nm5245: any more coming or is that it we'll get going er my name's namex i'm one of the er orthopaedic surgeons from Cov and Warwick Hospital and i think you've met one or two of my colleagues before er there's about sixteen of us there er all of us do general trauma obviously but we all have our s-, sub- specialities and er my particular speciality is spinal surgery er but obviously general orthopaedics as well now you you've had these academic half days where you've had one or two topics normally for some reason they've put three topics in for this afternoon and any one of those could easily take up a whole afternoon so we'll go through sort of the basic principles of each one an-, and the way we'll do it the three topics are er bone and joint infection er chronic hip pain and er low back pain and the way we'll do it is i'll do about ten m-, ten or twelve minutes on each of them as a sort of introductory er lecture on each and then there's two three pairs of students one for each will do a presentation on a patient they've seen with the relevant condition and we can have an answer an-, question and answer session if er if everybody wants so we'll get going hopefully it won't take too long right chronic bone and joint infection er two separate conditions but obviously interlinked now the patient they've seen is a patient with er osteomyelitis bone infection but for completion's sake i'll just say about er joint infections to start with bone infection obviously osteomyelitis joint infection septic arthritis straightforward joint infections septic arthritis is relatively common you're bound to see er one or two patients a year with er septic arthritis of one form or another and in this country probably at least half of it occurs in children and often under three's how does it get there er well haematogenous spread is the most likely cause if they've had an osteomyelitis of the adjacent bone er or if you've had a direct puncture into a joint so obviously in adults drug addicts not unusually get er septic arthritis in er the wrists or hip joints and so on depending upon where they've been injecting but by and large the one's you'll see as non-contaminant er osteomyelitis er septic arthritis will be er in kids probably haematogenous spread and staph aureus by far the single commonest organism so what does pus do in a joint like most things in orthopaedics pain is the one thing and they usually localise it to a joint in children obviously not so so er communicative and it's a question of deciding which limb they're not moving the joint swells obviously so you get an effusion in it and you get loss of use of the limb because obviously it's painful to use and generally speaking they tend to get quite unwell with it they'll have a fever er generally off their food and so on so forth what does the pus actually do to the joint itself th-, the single most important thing it'll do is is destroy the articular cartilage if you destroy the articular cartilage the likelihood is that in the long run you're going to be predisposed getting some degree of arthritis degenerative type arthritis in that joint how do you diagnose it again unless you suspect it you're not going to pick it up once you've got a patient with p-, painful swollen joint and they can't use the limb and you find that they they they're signs of er tenderness on m-, moving a particular limb er tally with the site of their pain then an ultrasound scan is usually the single most useful er examination to see if they've got actually got fluid in the joint or not and most children and that's when it's usually difficult to diagnose most children will be quite amenable to having an ultrasound scan er rather than going into any funny machines and if you have any suspicion at all you aspirate the joint it's quite straightforward there's nothing complicated about it put a needle into the joint obviously with a child you'll do that under general anaesthetic and if you get pus out er and you can er prove it's pus then er er er you've got septic arthritis and if you have any suspicion at all of having a septic arthritis any suspicion at all of pus in a joint or if you've got doubt in fact then the only way to be sure is er to actually wash the joint out so you do an arthromtomy i.e. open up the joint er under a general anaesthetic obviously you wash the joint out you send off all the er pus if there's any pus there and sometimes if you don't get any significant amount of pus out you actually lavage the joint and send the washings off er for culture to the er microbiologists and then you start them on antibiotics fairly straightforward really i'm not going to go into it any great more detail than that as i say we've got three other topics to cover but it's for completion's sake er and a lot of the principles of treatment we'll cover in er in the treatment of the osteomyelitis as well and the antibiotics you start them off as first guess best guess antibiotics it's going to be a staph until proven otherwise and then unless you get er er er cultures back saying otherwise that's in this country obviously overseas and third world countries T-B's still a big problem and you've got to suspect that if if you get people from overseas coming over and that that's all i'll say on the septic arthritis osteomyelitis okay so osteomyelitis an infectious process of the bone and its marrow and you get acute versus chronic like most things and again staph aureus by far the commonest organism in children not uncommon to get strep infections and in neonates er haemophilus influenzae as well the important thing is to make sure that you know that you're dealing with an osteomyelitis in the first place so what actually happens in a in a osteomyelitis once you get bugs settling in the bone and it's nearly always in the metaphysis so the commonest sites are distal femur proximal tibia er distal humerous proximal humerous i.e. the ends of longs bones you usually get pus forming in the er metaphysis which then gradually works it's way through through the nutrient channels sub-periosteal space you get pus in the sub- periosteal space and occasionally that can be s-, large enough that you get er soft tissue swelling or er pus er an abscess in the er the soft tissues and the bone that's got the pus in it like any abscess the bone dies so you get necrosis of the bone and that's the bit that you call the sequestrum the dead bone within the metaphysis whenever you disturb periosteum whether it be by infection trauma tumour or whatever it's natural reaction is to lay down new bone so the periosteum that's been lifted