HIP DISORDERS: RECENT ADVANCEMENT-THR

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Prepared by -Dr. Md Nazrul islam, MBBS, M.Sc.Supervised by -Dr. Sk. Abbas uddin AhmedMS (ortho), ao(basic), ao(spine).

Presenting by -

Dr. Golam Mahamud SuhashFrom -Department Of Orthopaedic & Traumatology, Shaheed Suhrawardy Medical College Hospital. Dhaka.

CME

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Hip Surgery And Hip-Replacement

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Hip-disordersRecent Advancement


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Hip is the joint where yourthigh bone meets your pelvisbone.

Hips are very stable. When they are healthy, it takes great force to hurt them.

Common Hip-disorders are- StrainsBursitisDislocations Fractures

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Over view

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Contents:

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Functions of Hip-jointMechanisms Hip injuryMost Common Types of Hip Injury- Epidemiology Anatomy of Hip-joint Pathophysiology of Hip-Injury Clinical features of Hip-Injury- Investigations DiagnosisManagement Rehabilitations Complications Prognosis Of Hip-Replacement- Conclusions Total Hip Replacement at Shaheed

Suhrawrdy Medical College Hopital-

Functions of Hip-joint

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To provide stability for weight bearing- standing, walking & running. To allow mobility of the leg in space. To transmit the loads from the thigh and then to the lower limb.

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Direct Stress

o Femoral Neck fracture

o Inter-trochanteric fracture

Repeated stress

o Degenerative joint disease (DJD) of the

Hip

Deformities

o Congenital dislocation of the Hip (CDH)

/ Developmental dysplasia of the Hip (DDH).

Mechanisms Hip injury-

Hip Strain is an overuse or injury that

tears or stretches the muscle fibers.

Most of the time, muscle strains in the

hip area occur when a stretched

muscle is forced to contract suddenly.

A fall or direct blow to the muscle,

overstretching and overuse can tear

muscle fibers, resulting in a strain.

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Strains

Most Common

Types Of Hip Injury-

Most Common


Bursa is a fluid filled sac that allows smooth motion between two uneven surfaces.

Hip bursitis is a common problem that causes pain over the outside of the upper thigh.

When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. 8

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Bursitis

Most Common


Types of dislocation:

Congenitical

Acquired

Anterior

Central

Posterior (90%)

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Most Common

Types Of Hip Injury-Dislocations- HIP

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Dislocations

AO/OTA Classification

Most thorough. Best for reporting data, to allow

comparison of patients from different studies.

30-D10 Anterior Hip Dislocation

30-D11 Posterior Hip Dislocation

30-D30 Obturator (Anterior-Inferior) Hip Dislocation

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FracturesFracture of Acetabular Component

Acetabular fracture

Central dislocation

Fracture of Femoral Components.

1. Femoral Neck fracture (NOF),

2. Femoral head fracture

3. Slipped capital femoral epiphysis in children

4. Trochanteric fracture

HIP can break at any age, but the

great majority of hip fractures occur

in people older than 65..

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Most Common


Worldwide gender distribution of Hip Fracture

Men: 4-5 per 1,000

Women: 8-10 per 1,000

Men: 30%

Women: 70%

Morbidity and Mortality

Mortality 20% within 1 year Hip Fracture

o Men: 31% mortality in 1 year

o Women: 17% mortality in 1 year

o ADL assistance needed in 50% of Hip Fractures

o Long term care needed in 25% of Hip Fractures.

Cooper (1992) Osteoporos Int 2:285-9

Forsen (1999) Osteoporos Int 10:73-8

Epidemiology

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Anatomy of Hip-jointRecent Advancement


The hip joint is a ball and socket joint, formed by the head of the Femur (thigh bone) and the acetabulum of the pelvis. The dome-shaped head of the femur forms the ball, which fits snuggly into the concave socket of the acetabulum. The hip joint is a very sturdy joint, due to the tight fitting of the bones and the strong surrounding ligaments and muscles.

Introduction to hip joint anatomy

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Anatomy of Hip-joint

Bones of the hip joint The hip joint capsule Ligaments of the hip joint Labrum of the hip joint Muscle Groups surrounding the hip joint. Neuro-vascular Components.

Vital Components of Hip-joint -

The ilium: This is the largest area of the hip bones. The ischium: The ischiumconsists of 2 broad curves of bone, one on each side, which lie below the ilium, The pubis: The pubis is the front-most area of the hip bones. It attaches to the iliumon the sides and the ischiumon the bottom.

