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Prophylactic Bipolar Hemiarthroplasty of the Hip

Planning

B

Preoperative Plan

1

Template instrumentation

  • bipolar hemiarthroplasty system

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • hip cemented hemiarthroplasty system

2

Room setup and equipment

  • standard OR table
  • sterile hoods with circulating fans for surgical team
  • hip positioners or bean bag
  • check back table to make sure correct equipment available

3

Patient positioning

  • lateral decubitus with operative extremity facing up
  • axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, Foley in place
  • in obese patients place towel or pad between positioners and skin
  • check to make sure operative leg can be flexed to 90° with positioners in place
  • arms stacked on top of each other with blankets underneath and in between, taped down to arm boards
  • prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area
  • bovie pad on contralateral thigh or abdomen
  • foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep

Technique

D

Posterolateral Approach to the Hip

1

Mark out GT and anterior/posterior borders of femur and anterior bow of femur

  • mark out the anatomy of GT

2

Mark incision posterior to midline of GT down shaft of femur

  • incision is curved posterior to edge of GT, aimed towards PSIS proximally
  • 1/3 of incision proximal to GT, 2/3 distal to GT (~10-15cm long)

3

Perform skin incision

  • use 10 blade for skin incision
  • curve incision posterior aiming for posterolateral corner of GT
  • incise fascia 2-3 cm with knife just posterior to midline of GT

4

Expose the fascia lata

  • insert 2 self retainers (Wheatlanders, Oberhills for larger patients) at 1/3 and 2/3 aspect of incision
  • cauterize bleeders in subcutaneous tissue
  • use knife down to fascia lata

5

Develop fascial plane

  • use Cobb and dry lap to sweep soft tissue
  • abduct leg 30° to relax TFL
  • place Hibbs retractor proximally

6

Incise fascia 2-3cm with knife just posterior to midline of GT

  • start distal and move proximal with cautery
E

Deep Dissection of Posterior Approach to the Hip

1

Place Charnley retractor anterior long blade, short blade posterior

  • retract glut medius and minimus anteriorly while just glut max posterior
  • use Charnley retractor.Split the glut max. Tag SERs with 5 ethibond.

2

Split glut max

  • perform blunt dissection using index fingers in center of decussating fibers
  • this will expose trochanteric bursa on lateral margin of GT

3

Dissect the SERs

  • abduct leg until short external rotators (SERs) are visualized
  • internally rotate hip to place SERs on stretch
  • incise soft tissue and bursa off of posterior aspect of GT with leg extended
  • this will keep the sciatic nerve out of field
  • identify SERs (piriformis and obturator internus, gamelli) and quadratus distally (can often feel piriformis tendon proximally)
  • start distally just proximal to quadratus and move proximally
  • extend proximally along posterior aspect of abductors, extend distally until quadratus femoris (will bleed due to medial femoral circumflex artery)
  • locate the sciatic nerve in fat deep to piriformis and superficial and posterior to SERs

4

Tag SERs

  • place #5 Ethibond tag sutures (x3) into SERs and anterior capsule
  • place hemostat on each pair grab enough soft tissue for repair later on

5

Release remaining capsule using longitudinal or T-shaped incision

6

Dislocate hip via flexion, adduction and internal rotation (leg perpendicular to ground, 90-90°)

F

Femoral Head Extraction

1

Make preliminary neck cut with sagital saw to get more room to remove femoral head

2

Remove femoral head via corkscrew or ring shaped tenaculum

  • cauterize soft tissue away and clean off with Cobb

3

Use native femoral head to measure size for templating implant head size (typically 46-52mm

G

Canal Preparation

1

Elevate the femur

  • use proximal femoral retractor (double prong, equal prongs on either side) and place under GT to help elevate femur and protect soft tissues
  • can use Hibbs or #1 acetabular retractor to get better calcar exposure

2

Make the femoral cut

  • make neck cut 0.5-1cm proximal to lesser trochanter
  • start with the box cutter , then canal finder then lateralizing reamer to make sure you are down canal and not in varus

3

Broach up sizes from small to larger

  • start at 10, then 11, 12 (typically 12-13 size stem final)
  • want snug fit but don’t need to overtighten
  • cement will fill void between implant and bone
  • need to hit broaches with same power to evaluate if it’s advancing

4

Check calcar for any evidence of fracture

  • place leg in extension and internal rotation to visualize the calcar

5

Trial implants

  • start extending leg and hyper internal rotation to get max exposure of proximal femur, then femoral head
  • place implants

6

Relocate the hip

7

Check for stability, range of motion and leg lengths

H

Cement Insertion

1

Dislocate hip, remove trials, size and place cement restrictor (typically 11-12mm)

  • place cement restrictor 15cm down from neck cut (length may vary depending on stem being used)

2

Clean and dry canal using epinephrine soaked sponge

  • suction out canal

3

Insert cement in retrograde fashion pressurized with gun

  • place sponge in acetabulum to block cement extrusion
  • cement typically takes 3.5-4.5min to reach appropriate consistency for insertion

4

Cover tip of stem with extra cement

I

Final Implants

1

Use stem pusher and Tommy bar to control depth and anteversion

  • place in 10-15° anteversion (angled posterior for increased anteversion)
  • add 5-10° if worried about posterior dislocation
  • hold in place until cement hard (~15min)

2

Trial head and neck size (typically +7, +10.5)

  • engage Morse taper, allow cement to dry, and relocate hip

3

Confirm Implant Position and Extremity

  • check final anteversion of stem and impingement, leg lengths, rotation when hip dislocates anterior and posterior
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • pulsatile irrigate acetabulum and deep tissues
  • cauterize peripheral bleeding vessels

2

Deep closure

  • repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures
  • tie to either glut medius anteriorly or through bone on posterior aspect of GT
  • close TFL with #1 Ethibond figure of 8 sutures

3

Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

4

Dressing and immediate immobilization

  • soft incision dressings over hip

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness
  • screen medical studies to identify and contraindications for surgery

2

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

3

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

4

Perform operative consent

  • describe complications of surgery including
  • Infection
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • appropriately orders and interprets basic imaging studies
  • post-op xrays of hip to evaluate cement mantle and stem position
  • appropriate medical management and medical consultation
  • inpatient physical therapy
  • start range of motion exercises of the hip and knee
  • weight bear as tolerated
  • posterior hip precautions

2

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
  • wound care
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • history:
  • past history of cancer or radiation,
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • check radiographs
  • start formal physical therapy
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • hardware failure
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • MRI
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
O

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

3

Discusses prognosis and end of life care with patient and family

 

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