off tries to lay new bone down and that's called the involucrum so you get a sleeve of new bone forming around the dead bone and you've got established osteomyelitis with pus in the centre how does it get there well again most likely haematogenous spread bacteremia's very common we all know that every time you brush your teeth you get several hundred thousand bugs flying around in your blood stream and if you're unwell or if you're in any way er er er immune compromised whether it be from a viral illness or flu-like illness or whatever then you you may be that much more susceptible to bugs actually settling down in any part of the body and one part is at the metaphyses of long bones and what's presumed is that you've got end arteries there that er either will terminate in the metaphysis or in the epiphysis depending upon the age of the child and that's a focus for the bugs to actually go and settle and that's in primary osteomyelitis direct impregnation is where you get bugs actually being physically put into the bone so if you have a compound fracture i.e an open fracture or if you've instrumented the bone for any reason so you've operated on them and you've created an open er open bone surface but by far and most common in children obviously is the haematogenous spread so in haematogenous spread in er is usually in children pain again single most common symptom the child usually holds the limb limp children if they have a sprain or a fracture or an infection they do the same thing they just don't move the arm or the leg or the foot or whatever and generally speaking obviously they're going to be unwell with it with or without a temperature you can get er in the early stages obviously er the child just being unwell without an established pyrexia and when you examine them they'll have tenderness over the the bone that's infected so if it's the hip or the knee if you try and touch it er they're going to they're going to let you know about it and if you try and attempt to move the joint adjacent to the infected bone occasionally you'll get soft tissue swelling obviously if you've got pus in the sub-periosteal space in the soft tissues around the proximal tibia or distal femur it's going to be much more easily palpable than if you've got it in the hip which is more deep-seated but even in the hip occasionally you'll feel a groin swelling or fullness er if they've got a significant amount of pus there so again you're going to diagnose it if you suspect it you'll diagnosis it and whenever you get a child in with a limp limb who's unwell it's septic arthritis or osteomyelitis until proven otherwise because missing either of those and you will not do them any good in the long run they usually have a temperature the single most important blood markers are probably E-S-R and C-R-P now you can get those raised with just about anything the C-R-P's a much more sensitive test white blood count white blood cells well they may or may not be raised in the early stages you'll have a perfectly normal blood count but a very markedly raised C-R-P and you get those off A-S-A-P so you get them on day one and you repeat them if need be every forty-eighty hours and certainly weekly until you've er er got the infection under control blood cultures i think you know just about every speciality in medicine you'll get you'll get you'll get no points if you don't do blood cultures if someone's unwell an-, and this is this is one of them and quite often you'll grow bugs from a blood culture but not from an aspirate of a hip joint or a knee joint so it's absolutely mandatory to do er blood cultures x-rays may or may not be useful again in the early stages er x-rays look perfectly normal er and with kids when you've got epiphyses and growth plates and so on so forth it's often difficult to interpret if it's well established and you've got a loosened zone in a bone then there's no doubt probably the gold standard investigation for diagnosing early osteomyelitis is the M-R-I scan but an M-R-I scan is virtually impossible to do in a child unless you do a general anaesthetic because they will not go into it high degree of failure of getting M-R-I scan done even in adults because of er claustrophobia er and in kids it's virtually impossible so there's never an indication to do it but er in adults certainly the way to do it treatment osteomyelitis now we're talking about er haematogenous spread yeah in children mainly number one as with any condition you resus the child children dehydrate very quickly so you don't have to have a pyrexia for very long and they've been off their food and they're not drinking and before you know it you've got an extremely ill child and you're just perpetuating the er the er the illness so fluids intravenous fluids must be in there pain relief make the child comfortable and co-operative those are the first things you do before you start seeing and examining them and you probably won't be able to see and examine them until you've got that that sorted if you've suspected osteomyelitis then er y-, I-V antibiotics is is the first line of treatment the-, there is some er debate about whether you go straight for surgery or not but you won't go wrong by putting them on best guess intravenous antibiotics because by and large it's going to be staph or strep once you've got the antibiotics under way you've resuscitated them you've got pain controlled then you can think about surgery pus anywhere whether it's an abscess on your thigh or on the bone or in the joint you're not going to get antibiotics to it the only way to treat it is to get the pus out so any pus anywhere has to come out and in particular the pus underneath the periosteum when it comes to gr-, growing bone so the usual thing that is done is if they're not settling er if you haven't got the er antibiotics in early enough or they've presented late which is usually the case ninety-nine per cent of the time then you take them to theatre you open up the bone you incise the periosteum you release the pus and then you need to get the pus out of the metaphysis er and you drill the bone and drilling again is a bit controversial er in some circumstances but you won't go wrong by drilling the bone and letting all the pus out and that's your best chance of stopping further bone necrosis er and perpetuation and er chronicity of the infection and then you do serial E-S-R C-R-P's until they're until they're well enough just another thing to say on the on the surgery once you've actually opened it up you don't then close it up you open up the bone you open up the periosteum you let it all