TOTAL HIP

ARTHROPLASTY Mr. Bautista, Christian Gerrold, PT4

 I. INTRODUCTION
The THA is a common procedure performed in cases of severe
joint damage resulting from OA, rheumatoid arthritis, displaced
femoral neck fractures, and avascular necrosis. Arthroplasty of
the hip may be categorized as a THA or a hemiarthroplasty. In a
THA, the articular surfaces of both the acetabulum and femur
are replaced. This involves either replacement of the femoral
head and neck (conventional THA) or replacement of the
surface of the femoral head (resurfacing THA).

2
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

The hip joint is a multiaxial ball-and-socket joint that has

maximum stability because of the deep insertion of the
head of the femur into the acetabulum. The femoral head
is much more stable in the acetabulum for the hip than the
humerus is in the glenoid for the shoulder. To allow
sufficient movement and proper alignment to occur at the
hip joint, the femur has a longer neck than the humerus
and is anteverted.

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
3 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

RP 30° flexion, 30° abduction, slight

lateral rotation

CPP Full extension, medial rotation, and

abduction

CP Flexion, abduction, medial rotation

(but in some cases, medial rotation is
limited)

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
4 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

In addition, the hip, like the shoulder, has a labrum, which

helps to deepen and stabilize the joint. The acetabular
labrum increases the articular surface area of the
acetabulum and volume, and it creates a seal for the
central compartment, which is part of the intra-articular hip
joint. The seal resists distraction of the femoral head from
the socket by maintaining a negative pressure and resists
fluid flow that enhances nutrition of the hip articular
cartilage, which in turn provides a smooth gliding surface.

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
5 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

The joint has a strong capsule and very strong

muscles that control its actions. The acetabulum is
formed by fusion of part of the ilium, ischium, and
pubis, which taken as a group are sometimes called
the innominate bone or pelvis. The acetabulum opens
outward, forward, and downward. It is half of a
sphere, and the femoral head is two thirds of a
sphere. The hip, already a stable joint because of its
bony configuration.
Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
6 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

Supported by three strong ligaments: the iliofemoral,

the ischiofemoral, and the pubofemoral ligaments.

The iliofemoral ligament (Y ligament of Bigelow) is

considered to be the strongest ligament in the body. It
is positioned to prevent excessive extension and
plays a significant role in stabilizing and in
maintaining upright posture at the hip while limiting
anterior translation.
Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
7 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY

The ischiofemoral ligament, the weakest of these

three strong ligaments, winds tightly on extension,
helping to stabilize the hip in extension. The
pubofemoral ligament prevents excessive abduction
of the femur and limits extension.

All three ligaments also limit medial rotation of the

femur.

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
8 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 II. ANATOMY/PHYSIOLOGY/ETIOLOGY
The ischiofemoral ligament, the weakest of these three strong
ligaments, winds tightly on extension, helping to stabilize the
hip in extension. The pubofemoral ligament prevents
excessive abduction of the femur and limits extension.

All three ligaments also limit medial rotation of the femur.

A fourth ligament of the hip that sometimes is injured is the

ligamentum teres or “ligament of the head,” which provides a
physical attachment of the head of the femur to the
acetabulum.
Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
9 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 ANATOMY OF THE HIP JOINT

10
 III. EPIDEMIOLOGY/ ETIOLOGY

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
11 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier
 III. EPIDEMIOLOGY/ ETIOLOGY
In general, any patient considered a candidate for THA
should have already undergone an earnest attempt at
nonoperative management.

This typically includes the use of assistive devices, oral

nonsteroidal medications, acetaminophen, and activity
modifications.

