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Hip

Dr. Domb is a nationally recognized orthopedic surgeon specializing in sports medicine, regenerative medicine, and arthroscopic surgery of the hip. A noted pioneer in advanced new techniques in hip arthroscopy, he delivers innovative treatments for patients with hip injuries such as impingement and labral tears.

Hip Anatomy

Hip Anatomy

The hip joint is a “ball and socket” joint. The “ball” is known anatomically as the femoral head; the “socket” is the part of the pelvis known as the acetabulum. Both the femoral head and the acetabulum are coated with articular cartilage. Like all joints, the hip has synovial or joint fluid, acting as a lubricant, which allows for smooth, painless movement within the hip joint.

The hip, like the shoulder, has a labrum; a ring of rubbery fibrocartilage around the rim of the acetabulum, which deepens the hip socket and acts as the suction seal of the hip joint. The intact labrum seals the lubricating fluid within the hip and contributes to stability of the joint. One of the most common causes of hip pain involves damage to the labrum, described most often as a labral tear. When the labrum is torn, the “suction seal” is broken, and the joint may lose its stability and lubrication. This can progress to loss of cartilage, or arthritis. Degenerative changes to the hip can also result in arthritis. Arthritis is the damage to the articular cartilage of the joint that lines on the head of the femur and the acetabulum, or socket. The joint capsule is an envelope of ligaments that encloses the hip, and is also essential for stability. The hip also contains a ligament known as the ligamentum teres, which connects the femoral head to the acetabulum. Both the capsule and the ligamentum teres can be injured in an unstable hip.

Diagnosis of Hip Problems

  • Diagnosis of hip injuries can be complex. Studies have shown that as many as 60% of patients requiring a hip arthroscopy were initially misdiagnosed. Hip pain may mimic many other conditions, including sciatica, spinal problems, muscle strains, and sports hernias.
  • Obtaining the correct diagnosis is of paramount importance in directing appropriate treatment. A systematic approach to diagnosis may include several steps:
    • Specialized clinical exam by a hip specialist
    • Specific new X-ray views designed for viewing hip anatomy
    • Specialized MRI scans at a center specializing in pre-arthritic and arthritic hip conditions.
    • Ultrasound guided Diagnostic intra-articular hip injections can help confirm the diagnosis and intra-articular involvement
    • It is important to note that many patients are misdiagnosed despite having a physical exam, X-rays, and an MRI, because the studies were not the specific studies designed for pre-arthritic or early arthritic hip injuries.
    • Dr. Domb and his team at Hinsdale Orthopaedics have been trained regarding the highest excellence in the hip physical exam, imaging techniques and performing diagnostic injections under ultrasound guidance.

Articles:

Publications by Dr. Domb on Hip Basics

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Hip Conditions

Hip Impingement

Hip Impingement

Femoro-acetabular Impingement (FAI) is a common generator of pain in the hip. Impingement can lead to labral tears and eventually advancement of osteoarthritis. Impingement is most commonly described as anatomic bony variability of the acetabulum (socket) and femur (leg bone) that causes the two bones to rub against each other during certain hip motions.

Snapping Hip

Snapping Hip

In a snapping hip, a tight iliopsoas tendon “pops” over top of the femoral head, the iliopectineal eminence and labrum. The “popping” may produce a loud sound, and may cause a sensation that the hip is popping out of its socket or dislocating.

Hip Instability

Hip Instability

Traumatic instability ranges from severe dislocation to subtle hip subluxation (hip joint sliding out of place, but immediately re-establishing correct anatomical positioning). Traumatic instability most often occurs from motor vehicle accidents and extreme athletic events.

Dysplasia

Dysplasia

Hip dysplasia is a congenital condition in which the acetabulum or socket is shallow. This creates under-coverage of the femoral head. The weight-bearing portion of the hip becomes overloaded as it is increasingly focused on a small area.

Bursitis

Bursitis

A bursa is a closed fluid-filled sac that functions to reduce friction between tissues of the body. Bursae are located near major joints such as shoulders, elbows, hips and knees. When a bursa becomes inflamed it is called bursitis. Two major types of bursitis exist in the hip: trochanteric bursitis and iliopsoas bursitis. Trochanteric bursitis causes pain on the outer and lateral portion of the hip, and may be confirmed by pain-numbing injection given by a physician.