drain but then you allow it to drain until it's finished so you put a corrugated drain in and they stay on the ward for a week ten days two weeks whatever it takes until the drainage stops and the pus has cleared up then you can go in and close the wound up so in traumatic osteomyelitis i.e. osteomyelitis secondary to either instrumentation or a compound fracture it's usually much easier to make you know they've had a compound fracture so you've already got a high index of suspicion you know you may have nailed a fracture that was closed that you've created an open fracture so you've got a high index of suspicion and again the things that give it away pain pyrexia and you may or may not see an abscess at the relevant site yes this is a patient which er er the girls will present er in a few minutes er a patient who had er a compound fracture of the proximal tibia and this is a current er x-ray you can see in the distal femur n-, normal bone texture and here you can see ir-, irregular bone texture one or two cysts if you go into the A-P view you can see a big hole where he's developed osteomyelitis secondary to having had this fixed so it was an open fracture in the first place and that's how it was dealt with open fracture you've got bugs going in you put a whole load of metal work in that's more foreign bodies going in and you've got the ideal er er set up for developing er osteomyelitis deep infection and that's the lateral view on it so how do you treat that again basic principles like with any infection or pus anywhere or any dead tissue er you've got to debride it so you've got to take them to theatre as soon as you've suspected it and seen it and er take out all the dead body all the dead bone sorry the dead tissue pus and that includes the metal work usually because metal work is foreign body and any foreign body is just there as a focus to perpetuate infection and then you start them on antibiotics bone just does not like being exposed you must have soft tissue cover of a bone otherwise you're going to get dead bone you're get chronicity of infection so nearly in all these cases you will need some degree of plastic surgery to cover the bone one because they've had a compound fracture and they have a defect of b-, er skin anyway and secondly you've taken away what dead skin there was and exposed the bone further unless you get cover over the bone you'll never get the infection under control so plastic surgery nearly always necessary and er as i say removal of the metal work sometimes replacement of the metal work prognosis in osteomyelitis from trauma very very variable anything from full return to normal function without any er longterm effects to amputation huge variation and it depends upon the site the type the degree of infection how soon you got it under control any other associated injuries and so on so forth chronic my-, osteomyelitis is not an uncommon er occurrence and that's the case we're going to present what that means is that you never ever quite get rid of the infection for years and years and years every year or two or once or twice a year you'll get the same patient coming back into clinic having developed an abscess or a discharging sinus and they get recurring flare- ups and that's the worst scenario you can get into they're not unwell with it it doesn't stop them using the limb but it's a social inconvenience you're constantly wearing dressings and not an uncommon scenario where patients will electively ask for an amputation it's not a nice situation to get into we'll leave it at that and we'll get the presentation on the er any questions just to be going on with as i say we'll just c-, cover each topic in that sort of broad general principles otherwise we'll be here until eight er do you want to get into yours if you've got any questions just shout out while we're swapping er sf5246: do we need to show the x-rays now you've just shown them nm5245: no you don't need to no sf5246: i'll just leave them nm5245: which one is yours sf5246: nm5245: yes sf5246: yes nm5245: what's your name i've forgotten your name again sf5246: Hannah i'm Hannah nm5245: so Hannah and Sarah will present the case they saw sf5246: okay er we saw Mr A P who's a thirty-three year old man and he self- presented to Cov and Warwick A and E he complained of a two-day history of a red swollen hot and painful region in his upper lower leg er just below the knee and he felt generally unwell with fever and nausea er he was still able to move the knee and he had quite a good range of movement er he was also able to weight bear and he sort of described only moderate pain there was no history of any recent trauma and he described the pain was similar to that he'd had with previous infections the background to this is that he was a cyclist involved in a road traffic accident in London in March of two-thousand-two er he sustained a comminuted compound fracture to the left proximal tibia and fibular and patella following this he had an open reduction and internal fixation and a cylinder cast was applied but three days later he developed an infection in the wound er this required urgent incision and drainage the fixation plates had to be removed due to infection around the lateral plate and the screws and following this he's had repeated readmissions over the past year following the development of an infective blister and an abscess over the left lateral tibial condyle but this didn't communicate with the knee joint other things in the history he suffers from depression there's no relevant family history socially he lives with his parents in Coventry now following the accident he's employed as a researcher he's got about a fifteen pack year history of smoking and he's just a moderate drinker er drug history he's taking an anti-depressant he's taking some night-time sedation and some pain relief and he's got no known allergies on examination he was comfortable at rest er he was apyrexial and his pulse and blood pressure were normal er the left upper tibial region was slightly swollen and red and there was a local increase in temperature but there was no sign of effusion there was a hard swollen area on the lateral aspect of the tibia with a central discharging sinus and this was over the area where he'd had skin grafts and muscle grafts following the accident there was still a good range of movement it was neurovascularly intact and he was still fully mobilising with a walking stick and there was nothing to note in any other symptoms so the diagnosis in this case was post-traumatic osteomyelitis er which was chronic he was then admitted