as the major pain generator.
Differential Diagnosis
The differential diagnosis of hip pain is extensive.
Neoplasm
In younger patients, important malignant bone tumors include:
Osteosarcoma and Ewing sarcoma.
In older adults, consideration should be given to:
Metastatic bone disease and multiple myeloma.
Femoral Neck Stress Fracture
Stress fractures should be considered in:
Runners, military recruits, patients with osteoporosis, and individuals with sudden increases in physical activity.
Greater Trochanteric Pain Syndrome
Lateral hip pain with focal tenderness over the greater trochanter suggests pathology outside the hip joint.
Lumbar Radiculopathy
Pain radiating below the knee, neurologic symptoms, or positive nerve-tension testing increases suspicion for a spinal source.
Treatment
General Principles
Initial treatment is usually nonoperative.
The main goals are to reduce pain, maintain mobility, preserve strength, and delay or avoid surgery when symptoms remain manageable.
Activity Modification
Activities that consistently worsen symptoms should be reduced or modified.
Running, repetitive impact loading, deep squatting, and heavy lifting may need to be limited.
Low-impact activities are generally better tolerated.
Weight Reduction
Weight loss can reduce joint loading and improve mobility in overweight patients.
It may also reduce perioperative risk if arthroplasty is ultimately required.
Cane Use
A cane should generally be held in the hand opposite the affected hip.
This reduces hip abductor demand and can decrease joint reaction forces during walking.
Physical Therapy
Physical therapy may help maintain:
Hip range of motion, muscle strength, gait efficiency, and overall mobility.
Contracture Prevention
Stretching and range-of-motion exercises can help delay development of fixed hip contractures.
Strengthening
Strengthening the hip abductors, extensors, flexors, and surrounding lower-extremity musculature may improve function and prepare the patient for later surgery if necessary.
Medication
Acetaminophen
Acetaminophen may provide symptomatic relief, particularly in patients who cannot take NSAIDs.
NSAIDs
NSAIDs are commonly used for pain relief when there are no contraindications.
They should be used at the lowest effective dose for an appropriate duration, particularly in patients with gastrointestinal, renal, or cardiovascular risk.
Intra-Articular Corticosteroid Injection
Occasional image-guided intra-articular corticosteroid injections may provide temporary relief in selected patients.
They are not a definitive treatment for cartilage loss.
Glucosamine
Glucosamine has been used by some patients with osteoarthritis, although evidence for clinically meaningful benefit in hip osteoarthritis remains inconsistent.
Complementary and Alternative Therapies
A variety of supplements and topical therapies have been studied for osteoarthritis.
Older reports have suggested possible benefit from agents such as:
Devil’s claw, avocado-soybean unsaponifiables, capsaicin, and certain herbal anti-inflammatory preparations.
Evidence is variable, and these products should not replace established treatments.
There is limited evidence supporting magnet or laser therapy, while the role of acupuncture remains uncertain.
Surgery
Surgery is considered when pain and functional limitation remain substantial despite appropriate nonoperative treatment.
Osteonecrosis
In selected patients with early femoral head osteonecrosis before collapse, core decompression may be considered.
Hip-Preserving Osteotomy
Young patients with structural abnormalities may benefit from corrective osteotomy.
Acetabular Dysplasia
A periacetabular osteotomy can improve femoral head coverage and redistribute joint loading in appropriately selected patients with symptomatic dysplasia and preserved cartilage.
Proximal Femoral Deformity
Femoral osteotomy may be useful in selected deformities of the proximal femur.
Femoroacetabular Impingement
Young patients with symptomatic femoroacetabular impingement and limited arthritic change may benefit from procedures that reshape the femoral head-neck junction, acetabulum, or both.
Hip Arthrodesis
Hip fusion has historically been used in selected young, highly active patients when arthroplasty was undesirable.
It is now performed infrequently because of its effects on the lumbar spine, ipsilateral knee, and gait.
Total Hip Arthroplasty
Total hip replacement is the principal surgical treatment for advanced symptomatic hip arthritis.
