Total Hip arthroplasty: choice of approach,intra-operative tips and tricks, choice of implants etc
Lateral transtrochanteric approach. Standard cemetless cup and stem. Some problems may arise with stem because of the shortened neck. In such a case a long stem with distal fixation should work instead of standard stem.
Potential posterior approach could be more easy due to the posterior inclination of the neck. In the same time release of the posterior muscles could be easier. Osteotomy in situ if not possible to dislocate. Removal of head and preparation for a standard cup of your preference in controlled anteversion. Release of the iliopsoas and the anterior capsule. A potential dual mobility head may be useful to achieve more ROM. Prosthesis could be un-cemented. Potential femoral resection of about 2 cm could be possible in case of tight soft tissues.
I did with modified Hardinge's approach. The femur was stuck to the acetabulum posteriorly and the head was neither dislocatable or irremovable in one piece,. Hence, it was removed piece meal. Acetabulum was grafted medially and an uncemented cup was used with 36 mm X3 poly liner.
The femur was more challenging as it had biplanar deformity (postero-lateral), with very posterior and medial entry and the use of image intensifier and femoral reamers I could enter the canal with some difficulty. Preferred to use a cemented Exeter stem here.
Trochanteric osteotomy could have been an alternative, but a good reattachment is not a cup of tea for everone!
Congratulations, Dr. Vaishya, for the well done implantation in this very difficult case.
In any case, I guessed the difficulties you have encountered. I do insist that a trochanteric osteotomy could have made them easier to overcome. Especially, the work on the femur: entry in the canal, height of neck resection, muscle balance, leg length discrepancy, etc.
Great result for this case. Very well done. I agree that the osteotomy, although as Panayot says it would help the access, it would be a challenge to re-attach successfully and "convince" the bone to heal under tension.
large postéro lateral approach; no trochanter ostomy; tenotomy psoas iliac muscle, tenotomy adductors if need; cementless THR ; femoral fragmented for acetabulum grafting after acetabulum reaming;impacted cementless cup dual mobility; cementless stem.
Do refer for physiotherapy following the surgical intervention. Functional ability is crucial!!!!
Dear Dr. Schwartz,
I wonder how I would perform a tenotomy of "psoas iliac muscles" and adductors tenotomy through a large postero-lateral approach ? Separate incisions ? Please, make it clear.
Regards,
Panayot Tanchev
in internal rotation the lesser trochanter is easy to reach and so the psoas;
adductors must be cut (if necessary) by a internal incision (3 or 4 cm)
Tenotomy of psoas can be done through the same approach after exposong the proximal fémur and identifying the lesser trochanter (at Its attachment)
Psoas can be divided from lesser thochander easily in either posterior or lateral approach by rotating the femur accordingly so the exposure of the bony prominence would be accessible. Adductor tenotomy can be done percutaneously with the tenotomy knives when patient will be moved from lateral to supine for transfer.
Posterior aproach, so you can identify sciatica all the time.
Tenotomy can be done either percutaneously or in the field.
S-Rom or alike sementless stem, inwich you can "dial" your version and you do not haveto follow distorted anatomy of the proximal femor. Bonecfraft behind the cup, so you can restore the center of rotation. You sholud be able to restore the leglength, but the patient will be painful due sciatica strain.
Not to sound critical, but if one sees the pre-op lateral view film, both offset and rotational challenges in deformed proximal femur are obvious. A stem similar to SROM would have been ideal to adjust the offsets as well as rotational alignment of femoral component.
Post-op, the cemented stem is in varus in the AP view posted. Wonder about stem position in lateral view??? Also, the cup appears a bit vertical (?Close to 55)! Would be really educative if you could share AP view of Pelvis (Post-op) and lateral view of operated hip.
Hi folks. Here is what I would do:
1. Posterior approach (because of my practice)
2. Maybe a in situ neck osteotomy is needed
3. Trochanteric osteotomy to correct deformity.
4. Temporary fixation with plate, with femoral ream in place, to avoid conflict with screws
5. Cemented stem (double taper)
6. Ceramics head and XLinked poly.
Greetings from Brazil
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