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An Introductory Surgical Anatomy Case Series: Hip Surgery Caity Ellis and Clare Gabrielle University of Edinburgh SSC5 Orthopaedics ProjectLearning Outcomes • Enhance Understanding of Hip Anatomy • Identify Important Surgical Landmarks of the Hip • Discuss Hip Fracture and Injuries • Revision of important UKMLA Orthopaedic Presentations • Provide an Introduction to real surgical procedures through images • Inspire Future Orthopaedic Surgeons!Introduction - Prevalence • Roughly 8000 in Scotland in 2023, this is increasing in prevalence • Most patients are 70-89 and are admitted from home Risk Factors • Inc. Age • F>M • OsteoporosisIntroduction – Quality of Life • Serious morbidity risk • Affects patient ambulation • 22% Mortality in the first year following fracture • Fraility and delirium are associated with higher mortalityIntroduction – Standards of Care • The Scottish target for hip fracture is for surgical management to be carried out within 36 hours of admission in order to improve mortality • Scotland-wide 68.6% of patients achieve thisHip anatomy - Bones 1. Head 2. Neck 3. Greater Trochanter 4. Lesser Trochanter 1 5. Trochanteric Line 2 3 5 4V ascular Anatomy Retinacular Arteries are inside the capsule and are the only Medial Cx Femoral Artery blood supply to the femoral Lateral Cx Femoral Artery head. They are within the capsule. CapsuleMusculature 4 1 1. Iliacus Muscle 2. Obturator Externus 3. Adductor Brevis 4. Psoas Major 5. Pectinus Muscle 2 5 6. Adductor Longus 3 6 1. Vastus Medialis 2. Vastus Intermedius 3. Superior Gemellus 4. Obturator Internus 3 5. Inferior Gemellus 5 4 6. Quadratus femoris 6 1 21 1. Gluteus Minimus 2. Piriformis 2 3. Gluteus Medius •After a fracture the muscles in 3 the hip can have a deforming effect on the joint. 1. Rectus Femoris 2. Tensor Fascia Latae 3. Gluteus Maximus 2 3 1T ypical Hip Fracture Presentation • Unable to weight bear • Pain – location dependent on fracture type • Discomfort with active and passive movement • Shortened, abducted, and externally rotated leg in displaced fractures • Fall mechanism – osteoporosis comobidity • Medications – steroids, anticoagulantsImaging and Diagnosis – X rays • AP view of the hip – look for Shenton’s line - If it’s disrupted then there is a fractured neck of femur • LateralImaging and Diagnosis - CT /MRI • CT - Occasionally useful if the fracture is commuted and displaced • MRI – Useful for occult fractures, particularly in patients with demineralisation. Consider in elderly patients who fall, have pain and are unable to bear weight.Intracapsular vs Extracapsular Hip Fractures • Intracapsular • Proximal to the intertrochanteric line • Can cut off blood supply to the head of the femur → Avascular necrosis •Due to the medial circumflex artery being the only blood supply to the head • Hemiarthroplasty is usually needed to preserve joint function • Extracapsular • Distal to the intertrochanteric line • Usually DHS or Femoral IM Nail •Depending pattern and stability •DHS for more stable fracturesLow Energy vs High Energy Fractures • Low Energy - Typically older/frailer individuals having falls secondary to –Worsening sight –Dementia –Medication sideeffects (e.g. steroids) –Osteoporosis (making them more prone to fractures) –Other health conditions • High Energy – Typically in younger/more active people secondary to high impact traumaNon-Surgical Management of Hip Fractures • Observation Alone • Appropriate if patient has high risk factors for surgical intervention • Managed through protected weight bearingCase #1 This patient is an 88 year old female, unwitnessed fall at home onto R hip Can not ambulate and has right hip pain Patient Background • HPC – Unwitnessed fall at home • PMHx – CHF, HTN, Alzeheimer's, Meningioma (resected) AVR, Appendectomy, HysterectomyOn Hip Examination • Unable to move secondary to pain. • Pain with axial loading and log roll • No swelling or ecchymosis • Skin intact • Active flex/extension of knee, minimal pain • Normal neurovascular examInvestigations • Bloods oFBC, Group and Save, Coag Screen oNo Abnormalities • Imaging o Radiographs - AP, Lateral What finding can be seen on the Xray radiograph? AP Intracapsular Fracture Trochanteric Fracture Subtrochanteric FractureLateral AP - Traction and Internal RotationManagement – T rochanteric Fracture • Conservative oUsually in the elderly or a more frail patient oHigh mortality rate • Surgical oExtracapsular → Femoral NailSurgical Overview Femoral Intramedullary Nailing oClosed Reduction oIncision oDissection oGuide Wire Placement oInsert Femoral Nail oGuidewire for Lag Screw and Pin oInsert Lag Screw and Pin oLock Distal Screw oClose Warning! The Following Slides will Contain Pictures of Real Anatomy Specimens If you feel uncomfortable or distressed at any time, feel free to take time for as long you need then return to the teaching or contact support if you need it. Some Resources Available: • University of Edinburgh Advice Place - https://www.eusa.ed.ac.uk/adviceplace/wellbeing/mentalhealth • Samaritans – 116 123 • Nightline – 0131 557 444Closed reduction is obtained by putting the foot in traction and slightly internally rotating it. Which surgical landmark should be Landmarking used for this incision to ensure proper access for the guidewire? Iliac Crests Greater T rochanter Lesser Trochanter Anterior Superior Iliac SpineLandmarking – The incision is made 10cm proximal to the Greater Trochanter in the anatomical axis of the femurDissection of the subcutaneous tissue and fasciaGuide pin placed at the proximal tip of the greater trochanterPin should be placed centrally in the femoral neck in the lateral view , to allow for placement of the lag screw• AP view is rechecked to ensure guide pin is in correct position. It should be just medial to the tip of the greater trochanter .