- significant hip flexion contracture: <>>> Lightfoot CJ, Coole C, Sehat KR, Drummond AE. The muscles below the skin are then moved aside without cutting them. Complete the exposure of the acetabulum by inserting appropriate retractors around the acetabulum. endobj An EMG and clinical review. Some approaches are more commonly used than others but hip replacement patients should understand that surgeons usually have specific approach(es) with which they are most experienced and comfortable. They think the restriction does not allow them to place the operated ankle on top of the unoperated knee in a figure 4 configuration.That Is Wrong! Anterolateral approach. The lateral aspect of the greater trochanter. It exposes the femur well with good access to the joint. begin 5cm proximal to tip of greater trochanter. Start the slightly anteriorly curved skin incision about 7-10 cm proximal of the lateral part of the greater trochanter (directed towards the tubercle of the iliac crest the posterior landmark of tensor fasciae latae origin). The approach does not give as wide an exposure as the anterolateral approach to hip joint with trochanteric osteotomy. Additionally, the modified Hardinge approach was the most familiar approach for us and is widely used in the treatment of pediatric hip septic arthritis and femoral neck fracture [17]. Patients undergoing THA at our institution are informed of the requirement to follow hip precautions at multiple points during their pre-operative screening, admission . In the lateral approach (also known as a Hardinge approach), the hip abductors (gluteus medius and gluteus minimus) are elevated not cut to provide access to the joint. Our mission is to share information and our experience, both as senior citizens and physical therapists, to help people age in place independently. Robotic Assisted Total Hip Replacement. Age In Place School is a participant in affiliate advertising programs designed to provide fees by advertising and linking to their products. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform open reduction of proximal periprosthetic femoral fractures or revision arthroplasty. The solution is to ALWAY lead with the operated leg when turning toward the operated side. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones . expose anterior joint capsule. Split the fibers of the vastus lateralis muscle overlying the lateral aspect of the base of the greater trochanter. The joint capsule seals the hip joint, much like a zip-lock baggie, to keep the lubricating fluids inside the capsule and bathing the hip joint in this fluid. With the greater trochanter and the gluteus medius muscle exposed, retract the tensor fascia lata anteriorly and the gluteus medius muscle posteriorly. No internal rotation with the Posterior Approach: The most common way that rule is broken is by pivoting on the operated leg when turning in that direction. The anterolateral approach in total hip arthroplasty offers superb exposure that can be easily extended for complicated primary and revision surgery. That is usually the journal article where the information was first stated. Over my career, I have seen several posterior approach total hip replacement dislocations, some as many as 20 years after surgery before they experienced their first dislocation. The greater trochanter at the upper end of the femur may also be cut in this approach (also referred to as an osteotomy), which greatly increases the exposure of the hip joint. When descending, step first with the leg that you had surgery on. - Positioning: Use retractors as necessary to expose the femoral head and neck. The main landmark for the incision is the greater trochanter which overlies the hip joint itself. Remember we are not going beyond 5 cms from tip of the greater trochanter to avoid damage to superior gluteal artery and nerve. https://www.tandfonline.com/doi/abs/10.1080/09638288.2020.1722262, http://www.sunnybrook.ca/content/?page=musckuloskeletal-hip-replacement-walking, https://www.youtube.com/watch?v=VfADxKAGdYM, https://www.youtube.com/watch?v=8OsN2J8HR6Q, https://www.youtube.com/watch?v=CUSSqFtolTU&app=desktop, https://www.physio-pedia.com/index.php?title=Hip_Precautions&oldid=324619. Lateral Approach Total Hip Replacement Precautions: The lateral approach to hip replacement, like the posterior approach, cuts the joint capsule in the posterior of the hip and the surgeon dislocates the femoral head through that incision to expose the femoral head and acetabular socket for preparation to receive the replacement components. See my article on No Crossing The Legs.. Are Hip Precautions Necessary Post Total Hip Arthroplasty?. They require ligation or cautery. We need to do so in a way that let us repair it in the end. