intraoperative challenges in thr
TRANSCRIPT
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Intraoperative Challenges in THR
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• Prompt attention required for managing intraoperative problems associated with THR
• The operating surgeon should be familiar with treatment options.
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• Intraop problems - Anticipated Unexpected
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Common intraop problems
• Gain sufficient exposure• Achieving implant fixation • Correction implant position• Intraop fractures• Intraop limb length • Hip stability
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Exposure
Anticipate Challenging exposure
• Prior surgery• Deformity• Stiffness• Heterotopic bone • Obesity • Muscle Bulk
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Exposure – How to get more exposure
Lateral Approach• Take down greater proportion of abductor musculature ( 50%
- 60%)
• Extend vastus release distally and expose inferior capsule
• Subperiosteally elevate capsule to lesser trochanter
• Insitu femoral neck osteotomy
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Exposure – How to get more exposure
Acetabular retractors
• Anteroinferior - under capsule /iliopsoas
• Anterosuperior - anterior coloumn
• Posteroinferior – ischium
• Posterosuperior – posterior wall
Lateral Approach
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Exposure – How to get more exposure
Femoral retractors
• Curved retractor under gr. troch
• Curved retractor under lesser troch.
• Pointed retractor – piriform fossae
Lateral Approach
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Exposure – How to get more exposure
• Posterior Approach
Release Quad femorisRelease inferior capsule
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Exposure – How to get more exposure
Acetabular retractors
• Anterior - Retract femur
• Inferior - Under transverse ligament
• Posterior – Posterior wall
Posterior Approach
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Exposure – How to get more exposure
Femoral retractors
• Femoral elevator under lesser troch
• Skid under greater trochanter
Posterior Approach
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Exposure – How to get more exposure
Improve anterior mobilization of femur
• Release inf. Capsule• Resect ant. Capsule• Partially / completely release rectus origin• Release gluteus maximus
Posterior Approach
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Acetabular press fit not good
Anticipate
• Small acetabulum
• Acetabular dysplasia
• Osteoporosis
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Acetabular press fit not good
Causes for poor fit
• Inadequate exposure
• Soft tissue interposition
• Insufficient bone contact
< 40 micron
movement
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Acetabular press fit not good
Tips To improve implant bone contact
• Uncovered cup – ream deeper
• Cup has good lateral coverage – ream for larger diameter
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Acetabular press fit not good
• Supplemental screws - safe zone
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Acetabular press fit not good – Over reaming
Anticipate
• Osteoporotic bone
• Dysplastic bone – Place cup in less inclination Ream deeper Crowe III &IV – perforate medial wall Cluster hole / multihole cup
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Acetabular press fit not good – Fracture
Suspect – component seated more medially than trial component
• Underreaming < 2 mm - fracture • Increased force of impaction• Elliptical design of cup – increased incidence
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Acetabular press fit not good – Fracture
Look for fracture
• Greater sciatic notch• Quadrilateral plate• Medial wall
• Undisplaced – Multihole cup• Displaced – Supplemental plate fixation
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Acetabular press fit not good – Fracture
Discovered in post op X ray
• Fit is good – protected weight bearing
• Fit is not good – Revise to multihole cup
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Optimizing acetabular component position
• Safe zone Anteversion 15 Deg. +/- 10 degInclination 40 Deg +/- 10 deg
Cup in safe zone Dislocation < 1.6%
Outside safe zone – dislocation > 6.1%
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Optimizing acetabular component position
• Anticipate increased version Perthe’s DDH
• Anticipate Retroversion FAI SCFE Previous osteotomies
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Optimizing acetabular component Anteversion
Tips to achieve acetabular component anteversion
• Preop planning
• Transverse acetabular ligament
• Acetabular notch angle
• Navigation
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Femoral crack
Anticipate
• Osteopenia• Femoral deformity• Canal stenosis• Protrusio• Presence of stress riser – core decomp, DHS Nail
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Femoral crack
Tips to avoid
• Meticulous cleaning of proximal femur to avoid wedge effect
• Inspect calcar – before and after broaching• Consistent hammer blows and stop in between
( Hoop Sterss) • Visual progression of implant• Auditory feedback
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Femoral crack
Suspect if component goes deeper than the broach
Expose the entire fracture
Undisplaced – circlageDisplaced – circlage Locked / Hybrid plate component with distal fit
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Femoral crack
Greater Trochanter fracture
• Undisplaced - Tension band wiring
• Displaced - Tension band wiring Claw plate Advancement plate
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Femoral crack
Shaft fractureAnticipateAltered anatomy / stress riserDuring dislocation – protrusio ( dislocate hip before hardware
removal )
Undisplaced longitudinal crack – protected weight bearingDisplaced - wiring plating longer stem
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Unstable Hip
Anticipate
• Morbidly obese• Elderly• Alcohol• Substance abuse• DDH• Parkinsonism
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Unstable Hip
• Intraop assessment
Leg length Offset Component orientation Range of motion – impingement
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Unstable Hip- Restoring offset
• Pre op planning and reproduce in post op X- rays
• Intraop fixed devices• Intraop radiographs – supine position• Palpation bony landmark
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Unstable Hip-Component Orientation
Tips• Reposition component• Face changing liners• Increase head diameter• Increase polyoffset• High offet femoral component• Make the limb longer ( inform pt preop)
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Short leg
• Shuck test – too much acetabulum head displacement
• Dislocate easily due to impingement
• Intraop – Re-evaluate acetabular component position
• Height of femoral cut
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Short leg
Tips
• Increase neck length – (Affects offset also Skirted neck – impingement)
• Upsize the femoral component and leave it proud ( c.f. Fracture )
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Long leg
Intraop assessment
• Flexion contracture• Cannot extend• Absent schuck test• Hip extended – knee cannot be flexed
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Long leg
Tips
Reduce the neck length ( c.f. offset is reduced )
Lower the femoral neck cut and pass a smaller broach deeper into canal
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Limb length discrepancy
• Counsel the patient• Length was necessary for stability• No shoe raise – 6 weeks• At 6 weeks – stretching of spine and hips
Shoe raise only if discrepancy > 1-2 cm & rigid spine
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Summarize
• Intraop complication – ineveitable part of any surgery
• Anticipating problems – reduce the event
• Understanding treatment strategies – optimize treatment outcomes