Bipolar hemiarthroplasty involves replacing the femoral head with a prosthesis while retaining the natural acetabulum. It is commonly used to treat fractures of the femoral neck in elderly patients. The direct lateral approach is used to expose the hip joint, after which the femoral neck is osteotomized and reamed. A appropriately sized bipolar prosthesis is implanted with or without cement. Post-operatively, mobilization is started after 2 days for cemented and 2 weeks for uncemented implants, and precautions are taken to prevent dislocation and excess motion at the hip.

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