Path total hip replacement by bose

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  • Knee exercises can be an effective treatment for knee joint and help to bring relief from the pain. Knee exercises are very important for proper movement of knee:

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