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Common Problems C1 lecture 2025.Best note for medical studentspptx

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Common Problems Affecting Hip, Knee, Ankle and foot Biniam Tadesse (MD,COTS)
04/22/2025 Hip Knee Ankle 2 Common Problems Affecting Hip • Tumors • Infections • Degenerative • Trauma • Pelvic, Hip and thigh sport conditions • Adult hip problems – OA – AVN – Adult Dysplasia of the hip – etc .. • Pediatric conditions of the hip – DDH – Perthes disease – SCFE – etc..
04/22/2025 Hip Knee Ankle 3 Common Problems AffectingThe Knee • Tumors • Infections • Degenerative • Trauma • KNEE sport conditions • Adult conditions – OA – Sport injuries – Trauma • Pediatric conditions – CKD – Angular deformities around the knee joint – Osgood-schlatter disease
04/22/2025 Hip Knee Ankle 4 Common Problems AffectingThe Ankle and Foot • Tumors • Infections • Degenerative • Trauma • KNEE sport conditions • Adult conditions – OA – Sport conditions – Plantar fascitis – Angular defotmities of Hallux • Pediatric conditions – Club foot – Tarsal coalition – Digital duplications
04/22/2025 Hip Knee Ankle 5 osteoarthritis • is a chronic disease that predominantly affects the synovial joints. • There is – progressive softening and disintegration of articular cartilage – New Growth of cartilage & bone at joint margins(osteophytes) – Cyst formation and sclerosis in the subchondral bone and – Mild synovitis and capsular fibrosis • It is a disease closely associated with aging process • It is a disabling disease that affects 1 in 3 individuals over 60 years if age
04/22/2025 Hip Knee Ankle 6 Anatomy of synovial joint
Osteoarthritis may result from wear and tear on the joint(often associated with abnormal loading rather than frictional wear. •The normal cartilage lining is gradually worn away and the underlying bone is exposed. 04/22/2025 Hip Knee Ankle 7
04/22/2025 Hip Knee Ankle 8
Risk factors Joint dysplasia Trauma Occupation Bone density Obesity Family history 04/22/2025 Hip Knee Ankle 9
04/22/2025 Hip Knee Ankle 10 Clinical... • Age of onset – usually after age of 40 • Commonly affected joints – Cervical and lumbar spine – First carpometacarpal joint – Proximal interphalangeal joint – Distal interphalangeal joint – Hip – Knee – Subtalar joint – First metarsophalangeal joint
Symptoms • Pain • Stiffness • Swelling • Deformity • Loss of function 04/22/2025 Hip Knee Ankle 11
Imaging • X-rays – Asymmetric loss of cartilage (narrowing of the ‘joint space’), – sclerosis of the subchondral bone under the area of cartilage loss, – cysts close to the articular surface, – osteophytes at the margins of the joint and – remodeling of the bone ends on either side of the joint. – Late features may include joint displacement and bone destruction. 04/22/2025 Hip Knee Ankle 12
Asymmetrical joint space narrowing from loss of articular cartilage The medial (inside) part of the knee is most commonly affected by osteoarthritis OA – Radiographic Diagnosis 04/22/2025 Hip Knee Ankle 13
OA – Radiographic Diagnosis •Asymmetrical joint space narrowing •Periarticular sclerosis •Osteophytes •Sub-chrondral bone cysts 04/22/2025 Hip Knee Ankle 14
04/22/2025 Hip Knee Ankle 15
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04/22/2025 Hip Knee Ankle 17 Management principles of OA • Goals of Management To control pain and swelling To minimize disability To improve quality of life To prevent progression of the process To educate the patient about his/her role in management team • Management depends  Joint involved  the stage of the disorder  the severity of the symptoms  The age of the patient  Functional needs
04/22/2025 Hip Knee Ankle 18 Management principles of OA • Non pharmacologic • Pharmacologic • Surgical
04/22/2025 Hip Knee Ankle 19 Non pharmacologic • WEIGHT LOSS  Studies suggest that obesity is strongly associated with OA  One study, noted an increased risk of developing OA of the knee in patients with high body mass indices (1.5 and 2.1 for men and women, respectively)  On follow up study risk of developing OA was reduced following weight loss  a ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50 percent.  The relation between the degree of weight loss and the reduced incidence of OA was linear, suggesting that even modest weight loss may be beneficial.
04/22/2025 Hip Knee Ankle 20 Non pharmacologic… • WEIGHT LOSS… – In addition to reducing the risk of progression of OA, weight loss of even modest degree, may produce improvement in joint pain and function – in a prospective study 316 overweight people with symptomatic and radiographic OA of the knees were randomly assigned to one of four groups: – diet alone, – exercise alone, – diet and exercise, or – education in healthy living • The combination of diet and exercise was the most effective and was associated with decreased knee pain and improved self- reported and measured function.
