bipolar hemi

1. BIPOLAR
HEMIARTHROPLASTY
LATERAL APPROACH
DR. MUHAMMAD MUNEEB
MEDICAL OFFICER
DEPARTMENT OF ORTHOPEDICS AND TRAUMATOLGY, IHT

2. HEMIARTHROPLASTY
HALF JOINT REPLACEMENT
IT INVOLVES REPLACING THE FEMORAL HEAD WITH A PROSTHESIS, WHILE
RETAINING THE NATURAL ACETABULUM (ENDOPROSTHESIS)

3. HISTORY
• 1932: HEY GROOVES REPLACED A FEMORAL HEAD WITH IVORY
• 1938: SMITH PETERSON FIRST USED VITALLIUM MOULD ARTHROPLASTY IN THE HIP IN CASE
OF ANKYLOSIS AS A RESULT OF RHEUMATOID ARTHRITIS
• 1944: JUDET BROTHERS INTRODUCED ACRYLIC FEMORAL HEAD FOR THE TREATMENT OF
OSTEOARTHRITIS.
• 1948: MC BRIDE INTRODUCED THREADED STEM.
• 1950: MOORE INTRODUCED A SELF LOCKING COBALT CHROME ALLOY PROSTHESIS
• 1952 : THOMPSON WORKED ON A PROSTHESIS AT THE SAME TIME AS MOORE
• IN 1947: THE BIPOLAR PROSTHESIS FIRST INTRODUCED BY JAMES E.BATEMAN AND GILBERTY
• 1983 : CHARNLEY-HASTINGS USED BIPOLAR PROSTHESIS

5. INDICATIONS
• FRACTURES OF THE NECK OF FEMUR IS THE COMMONEST FRACTURE IN OLD
AGED INDIVIDUALS BECAUSE OF SEVERE OSTEOPOROSIS
• NON UNION AND AVASCULAR NECROSIS ARE THE TWO PRINCIPAL
COMPLICATIONS OF THIS FRACTURE
• SUBCAPITAL NECK FRACTURES THAT ARE DISPLACED AND AT HIGH RISK OF
FEMORAL HEAD AVASCULAR NECROSIS (GARDEN III AND IV FRACTURES)

6. TYPES OF PROSTHESIS
UNIPOLAR
• HEAD: (37MM TO 59MM)
• NECK
• STEM: TRIANGULAR IN SHAPE THIN
• COLLAR (TRANSVERSE IN MOORES & IN
THOMPSONS IS ACUTELY ANGLED AND
WIDE)
• FENESTRATIONS (AUSTIN MOORE)
BIPOLAR
• FEMORAL STEM
• FEMORAL HEAD
• PLASTIC LINER
• ACETABULAR COMPONENT

7. THOMSONS VS AUSTIN MOORE VS BIPOLAR

8. ADVANTAGES OF BIPOLAR
HEMIARTHROPLASTY
• WIDE RANGE OF MOVEMENTS (DUE TO SIZE AND GEOMETRY OF INNER BEARING)
• STABILITY WILL BE IMPROVED
• PREVENTS THE COMPLICATIONS (ACETABULAR EROSION & LOOSENING OF STEM)
• INCREASED LIFE SPAN OF PROSTHESIS (LESS WEAR & TEAR)
• CAN DO A TOTAL HIP LATE

9. CEMENT VS PRESS FIT
CEMENT (METHYL
METHACRYLATE)
• –IMPROVED MOBILITY, FUNCTION,
WALKING AIDS
• SUDDEN INTRA-OP CARDIAC DEATH
RISK SLIGHTLY INCREASED:
PRESS FIT
• PAIN / LOOSENING HIGHER
• INTRA-OP FRACTURE

10. SURGICAL APPROACHES
• HIP ANTERIOR APPROACH (SMITH-PETERSON)
• HIP ANTEROLATERAL APPROACH (WATSON-JONES)
• HIP MEDIAL APPROACH
• HIP DIRECT LATERAL APPROACH (HARDINGE)
• HIP POSTERIOR APPROACH (MOORE OR SOUTHERN)

11. HIP DIRECT LATERAL APPROACH
HARDINGE’S APPROACH
OR
TRANSGLUTEAL APPROACH

12. INCISION
• BEGIN 5CM PROXIMAL TO TIP OF GREATER TROCHANTER
• LONGITUDINAL INCISION CENTERED OVER TIP OF GREATER TROCHANTER AND
EXTENDS DOWN THE LINE OF THE FEMUR ABOUT 8CM

13. SUPERFICIAL DISSECTION
• SPLIT FASCIA LATA AND RETRACT ANTERIORLY TO EXPOSE TENDON OF
GLUTEUS MEDIUS
• DETACH FIBERS OF GLUTEUS MEDIUS THAT ATTACH TO FASCIA LATA USING
SHARP DISSECTION

14. DEEP DISSECTION
• SPLIT FIBERS OF GLUTEUS MEDIUS LONGITUDINALLY STARTING AT MIDDLE OF
GREATER TROCHANTER
• DO NOT EXTEND MORE THAN 3-5 CM ABOVE GREATER TROCHANTER TO
PREVENT INJURY TO SUPERIOR GLUTEAL NERVE
• EXTEND INCISON INFERIOR THROUGH THE FIBERS OF VASTUS LATERALIS
• DEVELOP ANTERIOR FLAP
• ANTERIOR ASPECT OF GLUTEUS MEDIUS FROM ANTERIOR GREATER TROCHANTER
WITH ITS UNDERLYING GLUTEUS MINIMUS
• ANTERIOR PART OF VASTUS LATERALIS

