THE HIP

ALTAR
RAMOS
VERGARA
ZALDARRIAGA

ANATOMY, PHYSIOLOGY
& KINESIOLOGY

BONES OF THE PELVIC

GIRDLE
1.
2.
3.
4.

INNOMINATE BONES
Os Coxa
Full ossification at 20-25y/o
1. Largest, most superior
2. Most posterior
3. Most inferior

ACETABULUM
Ilium 2/5
Ischium 2/5
Pubis 1/5
(+) Acetabular fossa dashboard injury
(+) Lunate Surface
(+) Acetabular Notch
Opening: Lat tilted 50deg; Ant tilted and rotated 20deg

FALSE PELVIS
Ant: Symphisis
Post: Sacral Promontory
Lat: Iliopectineal line

TRUE PELVIS
Ant: Pubic Arch
Post: Coccyx
Lat: Ischial Tuberosity

NUTATION
PPT
Dec lordosis
Sacral promontory: antly and infly
Coccyx: postly and suply
Iliac crest: approximates
Ischial tube: widens

COUNTER-NUTATION
APT
Inc lordosis
Sacral promontory: postly and infly
Coccyx: antly and suply
Iliac crest: widens
Ischial tube: approximates

PROXIMAL FEMUR
(+) Fovea Capitis, Lig Teres
Fem head is a perfect sphere
Largest suply and antly
Head has an ave of 4-5cm; S A M
Fem neck normal length 5cm
Avascular necrosis: in child? In adult?
FABER(quadruped position) fem head is perfectly
joined to the acetabulum

ANGLE OF INCLINATION
Neck-shaft angle
Mean angle: 125deg
COXA VALGA - >125deg; (+)instab;
longer limb
COXA VARA - <125deg; stable,
prone to impingement; shorter limb

ANGLE OF TORSION
Angle between fem head, neck and
condyles
Sup viewing(birds eye view):
Birth: 15-23deg(mean 30deg)
Adult: 15-20deg(Norkins)

ABNORMALITY OF
INCLINATION
1.Femoral Anteversion angle of
torsion is >15-20deg; (+) Instability
2. Retroversion angle of torsion is
<15-20deg; prone to impingement

Q-ANGLE
ASIS PATELLA Tibial Tubercle

JOINTS
1. SI JT diarthrodial non-axial;

shock absorber
2. Pubic Symphisis
cartilagenous jt; (+) very little
mvmt during labor and delivery
3. Hip JT (acetabulum) moost

3MAJOR LIGAMENTS OF HIP

1. ILIOFEMORAL
Y lig of bigelow
Strongest lig of the body(triangular
shaped)
Checks hip extension and ER
During extension, it is taut and
maintains posture
Antero superior

2. PUBOEMORAL
Taut in extension, ER and abd
Antero inferior
3.ISCHIOFEMORAL
Weakest
Checks extension, abd and IR
Postero inferior

RED CARPET MUSCLES

Inf gemellus
Sup gemellus
Quads fem
Piriformis
Obturatoor externus & internus

G.Max
G.Med
G.Min
Piriformis(PIXER Ms)

ETIOLOGY

Osteoporosis and osteomalacia are

significant factors responsible for the
high incidence of hip fractures within the
elderly population.
Arthritis is a common degenerative
process occuring in joints within this
elderly population, with osteoarthritis
being the most common of the varieties.

It is also common treatment for

(juvenile) rheumatoid arthritis but only if
all the other options have failed.
Trauma

EPIDEMIOLOGY

Approximately 0.8 percent of

Americans are living with a hip
replacement.
Female>Male
Prevalence of THR among adults age 50
and older is as high as 2.3 and 4.6
percent, respectively.

The prevalence of THR rises to nearly 6

percent by 80 years of age.
The states with the highest number of
THR patients are California, Florida and
Texas; the two states with the lowest
numbers are Alaska and Hawaii.

