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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!!!