IT Band Syndrome

IT Band Syndrome

Iliotibial band syndrome (IT band syndrome) can be a cause of lateral hip pain. The IT band is a thick fascia that begins at the ilium of the pelvis, crosses the lateral aspect of the hip (greater trochanter) and extends to the tibia, on the lateral aspect of the knee.

Piriformis Syndrome

Piriformis Syndrome

Piriformis syndrome is a nueromuscular condition which can cause posterior hip pain, deep buttock pain and even shooting pain down the back of the leg. Piriformis Syndrome is commonly misdiagnosed. The piriformis is a muscle located posteriorly which functions to rotate the hip.

AVN (Avascular Necrosis)

AVN (Avascular Necrosis)

Avascular necrosis is a condition that occurs when the blood supply to the femoral head is compromised, causing part of the bone of the femoral head to die. Lack of blood supply can occur from a traumatic event, such as a fracture or dislocation, or from chronic medical conditions such as diabetes, prolonged steroid use and excessive tobacco or alcohol consumption.

Arthritis

Arthritis

Osteoarthritis is the most common type of hip arthritis; involving chronic wear-and-tear of the cartilage in the hip joint. When the cartilage is worn away, bone-to-bone contact is present, causing severe pain, decreased function and range of motion.

Hip Injuries

Sports Injuries

Sports Injuries

Hip injuries are extremely common in competitive sports due to tremendous forces placed on the hips. Many professional athletes have undergone hip arthroscopy for hip injuries, including Alex Rodriguez, Mike Lowell and Kurt Warner.

Labral Tears

Labral Tears

A labral tear involves a tear of the cartilage rim on the edge of the hip socket. Labral tears can occur with sports, a specific injury or incident, or may develop over time. Some underlying causes of labral tears include hip impingement, instability, and internal snapping hip. When the labrum tears, the hip's suction seal is disrupted and the joint loses its lubrication and stability.

Femoro-Acetabular Impingement

Femoro-Acetabular Impingement

Femoro-acetabular Impingement (FAI) is a common generator of pain in the hip. Impingement can lead to labral tears and eventually advancement of osteoarthritis. Impingement is most commonly described as anatomic bony variability of the acetabulum (socket) and femur (leg bone) that causes the two bones to rub against each other during certain hip motions.

Snapping Hip

Snapping Hip

In a snapping hip, a tight iliopsoas tendon “pops” over top of the femoral head, the iliopectineal eminence and labrum. The “popping” may produce a loud sound, and may cause a sensation that the hip is popping out of its socket or dislocating.

Hip Instability

Hip Instability

Traumatic instability ranges from severe dislocation to subtle hip subluxation (hip joint sliding out of place, but immediately re-establishing correct anatomical positioning). Traumatic instability most often occurs from motor vehicle accidents and extreme athletic events.

Dysplasia

Dysplasia

Hip dysplasia is a congenital condition in which the acetabulum or socket is shallow. This creates under-coverage of the femoral head. The weight-bearing portion of the hip becomes overloaded as it is increasingly focused on a small area.

Loose Bodies

Loose Bodies

A loose body is a small piece of cartilage or bone that is floating within the joint. These often result from injury or severe muscle strain at the muscular insertion. Loose bodies can cause sharp pain and may even cause a person to feel their joint give way. Certain conditions such as synovial chondromatosis of the hip may cause multiple loose bodies within the joint.

Cartilage defects

Cartilage defects

Cartilage defects may result from an acute traumatic event or chronic degeneration due to overuse of the hips joint. They can become a significant cause of pain in the hip. Left untreated, cartilage defects continue to worsen over time, a process known as arthritis. Microfracture is an arthroscopic procedure performed to restore injured cartilage.

Trochanteric Bursitis

Trochanteric Bursitis

A bursa is a closed fluid-filled sac that functions to reduce friction between tissues of the body. Bursae are located near major joints such as shoulders, elbows, hips and knees. When a bursa becomes inflamed it is called bursitis. Two major types of bursitis exist in the hip: trochanteric bursitis and iliopsoas bursitis.

Iliotibial band syndrome/IT Band Syndrome

Iliotibial band syndrome/IT Band Syndrome

Iliotibial band syndrome (IT band syndrome) can be a cause of lateral hip pain. The IT band is a thick fascia that begins at the ilium of the pelvis, crosses the lateral aspect of the hip (greater trochanter) and extends to the tibia, on the lateral aspect of the knee.

