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Difficult primary hip replacement - Step by Step Guide for THR

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A presentation about how to make difficult primary easy. Specifically about DDH, ankylosis, protrusion, fracture acetabulum

Published in: Health & Medicine

Difficult primary hip replacement - Step by Step Guide for THR

  1. 1. 1 Dr VAIBHAV BAGARIA
 Joint Replacement Surgeon Sir HN Reliance Foundation Hospital Mumbai, India Uncomplicating Complications: Your First Difficult Hip
  2. 2. What Constitutes a difficult Primary? ⬥ Protrusio Hip ⬥ Dysplastic Hip ⬥ Failed Osteosynthesis/ Bipolar ⬥ Ankylosed Hip ⬥ Fracture Acetabulum
  3. 3. 3
  4. 4. 4
  5. 5. Key points ⬥ Implant Selection ⬥ Approach ⬥ Techniques ⬥ Anticipating complications ⬥ Post Operative Care
  6. 6. 6
  7. 7. GOAL • Bio-mechanically sound, stable hip joint with restoration to normal centre of rotation of femoral head
  8. 8. Restoring Hip Biomechanics
  9. 9. Restoring Hip Biomechanics
  10. 10. Restoring Femur Biomechanics
  11. 11. 11
  12. 12. 12
  13. 13. 13
  14. 14. 14 IMPLANT SELECTION
  15. 15. IMPLANT SELECTION • Patients Condition • Anticipated Longevity & Level of Activity • Bone Quality & Dimensions • Ready availability of Implants • Experience of the Surgeon
  16. 16. 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!
  17. 17. 17 Different Approach
  18. 18. 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’
  19. 19. 19 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
  20. 20. 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
  21. 21. Known the anatomy & Pathology
  22. 22. 22
  23. 23. 23
  24. 24. 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
  25. 25. 25
  26. 26. 26
  27. 27. 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
  28. 28. Femoral Side - Implant Selection ⬥ Cementless Modular Stem ⬥ Long stem ⬥ Height & Offset options ⬥ Calcar options ⬥ Sleeve - ? HA Coated ⬥ Keep wires ready for osteotomy
  29. 29. 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
  30. 30. 30
  31. 31. Technical Consideration ⬥ Secure distal fit, Intimate proximal Fit ⬥ Optimise Version, Offset ⬥ Optimise Length - Based on Osteotomy & Trialing ⬥ Choose appropriate Head Size
  32. 32. 32
  33. 33. 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
  34. 34. 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
  35. 35. 35 Bone Hook technique
  36. 36. 36 Insitu Osteotomy
  37. 37. 37 Morselized Graft for Medial defect
  38. 38. 38 Restore lateral Offset - Prevent Impingement Neck with Liner Neck with Acetabulum Bone to Bone ( Trochanter with Pelvis)
  39. 39. Protrusio - 3 key Points Controlled Dislocation Build Medial Wall Restore Lateral Offset
  40. 40. Ankylosed hip - Facts ⬥ Anesthesia: Upper Airway issue & PFT ⬥ Preoperative Orthopedic Considerations ⬥ Exposure Issues ⬥ Implant Issues
  41. 41. Ortho Assesment - Ank Spond ⬥ Spinal Involvement: Fusion/ Anderson’s Lesion ⬥ Pelvic Obliquity ⬥ LLD; Opposite Hip, Both Knees ⬥ Integrity of Sciatic Nerve
  42. 42. Pre operative consideration ⬥ Templating is of paramount importance ⬥ MTx is fine ⬥ Anti TNF stop ⬥ Spinal Osteotomy before Hip???
  43. 43. Key Issues ⬥ Positioning ⬥ Exposure & Adequate Releases ⬥ Neck Cut ⬥ Joint Line identification & Correct Acetabular positioning ⬥ Post op HO
  44. 44. 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
  45. 45. Identifying Joint line ⬥ Insitu reaming ⬥ Foveal soft tissue ⬥ Incomplete grey ossifying cartilage ⬥ Intraoperative flurosocpy
  46. 46. 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
  47. 47. Adequate Soft tissue Release - Ank Spond ⬥ Adductor Tenotomy ⬥ G Max release ⬥ Illiopsoas tenotomy ⬥ Anterior capsule release ⬥ Do not forget over friend ‘Sciatic Nerve’
  48. 48. 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
  49. 49. 49
  50. 50. 50 Post Operative Care Do not Forget: Check X Ray Limb Positioning DVT Mobilization Schedules HO Prevention
  51. 51. 51 Uncomplicate: OrganiseYour 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
  52. 52. 52 Un-complicate Complications!!!

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