The diseased femoral head and acetabular cartilage are replaced with prosthetic components.
Follow-Up
Prognosis With Nonoperative Treatment
Patients with mild or early arthritis may obtain substantial symptom relief from:
Activity modification, weight reduction, analgesics, NSAIDs, physical therapy, and assistive devices.
Prognosis After Total Hip Arthroplasty
The prognosis after modern total hip replacement is generally excellent.
Most appropriately selected patients achieve:
Major pain relief, improved range of motion, better walking ability, and substantial improvement in overall function.
Complications of Untreated or Progressive Hip Arthritis
Progressive disease may lead to:
Hip stiffness, flexion contracture, limp, leg-length discrepancy, muscle weakness, reduced walking tolerance, and inability to perform activities of daily living.
Complications of Total Hip Arthroplasty
Potential complications include:
Infection, dislocation, periprosthetic femoral or acetabular fracture, nerve palsy, deep venous thrombosis, pulmonary embolism, heterotopic ossification, implant loosening, liner wear, osteolysis, and stiffness.
Dislocation
Dislocation is an important complication and is generally more common after revision arthroplasty than after uncomplicated primary hip replacement.
Nerve Injury
When nerve palsy occurs, the sciatic nerve is the nerve most commonly affected.
Implant Wear and Osteolysis
Long-term prosthetic wear can generate particulate debris that contributes to bone resorption around the implant.
This process can eventually cause loosening and may require revision surgery.
Patient Monitoring
Patients with hip arthritis should be reassessed when symptoms worsen, function declines, or the pattern of pain changes.
Follow-up should monitor:
Pain severity, walking tolerance, range of motion, gait, muscle strength, limb length, response to nonoperative treatment, and radiographic progression when clinically indicated.
A sudden or atypical increase in pain should prompt evaluation for alternative diagnoses such as occult fracture, osteonecrosis, infection, or neoplasm.
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Orthopaedic Surgery - Heterotopic Ossification
Basics
Heterotopic ossification (HO) is the abnormal formation of mature bone within soft tissues where bone does not normally exist, such as muscle, subcutaneous tissue, or around nerves.
It most commonly develops after major trauma, surgery, traumatic brain injury, or spinal cord injury.
Common Sites
The joints most frequently affected are the:
Hip, elbow, and shoulder.
The resulting ectopic bone may progressively restrict joint motion and, in severe cases, bridge the joint and produce ankylosis.
Epidemiology
Heterotopic ossification is less common in children than in adults and occurs more frequently in males.
Incidence
After major neurologic or traumatic injury, HO has been reported in approximately 10–20% of patients, although incidence varies substantially according to the underlying condition and the population studied.
Clinical onset often occurs within the first several months after injury, with an average onset near 2 months in older series.
Risk Factors
Important risk factors include:
Traumatic brain injury, spinal cord injury, major trauma, previous heterotopic ossification, ankylosing spondylitis, osteoarthritis, extensive osteophyte formation, repeated surgery, certain surgical approaches, and trochanteric osteotomy.
Previous HO
A history of heterotopic ossification after prior surgery substantially increases the risk of recurrence with later procedures.
Genetics
No routine genetic test predicts susceptibility to ordinary post-traumatic or postoperative heterotopic ossification.
However, rare inherited disorders of ectopic bone formation have specific genetic causes.
Etiology
Common precipitating conditions include:
Traumatic brain injury, spinal cord injury, direct musculoskeletal trauma, and major orthopaedic surgery.
The precise biologic mechanism involves abnormal differentiation of local progenitor cells toward bone-forming pathways within inflamed soft tissues.
Associated Conditions
Fibrodysplasia Ossificans Progressiva
Fibrodysplasia ossificans progressiva is a rare genetic disorder characterized by progressive heterotopic bone formation.
It is associated with an activating mutation involving the ACVR1 gene.
This disorder differs substantially from ordinary post-traumatic HO.
