Hip-disorders:

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1 Prepared by - Dr. Md Nazrul islam, MBBS, M.Sc. Supervised by - Dr. Sk. Abbas uddin Ahmed MS (ortho), ao(basic), ao(spine). Presenting by - Dr. Golam Mahamud Suhash From - Department Of Orthopaedic & Traumatology, Shaheed Suhrawardy Medical College Hospital. Dhaka. Hip-disorders: RECENT ADVANCEMENTHip Surgery And Hip- Replacement CME Recent Advancement Hip Surgery And Hip-Replacement ON

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Recent Advancement Hip Surgery And Hip-Replacement Hip-disorders Recent Advancement Hip Surgery And Hip-Replacement 2

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Hip is the joint where your thigh bone meets your pelvis bone. Hips are very stable. When they are healthy, it takes great force to hurt them. Common Hip-disorders are- Strains Bursitis Dislocations Fractures Recent Advancement Hip Surgery And Hip-Replacement Over view 3

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Recent Advancement Hip Surgery And Hip-Replacement Contents: 4 Functions of Hip-joint Mechanisms Hip injury Most Common Types of Hip Injury- Epidemiology Anatomy of Hip-joint Pathophysiology of Hip-Injury Clinical features of Hip-Injury- Investigations Diagnosis Management Rehabilitations Complications Prognosis Of Hip-Replacement- Conclusions Total Hip Replacement at Shaheed Suhrawrdy Medical College Hopital-

Functions of Hip-joint : 

Functions of Hip-joint 5 Recent Advancement Hip Surgery And Hip-Replacement To provide stability for weight bearing- standing, walking & running. To allow mobility of the leg in space. To transmit the loads from the thigh and then to the lower limb.

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6 Direct Stress Femoral Neck fracture Inter-trochanteric fracture Repeated stress Degenerative joint disease (DJD) of the Hip Deformities Congenital dislocation of the Hip (CDH) / Developmental dysplasia of the Hip (DDH). Mechanisms Hip injury-

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Hip Strain is an overuse or injury that tears or stretches the muscle fibers. Most of the time, muscle strains in the hip area occur when a stretched muscle is forced to contract suddenly. A fall or direct blow to the muscle, overstretching and overuse can tear muscle fibers, resulting in a strain. 7 Recent Advancement Hip Surgery And Hip-Replacement Strains Most Common Types Of Hip Injury- Most Common Types Of Hip Injury-

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Bursa is a fluid filled sac that allows smooth motion between two uneven surfaces. Hip bursitis is a common problem that causes pain over the outside of the upper thigh. When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. 8 Recent Advancement Hip Surgery And Hip-Replacement Bursitis Most Common Types Of Hip Injury-

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Types of dislocation: Congenitical Acquired Anterior Central Posterior (90%) 9 Recent Advancement Hip Surgery And Hip-Replacement Most Common Types Of Hip Injury- Dislocations- HIP

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10 Dislocations AO/OTA Classification Most thorough. Best for reporting data, to allow comparison of patients from different studies. 30-D10 Anterior Hip Dislocation 30-D11 Posterior Hip Dislocation 30-D30 Obturator (Anterior-Inferior) Hip Dislocation Recent Advancement Hip Surgery And Hip-Replacement

Fractures : 

Fractures Fracture of Acetabular Component Acetabular fracture Central dislocation Fracture of Femoral Components. 1. Femoral  Neck fracture  (NOF),  2. Femoral head fracture 3. Slipped capital femoral epiphysis in children 4. Trochanteric fracture HIP can break at any age, but the great majority of hip fractures occur in people older than 65. . 11 Recent Advancement Hip Surgery And Hip-Replacement Most Common Types Of Hip Injury-

