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CASE PRESENTATION
PARS CLINIC
CAROLYN PAGE
78 year old female patient 3 months post THJR (left)
Pre op diagnosis: osteoarthritis left hip
Pre operative function
and disability
Post operative journey
and presentation today
Preoperative
•Pain groin and lateral left hip gradual onset over 2-3 years
•No neurological signs or symptoms
•Using stick all the time and occasionally a 4 wheel walker
•Limited activity/almost housebound
•No major medical problems except some mild hypertension
•Regular panadol osteo and occasional NSAID but no effect
•Smoker
•Had no conservative treatment
•Was seen in ortho and booked into have surgery
Kellgren and Lawrence Grading System
• grade 0 : normal
• grade 1 : possible joint space narrowing and subtle osteophytes
• grade 2 : definite joint space narrowing, defined osteophytes and some
sclerosis
• grade 3 : marked joint space narrowing, small osteophytes, some
sclerosis and cyst formation and deformity.
• grade 4 : Gross loss of joint space with above features plus large
osteophytes and increased deformity.
Operation
Prothesis : Stryker Exeter
cemented
smooth for less friction
number of sizes and off set
Approach: Hardinge (1982)
direct lateral: preserves insertion glut med/min
avoids need for trochanteric osteotomy
good access to joint
allows good alignment of prothesis
Easy to identify major nerves
Post management: referred to PACs and then
To CRC discharged at 6 weeks
6 week review
•Excellent Progress
•No pain
•No gait aid
•Gait: slight trendelenburg gait pattern/painfree
•Range Hip Flexion 80, Abduction 20, ER 25, IR 10 painfree
•wound well Healed
•Medications: occasional panadol
•Function: ADLs independent, help with shopping, housework
•Xray: enlocated, no signs of lucency, no fractures, cup position slightly vertical
•Plan: review xray with surgeon (normal practice) and follow up at 3 months
•Correct position of cup orientation is critical for short and long term complications
•Can restrict movement, cause impingement, dislocation, increased wear and
loosening
•Increased risk: surgical approach, BMI, surgeon volume
•Main angles are: abduction (30-45) and ante version(5-25)
3 month review
Awkwardly twist at home
Now severe sharp pain over lateral hip radiating into thigh
Difficult to do any activity
No neurological signs and no bladder/bowel
No SOB, no LOW, no fever, not unwell
Not sleeping well as difficult to get comfortable
O/E: pain limiting gait and requiring crutches
ROM: Flexion 80, Abduction 10, IR 10, ER 15
No obvious deformity of leg or shortening noted
Palpation over greater trochanter very painful
Any resistance to hip muscles was painful but mostly hip abduction
Differential diagnosis
Prosthetic joint:
fracture
loosening
infection
heterotopic ossification
dislocation
Musculoskeletal:
bursitis
gluteal Tendinopathy
Referred Pain
radicular pain from Low Back
Plan: Xray and review on same day
Fracture Greater Trochanter
Fractures :Post THJR (Vancouver Classification)
Type A Gr Tronchanter fracture:
If undisplaced manage conservative, protective weight bearing 6-12 weeks, avoid
hip abduction
Often associated with osteopenia of proximal femoral bone
Displaced fractures may require ORIF
If this fracture occurs due to osteolysis then surgery, bone graft and acetabular
lining revision should occur.
Patient management:
Patient condition discussed immediately with surgeon and
subsequent consultation was had.
Surgeon confirmed fracture of the greater trochanter
Management: non operative, protected weight bearing
Review with surgeon in 6 weeks
Lessons learnt
•Fractures post joint replacement can occur with minor activity
•Importance of documentation to detect changes
•Importance of regular xrays and comparisons between serial xrays