to hospital and routine bloods were taken as you can see sort of the inflammatory markers the C-R-P and the E-S-R were raised but the other values were normal he was given analgesia x-rays which er Mr Shergill's already shown and IV antibiotics which were flucloxacillin and oral antibiotics fucidin er he was then taken to theatre for incision incision and drainage and the sinus they found tracked back to a large er tibial cavity proximal to the left tibia and he was given curettage debridement and lavage er just to point out a sinus is an infected tract leading from a focus of infection to the surface of the skin or a hollow organ er and this chap's to be followed up in the fracture clinic in two weeks er we'll just run through what's already been said really but er acute osteomyelitis an infection in the bone which affects the cortex medulla and periosteum it's more common in children and common organisms include staph aureus e.coli salmonella and TB the organisms can gain access to the medullary cavity via two main routes er firstly directly through the wound following trauma or operation or blood borne spread from following bacteraemia or sepsis elsewhere there's pain tenderness and redness over the involved bone with general illness and high fever and the sequelae follow as been said there's a focus of acute inflammation necrosis of the bone trabeculae destruction of the cortical bone allowing pus to dichar-, discharge into the surrounding tissue and the infection may track to the skin surface producing a chronic discharging sinus as was seen in our case and the infection can become chronic er chronic osteomyelitis results from partially treated acute or post trauma and surgery you get extensive bone destruction marrow fibrosis abscesses forming reactive new bone formation around the inflamed periosteum and abnormally shaped bone and just to mention septic arthritis er this is an infection in a joint it's typically mono-articular in it's presentation common organisms include staph aureus again streptococci haemophilus haemophilus and gonococcus the joint is swollen hot and tender movement's restricted and painful er the infecting organism can again enter via the blood or from a penetrating injury or from adjacent infection if it's untreated as was said the articular cartilage can be destroyed leaving a stiff and deformed joint the end nm5245: any questions to either me or Hannah no su: what's curettage nm5245: curettage anybody ss: scrape it nm5245: scrape it out su: irritable hip because its exactly isn?t it nm5245: yeah irritable hip er the most common thing you'll see coming into in into kid's wards is an irritable hip er from mus-, musculoskeletal point of view irritable hip is a diagnosis of exclusion you get a child comes in with a limp er painful limb they're not using it once you've excluded septic arthritis osteomyelitic fractures er then you can say that you've got an irritable hip ergo irritable hip with or without an effusion in the hip joint er but yeah it's a diagnosis of exclusion it's just a sort of cover all to say we're not really surely exactly way he's limping probably sprained it or strained it anybody else should we move onto the next bit i think we're more or less keeping to time at the moment right the next topic is er sorry just let me get to the right bit er chronic hip pain so chronic hip pain i've put in brackets osteoarthritis because without er a doubt the most common condition you're going to see er with ongoing er hip pain is going to be er O-A of the hip and er i'm not sure exactly how they run the the finals here but er i-, it's one condition that you really need to know inside out er because patients with O-A hip very common they're always willing to come to an exam they've got nothing else to do and in the surgical finals certainly up to twenty twenty-five per cent of long cases could easily be er either O-A hip or O-A knee so it it's worth knowing the condition well even if you've got no interest in er er in in er orthopaedics site of hip pain er if you ask a lot of people put your hand on your hip they'll all go like this and it's important to know where the hip is and it it's not an uncommon thing actually even amongst er er er other specialities they'll refer patients G-P's will refer patients saying this patient's got pain in the hip and when you see them they say there's pain over here okay just to clarify where the hip is and where pain from the hip comes classically groin because your hip is seated deep inside er inside your groin anterior thigh pain to the knee and occasionally hip pathology can present just as knee pain again there are plenty of patients going around who'll who'll present at the exams with just knee pain and they've got er O-A hip so groin to anterior thigh to knee one or all of those or any of those er put together in any combination so just to remind you yeah greater trochanters femoral heads acetabulum pubic synthesis mid-line pubic synthesis the most prominent most lateral part of your er er lower limb bone's is your greater trochanter your tip of your greater trochanter and obviously your hip hip joint's about half way across or nearly half way across from there what is osteoarthritis yeah i'm not sure you need to write this down it's fairly er fairly well written down in most books basically it's loss of articular cartilage okay for whatever reason it's a degenerative process in other words it's not an inflammatory condition like rheumatoid or er er such like and the vast majority of it are primary in other words in the vast majority of patients your little old lady walking around with osteoarthritis hip there's no reason why she's got it it was just her turn however you can get it secondary to damage to the articular cartilage itself so interarticular fractures septic arthritis er so intra-cap-, intracapsular fractures next to femur and A-V-N which is avascular necrosis are probably four of the more common causes of getting er er er secondary osteoarthritis from damage er to the er to the joint surface it doesn't have to be a fracture it doesn't have to be an actual radiological injury you can get trauma to a joint and the articular surface you can get chondrolysis where the surface layer of the cartilage er dies and then you can get degenerative changes secondary to that but the vast majority of patients you're going to see er are going to be patients er who've got primary osteoarthritis for no obvious underlying reason just to highlight a bit on the er the er er A-V-N avascular necrosis er avascular necrosis simply means dead bone er because of