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THA - Posterior Approach

Planning

B

Preoperative Plan

1

Identifying patient specific radiographic findings

  • Leg length discrepancy
  • Acetabular morphology (depth, erosions, cysts)
  • Femoral neck offset
  • Femoral shaft morphology

2

Template the implants

3

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

  • Verify that all necessary surgical instrumentation is present and sterile on the back table prior to the patient entering the room.
  • Consider any additional or special equipment necessary for successful completion of the case.
  • Verify with the company rep that all necessary implants and potential sizes (based on templating) are present.

2

Room setup and equipment

  • Standard OR table
  • Preferred hip positioning device (pegboard, Wixson, etc.)
  • Imaging equipment (e.g., digital radiographs)
  • Laminar flow hoods
  • Intra-op DVT prophylaxis methodology (TED hose, SCDs/venaflow)
  • Axillary roll
  • Warming blanket

3

Patient Positioning

  • Lateral decubitus positioning
  • Position head/neck to maintain alignment with torso
  • Place axillary roll
  • Position arms extended at 90 degrees to patient on padded arm board with pillows between arms
  • Ensure TEDs/SCDs are placed on the contralateral leg unless contraindicated
  • Pad bony prominences of contralateral "down" leg and position flexed to allow for measurement of leg lengths during surgery
  • Place hip positioner with bony prominences padded
  • Ensure proper rotational position and stability of the patient
  • Ensure adequate hip flexion to allow for dislocation/relocation
  • Place warming blanket over the patient's upper torso
  • Secure patient further with safety belt

4

Establish Sterile Surgical Field (Prepping and Draping)

5

Surgical Team Timeout

Technique

D

Posterior Approach to Trochanter

1

Identify Bony Landmarks

  • Tip of the Greater Trochanter
  • Femoral shaft
  • ASIS
  • Lateral Epicondyle
  • Can establish femoral longitudinal axis in larger patients where palpation is challenging

2

Draw incision

  • Patient morphology dictates incisional location and length
  • With hip flexed at 45 degrees, draw straight line along the posterior 1/3 of the greater trochanter in line with the femoral shaft. When the hip is extended again, the incision appears to gently curve posteriorly.

3

Perform superficial dissection through subcutaneous tissue

  • Skin incision
  • Sharp subcutaneous dissection with either a knife or Bovie electrocautery in line with the incision down to the level of the fascia.
  • Retraction of the skin edges and subcutaneous fat can facilitate dissection. Periodically palpate the greater trochanter and proximal femur to avoid straying posteriorly toward the sciatic nerve.
  • A cobb elevator or lap can be used to further define the plane between fat and fascia
  • Establish hemostasis

4

Incise the IT band

  • Palpate the femur in the distal incision and incise the IT band
  • Abduct the hip, allowing space to sweep a finger under the IT band to bluntly dissect the bursal plane
  • Maintaining a finger in this plane, lift up and use the Bovie to complete the fascial incision proximally
  • Blunt finger dissection or Bovie electrocautery can be used to split the gluteus maximus in line with its fibers

5

Place Charnley Retractor

  • Maintaining the same finger in the plane of dissection, place the Charnley under the IT band / gluteus maximus
  • Ensure that the retractor is not compressing the sciatic nerve
  • Ensure that the skin is not placed under excessive tension and lengthen the incision if necessary to minimize necrosis
E

Myocapsular Release, Hip Dislocation, and Femoral Neck Cut

1

Identify Anatomic Course and Tension on Sciatic Nerve

  • Digital palpation can be used to identify the sciatic nerve and ensure it is not excessively tensioned
  • Additional proximal release of the gluteus maximus can alleviate tension on the nerve

2

Identify the Piriformis and Protect Abductor Mechanism (Gluteus Medius and Minimus)

  • Palpate the piriformis tendon immediately adjacent to the greater trochanter
  • Place a retractor (e.g. sharp hohmann) immediately superior to the piriformis tendon to retract the abductors
  • Ensure that the retractor is not between the gluteus medius and gluteus minimus. If so, replace the retractor under the gluteus minimus to ensure the abductors are protected.

3

Release Short External Rotators (Myocapsular)

  • Excise the bursal tissue overlying the short external rotators
  • Visualize the piriformis tendon
  • Use the Bovie to release the piriformis tendon directly from its bony insertion
  • Internal rotation of the hip may aid in visualization
  • Tag the piriformis tendon for later identification
  • Use the Bovie to release the short external rotators and capsule as a single sleeve directly off of bone. Carry dissection until the lesser trochanter is identified.

