Hip Complex Flashcards
Angle of Inclination (Frontal Plane)
(3)
Coxa Valga: 170 degrees
- Tilt down = varus knee
Normal: 120-135 degrees
Coxa Vara: 100 degree (< 120)
Tilt up = valgus knee
Disburses FORCES differently through knee
Congenital Deformities - sometimes develop depending on the forces put through it
Angle of Torison (Transverse Plane)
(3)
Anteverison (Medial Femoral Torsion)
- Toeing-in
- Femur internal - associated w/ W-sitting > widen base of support, especially in children w/ hypotonia
Normal = 8-15 degrees
Retroversion (Lateral Femoral Torsion)
- Toeing-out
Does not mean pt will experience pain
May put them at a greater risk of developing a pathology
** May need different variations of how they squat / walk / run
Osteoarthritis (HIP)
Defintion
Degeneration of the articular & subcondral bone
Leads to joint space narrowing, rubbing of bone on done due to degeneration & break down of overlying articular cartilage, which may lead to osteophyte formation
NOCIEBO affect - expectations of something bad/negative is going to cause symptoms - imagine that they should have pain as a result of blank
Hip OA: Etiology
Risk Factors: Non-Modifiable & Modifiable
Non-Modifiable
- Age
- Gender (F>M)
- Heredity
- Congential Malformations - coxa valga/vara, ante/retroversion
Modifiable:
- Obesity: lead bearing = more load w/ INC wt
- Abnormal repetitive stress
- Trauma: previous injury = INC risk
- Joint mechanics (may or may not be able to modify)
May be natural - depends on the context of the activity (wt lifting vs running)
Hip OA: S/S
(6)
- Pain in groin, hip (greater trochanter), buttock, thigh, back, or knee
Any hip pathology of the HIP JOINT - deep & around groin - Pain w/ weight bearing activities
- DEC paini in loose packed position: 30 flexion, 30 abduction, slight ER
- Stiffness
Limits motiono with a firm capsular end-feel
Capsular pattern of restriction: IR > flexion > abduction
Initally, limitations ONLY in IR. Advance stages hip is fiexed in adduction (limitation abduction), no IR or extension past neutral & limitations in hip flexion to 90 degrees - DEC mm strength
- Limited functional abilities (LATER STAGES)
- Difficulty w/ sit<-> stand (squating)
- Difficulty walking on uneven surface
- Difficult w/ ADLs
- DEC walking distance (d/t pain)
- DEC time in standing
Special Test: Scour
Not specific for hip OA rather a hip pathology
PT: flexion + add/abduction - moving femur on different surfaces of acetabulum
(+) = pain, spasm - “catch” feel resistance & moving over it
Special Test: Patrick’s (FABER) Test
Not specific for hip OA rather a hip pathology
“Figure 4” position
(+) = if ROM is limited & knee is not dropping down to parallel or lower
*Also part of cluster test for SI pain
Special Test: Flexion-Adduction (Hip Quadrant) Test
Not specific for hip OA rather a hip pathology
Looking for pain or discomfort
NOT scouing - just going into both mvmt
(+) = pain or discomfort
Hip OA: Interventions
4
Education:
- Safe ambulation patterns
- Minimizing aggravating activities stressing joints - ex. high impact
Decrease Pain:
- Grade I or II oscillation techniques w/ the joint in resting positon (30F, 30AB, ER)
- Provide assistive device during ambulation - cane on contralateral side
- If LLD is causing joint stress, gradually elevate short leg with shoe lifts
- Modiify chairs & commodes to make sitting & standing up easier = higher surface (limit in/out of deep squats)
- Modalities (TENS, heat, etc)
INC ROM = more functional ability
- ROM exercises w/in tolerable limitis
- Grade III or IV oscillation techniques using glides that stretch restricting capsular tissue
- Stretching (NO vigorous stretching until the chronic stage of healing)
ACUTE = INC irritability = DEC activity/exercise = INC deconditioning = DEC mvmt = INC stiffness/mm guarding
Strengthening:
- Hip strengthening as tolerated
- Begin with OKC (maybe more tolerable) & progress to functional exercsise using CKC as tolerated
CKC = WB which could INC pain/ discomfort
More functional activities = general WB <- progress to this
Total Hip Athroplasty
Description & indications
Surgical procedure performed where the femoral head & acetabulum are replaced w/ artificial components
Indication for THA:
- Severe hip pain, loss of function, DEC QoL as a result of joint deterioration associated with OA, RA, AS, avascular necrosis w/ failure of conservative management