04/22/2025 Hip Knee Ankle 21 Non pharmacologic… • REST: Resting the affected joint may alleviate pain However prolonged rest will lead to muscle atrophy &decreased joint mobility It is recommended for short period of time typically 12 to 24 hours after which active and passive joint motion and exercises should resume
04/22/2025 Hip Knee Ankle 22 Non pharmacologic… • PHYSICAL THERAPY AND ORTHOSES – There is evidence and general belief that physical therapy and exercise improve clinical outcome in OA – By improving flexibility and strengthening muscles supporting the affected joints, patients improve functional outcome and pain scores – wedged insoles – Braces-eg. valgus bracing of the knee – Knee taping
04/22/2025 Hip Knee Ankle 23 Non pharmacologic… • Exercise – Exercises that cause low load effects such as – swimming, – bicycling, – walking, or – Tai Chi • avoid excessive stair climbing • All programs include ROM & isometric strengthening exercises } are helpful in developing muscular strength while protecting joints
04/22/2025 Hip Knee Ankle 24 Pharmacologic Treatment • Analgesics • NSAIDS • Intraarticular glucocorticoid injections • intraarticular Hyaluronans
04/22/2025 Hip Knee Ankle 25 Surgical Treatment • Debridement • Osteotomy • Arthrodesis • Joint replacement
04/22/2025 Hip Knee Ankle 26 Surgical Treatment…
Management • EARLY TREATMENT – Physical therapy – Load reduction – Analgesic medication • INTERMEDIATE TREATMENT – Debridement – Correction osteotomy • LATE TREATMENT – Realignment osteotomy – Joint replacement 04/22/2025 Hip Knee Ankle 27
Osteonecrosis of Femoral Head • Cellular death of bone components secondary to interruption of blood supply to the bone. -Consequent collapse of bone components • Femoral head - most commonly affected • Aseptic bone necrosis or AVN or ischemic necrosis 04/22/2025 Hip Knee Ankle 28
04/22/2025 29 Epidemiology • Incidence – 20,000 patients newly diagnosed each year in US – accounts for 10% of total hip arthroplasties performed • Demographis – male > females • Mostly affect age b/n 35-50 yrs(mean 38yr) Hip Knee Ankle
04/22/2025 30 Pathology • Compromised circulation in Osteonecrosis may be grouped in to 4 possible mechanisms • 1) mechanical disruption of the vessels; • (2)occlusion of the arterial vessels; • (3) injury to or pressure on the arterial wall; and • (4) occlusion to the venous outflow vessels. Hip Knee Ankle
04/22/2025 31 Blood supply … Hip Knee Ankle
04/22/2025 32 Hip Knee Ankle
04/22/2025 33 Presentation History • insidious onset of pain • pain with stairs, inclines, and impact • pain common in anterior hip • ‘Click’ in the joint • Deformity and stiffness – later stages • Trauma • Corticosteroid use • Alcohol intake • Medical conditions – malignancy, thrombophilia, SLE, Hip Knee Ankle
04/22/2025 34 Physical examination • Mostly normal initially • Limp • Antalgic gait • Restricted ROM • Tenderness around bone • Joint deformity • Muscle wasting Hip Knee Ankle
04/22/2025 35 Investigations • For diagnosis of the underlying disorder • CBC • Liver enzymes • Lipid profile • Antiphospholipid antibodies Hip Knee Ankle
04/22/2025 36 Imaging X ray • Early – Normal • Crescent sign • Osteoporosis • Sclerosis • Cystic change • Loss of spherical of weight bearing dome • Partial collapse of head • Secondary osteoarthritis Hip Knee Ankle
04/22/2025 37 MRI • highest sensitivity (99%) and specificity (99%) • T1 :dark (low intensity band) • T2: focal brightness (marrow edema) Hip Knee Ankle
04/22/2025 38 Hip Knee Ankle
04/22/2025 39 Classifications • Ficat and Arlet Classification • Steinberg classification • ARCO Hip Knee Ankle
04/22/2025 40 Ficat and Arlet Classification Hip Knee Ankle
04/22/2025 41 STEINBERG CLASSFICATION Hip Knee Ankle
04/22/2025 42 Treatment Options • Surgery is the mainstay of treatment for ON • The goal of therapy is to preserve the native joint for as long as possible • There are three main therapeutic options – Nonoperative management – Joint-preserving procedures – Joint replacement Hip Knee Ankle
04/22/2025 43 Management principles • Early stages (I & II): – Bisphosphonates ?prevent collapse – Medullary decompression + bone grafting • Intermediate stage (III & IV): – Realignment osteotomies, decompression – Arthroplasties • Late stage (V & VI): – Analgesia, activity modification – Arthroplasties – Arthrodesis Hip Knee Ankle
04/22/2025 44 Management - conservative • Off loading affected joints with use of crutches • Immobilization • Analgesia • Bisphosphonates to delay femoral head collapse (long term effect is unclear) • Statins in patients on high dose corticosteroids – reduced lipid deposition • Shock wave Hip Knee Ankle
Developmental dysplasia of the hip • Spectrum of disorders of developing hip • from dysplasia to subluxation to dislocation of the hip joint • Gradually progressive • present in different forms at different ages. 04/22/2025 Hip Knee Ankle 45
04/22/2025 Hip Knee Ankle 46 spectrum of DDH
Incidence • 1-1.5 per 1000 births • Highest in whites and native Americans -15 per 1000 • Lowest in Africans and Asians -0.1 per 1000 • Left 60% (left occiput ant), Right 20%, both 20% 04/22/2025 Hip Knee Ankle 47
04/22/2025 Hip Knee Ankle 48 Etiology • There is no a single cause for DDH(multifactorial) • There are different predisposing factors -ligaments laxity - prenatal conditions -post natal condition - genetic factor - others - racial predilection -primary acetabular dysplasia - musculoskeletal abnormality
04/22/2025 Hip Knee Ankle 49 1. Ligamentous laxity:  Hormone induced:  maternal hormones that produces relaxation of the pelvic during delivery may causes enough ligamentous laxity in the child in utero and during neonatal period to allow dislocation of femoral head.  Estrogen, Relaxin  May affect baby girls more? – receptors.  Familial ligamentous laxity: –Mild – Moderate – Severe.
04/22/2025 Hip Knee Ankle 50 Ligamentous Laxity: hypermobile joint .
04/22/2025 Hip Knee Ankle 51 Prenatal condition • First born baby • Oligohydramnious • Fetal position
04/22/2025 Hip Knee Ankle 52 Post natal condition
04/22/2025 Hip Knee Ankle 53 Clinical presentations • Neonate - Diagnosed by Barlow test , Ortolan sign and by U/S -Radiographs not reliable in making the diagnosis
04/22/2025 Hip Knee Ankle 54 Barlow and ortolani test
04/22/2025 Hip Knee Ankle 55 INFANT - Limitation of abduction ( the most reliable sign of a dislocated hip) - Shortening of thigh ( galleazzi sign) - Asymmetry of of thigh folds
04/22/2025 Hip Knee Ankle 56 Walking Child -The affected side appears to be shorter - child toe-walks on the affected side -Trendelenburg sign+ -Galeazzi sign+ -limited abduction -Excessive lordosis(in bilateral cases)
Hip Knee Ankle 57 Diagnostic imaging • Clinical evaluation remains gold standard in early infancy. 1.Ultrasonography: A.Morphologic Assessment: Critical evaluation of bony anatomy of Hip joint. Measure α and β angle of the acetabulum. B.Dynamic Assessment: • Observe what occur with ortolani & Barlow test. 04/22/2025
04/22/2025 Hip Knee Ankle 58 2. x-ray • Demonstrates frankly dislocated hip. • Several classic lines are helpful in evaluating the immature hip • The most commonly used lines of reference are the vertical line of Perkins and the horizontal line of Hilgenreiner, both used to assess the position of the femoral head. • Normally, the metaphyseal beak of the proximal femur lies within the inner lower quadrant of the reference lines noted by Perkins and Hilgenreiner.