loss of blood supply and there's quite a few patients nowadays that you'll see er youngish patients with er O-A hip who've er got it secondary to A-V-N and one of the commonest causes is high dose usage of steroids so you do see it actually in a lot of er er dodgy athletes and er patients with asthma who've been put on steroids and and so on so forth so it's not that uncommon symptoms surprise surprise pain again limp and difficulty with pedicure i've put that down as a very specific thing because there's a whole load of other symptoms they might present with they kept tripping over things or they er can't get up and down the stairs but pain they'll all have and nearly all of them will describe some degree of limping or some degree of compromise of use of that leg the reason i've put down difficulty with pedicure is that often patients don't declare it but a very very common sign of hip pathology stiffness er or O-A of the hip is they just can't get down to their toe nails they can't do their shoes up er they can't cut their toe nails or er er er and deal with their corns and so on so forth nearly always it's the one side that they got the O-A hip it might sound a bit bizarre but it's a very very telling sign of a stiffness of the hip joint signs generally antalgic gait simply means a painful limp okay there's really two types of er er limping you've either got pain in a lim-, in a limb and it causes you to limp or you've got leg length discrepancy so you've got one leg shorter than the other and that's the only two really stooped posture if you get deformities in the hip joint you often find that they're walking around like this and you get patients coming to the back pain clinic saying er my GP tells me i've got a problem with my back because i can't stand up straight and what they've really got is a very stiff hip with a marked fixed flexion deformity decreased range of movement pain on passive movement yeah in in in one or all of the directions so you may get pain in early osteoarthritis just in internal external rotation and flexion in advanced arthritis you might not get any movement in the hip joint at all and you don't get any pain and in between er fixed deformities it's one of the few sort of er named tests that these days er you need to know in er in er orthopaedics er it's sort of not very P-C to be sort of having named tests Thomas' test for fixed flexion deformities is one you must all know okay even the general surgeons know how to do it and if you get a patient in the exam they'll ask you to do it even if it's not relevant so you must know how to do it and it's all it is is a test for fixed flexion deformity and you always compare it to the other side it might just be normal for them now do you all understand what fixed flexion deformity is i think prof and er his team did a hip half day three weeks ago anybody willing to tell us what fixed flexion deformity means it's quite important to know about i know it's not relevant to the O-A itself su: is it something to do when you've a hip problem the er you get a lumbar lordosis which unless you raise the opposite leg then it uncovers it in effect and you get the flexion deformity in the affected side nm5245: right you've used all the right words i'm not sure in the right order but er any fixed deformity right is a deformity where by you can't move in the opposite direction so if you've got a fixed flexion deformity by definition you cannot extend your hip and it means your hip's stuck here and the only way you can compensate for it is by tilting your pelvis to get the foot to the ground and by tilting your pelvis you increase your lumbar lordosis i think you was i think you were right i just didn't er catch the gist of it so that's a fixed flexion deformity and that's the only one that everybody normally picks up on but you can get fixed abdexion deformity so you get patients who can't abduct their hip or a fixed external rotation deformity you can't internally rotate the hip so you can get a fixed deformity in any direction but fixed flexion deformity's the one that usually comes to light because they can't stand up straight they're always bending forward and er it's the easiest one to detect because normally flexion is the the movement which have the greatest range of movement investigations x-rays are usually diagnostic there's a lot a high- flying tests for a whole load of things er er i-, in all specialities but still the single most useful investigation is a straightforward plain A-P pelvis x- ray to diagnose it so normal hip would look like this on both sides femoral head acetabulum and normal joint space which should be symmetrical er all the way round if you get an O-A hip if the patient's unfortunate to have bilateral O-A hip you can see marked loss of joint space some extra bits of bo-, bone sticking out here and here i.e. osteophytes a few little cysts which you can just about see i think little holes in the femoral head there and sclerosis increasing whitening thickening if you like increased density of the bone around so the four cardinal er sort of radiological signs of O-A hip or O-A anywhere i think most people are familiar with those how else can you investigate them if you've got a painful hip in a young chap and they're thirty thirty-five and you think they might have A-V-N er then er obviously you don't want to wait until they get advanced er O-A hip you want to try and detect it earlier so you get painful hip in a young person it's worth investigating them a bit more er thoroughly M-R-I scan is probably again the gold standard investigation an M-R-I scan will pick up changes in the femoral head even before you get symptoms let alone before you get changes on the er plain x- ray's it'll chan-, show you bone oedema marrow oedema it'll show you early small amounts of er fluid in the joint and so on C-T scan is sometimes helpful you can get painful hips in young people er osteoid osteomas or other er benign tumours and an arthrogram an arthrogram you're all happy familiar with what an arthrogram is no arthrogram is where you put dye into a joint so you can do a plain x-ray like we did earlier on or you can x-ray it with some radio-, er radiopaque dye come the x-ray all you're seeing is the bony components of the hip joint you're not seeing er the actual cavity of the joint if you like if you do an arthrogram you put dye into a joint you can often pick up tears of the labrum of the capsule you can pick up loose bodies in the in in the joint itself er and it can give you a bit better idea as to the actual contour of the joint so you may only