The document discusses various hip conditions that may require total hip arthroplasty. It describes the anatomical features and surgical considerations for osteoarthritis, inflammatory arthritis, osteonecrosis, protrusio acetabuli, developmental dysplasia of the hip, Legg Calve Perthes disease, and slipped capital femoral epiphysis. Key steps in the surgical procedures are outlined, including the need for osteophyte removal, acetabular reaming, femoral component positioning, and correcting any deformities through osteotomies when required. Patient-specific factors like bone quality and prior interventions must be considered to plan the appropriate reconstruction technique and implant selection.

1. Dr.Gitesh Singh
Junior Resident
Deptt. Of Orthopedics
Governmemt Medical College, Patiala

2. OSTEOARTHRITIS(PRIMARY OR SECONDARY
OR HYPERTROPHIC OR DEGENERATIVE
ARTHRITIS)
 The hip often is flexed, externally rotated, and adducted,
and there is additional apparent shortening of the limb
because of the deformity. Less commonly, the limb may
appear lengthened because of a fxed abduction
contracture.
 The subchondral bone of the acetabulum is thick and hard.
 Osteophytes may completely cover the pulvinar and
obscure the location of the medial wall.
 he femoral head has been displaced laterally, intraar-
ticular osteophytes inferiorly may thicken the bone
considerably.
 often the greater trochanter is enlarged.

4. SOLUTION:-
 Removal of the osteophytes from the anterior or posterior margin of
the acetabulum may be necessary to dislocate the hip safely.
 Considerable reaming of the acetabulum may be required before a
bleeding surface satisfactory for bone ingrowth is reached.
 Deepening of the acetabulum may be required to contain the cup
fully.
 Failure to medialize the acetabulum in this instance may leave the
superior portion of the cup unsup- ported or supported primarily by
osteophytes.
 Careful attention to the removal of acetabular osteophytes is
necessary to avoid impingement, decreased range of motion, and
dislocation.
 Trochanteric osteotomy may be needed to prevent impingement
during rotation.

5. INFLAMMATORY ARTHRITIS
 Includes rheumatoid arthritis, juvenile idiopathic arthritis, juvenile
rheumatoid arthritis or Still disease, psoriatic arthritis, and systemic
lupus erythematosus.
 Mostly is bilateral.
 Often these patients are generally disabled, having varying degrees of
dermatitis, vasculitis, fragile skin, osteopenia, and poor musculature.
In addition, they have been or are receiving corticosteroids and other
immunosuppressive drugs; consequently, the risks of fracture during
surgery and infection after surgery are greater.
 The femoral head may be partially absent because of erosion or
osteonecrosis, and some degree of acetabular protrusion may be
present.
 Limitation of motion of the cervical spine, upper extremities, and
temporomandibular joints complicates the anesthesia.
 The femoral canal is wide, but the cortex is thin and easily penetrated
or fractured.

6.  The acetabulum is soft and easily reamed, and the
medial wall is easily penetrated.
 Severe osteopenia often makes cementless fxation
more difficult.
 Excessive femoral anteversion and anterior bowing of
the proximal femur also are common in patients with
juvenile idiopathic arthritis.
 In most series, radiolucencies and demarcation are
more common around the acetabulum than the femur
for cemented and cementless fxation.

7. SOLUTION:-
 Special handling of the limb is necessary so as not to
fracture the femur or acetabulum or damage the skin.
 Care must be taken not to fracture the anterior margin
of the acetabulum or the femoral neck with a retractor
used to lever the femur anteriorly.
 Small components may be necessary, especially in
patients with juvenile idiopathic arthritis, because the
bones often are underdeveloped.
 Extreme deformity may require femoral osteotomy.