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Worldwide gender distribution of Hip Fracture Men: 4-5 per 1,000 Women: 8-10 per 1,000 Men: 30% Women: 70% Morbidity and Mortality Mortality 20% within 1 year Hip Fracture Men: 31% mortality in 1 year Women: 17% mortality in 1 year ADL assistance needed in 50% of Hip Fractures Long term care needed in 25% of Hip Fractures. Cooper (1992) Osteoporos Int 2:285-9 Forsen (1999) Osteoporos Int 10:73-8 Epidemiology 12 Recent Advancement Hip Surgery And Hip-Replacement

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13 Anatomy of Hip-joint Recent Advancement Hip Surgery And Hip-Replacement The hip joint is a ball and socket joint, formed by the head of the Femur (thigh bone) and the acetabulum of the pelvis. The dome-shaped head of the femur forms the ball, which fits snuggly into the concave socket of the acetabulum. The hip joint is a very sturdy joint, due to the tight fitting of the bones and the strong surrounding ligaments and muscles. Introduction to hip joint anatomy

Recent Advancement Hip Surgery And Hip-Replacement 14 Anatomy of Hip-joint Bones of the hip joint The hip joint capsule Ligaments of the hip joint Labrum of the hip joint Muscle Groups surrounding the hip joint. Neuro-vascular Components. Vital Components of Hip-joint -

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The ilium: This is the largest area of the hip bones. The ischium: The ischium consists of 2 broad curves of bone, one on each side, which lie below the ilium, The pubis: The pubis is the front-most area of the hip bones. It attaches to the ilium on the sides and the ischium on the bottom. Anatomy of Hip-joint Bones 15 Recent Advancement Hip Surgery And Hip-Replacement Hip bones -

Muscles Muscles which attach to or cover the hip joint: Gluteals.  Quadriceps- Iliopsoas. Hamstrings. Groin muscles. Ligaments. Iliofemoral ligament:  Pubofemoral ligament:  Ischiofemoral ligament: Muscles And Ligaments- 16 Recent Advancement Hip Surgery And Hip-Replacement

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17 Mainly by – Medial and lateral circumflex femoral arteries. AndDeep division of the superior gluteal arteryInferior gluteal arteryPosterior division of the obturator artery(Head of the femur ). Blood supply Recent Advancement Hip Surgery And Hip-Replacement Neurovascular Components-

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Recent Advancement Hip Surgery And Hip-Replacement 18 Femoral nerve - Via nerve to the rectus femoris muscle Obturator nerve - Via it’s anterior division. Sciatic nerve - Via the nerve to the quadratus femoris muscle. Superior gluteal nerve - Here the femoral, sciatic and oburator nerves also supply the knee joint, so hip disease may cause a refered pain to the hipjoint. Nerve supply Neurovascular Components-

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Recent Advancement Hip Surgery And Hip-Replacement 19 Age. The rate increases for people 65 and older. Gender. Women have two to three times as many hip fractures as men. Heredity. A family history of fractures in later life, particularly in Caucasians and Asians. A small-boned, slender body. Nutrition. A low calcium dietary intake or reduced ability to absorb calcium. Personal habits. Smoking or excessive alcohol use. Physical impairments. Physical frailty, arthritis, unsteady balance, and poor eyesight. Mental impairments. Senility, dementia, e.g., Alzheimer's disease. Weakness or dizziness from side effects of medication Pathophysiology of Hip-Injury Who is vulnerable to hip fracture?

Recent Advancement Hip Surgery And Hip-Replacement Shortened limb on Fracture side Hip externally rotated and abducted (But internally rotated and adducted in post. dislocation of hip). Tenderness to palpation over injured hip Limited range of motion Do not test ROM unless XRay normal Resisted passive range of motion 20 Signs - Clinical features of Hip-fracture(prox. Femur)

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21 Hip fractures usually are caused by a fall. If you fracture your hip, you may experience the following symptoms: Severe pain in your hip or pelvic area Bruising and/or swelling in your hip area Inability to put weight on your hip Difficulty walking The injured leg may look shorter than the other leg and may be turned outward. symptoms Recent Advancement Hip Surgery And Hip-Replacement Clinical features of Hip-Injury-