04/22/2025 Hip Knee Ankle 59
Screening critrea • Family history • Breech birth • Torticollis • Metatarsus adductus • Oligohydraminos • First born whites • Girls 04/22/2025 Hip Knee Ankle 60
04/22/2025 Hip Knee Ankle 61 TREATMENT OF DDH • The goal of the treatment is to obtain reduction and maintain it to provide optimal environment for development of femoral head and acetabulum. • Method depends on age. • The earlier started, the easier it is. • The earlier started, the better the results are • Should be detected EARLY
Tx • 0-6 month – pavlik harness, 6 weeks • 6-18 month – traction, closed reduction,cast for three month • 18- 24 month – closed or open reduction • > 24 month – open reduction, femoral shortening, with or without pelvic osteotomy 04/22/2025 Hip Knee Ankle 62
Tx 04/22/2025 Hip Knee Ankle 63
 Complications  Avascular necrosis  Forced hip abduction  Safe zone (abd/adduction and flexion/extension)  Femoral nerve palsy  Hyperflexion 04/22/2025 Hip Knee Ankle 64
• Closed reduction + Spica • Failure after 3 weeks of Pavlik trial 04/22/2025 Hip Knee Ankle 65
04/22/2025 Hip Knee Ankle 66
04/22/2025 Hip Knee Ankle 67
Complications • AVN • Inadequate and redislocation • Residual acetublar dysplasia 04/22/2025 Hip Knee Ankle 68
PERTHES’ DISEASE (LEGG-CALVE- PERTHES’DISEASE • Legg- calve-Perthes disease(LCPD) - is a childhood disorder characterized by avascular necrosis of the femoral epiphysis( head) 04/22/2025 Hip Knee Ankle 69
Epidemiology • Incidence 1-4/10,000 • Age 4 - 10years; average 7 yrs – As early as 2yrs and as late as teens • Boys : girls 4:1 • Bilateral 10-12% • Common in Caucasians; rare in black races 04/22/2025 Hip Knee Ankle 70
Etiology • The etiology is multifactorial, with the exact cause uncertain • Factors that may be etiologic :- – Trauma – Susceptible child – Hereditary factors –Coagulopathy –Hyperactivity –Passive smoking –Synovitis 04/22/2025 Hip Knee Ankle 71
Pathology  Goes through stages which may last 3 to 4 years  Stage 1  Ischemia and bone death, cartilage thickens  Stage 2  Revascularization and repair  Dead marrow replaced by granulation tissue  Bone revascularized and new bone laid down  Dead bone resorbed, replaced by fibrous tissue, fragmentation  Stage 3  Distortion and remodeling  Restoration of femoral architecture or collapse  Femoral head displaces laterally in relation to acetabulum 04/22/2025 Hip Knee Ankle 72
Pathology…. 04/22/2025 Hip Knee Ankle 73
Clinical features • Symptoms • Limping • Hip pain • Knee pain • History of trauma (?) • Signs – Limp – Decreased hip range of motion – atrophy of muscles. – antalgic gait and a Trendelenburg gait 04/22/2025 Hip Knee Ankle 74
Investigations  Blood tests CBC, ESR, CRP  Imaging Plain X-rays Hip U/S Bone scintigrpahy MRI  Bilateral perthes Skeletal survey as part of work-up 04/22/2025 Hip Knee Ankle 75
Treatment Goals of tratment Maintain femoral head spherity – containment Avoid severe degenerative arthritis Guided by Age Severity Limitation in ROM 04/22/2025 Hip Knee Ankle 76
Treatment: Two main choices • symptomatic • Pain control • Gentle exercises • Regular re-assessment • Avoid sport and strenous activities • Containment • Hold hips widely abducted in cast/brace >1yr • Operation • Varus osteotomy of femur • Innominate osteotomy of pelvis • Both 04/22/2025 Hip Knee Ankle 77
04/22/2025 Hip Knee Ankle 78
CLUB FOOT 04/22/2025 Hip Knee Ankle 79
04/22/2025 80 INTRODUCTION • Club foot: – Congenital condition affecting the foot with CAVUS, ADDUCTION , VARUS & EQUINUS of the newborn’s foot. – Pes equinovarus , talipes equinovarus – Isolated deformity Vs part of a systemic affection. – Developmental. Hip Knee Ankle
04/22/2025 81 Epidemiology • The commonest congenital foot problem needing treatment & causing permanent disability • M:F ranging b/n 2:1 & 4:1 • 1-2 live birth)/1000 globally • 17x increased risk if 1st & 6x with 2nd degree relative • 25% could have family history • 32% in MZ & 3% in DZ twins • 50% bilateral. Hip Knee Ankle
04/22/2025 82 PATHOGENESIS • Several theories I. Embryonic developmental arrest : arrested development around the 8th wk, no abnormal talar head & navicular dislocation II. Myofibroblastic retractile tissue hyper cellular & wavy collagenous ST III. Germplasm defect: talar cartilage analge hypoplasia IV. Neuromuscular imbalance: peroneal Vs Tibials Hip Knee Ankle
04/22/2025 83 Classification • Etiologic – Idiopathic – Positional /postural – Syndromic – Neurogenic Hip Knee Ankle
04/22/2025 84 • Based on treatment – Untreated:<2 yrs – Neglected:>2 yrs with the effect of walking & severe bony & ST effects – Treated: no sign of recurrence & on follow up – Resistant: no/minimal change seen with Ponseti & are seen in association with syndromes such as arthrogryposis – Relapse: signs of the previous deformity (equinus, supination) – Complex: clubfoot treated with non Ponseti method & has added effects of the treatment Hip Knee Ankle
04/22/2025 85 Hip Knee Ankle
04/22/2025 86 TREATMENT • All clubfoots need treatment • Goals – Painless – Functional – Supple – Plantigrade • When – As soon as possible Hip Knee Ankle
04/22/2025 87 • Options – Conservative • Serial casting & stretching • Functional splint – Surgical • Soft tissue • Bony • combined Hip Knee Ankle