PROCEDURE
BACKGROUND

PROSTETHIC DESIGNS AND

MATERIALS
FEMORAL COMPONENT inert
metal (cobalt-chrome and titanium)
ACETABULAR COMPONENT highdensity polyethylene

CEMENTED VS.
CEMENTLESS
early THA procedures acrylic
cement (methylmethacrylate) for
prosthetic fixation
CEMENTED allow very early postop weight bearing and short period
of rehab

CEMENTED VS.
CEMENTLESS
CEMENTLESS
A) Porous-coated prostheses that
allows osseous in-growth into
mesh-like surface
B) Press-fit technique

CEMENTED VS.
CEMENTLESS
Some components are
manufactured c a coating of a
bioactive compound called
HYDROXYAPATITE to promote initial
osseous growth
3-6 mos

CEMENTED VS.
CEMENTLESS
Cemented is used for px with
osteoporosis and poor bone stock
Cementless for px <60 y/o who are
physically active and has good bone

OVERVIEW OF OPERATIVE
PROCEDURES
Can be divided into 2
1. Standard 15-25 cm
2. Minimally invasive - <10 cm

OVERVIEW OF OPERATIVE
PROCEDURES
Can be divided into 2
1. Standard 15-25 cm
2. Minimally invasive - <10 cm

A. STANDARD APPROACH
1. POSTEROLATERAL
2. DIRECT LATERAL
3. ANTEROLATERAL

A. STANDARD APPROACH
1. POSTEROLATERAL
Most frequently used
Short external rotators are transected
near their insertion
Capsule is incised posteriorly for
posterior d/l of hip

A. STANDARD APPROACH
1. POSTEROLATERAL
Disadvantage: high incidence of
post-op joint instability d/l
subluxation of hip
Posterior capsulorrhaphy to reduce
the risk

A. STANDARD APPROACH
2. DIRECT LATERAL
Longitudinal division of TFL
Release of up to of the proximal
insertion of G. med
Splitting of vastus lateralis

A. STANDARD APPROACH
2. DIRECT LATERAL
Disruption of abductor mechanism
post-op weakness and gait
abnormalities (Trendelenburg sign)

A. STANDARD APPROACH
3. ANTEROLATERAL
Frequently used during early years of THA
Today, complex reconstruction
Px c mm imbalances assoc c stroke or CP
whose standing position is HIP FLEXION and IR
Px inhibiting this posture are at higher risk of
d/l if posterolateral approach

A. STANDARD APPROACH
3. ANTEROLATERAL
Involves detachment and
subsequent repair of G. med
Or may involve greater troch
osteotomy for adequate exposure of
hip jt

A. STANDARD APPROACH
3. ANTEROLATERAL
Soft tissue disturbed
G. min
TFL
Ilipsoas
Rectus femoris
Vastus lateralis
Anterior capsule

B. MINIMALLY INVASIVE
APPROACH
1. Single inicision
Posterior/anterior/lateral
2. Two-incision 4-5cm;
anterior acetubalar
posterior - femoral

B. MINIMALLY INVASIVE
APPROACH
Reduced blood loss
Reduced post-op pain
Shorter length of hospital stay
Cheaper
Rapid recovery
Better scar appearance
HOWEVER: TECHNICALLY CHALLENGING

IMPLANTATION OF
COMPONENTS AND CLOSURE
After d/l of hip osteotomy at the femoral
neck and head is removed
Acetabulum is reamed and remodeled
polyethylene cup is inserted

*A px c developmental dysplasia may require

bone grafting to improve stability

IMPLANTATION OF
COMPONENTS AND CLOSURE
Intramedullary canal in femur
may be broadened esp if cement
fixation
Metal prosthesis is inserted into
the shaft of femur

COMPLICATIONS
Minimally invasive > standard
d/t less exposure of hip joint

COMPLICATIONS
1. INTRAOPERATIVE
2. EARLY POST-OP
3. LATE POST-OP

COMPLICATIONS
1. INTRAOPERATIVE
Malpositioning
Femoral
Fx
Nerve injury
Infection
pneumonia

COMPLICATIONS
2. EARLY POST-OP (6 wks 3 mos)
Wound healing problems
d/l of prosthesis
Disruption of bone graft site before
sufficient bone healing has occurred
Leg length discrepancy

COMPLICATIONS
3. LATE POST-OP
D/L
Mechanical loosening
Polyethylene wear
HO

COMPLICATIONS
d/l occurs most frequently
during 2-3mos
This is non-traumatic and
usually in POSTERIOR direction

COMPLICATIONS
Unequal leg length complaint of
some of px during early period of
recovery p THA
Assymetry of pelvis and trunk during
standing, walking d/t mm spasm and
weakness and contracture of hip mm.

COMPLICATIONS
TLL discrepancy assoc c low
back and hip pain d/t malposition
of the components