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Hip Dysplasia in the Child and Adolescent

Key Points Developmental dysplasia of the hip (DDH) represents a spectrum of abnormal hip mechanics and anatomy that can manifest during the newborn period, infancy, and later in life. A high degree of clinical suspicion can allow for early diagnosis of acetabular dysplasia during the newborn period. Well-recognized risk factors for DDH include female sex, positive family history, and breech position during gestation. Early treatment of…

Soft Tissue Pathology: Bursal, Tendon, and Muscle Diseases

Key Points Extraarticular hip disorders coexist with intraarticular hip disorders. Biomechanics of the pelvic girdle and its relationship to the hip and spine are complex. Some extraarticular hip disorders are diagnosed best by clinical presentation and exclusion of other diagnoses. The distribution of pain and pertinent findings on clinical examination are typically essential in directing the differential diagnosis and determining the source of pain and dysfunction.…

Hip Joint Infection

Key Points Septic arthritis of the hip, if untreated, can lead to significant joint destruction and disability or systemic illness. Early diagnosis and treatment are important for optimizing outcomes. Clinical history, physical examination, and joint aspiration identify most cases. Advanced imaging techniques (magnetic resonance imaging [MRI], nuclear medicine) may assist in the assessment of early or subclinical infection. Multiple surgical options—including arthroscopy, arthrotomy, arthroplasty, and arthrodesis—may…

Acetabular Rim Damage

Key Points Most cases of acetabular rim damage are related to mechanical conflicts secondary to instability (i.e., hip dysplasia) or incongruity because of abnormal shape of the femoral head or the socket (i.e., femoroacetabular impingement). Progression of this damage will lead to osteoarthritis of the hip. Acetabular rim damage includes injury to the labrum, chondrolabral junction, or both. Pathomechanics of hip dysplasia is edge loading of…

Synovial Diseases of the Hip

Key Points Synovial chondromatosis and pigmented villonodular synovitis (PVNS) are the most common primary disorders of the hip synovium. Early diagnosis of synovial disorders is important to optimize treatment results and minimize secondary degenerative disease of the hip. Surgical techniques of tumor excision include open procedures and arthroscopy depending on the disease pattern. Radiation therapy has a role in the treatment of PVNS, usually in the…

Osteonecrosis and Bone Marrow Edema Syndrome

Key Points As many as 10,000 to 20,000 new cases of osteonecrosis (ON) are reported each year in the United States. Bone marrow edema syndrome (BMES) is a relatively rare disease. ON and BMES similarly present in young and middle-aged patients with hip or groin pain. Magnetic resonance imaging is the most sensitive and specific diagnostic tool for diagnosing both ON and BMES. ON progresses to…

Dysplasia in the Skeletally Mature Patient

Key Points Hip dysplasia commonly presents in adolescent and young adult patients with no known history of hip disease. Early diagnosis is essential to provide the opportunity for optimal hip preservation treatments. History, examination, and plain radiographs are the essential components of the diagnostic workup. Multiple hip preservation surgical treatments can be considered for the treatment of symptomatic hip dysplasia before established secondary osteoarthritis, yet acetabular…

Femoroacetabular Impingement

Key Points Femoroacetabular impingement is a cause of hip osteoarthritis. Osseous deformities of the proximal femur and acetabulum can result in increased forces and damage to the acetabular rim complex caused by a process of hip motion. The femoral deformity, known as the cam mechanism, causes an “outside-in” shearing injury to the labral-chondral junction. The acetabular deformity is due to overcoverage from a retroverted acetabulum, a…

Osteoarthritis

Key Points Epidemiology and Risk Factors Hip osteoarthritis (OA) affects up to one-third of the population and has a varied clinical course, with a final degenerative pathway. Plain radiographs are widely used to diagnosis osteoarthritis, with joint space narrowing being the best predictor of symptomatic OA. Newer imaging modalities, including magnetic resonance imaging (MRI) and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), assess hip joint integrity before…

Imaging of the Hip

Key Points A broad spectrum of radiologic investigations can be used to provide the orthopedic surgeon with important information regarding hip anatomy and pathology, facilitating diagnosis, monitoring, and treatment planning for hip disease. Radiography is the first line of imaging in investigating the hip; various techniques and projections are used to optimize visualization of select structures and regions of the hip joint. Femoroacetabular impingement results from…

