Path total hip replacement by bose


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Path total hip replacement by bose

  1. 1. PATH™<br />“Percuntaneous Assisted Total Hip Arthroplasty”<br />
  2. 2. What is PATH®?<br />PATH is an acronym that stands for Percutaneous Assisted Total Hip<br />Why would a surgeon want to perform the PATH technique?<br />Benefits include<br />Tissue Sparing – that minimizes functional tissue trauma that allows quick patient recovery<br />Less Blood loss<br />Less Pain medication<br />Piriformis Release only technique that saves short external rotators <br />What does all this mean for the patient?<br />Quicker recovery and return to functional mobility<br />
  3. 3. Why do MIS or TS techniques?(Minimally Invasive or Tissue Sparing)<br /> To minimize functional tissue trauma for immediate post-op mobility!! <br />
  4. 4. What are the benefits for the Patient?<br />No blood donation<br />No blood transfusion<br />Reduces the risk of catching an infectious disease<br />More functioning tissue for immediate post-op mobility<br />Short external rotators spared<br />Abductors (medius and minimus) are spared<br />Piriformis release only<br />Reduced dislocation rate<br />Quicker rehabilitation<br />Quicker release from hospital<br />Shorter recovery back to an active lifestyle<br />
  5. 5. Pain Management Protocol<br />Medication Regimen for PATH® MIS Study<br />Pre Op Hct and Hgb<br />2 hours Pre operative<br />Oxycontin 10 mg. P.O.<br />Celebrex 200 mg. P.O.<br />Tylenol 1 gram P.O.<br />General, spinal or epidural anesthesia can be utilized<br />Injection # 1: Into capsule and greater trochanter <br />Marcaine 30cc 0.5% (.25% each hip for bilateral cases)<br />Depo Medrol 80 mg *not in diabetics, immune-compromised or history of infection<br />Toradol 30 mg<br />Injection #2:*change to a second syringe and needle<br />SQ: Marcaine 20 to 30 cc 0.5 % (0.25% each hip for bilateral) <br />Marcaine 30 cc ½ %<br />Post Operative medications may be offered to patient as needed and as tolerated post operative for 48 to 72 hours:<br />Oxycontin 10mg-20mg Bid P.O.<br />Oxycodone 5mg PO Q. 2 hrs<br />Celebrex 200 mg PO BID<br />Tylenol 1 gram 6AM, Noon, 6 PM P.O.<br />Morphine Sulfate or Dilaudid as needed I.M. <br />No Drain <br />Mobilize Patient 4-6 hours weight bearing as tolerated<br />
  6. 6. A-Class™ Advanced Metal<br />with <br />BFH® Technology<br />
  7. 7. A-Class™ Advanced Metal<br />A-Class Advanced Metal innovation is a patent-pending process that is the solution to the reduction of wear and potentially the reduction of metal ions.<br />
  8. 8. A-Class™ SUPERIOR PRODUCT<br />Reduction of wear<br />90% reduction in initial (run-in) wear<br />68% reduction in lifetime wear of the implant<br />
  9. 9. Run-In versus Steady State Wear<br />Run-In: Surface carbides dislodged, 3rd-body abrasion, high wear rate<br />Steady state: High polish, large contact area, smooth surface, low wear rate<br />New Implant<br />Run-In Wear<br />Steady State<br />
  10. 10. A-Class™ SUPERIOR PRODUCT<br />Optimized Bearing System<br />Surface Hardness<br />Component Clearances<br />Sphericity<br />Surface Finish<br />Surface Velocity<br />
  11. 11. Optimized Bearing – Key Points<br />Surface Hardness<br />The femoral head is responsible for 80-95% of the wear in a hip bearing system.<br />The differential hardness between the head and the cup reduces metal wear. (the head is harder than the cup)<br />Surface Finish<br />Extremely tight tolerance promotes a reduction in metal wear.<br />Surface Velocity<br />Increased head size creates increased surface velocity.<br />Greater Surface Velocity = Greater Fluid Film Separation<br />Increased fluid film separation decreases metal wear.<br />
  12. 12. A-Class™ Advanced Metal Comparison(Tested under different conditions)<br />
  13. 13. A-Class™ SUPERIOR PRODUCT<br />Advanced Metal with BFH™ Technology<br />Reduction of dislocation<br />Increased range of motion<br />Increased jump distance<br />
  14. 14. A-Class™ SUPERIOR PRODUCT<br />
  15. 15. A-Class™ SUPERIOR PRODUCT<br />
  16. 16. A-Class™ SUPERIOR PRODUCT<br />An increase of 9.3 mm in jump distance from 36mm to 56mm heads.<br />A range of motion that is substantially greater than the typical competitor’s 130° to 135° range of motion for smaller diameter heads.<br />WMT’s range of motion is 150° to 165 °<br />