Investigations : 

22 Complete medical history Physical examination to assess hip mobility, strength, and alignment. Blood tests X-rays (radiographs) to determine the extent of damage or deformity in your hip. MRI / CT scan. Ultrasound scans Bone scans Biopsy The orthopaedic evaluation will typically include - Investigations Recent Advancement Hip Surgery And Hip-Replacement

Investigations : 

Investigations Recent Advancement Hip Surgery And Hip-Replacement 23 1. Blood tests. 2. Kidney, Liver tests. 3. Lungs, Heart and Neurological assessments. 1. Assessment of bone strength 2. Assessment of bone infection 3. Assessment of bone TB/ Carcinoma. 4. Assessment of metabolic/systemic bone diseases. Routine Pre-operative Investigations- Bone pathology specific Investigations-

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Recent Advancement Hip Surgery And Hip-Replacement Hip Xray Usually identifies Fracture and Dislocation Hip MRI (T1-weighted) Indicated for high suspicion despite normal XRay Test Sensitivity: 100% Does not require delay after injury Hip Bone Scan with Technetium Tc99m Polyphosphate Test Sensitivity: 98% Delay scan at least 72 hours after time of injury 24 Imaging MR Arthrogram MR Arthrogram An MRI may identify a hip fracture otherwise missed on plain X-ray.

Diagnosis : 

Diagnosis Recent Advancement Hip Surgery And Hip-Replacement 25 Subjective Assessment Pain localized in hip region Exaggerated gait pattern (limp) Increase in pain when weight barring Reduction in the degree of ROM As the degeneration of the joint worsen, individual may be awakened at night with pain Bone spurs may occur

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26 Objective Assessment Gait pattern – Adaptive walking pattern that reduces pressure on the affected side. Muscle atrophy – Muscles in affected area are not used as much due to pain, therefore, use-it-or-lose-it applies. Active Range Of Motion – Limited ROM, stiffness Passive ROM – End feels causes severe pain X-ray – clear degeneration of the bone MRI – determines underlying complications (e.g.avascular necrosis) Diagnosis Recent Advancement Hip Surgery And Hip-Replacement

Management : 

Management Recent Advancement Hip Surgery And Hip-Replacement Treatment for hip disorders may include- Medical- Rest, Medicines, Physical therapy Immobilization and/ or Reduction(dislocation) 27

Management : 

28 Surgical- Osteotomy ORIF HIP Resurfacing Hip replacement. Management

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29 Acetabular Component- Dysplasia, Impingement. Femoral Components. Common HIP Condition Which Requires Internal Fixation- Fixation Recent Advancement Hip Surgery And Hip-Replacement Femoral  Neck fracture  (NOF),  2. Femoral head fracture 3. Slipped capital femoral epiphysis in children 4. Trochanteric fracture

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30 HIP Resurfacing- Developed in late nineties in UK by Dr.Derek Mcminn Surface hip replacements Longevity of any primary THA cannot be predicted Revision remains an issue Young/active patient may outlive primary THA. Hip resurfacing extends continuum of care in young patients with hip disease Recent Advancement Hip Surgery And Hip-Replacement

Candidates for hip resurfacing : 

www.hipsurgery.in Candidates for hip resurfacing Young & active patients with hip arthritis or secondary osteo-arthritis Primary OA in young patients Avascular necrosis Ankylosing spondylitis Post traumatic arthritis DDH Slipped capital femoral epiphysis 31 Recent Advancement Hip Surgery And Hip-Replacement HIP Resurfacing

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32 Recent Advancement Hip Surgery And Hip-Replacement HIP Resurfacing Hip resurfacing- considerations and steps- Head of femur is sculpted and not chopped off to receive a cap or resurfaced. Socket is deepened and a new socket banged in Could survive for long term as bearings are made of metal on metal – Unknown at present Recovery is faster. Function is better.