have loss of articular surfa-, er articular cartilage in one particular area of the hip joint er or the femoral head rather than the while of it an arthrogram is very much more useful for chronic hip pain in kids so children with perthes will almost routinely have an arthrogram rather than an M-R-I scan or a C-T and you can do C-T arthrogram so you put dye in and then you do a C-T scan so there's all lots of combinations er of er of the investigations that you can do but without a doubt when you've got standard adult er chronic painful hip er the the gold standard investigation is plain x- ray for O-A of the hip what are you going to do about it like everything else er common sense measures first so change in lifestyle use a walking stick er move to a bungalow er things like that simple pain killers you don't go straight for the er the hip replacement you start paracetamol panadol or whatever you want to initially and then you move on to your er anti- inflammatories and so on and surgery is very much a last resort so the ones that get to surgery er will be ones who have failed conservative treatment so physiotherapy would be also part of the conservative treatment when it comes to surgery and this goes for O-A any where whether it's hip or knee or er big toe there's three main procedures you either debride the joint so if you get early O-A you can debride the joint and most commonly you'll see it done in the knee joint you literally rebore it you take away the osteophytes and fish out any loose bodies and you tidy up any tears of cartilages and so one er and er hope for the best osteotomy er again i think the girls will probably in their presentation as well is where you cut the bone adjacent to the joint and you realign it and you fix it there and what you're trying to do there is if you get O-A hip where you've got the ball and you've only got loss articular surface on the surface say on the weight bearing surface and the rest of the articular surface is intact you realign the hip to utilise that er viable arth-, er articular cartilage as the weight bearing part of the joint and that would buy them time before they need any major surgery and then joint replacement obviously in one or other of it's forms i-, is the is the final solution if all other measures have failed and obviously the younger the patient the more likely you are to try debridement and osteotomy and conservative measures because the longer you can leave er doing a hip replacement the better but the best er for the best prostheses and the best places your hip arthroplasty's going to last you fifteen twenty years and so you want to wait until your sixty- five seventy before you have your first hip replacement that's all i'm going to say about painful hip O-A hip is going to be without a doubt er the most common thing you're going to see in adults er you very rarely get chronic painful hip in children it's usually the sort of thing we said earlier on irritable hip or er a transient painful hip but by and large it's an adult O-A hip condition any questions before the er are you doing it do you want to set it up nm5245: any questions while they're setting their talk up no good i'll take a seat are you happy doing that sm5247: yeah okay we saw Mrs T who's a fifty-six year old w-, who's a retired teacher she presented with increasing pain affecting her left groin buttocks thigh and knee over the last two years increasing left lower limb stiffness and decreasing mobility her pain initially started as a stabbing s-, stinging sensation in the groin but this progressed to a constant pain in the groin buttocks pulling down towards her knee and into her ankle which she described as like having a constant toothache it worsens when she moves suddenly she says when she forgets that she's got a problem or er when she mobilises after a period of rest and it's now affecting her sleep her stiffness is worse in the morning after maintaining one position for a period of time it affects her lumbar spine her hip and her knee the worst and it's got progressively worse over time she now walks with two crutches she's got a reduced range of movement and she has to use grab rails on the stairs and in the bathroom she's had to stop swimming walking and gardening and last year she had to change to an automatic car her hip feels hot and she's aware of crepitus on movement of her hip and she's got constantly swollen knees she does have O-A of the knees as well her past medical history she was diagnosed in nineteen-eighty with rheumatoid arthritis following a viral infection she's currently in remission and she's been discharged from the rheumatologist at the moment she was diagnosed with osteoarthritis eight years ago had successful right total hip replacement in nineteen-ninety-eight because of an O-A hip she's had bilateral surgery for Carpal Tunnel Syndrome which was successful she's hypothyroids she's had a hysterectomy and a bladder repair in nineteen-eighty-eight and she's depressed as a result of the pain from her hip she's got positive history for both rheumatoid arthritis and osteoarthritis she's married she's got a seventy-nine year old husband who's diabetic has a triple A and also has osteoarthritis of his hip but he is still quite mobile she has a son and granddaughter who visit her regularly and her eighty year old mother lives locally and is in reasonable health she lives in a house has an up and downstairs bathroom and the bedroom's upstairs but she's actually had a lift installed so she doesn't have any problems with the stairs she is a retired teacher had to retire due to her pain and she's very annoyed at having to do that er she's a non-smoker and occasional alcohol she is on a load of medication for her arthritis heart problems and she's stopped her H-R-T prior to surgery because of the increased risk of D-V-T's differential diagnosis at this stage was obviously O-A hip but in the back of her mind she knew she had rheumatoid arthritis and avascular necrosis on examination she is well she's quite a large lady er she has no significant Heberden's or Bouchard's nodes but she does have had rheumatoid arthritis hand deformities her M-C-P's were very inflamed and red and spongy to feel and her wrists were significantly involved she has a scar from her right total hip replacement but there were no other skin changes she has bilateral knee joint effusions and left quadriceps wasting there's no apparent leg length discrepancy but her left leg is held in a slight external rotation she's got a slight left lower limb fixed flexion deformity which they tested using Thomas and