Gluteus Medius Tears

Gluteus Medius Tears

The gluteus medius is a muscle on the outside of the hip, which is important for abduction (lateral movement away from the body). These muscles help one stand up right and walk without a limp. Gluteus medius tears, also known as the rotator cuff tear of the hip, involve tearing of the gluteus medius muscle from its attachment to the greater trochanter, commonly known as the “lateral hip bone”.

Proximal Hamstring Tear

Proximal Hamstring Tear

The hamstrings are a group of four muscles on the back (posterior) part of the thigh (femur), which are important for hip extension and knee flexion. The four muscles include the semitendinosus, semimembranosus and the long and short head of the biceps femoris.

Avascular Necrosis

Avascular Necrosis

Avascular necrosis is a condition that occurs when the blood supply to the femoral head is compromised, causing part of the bone of the femoral head to die. Lack of blood supply can occur from a traumatic event, such as a fracture or dislocation, or from chronic medical conditions such as diabetes, prolonged steroid use and excessive tobacco or alcohol consumption.

Ultrasound Guided Injections

Ultrasound Guided Injections

Dr. Domb and his team are highly trained in ultrasound-guided injections. These procedures are performed in the office at the time of your visit. The ultrasound machine assists Dr. Domb and his Physician Assistants to safely place injectable medications into or around the joint. Hip injection options include:

Diagnostic injections Comprised of local anesthetic, designed to confirm or deny the intra-articular cause of your hip pain. The injection may take up to 30 minutes to work. It is considered a diagnostic procedure, not a form of treatment.

Cortisone A combination of steroid medication and local anesthetic to provide pain relief and decrease inflammation caused by an inflammatory process, muscle sprain or strain, intra-articular injury or arthritis. A patient can have a cortisone injection every 3-4 months to treat:

  • Intra-articular injury
  • Trochanteric bursitis
  • Iliopsoas tendinosis
  • Piriformis tendinosis

Platelet Rich Plasma (PRP)

Platelet Rich Plasma (PRP) is an injection of your own platelets and growth factors, similar to stem cell treatment, extracted from your blood. The blood draw and injection are done at the same office visit, an outpatient clinical procedure.

PRP has shown great promise in stimulating repair of body tissues including tendons, ligaments and cartilage. PRP mimics the body's innate response to an injury by stimulating platelet activation. The activation of platelets plays a dynamic role in soft tissue healing. Research shows that PRP is superior to other injections in the treatment of osteoarthritis and healing of chronic tendinitis.

In osteoarthritis, PRP can enhance the body's normal healing response in an acute manner for a chronic condition. This can result in the development of new collagen, a benefit that other injections are unable to offer.

In tendinitis, the growth factors in PRP can signal the body to initiate a healing response in the local injected tissues. Healing is the first step in injured tissues regenerating their strength and function. It has been used extensively in professional athletes who seek hurried return to play. Star athlete success stories include: Kobe Bryant (NBA), Tiger Woods (PGA tour), Alex Rodriquez (MLB), Hines Ward (NFL) and Rafael Nadal (ATP).

If you have an injury or condition involving a tendon, ligament, joint or osteoarthritis, PRP may be a nonsurgical option for you.

Indications (including but not limited to):

  • Osteoarthritis (Intraarticular)
  • Tendinosis & Tendinitis

Process

  • 3 Injections spaced 1 week apart x 3 weeks
  • Can have injection series every 6 months
  • Day of Injection
    • Blood Draw
    • Centrifuge x 5 minutes
    • Ultrasound Guided Injection

Stem Cell Therapy

Stem cell therapy is a form of regenerative medicine that utilizes the body’s natural healing mechanism to treat various conditions.

Stem cells are being used in regenerative medicine to renew and repair diseased or damaged tissues and have shown promising results in treatments of various orthopedic, cardiovascular, neuromuscular and autoimmune conditions.

Stem cells are present in all of us acting like a repair system for the body. However, with increased age sometimes the optimum amount of stem cells are not delivered to the injured area. The goal of Stem Cell therapy is to amplify the natural repair system of the patient’s body.

Types of Stem Cells

There are two major types of stem cells embryonic stem cells and adult stem cells. Embryonic stem cells (ESCs) are stem cells derived from human embryos. They are pluripotent, which means they have the ability to develop into almost any of the various cell types of the body.