8. OSTEONECROSIS
 With osteonecrosis, the capsule and synovial tissue proliferation
frequently is quite hyperemic; and on entering the capsule, a
considerable amount of bleeding may be encountered.
 Often a large synovial effusion is present and may raise suspicion
of infection, although this is uncommon.
 If cortical bone grafting of the femoral head was done
previously, such as with a vascularized fibular graft, careful
attention must be paid to removing the intramedullary portion
of the graft completely as conventional reamers and broaches are
ineffective in this regard.
 Undersizing and varus placement of the femoral component is
common because of inadequate graft removal, especially in the
trochanteric fossa.
 Patients with osteonecrosis potentially are at greater risk of
complications because of the various comorbidities.

9. SOLUTION:-
 Remove the graft remnants with a high-speed burr and
using intraoperative radiographs with the broach in
place to ensure adequate removal of the graft and a
good femoral ft.
 Hip fusion is not recommended because the
involvement often is bilateral.
 Resurfacing arthroplasty is recommended only if the
avascular segment constitutes a small segment of the
femoral head (usually <50%). Resurfacing of only the
femoral head is an option as an interim procedure if
the acetabulum appears normal.

10. PROTRUSIO ACTABULI
 The primary form, arthrokatadysis (Otto pelvis), involves both
hips, occurs most often in younger women, and causes pain and
limitation of motion at a relatively early age.
 The secondary form can be caused by migration of an
endoprosthesis, septic arthritis, or prior acetabular fracture. It
can be present bilaterally in Paget disease, arachnodactyly
(Marfan syndrome), rheumatoid arthritis, ankylosing
spondylitis, and osteomalacia.
 Frequently, there is an associated varus deformity of the femoral
neck.
 Often, because of the medial migration of the femur, the sciatic
nerve is nearer to the joint than normally.
 Dislocation of the hip can be extremely difficult.

12. A B

14.  In severe cases, the femoral head is incarcerated
within the acetabulum and dislocation is impossible.
 The medial wall of the acetabulum usually is thin or
may be partly membranous, and it should not be
penetrated.
 When the femoral head has protruded into the pelvis,
an “hourglass” deformity is created and the walls of the
periphery of the acetabulum diverge
 Surgical correction of protrusio acetabuli often entails
signifcant lengthening of the limb.

15. SOLUTION:-
 The principles of reconstruction of a protrusion defor- mity are
as follows:
(1) the hip center must be placed in an anatomic location to
restore proper joint biomechanics;
(2) the intact peripheral rim of the acetabulum should be
used to support the acetabular component; and
(3) the remaining cavitary and segmental defects in the
medial wall must be reconstructed, preferably with bone grafting
 The sciatic nerve is nearer the joint than normally, and conse-
quently it should be identifed early in the operation and
protected.
 Trochanteric osteotomy occasionally may be required for
exposure.

16.  Removal of a small overhanging portion of the posterior acetabular
wall may facilitate dislocation.
 In SEVERE instance, the femoral neck must be osteotomized in situ.
 Considerable capsular release is necessary to deliver the prox- imal end
of the femur out of the depth of the wound.
 Medial reaming is unnecessary; instead, the cartilage and soft tissues
are removed with a curet. The smooth, sclerotic floor is rough- ened
with a curet or chisel, but penetrating into the pelvis is avoided.
 only the periphery of the acetabulum is reamed to a larger size, the
walls can be made to converge. The acetabular com- ponent is
stabilized on the reshaped rim, and the thin or defcient medial wall is
not relied on to prevent recurrent deformity. Reaming is begun with
the largest size reamer that fts comfortably into the opening of the
acetabulum. The reamer is advanced only until it is flush with the rim,
and the medial wall is not reamed.

17. DDH
 Total hip arthroplasty still is often required only for patients with
symptomatic arthritis secondary to dysplasia.
 The complexity of the reconstruction is influenced by the degree
of anatomic abnormality, including the amount of acetabular
dysplasia , magnitude of proximal femoral migration relative to
the acetabulum and the degree of subluxation.
 The femoral head is small and deformed; the femoral neck is
narrow and short, with varying but often marked anteversion.
 The greater trochanter usually is small and often located
posteriorly.
 The femoral canal is narrow, the narrowness of the femur and
the increased anterior bowing of the proximal third make canal
preparation difficult.