• Reamer is used to open the site for nail placement• Reduces fracture before placing nail. • Nail is inserted over the wire• Determine Nail depth • Lateral incision is made using the guide• Second guidewire passed into the femoral head. • A reamer then forms a channel for the lag screw• Lag screw is inserted over the guidewire. • Radiographic confirmation• Incision is made for distal locking. • Th distal screw is measured and placed• Wounds are closed in layers. • Deep fascia, Subcutaneous and SkinCase #2 Presenting at A and E: A 76-year-old woman, is brought in by her daughter after a fall at home. She reports sudden pain in her left hip and is unable to bear weight on her left leg.Patient Background • HxPC – unable to weight bear , left leg is shortened and externally rotated • PMHx – Osteoporosis, dementia, hypertension • DHx – Amlodipine, simvastatin, alendronate, vitamin D supplementation, paracetamol PRN • SHx – Lives at home with help from carers, lives in a bungalow, mobilizes with a stick, • FHx – unknown hxOn Hip Examination • Shortened and externally rotated left leg • Swelling and bruising around the site • Tenderness upon palpation of the left hip joint • Unable to actively/passively move the leg without pain, unable to bear weight • Normal Neurovascular Examination • No abnormalities on knee examination/injury elsewhereInvestigations • Bloods oFBC, Group and Save, Calcium and Vit D, Coag Screen oNo Abnormalities • Imaging o Radiographs - AP, LateralXray AP LateralGarden Classification of Intracapsular Fractures • Grade 1 – Incomplete Not displaced – May still have intact blood supply • Grade 2 – Complete Non-displaced • Grade 3 – Partial Displacement • Grade 4 – Full displacementManagement – Intertrochanteric Fractures • Conservative oUsually in a more frail patient with surgery contraindications oHigh mortality rate • Surgical oIntracapsular oHemiarthroplasty – more common in patients who are less active/not walking independently oTotal Hip Arthroplasty – more active patients oCan also be surgeon dependentSurgical Overview Hip Hemiarthroplasty oIncision oApproach oFemoral Neck Cut oFemoral Head Removal oCanal Preparation oSizing of Trial Heads oWashout and Cementing oStem and Head insertion oReduction back into Joint oClosure Retraction of Skin and Incision of Incision of the Skin Subcutaneous Tissue cauterizing bleeders as you goApproach approach and must be split in order to continue approaching the joint capsule? Gluteus Maximus Gluteus Medius Tensor Fascia Lata V astus LateralisTensor Fascia Lata is Split to Branch of Medial Femoral access adductors below cauterized Artery must beApproach the femoral head and joint expose capsule? Gluteus Maximus Gluteus Medius Gluteus Minimus Obturator InternusCapsulotomy + Mark Flex and Externally Rotate Hip Capsule and Adductors to gain exposure of femoral neck Corkscrew Device is inserted Cut Femoral Neck into head then head is removedSizing of ProsthesisFemoral Canal Preparation (Reaming)TrialThe Assistant is applying gentle tractiWhat movement is the surgeon whilst the surgeon guides the head intosocket?o put the hip back into its the socket. Flexion Extension Adduction Internal RotationWashout CementingStem is put in Head is put inClosing Tensor Capsule Gluteus Fascia LataReferences HC Orthopaedic Surgery. (n.d.). Avascular necrosis of the femoral head. Retrieved January 21, 2025, from https://www.hcortho.sg Quizlet. (n.d.). CM: Pelvis and hip [Flash cards]. Retrieved January 21, 2025, from https://quizlet.com/gb/543357066/cm-pelvis-and-hip-flash-cards/ VuMedi. (n.d.). Anterolateral approach for hemiarthroplasty for femoral neck fracture [Video]. Retrieved January 21, 2025, from https://www.vumedi.com/video/anterolateral-approach-for-hemiarthroplasty- for-femoral-neck-fracture/ Radiology Masterclass. (n.d.). Hip fracture X-ray. Retrieved January 21, 2025, from https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x- ray_trauma_lower_limb/hip_fracture_x-ray White, T. O., & Mackenzie, S. . (2023). McRae's orthopaedic trauma and emergency fracture management (4th ed.). Elsevier .References • Scottish Hip Fracture Audit. https://publichealthscotland.scot/publications/scottish-hip-fracture-audit/scottish-hip- fracture-audit-reporting-on-2023/ Accessed 22/01/25 • Unstable Intertrochanteric Hip Repair With Cephalomedullary Nail https://www.vumedi.com/video/unstable- intertrochanteric-hip-repair-with-cephalomedullary-nail/ • Accessed 22/01/25 • Complete Anatomy App • Radiopedia Femoral neck fracture – basicervical https://radiopaedia.org/cases/femoral-neck-fracture- basicervical?lang=gb Accessed 22/01/25 • Changing trends in the mortality rate at 1-year post hip fracture - a systematic review https://pmc.ncbi.nlm.nih.gov/articles/PMC6428998/#:~:text=The%20results%20of%20this%20study,mortality%20rat e%20post%20hip%20fracture.