  17. 17. A-Class™ EASE OF USE<br />Multiple BFH® Technology head sizes<br />36mm – 56mm<br />Long, medium, and short BFH® Technology neck options<br />Long = +3.5mm<br />Medium = 0mm<br />Short = -3.5mm<br />Multiple PROFEMUR® stem options<br />
  18. 18. A-Class™ EASE OF USE<br />Multiple cup options provide<br />Intraoperative flexibility<br />6mm HA Cup with BFH®<br />6mm Cup<br />10mm Cup<br />6mm Spiked Cup<br />14mm SUPER-Fix™<br />
  19. 19. A-Class™ INNOVATION<br />A-Class™ Advanced Metal<br />BFH® Technology<br />Modular Necks – optimal restoration of normal hip biomechanics<br />Leg length<br />Varus, Valgus<br />Anteversion, Retroversion<br />Your Philosophy,<br />Our Modular Necks.<br />
  20. 20. Patient Positioning<br />
  21. 21. Peg is positioned proximal to the sacrum<br />
  22. 22. Final peg is positioned on lower chest<br />
  23. 23. Preliminary leg length is checked using relative knee height<br />
  24. 24. Move patient <br />anteriorly on table<br />to permit <br />maximum adduction<br />
  25. 25. Pre-operative Planning<br />
  26. 26. Pre-op X-ray evaluation<br />
  27. 27. Surgical TechniqueHip Exposure<br />
  28. 28. Initial Incision<br />Place the hip in 20 to 30 degrees of flexion<br />Foot resting on Mayo to facilitate maximum internal rotation<br />Internal rotation will facilitate maximum exposure of piriformis and conjoined tendon<br />Outline the greater Trochanter<br />Mark the incision posterior to the corner of the greater Trochanter, overlapping 1cm and extending obliquely 30º to 50º to the axis of the patient<br />
  29. 29. Expose the fascia over the gluteus maximus<br />Cobb is used to tease apart gluteus maximus muscle fibers <br />ANT<br />POST<br />
  30. 30. A cobb elevator separates the muscle for reduced trauma<br />Deeper dissection is continued proximal and posterior to the greater Trochanter<br />Try not to disturb the Iliotibial band/tensor<br />
  31. 31. The piriformis tendon is palpated<br />On some occasions the piriformis is difficult to identify<br />Internally rotate the leg for help identification of the piriformis<br />The tip of the greater Trochanter should also be noted<br />
  32. 32. The piriformis tendon is released<br />Place blunt Hohmann just above piriformis tendon – deep to the capsular minimus muscle<br />Then release piriformis as close to the attachment of the greater Trochanter as possible<br />Preserve maximum piriformis length<br />Hohmann Retractor<br />
  33. 33. Capsular incision<br />Continue to release soft tissues under piriformis to access the capsule<br />After the Piriformis is released a J shaped capusular incision is made<br />Make the capsular incision parallel to the neck axis and obturator internus tendon <br />Intertrochanteric attachments are released<br />Anterior<br />I<br />J<br />Posterior<br />
  34. 34. The hip is adducted, flexed, and maximally internally rotated to dislocate the head<br />An anterior acetabulum retractor is placed along inferior neck<br />Hohmann is placed on superior neck<br />The hip is in 45º of flexion and 60º-70º of internal rotation for neck resection<br />The neck is resected<br />Anterior Acetabular Retractor<br />HEAD<br />FOOT<br />
  35. 35. Neck Resection<br />Penetrate the anterior cortex to center of the femoral neck with oscillating saw<br />Complete cut with reciprocating saw to minimize soft tissue damage<br />
  36. 36. A schantz screw is threaded into the femoral head and used to extract the femoral head<br />
  37. 37. Retractor positioning for acetabular exposure<br />Return to approximately 30º flexion, 20º adduction and approximately 30º internal rotation<br />Anterior retractor is placed on anterior rim<br />This retractor should lever on the tip of the greater Trochanter and anterior rim of the acetabulum<br />Anterior Act. Retractor<br />Superior Pin<br />Anterior Rim<br />
  38. 38. PINPOINT™ retractor placement<br />PINPOINT™ Posterior Acetabular Retractor is placed posteriorly on the ischium between the capsule and labrum<br />
  39. 39. PINPOINT™ retractor placement<br />Insert two Steinmann pins to hold the PINPOINT™ retractor in place<br />Complete the removal of the labrum<br />Superior<br />Posterior<br />
  40. 40. PINPOINT™ Retractor & Pins are secured to the ischium<br />SUPERIOR<br />POSTERIOR<br />