Anatomy of Hip-joint Bones

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Hip bones -

http://www.wikidoc.org/index.php/Ilium_(bone)

http://www.wikidoc.org/index.php/Ischium

http://www.wikidoc.org/index.php/Pubis_(bone)

Muscles Muscles which attach to or cover the hip joint:

• Gluteals.• Quadriceps-• Iliopsoas. • Hamstrings.• Groin muscles.

Ligaments.

• Iliofemoral ligament:• Pubofemoral ligament:• Ischiofemoral ligament:

Muscles And Ligaments-

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Mainly by –

Medial and lateral circumflex

femoral arteries.

And

Deep division of the superior

gluteal artery

Inferior gluteal artery

Posterior division of the obturator

artery(Head of the femur ).

Blood supply

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Neurovascular Components-

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Femoral nerve - Via nerve to the rectus femoris muscle Obturator nerve - Via it’s anterior division. Sciatic nerve - Via the nerve to the quadratus femoris muscle. Superior gluteal nerve - Here the femoral, sciatic and oburatornerves also supply the knee joint, so hip disease may cause a refered pain to the hipjoint.

Nerve supply

Neurovascular Components-

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Age. The rate increases for people 65 and older. Gender. Women have two to three times as many hip fractures as men. Heredity. A family history of fractures in later life, particularly in Caucasians and Asians. A small-boned, slender body. Nutrition. A low calcium dietary intake or reduced ability to absorb calcium. Personal habits. Smoking or excessive alcoholuse. Physical impairments. Physical frailty, arthritis, unsteady balance, and poor eyesight. Mental impairments. Senility, dementia, e.g., Alzheimer's disease.Weakness or dizziness from side effects of medication

Pathophysiology of Hip-Injury

Who is vulnerable to hip fracture?

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Shortened limb on Fracture side Hip externally rotated and abducted

(But internally rotated and adducted in post. dislocation of hip).

Tenderness to palpation over injured hip Limited range of motion

oDo not test ROM unless XRaynormal

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Signs -

Clinical features of Hip-

fracture(prox. Femur)

http://www.fpnotebook.com/Ortho/Fracture/Frctr.htm

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Hip fractures usually are caused by a fall. If you fracture your hip, you may experience the following symptoms:

Severe pain in your hip or pelvic areaBruising and/or swelling in your hip areaInability to put weight on your hipDifficulty walkingThe injured leg may look shorter than the other leg and may be turned outward.

symptoms

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Clinical features of Hip-Injury-

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Complete medical history Physical examination to assess hip mobility, strength, and alignment. Blood tests X-rays (radiographs) to determine the extent of damage or deformity in your hip. MRI / CT scan. Ultrasound scans Bone scans Biopsy

The orthopaedicevaluation will typically include -

InvestigationsRecent Advancement


InvestigationsRecent Advancement


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1. Blood tests.2. Kidney, Liver tests.3. Lungs, Heart and Neurological assessments.

1. Assessment of bone strength 2. Assessment of bone infection 3. Assessment of bone TB/ Carcinoma.4. Assessment of metabolic/systemic bone diseases.

Routine Pre-operative Investigations-

Bone pathology specific Investigations-

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Hip Xray Usually identifies Fracture and

Dislocation Hip MRI (T1-weighted) Indicated for high suspicion despite normal XRay Test Sensitivity: 100% Does not require delay after injury

Hip Bone Scan with Technetium Tc99m Polyphosphate Test Sensitivity: 98% Delay scan at least 72 hours after time of injury 24

Imaging

MR Arthrogram

MR Arthrogram

An MRI may identify a

hip fracture otherwise missed on plain X-ray.

http://www.fpnotebook.com/Ortho/Fracture/Frctr.htm

http://www.fpnotebook.com/Prevent/Epi/TstSnstvty.htm




DiagnosisRecent Advancement


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Subjective Assessment Pain localized in hip region Exaggerated gait pattern (limp) Increase in pain when weight barring Reduction in the degree of ROM As the degeneration of the joint worsen, individual may be awakened at night with pain Bone spurs may occur

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Objective Assessment Gait pattern – Adaptive walking pattern that reduces pressure on the affected side. Muscle atrophy – Muscles in affected area are not used as much due to pain, therefore, use-it-or-lose-it applies. Active Range Of Motion – Limited ROM, stiffnessPassive ROM – End feels causes severe pain X-ray – clear degeneration of the bone MRI – determines underlying complications (e.g.avascular necrosis)

Diagnosis

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ManagementRecent Advancement


Treatment for hip disorders may include-

Medical- Rest, Medicines, Physical therapy Immobilization and/ or Reduction(dislocation)

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Surgical-

Osteotomy

ORIF

HIP Resurfacing

Hip replacement.