04/22/2025 88 CONSERVATIVE • Should the 1st step in managing new pts . • The sooner the better. • Significant reduction in number & extent of surgery with its complications. • Gradual correction using the visico-elastic nature of the neonatal tissue. • Should be done with at most attention for details & with patience Hip Knee Ankle
04/22/2025 89 PONSETI • Early method (1940’s) but delayed acceptance by the medical society. • Simultaneous weekly manipulative correction of the foot with cast immobilization to achieve overcorrection. • Atraumatic ST manupulation with time for remodeling & correction • 95% successful outcome esp. in younger pts. • Aim for Overcorrection Hip Knee Ankle
04/22/2025 90 Techniques of Ponseti . Gentel manipulation & gradual serial casting • Fulcrum always LHT • Padding, 3-4 turns over toes. • 1st SLC……..Always LLC (toe-to-groin cast) • Light pressure molding • Abduction of the foot always in supination Hip Knee Ankle
04/22/2025 91 Reduce the cavus Hip Knee Ankle
04/22/2025 92 Hip Knee Ankle
04/22/2025 93 Abduction with forefoot supination Hip Knee Ankle
04/22/2025 94 Hip Knee Ankle
04/22/2025 95 Hip Knee Ankle
04/22/2025 96 Hip Knee Ankle
04/22/2025 97 Time for Tenotomy • Liberally use tenotomies • When?? – Adequate abduction – Dorsiflextion ~ neutral to 5 degrees – Midfoot score = 0, Hindfoot score > 0 Hip Knee Ankle
04/22/2025 98 Bracing • Maintenance phase to prevent recurrence/relapse. • High top, 60° ER, & padded heal shoes for a long time. • Full time 3mo...Night time till 3yrs…discontinue when plantigrade foot. • Relapse in > 80% of case in non-compliant families in contrast to relapse rate of 6% in compliant family. • Educate the family about Ponseti management . Hip Knee Ankle
04/22/2025 99 • Brace followup – In 10-14 days to monitor – Next in 3 month. – Then every 4 month – At age 3-4 yrs every 6month – From 4 years until maturity check every 1 to 2 years. Hip Knee Ankle
THANK YOU 04/22/2025 Hip Knee Ankle 100

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Common Problems C1 lecture 2025.Best note for medical studentspptx

  • 1.
    Common Problems AffectingHip, Knee, Ankle and foot Biniam Tadesse (MD,COTS)
  • 2.
    04/22/2025 Hip KneeAnkle 2 Common Problems Affecting Hip • Tumors • Infections • Degenerative • Trauma • Pelvic, Hip and thigh sport conditions • Adult hip problems – OA – AVN – Adult Dysplasia of the hip – etc .. • Pediatric conditions of the hip – DDH – Perthes disease – SCFE – etc..
  • 3.
    04/22/2025 Hip KneeAnkle 3 Common Problems AffectingThe Knee • Tumors • Infections • Degenerative • Trauma • KNEE sport conditions • Adult conditions – OA – Sport injuries – Trauma • Pediatric conditions – CKD – Angular deformities around the knee joint – Osgood-schlatter disease
  • 4.
    04/22/2025 Hip KneeAnkle 4 Common Problems AffectingThe Ankle and Foot • Tumors • Infections • Degenerative • Trauma • KNEE sport conditions • Adult conditions – OA – Sport conditions – Plantar fascitis – Angular defotmities of Hallux • Pediatric conditions – Club foot – Tarsal coalition – Digital duplications
  • 5.
    04/22/2025 Hip KneeAnkle 5 osteoarthritis • is a chronic disease that predominantly affects the synovial joints. • There is – progressive softening and disintegration of articular cartilage – New Growth of cartilage & bone at joint margins(osteophytes) – Cyst formation and sclerosis in the subchondral bone and – Mild synovitis and capsular fibrosis • It is a disease closely associated with aging process • It is a disabling disease that affects 1 in 3 individuals over 60 years if age
  • 6.
    04/22/2025 Hip KneeAnkle 6 Anatomy of synovial joint
  • 7.
    Osteoarthritis may resultfrom wear and tear on the joint(often associated with abnormal loading rather than frictional wear. •The normal cartilage lining is gradually worn away and the underlying bone is exposed. 04/22/2025 Hip Knee Ankle 7
  • 8.
  • 9.
    Risk factors Joint dysplasia Trauma Occupation Bonedensity Obesity Family history 04/22/2025 Hip Knee Ankle 9
  • 10.
    04/22/2025 Hip KneeAnkle 10 Clinical... • Age of onset – usually after age of 40 • Commonly affected joints – Cervical and lumbar spine – First carpometacarpal joint – Proximal interphalangeal joint – Distal interphalangeal joint – Hip – Knee – Subtalar joint – First metarsophalangeal joint
  • 11.
    Symptoms • Pain • Stiffness •Swelling • Deformity • Loss of function 04/22/2025 Hip Knee Ankle 11
  • 12.
    Imaging • X-rays – Asymmetricloss of cartilage (narrowing of the ‘joint space’), – sclerosis of the subchondral bone under the area of cartilage loss, – cysts close to the articular surface, – osteophytes at the margins of the joint and – remodeling of the bone ends on either side of the joint. – Late features may include joint displacement and bone destruction. 04/22/2025 Hip Knee Ankle 12
  • 13.
    Asymmetrical joint spacenarrowing from loss of articular cartilage The medial (inside) part of the knee is most commonly affected by osteoarthritis OA – Radiographic Diagnosis 04/22/2025 Hip Knee Ankle 13
  • 14.
    OA – RadiographicDiagnosis •Asymmetrical joint space narrowing •Periarticular sclerosis •Osteophytes •Sub-chrondral bone cysts 04/22/2025 Hip Knee Ankle 14
  • 15.
  • 16.
  • 17.
