As a licensed physical therapist I have seen hundreds, if not thousands, of total hip replacement surgeries over the more than 4 decades of treating patients as a hospital-based physical therapist, outpatient physical therapy owner/operator, and for the past several years seeing total hip replacement patients in their homes just a day or two after their surgeries. Modified Hardinge Approach for Total Hip Arthroplasty | VuMedi All the patients underwent bipolar hemiarthroplasty through modified Hardinge approach. endobj begin 5cm proximal to tip of greater trochanter. Never cross legs or ankle on sitting, standing or lying down, Avoid bending your leg greater than 90 degrees. The superior approach can be extended into a posterior approach if the surgeon needs more access to the femur or pelvis. I dont expect my patients to be as strict with the restrictions after 12 weeks but I do expect them to be aware of the restrictions and follow them as best they can after the 12-week mark. Total hip arthroplasty: it has lower rate of total hip prosthetic dislocations. 2 Comments . - this approach allows a rather direct approach to the hip with minimal need for surgical assistants and affords excellent acetabular exposure; The incision is in line with the femur and it goes from 5cm proximal to greater trochanter to 10cm distal to the greater trochanter. elevate part of the psoas tendon from the capsule. It provides information to make you a better-informed consumer. It is later re-attached. When descending, step first with the leg that you had surgery on. 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. How To Choose A Surgeon For Hip Replacement, Speed Up Recovery After Total Hip Replacement, Can I Sit In A Recliner After Hip Replacement, Crossing Legs After Total Hip Surgery: (A PTs Complete Guide), Stairs After Total Hip Replacement: A Physical Therapy Guide, Ice After Total Knee Replacement: A PTs Complete Guide. Underneath this muscle is the hip capsule itself. Proximally, this extends into the tendinous insertion of gluteus medius and splitting fibers of vastus lateralis distally. Additionally, there are many variations of the Anterior, Posterior, and Lateral surgical approaches and each surgeon has their own range-of-motion restrictions.Always follow the surgeons specific range-of-motion restrictions, the surgeon is the only one that knows exactly what was done during the surgery. Hip Precautions - Anterior Approach Available from: Harkess JW, Crockarell JR. Arthroplasty of the hip. Login to view comments. Physiotherapists and nurses in conjunction with surgeons usually . Underneath the fascia is the muscle layer. Begin the incision 5 cm above the tip of the greater trochanter. Modified Hardinge Anterolateral Approach to the Hip Joint The direct lateral approach to the proximal femur releases the anterior third of the gluteus medius and minimus while preserving the posterior femoral attachment of the major part of these muscles. - unfortunately, many of these patients will re-gain their flexion contracture postoperatively; 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. In: Azar FM, Beaty JH, Canale ST, eds. 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. Patients undergoing THA at our institution are informed of the requirement to follow hip precautions at multiple points during their pre-operative screening, admission . Perhaps you are approaching or already retire and wondering how you could earn extra money in retirement.One option would be to do as I am doing.Read my article How To Generate Retirement Income: Cash In On Your Knowledge. This capsule will need to have time to heal before it can withstand the pressure from the femoral head as it rotates forward when the patient moves into the range-of-motion of external rotation and extension. Partial Hip Replacement. Data Trace is the publisher of Next, develop an anterior flap that consists of the anterior part of the gluteus medius muscle with its underlying gluteus minimus and the anterior part of the vastus lateralis muscle. Be aware of vessels running across this interval. The other is a very small incision in the thigh through which a special instrument is employed to work on the acetabulum (socket). They understand the concept of not crossing their legs at the ankles but most of my patients do not know what dont cross your legs at the knee instructions mean. Posterior Approach to the Acetabulum (Kocher-Langenbeck) Insert suction drains if desired. Distally, the anterior fibers of the vastus lateralis are elevated from the anterior femur. Make a longitudinal incision through the skin and subcutaneous tissue, with its proximal end directed slightly posteriorly. Superior gluteal nerve runs between gluteus medius and minimus muscles 3-5 cm above greater trochanter. 