The primary indication for THA in a patient with endstage

arthropathy is pain resulting in significant limitation of physical
activity.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
12
 IV. PATHOPHYSIOLOGY
Osteoclast precursor cells (OCP) recruited to the periprosthetic
tissues differentiate into functional osteoclasts (OC), which resorb
bone by generation of a resorption pit into which enzymes such as
Cathepsin K, tartrate-resistant acid phosphatase (TRAP), and
carbonic anhydrase II (CAII) are secreted. Osteoclast maturation
and activation are mediated by interaction of RANKL with the OCP
receptor RANK. Osteoprotegerin (OPG), a soluble decoy receptor
for RANKL, inhibits this pathway, as does the T lymphocyte
cytokine, interferon gamma (IFN). Positive (+) and negative (−)
effects of wear particles on key aspects of this complex regulatory
system are shown as are important steps where possible particles
involvement have yet to be established.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
13
 IV. PATHOPHYSIOLOGY

14 Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
 V. CLINICAL MANIFESTATIONS OF S/SXS
The primary manifestations of fracture include pain and
tenderness, increased pain on weight bearing, edema,
ecchymosis, loss of mobility, and loss of function of the
involved body part.

Point tenderness over the site of the fracture is usually

present.

With many fractures, attempts to move the injured limb will

provoke severe pain, but in the presence of a fatigue fracture
(stress reaction) active movement is typically painless.
Source: Goodman, C.C. & Fuller, K.S. (2015). Pathology implications for the physical therapist. 4th ed.
15 Missouri: Elsevier Saunders
 V. CLINICAL MANIFESTATIONS OF S/SXS

Resistive motions or repetitive weight bearing will

cause pain, and the area will be exquisitely tender to
local palpation.

Clinical manifestations are most severe when the

fracture is unstable.

Source: Goodman, C.C. & Fuller, K.S. (2015). Pathology implications for the physical therapist. 4th ed.
16 Missouri: Elsevier Saunders
 VI. CLINICAL COURSE
FRACTURE HEALING
The inflammatory phase occurs as inflammatory cells arrive at
the injured site accompanied by the vascular response and
cellular proliferation. Clinical evidence of this phase includes
pain, swelling, and heat.

Clotting factors from the blood initiate the formation of a fibrin

meshwork. This meshwork is the scaffolding for the ingrowth of
fibroblasts and capillary buds around and between the bony
ends. By the end of the first week, phagocytic cells have
removed a majority of the hematoma, and neovascularization
and initial fibrosis are occurring.
Source: Goodman, C.C. & Fuller, K.S. (2015). Pathology implications for the physical therapist. 4th ed.
17 Missouri: Elsevier Saunders
 VI. CLINICAL COURSE
FRACTURE HEALING
The reparative phase begins during the next few weeks and includes the
formation of the soft callus seen on radiographs around 2 weeks after the
injury, which is eventually replaced by a hard callus. During this phase,
osteoclasts (bone macrophages) clear away the necrotic bone while the
periosteum and endosteum regenerate and begin to differentiate into
formation of hyaline cartilage (soft callus) and primary bony spicules (hard
callus). Bone growth factors, including bone morphogenetic proteins,
fibroblast growth factor, insulin-like growth factors, platelet-derived growth
factor, transforming growth factor–β, and vascular endothelial growth factor,
are major components of the fracture healing (reparative) phase.The
completion of the reparative phase (usually occurring between 6 and 12
weeks) is indicated by fracture stability. Radiographically, the fracture line
begins to disappear.
Source: Goodman, C.C. & Fuller, K.S. (2015). Pathology implications for the physical therapist. 4th ed.
18 Missouri: Elsevier Saunders
 VI. CLINICAL COURSE
FRACTURE HEALING
The remodeling phase begins with clinical and roentgenographic
union and persists until the bone is returned to normal, including
restoration of the medullary canal. During this phase, which may
take months to years, the immature, disorganized woven bone is
replaced with a mature organized lamellar bone that adds further
stability to the fracture site. The excessive bony callus is resorbed,
and the bone remodels in response to the mechanical stresses
placed on it.
In the normal adult skeleton, approximately 10% to 30% of the bone
is replaced or remodeled to replace microfractures from stress and
maintain mineral balance. Bone remodeling is carried out by bone
cells, including osteoblasts, osteoclasts, and osteocytes.
Source: Goodman, C.C. & Fuller, K.S. (2015). Pathology implications for the physical therapist. 4th ed.
19 Missouri: Elsevier Saunders
20
FRACTURE HEALING
 VI. CLINICAL COURSE FRACTURE HEALING WITH
REPLACEMENT
In the ideal situation, the introduction of an implant and the
subsequent reaming of the bone for implant placement
would lead to healing, not unlike that seen in normal
fracture healing. The implant would stimulate the
differentiation of osteoblasts in adjacent tissue, with
eventual osseous anchorage. In actual practice, however,
micromotion may lead to fibrosis rather than bone, the
final result being the formation of a fibrous or, in some
instances, synovial and bursa-like membrane, similar to
that seen in pseudoarthroses.
Source: Vigorita, V.J. (2015). Orthopaedic pathology. 3rd ed. Netherlands: Wolters Kluwe
21
 VI. CLINICAL COURSE
BONE-CEMENT INTERFACE
An initial stage of postoperative tissue necrosis and
damage induced by the operative procedure was
followed by a second stage in which a fibroblastic
ingrowth led to remodeling, repair, and replacement
of the former necrotic bone. A final stage, occurring
several years after implantation, led to the production
of a membrane consisting of acellular,
noninflammatory fibroblastic tissue.

