Hip and femur

Hip and femur

Katherine Sharpe and Deana Bahrman

Anatomy

Bones: Figures 6-1 and 6-2

Figure 6-1. External surface of the hip bones. (From Bogart BI, Ort VH: Elsevier’s integrated anatomy and embryology, Philadelphia, 2007, Mosby.)

Figure 6-2. Proximal femur. (Elsevier illustration from www.elsevierimages.com. Copyright, Elsevier Inc. All rights reserved.)

Ligaments: Figure 6-3

Figure 6-3. Ligaments of the hip. (From Bogart BI, Ort VH: Elsevier’s integrated anatomy and embryology, Philadelphia, 2007, Mosby.)

Muscles and tendons: Figures 6-4 and 6-5

Figure 6-4. Anterior compartment muscles of the thigh. (Elsevier illustration from www. elsevierimages.com. Copyright, Elsevier Inc. All rights reserved.)

Figure 6-5. Gluteal region: superficial and deep muscles.
CT, computed tomography. (Elsevier illustration from www.elsevierimages.com. Copyright, Elsevier Inc. All rights reserved.)

Nerves and arteries: Figure 6-6 and table 6-1

Table 6-1.

Nerves of the Hip and Thigh

Figure 6-6. Gluteal region: arteries and nerves. (Elsevier illustration from www.elsevierimages.com. Copyright, Elsevier Inc. All rights reserved.)

Surface anatomy: Figure 6-7

Figure 6-7. Hip surface anatomy. (Elsevier illustration from www.elsevierimages.com. Copyright, Elsevier Inc. All rights reserved.)

Normal radiographic findings: Figure 6-8

Figure 6-8. Normal radiograph of the hip.

Physical examination

Inspect the patient’s gait and look for deformity.

• Greater trochanter

• Iliopsoas tendon

• Sacroiliac joint

• Iliotibial band

Normal range of motion (ROM): Table 6-2

Table 6-2.

Normal Range of Motion of the Hip

Extension	115 degrees
Flexion	125 degrees
External rotation	45 degrees
Internal rotation	45 degrees
Abduction	45 degrees
Adduction	45 degrees

Neurovascular examination: Table 6-3

Table 6-3.

Neurovascular Examination

Special tests

FABERE test: This maneuver tests for hip osteoarthritis (OA). The patient lies supine while the examiner flexes hip and knee and places the lateral malleolus across the contralateral knee. The examiner then extends the hip by pushing the flexed knee toward the table. A positive test result is when this maneuver elicits severe pain or restriction. The name of this test is an acronym for flexion abduction external rotation and extension.

Differential diagnosis: Table 6-4

Table 6-4.

Differential Diagnosis of Hip and Thigh Pain

Buttock pain	Ischial bursitis Sciatica Hamstring strain Piriformis syndrome Gluteal tear Sacroiliac dysfunction
Groin pain	Hip arthritis Avascular necrosis Femoral acetabular impingement Adductor strain Femoral neck fracture Sacroiliac dysfunction Osteitis pubis
Lateral hip pain	Trochanteric bursitis
Posterior thigh pain	Sciatica
Anterior thigh pain	Iliopsoas tendinitis/bursitis Hip arthritis Hamstring strain Femoral shaft fracture

Suggested readings

Eustice C: Osteoarthritis (website). http://osteoarthritis.about.com/od/osteoarthritisdiagnosis/a/range_of_motion.htm. Accessed September 11, 2012.

Greene WB: Netter’s orthopaedics, Philadelphia, 2006, Saunders.

Hansen JT: Netter’s clinical anatomy, ed 2, Philadelphia, 2010, Saunders.

