1. SURGICAL HIP DISLOCATION By Sabrina Cerciello

2. SURGICAL HIP DISLOCATION is a demanding surgical procedure that permits unlimited access to the entire hip joint to address lesions and labral pathology

3. Age Consideration Patient age is highly variable Patient age is highly variable Younger patients Younger patients more common more common better results better results less irreversible tissue damage less irreversible tissue damage Older patients Older patients caution with patient selection d/t co-morbidities and poor bone quality caution with patient selection d/t co-morbidities and poor bone quality at this point in life, may be more beneficial or necessary for a Total Hip Replacement (THR) at this point in life, may be more beneficial or necessary for a Total Hip Replacement (THR)

4. FAI Femoro-Acetabular Impingement Femoro-Acetabular Impingement Abnormal and wearing contact between the ball and socket of the hip joint, resulting in increased friction during movement that may damage joint (ref) Abnormal and wearing contact between the ball and socket of the hip joint, resulting in increased friction during movement that may damage joint (ref) Most common indication Most common indication Typically young athletic men d/t over- activity of hip joint Typically young athletic men d/t over- activity of hip joint

5. TYPES Two Types Two Types Cam Cam femoral head/neck deformity femoral head/neck deformity cartilage delamination cartilage delamination acetabular cartilage lifted from underlying bone acetabular cartilage lifted from underlying bone Pincer Pincer “over-coverage” of acetabulum “over-coverage” of acetabulum labral tear labral tear labrum = ring of elastic tissue on rim of socket of hip joint labrum = ring of elastic tissue on rim of socket of hip joint

6. FAI TYPES

7. Pre-Operative Cam Lesion Labral Tear d/t Cam Lesion Post-Operative improved sphericity of femoral head Radiograph of 10 y.o. girl diagnosed with Perthes disease

8. OTHER INDICATIONS Slipped Capital Femoral Epiphysis Slipped Capital Femoral Epiphysis separation of the femoral head from the femur at the growth plate separation of the femoral head from the femur at the growth plate Perthes Disease Perthes Disease osteonecrosis at the femoral head osteonecrosis at the femoral head Developmental Dysplasia of the Hip (DDH) Developmental Dysplasia of the Hip (DDH) Abnormal development of hip joint Abnormal development of hip joint Exostoses Exostoses extra bone growth extra bone growth Hip Abnormalities Hip Abnormalities

9. GANZ TECHNIQUE Trochanteric Flip Osteotomy Trochanteric Flip Osteotomy Anterior dislocation through a posterior approach Anterior dislocation through a posterior approach ~1.5 cm removed and reattached with screws ~1.5 cm removed and reattached with screws Keeps external rotator muscles intact Keeps external rotator muscles intact Preserves MFCA and femoral blood supply Preserves MFCA and femoral blood supply 2-3 hours 2-3 hours

10. COMPLICATIONS Necrosis Necrosis Nerve palsies Nerve palsies Infections Infections Adhesions Adhesions Nonunions Nonunions Hardware failures Hardware failures Blood loss Blood loss RARE RARE

11. POST-OP TREATMENT TTWB or flat foot PWB TTWB or flat foot PWB 6-8 weeks on crutches 6-8 weeks on crutches Anti-inflammatory Anti-inflammatory NO! active abduction, passive adduction, flexion >80 degrees, external rotation NO! active abduction, passive adduction, flexion >80 degrees, external rotation Pillow under femur Pillow under femur CPM 0°-30° CPM 0°-30° Seated AAROM for knee flexion/extension Seated AAROM for knee flexion/extension May return to work in 4-6 weeks and sports in 16-24 weeks as permitted May return to work in 4-6 weeks and sports in 16-24 weeks as permitted

12. POST-OP PHASES Phase I Phase I Day 1 – Week 6 Day 1 – Week 6 Protect surgical site, minimize pain and inflammation, patient compliance w/ activity modification Protect surgical site, minimize pain and inflammation, patient compliance w/ activity modification Phase II Phase II Weeks 6 – 12 Weeks 6 – 12 same emphasis as Phase I same emphasis as Phase I Phase III Phase III Weeks 12 – 16 Weeks 12 – 16 Independent HEP, optimized ROM, 5/5 strength, pain free ADLs Independent HEP, optimized ROM, 5/5 strength, pain free ADLs Phase IV Phase IV Weeks 16 – 20 Weeks 16 – 20 Independent HEP, minimize post-exercise soreness Independent HEP, minimize post-exercise soreness