Source: Vigorita, V.J. (2015). Orthopaedic pathology. 3rd ed. Netherlands: Wolters Kluwe
22
 VII. PROGNOSIS

Total hip arthroplasty (THA) is one of the most successful

and cost-effective elective orthopedic procedures. THA
eliminates patient suffering due to debilitating end-stage
arthritis of the hip and improves function and mobility, with
remarkable long-term survivorship.
Accordingly, the use of hip prostheses in young individuals is
becoming more prevalent. The high activity level of the young
patients puts a high demand on these arthroplasties and
leads to early failure.

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
23
 VII. PROGNOSIS

In addition, the generally increased life expectancy of the

population will require longer-term survival than in the elderly
who receive THA. As a consequence, scientists now focus on
appreciating the mechanisms and timing of THA failure to
identify preventable causes and to more efficiently direct efforts
aimed at increasing durability of hip prostheses.

Improving survival of THA would reduce the number of revision

arthroplasties. Revision THA places an enormous financial
burden on the health care system, and also has a less favorable
outcome than primary hip replacement.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
24
 VII. PROGNOSIS

Revision THA places an enormous financial burden on the

health care system, and also has a less favorable outcome than
primary hip replacement.
There are various mechanisms of failure that limit the longevity
of THA: aseptic loosening, osteolysis, polyethylene (PE) wear,
infection, pain, periprosthetic or component fracture, technical
surgical errors, and instability.
The incidence of aseptic loosening increases as time progresses
but failures resulting from instability, poor surgical technique,
and infection are more frequent causes of early failure.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
25
 VIII. DIAGNOSIS AND EVALUATION PROCEDURE

Source: Scottish Intercollegiate Guidelines Network. (2009). Managememt of hip fracture in older people:
26 national clinical guideline. Edinburgh: SIGN
 IX.DIFFERENTIAL DIAGNOSIS

27
 IX.DIFFERENTIAL DIAGNOSIS

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
28
 IX.DIFFERENTIAL DIAGNOSIS

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
29
 X. TREATMENT

A. MEDICAL

• NSAIDS
• Intravenous opiate analgesia

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
30 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 X. TREATMENT B. SURGICAL

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of musculoskeletal rehabilitation.
31
2nd Ed. Missouri: Saunder and Elsevier.
 SURGICAL
X. TREATMENT
APPROACHES
ANTERIOR APPROACH
The anterior approach is known as the Smith-
Peterson approach and utilizes the internervous
intervals between the sartorius and tensor fascia lata
in the superficial plane and the rectus femoris muscle
and gluteus medius and minimus in the deep plane.
The sartorius and rectus femoris are supplied by the
femoral nerve, while the tensor fascia lata and glutei
receive innervations from the superior gluteal nerve.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
32
 SURGICAL
X. TREATMENT
APPROACHES

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
33
 SURGICAL
X. TREATMENT
APPROACHES