- Nonunion fracture, instability, or deformity of the hip
- Bone tumors
- Failure of previous reconstrcution procedures
HEMI - replace only one component (ball or socket)
THA - Preoperative Management
(6)
- Preoperative examination of patient’s status
Ie. pain, ROM, mm strength, balance, gait, function, etc - Education regarding operative procedure - how its done, equipment
- Education regarding post-operative precautions & rationale
- Functional training for early post-operative days
Ie. bed mobility, transfers, ambulation device training - Early post-operative exercises
- Criteria for discharge for the hospital
TKA: Surgical Approaches
(3)
- Posterior / Posterolateral
- Lateral
- Anterior
Surgical Approach:
Posterior / Posterolateral
Involvement of Soft Tissues & Impact on Postoperative Function
Posterior or Posterolateral
Involvement of Soft Tissues:
1. Gluteus maximus divided in line with its fibers with a posterior approach
2. Interval b/t gluteus maximus & medius divided in posterolateral approach
3. Short ERs & piriformis released & repaired
4. Gluteus maximus tendon possibly released from femur; repaired at conclusion
5. Posterior capsule is incised & repaired
6. Gluteus medius & TFL left intact
Impact on Postoperative Function
- Possible earlier recovery of normal gait pattern d/t intact gluteus medius & TFL
Lurch or Trendelenberg
- Highest risk of dislocation or subluxation of prosthetic hip
Surgicial Approach:
Direct Lateral
Involvement of Soft Tissues & Impact on Postoperative Function
Direct Lateral
Involvement of Soft Tissues
1. Longitudinal division od the TFL
2. Release of up to one-half of proximal insertion of the gluteus medius & minimus; reaatched prior to closure
3. Longitudinal splitting of the vastus lateralis
4. Capsulotomy & repair
Impact on Postoperative Function:
- Weakness of the hip abductors
- Possible pelvic obliquity
Pelvic Obliquity is the misalignment of the pelvis, typically where one hip is higher than the other
- Delayed recovery of symmetrical gait
Surgical Approach:
Direct Anterior
Involvement of Soft Tissues & Impact on Postoperative Function
Involvement of Soft Tissues
1. Incision made anterior & distal to the ASIS, slightly anterior to the greater trochanter & medial to TFL
2. No muscles incised or detached but rectus femoris & sartorius retacted medially to access the joint
3. Anterior capulotomy & repair
Impact on Postoperative Function
- WBAT immediately after Sx
- More rapid recovery of hip mm strength & normal gait pattern comparde with anterolateral approach
TKA: Complications
(3)
Intra-operative:
- Malpositioning of the prosthetic component (takes load in ackward way)
- Femoral fracture
- Nerve injury
Anterior - femoral, superior gluteal, obturator
Peroneal division of the sciatic is the most common - exspecially w/ posterior & posteolateral approach
- Leg-length discrepancy (appliance is not fitted properly)
Early post-operative complications:
- DVT - d/t immobility - venous stasis (dislodge = life-treatening)
- Infection - invasive procedure - entry port for bacteria
- Wound healing problems - delayed = ?infection
- Dislcation of prosthetic joint
Later post-operative complications:
- Mechanical losening of components
- Atraumatic wearing out of components (lifespan ~10 years before need to be replaced)
TKA: Post-operative Precautions
Posterior / Posterolateral Approaches:
- No hip flexion > 90 degrees
NO low seats - “nose over toes” = hip > 90
Need to be aware of functional activities
Use arms to stand up straight
- No hip internal rotation beyond neutral
No pivoting on leg = functional IR
- No hip ADDuction beyond neutral
No side-lying - lying w/o pillow between legs
ABD affected leg & ASS non-affected leg
Cognitive issues - lots of natural mvmt - could be at risk for post-operative complications as a result
Anterior / Anterolateral & Direct Lateral Approaches
- No hip flexion > 90
- No hip extension - very natural w/ reciporcal gait - Need to do STEP-TO gait
- No ER beyond neutral
- No hipp ADDuction beyond neutral
- No combined motion of hip flexion, ABDuction, & ER (FABER)
- If gluteus medius was incised, no resisted or antigravity hip ABDuction for > 6-8 weeks (at least)
Faster healing & lower risk of dislocation
