orthpedics

1. BASIC ARTHROPLASTY WORKSHOP
ARTHROCON
HIP SURGICAL ANATOMY & APPROCHES
OP LAKHWANI
Associate Professor, Orthopedics Surgery,
ESIC – Postgraduate Institute Of Medical Sciences & Research,
ESI Hospital, New Delhi

2. SURGICAL ANATOMY
HIP Ball & socket joint
6 degree movements
Hip inclined plane shearing forces.
Cement – strong compression than shearing forces
Femur > Acetabulum wear

4. DISSECTION
Superior and
inferior Gluteal
Nerve

5. ACETABULUM
Anterior - iliopubic eminence
Superior - strong thick
Posterior - Stability
Medial - Tear drop
ilioischial line
Inferior - deficient, TAL

6. ACETABULUM EXPOSORE
360 degree exposure
Superior
large smooth Steinman pin to
retract abductor
Anterior
Iliopubic eminence place a
curved pointed retractor
translate the femur anteriorly.
 Difficult exposure - check distal
insertion of the gluteus maximus
tendon on the femur and the retained
superior capsule and tendon of the
reflected proximal rectus femoris have
been adequately released.

7. ACETABULUM EXPOSURE
 Inferior - a cobra retractor at
transverse acetabular
ligament.
Posterior - wide
Hohman- type
retractor into the
tuberosity of the
ischium. Take care
not place posterior
acetabular
wall and into the
acetabular fossa.

8. ACETABULUM EXPOSURE
 Remove remnants of acetabular labrum,
osteophyts from the acetabular brim. Next
remove the pulvinar (fibrofatty material
medially).
 avoid the ascending branch of the
obturator artery when removing the
inferior pulvinar near the transverse
acetabular ligament.
 medial osteophyte is present, the pulvinar
may not visible. This means that
acetabular reaming needs to proceed
medially down to the true medial aspect of
the acetabulum.

9. Acetabular Fixation Safe Area

10. The successful total hip arthroplasty -
fixation and stability with appropriate
component positioning.
Restore center of rotation, leg length, and
offset, Inclination, Anteversion,

11. POSITIONING OF ACETABULUM CUP
 Orientation -10 – 300 of anteversion, 40 - 500
abduction
 Position – flexion deformity , lumbar lardosis – ant
Pelvic tilt
 Inclination - targeted to 40° ± 5°
 Combined anteversion
customized according to femur to combined
anteversion of 30° to 45° (with 5° margin of error
for safe zone of 25° to 50°), lower r men with low
femoral anteversion, and higher women .
 Center of rotation - Reaming medially is done to
the cotyloid notch which medializes the center of
rotation 3 to 6 mm; removal of the lunate bone
and formation of a hemisphere moves the center
of rotation cephalad to 5 mm.
Surface land marks - ASIS, iliac tubercle, Shoulder
Patient positioning, Greater trochanter
Inter conlar axis patella
 Positional guide

12. Intra-articular landmarks
 orient the inferior most portion
of the cup at the level of the
teardrop and margin at TAL,
anterior margin at level of ant
wall the posterior edge of the
cup at the level of the
ischium.posterior superior
edge may over hang mm
anterior.
,
 Notch Acetabular angle - lies
parallel to acetabular opening
hence aligning the cup along
sciatic notch acetabular angle
reproduces normal
anteversion aligning socket
towards notch add 10-15 0
additional antevesion

13. Cup stability – combined anteversion
 anatomy of acetabulum not permit anteversion of cup
beyond 30°. Abn anteversion , modular stem, or
cementing .
 limits 25° to 45° anterior dislocations if more than 50°
combined anteversion
lower in men because femoral anteversion.7° in women in
our study.
To accomplish the combined anteversion requires femoral
preparation first so the cup can be adjusted to the stem.
The combined anteversion test assesses component
positioning With the limb in 10 adduction, the femoral head
should be coplanar with the face of the acetabulum. when
the limb is internally rotated.

14. FEMORAL PREPERATION - LIMB LENGTH
 Measure length before dislocation
and compare after
 Offset
 Cut – level , Direction, anteversion
 Anteversionpatella, transcondylar
axis
 Measuring the distance from the lesser
trochanter to the center of the femoral
head and reproducing this dimension
post-arthroplasty will help to minimize
leg length discrepancies.