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
34
 SURGICAL
X. TREATMENT
APPROACHES
ANTEROLATERAL APPROACH
The anterolateral approach was popularized by WatsonJones
early on for hip fracture fixation. The anterolateral approach
utilizes the plane between the gluteus medius and tensor
fascia muscle that are both innervated by the superior gluteal
nerve. Although the anterolateral approach does not permit
extensive exposure of the anterior column as the anterior
approach, it allows good acetabular exposure with safe
femoral reaming. There is also less dissection of the
abductors as compared to the Smith-Petersen approach.
Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
35
 SURGICAL
X. TREATMENT
APPROACHES

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
36
 SURGICAL
X. TREATMENT
APPROACHES
DIRECT LATERAL APPROACH
The direct lateral approach was popularized by
Harding for performing THA. It can provide excellent
exposure to both the anterior hip and upper femur
without the need for trochanteric osteotomy. At the
same time, the posterior hip soft tissue structures are
preserved, which decreases the risk of postoperative
dislocation.

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
37
 SURGICAL
X. TREATMENT
APPROACHES

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
38
 SURGICAL
X. TREATMENT
APPROACHES
POSTERIOR/POSTEROLATERAL APPROACH
The posterior approach was originally described by
Austin Moore and utilized for exposure of the
posterior capsule and acetabular wall by splitting the
gluteus maximus. It permits excellent exposure of the
proximal femoral shaft. One advantage over the other
approaches is the preservation of the abductor
mechanism.

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
39
 SURGICAL
X. TREATMENT
APPROACHES

Source: Parvizi, J. & Klatt, B. (2013). Essentials in total arthroplasty. West Depforth; SLACK incorporated
40
 X. TREATMENT TYPE OF FIXATION

Cemented vs Uncemented
- The revolutionary aspect of the early THA procedures was the
use of acrylic cement, methyl methacrylate, for prosthetic
fixation.
- Cement fixation allowed very early postoperative weight
bearing and shortened the period of rehabilitation, whereas prior
to the use of cement fixation, patients were subjected to months
of restricted weight bearing and limited mobility.
- Cement fixation continues to be in common use today,
particularly in THA for elderly and physically inactive younger
patients, but has been shown to have its drawbacks.
Source: Kisner, C. & Colby, L.A. (2012). Therapeutic exercise foundations and techniques. 6th ed.
41 Philadelphia: F.A. Davis Company
 X. TREATMENT TYPE OF FIXATION

- A significant postoperative complication associated with

cemented fixation is aseptic (biomechanical) loosening of the
prosthetic components at the bone-cement interface.
- It has been shown that loosening subsequently leads to a
gradual recurrence of hip pain and the need for surgical revision.
- Patients who most often develop implant loosening are the
younger, physically active patients. In contrast, loosening has
not been shown to be a particularly prevalent problem in elderly
patients or in young patients with multiple joint involvement who
typically have a limited degree of physical activity.

Source: Kisner, C. & Colby, L.A. (2012). Therapeutic exercise foundations and techniques. 6th ed.
42 Philadelphia: F.A. Davis Company
 X. TREATMENT TYPE OF FIXATION

The long-term problem of mechanical loosening of cemented

implants gave rise to the development and use of cementless
(biological) fixation.
- Cement-free fixation is achieved either by use of porous-coated
implants that allow osseous ingrowth into the beaded or textured
surfaces of an implant or by a precise press-fit technique.
- Ingrowth of boney tissue occurs over a 3- to 6-month period
with continued bone remodeling beyond that time period.
- Initial long-term studies of cementless fixation have
demonstrated better durability of the fixation of the acetabular
component than the femoral stem component.
Source: Kisner, C. & Colby, L.A. (2012). Therapeutic exercise foundations and techniques. 6th ed.
43 Philadelphia: F.A. Davis Company
 AREAS AND
XI. REHABILITATION INSTRUMENTATIONS

ROM: MMT:
- HIP FLEXION - HIP FLEXORS
- HIP EXTENSION - HIP EXTENSORS
- HIP ABDUCTION - HIP ABDUCTORS
- HIP ER - HIP EXTERNAL
- HIP IR ROTATORS
- HIP INTERNAL
ROTATORS