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. Enter the capsule using a longitudinal T-shaped incision. We used this modified SPAIRE approach as this patient lives in a 'Mahjong' center . Close also the gluteus medius tendon and fascia proximally, and the vastus lateralis fascia distally. if(typeof(jQuery)=="function"){(function($){$.fn.fitVids=function(){}})(jQuery)}; Approach. Hardinge Approach to Hip Joint (Direct Lateral Approach) can easily be extended distally: To expose the shaft of the femur, split the vastus lateralis muscle in the direction of its fibers (. Abductor function after total hip replacement. Underneath gluteus medius is gluteus minimus which also inserts into the greater trochanter. Direct Anterior Approach Total Hip Arthroplasty 10:21. Retract the cut edges of the fascia to pull the tensor fasciae latae anteriorly and the gluteus maximus posteriorly. An EMG and clinical review. Hospital for Special Surgery. Precautions include: This 2 minute video reviews the three main hip precautions used for several weeks after posterior THR to prevent complications such as dislocation. Do not go more proximal than 5 cms because the superior gluteal artery and nerve which supplies the abductor muscles, runs across the incision here and can get damaged on deeper dissection. 2 0 obj - note that many patients will have a reduced hip flexion contracture under anesthesia, which will give the surgeon the false sense of having corrected the contracture; - lateral position, with a sterile surgical drape folded in a "saddle bag" fashion to allow the leg to hang over the edge of the table in a flexed and externally rotated position (inside of the saddle bag); All right rerserved. 3 0 obj Anterior Approach Total Hip Replacement Precautions: No extreme hip extension combined with external rotation with Anterior Approach: This is the position the surgeon places the leg in when they are dislocating the femoral head from the acetabular socket (hip socket), which they do to be able to remove the femoral head and prepare the acetabulum to receive the socket component of the total hip replacement surgery. This is counterintuitive to the normal way to get up from a chair by leaning forward and pushing up with the legs.The legs will continue to supply most of the muscle power to stand from sitting, but the arms become important to keep the trunk erect coming from sitting to standing. Patients can also have as little as a 3-inch incision. [2] Hip precautions mainly apply to the posterior or posterior lateral hip replacement procedure. By Pil Whan Yoon 7 Videos. See Also: Hip Joint Anatomy Hardinge Approach to Hip Joint indications. Hip Precautions - Anterior Approach Available from: Harkess JW, Crockarell JR. Arthroplasty of the hip. - Checklist for THR This approach has fewer restrictions. Superficial dissection. - if the surgeon attempts to correct the contracture by performing an aggressive anterior capsulotomy, then there is an increased risk of dislocating out the front; - PreOp: This article will explain the correct way to use cold therapy options to reduce pain and swelling after a total hip replacement surgery. Patient positioning in case of anterolateral approach to the right hip -patient is on his left hand side, surgeon stands behind and looks down on the patients right hip which has been prepared. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. Continue developing this anterior flap, following the contour of the bone onto the femoral neck, until the anterior hip joint capsule is fully exposed. We are then going to cut straight across the tendon where it inserts into the greater trochanter but leave enough cuff on both sides so as to repair it later. Exposure of the hip using a modified anterolateral approach. Keep retractors on bone with no soft tissue under to prevent iatrogenic injury. ); The Foundation for the Advancement in Research in Medicine, Inc. A 501(c)(3) non-profit organization. Distally, the anterior fibers of the vastus lateralis are elevated from the anterior femur. Each hip replacement approach has its own specific restrictions. By reducing the size of their incisions to as small as 2.5 inches, they hope to reduce soft tissue damage and speed healing. Organize in-house training events for your surgical staff, Hand Distal phalanges revision published. easier with leg flexed slightly. We are compensated for referring traffic and business to companies linked to on this site. Be aware of vessels running across this interval. The hip joint is then dislocated and the acetabular