Osteoma Cutis
Primary osteoma cutis represents another uncommon disorder in which bone forms within the skin or subcutaneous tissues.
Diagnosis
Signs and Symptoms
Early symptoms are often nonspecific.
Patients may develop:
Increasing pain, progressive stiffness, worsening spasticity, muscle guarding, swelling, and decreasing joint range of motion.
Reduced Range of Motion
Loss of motion is often the earliest and most clinically important finding.
A previously mobile joint may become progressively stiff over days to weeks.
Inflammatory Appearance
During the early phase, the affected area may demonstrate erythema, warmth, swelling, and tenderness, sometimes mimicking infection or thrombosis.
Physical Examination
The examiner should carefully document active and passive range of motion.
The joint should also be assessed for:
Swelling, warmth, erythema, tenderness, spasticity, palpable mass formation, and neurovascular changes.
Neurologic Examination
When HO develops near a major nerve, motor and sensory function should be assessed because progressive ossification may cause nerve entrapment.
Laboratory Tests
Alkaline Phosphatase
Serum alkaline phosphatase may become elevated during active heterotopic bone formation.
The level may begin to rise approximately 2–3 weeks after the inciting injury.
However, this test is nonspecific and cannot establish the diagnosis by itself.
Imaging
Plain Radiographs
Radiographic evidence of new bone may become visible approximately 3–6 weeks after injury, although early films can be normal.
Mature and clearly diagnostic ossification may take several months to become obvious.
Bone Scintigraphy
Bone scintigraphy can detect HO earlier than plain radiographs.
The developing lesion demonstrates intense radionuclide uptake during the metabolically active phase.
Historically, bone scans were also used to assess lesion activity before excision.
CT
CT is particularly useful for defining the location, extent, relationship to surrounding bone and neurovascular structures, and operative anatomy.
Zonal Pattern
A characteristic maturation pattern may be seen, with more mature mineralization at the periphery and a relatively lucent or less mineralized center.
This zonal architecture can help distinguish HO from some malignant soft-tissue tumors.
MRI
MRI appearance varies according to lesion maturity.
Early HO may demonstrate low to intermediate signal on T1-weighted images and high signal on T2 or fluid-sensitive sequences, often with surrounding edema.
As ossification matures, the lesion develops signal characteristics resembling cortical and medullary bone.
Preserved Muscle Architecture
Early lesions may show residual muscle fibers coursing through the abnormal tissue, an appearance sometimes described as a texture sign.
Pathological Findings
Early heterotopic ossification produces an intense inflammatory and proliferative response.
The lesion contains myofibroblasts, fibroblasts, osteoblasts, and developing osteoid and bone.
Diagnostic Pitfall
The high cellularity and rapid growth of early HO can resemble a soft-tissue neoplasm histologically.
Recognition of its characteristic zonal maturation pattern is therefore important.
Differential Diagnosis
Important alternatives include:
Septic arthritis, deep infection, thrombophlebitis or deep venous thrombosis, and soft-tissue neoplasm.
Early HO can resemble all of these conditions clinically.
Treatment
General Principles
Most patients are managed nonoperatively.
The main goals are to:
Maintain functional joint motion, control pain, minimize contracture, and prevent further clinically significant ossification when prophylaxis is appropriate.
Physical Therapy
Gentle range-of-motion exercises are important for preserving mobility.
Therapy should emphasize functional motion without forceful manipulation that causes substantial pain or tissue trauma.
Rehabilitation
Treatment may also include positioning, stretching, strengthening of unaffected muscle groups, and strategies to maintain functional independence.
Analgesia
Analgesics may be used for symptomatic relief.
NSAIDs may provide both pain control and prophylactic benefit in selected postoperative settings.
NSAID Prophylaxis
NSAIDs are commonly used to reduce the risk of heterotopic ossification after high-risk procedures or after surgical excision.
Agents may include:
Indomethacin, naproxen, or other appropriate NSAIDs.
A course of approximately several weeks, often around 6 weeks, has traditionally been used.