Source: Magee, D.J. (2014). Orthopedic physical assessment. 6th ed. Missouri: Elsevier inc & Saunders
44
 XI. REHABILITATION

SPECIAL TEST RULE OUT

- HEEL STRIKE TEST - HIP SCOUR TEST
- PATELLAR-PUBIC - PATRICK’S TEST
PERCUSSION SIGN - Anterior Labral Tear Test
(Flexion, Adduction, and
Internal Rotation [FADDIR]
Test)
- Gapping Test
- Thigh Thrust Test
- Gaenslen’s Test
Source: Magee, D.J. (2014). Orthopedic physical assessment. 6th ed. Missouri: Elsevier inc & Saunders
45
 PROBLEMS
XI. REHABILITATION

Intraoperative complications
- Malpositioning of the prosthetic components
- Femoral fracture
- Insufficient equalization of leg lengths
- Nerve injury

Early postoperative complications

- DVT
- Infection
- pneumonia
- dislocation of the prosthetic joint
Source: Kisner, C. & Colby, L.A. (2012). Therapeutic exercise foundations and techniques. 6th ed.
46 Philadelphia: F.A. Davis Company
 PROBLEMS
XI. REHABILITATION
Dislocation of the prosthetic joint
- mechanical loosening of either implant at the bone-
cement or boneimplant interface
- periprosthetic fracture
- polyethylene wear

Source: Kisner, C. & Colby, L.A. (2012). Therapeutic exercise foundations and techniques. 6th ed.
47 Philadelphia: F.A. Davis Company
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
48 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
49 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
50 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

The functional abilities deemed necessary for safe transition

home are defined by functional milestones:

1. Independent transfers.
2. Independent ambulation at least 30.5m (with crutches/walker)
3. Independence in going up and coming down stairs
4. Adherence to hip dislocation and weight bearing precautions.

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
51 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
52 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
53 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Outpatient rehabilitation is based on the surgeon’s

recommendation and the patient’s continued
functional limitations. It may be initiated as early as 4
to 6 weeks after surgery.

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
54 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 REHABILITATION
XI. REHABILITATION

Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
55 musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
 XI. REHABILITATION PRECAUTIONS

56 Source: Magee, D.J., Zachazewski J.E., & Quillen W.S. (2008). Pathology and intervention of
musculoskeletal rehabilitation. 2nd Ed. Missouri: Saunder and Elsevier.
CASE REPORT
TOTAL HIP REPLACEMENT

57
GENERAL INFORMATION
□ Name: G.L
□ Age: 65 y/o.
□ Sex: FEMALE
□ Address: BLK 1 LOT 3 Rising □
subdv. 88city
□ Civil Status: Married
□ Handedness ®
□ Occupation: Retired
□ Religion: Roman Catholic
□ Citizenship: Filipino
□ Nationality: Filipino
□ Date of Onset: Dec 31, 2018
□ Date of Consultation: Jan 1, 2019
ER Doctor: Dr. Hollie Days
□ Surgeon: Dr. Bucks Star
□ Physical Therapist: Dell Monte
□ Date of admission: Aug 1, 2019
□ Date of IE: Jan 4, 2019
□ Dx:
58
HISTORY OF PRESENT ILLNESS
A 68 y/o female with a history of previous falls walked into the dirty kitchen to
grab some condiments but then suddenly fell and landed on the lateral side of
her thigh due to the slippery floor and felt pain after the fall (PS:8/10) at
around 11:15pm Dec 31, 2018. Her grandson tried to help her to stand up but
she can’t get up due to pain and the loss of mobility on her R hip. The
grandson told the family about the incident and immediately rushed and
arrived at the Emergency Room exactly 12:01 am, Dr. H.D who was the doctor
present at that timr attended the patient who was complaining of untolerable
pain (PS: 8/10) and decided to give her analgesia before transferring the
patient to the CT scan table from her wheelchair that the staffs gave to her. CT
scan results showed a displaced femoral neck fracture, Dr. H.D then referred
the patient to Dr. B.S for the surgery using the Direct anterior approach with
uncemented fixation of her R hip on Jan 3, 2019. Post surgical rehabilitation
was then taken care of Dell Monte,RPT following the day after surgery.