Management

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Acetabular Component- Dysplasia, Impingement. Femoral Components.

Common HIP Condition Which Requires Internal Fixation-

Fixation

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1. Femoral Neck fracture (NOF),

2. Femoral head fracture3. Slipped capital femoral

epiphysis in children 4. Trochanteric fracture

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HIP Resurfacing-

Developed in late nineties in UK by Dr.Derek Mcminn

Surface hip replacements

Longevity of any primary THA cannot be predicted

Revision remains an issue

Young/active patient may outlive primary THA.

Hip resurfacing extends continuum of care in young patients with hip disease

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www.hipsurgery.in

Candidates for hip

resurfacing

Young & active patients with hip arthritis or secondary osteo-arthritis

Primary OA in young patients

Avascular necrosis

Ankylosing spondylitis

Post traumatic arthritis

DDH

Slipped capital femoral epiphysis

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HIP Resurfacing

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HIP Resurfacing Hip resurfacing-considerations and steps-

Head of femur is sculpted and not

chopped off to receive a cap or

resurfaced.

Socket is deepened and a new

socket banged in

Could survive for long term as

bearings are made of metal on

metal – Unknown at present

Recovery is faster.

Function is better.

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HIP REPLACEMENT

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Alternative Names

• Hip arthroplasty;

• Total hip replacement;

• Hip hemiarthroplasty.

Definition of Hip joint replacement:

Hip joint replacement is surgery to replace all or part of the hip joint with an artificial joint. The artificial joint is called a prosthesis.

http://www.umm.edu/ency/article/002286.htm

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Description:The artificial hip joint has 4 parts:A. A socket that replaces your old hip

socket. The socket is usually made ofmetal.

B. The liner fits inside the socket. It isusually plastic, but some surgeons arenow trying other materials, likeceramic and metal. The liner allowsthe hip to move smoothly.

C. A metal or ceramic ball that willreplace the round head (top) of yourthigh bone.

D. A metal stem that is attached to theshaft of the bone to add stability tothe joint.

HIP REPLACEMENT

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Types of Hip Replacement

Traditional (Conventional) Hip ReplacementTraditional hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip. The muscles are split or detached from the hip, allowing the hip to be dislocated. Minimally Invasive Hip ReplacementMinimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions (2 to 4 inch).

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HIP REPLACEMENT

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Rheumatoid Arthritis Secondary Osteoarthritis Ankylosing Spondylitis Old Perthes' disease Broken hip Bone tumor Avascular necrosis of the femoral head Fused Hip Joint.

Hip conditions that frequently lead to total hip replacement are the following-

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HIP REPLACEMENT

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Hip pain limits your everyday activities such as walking or bending. Hip pain continues while resting, either day or night. Stiffness in a hip limits your ability to move or lift your leg. You have little pain relief from anti-inflammatory drugs or glucosamine sulfate. You have harmful or unpleasant side effects from your hip medications. Other treatments such as physical therapy or the use of a gait aid such as a cane do not relieve hip pain.

Benefit from hip replacement

surgery if:

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Intelligent Hip surgery

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Conventional Total Hip

replacements

Introduced in 1960’s by Dr.JohnCharnley, an English Orthopedic surgeon.

Upper end of the femur is resectedconsisting of the head and neck portion .

Socket of the pelvic bone is deepened Prosthesis is implanted with bone

cement. Metal articulates with High density

polyetheylene. Risk of dislocation results in poor

function Recovery takes upto three months 41

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Minimally invasive Hip

surgery - What is it?

Skin incisions are smaller than conventional surgery

It is not Key hole or arthroscopic surgery

Inside soft tissue dissection is less.

More Bone, tendons, soft tissues are preserved

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Difference Between Traditional and

Minimally Invasive Hip Replacement

Surgery-

Traditional Hip Replacement Surgery-

Proven in clinical studies and successfully performed for decades

Allows surgeon full visualization of operative area

Larger incision/ scar (12-18 inches)

More disruption of muscles and tissues

May lead to more blood loss .