Limitations
NSAID prophylaxis may be limited by:
Gastrointestinal intolerance, renal disease, bleeding risk, and other contraindications.
A proportion of patients are unable to complete treatment because of adverse effects.
Radiotherapy
Radiotherapy is primarily used as prophylaxis, not as treatment for mature established HO.
Timing
When selected for prevention after surgery, low-dose radiation is generally administered shortly before or within approximately 72 hours after the operative procedure.
Once mature ectopic bone is established, radiation does not remove the lesion.
Surgery
Surgical excision is considered when HO causes substantial disability.
Indications
Potential indications include:
Severe restriction of joint motion, painful mechanical block, contracture, difficulty with sitting or hygiene, nerve entrapment, or major functional impairment.
Timing of Excision
Historically, surgeons waited at least 6 months or longer for maturation before excision.
Modern practice may permit earlier removal when the lesion is sufficiently mature and symptoms justify intervention, particularly when prolonged delay would lead to permanent contracture or functional loss.
The timing should therefore be individualized according to radiographic maturity, neurologic status, joint function, and recurrence risk.
Operative Planning
CT is often useful before surgery to determine the relationship of the ectopic bone to:
Major vessels, nerves, the joint capsule, and surrounding musculature.
Postoperative Prophylaxis
After excision, prophylaxis is commonly used because recurrence is possible.
Options include:
NSAIDs and/or low-dose radiation therapy, depending on patient factors and institutional practice.
Radiation After Resection
If radiation is chosen, it is generally delivered within approximately 72 hours of surgery.
NSAIDs After Resection
A postoperative NSAID course, often lasting approximately 6 weeks, may be prescribed when not contraindicated.
Follow-Up
Patients who undergo surgical excision should be monitored until the wound has healed and functional range of motion has stabilized.
Continued rehabilitation is important to preserve the motion gained at surgery.
Prognosis
Outcome depends on the location, underlying cause, neurologic status, and extent of ossification.
Most patients with non-neurogenic HO retain reasonable function and never require excision.
Neurogenic HO
Patients with traumatic brain or spinal cord injury may develop more extensive lesions and have a greater risk of severe stiffness or ankylosis.
Complications
Loss of Motion
Progressive ectopic bone can substantially restrict joint motion.
Ankylosis
Severe HO may bridge a joint and result in near-complete or complete ankylosis.
Nerve Entrapment
Ectopic bone may surround or compress a major nerve, producing pain, sensory loss, or motor weakness.
Recurrence
HO may recur after surgical excision, particularly in patients with persistent neurologic risk factors or previous recurrent disease.
Patient Monitoring
Serial clinical examinations should document pain, swelling, range of motion, neurologic status, and functional ability.
Radiographs may be obtained at approximately 1–3-month intervals during the first 6 months when progression or maturation needs to be followed.
Imaging frequency should be individualized according to symptoms, lesion location, and whether surgery is being considered.
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Orthopaedic Surgery - Hemophilia
Basics
Hemophilia is an inherited coagulation-factor deficiency that causes abnormal and prolonged bleeding.
The direct disorder involves the clotting system, but repeated hemorrhage can secondarily affect many organ systems, particularly the joints, muscles, peripheral nerves, and central nervous system.
The age at diagnosis depends largely on disease severity. Severe forms are usually recognized in infancy or early childhood, whereas mild disease may not become apparent until surgery, dental work, or significant trauma.
Classification by Factor Activity
Severity is classified according to the percentage of normal clotting-factor activity.
Severe Hemophilia
Severe disease is defined by <1% normal factor activity.
These patients may experience spontaneous bleeding, particularly into joints and muscles.
Moderate Hemophilia
Moderate disease is characterized by approximately 1–5% factor activity.
Bleeding usually follows relatively minor trauma but may occasionally occur spontaneously.
Mild Hemophilia
Mild disease is associated with >5% factor activity.
Bleeding usually becomes evident only after significant trauma, surgery, or invasive procedures.
Types
Hemophilia A
Hemophilia A, historically called classic hemophilia, results from deficiency or dysfunction of factor VIII.
