Hip Pathophysiology - Dr. Davies Flashcards
How many CT scans were taken in one surgery that Dr. Davies gave us as an example?
73
Bracing for Labral tear surgery
Often use different types of braces, and limit motion in the hip.
This is pretty new, so we may not have seen these much in the clinic. One of our labs will actually be putting braces on.
Can dial in ROM limits. During surgery MD will do PROM and see where excessive strain is starting. They determine safe ROM, and then set the brace accordingly
90-0 is typically the safe range
Guideline is about 6 weeks MINIMUM.
Some motion is helpful to the joint, but the labrum must be protected!
What are some scale components in the modified harris hip scoring system?
Gait: Limp, Support, Distance Walked
Functional: Stairs, socks/shoes, public transportation
Hemiprosthesis for hip
Hemi means half, so this is when only half the joint is messed up.
Could be just the femoral prosthesis or the acetabular prosthesis
Labral Repair Surgery
Will do if labrum looks salvagable on MRI/MRA
Lots of different ways to repair
Use suture anchors, which look like little barbs that go into the bone.
Sutures are then sewn around labrum to proximate it
How does the press-fit prosthesis become secured?
it has rough edges and holes that bone tissue grows into
What percentage of sciatic nerves pierce the piriformis muscle?
10-15%
What is a hip structure that is more commonly being reconstructed now and has more to do with stability than originally thought?
Ligamentum teres
Labral tear: Repair with graft
When is it appropriate (who gets one)?
Why would we go to that much trouble?
- Young person, macro-traumatic injury, MRA shows labrum tear
- We want to fix it and restore normal anatomy. The best is always to restore normal anatomy.
should you be more careful during rehab of labral debriedment or repair?
Be more careful with Labrum repair
what is an Awl?
a surgical tool used in microfracture procedures
Is blood supply to the femoral head a large concern in hip resurfacing (since the ligamentum teres, the main source of nutrition for the femoral head, is severed)?
blood supply is already bad usually before resurfacing (usually performed in older adults) so the fact that it is now totally cut off is not as concerning.
What are hip exam techniques predicated on? (4)
- Clusters of s/s
- Critical pathways
- Clinical Practice Guidelines
- Clinical decision making
MOI for FAI
many different MOI possible
Example given was direct macrotraumatic (fall on greater trochanter, where femoral head is jammed into acetabulum)
Macrotraumatic contusions often lead to degeneration because the affect the chrondrocyte cells. Many people get degeneration because of this from surgery itself.
Are MDs reccomending THA earlier or later than before? and why?
They are starting to do THA earlier because of concerns that pt waits so long that they are in such bad condition by the time it is done that recovery is extremely hard
Definition of Extravigate
to go beyond proper limits
Source: http://www.merriam-webster.com/dictionary/extravagate
What is something we should always use during post-op rehab?
Patient-reported outcomes (as opposed to just objective measurements we take with our physical tools)
Three different THA surgical approaches:
- Posterior approach: traditional
- Lateral approach: less common
- Anterior approach: new & trendy
all relative to the greater trochanter landmark
Occurance percentages of Isolated Cam, Isolated PIncer, and combined Cam-Pincer FAIs
Isolated CAM FAI: 17%
Isolated Pincer FAI: 11%
Combined Cam-Pincer FAI: 72%
KNOW THIS!
Nine more complications of surgery
(the things that go wrong with the prosthesis)
- Component loosening
- Components breaking
- Associated bony fractures
- Osteolysis
- Osteonecrosis
- Heterotrophic ossification extra bone formation around surgery)
- Squeaky joints
- Debris buildup
- Components wearing out
match FAI’s to location of labral tear, and why if applicable
CAM type involves Anteirior superior portion
Pincer translates force to the posterior part (contra-coup)
could effect anywhere along the labrum (not just in posterior part) but it shows up most often in the posterior part. Most commonly found in the posterior part.
Hip labrum tear repair with graft: limitations
Limitations:
- Body might reject allograph
- Disease transmission from allograph (example, AIDS)
What does inflow-outflow do during surgery
Constant flow of fluid
- keeps things visible
- Provides a bit of an abresement effect
what does osteoplasty mean?
Oteoplasty = surgery to change the bone
Iliocapsularis muscle
a new muscle Dr. Davies has never heard of that was just reported in a JBJS Article
Does soft tissue or bone take longer to heal?
soft tissue
Two types of femoral stems
- cemented
- uncemented (press-fit)
How old is hip arthroscopy?
Has only been around the last 10 years
FAI Post-Op Recovery in Hip
- Rehab program is dependent on the exact surgical interventions
- Tx options for lesions with FAI indclude osteoplasty of the femoral neck and acetabular osteotomy
- Post-op rehab of these procedures typically involves protected WB and ROM limitations for up to 8 Weeks
- 4.7 yeasr post-op follow up: good to excellent results!
When is a labral resection performed?
Labrum is so macerated that it is not good quality tissue and it needs to be removed
(not fix-able for some reason)
Outcomes are not too great
What is a new technique that surgeons are using more in place of THA?
Hip Resurfacing
Instead of literally whacking off entire femoral head, they smooth down the femoral head and put a cap on it
It is sort of a stop-gap measure, so it is good for several years, but it doesn’t stop degeneration and eventually they still need THA. People can go back to a higher level of activity than if they had a THA
Eleven Complications of THA
- Death from surgery (4% die from all surgeries)
- Transfusions
- PE (pulmonary embolism
- DVT
- Pain
- Swelling
- Chronic synovitis
- Abscesses
- Superficial infections
- Deep infections
- Dislocations (one of the most common)
Five general advangates to Anterior approach to THA
(don’t worry about this as much)
- Can split the muscles more than cut through the muscles.(Typically, the less cutting you can do, the quicker the recovery)
- Pt is usually supine, easier to do C-Arm for radiographs and detect leg lenght differences
- NO Hip precuations for anterior apporach (but many still use)
- Shorter hpsital stay and
- lower risk of dislocations
what test is very important to do before any labrum surgery
MRI or MRA
Don’t want any surprises after surgery starts
What does surgical management of FAI in the hip focus on?
Surgical intervention has focused on improving the clearance of hip motion and alleviating femoral abutment against the acetabular rim, thus reieving pathologic changes in the labrum and articular cartilage.
Clearing stuff to improve motion
Draw a Labral tear
Hip Labral repair with graft: how to perform
- Debride bad tissue first and burr the bone to create subchondral bleeding because it will facilitate healing
- Will take some tissue (usually allograph), and put along periphery and sow it down.
- “artificial” way to try to compensate for incompetent labrum in the hip.
In the hip, is loose pack position and max volume position the same?
yes
The position for both is:
30 degrees flexion
30 degrees of abduction
15 degrees of ER
Does Cam and Pincer type FAI’s usually occur in isolation or together?
Most often together (72%)
Vascularity is important in labral surgery decisions because
It can tell you how likely a repair is to be successful. Better outcomes will happen in more vascularized areas. There is a test that can show vascularization and the sections of the labrum can be caterorized into areas that can be resected or repaired.
Which THA surgical approaches are the most common?
Posterior: less recently trained physicians
Anterior: more recently trained physicians (trend by far!)
What is the most up and coming Extra-articular hip arthroscopy surgery for and what it is anagolous to?
Gluteus Medius tendon repair
Anagolous to RTC repair
G. Medi is like supraspinatus
What is glute med injuries comparible to in the shoulder?
RTC tear