Intraoperative challenges in thr

Intraoperative Challenges in THR

• Prompt attention required for managing intraoperative problems associated with THR

• The operating surgeon should be familiar with treatment options.

• Intraop problems - Anticipated Unexpected

Common intraop problems

• Gain sufficient exposure• Achieving implant fixation • Correction implant position• Intraop fractures• Intraop limb length • Hip stability

Exposure

Anticipate Challenging exposure

• Prior surgery• Deformity• Stiffness• Heterotopic bone • Obesity • Muscle Bulk

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


Acetabular retractors

• Anteroinferior - under capsule /iliopsoas

• Anterosuperior - anterior coloumn

• Posteroinferior – ischium

• Posterosuperior – posterior wall

Lateral Approach


Femoral retractors

• Curved retractor under gr. troch

• Curved retractor under lesser troch.

• Pointed retractor – piriform fossae

Lateral Approach


• Posterior Approach

Release Quad femorisRelease inferior capsule


Acetabular retractors

• Anterior - Retract femur

• Inferior - Under transverse ligament

• Posterior – Posterior wall

Posterior Approach


Femoral retractors

• Femoral elevator under lesser troch

• Skid under greater trochanter

Posterior Approach


Improve anterior mobilization of femur

• Release inf. Capsule• Resect ant. Capsule• Partially / completely release rectus origin• Release gluteus maximus

Posterior Approach

Acetabular press fit not good

Anticipate

• Small acetabulum

• Acetabular dysplasia

• Osteoporosis


Causes for poor fit

• Inadequate exposure

• Soft tissue interposition

• Insufficient bone contact

< 40 micron

movement


Tips To improve implant bone contact

• Uncovered cup – ream deeper

• Cup has good lateral coverage – ream for larger diameter


• Supplemental screws - safe zone

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

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


Look for fracture

• Greater sciatic notch• Quadrilateral plate• Medial wall

• Undisplaced – Multihole cup• Displaced – Supplemental plate fixation


Discovered in post op X ray

• Fit is good – protected weight bearing

• Fit is not good – Revise to multihole cup

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%

Optimizing acetabular component position

• Anticipate increased version Perthe’s DDH

• Anticipate Retroversion FAI SCFE Previous osteotomies

Optimizing acetabular component Anteversion

Tips to achieve acetabular component anteversion

• Preop planning

• Transverse acetabular ligament

• Acetabular notch angle

• Navigation

Femoral crack

Anticipate

• Osteopenia• Femoral deformity• Canal stenosis• Protrusio• Presence of stress riser – core decomp, DHS Nail

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

Femoral crack

Suspect if component goes deeper than the broach

Expose the entire fracture

Undisplaced – circlageDisplaced – circlage Locked / Hybrid plate component with distal fit

Femoral crack

Greater Trochanter fracture

• Undisplaced - Tension band wiring

• Displaced - Tension band wiring Claw plate Advancement plate

Femoral crack

Shaft fractureAnticipateAltered anatomy / stress riserDuring dislocation – protrusio ( dislocate hip before hardware

removal )

Undisplaced longitudinal crack – protected weight bearingDisplaced - wiring plating longer stem

Unstable Hip

Anticipate

• Morbidly obese• Elderly• Alcohol• Substance abuse• DDH• Parkinsonism

Unstable Hip

• Intraop assessment

Leg length Offset Component orientation Range of motion – impingement

Unstable Hip- Restoring offset

• Pre op planning and reproduce in post op X- rays

• Intraop fixed devices• Intraop radiographs – supine position• Palpation bony landmark

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)

Short leg

• Shuck test – too much acetabulum head displacement

• Dislocate easily due to impingement

• Intraop – Re-evaluate acetabular component position

• Height of femoral cut

Short leg

Tips

• Increase neck length – (Affects offset also Skirted neck – impingement)

• Upsize the femoral component and leave it proud ( c.f. Fracture )

Long leg

Intraop assessment

• Flexion contracture• Cannot extend• Absent schuck test• Hip extended – knee cannot be flexed

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

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

Summarize

• Intraop complication – ineveitable part of any surgery

• Anticipating problems – reduce the event

• Understanding treatment strategies – optimize treatment outcomes

Intraoperative challenges in thr

Health & Medicine

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