    04/22/2025 Hip KneeAnkle 17 Management principles of OA • Goals of Management To control pain and swelling To minimize disability To improve quality of life To prevent progression of the process To educate the patient about his/her role in management team • Management depends  Joint involved  the stage of the disorder  the severity of the symptoms  The age of the patient  Functional needs
  • 18.
    04/22/2025 Hip KneeAnkle 18 Management principles of OA • Non pharmacologic • Pharmacologic • Surgical
  • 19.
    04/22/2025 Hip KneeAnkle 19 Non pharmacologic • WEIGHT LOSS  Studies suggest that obesity is strongly associated with OA  One study, noted an increased risk of developing OA of the knee in patients with high body mass indices (1.5 and 2.1 for men and women, respectively)  On follow up study risk of developing OA was reduced following weight loss  a ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50 percent.  The relation between the degree of weight loss and the reduced incidence of OA was linear, suggesting that even modest weight loss may be beneficial.
  • 20.
    04/22/2025 Hip KneeAnkle 20 Non pharmacologic… • WEIGHT LOSS… – In addition to reducing the risk of progression of OA, weight loss of even modest degree, may produce improvement in joint pain and function – in a prospective study 316 overweight people with symptomatic and radiographic OA of the knees were randomly assigned to one of four groups: – diet alone, – exercise alone, – diet and exercise, or – education in healthy living • The combination of diet and exercise was the most effective and was associated with decreased knee pain and improved self- reported and measured function.
  • 21.
    04/22/2025 Hip KneeAnkle 21 Non pharmacologic… • REST: Resting the affected joint may alleviate pain However prolonged rest will lead to muscle atrophy &decreased joint mobility It is recommended for short period of time typically 12 to 24 hours after which active and passive joint motion and exercises should resume
  • 22.
    04/22/2025 Hip KneeAnkle 22 Non pharmacologic… • PHYSICAL THERAPY AND ORTHOSES – There is evidence and general belief that physical therapy and exercise improve clinical outcome in OA – By improving flexibility and strengthening muscles supporting the affected joints, patients improve functional outcome and pain scores – wedged insoles – Braces-eg. valgus bracing of the knee – Knee taping
  • 23.
    04/22/2025 Hip KneeAnkle 23 Non pharmacologic… • Exercise – Exercises that cause low load effects such as – swimming, – bicycling, – walking, or – Tai Chi • avoid excessive stair climbing • All programs include ROM & isometric strengthening exercises } are helpful in developing muscular strength while protecting joints
  • 24.
    04/22/2025 Hip KneeAnkle 24 Pharmacologic Treatment • Analgesics • NSAIDS • Intraarticular glucocorticoid injections • intraarticular Hyaluronans
  • 25.
    04/22/2025 Hip KneeAnkle 25 Surgical Treatment • Debridement • Osteotomy • Arthrodesis • Joint replacement
  • 26.
    04/22/2025 Hip KneeAnkle 26 Surgical Treatment…
  • 27.
    Management • EARLY TREATMENT –Physical therapy – Load reduction – Analgesic medication • INTERMEDIATE TREATMENT – Debridement – Correction osteotomy • LATE TREATMENT – Realignment osteotomy – Joint replacement 04/22/2025 Hip Knee Ankle 27
  • 28.
    Osteonecrosis of FemoralHead • Cellular death of bone components secondary to interruption of blood supply to the bone. -Consequent collapse of bone components • Femoral head - most commonly affected • Aseptic bone necrosis or AVN or ischemic necrosis 04/22/2025 Hip Knee Ankle 28
  • 29.
    04/22/2025 29 Epidemiology • Incidence –20,000 patients newly diagnosed each year in US – accounts for 10% of total hip arthroplasties performed • Demographis – male > females • Mostly affect age b/n 35-50 yrs(mean 38yr) Hip Knee Ankle
  • 30.
    04/22/2025 30 Pathology • Compromisedcirculation in Osteonecrosis may be grouped in to 4 possible mechanisms • 1) mechanical disruption of the vessels; • (2)occlusion of the arterial vessels; • (3) injury to or pressure on the arterial wall; and • (4) occlusion to the venous outflow vessels. Hip Knee Ankle
  • 31.
    04/22/2025 31 Blood supply… Hip Knee Ankle
  • 32.
  • 33.
    04/22/2025 33 Presentation History • insidiousonset of pain • pain with stairs, inclines, and impact • pain common in anterior hip • ‘Click’ in the joint • Deformity and stiffness – later stages • Trauma • Corticosteroid use • Alcohol intake • Medical conditions – malignancy, thrombophilia, SLE, Hip Knee Ankle
  • 34.
    04/22/2025 34 Physical examination •Mostly normal initially • Limp • Antalgic gait • Restricted ROM • Tenderness around bone • Joint deformity • Muscle wasting Hip Knee Ankle
  • 35.
    04/22/2025 35 Investigations • Fordiagnosis of the underlying disorder • CBC • Liver enzymes • Lipid profile • Antiphospholipid antibodies Hip Knee Ankle
  • 36.
    04/22/2025 36 Imaging X ray •Early – Normal • Crescent sign • Osteoporosis • Sclerosis • Cystic change • Loss of spherical of weight bearing dome • Partial collapse of head • Secondary osteoarthritis Hip Knee Ankle
  • 37.
    04/22/2025 37 MRI • highestsensitivity (99%) and specificity (99%) • T1 :dark (low intensity band) • T2: focal brightness (marrow edema) Hip Knee Ankle
  • 38.
  • 39.
    04/22/2025 39 Classifications • Ficatand Arlet Classification • Steinberg classification • ARCO Hip Knee Ankle
  • 40.
    04/22/2025 40 Ficat andArlet Classification Hip Knee Ankle
  • 41.
  • 42.
    04/22/2025 42 Treatment Options •Surgery is the mainstay of treatment for ON • The goal of therapy is to preserve the native joint for as long as possible • There are three main therapeutic options – Nonoperative management – Joint-preserving procedures – Joint replacement Hip Knee Ankle
  • 43.