18. A B C

19. A C

20. BA

21.  In high and intermediate dis- locations, the
impingement of the femoral head on the ilium
stimulates the formation of a false acetabulum.
 The abductor muscles frequently are poorly developed
and oriented more transversely than normal.
 The adductors, psoas, hamstrings, and rectus femoris
muscles usually are shortened.
 The capsule is elongated and redundant.
 The sciatic nerve has never assumed its normal length
and is susceptible to stretch injury when the bony and
soft-tissue deformities are corrected.

22. SOLUTION:-
 In surgery for developmental dysplasia of the hip, proper patient
selection is crucial.
 Before surgery, anteroposterior radiographs of the pelvis and
proximal femur and a lateral view of the femur must be studied
carefully to determine the amount of bone available in which to
fx the cup, the level at which it should be fxed, the problems
likely to be encountered in reaming the femoral canal because of
the anterior bowing and narrow width, the need for a femoral
osteotomy, and the size and type of com- ponents to be used.
 The shallow dysplastic acetabulum may require a very small
acetabular component (≤40 mm). Implants of this size are not
typically part of the standard implant sets and may need to be
specially ordered. A 22-mm femoral head size should be used
because it can be difficult to maintain ade- quate polyethylene
thickness when a larger head size is used with a small cup.

24.  In partially or completely subluxated hips, when the socket
is placed within the true acetabulum, a large supe- rior
segmental defcit remains with a lack of superior cover- age
of the component .
 With a high dislocation, the acetabu- lum is hypoplastic,
but its superior rim has not been eroded by the femoral
head. The reconstruction usually can be done with a
conventional cup placed within the true acetabulum and
without structural bone grafting.
 When enlargement of the acetabulum from anterior to
posterior is necessary, more bone is resected from the
poste- rior wall than from the anterior wall. Any reaming
must be done with care so as not to compromise the
edges of the acetabulum or penetrate the medial wall.

25.  When the center of the acetabulum has changed little,
femoral length is not problematic and the femoral
reconstruction generally is straightforward.
 Excessive femoral anteversion can be corrected with a
modular cementless femoral component that can be
rotated into any degree of version.
 In severe dislocations, when the prosthetic socket has been
placed in the true acetabulum, the femur must be
translated distally several centimeters to reduce the
prosthetic femoral head into the acetabulum.
 In such cases, a femoral shortening osteotomy of 2-3 cms
from metahysis allows reduction of the femoral head into
the true acetabulum without extensive soft-tissue release.

27.  The bone should be resected 0.5 cm at a time, and trial
reductions are repeated until enough shortening is
obtained.
 The narrow canal and the resection of the metaphyseal
flare of the femur often require the use of a component
with a small, straight stem.

28. LEGG CALVE PERTHES DISEASE
 13% of patients with LCPD eventually required hip
arthroplasty; the prevalence was highest in patients
with more severe head involvement.
 The acetabulum often is dysplastic and may be
retroverted.
 The limb is shortened due to coxa vara deformity, and
the greater trochanter is increased in height.
 Femoral neck version abnormalities may result from
the disease process or prior reconstructive surgery.
 Often there is a size mismatch between the
metaphyseal and diaphyseal regions of femur.

29. SOLUTION:-
 Use of cemented over cementless components.
 Femoral derotation osteotomy is seldon required but
can be performed if needed.

30. SLIPPED CAPITAL FEMORAL
EPIPHYSIS(SCFE)
 Patients with adolescent slipped capital femoral
epiphysis (SCFE) may develop secondary osteoarthritis
due to femoro- acetabular impingement with
abnormal hip mechanics.
 In a report from the New Zealand National Joint
Registry, Boyle, Frampton and Crawford found no
difference in out- comes between patients with SCFE
and primary osteoarthri- tis undergoing hip
arthroplasty.

32. THANK YOU