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33 HIP REPLACEMENT Recent Advancement Hip Surgery And Hip-Replacement Alternative Names Hip arthroplasty; Total hip replacement; Hip hemiarthroplasty. Definition of Hip joint replacement: Hip joint replacement is surgery to replace all or part of the hip joint with an artificial joint. The artificial joint is called a prosthesis.

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34 Description: The artificial hip joint has 4 parts: A socket that replaces your old hip socket. The socket is usually made of metal. The liner fits inside the socket. It is usually plastic, but some surgeons are now trying other materials, like ceramic and metal. The liner allows the hip to move smoothly. A metal or ceramic ball that will replace the round head (top) of your thigh bone. A metal stem that is attached to the shaft of the bone to add stability to the joint. HIP REPLACEMENT

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35 Types of Hip Replacement Traditional (Conventional) Hip Replacement Traditional hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip. The muscles are split or detached from the hip, allowing the hip to be dislocated. Minimally Invasive Hip Replacement Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions (2 to 4 inch). Recent Advancement Hip Surgery And Hip-Replacement HIP REPLACEMENT

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Recent Advancement Hip Surgery And Hip-Replacement Rheumatoid Arthritis Secondary Osteoarthritis Ankylosing Spondylitis Old Perthes' disease Broken hip Bone tumor Avascular necrosis of the femoral head Fused Hip Joint. Hip conditions that frequently lead to total hip replacement are the following- 36 HIP REPLACEMENT

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37 Hip pain limits your everyday activities such as walking or bending. Hip pain continues while resting, either day or night. Stiffness in a hip limits your ability to move or lift your leg. You have little pain relief from anti-inflammatory drugs or glucosamine sulfate. You have harmful or unpleasant side effects from your hip medications. Other treatments such as physical therapy or the use of a gait aid such as a cane do not relieve hip pain. Benefit from hip replacement surgery if: Recent Advancement Hip Surgery And Hip-Replacement

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38 Recent Advancement Hip Surgery And Hip-Replacement

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39 Recent Advancement Hip Surgery And Hip-Replacement Intelligent Hip surgery

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Conventional Total Hip replacements : 

Conventional Total Hip replacements Introduced in 1960’s by Dr.John Charnley, an English Orthopedic surgeon. Upper end of the femur is resected consisting of the head and neck portion . Socket of the pelvic bone is deepened Prosthesis is implanted with bone cement. Metal articulates with High density polyetheylene. Risk of dislocation results in poor function Recovery takes upto three months 41 Recent Advancement Hip Surgery And Hip-Replacement

Minimally invasive Hip surgery - What is it? : 

Minimally invasive Hip surgery - What is it? Skin incisions are smaller than conventional surgery It is not Key hole or arthroscopic surgery Inside soft tissue dissection is less. More Bone, tendons, soft tissues are preserved 42 Recent Advancement Hip Surgery And Hip-Replacement

Difference Between Traditional and Minimally Invasive Hip Replacement Surgery- : 

Difference Between Traditional and Minimally Invasive Hip Replacement Surgery- Traditional Hip Replacement Surgery- Proven in clinical studies and successfully performed for decades Allows surgeon full visualization of operative area Larger incision/ scar (12-18 inches) More disruption of muscles and tissues May lead to more blood loss . May lead to a extendeded hospital stay/ recovery time Minimally Invasive Hip Replacement Surgery- Long-term effects and success are being studied Smaller incisions/ Scars (2-4 inches) Potentially less disruption of muscles and tissues May lead to less blood loss Potential for less postoperative pain May lead to a shortened hospital stay/ recovery time 43 Recent Advancement Hip Surgery And Hip-Replacement

Recent Advancement Hip Surgery And Hip-Replacement 44 PROSTHESIS  TYPE

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45 The major problems with standard hip replacements are: Wearing out of plastic sockets. Loosening of the bond between the implant and bone. In time the cement can crack, directly resulting in loosening. Secondly, the body reacts to minute fragments of cement, plastic or metal, and attempts to remove them, and also removes bone adjacent to the particles, leaving the bone structurally weakened. If the implant loosens, a second surgery may become necessary to reattach it. Recent Advancement Hip Surgery And Hip-Replacement Recent Advancement