15. CONTINUED…
• EXPOSE ANTERIOR JOINT CAPSULE
• FOLLOW DISSECTION ANTERIORLY ALONG GREATER TROCHANTER AND ONTO
FEMORAL NECK WHICH LEADS TO CAPSULE
• GLUTEUS MINIMUS NEEDS TO BE RELEASED FROM ANTERIOR GREATER
TROCHANTER

18. SUMMARY OF BIPOLAR HEMIARTHROPLASTY
• POSITION: ACCORDING TO THE APPROACH SELECTED FOR HEMIARTHROPLASTY
• THROUGH SELECTED APPROACH HIP JOINT IS EXPOSED
• IN OSTEOARTHRITIS HIP IS DISLOCATED BY FLEXION ADDUCTION AND INERNAL
ROTATION AND NECK IS OSTETOMISED IN POSTERIOR APPROACH
• IN LATERAL APPROACH DISLOCATE THE HIP ANTERIORLY
• THE NECK SHOULD BE OSTEOTOMISED APPROXIMATELY 1CM PROXIMAL TO THE
LESSER TROCHANTER.
• IN FRACTURE NECK OF FEMUR ,HEAD IS REMOVED BY USING CORK SCREW BY
INCISING THE LIGAMENTUM TERES.

19. CONTINUED…
• SHORTENING OF THE LIMB BY EXCESSIVE FEMORAL NECK RESECTION AND
SHORT FEMORAL NECK COMPONENT MAY LEAD TO PROSTHETIC DISLOCATION
DUE TO SOFT TISSUE LAXITY
• LENGTHENING OF THE LIMB WILL RESULT IN INCREASED PRESSURE ON THE
ACETABULAR CARTILAGE AND ACETABULAR EROSION
• FEMORAL HEAD SIZE SHOULD BE MEASURED BY USING CALIPER OR TEMPLATE
• HEAD IN SMALLER DIAMETER WILL RESULT IN ASYMETRIC LOAD IN ACETABULUM
• HEAD IN LARGER DIAMETER WILL NOT FULLY SEAT WITH IN ACETABULUM AND
LEADS TO INCREASE RISK OF PROSTHETIC DISLOCATION

20. CONTINUED…
• BOX OSTEOTOME IS USED TO OPEN THE FEMORAL CANAL
• SEQUENTIAL REAMING DONE WITH RASP (REAMER) UNTIL THE APPROPRIATE SIZE
(2SIZE SMALLER TO THE TEMPLATE) IN APPROPRIATE ANTEVERSION
• IN MOST CASES, THE FEMORAL NECK IS ORIENTED ANTERIORLY AS COMPARED
TO THE FEMORAL CONDYLES (ANTEVERSION 8 X 14𝑜)
• TRIAL FEMORAL COMPONENT NECK AND HEAD IS PLACED
• REDUCE THE HIP BY TRACTION AND EXTERNAL ROTATION
• HIP STABILITY IS ASSESSED THROUGH RANGE OF MOTION.

21. CONTINUED…
• TRIAL IMPLANT REPLACED WITH APPROPRIATE PROSTHESIS
• IF CEMENTING, THE BONE PLUG IS INSERTED AND VACCUM IS CREATED BY
SUCTION
• CEMENTING IS DONE THROUGH RETROGRADE FASHION USING A CEMENT GUN
AND GOOD PRESSURIZATION TECHNIQUE
• PROSTHESIS IS INSERTED USING MANUAL FORCE AND LIGHT TAPS WITH MALLET
UNTIL THE FULLY SEATED TO THE LEVEL OF CALCAR CUT
• EXCESS CEMENT IS REMOVED

22. CONTINUED…
• HEAD IS REDUCED
• STABILITY IS REASSESSED
• SHORT EXTERNAL ROTATORS AND UNDERLYING CAPSULE ARE REPAIRED
• SUTURING DONE BY LAYERS.
• SHIFT THE PATIENT IN ABDUCTION BY KEEPING A PILLOW BETWEEN LEGS

23. OPERATIVE COMPLICATIONS
• EROSION OF ACETABULUM
• FRACTURE OF STEM OF PROSTHESIS
• DISLOCATION OF PROSTHESIS
• FRACTURE OF FEMUR
• RETROVERSION AND ANTEVERSION OF PROSTHESIS
• VARUS ANGULATION
• NECK LENGTH VARIATION
• POSSIBILITY OF THE SCIATIC NERVE INJURY

24. POST OPERATIVE MANAGEMENT
• IN CASE OF CEMENTED HEMIARTHROPLASTY MOBILIZATION WILL BE STARTED
ON THE SECOND DAY & IN UNCEMENTED WILL BE AFTER 2WEEKS
• USE OF WALKER
• AVOIDANCE OF STAIRS AND PREVENTION OF EXCESSIVE HIP FLEXION OR
ADDUCTION
• AVOID SQUATTING & SITTING CROSS LEGGED