15. Leg length
 The lesser trochanter should not impinge on the
ischium in full extension and should be one
fingerbreadth above the tip of the ischium for correct
leg length.
 In external rotation and abduction, the metal neck
should not impinge on the cup nor the greater
trochanter on the posterior ilium. In flexion and
internal rotation, the metal
 neck should not impinge on the anterior-superior
cup or the greater trochanter on the anterior ilium.
 Several tests are available to assess the quality of
the arthroplasty including the combined anteversion
test, the shuck test, the Ober test, and the range-of-
motion test.
 Failure to restore component offset may result in
instability, limp, and excessive wear. Increasing the
offset may lead to pain, stiffness, and functional leg
lengthening due to abduction contracture.

16. SURGICAL APPROACEHS
 Surgeon driven
Expertise
Training
Personal philosophy
95% case primary hip can be
operated with one approach
hence said master the one
approach
 Situation - Altered anatomy
Previous surgery
Pt related factors
Preference one over
other

17.  Internervous Intermuscular plane Least
interfering Neurovacular structure and
tissue trauma.
 Classic ilitibial band Gluteus med Key
Muscle, Essentially lateral differ only in so
far as they may be slightly anterior or
posterior to the lateral plane. The
anatomical structure which determines the
question is theGlutus med tensor fascia
Approach in front of this muscle antero-
lateral: if behind, then postelo-late'al.
Trans trocha main door Charnley
AnteroL
PosteroL
SURGICAL APPROACEHS

18. Postero lateral Approach
POSITION - lateral decubitus
INSCISION
advancing anteriorly moore to gibson.
Posterior border of the greater trochanter,
and extends proximally from the level of the
vastus tubercle for 10 cm cephalad.
STEPS
 Gluteus maximus incised 6 to 8 cm along
the posterior border greater trochanter.
 external rotators and the posterior capsule
with the leg in internal rotation as a single
flap just proximal to the quadratus femoris
 In flexible hips, the Piriformis tendon+/-
preserved and an L-shaped incision one arm
parallel to the piriformis tendon.
 The hip is dislocated third incision is of the
inferior medial capsule, which is incised
from the anterior femur to the acetabulum
through the transverse acetabular ligament.

19. Postero lateral Approach….
 Decrease dislocation – tagging before
release External rotator repair
 Larger head
 Adv – excellent view acetabulum and
femur, risk of sciatic nerve, dislocation
– post soft tissue repair - Transosseus
nonabsorbable suture to repair the
anterior released fiber of G medius,
 easier to make these drill holes prior to
reducing the hip
 advantage of dependent drainage,
extensile
 Avoid abductor damage Ext rotator
release – dislocation , Sciatic nerve
 Tight hips may require 1 cms more
release of G medius at anterior
superior corner of GT.
 difficult dislocation require ITB release
and allow to slip posterior to GT.

20. Ant Lateral Approach
POSITION - Supine/ Lateral
INCISION - Centered over greater anterior
aspect of Greater Trochanter.
STEPS
-Split ITB distally and G.Max proximally.
- Exposing – Vastus lateralis and G medius
- Idetify position of head , Tip of greater
trochanter , Slit Vastus lateralis and G.Medius
at anterior 1/3 maintain continuty of anterior
sleeve
 Differ in manner and effect of releasing
Gluteus medius and vastus lateralis insertion
and protection of Superior Gluteal nerve and
vessels.
 Flexible hip, Less risk of avn head preserving
surgery Limitation – superior gluteal nerve and
branches , imited posterior collumn access,
ant dislocation
 Trochanter overhang – varus positioning of
implant
Safe limit area

21. Surgical Approaches
Trans troch
Approach Dislocation HO Limp
PosterL ++ + +
Antero L + ++ ++
Trans troch + + +

22. STABILITY CHECK
 Assess component stability. Examine the
hip at: 90 degrees of hip flexion-simulating
sitting;
 flexion, adduction and internal rotation
 simulating the fetal sleeping position; and
in
 extension, abduction and external rotation,
assessing for any evidence of anterior
instability.