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46 There has been much research into the loosening problem. This led to the development of the: Cementless Hip Replacement in which the surface of the metal parts is porous, and looks like coral. Bone can grow into the metal pores and bond the implant to the bone without the use of cement. The AML Total Hip Replacement (DePuy / Johnson & Johnson) is the most widely used cementless implant in the world, and has the longest track record (since 1978). Cement is still used with very soft bones, regardless of age. RECENT ADVANCEMENT Recent Advancement Hip Surgery And Hip-Replacement

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47 Technique: Total Hip Replacement Acetabular reaming Insertion of acetabular component Recent Advancement Hip Surgery And Hip-Replacement

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48 Technique: Total Hip Replacement Reaming/broaching of femoral component Insertion of femoral component Recent Advancement Hip Surgery And Hip-Replacement

Technique: Total Hip Replacement : 

49 Technique: Total Hip Replacement Femoral head impaction Final implant Recent Advancement Hip Surgery And Hip-Replacement

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What are the alternative operations? Arthroscopy Osteotomy Surface replacement Fusion (arthrodesis) of the hip Some alternative operations for avascular hip necrosis Core decompression Vascularized graft Hemiarthroplasty Resection arthroplasty - Girdlestone 50 Recent Advancement Hip Surgery And Hip-Replacement

Rehabilitations : 

Rehabilitations Recent Advancement Hip Surgery And Hip-Replacement 51 REHAB GOALS Get the patient up out of bed and moving (the fracture is painful, but the pt must get moving) pain is usually a symptom of stress on fx Begin functional activities Prevent DVTs Prevent inactivity.

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Recent Advancement Hip Surgery And Hip-Replacement 52 The Don'ts Don't cross your legs at the knees for at least 8 weeks. Don't bring your knee up higher than your hip. Don't lean forward while sitting or as you sit down. Don't try to pick up something on the floor while you are sitting. Don't turn your feet excessively inward or outward when you bend down. Don't reach down to pull up blankets when lying in bed. Don't bend at the waist beyond 90°. Don't stand pigeon-toed. Don't kneel on the knee on the unoperated leg (the good side). Don't use pain as a guide for what you may or may not do. The Dos Do keep the leg facing forward. Do keep the affected leg in front as you sit or stand. Do use a high kitchen or barstool in the kitchen. Do kneel on the knee on the operated leg (the bad side). Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Don't apply ice directly to the skin; use an ice pack or wrap it in a damp towel. Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towel for 15 to 20 minutes. Do cut back on your exercises if your muscles begin to ache, but don't stop doing them! Rehabilitations

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Recent Advancement Hip Surgery And Hip-Replacement 53 An appropriate and progressive rehab program should be started early in the treatment of patients with hip injuries. Several rehab techniques are available, none of which require expensive equipment or great time commitments. Selecting the best exercise approach for each patient’s hip problem is not difficult. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitation care. Rehabilitations

Complications : 

Complications Recent Advancement Hip Surgery And Hip-Replacement The most common hip problem that may arise soon after hip replacement surgery is hip dislocation. The most common later complication of hip replacement surgery is an inflammatory reaction Heterotopic bone formation (bone growth beyond the normal edges of bone). Leg length discrepancy which may be caused by the prosthesis or by weakness in the muscles of the hip Breakage of the prosthesis which may require an additional surgery for replacement Wound infection. 54

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55 Other (systemic) complications include: Blood clots in the deep veins of the leg (deep vein thrombosis or DVT) that can move to the lung and cause pulmonary embolism (PE) Urinary infection or difficulty with urination Pneumonia that may result from difficulty taking deep breaths and coughing after anesthesia. Complications

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56 Recent Advancement Hip Surgery And Hip-Replacement Complications-