- Especially for pt w/ cognitive / memory issues = less natural movements occuring that could lead to complications (compared to other approaches)
TKA: Interventions
Maximum, Moderate & Minimal Protection Phase
Maximum Portection Phase:
Goals:
1. Prevent complications:
- Education to reduce risk of complications (precautions, safe bed mobility & transfers = reduce risk of falls, & S/S to look out for infection)
Infection = fever, INC/excessive pain, heat/warmth in area, feels inflammed, etc
- Ankle Pumps - reduce DVT risk
- Deep breathing exercises & secretion clearance - want them to cough & not retain mucus (= INC risk of infection)
- Prevent mm atrophy:
- Submaximal mm setting (isometrics) of quadriceps, hip extensors (glute max & hamstrings), & hip abductors (Do NOT want to contract mm if they were cut - ie direct lateral approach) - Regain active mobility & control
- AROM or AAROM of hip w/in protected ranges
- Bilateral closed-chain weight shifting, balance activities, heel raises, and mini-squats (repecting WB resistrictions) - Achieve independent functional mobility
- Bed mobility
- Sit <-> stand
- Transfer training
- Ambulation w/ asistive device (older = walker / younger = crutches if adequate balance/stretch)
- Stairs training
Moderate Protection Phase
Goals:
1. Regain strength & mm endurance
2. Improve cardiopulmonary endurance
3. Restore ROM (while adhering to precautions)
4. Improve postural stability, balance & gait
Minimal Protection Phase
Goals:
1. Continue previous goals if not met
2. Resume or modify functional activities
3. Return to sport activities (depending on surgeons’ approval of sport actvities)
Guidelines for Sport, Recreational, & Fitness Activity Participation following TKA
(3 levels)
Allowed:
- Golf
- Swimming
- Walking
- Stationary cycling
- Elliptical trainer
- Cross country ski unit
- Bowling
- Low-impact aerobics
- Speed walking
- Hiking
- Stair-climbing unit
- Rowing unit
- Doubles tennis
- Use of weight machines
Allowed with Caution & Prior Experience
- Pilates
- Cross-country skiing
- Rollerblading
- Ice skating
- Downhill skiiing
Not Allowed
- Jogging / running
- Baseball / softball
- Raquetball / squash
- Snow boarding
- High-impact aerobics
- Contact sports (ie football, basketball, soccer)
AVOID high-impact activites
AVOID slippery surfaces where it is possible for pt to fall PR causes leg to go in ackward position (compromise the prosthetic components)
Hip Fractures
Description & Epi
A fracture of the proximal hip
DISTAL = Extracapsular
PROXIMAL = Intracapsular
- Intra = potential to compromise the vascular strcture
Avascular necrosis = no longer congruent w/ hip - poor hip structure & wearing out of acetabulum > TKA
Delayed healing if vascular supplu is affected = nonunion
Epi:
- Majority of hip # occur in elderly populations (> 75 years old)
- F>M (osteoporotic factors)
Hip Fractures: Etiology
(3)
Falls
- Age-related DEC in mm strength & flexibility
- DEC balance & gait deficits
- Poor vision
- Cognitive decline
- Medications - drowsy
Osteoporosis - less impact needed for a fracture to occur
Sudden twisting motion of LE
Walking speed decreases w/ age - when older ppl lose balance & fall -> typically fall to side = positionn likely to break femure
Faster gait speed = ppl are more likley to stick their hand out = more likely to fracture wrist
Hip Fracture: S/S
(5)
- Pain in groin (INTRA) or hip region (EXTRA)
- Pain w/ AROM or PROM of the hip
- Pain w/ LE weight bearing - # caused femur to shift superiorly
- LLD (shorter leg)
- **LE assumed an ER / ABDucted position
Hip Fracture: Interventions
(2)
Surgery
- ORIF - nails/pins to fixate it
- Hemiarthroplasty - just replace the FEMUR component - BALL not socket
Displaced intracapsular # gets a hemi instead of an ORIF > less risk for non-union
- TKA - may replace both acetabulum & femur depending on their state
Post-operative rehabilitation
- Goals
Hip Fracture:
Post-operative Rehabiliation
Goal: Minimize adverse effects of bed rest (while protecting the surgicial site)
- Bed mobility training
- Transfer training
- Ambulation w/ assistive device - based on WB precautions
- Deep breathing & coughing exercise - limit infection from secretion retention
- LE edema control (compressive stockings)
Exercise program
- ROM - as much as we can - as soon as we can
- Strengthening
- Balance training