    04/22/2025 43 Management principles •Early stages (I & II): – Bisphosphonates ?prevent collapse – Medullary decompression + bone grafting • Intermediate stage (III & IV): – Realignment osteotomies, decompression – Arthroplasties • Late stage (V & VI): – Analgesia, activity modification – Arthroplasties – Arthrodesis Hip Knee Ankle
  • 44.
    04/22/2025 44 Management -conservative • Off loading affected joints with use of crutches • Immobilization • Analgesia • Bisphosphonates to delay femoral head collapse (long term effect is unclear) • Statins in patients on high dose corticosteroids – reduced lipid deposition • Shock wave Hip Knee Ankle
  • 45.
    Developmental dysplasia ofthe hip • Spectrum of disorders of developing hip • from dysplasia to subluxation to dislocation of the hip joint • Gradually progressive • present in different forms at different ages. 04/22/2025 Hip Knee Ankle 45
  • 46.
    04/22/2025 Hip KneeAnkle 46 spectrum of DDH
  • 47.
    Incidence • 1-1.5 per1000 births • Highest in whites and native Americans -15 per 1000 • Lowest in Africans and Asians -0.1 per 1000 • Left 60% (left occiput ant), Right 20%, both 20% 04/22/2025 Hip Knee Ankle 47
  • 48.
    04/22/2025 Hip KneeAnkle 48 Etiology • There is no a single cause for DDH(multifactorial) • There are different predisposing factors -ligaments laxity - prenatal conditions -post natal condition - genetic factor - others - racial predilection -primary acetabular dysplasia - musculoskeletal abnormality
  • 49.
    04/22/2025 Hip KneeAnkle 49 1. Ligamentous laxity:  Hormone induced:  maternal hormones that produces relaxation of the pelvic during delivery may causes enough ligamentous laxity in the child in utero and during neonatal period to allow dislocation of femoral head.  Estrogen, Relaxin  May affect baby girls more? – receptors.  Familial ligamentous laxity: –Mild – Moderate – Severe.
  • 50.
    04/22/2025 Hip KneeAnkle 50 Ligamentous Laxity: hypermobile joint .
  • 51.
    04/22/2025 Hip KneeAnkle 51 Prenatal condition • First born baby • Oligohydramnious • Fetal position
  • 52.
    04/22/2025 Hip KneeAnkle 52 Post natal condition
  • 53.
    04/22/2025 Hip KneeAnkle 53 Clinical presentations • Neonate - Diagnosed by Barlow test , Ortolan sign and by U/S -Radiographs not reliable in making the diagnosis
  • 54.
    04/22/2025 Hip KneeAnkle 54 Barlow and ortolani test
  • 55.
    04/22/2025 Hip KneeAnkle 55 INFANT - Limitation of abduction ( the most reliable sign of a dislocated hip) - Shortening of thigh ( galleazzi sign) - Asymmetry of of thigh folds
  • 56.
    04/22/2025 Hip KneeAnkle 56 Walking Child -The affected side appears to be shorter - child toe-walks on the affected side -Trendelenburg sign+ -Galeazzi sign+ -limited abduction -Excessive lordosis(in bilateral cases)
  • 57.
    Hip Knee Ankle57 Diagnostic imaging • Clinical evaluation remains gold standard in early infancy. 1.Ultrasonography: A.Morphologic Assessment: Critical evaluation of bony anatomy of Hip joint. Measure α and β angle of the acetabulum. B.Dynamic Assessment: • Observe what occur with ortolani & Barlow test. 04/22/2025
  • 58.
    04/22/2025 Hip KneeAnkle 58 2. x-ray • Demonstrates frankly dislocated hip. • Several classic lines are helpful in evaluating the immature hip • The most commonly used lines of reference are the vertical line of Perkins and the horizontal line of Hilgenreiner, both used to assess the position of the femoral head. • Normally, the metaphyseal beak of the proximal femur lies within the inner lower quadrant of the reference lines noted by Perkins and Hilgenreiner.
  • 59.
  • 60.
    Screening critrea • Familyhistory • Breech birth • Torticollis • Metatarsus adductus • Oligohydraminos • First born whites • Girls 04/22/2025 Hip Knee Ankle 60
  • 61.
    04/22/2025 Hip KneeAnkle 61 TREATMENT OF DDH • The goal of the treatment is to obtain reduction and maintain it to provide optimal environment for development of femoral head and acetabulum. • Method depends on age. • The earlier started, the easier it is. • The earlier started, the better the results are • Should be detected EARLY
  • 62.
    Tx • 0-6 month– pavlik harness, 6 weeks • 6-18 month – traction, closed reduction,cast for three month • 18- 24 month – closed or open reduction • > 24 month – open reduction, femoral shortening, with or without pelvic osteotomy 04/22/2025 Hip Knee Ankle 62
  • 63.
  • 64.
     Complications  Avascularnecrosis  Forced hip abduction  Safe zone (abd/adduction and flexion/extension)  Femoral nerve palsy  Hyperflexion 04/22/2025 Hip Knee Ankle 64
  • 65.
    • Closed reduction+ Spica • Failure after 3 weeks of Pavlik trial 04/22/2025 Hip Knee Ankle 65
  • 66.
  • 67.
  • 68.
    Complications • AVN • Inadequateand redislocation • Residual acetublar dysplasia 04/22/2025 Hip Knee Ankle 68
  • 69.
    PERTHES’ DISEASE (LEGG-CALVE- PERTHES’DISEASE •Legg- calve-Perthes disease(LCPD) - is a childhood disorder characterized by avascular necrosis of the femoral epiphysis( head) 04/22/2025 Hip Knee Ankle 69
  • 70.
    Epidemiology • Incidence 1-4/10,000 •Age 4 - 10years; average 7 yrs – As early as 2yrs and as late as teens • Boys : girls 4:1 • Bilateral 10-12% • Common in Caucasians; rare in black races 04/22/2025 Hip Knee Ankle 70
  • 71.
    Etiology • The etiologyis multifactorial, with the exact cause uncertain • Factors that may be etiologic :- – Trauma – Susceptible child – Hereditary factors –Coagulopathy –Hyperactivity –Passive smoking –Synovitis 04/22/2025 Hip Knee Ankle 71
  • 72.