socket and femur are exposed for preparation and insertion of the prosthesis components. The Femoral nerve is the most lateral structure in neurovascular bundle of anterior thigh. This 1 minute video shows the precautions. Cabrera JA, Cabrera AL. GkRH!TGFmx0kmFIJe+GIORI]zS#e' mvbRNI(FI&9hDw|pdaOYL;dG4ZA_+h: MOazznTT~# V`~}%}7m=6G`P+nN&M'R6jV{(JBiz4~=V#cWvP5(hA+H/~7 2Gw#QQOz90sT9{7"wTo$;9noE0J=70wzx+2r7dvD&XR2H{ _J3D(m 5'AVDWh'0&[FOtFd.bYJm3e,L@/Qn?];Tg1 They have been told not to cross their legs at the knee or the ankles. - alcoholism: A surgical incision, approximately 6 cm in size, is made to the anterolateral side of the thigh to gain access to the hip joint. We also participate in other affiliate programs which compensate us for referring traffic. The prosthesis can be dislocated anteriorly. Data Trace is the publisher of The example I give my patients is:Say you are standing and your spouse calls to you while standing on the side of the new hip.In response to that call, you turn to the operated side by moving the unoperated leg across the front of the operated leg as the first step while the operated leg stays firmly planted on the floor.You have now broken TWO of the restriction rules: the no internal rotation PLUS the no crossing midline restriction rules. ^!#*\E'l[l`}c5f ;mr$"d^M5!%T/FSQK]0V9]VCfId ykOP]hHE{0aSI4Zv/ZIyO{ j2xm;nS6wR71]48"NYMa&!MrvN1kwOQJsdB+PO ~SD8LyX^0n;qGNqeB{.-I&n(TFKgF>!8 A%6M?K]uj)F$~/hrrO2_TB uPa&))xB4%n TA !RRrj;5I.rn8CM},jvJm,[jbF$OT>]/{GVxTq2NcEt|EJ'ki Q{6s8*%EM8QL'gbsG-[a*"$lA[H[F4rW* a M1|mA}y$1u5wa The direct lateral approach to the hip for arthroplasty. There will be small variations in the approach from surgeon to surgeon, therefore most people will described there approach as a modified Hardinge approach. A subfascial drain should be considered as blood loss can be significant and periprosthetic fracture patients are at high risk of requiring anticoagulation immediately postoperatively. These same range-of-motions that are used to dislocate the hip at the surgery are the same range-of-motion movements that are restricted. Environmental modifications that are recommended to prevent hip dislocations including removing tripping hazards from home and installing grab rails around the house. Physiotherapists and nurses in conjunction with surgeons usually teach these precautions to the patient in the perioperative period. <> Hardinge Approach to Hip Joint (Direct Lateral Approach) is used for: There is no true internervous plane for Hardinge approach to hip joint (direct lateral approach). Replacement is designed to precisely reconstruct the hip without stretching or traumatizing muscles that are important to hip function. The anterolateral (Watson Jones) approach involves the detachment of about one third of the gluteus medius from the bone. . The surgeon should be able to explain his or her preference to you and help you understand why any particular approach is best for your situation. Leg Extension Machine (hip precautions) 10. Filed Under: See My Other Total Hip Replacement Articles: How To Choose A Surgeon For Hip ReplacementSpeed Up Recovery After Total Hip ReplacementCan I Sit In A Recliner After Hip ReplacementCrossing Legs After Total Hip Surgery: (A PTs Complete Guide)Stairs After Total Hip Replacement: A Physical Therapy GuideIce After Total Knee Replacement: A PTs Complete Guide. The direct lateral approach to the hip for arthroplasty. Hip precautions after total hip replacement and their discontinuation from practice: patient perceptions and experiences. The Hardinge approach was once the commonest approach for THR, but the issues with it are that it can damage the hip abductors, which can leave the patient with a persistent limp. Damage to the superior gluteal nerve after the Hardinge approach to the hip. The structures at risk duringhardinge approach to hip joint (direct lateral approach)include: Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. Fascia, The 'Hardinge direct lateral or transgluteal approach' has many different flavours. Remove bursal tissue over the trochanter as needed. You will need to detach the insertion of the gluteus minimus tendon to the anterior part of the greater trochanter. You will need to detach the muscles from the greater trochanter either by sharp dissection or by lifting off a small flake of bone. