Case Study: Right Hip Coxa Plana Management

in a 56-year-old male by Total Hip Replacement

A 56-year-old male presented to our office with complaints of a worsening pain of the right hip with associated limp. The patient explained that he has had this pain since he was a child and he could live with it, but it has gotten worse. The pain was so unbearable that he had to go to the hospital and they told him there was nothing more they can do, but perform surgery.

The pain was associated with a limp and a lurch. He stated he used a shoe raise on the right side to avoid the limp. He felt his right leg was shorter than the left one. The patient stated he was able to sit, squat and sit cross-legged before but recently over the past year he was unable to do so.

The patient doesn’t recall the initial onset of the pain but denied any history of trauma. The limp was first noticed by his parents when he was in Columbia. He was managed conservatively for pain and limp in the form of traction and splint.

He denied any childhood infection/discharge from the right hip. He also denied any childhood endocrine disease or a history of tuberculosis.

The patient tried conservative management in the past year in the form of physical therapy and pain medications. The pain was located in the right groin radiating to the knee anteriorly. The pain was worse with walking and better with rest. Limping increased as the intensity of pain increased and he used a cane for ambulation.

The patient denies any family history of hip disease associated with limping and pain. He was currently on disability. The patient has had two arthroscopic surgery on both shoulders due to a work accident. The patient has no known allergies or is taking any medications.

On his physical examination, his gait was bipedal, antalgic, steady, unassisted with a lurch towards the right side. There was a presence of mild functional scoliosis with convexity towards the right side. Scoliosis disappeared on sitting or bending forward (Adam’s test).

There was no exaggeration of lumbar lordosis. The right anterior superior iliac spine was at a higher level than the left. On squaring the pelvis, both the apparent and true shortening were equal. There was no coronal or sagittal plane deformity. The rotational movements were restricted due to pain.

There was no distal neurological deficit. The bilateral lower extremity pulses were good volume and comparable. The skin overlying the hip joint was normal with no scar or sinus. There was no fullness of scarpa’s triangle and three digit palpation of hip joint revealed the right greater trochanter higher than the left side.

There was no broadening or thickening of the trochanter. Telescopy was negative and there was no abnormal bony mass in the right gluteal region. Tenderness was present along the right anterior joint line. There were no enlarged lymph nodes in the inguinal region.

Preoperative X-ray showing the AP view of the pelvis with both hip joints

Preoperative X-ray showing the AP view of the pelvis with both hip joints

AP and lateral views of the right hip joint AP and lateral views of the right hip joint - img 2

AP and lateral views of the right hip joint

Imaging revealed markedly deformed right femoral head and impacted the femoral neck. There were severe degenerative changes of the right hip.

Considering the DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining informed consent,imaging and physical examination, the patient was advised surgical management for the squeal of coxa plana. He was advised about total hip replacement. Risks, benefits, and alternatives were discussed with him at length. He agreed to go ahead with the procedure.

IMPLANTS USED: Restoration modular stem 195-mm with a 15-mm diameter with a constrained liner with a 22.2-mm femoral head with proximal body 19-mm plus 0.

Signing the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient as well as with the family prior to the procedure. The patient understands the significantly increased risk of orthopedic complications because of the complexity of the primary hip replacement that he is undergoing.

The patient was brought to the operating room and was definitively positioned with the right hip up and the right hip was then draped and prepped in the usual sterile manner. A curved incision centered over the greater trochanter was used for the arthrotomy. Skin and subcutaneous tissues were incised.

Fascia was then divided. The posterior soft tissue structures were then taken down and tagged for future repair. The incision was extended distally for the release of the gluteus tendon. The hip was significantly tight and significant tendon releases had to be done for exposure of the acetabulum and for anterior translation of the femur.

The hip was then dislocated. Lesser trochanter to the center measurement was taken and was compared to the preoperative planning. The head was then resected. Attention was then turned towards the acetabulum. A significant superior dissection was needed for exposure of the acetabulum.

The reflected head of the rectus femoris was incised for anterior translation of the femur. The acetabulum was exposed. Remainder of the labrum was then debrided. The acetabulum was sequentially reamed. The final shell was then placed into position in the correct abduction and anteversion. A liner was then placed onto the shell. Attention was then turned towards the femur.

The femoral resection was performed before for exposure of the acetabulum and the femur was reamed for placement of the restoration modular stem. The distal stem was then placed into position after reaming. The proximal reaming was then performed and the proximal body was then placed into position. The head was placed over the body. Lesser trochanter to center distance was then taken.

An attempt was made to lessen the hip by doing adequate releases. The hip was then attempted to be reduced. When trialing, it was found that the hip was dislocating posteriorly. This was accounted for despite the releases and that the releases would be closed at the end of the procedure.

The hip was dislocated. The anteversion of the proximal body was increased and the reduction was attempted again. The hip was still unstable. It was decided to do a constrained liner. The hip was dislocated. Attention was then turned towards the cup, then the liner was removed.

The constrained liner was then placed into position. The head for the constrained liner was then placed over the stem. The stem was then articulated with the constrained liner. The hip was then trialed again and the hip was stable.

Thorough lavage was given. Posterior soft tissue structures were then tacked with the greater trochanter through transosseous tunnels. The release was closed. The fascia was closed with Ethibond and #1 Vicryl. Cutaneous tissues were closed with O Vicryl.

Subcuticular tissues were closed with 2-0 Vicryl. The skin was closed with staples. Sterile dressing was applied over the wound. The patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray showing AP view of the pelvisPostoperative X-ray showing AP view of the pelvis - img 2

Postoperative X-ray showing AP view of the pelvis.

The recovery of the patient was unremarkable. He was started on aspirin 325mg BID for deep vein thrombosis prophylaxis. The pain was managed with medications. Hip precautions were explained to the patient. Weight-bearing was allowed as tolerated. Postoperatively there was no neurological deficit in bilateral lower extremities.

He was advised physical therapy focusing on gait training, fall prevention, muscle strengthening, range of motion and home safety. The sutures were removed uneventfully.

The three months post-surgery follow up demonstrated good pain control. The aspirin was discontinued and the patient was advised to wean off the hip precautions gradually. He follows up regularly.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:28 23 May 22
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19:54 16 May 22
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00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
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23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
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19:54 05 May 22
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20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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03:25 09 Apr 22
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22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
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16:06 01 Apr 22
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14:53 03 Mar 22
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Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
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21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
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18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
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17:26 17 Nov 20
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16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.