The majority of inpatient orthopedics focus on the hip, knee, and spine. Improvements in orthopedic implants, techniques, and overall medical care have expanded indications for reconstructive efforts to restore function, reduce pain, and improve quality of life. This chapter reviews the most common major operations typically encountered in the hospital setting.
The hip, a ball and socket joint with articular cartilage, provides for load bearing and low-friction motion. The bony architecture supported by a fibrocartilaginous labrum, joint capsule, and traversing muscle groups provides stability. These muscle groups load the hip joint at 2 to 3 times the body weight and are highly sensitive to any changes in hip center of rotation or length of the lever arms. Synovial fluid provides nutrition to the avascular cartilage. The femoral head receives blood from the ascending branches off the medial circumflex femoral artery. Disruption of this retrograde blood supply may lead to avascular necrosis.
Any surgical approaches require significant soft tissue dissection to reach the hip joint. The most commonly used and most extensile posterior approach provides excellent visualization of the femur and acetabulum. The sciatic nerve is the main structure at risk. With meticulous repair following dissection of the posterior capsule, dislocation rates have been dramatically reduced. The lateral and anterior approaches both leave the posterior joint capsule intact resulting in low instability rates. Lateral approaches require hip abductor dissection and may lead to abductor insufficiency and a Trendelenburg gait. Anterior approaches provide limited exposure to any posterior structures. Trochanteric osteotomy provides extensile exposure but risks nonunion. The specific approach is chosen based on pathology, patient factors, and surgeon preference.
Total hip arthroplasty (THA) can dramatically relieve pain and improve function (Table 65-1). Surgical candidates have generally tried and failed a conservative course of weight loss, analgesics, assistive devices, therapy, and activity modifications. Preoperative radiographs should confirm destruction of the hip joint and allow for surgical planning. Other causes of “hip pain” should be ruled out. Arthritis often coexists in the hip and spine, with true hip pain perceived in the groin and anterior thigh.
Table 65-1 Hip Surgery ||Download (.pdf)
Table 65-1 Hip Surgery
|Hip Arthroplasty Procedures||Indication for the Procedure||Contraindications||Procedure||Comments|
|Primary total hip replacement||Degenerative joint disease, inflammatory arthritis, avascular necrosis, developmental dysplasia||Active infections, unstable medical illness, any general condition incompatible with surgery or rehabilitation|
2 h, 500 mL acute blood loss, and slow blood loss postoperatively
↑ Risk for venous thromboembolism and fat emboli
Infection rates <1%
|Regional anesthesia may be associated with better initial outcomes; hypotensive anesthesia associated with decreased intraoperative blood loss|
|Total hip resurfacing||Younger, high-demand patients||Active infections, unstable medical illness, general condition incompatible with surgery or rehabilitation||Increased blood loss and operative time expected but revision surgery likely less demanding than ...|