13. STRENGTHENING Isometric Therex IMMEDIATELY after surgery Isometric Therex IMMEDIATELY after surgery Ankle pumps x10 Ankle pumps x10 Gluteal sets x10 Gluteal sets x10 Quadriceps sets x10 Quadriceps sets x10 3 sets/day 3 sets/day Aquatic walking at chest height~2 weeks Aquatic walking at chest height~2 weeks More intensive strengthening may begin after ~3 months More intensive strengthening may begin after ~3 months closed chain, eccentric loading, treadmill closed chain, eccentric loading, treadmill

14. STRETCHING BE VERY CAUTIOUS! BE VERY CAUTIOUS! starts ~3 mos. post-op starts ~3 mos. post-op Independent ROM 1-2 years post-op Independent ROM 1-2 years post-op Dependent on stable pelvis Dependent on stable pelvis pelvis motion creates “false movement” of hip joint & no stretching is achieved pelvis motion creates “false movement” of hip joint & no stretching is achieved Paired with proprioception or balance work Paired with proprioception or balance work Bosu, Biodex, single limb stance, swiss balls Bosu, Biodex, single limb stance, swiss balls

15. HOME EXERCISE PROGRAM Isometric Quad sets Isometric Quad sets Towel roll under knee Towel roll under knee Ankle pumps Ankle pumps Abdominal sets Abdominal sets Abdominal control with arm motion Abdominal control with arm motion 2-5lbs in hand 2-5lbs in hand AAROM AAROM Knee Extension Knee Extension

16. WHY NOT A THR? Limited access to the various specific sections of the hip joint Limited access to the various specific sections of the hip joint Inability to reshape the acetabulum Inability to reshape the acetabulum Decreased ability to meticulously reshape the femoral head Decreased ability to meticulously reshape the femoral head Higher risk of cartilage damage Higher risk of cartilage damage

17. REFERENCES 1. Beck, M. "Groin Pain after Open FAI Surgery: the Role of Intraarticular Adhesions.” National Center for Biotechnology Information, 10 Dec. 2008. Web. Retrieved 10 Oct. 2012.. 2. “Femoro-Acetabular Impingement (FAI).” The Hospital for Special Surgery. Retrieved 20 Oct. 2012.. 3. Ganz, R., T. J. Gill, E. Gautier, K. Ganz, N. Krugel, and U. Berlemann. "Surgical Dislocation of the Adult Hip." Jbjs.org. The Journal of Bone and Joint Surgery, Nov. 2001. Web. 13 Retrieved Oct. 2012. 4. Jamali, Amir. (2010) Surgical Hip Dislocation. Retrieved 11 Oct. 2012. Joint Preservation Institute web site. 4. Jamali, Amir. (2010) Surgical Hip Dislocation. Retrieved 11 Oct. 2012. Joint Preservation Institute web site. 5. Krueger, Andreas, Michael Leunig, Klaus A. Siebenrock, and Martin Beck. "Hip Arthroscopy After Previous Surgical Hip Dislocation for Femoroacetabular Impingement.” Science Direct, Dec. 2007. Web. Retrieved 10 Oct. 2012.. 6. Munting, T.W. Open Hip Dislocation (Debridment) Surgery. Retrieved 13 Oct. 2012. Cape Town Sports and Orthopedic Clinic web site. 6. Munting, T.W. Open Hip Dislocation (Debridment) Surgery. Retrieved 13 Oct. 2012. Cape Town Sports and Orthopedic Clinic web site. 7. Peters, Christopher L., and Jill A. Erickson. "Treatment of Femoro-Acetabular Impingement with Surgical Dislocation and Débridement in Young Adults.” Journal of Bone and Joint Surgery, 2006. Web. Retrieved 11 Oct. 2012.. 8. Ray, Linda. (2011) Hip Dislocation Surgery and Rehabilitation. Retrieved 11 Oct. 2012. Livestrong. 8. Ray, Linda. (2011) Hip Dislocation Surgery and Rehabilitation. Retrieved 11 Oct. 2012. Livestrong. 9. Rebello, Gleeson, Samantha Spencer, Michael Millis, and Young-Jo Kim. "Surgical Dislocation in the Management of Pediatric and Adolescent Hip Deformity.” National Center for Biotechnology Information, U.S. National Library of Medicine, 6 Oct. 2008. Web. Retrieved 12 Oct. 2012.. 10. Sink, E. “Surgical Hip Dislocation.” Orthopedics. May 2009. Retrieved 11 Oct. 2012..