3 0 obj longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm. The solution is to ALWAY lead with the operated leg when turning toward the operated side. Hamstring Curl Machine (hip precautions) 9. #reeltruthscience,#hipapproach,#hipfractures,#surgicalapproach,#hardingeapproach,#hardinge,#anterolateralapproachtothehip, #hiparthrotomy,#hipcapsule,#hipfra. 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. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. This approach has fewer restrictions. Anterolateral approach for total hip arthroplasty - ScienceDirect - consider removal of anterior portion of abductors w/ attached thin wafer of bone from anterior edge of greater trochanter to facilitate later repair; Expose the fascia lata sharply. Hip ReplacementHip Replacement, Resurfacing, Revision. Distally, the incision extends along the femur about 10 cm below the greater trochanter. Age In Place School is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Modified Hardinge Approach for Total Hip Arthroplasty. The superior approach is most similar to the posterior approach without cutting the posterior capsule or short external rotator muscles and without dislocating the joint. There are two small incisions made in this approach, one being the main access to the joint and through which nearly all the work is performed. The standard approach used in our hospital for THR in NOF fractures is the modified Hardinge approach to the hip. 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. This is a unique and innovative method of carrying out the replacement and unlike other MIS approaches, allows full vision for the surgeon throughout the procedure. Use retractors, to pull the edges of the fascia lata away so as to get a good view and access to the abductor muscles-the gluteus medius and minimus and the hip joint underneath that. Direct Anterior Approach Total Hip Arthroplasty 10:21. Develop the plane between the hip joint capsule and the overlying muscles, using a swab pushed into the potential space using a blunt instrument. Being compliant with range-of-motion restrictions for 12 weeks after Anterior, Posterior or Lateral hip replacement approach allows the joint capsule to heal and shrink enough to resist dislocation.Posterior and Lateral surgical approach restrictions are completely different than for an Anterior surgical approach. Other features include a new section on post polio syndrome, additional case studies comparing Guillain Barr [], Courtesy: Zaid al Rub, Founder, OrthoPass. if(typeof(jQuery)=="function"){(function($){$.fn.fitVids=function(){}})(jQuery)}; Perform a meticulous debridement of all soft tissues before starting wound closure. The direct lateral approach to the hip for arthroplasty. Because of this, I recommend my posterior approach hip replacements follow the three restrictions for the rest of their lives. 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! The anterolateral approach to the hip, described in 1936 by Sir Watson Jones, still is in current use when implanting THA. The surgeon uses a special surgical table specifically designed to position the patient so that the hip joint may be easily accessed from the front as opposed to the side or back. Surgeons will also use a curved femoral replacement because the typical straight femoral components are extremely difficult to insert without injuring the abductor muscles. They have been told not to cross their legs at the knee or the ankles. The direct lateral approach to the hip for arthroplasty. Hip Abduction Can Be Considered the Sole Posterior - ScienceDirect The posterior (also referred to as a Moore or Southern) approach allows the surgeon to access the hip joint from the back. Use a pillow between legs when rolling. mini-incision approach shows no longterm benefits to hip function extend to 10 cm below tip of greater trochanter Superficial dissection through subcutaneous fat incise fascia lata in lower half of incision extend proximally along anterior border of gluteus maximus split gluteus maximus muscle along avascular plane This is because muscles/tendons are usually cut/detached during the operation and then repaired during closure. The modified-Hardinge approach, which preserves the posterior capsule, has been shown to have the lowest rate of dislocation, even in the absence of formal postoperative hip precautions.4,5 The posterior approach, which violates the posterior structures of the hip, has been historically associated with a higher rate of dislocation.6-10 Fascia, Surgical landmarks are now considered- the iliac crest,anterior superior iliac spine. 