Presentation on theme: "Making the Right Diagnosis Symposium: Joint Preservation Hip Surgery – How to Avoid and Treat Complications and Failures Wednesday, February 16 th, 2011."— Presentation transcript:
Making the Right Diagnosis Symposium: Joint Preservation Hip Surgery – How to Avoid and Treat Complications and Failures Wednesday, February 16 th, 2011 Bryan T. Kelly, MD Co-Director Center for Hip Pain and Preservation
Bryan T. Kelly, MD Hospital for Special Surgery Disclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND DO NOT INTEND to discuss off label or investigational use of products or services.
Types of financial relationships and the companies with whom I have relationships are as follows: Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant A2 Surgical: Consultant
Diagnostic Dilemma Origin of hip pain can be difficult to identify MUST DISTINGUISH BETWEEN INTRA- AND EXTRA-ARTICULAR PAIN
COMPREHENSIVE EXAMINATION OF THE ADULT HIP Five points for five body positions –STANDING –SITTING –SUPINE –LATERAL –PRONE ADDITIONAL TESTS AS NEEDED
STANDING EXAMINATION General –Laxity, Body Habitus, Posture Gait –Swing, Stance, Foot Progression, Pelvis Spine –Lateral, Posterior, Scoliosis, Lordosis Pelvis –Shoulder height, Iliac Crest Trendelenburg Test –Positive, Shift or Weakness
STANDING EXAMINATION Gait a.Trendelenburg b.Abductor lurch c.Antalgic d.Foot progression angle a.Excessive External Rotation b.Excessive Internal Rotation e.Short Leg Limp
STANDING EXAMINATION Trendelenburg Test –Weak abductors lead to the pelvis dropping to the unsupported side With Compensation –Severe weakness the pt is unable to lift the opposite side without leaning toward the wt bearing limb to decrease the moment arm.
SUPINE EXAMINATION Passive ROM –Flexion, Abduction, Adduction, IR, ER Strength Testing –Flexion, Adduction, Abduction Provocative Pain Test Pubalgia Testing Special Tests –Thomas Test –Patrick / Faber’s –Instability Test (extension / ER)
LATERAL EXAMINATION Palpation GT, ABDUCTORS, SI, ISCHIAL BURSAE Obers Test FLEXION, EXTENSION Passive / Active ROM MEDIUS / MAX FADDIR IMPINGEMENT Lateral Rim Impingement
Palpation 1 SI 2 Greater Trochanter Medius, Minimus Maximus origin 3 Ischial Tuberosity 4 Piriformis
Lateral Hip Anatomy Gluteus MediusGluteus Minimus
Dwek J. Pfirrmann C. Stanley A. Pathria M. Chung CB. MR imaging of the hip abductors: normal anatomy and commonly encountered pathology at the greater trochanter. Magnetic Resonance Imaging Clinics of North America. 13(4): , vii, 2005 Nov 4 facets, 3 have distinct insertions
OBERS TEST ILIOTIBIAL BAND IN EXTENSION
Touch the table o/3 3=above neutral Obers in Flexion Tight Maximus contribution
Active ABD Medius vs Max Strength
PRONE EXAMINATION Craig’s Test –Femoral anteversion Ely’s –Rectus Femoris Contracture Hyperextension –Lumbar Spine Palpation –Paravertebral muscles, spinous process
Anteverted 82.6% Retroverted 17.2% Retroverted 17.2% Elys Craigs Test
Anatomic Approach to Evaluation of the Non- Arthritic Hip History Clinical Exam Radiographic / Mechanical Diagnosis Intra-articular Damage Pattern –MRI / Arthrogram –Intra-operative findings
Layer 4: Neuromechanical Layer Structures: TLS Plexus, Lumbopelvic structures, LE structures Purpose: Neuromuscular linking and functional control of the entire segment as it functions within its environment Nerve compression syndromes Pain syndromes Neuromuscular dysfunction Spine referral patterns
Patient Selection Hip loaded pelvis usually rotates over fixed femur creating anterior and medial forces with rotary moments Neuromuscular Research Laboratory University of Pittsburgh
LABRAL TEARS Combine these forces with dynamic or static overload to the joint…
Treatment Plan The location and quality of the pain should correspond to the mechanical diagnosis and primary and secondary injury patterns. If they do, then correcting the mechanical problems and primary and secondary injuries should lead to a good outcome….