Courtesy: Dr T Vail, Ashok Shyam TV, Ortho

1?? Evaluation of Labral Pathology and Femoroacetabular Impingement

Patient Counseling and Expectations

When evaluating patients with:

Labral tears
Femoroacetabular impingement

Key counseling points include:

Recovery Timeline

Simple labral debridement:
- Recovery approximately 6 weeks.
Extensive impingement correction (cam/pincer correction, labral repair):
- Recovery 4 to 6 months.
Recovery after major hip arthroscopy may be longer than total hip replacement in some cases.

Long-Term Considerations

Primary goal:
- Improve pain
- Improve function
Not primarily proven as a hip preservation procedure to prevent future total hip replacement.
Limited long-term data supporting disease-modifying effects.

Important Historical Insight

Before femoroacetabular impingement was widely recognized:

Approximately 8 percent of patients had persistent symptoms.
These failures often had uncorrected periarticular pathology.
Treating labral tears without correcting impingement leads to poorer outcomes.

2?? Management of Osteonecrosis with Femoral Head Collapse

Case Scenario

50-year-old male
Idiopathic osteonecrosis
Collapse in superolateral femoral head

Key Principle

Collapse represents the watershed point.
Once collapse occurs, joint-preserving procedures are generally not recommended.

Treatment Options

Total Hip Replacement

Most predictable option after collapse.
Preferred in moderate to large lesions.
Reliable long-term outcome.

Hip Resurfacing (Selective Cases)

Consider only if:

Small necrotic lesion
Viable supporting bone remains
Minimal collapse
Lesion not structurally compromising head support

Important determinant:

Size of necrotic segment
Location (caput vs head-neck junction)
Viability of remaining bone

If the femoral head bone is not viable, resurfacing is not logical.

3?? Preoperative Planning for Total Hip Replacement

Successful total hip replacement begins before entering the operating room.

Core Principles

Recognize the problem.
Develop a surgical plan.
Ensure correct implants and instruments are available.
Avoid intraoperative surprises.

A. History and Risk Assessment

Essential Elements

Prior sepsis
Prior trauma
Radiation exposure
Neurologic disorders
Alcoholism or dementia
Rheumatologic disease
Paget disease
Childhood hip disorders

These influence:

Surgical approach
Implant choice
Head size selection
Stability strategy

Neurologic Conditions

Patients with:

Parkinson disease
Stroke
Neuromuscular disorders

Have higher dislocation risk.

Consider:

Larger femoral head
Anterior or anterolateral approach
Dual mobility systems (if indicated)

B. Childhood Hip Disorders

Perthes Disease

Metaphyseal-diaphyseal mismatch
Large metaphysis
Narrow diaphysis
Challenging stem sizing

Developmental Dysplasia of the Hip

Small acetabulum
Excessive anteversion
Leg length discrepancy
Possible need for subtrochanteric osteotomy in severe cases

Prior Pediatric Osteotomies

Altered anatomy
Rotational deformities
Retained hardware
Changed biomechanics

C. Contractures and Pelvic Obliquity

Preoperative checklist:

Pelvic obliquity
Adduction contracture
Abduction contracture
Fixed flexion deformity
Leg length discrepancy
Gait assessment

Contractures affect:

Stability
Final leg length
Implant positioning

D. Radiographic Evaluation

Required Views

Low anteroposterior pelvis
Orthogonal femur views
Judet views if column involvement suspected
Computed tomography in complex deformity

4?? Templating Goals in Total Hip Replacement

Templating allows you to:

Estimate component size
Restore offset
Restore center of rotation
Correct leg length
Anticipate need for osteotomy

Acetabular Planning

Identify teardrop as landmark.
Determine cup size.
Establish hip center.
Restore native center of rotation whenever possible.

Femoral Planning

Depends on implant type:

Cemented Stems

Position determined by neck cut.

Cementless Tapered Stems

Position determined by metaphyseal and diaphyseal fit.
Stem depth depends on taper geometry.
Double-taper stems behave differently than round stems.

Offset and Length Restoration

By marking:

Acetabular center of rotation
Femoral neck center

You can determine:

Expected change in leg length
Expected change in offset
Whether lengthening is excessive
Whether subtrochanteric osteotomy is required

5?? High-Risk Planning Scenarios

Templating may reveal:

Excessive required lengthening
Severe deformity
Inability to restore hip center safely
Need for staged or complex reconstruction

6?? Key Take-Home Points

Labral and Impingement Surgery

Long recovery for extensive procedures.
Improves symptoms, not proven to prevent arthritis.
Uncorrected impingement leads to failure.

Osteonecrosis with Collapse

Collapse = joint replacement in most cases.
Resurfacing only for small, viable lesions.

Total Hip Replacement Planning

History influences approach and implant choice.
Childhood deformity creates subtle challenges.
Templating restores biomechanics and avoids errors.
Proper planning prevents intraoperative surprises

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