Hemophilia B
Hemophilia B, historically called Christmas disease, results from deficiency or dysfunction of factor IX.
General Prevention
A major goal of long-term care is prevention of recurrent joint bleeding and development of target joints.
Modern prophylactic factor replacement or other hematologic therapy, together with patient education and appropriate activity modification, can substantially reduce cumulative joint damage.
Epidemiology
The combined frequency of hemophilia has historically been estimated at approximately 1 per 10,000 people, although prevalence varies by population and method of ascertainment.
Males are affected far more commonly because the classic forms are X-linked disorders.
Relative Frequency
Hemophilia A is considerably more common than hemophilia B.
Older series have estimated approximately:
75% hemophilia A, 12% hemophilia B, with the remainder representing other rare coagulation-factor deficiencies.
Risk Factors
The principal risk factor is a positive family history, particularly affected males on the maternal side.
However, new mutations may occur, so absence of a known family history does not exclude the diagnosis.
Genetics
Hemophilia A and B are generally inherited in an X-linked recessive pattern.
Affected males inherit the pathogenic variant through the maternal line, while females are usually carriers, although some carriers can have reduced factor levels and clinically important bleeding.
Etiology
Hemophilia A
Hemophilia A results from a pathogenic variant affecting the F8 gene, leading to factor VIII deficiency.
Hemophilia B
Hemophilia B results from a pathogenic variant affecting the F9 gene, leading to factor IX deficiency.
Diagnosis
Early Presentation
In severe hemophilia, the diagnosis may become apparent during infancy because of excessive bleeding after:
Circumcision, immunizations, oral or lip trauma, venipuncture, or minor falls.
Mild Disease
Patients with milder hemophilia may remain undiagnosed until a major laceration, dental procedure, or operation causes unexpectedly prolonged bleeding.
Recurrent Hemarthrosis
Repeated bleeding into joints is one of the most important long-term manifestations.
The joints most often involved include the:
Knees, ankles, and elbows.
Shoulders may also be affected.
Target Joint
After a joint has bled repeatedly, it becomes increasingly susceptible to additional hemorrhage.
Such a repeatedly affected joint is termed a target joint.
Symptoms of Joint Bleeding
An acute hemarthrosis often begins with deep pain, pressure, or tightness before visible swelling develops.
As blood accumulates, the joint becomes swollen, warm, painful, and increasingly restricted in motion.
Muscle Hemorrhage
Muscle bleeding may cause swelling, pain, loss of motion, and compression of nearby nerves.
Iliopsoas Hemorrhage
An important example is bleeding into the iliopsoas muscle, which may compress the femoral nerve and produce weakness, sensory loss, or femoral neuropraxia.
Chronic Hemophilic Arthropathy
Repeated hemarthroses stimulate synovial hypertrophy and chronic joint damage.
Over years, the affected joint may develop:
Stiffness, flexion contracture, cartilage destruction, subchondral changes, chronic pain, and degenerative arthritis.
Physical Examination
Joint Examination
All major joints should be assessed for:
Effusion, tenderness, warmth, swelling, range-of-motion loss, deformity, and contracture.
Particular attention should be given to the knees, ankles, elbows, and shoulders.
Ankle Examination
An early ankle effusion may be suggested by loss of the normal soft-tissue depressions around the malleoli.
Knee Examination
Knee flexion should be compared bilaterally.
The examiner should also assess whether the patient retains the normal small amount of hyperextension, often approximately 5–10°.
Joint Enlargement
Chronically affected joints may appear enlarged because of:
Synovial hypertrophy, epiphyseal overgrowth related to hyperemia, and atrophy of surrounding muscle.
Bleeding Log
Patients may be encouraged to keep a record of bleeding episodes.
This can help identify development of a target joint and guide prophylactic treatment.
Neurologic Examination
The examiner should look for neurologic sequelae of previous bleeding.