Recent Advancement Hip Surgery And Hip-Replacement Failure rates for individual hip diseases 57

Prognosis Of Hip-Replacement- : 

Prognosis Of Hip-Replacement- 58 Hip replacement surgery results are usually excellent. Most or all of your pain and stiffness should go away. Some people may have problems with infection or loosening, or even dislocation, of the new hip joint. Over time -- sometimes as long as 20 years -- the artificial hip joint will loosen. A second replacement may be needed. Younger, more active, people may wear out parts of their new hip. It may need to be replaced before the artificial hip loosens. Outlook (Prognosis): Recent Advancement Hip Surgery And Hip-Replacement

Conclusions- : 

Conclusions- Recent Advancement Hip Surgery And Hip-Replacement 59 Next to Spine injury, Hip-joint is the most important issue in orthopedic surgery. Hip disorder/ injury needs throughout assessment before starting treatment. Treatment strategy/ plan is changing rapidly with the advent of new research/ investigation procedures/ biomaterial. Hip Replacement surgery in orthopedics' changing our life with rapidly increasing success. Successful Hip replacement surgery in orthopedics’ can play a pivotal role in medical science.

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Name Of Operation: Total Hip Replacement. Patient Name: Md Sayoeb Ahmed,Age:27 ys. Indication: Rheumatoid Arthritis ( Lt. Hip ). Team Leader: Associate Professor Dr. Sheikh Abbasuddin Team Members: Associate Professor Dr.Paritosh Ch.Debenath Assistant Professor Kazi Shamimuzzaman Dr. Md Nazrul Islam, Resident Surgeon. Assistant Professor Md. Hasan Masud (NITOR), Dr Golam Mahamud Susash ( Suhash ) . Anesthesiologist : Dr. Julfiqar Bhai(Consultant). Dr. Nizam Bhai (Consultant). & Dr. Shamim-Ara (Apa), Dr. Nizam Bhai And Dr. Anwar Hossain Venue: Shaheed Suhrawardy Medical college Hospital, Department Of Orthopaedics & Traumatology. 60 Recent Advancement Hip Surgery And Hip-Replacement “Total Hip Replacement” At- Shaheed Suhrawrdy Medical College Hopital-

“Total Hip Replacement” done at Shaheed Suhrawardy Medical College Hospital,December-2010”. : 

61 Recent Advancement Hip Surgery And Hip-Replacement “Total Hip Replacement” done at Shaheed Suhrawardy Medical College Hospital,December-2010”. Department of Orthopadic & Traumatology.

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62 Recent Advancement Hip Surgery And Hip-Replacement “Total Hip Replacement” At- Shaheed Suhrawrdy Medical College Hopital-2010

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Recent Advancement Hip Surgery And Hip-Replacement 63 Associate Professor Dr. Sheikh Abbasuddin

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From- Department Of Orthopedics’ & Traumatology Shaheed Suhrawardy Medical College Hospital. Recent Advancement Hip Surgery And Hip-Replacement Mobile Hip, Mobile Man. Have a Healthy Hip with Fruitful Life. 64

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65 Associate Prof. Dr. P. C. Debenath Associate Prof. Dr. Sheikh Abbas Uddin. Associate Prof. Dr. Ziaul Haq Associate Prof. Dr. Shamimul Haq Associate Prof. Dr. Monowarul Islam Associate Surgeon Dr. Md. Aminur Rahman Assistant Prof. Dr. Kazi Shamimuzzaman Assistant Prof. Dr. A T M Bahar Uddin Dr. Abdul Hannan Mr. Anisul Haque Khandaker (Incepta). & Dr. Md Nazrul Islam Resident Surgeon, Department of Orthopedic & Traumatology. Shaheed Suhrawardy Medical College Hospital. Sponsored By- Incepta Pharmaceuticals Ltd. Bangladesh. Special Thanks Are Due To- Recent Advancement Hip Surgery And Hip-Replacement

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