she has an antalgic gait her sk-, the skin around her hip was warm she was very tender over the hip and groin there was no sensory loss all the lower limb pulses were intact and all her hip movements were restricted particularly internal rotation abduction and extension and she had a positive Trendelenburg sign and she described the crepitus on movement of her hip you couldn't feel that when she was moving her hip but you could definitely feel it in the knees i saw her this morning she's three days post-op she's had a total hip replacement on the left she's very well she's mobilising with two crutches her pain's controlled and there's no sign of wound infection su: i'm going to quickly go through osteoarthritis again for you er it's a problem of the synovial joint it's a chronic joint disorder which is characterised by progressive softening and disintegration of articular cartilage subchondral bone sclerosis and cyst formation osteophyte formation and capsular fibrosis er you find it increased instance prevalence i-, with increasing age but you also find ma-, male and fe-, er women are act-, actually affected the same but you do find distribution actually differences differences with the sex you get primary O-A and secondary O-A primary O-A O-A occurs spontaneously there's no previous cause secondary O-A normally O-A occurs after either developmental abnormality trauma or previous arthritis O-A typically affects the fingers the hip the knee and the spine more than it affects the elbow the wrist and the ankle clinical features are pain which goes from groin anterior thigh radiating towards the knee it starts off after inac-, after inactivity becomes constant and then actually affects sleep you get stiffness a limp limitation of movement and swelling and deformity you get an antalgic gait positive Trendelenburg signs affects the er the affected leg lies in external rotation and ad-, adduction you get a fixed flexion deformity with muscle wasting especially the quadriceps the greater trochanter is actually higher than the on the affected side than the unaffected side er tenderness over the groin hip and anterior thigh and movements are restricted especially internal rotation abduction and extension er diagnosis mostly from the history but the gold standard is a plain x-ray where you'll find a narrowed joint space sclerosis of the subchondral bone cyst formation osteophyte formation management is through education self-management things like weight reduction lifestyle change like changing job you also do physiotherapy and occupational therapy for you know maintaining joint movements and increasing sp-, st-, er stability including mobility aids such as stair lifts walking sticks you might say have things like like shoe wedges as well and you might have thin-, do things like hydrotherapy and acupuncture you can have pharmacological treatment which is mainly pain control and er anti-inflammatories and you can also go to surgery including arthr-, arthr-, arthroscopy which is j-, joint debridement osteotomy which is joint realignment and arthroplasty which is joint replacement indications for surgery are uncontrolled pain significant restriction of activities marked deformity progressive loss of movement and x- ray signs of joint destruction and that's it nm5245: i'm not sure how well these will project but er i think most of you have probably seen the er x-rays er if it comes up i don't know how well that's projecting or not but you can see the difference between the two hips quite destroyed joint and the hip replacements now you don't need to get too bogged down when it comes to exams and thing about types of hip replacement or er your it doesn't project very well or the make or the model of it it's the basic principles you really want to know all you're doing is replacing the destroyed joint and in in order to do that you need to get rid of the socket er and er the femoral head so you have the standard hip replacement consists it's not projecting very well is a er high density er ultra high molecular weight polyethylene er cup and er a metallic stem and femoral head but nowadays metal on metal because of refined engineering techniques er er more and more being used so you can get more bone preservation these standard stems are cemented you can probably see a little white dot here that's a cement restrictor you get c-, bone cement down here and the stem is put in it leads to quite a lot of bone destruction y-, you're taking away a whole chunk of bone and bone cement itself causes bone destruction so when hips come loose eventually you get less and less bone stock so when it comes to revision fifteen years down the line when you come to revise the hip replacement you'll get whole chunks of bone missing there'll be segmental defects in the acetabulum and revision surgery is really quite complex and becomes quite troublesome so more and more of the hip replacements these days are er er aimed at trying to preserve as much of the bone as possible and er metal on metal surface replacement is is one of the things that they er have developed to to try and preserve bone just to show that actually it doesn't have to be older people this is a patient that just happened to come into clinic last week he's only twenty-eight and er he's convinced that his hip pain started following a road traffic accident er and he's suing other the other driver and it happened about a year ago and he developed pain he was referred to the clinic because of back pain following injury and again when you ask him his pain's in the groin and he says that he can't stand up straight and he's er he he swears this all started the day he was er crashed into from behind and his lawyer convinced him of that er right hip left hip is er these are inversed aren't they right hip is absolutely fine left hip you can see that there's a concentric loss of joint space on this side yeah it's irregular compared to the opposite side there's some sclerosis it doesn't show up on the projection very well but there are some cysts no osteophyte formation of any significance yet and as i say he's only in his in his mid to late twenties and what he's got is all the features of a quite aggressive destructive inflammatory arthropathy so he hasn't got osteoarthritis he's got other some other form of er er er arthropathy a-, akin to rheumatoid or sero negative arthropathy of some sorts er and clearly that's been going on for a lot longer than when he had his road traffic accident and try as he may he's not going to win the case to blame them but he's going to need a hip replacement before