May lead to a extendededhospital stay/ recovery time

Minimally Invasive Hip Replacement Surgery-

Long-term effects and success are being studied

Smaller incisions/ Scars (2-4 inches)

Potentially less disruption of muscles and tissues

May lead to less blood loss

Potential for less postoperative pain

May lead to a shortened hospital stay/ recovery time

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1. Conventional1. Conventional total hip

2. Metal-on-metal1. Metal-on-metal total hip

3. Ceramic1. Ceramic total hip

4. Cemented / Cementless1. Cemented and cementless

total hip5. Other prostheses

1. Prostheses for other operations 44

PROSTHESIS TYPE

http://www.totaljoints.info/conven_thr.htm

http://www.totaljoints.info/metal_on_metal_total_hips.htm





http://www.totaljoints.info/ceramic_total_hips.htm

http://www.totaljoints.info/cemented_and_cementless_thr.htm




http://www.totaljoints.info/prostheses_for_other_hip_replace.htm

http://www.totaljoints.info/prostheses_for_other_hip_replace.htm

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The major problems with standard hip replacements are: Wearing out of plastic sockets. Loosening of the bond between the implant and bone. In time the cement can crack, directly resulting in loosening. Secondly, the body reacts to minute fragments of cement, plastic or metal, and attempts to remove them, and also removes bone adjacent to the particles, leaving the bone structurally weakened. If the implant loosens, a second surgery may become necessary to reattach it.

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There has been much research into theloosening problem. This led to thedevelopment of the: Cementless Hip Replacement in whichthe surface of the metal parts is porous, andlooks like coral. Bone can grow into themetal pores and bond the implant to thebone without the use of cement. The AML Total Hip Replacement (DePuy/ Johnson & Johnson) is the most widely used cementless implant in the world, and has the longest track record (since 1978). Cement is still used with very soft bones,regardless of age.

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Technique:

Total Hip Replacement

Acetabular reaming

Insertion of acetabularcomponent

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Technique:


Reaming/broaching of

femoral component

Insertion of femoral component

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Technique:


Femoral head impaction

Final implant

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What are the alternative operations?

Arthroscopy Osteotomy Surface replacement Fusion (arthrodesis) of the hip Some alternative operations for

avascular hip necrosis• Core decompression• Vascularized graft• Hemiarthroplasty• Resection arthroplasty -Girdlestone

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Rehabilitations

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REHAB GOALS

Get the patient up out of bed

and moving (the fracture is

painful, but the pt must get

moving)

opain is usually a symptom

of stress on fx

Begin functional activities

Prevent DVTs

Prevent inactivity.

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The Don'ts Don't cross your legs at the knees for at least 8 weeks. Don't bring your knee up higher than your hip. Don't lean forward while sitting or as you sit down. Don't try to pick up something on the floor while you are sitting. Don't turn your feet excessively inward or outward when you bend down. Don't reach down to pull up blankets when lying in bed. Don't bend at the waist beyond 90°. Don't stand pigeon-toed. Don't kneel on the knee on the unoperated leg (the good side). Don't use pain as a guide for what you may or may not do.The Dos Do keep the leg facing forward. Do keep the affected leg in front as you sit or stand. Do use a high kitchen or barstool in the kitchen. Do kneel on the knee on the operated leg (the bad side). Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Don't apply ice directly to the skin; use an ice pack or wrap it in a damp towel. Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towel for 15 to 20 minutes. Do cut back on your exercises if your muscles begin to ache, but don't stop doing them!

Rehabilitations

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An appropriate and progressive rehab program should be started early in the treatment of patients with hip injuries. Several rehab techniques are available, none of which require expensive equipment or great time commitments. Selecting the best exercise approach for each patient’s hip problem is not difficult. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitation care.

Rehabilitations

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The most common hip problem that may arise soon after hip replacement surgery is hip dislocation. The most common later complication of hip replacement surgery is an inflammatory reaction Heterotopic bone formation (bone growth beyond the normal edges of bone). Leg length discrepancy which may be caused by the prosthesis or by weakness in the muscles of the hip Breakage of the prosthesis which may require an additional surgery for replacement Wound infection. 54

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Other (systemic) complications include:

Blood clots in the deep veins of the leg (deep vein thrombosis or DVT) that can move to the lung and cause pulmonary embolism (PE) Urinary infection or difficulty with urination Pneumonia that may result from difficulty taking deep breaths and coughing after anesthesia.

