2. Primary Care Management The Hip Andrew Pearse Consultant Trauma and Orthopaedics Worcestershire Acute Hospitals NHS Trust

3. Primary Care Management Introduction Brief anatomy and topography History & examination Osteoarthritis Investigations Referral Oxford Hip Score

4. Primary Care Management Anatomy Ball and socket joint Movement –Flexion –Extension –Abduction –Adduction –Rotation Internal External

5. Primary Care Management Hip Topography Buttock pain - ?back Trochantric bursitis Meralgia parasthetica Deep groin pain – hip joint

6. Primary Care Management Examination LOOK FEEL MOVE Special tests

7. Primary Care Management Examination LOOK –Walk – limp –Position of hip when lying on couch – flexed / externally rotated –Short leg –Scars / erythema / sinuses / swellings

8. Primary Care Management Examination FEEL –Get patient to POINT to tender bit –Groin (tends to be hip joint pain) –Greater trochanter – bursitis / meralgia parasthetica –Buttocks – referred from back

9. Primary Care Management Examination MOVE –Take it through range of motion and…. ASK WHEN IT HURTS – OA is often painful in internal rotation –Back problems usually don’t affect hip movements when lying down

10. Primary Care Management Examination Special tests –Trendelenburg test –Thomas’ test?

11. Primary Care Management Osteoarthritis

12. Primary Care Management Osteoarthritis Osteoarthritis (OA) is a disorder of synovial joints: Focal areas of damage to the articular cartilage Remodelling of underlying bone Mild synovitis Osteoarthritis (OA) is the most common form of arthritis Post-mortem studies show that most people over the age of 65 years have OA in at least one joint X-ray studies show that at least 50% of people over the age of 65 years have evidence of OA. However, only 30% of people with X-ray evidence of OA have pain at the relevant site Symptomatic OA (pain with X-ray changes) is found in 6% of people over the age of 30 years

13. Primary Care Management OA Hip – The Patient History –Pain When? –How far do you walk? –Have you tried using a stick? Is your distance limited by hip pain or other medical conditions? – Does it wake you? –Function Can you tie your shoe laces / clip your toenails? –Analgesia Which and how often? Would you consider a hip replacement if appropriate?

14. Primary Care Management OA Hip – The Patient LOOK –Limp - antalgic / short leg / Trendelenburg gait –Use of a stick (in opposite hand) –Shortened leg FEEL –Groin pain MOVE –Stiff – particularly internal rotation

15. Primary Care Management OA Hip – The Patient +ve Trendelenburg test: –Failure of hip abductors or “pelvic elevators” Swung weight over bad leg

16. Primary Care Management OA Hip – The Patient Think about the back –Referred pain to thigh / buttocks / greater trochanter –Distal neurology REMEMBER – knee pain can be a presenting complaint of HIP OA

17. Primary Care Management Management XR AP hips Bloods – inflammatory markers Review analgesia and walking aids Physio – is there a role? CKS* recommended despite weak evidence Weight loss *www.cks.library.nhs.uk

18. Primary Care Management Current Evidence Exercise / physio? Yes – limited evidence TENS? No evidence Avocado soybean? Yes Steroid injections? Under X-ray  not in 1° care Chondroitin? No – lack of evidence Topical NSAIDs? Flare-ups only Magnetic braces? Yes - ?how they work

19. Primary Care Management Referral Recommendation Pain –Not controlled by appropriate analgesia –Waking at night Severe restriction of quality of life –Hobbies –Walking distance They want to be considered for surgery Oxford Hip Score…

20. Primary Care Management Oxford Hip Score Recent greater focus on patient-based outcome scores OHS –Validated + –Disease specific –Highly reliable + –Broadly used and accepted in peer-review literature - including national joint registries* + J Bone Joint Surg Br 1996, 78:185-190 *NJR / NZJR

21. Primary Care Management Oxford Hip Score 12 point questionnaire Designed for patients to fill out without aid of a doctor Pre-op and post-op measure –Patient gets to tell the surgeon how good his hip is rather than the other way around!

22. Primary Care Management Oxford Hip Score Score 0-48 –0-19 severe OA –20-29 moderate to severe OA –30-39 mild to moderate OA –40-48 satisfactory joint function Referral* “An Oxford Hip or Knee Assessment has been undertaken and a score of less than 30 has been identified as an indicator for possible surgery. Whilst specifying an Oxford Hip or Knee score of less than 30, this is only a guide and if considered clinically necessary onward referral with a score of more than 30 will be accepted” * NHSW Commissioning Policy

23. Primary Care Management Oxford Hip Score Score 0-48 –0-19 severe OA –20-29 moderate to severe OA –30-39 mild to moderate OA –40-48 satisfactory joint function Referral* “An Oxford Hip or Knee Assessment has been undertaken and a score of less than 30 has been identified as an indicator for possible surgery. Whilst specifying an Oxford Hip or Knee score of less than 30, this is only a guide and if considered clinically necessary onward referral with a score of more than 30 will be accepted” * NHSW Commissioning Policy

24. Primary Care Management Summary Anatomy History Examination –Look, Feel, Move Osteoarthritis Oxford Hip Score

25. Primary Care Management Any Questions?