History and Physical Examination of the Hip

Key Points Perform a standardized history and physical examination protocol of the hip. Perform examinations of the hip with consistent technique. Incorporate physical examination findings with quality radiographic and three-planar osseous assessment through magnetic resonance imaging (MRI) or computed tomography (CT). Use guided intraarticular/extraarticular injection tests to aid in diagnosis. Learn to recognize complex posterior hip pathology. Hip disease is commonly associated with a loss of…

Rehabilitation After Hip Surgery

Key Points The goal of rehabilitation is to maximize functional outcomes and improve an individual's ability to perform activities of daily living in a timely fashion after treatment has been rendered. Surgical treatment options for hip pathology include total hip arthroplasty (THA), resurfacing arthroplasty, arthroscopy, osteotomies, and fracture care. To be discharged home after hip surgery, a patient must be able to ambulate approximately 50 to…

Prevention of Venous Thromboembolism in Surgery of the Hip

Key Points Clinicians should assess all patients for factors increasing the risk of venous thromboembolic events (VTEs). Having total hip arthroplasty (THA) puts a patient in a high-risk group. THA patients are often older, with additional comorbidities that increase the risk of VTE. Multiple methods of VTE prophylaxis are available. Chemoprophylaxis Aspirin Vitamin K antagonist (VKA; warfarin) Low-molecular-weight heparin (LMWH) Factor Xa inhibitors Direct thrombin inhibitors…

Perioperative Pain Management

Key Points Multimodal analgesia, including regional blockade and nonopioid medication, reduces opioid requirements and side effects. Postoperative lumbar plexus blockade is superior to neuraxial analgesia for patients undergoing major hip surgery. Psoas compartment block provides complete unilateral lumbar plexus anesthesia Femoral and fascia iliaca techniques consistently block the femoral nerve but unreliably block the lateral femoral cutaneous and obturator nerves. Periarticular local anesthetic infiltration may be…

Perioperative Medical Management of Hip Surgery Patients

Key Points The pathophysiologic surgical stress response causes widespread changes in organ function and can lead to postoperative complications. Perioperative care should be aimed at minimizing the stress response. Preoperative assessment should include careful review of each patient's past medical history given that most adverse outcomes are due to an exacerbation of underlying medical problems rather than surgical or anesthetic complications. Patients should be medically optimized…

Mortality After Total Hip Arthroplasty

Key Points Reported mortality rates vary between 0.2% and 1% in the early postoperative period (30–90 days) Most deaths are related to cardiopulmonary complications. Advanced age and comorbidities have been associated with increased risk for death. Patients who have had a hip replacement appear to have a lower-than-expected risk for death at 1 to 10 years following surgery compared with controls in the general population. Introduction…

Anesthesia for Hip Surgery: Options and Risks

Key Points Patients undergoing hip surgery pose specific challenges to the anesthesiologist. Anesthetic options for hip surgery include general and regional techniques, but options will vary depending on patient- and procedure-specific characteristics. Patients undergoing hip surgery commonly suffer from arthritis and other musculoskeletal disorders that demand great care in airway management and patient positioning. Regional anesthesia—such as neuraxial (spinal or epidural) and peripheral techniques—may offer specific…

Blood Management

Key Points Blood transfusions remain relatively common following both primary and revision hip arthroplasty procedures and are associated with significant risks. Comprehensive blood management strategies reduce the need for blood transfusions; thus, they should be considered an integral part of contemporary orthopedic practice. Preoperative measures include the evaluation and treatment of chronic anemia. Intraoperative techniques include the routine use of antifibrinolytic medications such as tranexamic acid,…

Minimally Invasive Hip Arthroplasty

Key Points The risks and benefits of minimally invasive surgical approaches for total hip arthroplasty (THA) remain controversial. There is no single definition of “minimally invasive” THA, but the term has been used for approaches with a shorter skin incision and for approaches that spread rather than transect muscles, such as the direct anterior approach. Most prospective, randomized trials have shown little long-term demonstrable benefit of…

Extensile Approaches for Revision Total Hip Arthroplasty

Key Points Always plan for an extensile exposure on the femoral side, and template that plan preoperatively. Isolated acetabular revision with retention of a well-fixed femoral component requires extensile exposure. Femoral revision for removal of well-fixed implants and femoral canal cement and for varus remodeling of the proximal femur is the primary indication for extended trochanteric osteotomy. Extended trochanteric osteotomy may be performed via an anterolateral…