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. Now feel the greater trochanter and place the incision. Copyright@orthopaedicprinciples.com. The approach can be extended distally, for adequate exposure of the fracture. Divide the gluteus medius into two imaginary thirds. As a healthcare provider, a senior citizen, and a patient that required three medications to control my high blood pressure, I started taking L-Arginine as a dietary supplement in 2006 and it has Mission Statement: Age In Place School is a participant in affiliate advertising programs designed to provide fees by advertising and linking to their products. There will be small variations in the approach from surgeon to surgeon, therefore most people will described there approach as a modified Hardinge approach. 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. The modified-Hardinge approach, which preserves the posterior capsule, has been shown to have the lowest rate of dislocation, even in the absence of formal postoperative hip precautions. 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. Patients can also have as little as a 3-inch incision. The approach does not give as wide an exposure as the anterolateral approach to hip joint with trochanteric osteotomy. In addition, it can be adapted for small incision surgery. The 'Hardinge direct lateral or transgluteal approach' has many different flavours. 110 West Rd., Suite 227 If the hip replacement was done through the more traditional posterior or antero- lateral/Hardinge approach - most patients have hip precautions for upto 6-8 weeks. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones . After dissecting the fat,look for the thick white layer which is the fascia. stream This technique is a unique and innovative method of performing a hip replacement. For example raised toilet seats and chairs to prevent bending at the hip more than 90 degrees, sock aids and dressing sticks for dressing and changing clothing easier, "easy reachers" to help them get items from the ground. Retract the cut edges of the fascia to pull the tensor fasciae latae anteriorly and the gluteus maximus posteriorly. The different incisions used in a hip replacement surgery are all defined by their relation to the musculature of the hip. 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. The prosthesis can be dislocated anteriorly. ;ul] 0>ycNz]u +.6^tim Recovery and Rehabilitation: Western Health; 2013. Food for thought. )=(5NFV~Q};a?CQjvy'"%wJNCouX{Ey}C qFBlpK"TC@W!#Fh6>`>tE@~HEy\pIgGmj.+N&'>=9ai7m14t`i.r?hE9M\(1@:rQ!]+szt8{r7~;58 R:.n[8811X_jP>fgfiF2IV'9pv]9+b*qLR__$a9R.*[@TR*GGq#}dyfOdWL7pfYc $XyEvNd!#[3|US:a;W} OXs!8fJ! But there is also more than one way to go about performing a hip replacement surgery - known as different "approaches.". See "About Me" page. Complementary and Alternative Medicine (CAM) for Postop Pain, prosthetic components of an artificial hip, minimally invasive surgery in hip replacement, Minimally invasive hip replacement approaches and procedures, Hip Resurfacing vs. 1173185, Tran P, Fraval A. That is completely different from sitting with the ankle stacked on top of the knee forming a figure- 4 type appearance. Patient compliance with hip precautions 12 weeks following - Springer Michigan medicine. Keep retractors on bone with no soft tissue under to prevent iatrogenic injury. Do not roll or lie on the unoperated side for the first 6 weeks, Do not twist the upper body when standing, The patient may benefit from a shower chair or elevated seat for home use, Avoid bathing for 8 to 12 weeks (flexed and bent down in the tub). The trochanteric approach to the hip for prosthetic replacement. 1 0 obj The anterior approach to total hip replacement has the least amount of restrictions of any of the total hip surgical approaches. Release the capsule sufficiently anteroinferiorly and anterosuperiorly to expose the femoral head and neck and permit free external rotation of the femur. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform open reduction of proximal periprosthetic femoral fractures or revision arthroplasty. - alcoholism: - consider the Hardinge approach for any patient who will have difficulty with complying with the usual hip precautions following surgery; Telephone: 410.494.4994, Modified Hardinge Anterolateral Approach to the Hip, Partial anterior trochanteric osteotomy in total hip arthroplasty: Surgical technique and preliminary results of 127 cases, Acetabular Exposure and Preparation for Reaming. There is a layer between the fascia and muscle which is the trochanteric bursa. The greater trochanter is reattached later by wires or cables. - abductor function is better following bony reattachment of the anterior portions of these muscles. Do not go more than 3 cm above the