    Pathology  Goes throughstages which may last 3 to 4 years  Stage 1  Ischemia and bone death, cartilage thickens  Stage 2  Revascularization and repair  Dead marrow replaced by granulation tissue  Bone revascularized and new bone laid down  Dead bone resorbed, replaced by fibrous tissue, fragmentation  Stage 3  Distortion and remodeling  Restoration of femoral architecture or collapse  Femoral head displaces laterally in relation to acetabulum 04/22/2025 Hip Knee Ankle 72
  • 73.
  • 74.
    Clinical features • Symptoms •Limping • Hip pain • Knee pain • History of trauma (?) • Signs – Limp – Decreased hip range of motion – atrophy of muscles. – antalgic gait and a Trendelenburg gait 04/22/2025 Hip Knee Ankle 74
  • 75.
    Investigations  Blood tests CBC,ESR, CRP  Imaging Plain X-rays Hip U/S Bone scintigrpahy MRI  Bilateral perthes Skeletal survey as part of work-up 04/22/2025 Hip Knee Ankle 75
  • 76.
    Treatment Goals of tratment Maintainfemoral head spherity – containment Avoid severe degenerative arthritis Guided by Age Severity Limitation in ROM 04/22/2025 Hip Knee Ankle 76
  • 77.
    Treatment: Two mainchoices • symptomatic • Pain control • Gentle exercises • Regular re-assessment • Avoid sport and strenous activities • Containment • Hold hips widely abducted in cast/brace >1yr • Operation • Varus osteotomy of femur • Innominate osteotomy of pelvis • Both 04/22/2025 Hip Knee Ankle 77
  • 78.
  • 79.
  • 80.
    04/22/2025 80 INTRODUCTION • Clubfoot: – Congenital condition affecting the foot with CAVUS, ADDUCTION , VARUS & EQUINUS of the newborn’s foot. – Pes equinovarus , talipes equinovarus – Isolated deformity Vs part of a systemic affection. – Developmental. Hip Knee Ankle
  • 81.
    04/22/2025 81 Epidemiology • Thecommonest congenital foot problem needing treatment & causing permanent disability • M:F ranging b/n 2:1 & 4:1 • 1-2 live birth)/1000 globally • 17x increased risk if 1st & 6x with 2nd degree relative • 25% could have family history • 32% in MZ & 3% in DZ twins • 50% bilateral. Hip Knee Ankle
  • 82.
    04/22/2025 82 PATHOGENESIS • Severaltheories I. Embryonic developmental arrest : arrested development around the 8th wk, no abnormal talar head & navicular dislocation II. Myofibroblastic retractile tissue hyper cellular & wavy collagenous ST III. Germplasm defect: talar cartilage analge hypoplasia IV. Neuromuscular imbalance: peroneal Vs Tibials Hip Knee Ankle
  • 83.
    04/22/2025 83 Classification • Etiologic –Idiopathic – Positional /postural – Syndromic – Neurogenic Hip Knee Ankle
  • 84.
    04/22/2025 84 • Basedon treatment – Untreated:<2 yrs – Neglected:>2 yrs with the effect of walking & severe bony & ST effects – Treated: no sign of recurrence & on follow up – Resistant: no/minimal change seen with Ponseti & are seen in association with syndromes such as arthrogryposis – Relapse: signs of the previous deformity (equinus, supination) – Complex: clubfoot treated with non Ponseti method & has added effects of the treatment Hip Knee Ankle
  • 85.
  • 86.
    04/22/2025 86 TREATMENT • Allclubfoots need treatment • Goals – Painless – Functional – Supple – Plantigrade • When – As soon as possible Hip Knee Ankle
  • 87.
    04/22/2025 87 • Options –Conservative • Serial casting & stretching • Functional splint – Surgical • Soft tissue • Bony • combined Hip Knee Ankle
  • 88.
    04/22/2025 88 CONSERVATIVE • Shouldthe 1st step in managing new pts . • The sooner the better. • Significant reduction in number & extent of surgery with its complications. • Gradual correction using the visico-elastic nature of the neonatal tissue. • Should be done with at most attention for details & with patience Hip Knee Ankle
  • 89.
    04/22/2025 89 PONSETI • Earlymethod (1940’s) but delayed acceptance by the medical society. • Simultaneous weekly manipulative correction of the foot with cast immobilization to achieve overcorrection. • Atraumatic ST manupulation with time for remodeling & correction • 95% successful outcome esp. in younger pts. • Aim for Overcorrection Hip Knee Ankle
  • 90.
    04/22/2025 90 Techniques ofPonseti . Gentel manipulation & gradual serial casting • Fulcrum always LHT • Padding, 3-4 turns over toes. • 1st SLC……..Always LLC (toe-to-groin cast) • Light pressure molding • Abduction of the foot always in supination Hip Knee Ankle
  • 91.
    04/22/2025 91 Reduce thecavus Hip Knee Ankle
  • 92.
  • 93.
    04/22/2025 93 Abduction withforefoot supination Hip Knee Ankle
  • 94.
  • 95.
  • 96.
  • 97.
    04/22/2025 97 Time forTenotomy • Liberally use tenotomies • When?? – Adequate abduction – Dorsiflextion ~ neutral to 5 degrees – Midfoot score = 0, Hindfoot score > 0 Hip Knee Ankle
  • 98.
    04/22/2025 98 Bracing • Maintenancephase to prevent recurrence/relapse. • High top, 60° ER, & padded heal shoes for a long time. • Full time 3mo...Night time till 3yrs…discontinue when plantigrade foot. • Relapse in > 80% of case in non-compliant families in contrast to relapse rate of 6% in compliant family. • Educate the family about Ponseti management . Hip Knee Ankle
  • 99.
    04/22/2025 99 • Bracefollowup – In 10-14 days to monitor – Next in 3 month. – Then every 4 month – At age 3-4 yrs every 6month – From 4 years until maturity check every 1 to 2 years. Hip Knee Ankle
  • 100.