Examples include:
Hemiparesis after intracranial hemorrhage, femoral neuropathy from iliopsoas bleeding, or sciatic neuropathy from deep pelvic or gluteal bleeding.
Laboratory Tests
Factor Assays
Factor VIII or IX activity should be measured and expressed as a percentage of normal activity.
Clinical severity correlates broadly with the residual factor level.
Even relatively low levels, such as approximately 5–10%, may provide substantial protection against spontaneous bleeding compared with severe deficiency.
Inhibitors
If factor activity fails to rise as expected after replacement therapy, a neutralizing inhibitor should be suspected.
An inhibitor is an antibody directed against the replacement clotting factor, most commonly factor VIII.
Surgical Significance of an Inhibitor
The presence of a significant inhibitor complicates hemostatic management and increases the risk of elective surgery.
Procedures should therefore be coordinated with an experienced hematology team.
Additional Long-Term Screening
Historically, patients with hemophilia exposed to plasma-derived blood products were at increased risk for blood-borne infection.
Long-term care should take into account the patient’s status regarding:
Hepatitis, HIV, and factor inhibitors, when clinically relevant.
Pathological Findings
Gross Appearance of the Joint
The synovium of a chronically affected hemophilic joint may appear brown and velvety because of hemosiderin deposition and synovial hypertrophy.
Cartilage Damage
The articular cartilage progressively loses its normal smooth appearance.
Advanced disease may demonstrate erosions and irregular defects.
Microscopy
The synovial lining becomes:
Hypertrophic, hypervascular, and hemosiderin-laden.
The increased vascularity predisposes the joint to further bleeding.
With time, fibrosis develops and contributes to progressive stiffness and loss of motion.
Imaging
Plain radiographs of a hemophilic target joint may demonstrate a progressive sequence of abnormalities.
Early Changes
Initial findings include:
Soft-tissue swelling and periarticular osteopenia.
Intermediate Changes
With recurrent bleeding, radiographs may show:
Epiphyseal enlargement, joint-space narrowing, subchondral irregularity, and cyst formation.
Advanced Changes
Late hemophilic arthropathy resembles severe degenerative joint disease with:
Marked joint-space loss, deformity, subchondral cystic change, and articular destruction.
Differential Diagnosis
Important alternatives include:
Von Willebrand disease, pigmented villonodular synovitis, acquired coagulation-factor inhibitors, and thrombocytopenia.
Treatment
General Principles
Treatment depends on the severity and location of bleeding and should be coordinated closely with hematology.
The principal goals are to:
Stop hemorrhage, prevent recurrent bleeding, preserve joint motion, and avoid long-term arthropathy.
Acute Hemarthrosis
The cornerstone of treatment is prompt clotting-factor replacement or other appropriate hemostatic therapy.
Early treatment limits the amount of blood entering the joint and reduces secondary synovial damage.
Rest and Immobilization
A short period of rest and protective immobilization may be used during the acute painful phase.
Prolonged immobilization should be avoided because it promotes stiffness and muscle wasting.
Range of Motion
Gentle range-of-motion exercises should begin once bleeding and pain have settled.
Joint Aspiration
If a large tense hemarthrosis produces severe pain or threatens joint motion, aspiration may be considered after adequate factor replacement has been established.
The procedure should be performed under sterile conditions with hematologic support.
Compression
Compression and supportive measures may help reduce swelling after bleeding is controlled.
Chronic Hemophilic Synovitis
Repeated bleeding can produce hypertrophic synovium that itself becomes a source of further hemorrhage.
Synovectomy may therefore be considered for persistent target-joint bleeding despite optimized medical treatment.
Synovectomy
Synovectomy removes or ablates diseased hypertrophic synovium in an attempt to reduce recurrent bleeding.
Arthroscopic Synovectomy
In appropriate joints, synovectomy can be performed arthroscopically.
Radiosynovectomy
Injection of a radionuclide into the joint can produce chemical or radiation-induced synovial ablation.
This may reduce bleeding frequency in selected high-risk target joints.