4

Perform T-Capsulotomy

  • Palpate the femoral neck
  • Using a finger to protect the sciatic nerve posteriorly, use the Bovie to perform a T-capsulotomy along the femoral neck
  • Carry the capsulotomy posteriorly until the labrum and rim of the acetabulum is visualized

5

Dislocate the Hip

  • The assistant on the anterior side of the patient dislocates the hip
  • A combination of flexion, adduction, internal rotation, and inline traction are used in this maneuver

6

Perform the Femoral Neck Cut

  • Identify the level of the neck cut medially based upon the preoperative template
  • Distance from the center of the femoral
  • Distance from the lesser trochanter
  • The femoral neck cut is marked at its medial extent and carried to the junction of the superior neck and the greater trochanter
  • An oscillating or reciprocating saw is used to perform the femoral neck cut
  • An osteotome can be used to ensure the cut is complete and a Sweetheart clamp is used to extract the head
F

Acetabulum: Exposure, Preparation and Component Placement

1

Expose the bony acetabulum

  • Retractor Placement
  • An anterior retractor (e.g. double-bend hohmann) is placed along the anterior rim of the acetabulum at the 10 or 2 o'clock position (depending on left vs. right hip)
  • An inferior retractor (e.g. double-bend hohmann or Ranawat retractor) is placed immediately inferior to the transverse acetabular ligament (TAL) at the 6 o'clock position
  • A superior retractor (e.g. ball-spike or sharp hohmann) is placed under the abductor muscles at the 12 o'clock position and malleted into place
  • If necessary, a Gelpi retractor can be placed for additional posterior exposure
  • The anterior tine is placed under the abductors
  • The posterior tine is placed under the capsule to protect the sciatic nerve

2

Prepare the acetabular cavity

  • Using a long-handled knife and forceps, the labrum is circumferentially excised
  • The cotyloid fossa is identified and the pulvinar can be removed to expose the floor of the medial wall
  • This aids in assessing the depth of acetabular reaming
  • Circumferential reaming of the acetabulum is performed using sequentially-sized reamers
  • Start with a reamer ~4mm smaller than the measured femoral head size
  • Maintain appropriate center of rotation, abduction angle, and version
  • Sequential reaming by 2mm until peripheral rim fit achieved and bleeding bone visualized

3

Place Acetabular Components

  • The final reamer is positioned and the desired version is marked along the skin
  • Based upon the TAL, anterior, and posterior walls
  • The appropriate sized acetabular component is selected
  • 1mm larger than the last reamer
  • Acetabular component is secured to the appropriate insertion guide and malleted into place
  • Ensure appropriate abduction and version, circumferential rim fit, and that the component is fully seated
  • Assess component stability and bony purchase
  • Acetabular screws can be placed into the ilium for additional fixation if necessary
  • Remove overhanging osteophytes with a curved osteotome and mallet
  • Insert the poly
  • If proper positioning of the acetabular shell is uncertain, a trial poly can be used and the position can be verified on radiographs prior to final poly insertion
G

Femur: Exposure, Preparation and Trial Placement

1

Femoral Exposure

  • Flex and internally rotate the femur to visualize the canal
  • Protect the abductors by placing a hohmann retractor along the greater trochanter
  • Elevate the femoral canal from the wound and visualize the medial calcar using a Mueller retractor

2

Femoral Canal Preparation / Anteversion

  • The assistant rotates the leg so that the tibia is perpendicular to the operating room table
  • This facilitates determination of femoral anteversion
  • A rongeur is used to remove any residual superolateral femoral neck cortical bone
  • A box osteotome is set in appropriate anteversion and advanced with a mallet down the lateral aspect of the femoral canal
  • This sets the version for subsequent broaching
  • A canal finder is advanced manually down the intramedullary femur to guide the angle of subsequent reaming and broaching

3

Perform sequential reaming/broaching

  • Sequentially-sized lateralizing reamers are advanced to the appropriate level and removed until a good cortical fit is achieved
  • The preoperative template assists in determining appropriate sizing
  • Additional reaming may be necessary depending upon the femoral stem being used
  • Sequentially-sized broaches are inserted with a mallet until a cortical fit is achieved
  • Ensure the femoral canal is adequately lateralized and that the broach stems are not placed in varus angulation

4

Place Trial Femoral Head/Neck and Hip Reduction

  • Place the final broach seated to the desired depth with good cortical purchase and rotational stability
  • A rongeur or calcar planar can be used to remove any cortical prominences around the broach
  • Place trial femoral neck and head components
  • Size and offset determined by preoperative templating
  • Reduce the hip
  • A skid is placed under the femoral head to guide reduction into the acetabulum
  • The assistant performs the reduction maneuver (traction, external rotation, extension, and abduction) while the surgeon guides the femoral head into place
  • Assess stability and leg lengths manually
  • Obtain intraoperative AP pelvis radiograph
H