Hip osteoarthritis

Causes of hip arthritis

• Elevated bone density

• Femoral acetabular impingement (FAI)

• Congenital dysplasia (∼80% female)

• Trauma (three times more likely to develop)

• Slipped capital femoral epiphysis (SCFE)

• Legg-Calvé-Perthes disease

• Avascular necrosis (AVN) (likely from alcohol or systemic steroid use)

• Inflammatory disorders (rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis)

• Sepsis (complaint of sharp pain in the groin or anterior hip, worse with weight bearing; night pain in in patients with severe OA)

Physical examination

Antalgic gait; posture and use of assistive devices

Limb length discrepancy (LLD)

Positive Trendelenburg test result: difficulty standing on one leg on the affected side because of abductor weakness

Pain with active and passive ROM especially with hip flexion and internal rotation

Check of distal pulses (dorsalis pedis and posterior tibial)

Positive heel tap with occult fracture

Imaging: Figure 6-9

Figure 6-9. Osteoarthritis of the left hip on radiography (A, arrow) and magnetic resonance imaging (B, arrowheads). (From Haaga JR, Lanzieri CF, Gilkeson RC, editors: CT and MR imaging of the whole body, ed 4, St. Louis, 2003, Mosby.)

Order radiographs: pelvis and OR lateral of hip. OR lateral requires the patient to rotate the hip internally approximately 10 to 15 degrees to provide a true lateral view because of the natural anteversion of the femoral head in the acetabular cup. Consider a frog leg view to assess for FAI.

FAI: Order magnetic resonance imaging (MRI) without contrast to assess for soft tissue and labral damage. If labral damage is present, the patient will need total hip arthroplasty (THA); if not, consider surgical débridement of the femoral head.

AVN: Order MRI with and without contrast to assess the extent of necrosis. If the femoral head has collapsed, the patient will need THA; if not, consider core decompression and bone graft to restore the blood supply.

Order a computed tomography (CT) scan for complex cases to assess the acetabular cup.

Initial treatment

Patient education

OA is a progressive condition with three main risk factors: aging, obesity, and trauma. OA is nonreversible; treatment is geared toward pain control with conservative methods, and surgery is a last resort. THA is contraindicated in patients with a body mass index (BMI) greater than 40.

Treatment options

Nonoperative management

Nonsteroidal antiinflammatory drugs (NSAIDs)

Physical therapy (PT): possibly helpful for muscle weakness and gait, but discontinued if symptoms increase

Steroid or hyaluronic acid injections (may repeat at most every 3 months to prevent cartilage damage)

Follow-up in 3 months to assess effectiveness

Operative management

Codes

ICD-9 code: 715.15 Hip osteoarthritis

CPT code: 27130 Total hip arthroplasty

Operative indications

BMI lower than 40

Failed conservative treatment

Pain affecting activities of daily living (ADLs) and quality of life (QOL)

Informed consent and counseling

Risks include bleeding, infection, blood clots, and LLD.

The patient will need medical clearance.

The average hospital stay lasts 3 days.

Patients require 2 to 6 weeks of anticoagulation treatment.

Expect 6 weeks of healing, PT, and strict hip precautions to prevent dislocation (no flexion >90 degrees or adduction) if the posterolateral approach is used; if the anterolateral approach is chosen, no hip precautions are necessary.

Expect to wait about 3 months before returning to work. Work restrictions include no prolonged sitting or standing and a 40-lb lifting limit.

It may take 1 year to recover fully.

Anesthesia

Regional anesthetic, such as spinal block or femoral block with sedation, or general endotracheal

Patient positioning

Lateral decubitus, with the operative side up

Surgical procedures

Posterolateral approach:

Hardware consists of an acetabular cup, femoral head, femoral stem, polyethylene liner, and acetabular screws. Femoral and acetabular components may be made of titanium, stainless steel, or cobalt chrome (metal-on-polyethylene THA). Ceramic-on-ceramic components may also be used.

Posterolateral approach: An 8- to 10-cm incision is made along the posterior border of the greater trochanter to the vastus tubercle. Deep dissection is performed using a Cobb elevator through the gluteus maximus over the posterior border of the greater trochanter, and thus the posterior capsule is entered.

The hip is then dislocated, and the femoral neck is exposed and débrided. A transverse cut is made at the preoperative templated level on the femoral neck with an oscillating saw, and the femoral head is removed. The femur is then reamed, and trial components are placed.

The acetabulum is then exposed using long Hohmann retractors. The acetabular cup is reamed to create appropriate anteversion (ideally approximately 40 degrees, but no more than 45 degrees) while preserving appropriate bone coverage to ensure that the hip does not impinge, which may increase risk of dislocation. Osteophytes are removed using a rongeur, and soft tissue is débrided. Trial components are placed in the acetabulum.

The hip is then reduced with trial components and checked to ensure that there is no impingement, LLD, or dislocation at the extremes of flexion or extension.