59
ANCILLARY PROCEDURE:

PROCEDURE DATE RESULT

CT scan Jan1, 2019 CT scan results
showed a displaced
femoral neck fx

60
PMHx:

□ (+) Osteoporosis
□ (-)DM
□ (-)RA
□ (-) Obesity
□ (-) Cancer
□ (-) HTN
□ Hospitalization from 08/1/19 –
08/8/19

61
FMHx:

FATHER MOTHER

Osteoporosis (-) (+)

DM (-) (-)

HTN (-) (-)

CA (-) (-)

62
PSHx:

□ Type A personality
□ Sedentary lifestyle
□ Lives in a bungalow house
with husband and daughter
□ (-) Smoker
□ (-) Alcoholic

63
SUBJECTIVE

□ c/c: “Nung nadapa ako na pa - upo parang may

narinig ako na may nag crack tapos sobrang sakit
(PS:8/10) ng hita ko at tska hindi na rin ako
makatayo dahil di ko na rin ito maigalaw.”

□ PT Translation: “Pt. fell with the hip externally

rotated and heard a crack, Pt. was unable to stand
due to pain (PS:8/10) and the loss of mobility of
the R hip.”
64
OBJECTIVE
VS BEFORE AFTER
BP <120/80 mmHg <120/80 mmHg
RR 12 cpm 12 cpm
PR 80 bpm 80 bpm
T 37 ºC 37 ºC

□ Findings: All vital signs are all within normal range.

□ Significance: For baseline purposes and for precaution of dosage
of exercises

65
OBJECTIVE
□ (+) Surgical Scar on
□ OCULAR INSPECTION: ® proximal hip (3
□ Ambulatory aid c Walker cm lateral to the iliac
□ a/c/c crest boarder until it
□ Ectomorph approaches the ASIS
where it runs distally
□ (+) Swelling on ® proximal hip along the anterior
□ (+) Gait Deviation (See Gait ax) boarder of thigh for
□ (+) Postural Deviation 10cm)
□ (+) LLD
□ (-) Redness
□ (-) Deformity
66
OBJECTIVE
□ PALPATION:
□ (+) mm guarding during (R) Hip Flexion, Abduction, IR
□ (+) tenderness
□ (+) mm Spasm
□ (-) edema
□ (-) crepitus
□ (-) subluxation

67
OBJECTIVE
ROM:
□ all joints of (B) UE and LE are WNL except, actively and passively
done pain free, except for:
Motion Active Passive Normal Difference End-Feel
Active Passive
R HIP 1. 20º 1. 90 º 120 º 1. 100 º 30 º Empty due
FLEXION to mm
guarding

R HIP ABD. 1. 15 º 1. 30 º 1. 45 º 1. 30 º 1. 15 º Empty due

to mm
guarding

R HIP IR 20 º 30 º 45 º 1. 25 º 1. 15 º Empty due

to mm
guarding

68
OBJECTIVE

□ Findings: LOM on her (R) hip toward Flexion, Abduction, and IR

due to pain
□ Significance: Limitation of Motion 2° to pain that may limit the
patient’s ability on indepence of adl’s.

69
OBJECTIVE
MMT:
□ All muscles of (B) UE/LE are grossly graded 4-5/5 except for:
Muscle/ Muscle Group GRADE
(R) Hip Flexors 2/5
(R) Hip Abductors 2/5
(R) Hip Internal Rotators 2/5

□ Findings: Poor mm strength on ® Hip Flexors, Extensors, and

Internal Rotators
□ Significance: mm weakness 2º to pain that causes LOM and may
lead to being dependent on assistance throughout life.
70
OBJECTIVE

SENSORY Ax:
□ sensory testing device used: pin for pain, brush for light touch,
thumb for deep pressure.

□ Findings: 100% intact.

□ Significance: No nn affectation.

71
OBJECTIVE
DTRs:
GRADE INTERPRETATION
0 absent
1+ hyporeflexia
2+ normal
3+ hyperreflexia
4+ clonus

□ Findings: DTRs are normoreflexive.