upper border of the trochanter because more proximal dissection may damage branches of the superior gluteal nerve. This restriction is in addition to the posterior approach restrictions because of the cutting or splitting of the hip abductors during surgery. The first 6 weeks are critical to maintaining these range of motion restrictions and these restrictions will remain precautionary for the rest of life. A modified anterolateral approach. - consider the Hardinge approach for patients w/ significant contracture; x 9|1F:MZCqb~/5I:2 Xlm/S6|]K-EL'i! The superior approach is relatively new. - dislocations may occur in upto 20% of alcoholics who undergo THR via a posterior approach; A modified anterolateral approach. Are you sure you want to trigger topic in your Anconeus AI algorithm? That is usually the journal article where the information was first stated. Physiotherapists and nurses in conjunction with surgeons usually teach these precautions to the patient in the perioperative period. Neither the anterior nor the posterior capsule is cut in this approach. 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]. Web site http:// www.orthoanswer.org/hip/total-hip-replacement/recovery.html. 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. The advantages of this approach include a significantly lower dislocation rate compared with other approaches while allowing for excellent acetabular visualization. Place a Hohmann retractor into the bone proximal to the hip capsule. % This information is provided as an educational service and is not intended to serve as medical advice. A layered closure is preferred for periprosthetic fractures. Underneath gluteus medius is gluteus minimus which also inserts into the greater trochanter. 1. For further exposure of the femur and placement of hardware, the vastus lateralis can be released and repaired later. Courtesy: Malek Racey, UK Make a T-shaped incision in the capsule, if necessary, for exposure. . Hardinge K. The direct lateral approach to the hip. Detach any fibers of the gluteus medius that attach to the deep surface of this fascia by sharp dissection. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. The direct lateral approach to the hip for arthroplasty. Happy Total Hip Recovery Without Dislocation. - Positioning: Hip dysplasia can present unique challenges in achieving stability with THA and, as such, there is a higher incidence of instability . The provocative position for hip dislocation is: hip flexion, adduction, internal rotation. Many of my patients with a posterior total hip replacement decide to get an electrical lift recliner chair to eliminate the difficulty of coming from sitting in a recliner chair to standing erect. Fat, Jacqueline Donaldson, OT, PTA. *The anterolateral approach to hip* Stationary bicycle (seat high to maintain hip precautions) 11. 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. Draw a line between the anterior one third and posterior two thirds of the muscle and that line would be the line in which we split the muscle fibres. Advantages and complications. We need to do so in a way that let us repair it in the end. %PDF-1.5 In most cases Physiopedia articles are a secondary source and so should not be used as references. The provocative position for hip dislocation is: hip extension, external rotation. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Incise the fat and underlying deep fascia in line with the skin incision. The direct lateral approach to the proximal femur releases the anterior third of the gluteus medius and minimus while preserving the posterior femoral attachment of the major part of these muscles. - 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: Do not allow surgical leg to externally rotate (turn outwards). The hip joint is then dislocated and the acetabular socket and femur are exposed for preparation and insertion of the prosthesis components. 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. 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. Deepen the incision through the gluteus medius and minimus proximally, retracting the anterior flap to show the hip capsule superiorly and adjacent supraacetabular ilium. Many surgeons will prescribe a hip abduction brace to remind the patient they are not allowed to actively abduct the leg. easier with leg flexed slightly. Hardinge Approach to Hip Joint (or Direct Lateral Approach)allows excellent exposure to the hip joint for joint replacement. The mean hip score was 80. The lower the commode the more difficult the problem.Comfort height commodes greatly decrease the patients tendency to lean more forward than allowed and makes it easier to come to standing without bending the hip more than 90 degrees.