Approach

• Expose legs
• Should be divided into - examination while standing, walking, lying down

Examination while standing

1. Look from the front
   • Walking aids
   • Hip for scars or sinuses (lateral and posterior scars)
   • Muscle wasting (esp gluteals)
2. Look from the side
   • Spine - scoliosis may indicate a fixed flexion deformity
3. Feel
4. Move
   • Perform Trendelenburg test
     1. Ask patient to stand on good leg and flex other leg at the knee as you hold their hands
     2. Repeat on bad leg
     3. Test is positive if the pelvis on the unsupported side sags down (fails to rise)
     4. Causes of a positive trendelenburg
        1. Muscle
           1. Pain
           2. Myopathy
        2. Nerve
           1. Neuropathy
        3. Joint
           1. Short neck
           2. Developmental hip dysplasia

Examination While Walking

1. Ask patient to walk away and then back
2. Observe the gait
   • Trendelenburg gait due to abductor weakness characterised by a sideways lurch to bring body weight over affected limb
   • Antalgic gait (due to pain) - decreased stance phase and increased swing phas

Examination with the patient lying down

1. Measure real and apparent lenghts using a tape measure
   • Good leg should be measured first, then abnormal leg
   • Apparent lenght = xiphisternum (fixed midline bony point) to medial malleolus while the patient is lying supine with the legs in parallel
   • True lenght = ASIS to medial malleolus
   • If difference between apparent and true, there is a real difference between the lenght of bones
     1. Above/below trochanter
     2. Above/below knee
     3. Should flex knee to see
2. Feel
   • Palpate greater trochanter for any tenderness (trochanteric bursitis)
   • Palpate femoral head over midpoint of inguinal ligament
3. Move
   • Movements of the hip

     Hip movement	Muscle group	Expected range
     Flexion	Iliopsoas, rectus femoris, quadriceps	140
     Extension	Gluteus maximus, hamstrings	10
     Abduction	Gluteus medius and minimus	45
     Adduction	Adductors (longus, brevis, magnus) - obturator nerve	30
     Internal rotation	Gluteus medius, minmus	40
     External rotation	Pyriformis, gamelli, quadratus femoris	40

     1. Active
        1. Ask patient to flex hip (iliopsoas - femoral nerve)
     2. Passive
        1. Flexion / extension
        1. Abduction / adduction: with leg straight, detect any tilting of the pelvis by placing one hand over the ASIS
        1. Internal / external rotation: with legs straight and with legs flexed at 90'
        2. Thomas' test for fixed flexion deformity
           1. Place one hand in small of patient's back (feel for lumbar lordosis)
           2. Flex both hips as far as possible, feeling for flattening of lumbar lordosis
           3. Maintain flexion in one hip (ask patient to hold knee) while asking patient to extend other hip as far as possible - maintain flexion of other hi
           4. In the presence of any fixed flexion deformity, there will be a point at which further extension ceases and fixed flexion is measured from the horizontal
           5. Repeat with the other leg

Completion

1. Examine back and knee (joints above and below hip)
2. Examine neurology of limb
3. Examine vascular supply of limb
4. Offer patient to dress

Investigations

1. Blood tests
   • FBC, ESR
   • Immunological - Rheumatoid factor, ANA
2. X-rays
   • Plain AP / Lateral

X-ray features of osteoarthritisL LOSS

• Loss of joint space
• Osteophyte
• Sclerosis
• Subchondral cysts

Treatment options in Osteoarthritis

1. Lifestyle
   • Diet / exercise
   • Weight loss
2. Physiotherapy
3. Occupational therapy
   • Suitable devices to aid mobility
4. Medical therapy
   • Analgesics up the pain ladder
5. Surgical options
   • Osteotomy
   • Arthroplasty
     1. Indications: instability, pain, loss of mobility
   • Arthrodesis

Complications of hip replacement

1. Intraoperative
   • Perforation
   • Fracture of acetabulum
2. Post-operative
   • Dislocation
   • DVT
   • Sciatic nerve palsy
   • Infection
   • Fat Embolism
   • Infection
   • Loosening
   • Heterotopic ossification
   • Limb-lenght discrepancy
   • Periprosthetic fracture