□ Significance: Intact reflex arc.
72
OBJECTIVE
LEG-LENGTH MEASUREMENT:

□ LEG LENGTH MEASUREMENT (LLM):

□ True Leg Length Landmark: ASIS to medial malleolus
□ (R):36in (L):35in Difference: 1in
□ Significance: Normal True leg length
□ Apparent Leg Length Landmark: Umbilicus to medial malleolus
□ (R):35in (L): 33in Difference: 2in
□ Findings: (+) Functional leg length discrepancy
□ Significance: (+) LLD 2° muscle weakness and spasms.

73
OBJECTIVE
POSTURAL DEVIATION: Posterior View
Anterior View □ Head: aligned
□ Head: aligned □ Scapulae: Symmetrical
□ Mandible: Resting Position □ Pelvis: Tilted, Higher on ® Side
□ Shoulders: Level □ Knees: Popliteus is higher on ®
□ Rib cage: Symmetric Side
□ Pelvis: ® ASIS is higher □ Calcaneal: Normal Alignment
□ Hips: ® Hip is adducted and (L) hip
slightly abducted Findings: (+)Postural deviation on the
□ Knees: Straight pelvis
□ Ankle: ® Malleolus is slightly higher Significance: Pt. shows pelivic
asymmetry 2° weak ® Hip abductors

74
OBJECTIVE
GAIT Ax:
STANCE PHASE RIGHT LEFT SWING RIGHT LEFT
PHASE
HEEL STRIKE (+) (-)

FOOT FLAT (+) (+)

ACC Increased Increased
MIDSTANCE (+) (+)
MSW Increased Increased
HEEL OFF (+) (+)

TOE OFF (+) (+) DEC Increased Increased

□ Cadence: Not performed

75
OBJECTIVE
Stride Length:
□ Right: 56 inches
□ Left: 50 inches
□ Step length: 28 inches
□ Step width: 4 inches
□ Arm Swing: Decreased arm swing on Both upper extremity.

□ Findings: (+) Trendelnburg Gait

□ Significance: (+)Gait Deviation that is caused by Weak hip
abductors

76
OBJECTIVE
Funtional Analysis
□ This was not performed for the time being

ADL’S
□ Pt. demonstrates a need for maximal assistance as to
□ -self care
□ -bed mobility
□ -transfers
□ -ambulation

77
ASSESSMENT
□ Dx: Displaced Femoral neck fracture
□ PT Impression: Pt diagnosed of Displaced femoral neck fracture
was severely in pain (PS:8/10) after she had landed on her hip, Pt
was unable to stand up on her own 2° to pain and manifested
LOM during the incident.
□ Problem List
- Mm Weakness on ® Hip Flexors, Abuctors, Extensors, Internal
and External Rotators
- Pt. has difficulty on transfers and ambulation
- Restriction of motion due to 2° to pain (PS:4/10)
- LLD
78
STG:
□ Physical Therapist is able to prevent vascular and
pulmonary complications.
□ Physical Therapist is able to prevent postoperative
dislocation or subluxation of the operated hip.
□ Patient is able to regain active mobility and control of
the operated extremity.
□ Maintain a functional level of strength and muscular
endurance in the upper extremities and nonoperated
lower extremity.

79
LTG:

□ Patient is able to regain mm strength and endurance

□ Restore ROM
□ Improve Postural balance, stability and gait.

80
PLAN
PT Management:

- Patient and caregiver education about motion restrictions, safe bed

mobility, transfers, and precautions during other ADL.
- Ankle pumps x 30 reps x 1 set
- AAROM on ® Hip x 10 reps x 3 sets
- Isoms of Quads and Gluteals on ® Hip x 6 sh x 3 reps x 1 set
- Ice packs on ® Hip x 20 mins for pain relief
- Gait training

81
PLAN
HI

- AROM on ® Hip x 10 reps x 3 sets

- Theraband Exercise on ® Hip x 10 reps x 1 set
- Squats 10 reps x 1 set
- Walking 3 to 4 times a day
- Home safety education

82
😉 END

83