Complications

http://wiki.medpedia.com/Blood_Clot

http://wiki.medpedia.com/Blood_Clot

http://wiki.medpedia.com/Deep_Vein_Thrombosis

http://wiki.medpedia.com/Pulmonary_Embolism

http://wiki.medpedia.com/Urinary_Tract_Infection

http://wiki.medpedia.com/Urinary_Tract_Infection

http://wiki.medpedia.com/Pneumonia

http://wiki.medpedia.com/Pneumonia

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Complications-

FAILURE RATES FOR INDIVIDUAL HIP DISEASES

HIP DISEASE

FAILURE RATE

(during ten years after

operation)

A-vascular necrosis 0 %

Slipped epiphysis 3 %

Congenital hip dysplasia 5 %

Rheumatoid arthritis 15 %

Previous hip fracture 18%

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Hip Surgery And Hip-Replacement Failure rates for individual hip

diseases

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Prognosis Of Hip-Replacement-

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Hip replacement surgery results are usually excellent. Most or all of your pain and stiffness should go away. Some people may have problems with infection or loosening, or even dislocation, of the new hip joint. Over time -- sometimes as long as 20 years -- the artificial hip joint will loosen. A second replacement may be needed. Younger, more active, people may wear out parts of their new hip. It may need to be replaced before the artificial hip loosens.

Outlook (Prognosis):

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Conclusions-

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Next to Spine injury, Hip-joint is the most important issue in orthopedic surgery. Hip disorder/ injury needs throughout assessment before starting treatment. Treatment strategy/ plan is changing rapidly with the advent of new research/ investigation procedures/ biomaterial. Hip Replacement surgery in orthopedics' changing our life with rapidly increasing success. Successful Hip replacement surgery in orthopedics’ can play a pivotal role in medical science.

Name Of Operation: Total Hip Replacement.Patient Name: Md Sayoeb Ahmed,Age:27 ys.Indication: Rheumatoid Arthritis ( Lt. Hip ).Team Leader:Associate Professor Dr. Sheikh AbbasuddinTeam Members: Associate Professor Dr.Paritosh Ch.DebenathAssistant Professor Kazi ShamimuzzamanDr. Md Nazrul Islam, Resident Surgeon.Assistant Professor Md. Hasan Masud (NITOR),Dr Golam Mahamud Susash ( Suhash ) .Anesthesiologist : Dr. Julfiqar Bhai(Consultant).Dr. Nizam Bhai (Consultant).& Dr. Shamim-Ara (Apa), Dr. Nizam BhaiAnd Dr. Anwar HossainVenue: Shaheed Suhrawardy Medical college Hospital, Department Of Orthopaedics & Traumatology.

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“Total Hip Replacement”

At- Shaheed Suhrawrdy

Medical College Hopital-

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“Total Hip Replacement” done at Shaheed Suhrawardy

Medical College Hospital,December-2010”.

Department of Orthopadic & Traumatology.

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“Total Hip Replacement” At-

Shaheed Suhrawrdy Medical College Hopital-2010

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From-Department Of Orthopedics’ & Traumatology

Shaheed Suhrawardy Medical College Hospital.

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Mobile Hip, Mobile Man.

Have a Healthy Hip with

Fruitful Life.

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Associate Prof. Dr. P. C. Debenath

Associate Prof. Dr. Sheikh Abbas Uddin.

Associate Prof. Dr. Ziaul Haq

Associate Prof. Dr. Shamimul Haq

Associate Prof. Dr. Monowarul Islam

Associate Surgeon Dr. Md. Aminur Rahman

Assistant Prof. Dr. Kazi Shamimuzzaman

Assistant Prof. Dr. A T M Bahar Uddin

Dr. Abdul Hannan

Mr. Anisul Haque Khandaker (Incepta).

&Dr. Md Nazrul Islam

Resident Surgeon,

Department of Orthopedic & Traumatology.

Shaheed Suhrawardy Medical College Hospital.

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HIP DISORDERS: RECENT ADVANCEMENT-THR

Health & Medicine

hip injury hip strain

hip ddh

hipjoint bones

joint pathophysiology

hip joint labrum

hip injurytypes

joint anatomythe hip

common hipdisorders