End-Stage Arthropathy
Severely damaged painful joints may require reconstructive surgery.
Arthroplasty
Joint replacement can provide substantial pain relief and improved function, particularly for end-stage knee arthropathy.
Arthrodesis
Fusion may be appropriate for selected end-stage joints, especially the ankle, when painful destruction is severe.
Iliopsoas Hemorrhage
Psoas bleeding associated with femoral neuropraxia is generally treated with:
Hemostatic factor replacement, activity restriction, observation, and serial neurologic examination.
Most cases are managed nonoperatively unless another complication develops.
Compartment Syndrome
Compartment syndrome should be treated according to standard principles.
Because surgery itself carries major bleeding risk, clotting-factor correction should be initiated urgently, followed by decompression when clinically indicated.
Home Prophylaxis
Home treatment programs can substantially reduce the frequency and severity of bleeding episodes.
When the patient and family are appropriately trained, factor or other prescribed hemostatic treatment can be administered promptly at the first sign of bleeding.
Activity
Regular low-impact physical activity is generally beneficial because strong muscles help stabilize joints.
Activities with a high risk of collision or trauma may require modification according to disease severity and hematology guidance.
Physical Therapy
Physical therapy is important for monitoring and maintaining:
Joint range of motion, muscle strength, gait, balance, and overall function.
It is particularly useful after major bleeding episodes or orthopaedic surgery.
Medication
Analgesia
Medications that impair platelet function should generally be avoided unless specifically approved by the treating hematologist.
NSAIDs and Aspirin
Aspirin and many traditional NSAIDs can worsen bleeding because of their antiplatelet effects.
Acetaminophen
Acetaminophen is commonly used for pain control because it does not significantly impair platelet function.
Other analgesic choices should be individualized.
Surgery
Any operation in a patient with hemophilia requires careful perioperative coordination with hematology, including planned factor replacement or other hemostatic therapy before, during, and after the procedure.
Synovectomy
Surgical or radiosynovectomy may be performed for recurrent target-joint bleeding that persists despite adequate prophylaxis.
Total Knee Arthroplasty
Knee replacement may be indicated for severe end-stage hemophilic arthropathy with disabling pain and loss of function.
Ankle Arthrodesis
Fusion can be considered for severe painful ankle degeneration when reconstruction is unlikely to provide reliable function.
Follow-Up
Prognosis
With modern prophylaxis and multidisciplinary care, many patients can maintain substantially better joint function and life expectancy than was historically possible.
Outcome depends on:
Severity of factor deficiency, access to prophylactic treatment, inhibitor development, frequency of bleeding, and established joint damage.
Complications
Neurologic Hemorrhage
Bleeding into the brain or around major peripheral nerves may produce catastrophic neurologic injury.
Intracranial hemorrhage is a medical emergency.
Hemophilic Arthropathy
Repeated hemarthroses can cause:
Joint stiffness, contracture, chronic synovitis, cartilage destruction, and secondary arthritis.
Compartment Syndrome
Deep muscle hemorrhage may increase compartment pressure and threaten nerve and muscle viability.
Peripheral Nerve Compression
Large hematomas can compress nearby nerves, particularly the femoral or sciatic nerve.
Blood-Borne Infection
Historically, transfusion-transmitted hepatitis and HIV were major complications of plasma-derived treatment products.
Modern screening and recombinant therapies have greatly reduced this risk.
Inhibitor Formation
Development of neutralizing antibodies against replacement factor can make bleeding more difficult to control and complicate surgery.
Patient Monitoring
Patients should ideally be followed through a multidisciplinary hemophilia treatment program.
Care commonly involves:
Hematology, orthopaedics, physical therapy or rehabilitation, dentistry, nursing, and social services.
Orthopaedic Monitoring
Follow-up should assess:
Frequency of hemarthrosis, development of target joints, joint range of motion, contractures, muscle strength, gait, pain, and radiographic progression of arthropathy.
Early recognition of recurrent joint bleeding provides the best opportunity to prevent irreversible hemophilic arthropathy.