As the embryo develops and forms a baby, stem cells are distributed throughout the body where they reside in specific pockets of each tissue, such as the bone marrow and blood. As we age, these cells function to renew old and worn out tissue cells. These are called adult stem cells or somatic stem cells. Like embryonic stem cells, adult stem cells can also replicate into more than one cell type, but their replication is restricted to a limited number of cell types.

Use of Stem Cells in Orthopedics

The unique self-regeneration and differentiating ability of embryonic stem cells can be used in regenerative medicine. These stem cells can be derived from eggs collected during IVF procedures with informed consent from the patient. However, many questions have been raised on the ethics of destroying a potential human life for the treatment of another.

Adult stem cells are most commonly obtained from the bone marrow, specifically the mesenchymal stem cells, which have the ability to replicate into cells that form the musculoskeletal system such as tendons, ligaments, and articular cartilage. They can be obtained from the iliac crest of the pelvic bone by inserting a needle and extracting the stem cells from the bone marrow.

Currently, stem cell therapy is used to treat various degenerative conditions of the shoulder, knees, hips, and spine. They are also being used in the treatment of various soft tissue (muscle, ligaments and tendons) as well as bone-related injuries.

Who is a Good Candidate for a Stem Cell Procedure?

You may be a good candidate for stem cell therapy if you have been suffering from joint pain and want to improve your quality of life while avoiding complications related to invasive surgical procedures.

Preparing for the Procedure

  • It is important that you stop taking any non-steroidal anti-inflammatory drugs (NSAIDs) at least two weeks before your procedure.
  • Preparing for a stem cell procedure is relatively easy and your doctor will give you specific instructions depending on your condition.

Stem Cell procedure

The procedure begins with your doctor extracting stem cells from your own bone marrow. Bone marrow is usually aspirated from your hip region. Your doctor will first clean and numb your hip area. A needle is then introduced into an area of your pelvic bone known as the iliac crest. Bone marrow is then aspirated using a special syringe and the sample obtained is sent to the laboratory. In the laboratory, the aspirate is spun in a machine for 10 to 15 minutes and a concentrated stem cell sample is separated.

Your doctor then cleans and numbs your affected area to be treated and then, under the guidance of special x-rays, injects the stem cells into the diseased region. The whole procedure usually takes less than one hour and you may return home on the same day of the procedure.

Post-Operative Care

  • You will most likely be able to return to work the next day following your procedure.
  • You will need to take it easy and avoid any load bearing activities for at least two weeks following your procedure.
  • You will need to refrain from taking non-steroidal, anti-inflammatory medications (NSAIDS) for a while as this can affect the healing process of your body.

Advantages & Disadvantages

  • Stem cell therapy is a relatively simple procedure that avoids the complications associated with invasive surgical procedures.
  • As stem cell therapy uses the cells derived from your own body it reduces the chances of an immune rejection.

Disadvantages

  • The disadvantage of adult stem cell therapy is lack of data about its long-term effects as it is a newer evolving therapy.

Risks and complications

Stem cell therapy is generally considered a safe procedure with minimal complications, however, as with any medical procedure, complications can occur.

Some risks factors related to stem cell therapy include infection as the stem cells may become contaminated with bacteria, viruses or other pathogens that may cause disease during the preparation process.

The procedure to either remove or inject the cells also has the risk of introducing an infection to the damaged tissue into which they are injected. Rarely, an immune reaction may occur from injected stem cells.

Hip Arthroscopy

Hip Arthroscopy

Hip arthroscopy is one of the cutting-edge areas of orthopaedic surgery. The development of highly specialized procedures in hip arthroscopy over the last few years created new options for patients with hip pain, hip injuries, and early arthritis of the hip. These procedures bring athletes back to their sport, allow workers to return to work, and often prevent or delay the need for joint replacement.

Birmingham Hip Resurfacing

Hip resurfacing is an alternative surgical procedure to hip replacement for many active patients. Hip resurfacing differs from a hip replacement in that the femoral head and neck are not removed and replaced with synthetic parts. In hip resurfacing, the worn surfaces of the femoral head and acetabulum are smoothed out, and covered with metal bearing surfaces.

Mako Robotic-Arm Assisted Technology for total hip replacement

Mako Robotic-Arm Assisted Technology for total hip replacement

Mako Robotic-Arm Assisted Technology provides you with a personalized surgical plan based on your unique anatomy. First, a CT scan of the diseased joint is taken. This CT scan is uploaded into the Mako System software, where a 3D model of your hip is created. This 3D model is used to pre-plan and assist your surgeon in performing your total hip replacement.

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