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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