Editor's Notes

  • #10 ge of onsetUsually after age 40Commonly affected jointsCervical and lumbar spineFirst carpometacarpal jointProximal interphalangeal jointDistal interphalangeal jointHipKneeSubtalar jointFirst metarsophalangeal join
  • #17  The management of OA depends on the joint (or joints) involved, the stage of the disorder, the severity of the symptoms, the age of the patient and his or her functional needs. The goals of management of patients with osteoarthritis (OA) are to control pain and swelling, to minimize disability, to improve the quality of life, to prevent progression of the process, and to educate the patient about his or her role in the management team. Management should be individualized to the patient's expectations, level of function and activity, to the joints involved and the severity of the patient's disease, to occupational and vocational needs, and to the nature of any coexisting medical problems. Subjective complaints and objective findings may guide the clinician in designing appropriate therapeutic goals.  An essential component in the development of a therapeutic plan is the correct attribution of signs and symptoms at the target site. Pain and other symptoms of OA can be confused with soft tissue processes such as bursitis at periarticular sites; in addition, pain in a particular area may be referred from OA at other site or may be due to a nonarticular process.
  • #19 WEIGHT LOSS  — Epidemiologic studies suggest that obesity is strongly associated with the development of OA. One study, for example, noted an increased risk of developing OA of the knee in patients with high body mass indices (1.5 and 2.1 for men and women, respectively) [ 6 ]. In a follow-up study using the same population, the risk of developing OA was reduced following weight loss; a ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50 percent [ 7 ]. The relation between the degree of weight loss and the reduced incidence of OA was linear, suggesting that even modest weight loss may be beneficial.
  • #20 In addition to reducing the risk of progression of OA, weight loss of even modest degree, may produce improvement in joint pain and function. As an example, in a prospective study 316 overweight people with symptomatic and radiographic OA of the knees were randomly assigned to one of four groups: diet alone, exercise alone, diet and exercise, or education in healthy living [ 8 ]. The combination of diet and exercise was the most effective and was associated with decreased knee pain and improved self-reported and measured function.
  • #21 REST  — Osteoarthritis is associated with pain and other symptoms after prolonged use; these symptoms are improved with rest. Resting the affected joint may alleviate pain; however, prolonged rest may lead to muscle atrophy and decreased joint mobility. Therefore, rest is recommended for only short periods of time, typically 12 to 24 hours for acute pain and inflammatory signs, after which active and passive joint motion and exercises should resume
  • #22 — There is evidence and general belief that physical therapy and exercise improve clinical outcome in OA [ 9 ]. While some physicians may have the experience and training required to specify the type of therapy, the frequency, and the duration, others may wish to defer these decisions to a specialist in rehabilitation medicine or to the therapist. Thus, a prescription that includes the diagnosis and requests evaluation and treatment should suffice. A general description of any desired orthotics or assistive devices may also be included. By improving flexibility and strengthening muscles supporting the affected joints, patients improve functional outcome and pain scores. These interventions are believed to "unload" the joints by improving mechanical forces during use. Data supporting the role of physical therapy modalities continues to accumulate. One report, for example, examined the distribution of walking forces by muscular structures in patients with knee pain. These patients had abnormal joint loading at heel strike, leading to a 30 percent increase in force [ 10 ]. This abnormality may reflect the inability of musculoskeletal structures to absorb forces due to injury.
  • #23 Patients should avoid excessive stair climbing, which increases loading on the medial or weight-bearing aspect of the knee
  • #24 INTRAARTICULAR HYALURONANS 
  • #30 The process described above can be initiated in at least four different ways: 1 disruption of the local blood supply 2 venous stasis and retrograde arteriolar stoppage 3 intravascular thrombosis 4 compression of capillaries and sinusoids by marrow swelling. Mechanical vascular disruption may result from a fracture or dislocation, or from such atraumatic events as stress or fatigue fractures. Arterial occlusion can arise from thrombosis, embolism, circulating fat, nitrogen bubbles, or abnormally shaped cells (sickle cell crises). Temporary or permanent damage to an intact vessel wall can arise from within the wall as in vasculitis or radiation injury, from within the vessel as in the release of materials that can cause angiospasm, or from external pressure or chemical reaction on the wall as in extravasated blood, fat, or cellular elements in the marrow cavity. In a closed system, if the circulation in the venous outflow is compromised by any of these mechanisms so that venous pressure exceeds arterial pressure, circulation to the cells supplied by this source will be compromised. If a sufficient collateral circulation is pre- sent at any site where such compromise occurs, cells remain viable. Although bone has a rich blood supply, it may vary from site to site; therefore, it is likely that only cells in certain locations are susceptible to becoming nonviable.
  • #32 Osteonecrosis can be the result of trauma. A displaced fractured femoral neck, dislocation of the femoral head, displaced fracture of the scaphoid, displaced fracture of the talar neck, and a 4-part fracture of the humeral head are the most common traumatic injuries leading to osteonecrosis and its clinically significant secondary complications of collapse of the subchondral bone and adjacent articular surface. The osteonecrosis associated with infection (osteomyelitis or pyarthrosis) is thought to be produced by the combination of increased intramedullary pressure and arterial occlusion. In cases in which osteonecrosis is associated with Gaucher’s disease, the marrow cavity is packed with Gaucher’s cells (macrophages filled with cerebroside). In cases in which it is associated with sickle-cell disease, the marrow cavity is packed with sickled red blood cells. The osteonecrosis in these last 2 diseases seems to result from direct occlusion of the intraosseous arteries. The osteonecrosis associated with decompression sickness, so- called caisson disease, probably is caused by vascular occlusion by nitrogen bubbles that come out of solution with the rapid drop in barometric pressure. Osteonecrosis after irradiation of bone probably occurs as a result of radiation damage to the capillaries. It also occurs in association With ethanol abuse, Corticosteroid administration, hyperlipidemia, and pancreatitis, and, very often, in otherwise Normal individuals (those with idiopathic osteonecrosis).
  • #56 Although some authors have suggested that children with DDH are late to start walking, more recent studies have shown no significant delay. With each step, the pelvis drops as the dislocated hip adducts, and the child leans over the dislocated hip; this is known as an abductor lurch or Trendelenburg gait When the child attempts to stand on that foot with the other elevated off of the floor, he or she leans toward the affected side (Trendelenburg sign).
  • #80 It most likely represents congenital dysplasia of all musculoskeletal tissues (musculotendinous, ligamentous, osteoarticular, and neurovascular structures) distal to the knee.