MANAGEMENT OF HIP DISORDERS AND SURGERIES Need to Know Pathologies Surgical procedures Precautions Presenting impairments Functional limitations Possible disabilities surgical procedures precautions

JOINT HYPOMOBILITY: NONOPERATIVE MANAGEMENT Related Pathologies and Etiology of Symptoms Osteoarthritis (Degenerative Joint Disease) Rheumatoid arthritis Aseptic necrosis Slipped epiphyses, Dislocations, and congenital deformities Post immobilization Hypo mobility

Common Impairments Pain experienced in the groin Stiffness after rest. Limited motion with a firm capsular end-feel Antalgic gait Limited hip extension Limited Knee extension Impaired balance and postural control

Non-Operative Management

Common Functional Limitations/Disabilities Jobs Household work Arising from a chair climbing stairs Weight Bearing Restricted routine ADL

Management: Protection Phase Decrease Pain at Rest (grade1 or 2 mobilization) Decrease Pain During Weight-Bearing Activities (Provide assistive devices for ambulation) Decrease Effects of Stiffness and Maintain Available Motion (Range of motion exercises)

Management: Controlled Motion and Return to Function Phases Progressively Increase Joint Play and Soft Tissue Mobility Joint mobilization techniques Passive stretching, neuromuscular inhibition, and self- stretching techniques

Anterior Glide to Increase Hip Extension and External Rotation

Posterior Glide to Increase Hip Flexion & Internal Rotation

Increase Extension During Weight Bearing Improve Muscle Performance in Supporting Muscles Patient Education

Total Hip Arthroplasty

Indications for Surgery Severe hip pain with motion and weight bearing Joint deterioration and loss of articular cartilage Osteoarthritis Rheumatoid or traumatic arthritis Ankylosing spondylitis Osteonecrosis (avascular necrosis) Nonunion fracture Bone tumors Failure of conservative management or previous joint reconstruction procedures

Contraindications to Total Hip Arthroplasty Absolute Active joint infection Systemic infection Chronic osteomyelitis Significant loss of bone Neuropathic hip joint Severe paralysis of the muscle Relative Localized infection Progressive neurological disorder

Procedures Prosthetic designs and materials An inert metal (cobalt-chrome and titanium) modular femoral component A high-density polyethylene acetabular component Metal-on-metal systems and systems that utilize ceramic surfaces in the design.

Standard surgical approaches Posterolateral approach Most frequently use Preserves the integrity of the gluteus medius and vastus lateralis Trochanteric osteotomy is not necessary Disadvantage Postoperative joint instability Risk of postoperative dislocation,

Standard surgical approaches Direct lateral approach Release proximal insertion of the gluteus medius Longitudinal splitting of the vastus lateralis Detachment of gluteus minimus Trochanteric osteotomy is not necessary Disadvantage Postoperative weakness Gait abnormalities

Standard surgical approaches Anterolateral approach Involves complex reconstruction Indicated for patients with muscle imbalances Osteotomy of the greater trochanter Soft tissues disturbed

Conventional hip replacement Healthy hip Cuts Implant components Implanted

The BHR* System Healthy hip Cuts Implant components Implanted

Conventional vs. the BHR* System Total hip cuts BHR System cuts

Cemented or Cement less

Cemented versus cementless fixation Cemented Fixation Acrylic cement allow early postoperative weight bearing Disadvantage Aseptic (biomechanical) loosening of the prosthetic components at the bone–cement interface in younger, physically active patients

Procedures Cemented versus cementless fixation Cementless (biological) fixation porous-coated prostheses cementless press-fit technique Smooth (nonporous) femoral components with cementless arthroplasty Coating of a bioactive compound called hydroxyapatite Under 60 year of age Disadvantage Late weight bearing

Operative approaches Minimally invasive approaches

Step 1: Incision Removal of osteophytes Avoid transverse acetabular ligament Ref: Desert Orthopaedic Center http://www.desertorthopedic.com/mini.asp Ref: http://www.bonecement.com/application/totalhip.html

Step 2: Removal of Femoral Head Femoral head dislocated Femoral head removed at neck

Step 3: Prepare Acetabulum Drill and reamer used to remove cartilage and create cup shape Anchorage holes made (cemented case) Remove debris with brush

Step 4: Insertion of Acetabular Component Held in place by friction, screws or cement Pressurization carried out in cemented case See Reference Section

Step 5: Preparation of Femoral Canal Straight reamer creates hole Remove debris Insert distal plug See Reference Section

Step 6: Insertion of Femoral Stem Friction fit or cement If cement used pressurize cement to create an even cement mantle See Reference Section

Step 7: Attachment of Femoral Head Attach femoral head to stem (by Morse taper) See Reference Section

Step 8: Insertion of Head into Acetabular Component Femoral head is located into acetabular liner Range of motion is verified See Reference Section

Features of Minimally Invasive Total Hip Arthroplasty Incision location and muscles disturbed Posterior approach 7- to 10-cm posterior incision the abductor mechanism consistently is left intact Anterior approach 10 cm incision beginning just lateral and distal of the anterior superior iliac spine leaves all muscles intact no postopertive precautions Lateral approach least commonly used leaves the posterior capsule intact eliminating the need to postoperative precautions

Postoperative Management Immobilization After THA there is no need for immobilization The operated must be kept in a position of slight abduction and neutral rotation when the patient is lying in bed in the supine position.

Immediate postoperative weight bearing as tolerated Early Postoperative Weight-Bearing Restrictions After Total Hip Arthroplasty Method of Fixation Cemented: Immediate postoperative weight bearing as tolerated Cementless and hybrid At least 6 weeks from partial weight bearing to full weight bearing

Early Postoperative Weight-Bearing Restrictions After Total Hip Arthroplasty Surgical Approach Standard Restricted immediately after surgery Minimally invasive Weight bearing as tolerated immediately after surgery

Exercise: Maximum Protection Goals and interventions. Prevent vascular and pulmonary complications. Prevent postoperative dislocation or subluxation of the operated hip. Achieve independent functional mobility prior to discharge Maintain strength and endurance in the upper extremities and unoperated lower extremity Prevent reflex inhibition and atrophy of musculature Regain active mobility and control of the operated extremity.. Prevent a flexion contracture of the operated hip.

Exercise: Moderate and Minimum Protection Phases Goals and interventions Regain strength and muscular endurance. Improve cardiopulmonary endurance. Reduce contractures while adhering to motion precautions Improve postural stability, balance, and gait. Prepare for a full level of functional activities.

Accelerated Rehabilitation After Minimally Invasive THA Immediate postoperative therapy.(5 to 6 hours after surgery) Postoperative bed and chair transfers Ambulation with crutches Ascending and descending stairs Criteria for hospital discharge. Transfer in and out of bed Stand up from and sit down in a stand Walk 100 feet Ascend and descend a flight of stairs

Operative procedure A posterolateral approach is most commonly used After removing the head of the femur, the metal-stemmed prosthesis is inserted into the shaft of the proximal femur

Exercise: Maximum Protection Goals and interventions. Prevent vascular and pulmonary complications. Prevent postoperative dislocation or subluxation of the operated hip. Achieve independent functional mobility prior to discharge Maintain strength and endurance in the upper extremities and unoperated lower extremity Prevent reflex inhibition and atrophy of musculature Regain active mobility and control of the operated extremity Prevent a flexion contracture of the operated hip.