When trials are satisfactory, the actual components are placed. The capsule is then closed by using Tycron suture to secure the piriformis to the capsule, while avoiding injury to the sciatic nerve that runs directly posterolateral to the piriformis. A drain is placed in deep layer, and local anesthetic is injected. Deep layers are closed with Vicryl suture, and either nylon horizontal mattress or Monocryl subcutaneous sutures close the superficial layers. Use petrolatum gauze (Xeroform) and 4 × 4 gauze pads or Steri-Strips for a bandage, and affix a hip abduction pillow before extubation.

Estimated postoperative course:

Postoperative day 14

• Sutures are removed, and a wound check is performed.

• PT is begun for hip ROM, strengthening, balance, and gait training. The patient is weight bearing as tolerated.

Postoperative 6 weeks

• The patient returns to the clinic for radiographs of the pelvis and the lateral hip. Check for ROM, as well as abductor and quadriceps strength.

• Continue to wean the patient off assistive devices (walker, cane) with progressive PT.

• The patient may drive, if he or she is not taking narcotics. Stop anticoagulation.

Postoperative 3 months, 6 months, and 1 year

• The patient returns to the clinic for radiographs of the pelvis and hip.

• Assess for continued improvement in pain, gait, and strengthening. Assess for trochanteric bursitis or LLD. After 1 year of PT, if the patient complains of LLD, referral for a shoe lift fitting may be indicated.

Suggested readings: Boettner F, Altneu EI, Sculco TP: Mini-posterior total hip arthroplasty. In Brown TE, Cui Q, Mihalko WM, et al, editors: Arthritis and arthroplasty: the hip, Philadelphia, 2009, Saunders, pp 204–210.

McCarthy M, Brown TE, Saleh KJ: Etiology of hip arthritis. In Brown TE, Cui Q, Mihalko WM, et al, editors: Arthritis and arthroplasty: the hip, Philadelphia, 2009, Saunders, pp 3–11.

Miller CD, Stiltner AR, Cui Q: Preoperative planning for hip surgery. In Brown TE, Cui Q, Mihalko WM, et al, editors: Arthritis and arthroplasty: the hip, Philadelphia, 2009, Saunders, pp 24–36.

Muscle strains and injuries (adductors, hamstring, quadriceps)

Higher risk in active individuals and athletes

Typically the result of eccentric contraction

Patient-reported acute onset, popping sound, or snapping sensation at point of injury, followed by severe pain, possible swelling, tenderness to palpation, and ecchymosis.

Physical examination

Pain reproduced with active ROM of the affected muscle

Ecchymosis evident

Swelling, palpable mass, or gap in muscle noted

Tenderness to palpation noted at the point of injury

Imaging

MRI may assess for fluid collections or severity of tear, but the diagnosis is based on history and clinical presentation.

Classification

Point of injury

Origin of muscle

Musculotendinous junction

Insertion of muscle

American medical association grades for muscle strain

First-degree: tears of a few muscle fibers

Second-degree: more severe tear

Third-degree: complete disruption of the musculotendinous unit

Initial treatment

Patient education

The hamstrings (three muscles), quadriceps (four muscles), and adductors (four muscles) comprise the musculature of the thigh. Strains are tears in the muscle and are quite common in active individuals. The hamstrings and quadriceps are especially prone to injury because they cross the knee joint. These injuries are managed well with conservative treatment, and surgical intervention is exceedingly rare.

Treatment options

Nonoperative management

Acute phase (up to 5 days)

• Rest, ice, compression, elevation

Subacute phase (3 weeks)

• Beginning active ROM exercises

Remodeling phase (6 weeks)

• When the patient can do active ROM without pain, start increasing sport-specific activity and strengthening.

• Massage, ultrasound, and STIM treatment help prevent scar tissue buildup.

Functional phase (2 weeks to 6 months)

• When the patient can run for 20 to 30 minutes and perform sport movements without disability

• Patients with second- and third-degree strains unlikely to return to play before 5 weeks

Rehabilitation

Therapy is geared toward prevention by improving balance between opposing muscles (i.e., hamstrings and quadriceps), stretching techniques, and muscle conditioning.

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Tags: Orthopaedics for Physician Assistants

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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