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. The approach can be extended distally, for adequate exposure of the fracture. Mako Robotic-Arm Assisted Total Hip replacement is a surgical procedure intended for patients who suffer from non-inflammatory or inflammatory degenerative joint disease (DJD). Retract the muscle inferiorly. - residual abductor weakness and limp may occur post op if there is an avulsion of the repaired of anterior portion of abductors; Deepen the incision through the gluteus medius and minimus proximally, retracting the anterior flap to show the hip capsule superiorly and adjacent supraacetabular ilium. Use a pillow between legs when rolling. After capsular closure, repair the vastus lateralis to its origin. After 6 weeks the capsule is usually well-healed but 12 weeks is usually considered the time frame for the hip capsule to fully heal. The abductor muscle "split". Care transfer. The motion that would put the new hip in this extreme extension with external rotation would be something like kneeling on the operated leg with the foot turned out, then moving body weight forward onto the opposite foot. Make a T-shaped incision in the capsule, if necessary, for exposure. Split the fibers of the gluteus medius muscle in the direction of their fibers beginning in the middle of the trochanter. The hip is dislocated through this posterior incision in the joint capsule by the surgeon taking the patients leg into flexion, internal rotation (pigeon-toe), and adduction (across mid-line of the body) to expose the femoral head and acetabular (hip) socket for preparation to receive the replacement components. Because of this, I recommend my posterior approach hip replacements follow the three restrictions for the rest of their lives. Risk of dislocation & hip precautions: Risk is incredibly low (<1%). Data Trace Publishing Company The vastus lateralis and the gluteus medius are now exposed. Hip dysplasia can present unique challenges in achieving stability with THA and, as such, there is a higher incidence of instability . J Bone Joint Surg Br 1982;64B:1718. There is a layer between the fascia and muscle which is the trochanteric bursa. General guidelines (0-6 weeks) adhere to precautions Normalize gait pattern with appropriate aids based on WB'ing status ( time frame for using aids based on the discretion of therapist )on the discretion of therapist ) Hip ROM within restrictions Basic quadricep strength Total Hip Arthroplasty - Discussion: The posterior (also referred to as a Moore or Southern) approach allows the surgeon to access the hip joint from the back. - indications: A common way the No Crossing Mid-line rule is broken is by sleeping on the unoperated side and allowing the operated leg to drop down to the bed crossing the mid-line. A research paper published in the US National Library Of Medicine: Are Hip Precautions Necessary Post Total Hip Arthroplasty? backs up my observation that Anterior Surgical Approach total hips restrictions having little or no effect on dislocations. Hip precautions may needlessly increase patients anxieties and fear about dislocation following THR. Hip precautions are usually not needed: Translateral surgical approach to the hip. After surgery, moving the operated leg into flexion past 90 degrees, abduction past mid-line and/or internal rotation can move the femoral head against the posterior capsules incision risking dislocation or stretching out the capsule before it heals. Damage to the superior gluteal nerve after the Hardinge approach to the hip. Passive range of motion into hip abduction is permissible but it must be totally passive with the patient completely relaxed and someone else passively moving the leg into abduction. Develop the plane between the hip joint capsule and the overlying muscles, using a swab pushed into the potential space using a blunt instrument. The provocative position for hip dislocation is: hip flexion, adduction, internal rotation. Dislocation Precautions: Dislocation precautions are based on surgical approach and the direction in which the hip is dislocated intra-operatively (if at all) to gain exposure to the joint. Make a longitudinal incision through the skin and subcutaneous tissue, with its proximal end directed slightly posteriorly. The greater trochanter is reattached later by wires or cables. 4, 5 The . The incision is in line with the femur and it goes from 5cm proximal to greater trochanter to 10cm distal to the greater trochanter. The trochanteric approach to the hip for prosthetic replacement. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Preserve a substantial portion of gluteus medius insertion posteriorly. . Traditionally, protocols describing these restrictions and precautions require patients to sleep supine (usually with an abduction pillow in place), to use walking aids for several weeks, only to sit on high chairs and not to sit cross-legged, not to bend forward or to flex their hip joint beyond 90.