Treatment Interventions

Hip Extensors Table

The immediate postoperative phase is dominated by the acute vascular and inflammatory response to the surgery. Physical therapy intervention at this phase can best be summarized by the acronym PRICEM7 (Figure 17.1). This is the first tier of Fagerson's pyramid model of treatment intervention for the hip. The patient needs to protect the joint and ensure optimal loading by utilizing crutches with partial weightbearing. Crutches also allow for good postural alignment. The joint is protected...

Arthroscopy Following Total Hip Replacement

Most patients with painful total hip replacement do not require arthroscopic evaluation. The etiologies that generate symptoms following arthroplasty can usually be diagnosed by conventional means clinical (leg length discrepancy, abductor weakness, etc) radiographic (component loosening, mal position, trochanteric nonunion, etc) or by special studies such as a bone scan or aspiration arthrogram to detect subtle loosening or sepsis. When unexplained symptoms persist despite appropriate...

Portal Placement in the Supine Position Direct Anterior Portal

The direct anterior portal is commonly used in hip arthros-copy performed in the supine position, and during extensive synovectomy and debridement when in the lateral position. As noted above, the entry point for the arthroscope is at the perpendicular intersection of a horizontal line directed laterally from the symphysis pubis and a vertical line extended in-feriorly from the anterior superior iliac spine (ASIS). The superior margin of the greater trochanter has also been described as a...

Minimally Invasive Surgical Approaches

The surgical approach in any operative procedure, arthroscopic or open, is the foundation for success and safety. Hip arthroscopy has evolved significantly over the last 15 years, and the accurate anatomic mapping and delineation of safe entry points or portals to the hip joint has been a major factor in this evolution. The depth of the hip joint from the skin, the intervening muscle and capsule, and the proximity of major neurovascular structures make the arthroscopic approach in the hip...

Legg CalvePerthes Disease

Avascular necrosis of the skeletally immature femoral head, or Legg-Calve-Perthes disease, is characterized by os-teonecrosis of the ossific nucleus of the femoral head secondary to occlusion of the arterial or venous blood supply. After infarction, healing occurs by a process of creeping substitution and resorption of the dead bone, with deposition of new bone. The deformity of the femoral head and acetabu-lum may be extensive and can exceed the remodeling and healing capacity of the...

Positioning

The lateral approach requires that the patient be positioned in the lateral decubitus position with the affected hip up. Most surgeons use a modified fracture table. The positioning is similar to that used for lateral femoral nailing. Some centers still have access to a specially modified distraction device produced by Arthronix Corporation the Hip Distraktor , which can be fitted to a regular fluoroscopic surgery bed however, this apparatus is no longer in commercial production. Commercially...

Instrumentation

Arthroscopic access to the hip joint requires specialized instrumentation that allows controlled, atraumatic penetration of the periarticular soft tissues, abductor musculature, and hip joint capsule. Because of the depth of the hip joint from the surface, specially designed extra-long arthroscopic instruments are generally required to enter the hip joint and perform any necessary procedures. In selected smaller individuals who have thin soft tissue envelopes, it is sometimes possible to use...

Traditional Surgical Approaches

Hip Replacement Hardinge Approach Pics

Any discussion regarding minimally invasive approaches to the hip joint is predicated by the context in which it developed. The hip joint is the most deeply recessed joint in the body. Because of the many musculotendinous investing structures surrounding it, a number of open surgical approaches were developed. Each of these methods, importantly, passes through fascial planes between muscles supplied by major nerves. These planes are well detailed by Henry.1 Indications for hip surgery have...

Microangiographic Studies and Spalteholz Staining

The microvascular anatomy of 10 acetabula was determined using a modification of the Spalteholz tissue-clearing technique described by Crock 1967 34 and Arnoczky 1982 .35 Six male adult cadavers with an average age of 71 range, 62-82 years were obtained from the Gross Anatomy Laboratory. The femoral circumflex arteries and the internal iliac arteries of each cadaver were exposed, sequentially incised, and cannulated with a Foley catheter. The catheter balloon was inflated, and all adjacent...

Treatment Algorithms

McCarthy, and Jo-ann Lee During the history and physical, the clinician should note whether the hip pain is primarily in the anterior groin, in the buttocks or posterior thigh, or in the lateral aspect of the hip and thigh. Though there is some overlap, each of these regions has particular etiologies of pain associated with it. If patients with acute anterior groin pain following injury have negative radiographs and are able to ambulate and bear some weight,...

Perioperative Management

Position Arm Dependent Position

Hip arthroscopy as performed at the New England Baptist Hospital is generally an outpatient surgery procedure. The majority of patients undergoing hip arthroscopy are categorized as ASA I and II. Although in one series patient ages ranged from 17 to 69 years,1 most are young adults. They have few serious comorbid conditions and usually require minimal pre-anesthetic testing. Some patients present with severe chronic hip pain and are narcotic tolerant due to long-term analgesic use. Despite...

Anatomy

Piriformis Gemelli

The pelvis is formed from the fusion of three separate centers of ossification the pubis, ischium, and ilium. All fuse into a single bone by early adolescence. The site of convergence and fusion of all three centers of ossification is the tri-radiate cartilage, which eventually fuses and forms the mature acetabulum. In addition to these primary centers of ossification, the adolescent has seven other centers of secondary ossification, which include the iliac crest, ischial apophysis, anterior...

Assessment of the Painful

Hip Adductor Tendonitis Mri

Busconi, and Brett D. Owens Patients who present to a physician with hip pain will generally have a definable diagnosis based on a thorough history, physical examination, and radiologic evaluation. There exists a subset of patients, however, who develop intractable hip pain with reproducible physical findings yet escape a definitive diagnosis despite extensive noninvasive radiologic evaluation. This pain is often refractory to nonoperative management including rest,...