he's thirty-five or forty now then our last topic is back pain any questions on hips first any questions on hip pain we've got time it's going a bit faster than i thought er sf5248: hello right we're calling our patient Mrs S okay she was brought into A and E on the eleventh of May of this month er and what happened was she was trying to get out of her canal boat and she experienced severe shooting pains emerging from her lower back and down both both of her legs her legs gave way and she fell backwards onto her bottom and and then she couldn't feel her legs and was unable to move due to the pain in her back and as it says er she had urinary urgency but didn't but had no okay history of presenting complaint er she had a long history of chronic back pain er she said it started when she was twenty-one when she was a lorry driver er but first of all she just thought it was more back pain and attrib-, attributed it to er just jumping in and out of her cab all the time er but the pain changed in nature and it changed from an ache to a stabbing pain and it got progressively worse and it began to radiate down her buttocks and her upper thighs she eventually became unable to weight bear due to the pain and actually became wheelchair bound in nineteen-ninety- eight er she did regain some mobility and was a-, able to use crutches and did so for over three years and in January last year she had an I-D-E-T operation if you want to know what that is it's an Intra-Discal Electro-Thermal Annulaplasty and it's a recently developed technique for discogenic pain and there's only about twenty surgeons that do it in the UK and Mr Shergill's one of them and what they do is they have er a hollow needle and they insert it into the appropriate disc er in the side using x-ray guidance and a local anaesthetic and through this needle they put an electric wire er electrode and what they do is they wind the electrode round the the inside of the disc into the nucleus pulposus and once it's in the correct position they heat it for about fifteen minutes at ninety degrees C er and the theory is that it deadens the nerve endings and the nerve endings that are transmitting the discogenic pain okay so as it says er she regained almost full mobility and was really active after her operation er but unfortunately ten months later her symptoms er returned and these included spasms in her lower back and shooting pains in her legs and these pains were so bad that they er woke her up at night okay past medical history she was diagnosed with osteoporosis at seventeen she was really young er she has asthma endometriosis and last year IDET fusion and February this year she had a salpingectomy pregnancy drug history er she's on co-, co-proximal tablets er bisacodyl inhalers for asthma and diazepam anxiolytic and she's allergic to stemetil there's no significant family history in terms of social history er she's a thirty-two year old married lady and she alternates between living on her canal boat and a three bedroom house in Coventry depending on how her back feels er she has no children and has been unemployed for four years because of her back pain and she's never smoked and hardly drinks any alcohol systems review was unremarkable er James is going to tell you that sm5249: okay we did an examination on her it was a bit of nightmare really because she's bed bound she's in a lot of pain so her B-P was a hundred and thirty-seven over eighty-seven and her pulse was sixty-eight beats per minute we looked at her lower limbs first er the tone was increased bilaterally but that was more due to pain she didn't really want to move her legs er power we were unable to test due to the pain as well but there was no muscle atrophy there and her her calves and her thighs and everything looked pretty normal er reflexes in the knees in the an-, knee reflexes ankle reflexes and the plantars were normal on both the left and the right side sensation er it was bilateral er paraesthesiae in the L three L four dermatomal distributions er more so on the right side than the left side er we were unable to test the co-ordination due to pain and there was no problems in her upper limbs or any o-, any other systems looking at psychosocial issues er she lost her business er she can't ride her motorbike she can't have a family at the moment er she can't go on holiday this has led to kind of social isolation depression er financial problems because of her loss of business loss of independence and an increase in weight investigations carried out were plain x-rays to start with er then blood tests which were all normal and then there was an M-R-I scan of the lumbar spine which showed degeneration at the L four L five er disc level loss of disc height i?ll show you on here okay well basically this isn't her M-R-I either and it's at the L five S one level you can see there there's a loss of disc height and it's pushing the prolapse down probably pushing onto the nerve roots there but it's not hers as i say so that's just an idea right analysis of history and examination so obviously i've just said disc degeneration at the L four L five level with associated nerve root compression er differe-, differentials are spondylolisthesis ankylosing spodylitis osteoporosis and neoplasm management first of all it's analgesics just to control the back pain but er other things could be lifestyle changes which she's had to do she can't drive a lorry any more change in employment er ergonomics which means she has to buy one of those nice chairs to sit in anything like that er physiotherapy er she was wearing a spinal support corset just to give her spine extra support and finally if all of those things don't work surgery er she had the I-D-E-T but that hasn't worked so she's going to have this P-L-L P-L-I-F which is the fusion that's the end thank you cheers nm5245: thanks very much er it's actually worth seeing that patient because she's a typical typical back pain patient and er i think James said that they couldn't examine properly because she was bed bound and er so on so forth she's got a corset on she's got her crutches by her side er and all the rest of it and er she stormed out of that meeting after because she was just saying that refused to go to have more surgery very typical er back pain patient she's had one procedure hasn't worked eighty per cent success rate with any type of fusion but she is a very very difficult patient comes into play er one minute they're rational the next minute they're not i'm not saying that all patients with back pain are like that er but it's an important factor in management