  41. 41. Conventional reamers have angular constraints preventing optimal bone preparation<br />
  42. 42. Percutaneous Portal Hole Location is Determined<br />Find femur and mark with pen<br />Acetabulum Alignment guide should be placed in main incision into socket<br />The handle should be perpendicular to the table<br />Abduction angle is approximately 40º to 45º when alignment guide is straight up out of the wound<br />Cannula should be loaded on the Trocar / cannula inserter<br />Mark entrance point and make initial stab with scalpel with #11<br />Sharp Trocar<br />External<br />Alignment <br />Guide<br />FOOT<br />HEAD<br />
  43. 43. Cannula Placement<br />Trocar is removed and cannula is left in the incision<br />Superior<br />Cannula<br />
  44. 44. Cannula location is behind the femur<br />HEAD<br />Anterior<br />FEMUR<br />Posterior<br />FOOT<br />
  45. 45. Reaming the Acetabulum<br />
  46. 46. Reamer basket is introduced through main incision<br />HEAD<br />FOOT<br />
  47. 47. Reaming begins medially to remove any articular cartilage<br />Direct visualization to the acetabulum<br />
  48. 48. Abducting (how much?) the leg allows medialization<br />FOOT<br />
  49. 49. Reaming at a 40 to 45 degree angle for final socket sizing<br />HEAD<br />FOOT<br />
  50. 50. Cup Placement<br />
  51. 51. Conventional impactors prevent optimal implant positioning<br />
  52. 52. Acetabular component is introduce in-line with incision (just like reamers)<br />
  53. 53. Insertion is parallel to the incision then rotated into the acetabulum<br />
  54. 54. Rotate cup into position<br />Cup impaction is 40º of abduction and 20º -25º of anteversion using the alignment guide <br />Special consideration should be directed to the patient positioning and bony landmarks for cup placement<br />
  55. 55. Version and abduction are verified<br />With the crossbar portion of the handle perpendicular to the patient’s torso, anteversion is approximately 20º<br />40°<br />20°<br />20°<br />
  56. 56. Cup Impaction<br />Need another image here <br />of cup impaction<br />
  57. 57. Femoral Retractor Placement<br />
  58. 58. Retractors are positioned for femoral preparation<br />Remove soft tissue from lateral neck and intertrochanteric wall<br />The gluteus offset retractor is placed over the tip of the greater Trochanter <br />The anterior acetabular retractor is placed over the medial calcar and under the remaining short external rotators <br />HEAD<br />
  59. 59. Starting punch / Chisel is impacted lateral to the piriformis<br />The leg should be in 45º -80º of flexion and 45-80º of internal rotation <br />Chisel’s are inserted at the tip of the Greater Trochanter for maximum lateralization of the canal<br />
  60. 60. It is important to maintain axial alignment<br />
  61. 61. Reamer sleeve prevents skin trauma<br />
  62. 62. PROFEMUR® Z Broach design preserves endosteal blood flow potential around the stem<br />
  63. 63. Axial inline broaching is performed sequentially<br />
  64. 64. Outrigger guide allows alignment check<br />Alignment guide can be used to ensure proper alignment during broaching <br />
  65. 65. Modular neck and femoral ball is inserted and the hip is reduced<br />Key note – Metal trial necks can only be used with broaches<br />Plastic trial necks are to be utilized with the final implant<br />
  66. 66. Position is checked using tip of the Trochanter and lateral top of trial<br />
  67. 67. A bump should be put under the ankle to keep the leg parallel to the table<br />The hip should be stable in full extension and 70-80º external rotation with pressure applied to the posterior aspect of the Greater Trochanter<br />In addition, hip should be stable between 30º and 90º flexion, 30º-50 adduction, 70º-80º internal rotation, as well as 120º flexion in neutral rotation and neutral adduction <br />Inter op x-ray to check position and leg lengths (recommended for first 5 cases)<br />
  68. 68. !<br />Implant stability<br />Stability relies on STEM positioning… <br />…and NECK geometry!!!<br />
  69. 69. Leg is positioned for closure<br />
  70. 70. Post Op Events<br />Straight leg raise in recovery room<br />Weight bearing – day one<br />Walking halls unassisted day two<br />Leave hospital day two or three<br />No morphine pain pump<br />
  71. 71. THANK YOU<br />