Hip Surgery & Rehab Flashcards
What is arthroscopy?
Any surgery performed through portals and using an endoscope
What is considered prior to hip arthroscopy?
- History (symptoms, impairments)
- Examination of the hip (complete examination, medical imaging)
- Interpretation/diagnosis
- Intervention plan
What are ultrasounds, MRIs and CT scans used for in the hip?
- Ultrasound: Tendinopathies
- MRI: Labrum tears esp. in acetabulum, soft tissue lesions
CT: 3D image of bone
What conditions are associated with hip arthroscopy?
- Femoral acetabular labrum (FAI): neck of femur impinging on acetabular labrum
- Labral tears
- Debride hyaline cartilage lesions
- Extra-articular pathology: Glut med tears, chronic IT band snapping syndrome, snapping psoas syndrome
What are the different types of femoral acetabular impingement (FAI):
- Controlled action motion (CAM) impingement: Bump on femoral head/neck
- Pincer impingement: Overgrowth on acetabular side
- Mixture of both
What types of patients will commonly need debriding of hyaline cartilage lesions?
Patients with OA
What types of patients commonly get pincer FAI?
Young people, approx 20-35 years (not associated with OA)
What is the common clinical presentation of FAI?
- Groin pain
- Pain on high flexion activities, e.g. crouching
- Weight-bearing activities e.g. running, jumping
What is FABER?
Flexion, abduction, external rotation
What does the FABER position help diagnose?
- Labral tear
- OA
- Greater trochanteric pain syndrome
What is FADIR?
Flexion, adduction, internal rotation
What does the FADIR position help diagnose?
Labral tear, FAI
What is a negative consequence of debriding an acetabular labral tear of the hip?
Accelerates OA
How do surgeons increase visibility in a hip arthroscopy?
Inflate the joint with water
How is an osteoplasty used for FAI?
- Femur: to reshape femoral head/neck treat CAM
- Acetabulum: Reshape the acetabular rim to improve pincer impingement
- Results in improved ROM & function
What is micro fracture or abrasion chondroplasty?
- Debride bad hyaline cartilage
- Drill small holes in bone
- Causes inflammatory response, bringing fibroblasts to area
- Fibrocartilage is laid down in the area
What are the 2 positions a hip arthroscopy can be performed in?
- Supine: Easier operating room setup, but more difficult on obese patient
- Lateral: More complex room setup, requires special table attachment to position the leg, provides excellent access
What is the surgical procedure of a hip arthroscopy?
- Portals penetrate TFL, glut med or sartorius & rec fem
- Anterolateral portal established, then anterior portal
- Avoid injury to femoral cutaneous nerve
- Central compartment: Loose bodies, cartilage injuries etc
- Peripheral compartment: Labrum, acetabular rim, femoral neck
What are the common restrictions for hip arthroscopy rehab?
- AROM/PROM
- Weight-bearing status
- Cannot flex hip past 90 degrees
What are some of the issues that complicate decisions about hip arthroscopies?
- OA
- Tendinopathies
- Bursitis
- Core strength
What needs to be considered during hip arthroscopy rehab?
- Pain control is important for mobilisation
- Maintaining WB status is important for protecting healing structures
- Sudden stiffness/mechanical signs: Check complications, may be re-injury, rapid onset OA, avascular necrosis etc
What is involved in the initial postoperative exam for hip arthroscopies?
- Bulky dressing & abduction pillow
- May be in outpatient surgery centre or hospital
- Overnight stay may be considered
- Post op care based on surgery specifics
- Patients can use passive motion machine, crutches or walker
What are the 5 main things that need to be covered in a post-op exam?
- Chest/respiratory exam
- DVT: Check pain, swelling, redness in calves
- Mobility
- Other joints
- Surgical site/limb
What is the purpose of a hip open reduction internal fixation (ORIF)?
To stabilise a fracture by realigning the fragments under GA & open incision, then fixation with hardware
What is a common complication with neck of femur fractures?
Avascular necrosis of head of femur (blood supply cut off by fracture)
What does a dynamic hip screw (DHS) allow?
Compression in the joint
What are cannulated screws used for?
Holding a head of femur back on
What are the 3 types of hip fractures requiring ORIF?
- Head or neck of femur (displaced/undisplaced)
- Intertrochanteric (stable/unstable)
- Subtrochanteric
What is a complication of hip ORIF rehab?
Lots of co-morbidities due to population (older people, 80 years)
What are the features of an ORIF for displaced/minimally displaced/compression femoral neck fractures?
- Least severe of hip fractures
- Stable, FWB immediately post surgery
- No ROM limitations
What is involved in an ORIF for displaced/minimally displaced/compression femoral neck fractures?
- Incision down lateral side of hip (TFL, VL)
- Cannulated screws
- No major nerves/vessels at risk
What is the treatment for displaced femoral neck fractures?
- Femoral head separated widely from neck
- Vascular supply to femoral head often severed (avascular necrosis)
- Do not heal if reduced/fixed by screws
- Fixation attempted in young patients
- Older patients treated with THR
What are the features of intertrochanteric hip fractures?
- Usually most challenging
- Gluteus max pulls fracture apart
- Weight bearing often not possible immediately post op
How are stable intertrochanteric hip fractures treated?
- Stable = intact posteromedial cortex, fracture at base of femoral neck
- Compression hip screw (pin & plate)
- PWB post op
How are unstable intertrochanteric hip fractures treated?
- Dynamic hip screw through neck
- Cross pins at bottom to prevent rotation (static lock)
- Intermedullary pin through shaft
What is the approach for placing DHS in intertrochanteric hip fractures?
- Long lateral approach (through TFL, VL)
- Same for stable & unstable
What is one difference in the ORIF for stable & unstable intertrochanteric hip fractures?
Unstable: Lesser trochanter often left floating, can lead to weakness (hip flexors)
What are the healing rates for hip ORIF?
- Skin: 2 weeks
- Deep fascia/soft tissues: 6 weeks
- Bone: 12 weeks
(Older adults with OP, can be 4-6 months)
What are the weight-bearing guidelines for patients with unstable hip fractures?
Weight-bearing should be delayed until good bony healing is demonstrated (some PWB allowed)
What occurs in a subtrochanteric hip fracture?
Proximal fragment FABER, femoral shaft shortened/adducted
What occurs in an ORIF for subtrochanteric hip fractures?
- Intra-medullary nail & compression screw
- Needs to oppose angular & muscular deforming forces
- Poor blood supply
- Lateral approach
What are the weight bearing guidelines for subtrochanteric hip fractures post op?
PWB
What are the post op day 1 considerations for hip ORIF?
- Initial goal is getting out of bed, walking to bathroom using front-wheel walker (FWW)
- Usually emergency surgery, so often confused/emotion, no pre op education
- No ROM precautions
- May be groggy/in pain
