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Average 3.8 of 25 Ratings
A 66-year-old female underwent a surgical procedure 6 weeks ago, and video A demonstrates her gait during ambulation. Based on her gait pattern, which reconstructive procedure did the patient most likely have?
Right total hip arthroplasty through Smith-Petersen approach
Left total hip arthroplasty through Smith-Petersen approach
Left total hip arthroplasty through modified Hardinge approach
Right total hip arthroplasty through modified Hardinge approach
Left L2-L3 decompression foraminotomy
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The video demonstrates a left sided Trendelenberg gait resulting from left sided gluteus medius weakness. Left-sided abductor muscle weakness is most likely found in the setting of a left total hip arthroplasty performed through a lateral approach, of the options listed.
Abductor weakness will lead to an apparent leg length discrepancy with the left side feeling longer to the patient.
Maloney and Keeney note that most leg length discrepancies that are less than 1 centimeter are well tolerated by the patient. However, they also discuss that patient dissatisfaction with leg-length discrepancies after THA is the most common reason for litigation against orthopaedic surgeon.
Clark et al present a Level 5 review describing the differences between true and apparent leg length discrepancies. Increasing femoral neck length and not fully seating the femoral stem will lead to a true leg lengthening on the operative side.
Maloney WJ, Keeney JA.
J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. PMID: 15190563 (Link to Abstract)
Maloney, JARTHO 2004
Clark CR, Huddleston HD, Schoch EP 3rd, Thomas BJ.
J Am Acad Orthop Surg. 2006 Jan;14(1):38-45. PMID: 16394166 (Link to Abstract)
Clark, JAAOS 2006
Please rate question.
Average 3.0 of 31 Ratings
In a modified Hardinge (lateral) approach to the hip, what structure limits the proximal extent of the gluteus medius split?
Superior gluteal nerve
Inferior gluteal nerve
The superior gluteal nerve enters the deep surface of the gluteus medius approximately 5 cm proximal to the tip of the greater trochanter. Splitting the muscle, as in the Hardinge approach, has been reported to cause injury to this nerve if the split is carried above 5 cm. A simple tag suture can be placed at this level to prevent propogation of the split inadvertently during surgery.
Average 4.0 of 21 Ratings
Which of the following approaches for total hip arthroplasty is reported to have the lowest prosthetic dislocation rate?
Posterior approach with posterior soft tissue repair
Anterolateral (Watson Jones)
Direct lateral (Hardinge)
Posterior approach without posterior soft tissue repair
The direct lateral (Hardinge) approach has been cited to have the lowest associated dislocation rate of the options provided. The metanalysis by Masonis and Bourne found a dislocation rate for 14 studies involving 13000 total hips was 1.27% for the transtrochanteric approach, 3.23% for the posterior approach (3.95% without posterior repair and 2.03% with posterior repair), 2.18% for the anterolateral approach, and 0.55% for the direct lateral approach. Eight studies involving 2455 primary total hip arthroplasties evaluated postoperative limp. However, the article also found that the incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to 16% for patients who had the posterior approach. The article by Kwon et al found the lowest dislocation rate with direct lateral (0.43%) followed by anteroalateral (0.7%) and posterior with soft tissue repair (1.01%). The article by Farrell et al reviewed 27,004 patients and found the use of a posterior approach (p = 0.032) to be associated with a significantly increased odds ratio for the development of a postoperative motor nerve palsy.
Masonis JL, Bourne RB.
Clin Orthop Relat Res. 2002 Dec;(405):46-53. PMID: 12461355 (Link to Abstract)
Masonis, CORR 2002
Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ
Clin. Orthop. Relat. Res.. 2006 Jun;447:34-8. PMID: 16741471 (Link to Abstract)
Kwon, CORR 2006
Farrell CM, Springer BD, Haidukewych GJ, Morrey BF
J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID: 16322610 (Link to Abstract)
Farrell, JBJS 2005
Average 3.0 of 22 Ratings
Which of the following describes the internervous plane of the direct lateral approach to the hip?
Between femoral nerve and superior gluteal nerve
Between superior gluteal nerve and inferior gluteal nerve
Between superior gluteal nerve and sciatic nerve
No true internervous plane as the dissection splits a muscle innervated by the superior gluteal nerve
No true internervous plane as the dissection splits a muscle innervated by the inferior gluteal nerve
The direct lateral approach (Hardinge) splits the fibers of the gluteus medius which is innervated by the superior gluteal nerve. With this approach, there is no true internervous plane. After incising the fascia lata, the fibers of the gluteus medius are split as are the fibers of the vastus lateralis. The transverse branch of the lateral circumflex artery is often cut as the vastus lateralis is mobilized and must be cauterized during the dissection.
The anterior approach employs the interval between the sartorius/rectus femoris (femoral nerve) and TFL/gluteus medius (superior gluteal nerve).
The posterior approach utilizes the interval between the gluteus maximus (inferior gluteal nerve) and the gluteus medius (superior gluteal nerve). No true internervous plane exists with this approach as the gluteus maximus is split in the line of its fibers and it is supplied by the inferior gluteal nerve. However, the muscle is not typically denervated if one keeps the split less than 5cm proximal to the tip of the greater trochanter, as this theoretically limits damage to the inferior gluteal nerve.