Difficult primary hip replacement - Step by Step Guide for THR

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Dr VAIBHAV BAGARIAJoint Replacement Surgeon

Sir HN Reliance Foundation HospitalMumbai, India

Uncomplicating Complications: Your First Difficult Hip

What Constitutes a difficult Primary?

⬥ Protrusio Hip

⬥ Dysplastic Hip

⬥ Failed Osteosynthesis/ Bipolar

⬥ Ankylosed Hip

⬥ Fracture Acetabulum

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Key points

⬥ Implant Selection

⬥ Approach

⬥ Techniques

⬥ Anticipating complications

⬥ Post Operative Care

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GOAL

• Bio-mechanically sound, stable hip joint with restoration to normal centre of rotation of femoral head

Restoring Hip Biomechanics

Restoring Hip Biomechanics

Restoring Femur Biomechanics

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IMPLANT SELECTION

IMPLANT SELECTION

• Patients Condition

• Anticipated Longevity & Level of Activity

• Bone Quality & Dimensions

• Ready availability of Implants

• Experience of the Surgeon

General Tips -Implant Selection

• Have all inventory -‘Overprepare’

• Remember ‘Bail Out Buddies’ talk

• Hedge your bets: Involve different Co.

• Try Innovation but be conservative

• Check Instrumentation a day prior yourself!

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Different Approach

Approach Consideration -Tips

⬥ Every Approach - own pros an Cons

⬥ Choose - one that you are trained in

⬥ Approach should help in majority!

⬥ In short Choose Posterior approach

⬥ However do not be ‘dogamatic’

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Charnley: Anterolateral approach; Supine: Troch Osteotomy

Amstutz: Anterolateral, Lateral; Troch Ostotomy

Muller: Anterolateral, Lateral, Release anterior Abductors

Hardinge direct lateral: Muscle Splitting G Medius & Min

Posterolateral: Cut Rotators, lateral, Posterior dislocate

Approaches

Dysplastic Hips - Fact Sheet

⬥ Like a revision scenario

⬥ Native Acetabulum - Shallow, Abducted & Anteverted

⬥ Adaptive Changes - Hyper lordosis, Adduction contracture & LLD

⬥ Risk of component dislocation high

Known the anatomy & Pathology

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Dysplasia - Acetabular side

⬥ Restore  Centre  of  Rotation  ⬥ Un-­‐cemented  Fixation  ⬥ In  Subluxation  -­‐  Slight  medialization  ⬥ In  Low  hip  dislocation-­‐  Socket  uncoverage  to  

be  tackled  with  femoral  head  autograft  augmentation  

⬥ High  Dislocation:  Small  un-­‐cemented  without  graft  is  usually  obtained  or  High  Hip  centre  

⬥ Medial  Wall  fracture  Technique

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Technical Consideration for femur in DDH

⬥ Significant ante version up to 40 - warrants derotation osteotomy at subtroch level

⬥ Narrow canal ⬥ Previous Osteotomies? ⬥ Short Femoral Neck ⬥ LLD ⬥ Femoral Shortening: Carried out as

step cut or inverted Y subtroachanteric osteotomy

Femoral Side - Implant Selection

⬥ Cementless Modular Stem

⬥ Long stem

⬥ Height & Offset options

⬥ Calcar options

⬥ Sleeve - ? HA Coated

⬥ Keep wires ready for osteotomy

Osteotomy

⬥ Identify the need

⬥ Just Shortening or angular correction or rotational correction - usually combination

⬥ Step Cut/ ( Valgus Subtrochanteric) Schanz osteotomy

⬥ Fixation Wires and SROM stem

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Technical Consideration

⬥ Secure distal fit, Intimate proximal Fit

⬥ Optimise Version, Offset

⬥ Optimise Length - Based on Osteotomy & Trialing

⬥ Choose appropriate Head Size

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Protrusio Hip -Key facts

⬥ Head Medial to Ilioischial Line

⬥ Plan: restoration of offset both acetabular & Femoral

⬥ Primary defect is medial acetabular defect - managed by Head graft

Protrusio - technique

⬥ Surgical Exposure not to be taken for granted

Options for Exposure: ⬥ Controlled Dislocation with Hook

⬥ Insitu Neck Osteotomy

⬥ Trochanteric Osteotomy followed by neck osteotomy

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Bone Hook technique

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Insitu Osteotomy

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Morselized Graft for Medial defect

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Restore lateral Offset - Prevent Impingement

Neck with Liner

Neck with Acetabulum

Bone to Bone ( Trochanter with Pelvis)

Protrusio - 3 key Points

Controlled Dislocation

Build Medial Wall

Restore Lateral Offset

Ankylosed hip - Facts

⬥ Anesthesia: Upper Airway issue & PFT

⬥ Preoperative Orthopedic Considerations

⬥ Exposure Issues

⬥ Implant Issues

Ortho Assesment - Ank Spond

⬥ Spinal Involvement: Fusion/ Anderson’s Lesion

⬥ Pelvic Obliquity

⬥ LLD; Opposite Hip, Both Knees

⬥ Integrity of Sciatic Nerve

Pre operative consideration

⬥ Templating is of paramount importance

⬥ MTx is fine

⬥ Anti TNF stop

⬥ Spinal Osteotomy before Hip???

Key Issues

⬥ Positioning

⬥ Exposure & Adequate Releases

⬥ Neck Cut

⬥ Joint Line identification & Correct Acetabular positioning

⬥ Post op HO

Key Tips

⬥ Positioning: Be present yourself/ Opp Hip and Spine

⬥ In case of external rotation fixed deformity, identifying neck may be difficult.

⬥ Can go anterior to neck and identify the structure. May need to sacrifice acetabular post wall & do osteotomy

Identifying Joint line

⬥ Insitu reaming

⬥ Foveal soft tissue

⬥ Incomplete grey ossifying cartilage

⬥ Intraoperative flurosocpy

Acetabular Component positioning

⬥ Remember Kyphotic Spine makes them hyper extend & Pelvic Obliquity

⬥ Malpositioning -> Anterior dislocation

⬥ For each 10° of sagittal pelvic malrotation above 20°, the cup position should be modified so that it is 5° less inclined and anteverted

Adequate Soft tissue Release - Ank Spond

⬥ Adductor Tenotomy

⬥ G Max release

⬥ Illiopsoas tenotomy

⬥ Anterior capsule release

⬥ Do not forget over friend ‘Sciatic Nerve’

Primary Hip for Acetabular fracture

⬥ Should be done for right Indication

⬥ Reduce and Fix well: Posterior column Integrity is critical

⬥ Use TM cup - multi holed ( Revision Shell)

⬥ For Large Bone Defect - Consider Cages

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Post Operative Care

Do not Forget:

Check X Ray

Limb Positioning

DVT

Mobilization Schedules

HO Prevention

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Uncomplicate: Organise Your thoughts

Preoperative Planning : Well begun is half done

Inventory: Be liberal in ordering

Exposure: Comfort is a priority

Biomechanics: Hip Surgery is understanding mechanics

Remain Cool, Calculated & Finally…

TAKE HOME MESSAGE

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Un-complicate Complications!!!