Assessing Stability and Leg Length Recreation

1

Assess Leg Lengths

  • Gross Assessment
  • Flex the operative leg to mirror the contralateral "down" leg position
  • Assess discrepancy between legs at the knee and at the heel
  • Excessive joint gapping with shuck test may indicate the leg is short
  • IT band tightness with hip extension and knee flexion may indicate the leg is long
  • Radiographic Assessment
  • Measure difference in heights between the most prominent aspect of lesser trochanters on both legs relative to line tangential to the inferior aspect of both ischial spines or the tear drops
  • Leg lengths should be within 5mm
  • If leg too long: decrease broach size and insert deeper vs. placing a minus head
  • If leg too short: increase broach size and leave proud vs. placing a plus head

2

ROM and Stability Testing

  • Ranawat combined version (RCV) determined by creating colinearity between the femoral ball and the acetabular liner and measuring angle between the leg and horizontal plane.
  • Ideal RCV 40-55 degrees
  • RCV > 55 degrees implies excessive anteversion - potential anterior instability or posterior impingement
  • RCV < 40 degrees implies inadequate anteversion - potential posterior instability or anterior impingement
  • Stability Testing
  • test posterior instability and anterior impingement in 90 degs of flexion, neutral abduction/adduction, and internal rotation
  • test anterior instability and posterior impingement in full extension, neutral abduction/adduction, and external rotation

3

Options/strategies available for optimizing stability and LLD

  • Liner trials (typically 4 options)
  • Femoral neck offset (typically 2 options)
  • Femoral neck length (implant system dependent)
  • Femoral head diameter (implant system dependent)

4

Methodology to obtain optimal stability and leg length recreation

  • Once leg length equality achieved, test ROM and stability (see above)
  • If hip unstable anteriorly, and... :
  • If RCV high, consider increasing anterior coverage
  • Option 1: cup repositioning (decreasing anteversion)
  • Option 2: altering liner used (face-changing vs lipped)
  • Option 3: stem version change (decrease anteversion if malverted)
  • If RCV acceptable, check for impingement posteriorly and remove etiology of dislocation
  • if instability persists, consider
    1. lateralized liner
    2. increasing femoral offset
    3. increasing neck length (last option)
  • If hip unstable posteriorly, and ... :
  • If RCV low, consider increasing posterior coverage
  • Option 1: cup repositioning (increasing anteversion)
  • Option 2: alternative liner (face-changing or lipped)
  • Option 3: stem version change (increase antevervion if malverted)
  • If RCV acceptable, check for any etiologies of impingement
  • If internal (component-component) impingement, follow low RCV algorithm
  • If external (non-component) impingement, remove anterior osteophytes or impinging etiology
  • If instability persists, consider
    1. ateralized liner
    2. increasing femoral offset
    3. increasing neck length
  • After assessing ROM and gaining adequate stability, recheck leg length
I

Placement of Final Components

1

Dislocate the hip and remove the trial components

  • The surgeon places a bone hook around the inferior femoral neck to guide the head while the assistant dislocates the hip
  • The head and neck trials are removed by hand, minimizing potential for compression on the sciatic nerve
  • A Mueller retractor is placed to elevate the femoral canal and expose the medial calcar
  • The broach handle is reattached and the broach is removed
  • Attention should be paid to the component anteversion and the depth of insertion as this should be replicated with the final implant

2

Implant Femoral Components

  • Visualize the femoral canal
  • retract abductors
  • clean the Intramedullary canal of all debris especially in zone of implant fixation/ingrowth
  • verify the implant is correct
  • check component size and offset on the box
  • place the femoral component
  • impact the femoral stem to the pre-broached depth and version with constant force per mallet blow
  • visualize the calcar to check for insertional fracture or fracture propogation if present
  • If fracture seen, remove the implant and place a circumfrential cable along proximal femur, followed by insertion of implant to pre-broached location with careful attention to the fracture and potential of fracture propagation
  • If fracture not seen, tonal change note with full seating of implant

3

Perform final trial and complete implantation

  • place the ball on trunion
  • If final components implanted at location of trials, optimal ball size verified an placed onto clean dry trunion
  • If any deviation between trial(s) and location of final components, re-optimize ROM, stability and leg length. Once achieved, final femoral head impacted as noted above

4

Test the components

  • relocate the hip and check ROM and LLD and stability
J

Wound Closure

1

Irrigate the Surgical Site

2

Confirm hemostasis

  • Pericapsular ring
  • Infra-acetabular (Obturator branches)
  • Gluteus maximus insertion (Medial Femoral Circumflex Artery)
  • Anterior/Supra-acetabular (Superior gluteal branches)

3

Evaluate the Sciatic nerve

  • visualize or palpate the Sciatic nerve for any direct trauma or evidence of excessive tension

4

Perform Posterior Myocapsular Repair

  • isolate the posterior capsule and the piriformis tendon
  • A suture is passed through the capsule and tendon of the superior limb of the T-capsulotomy with the needle directed away from the nerve
  • This is repeated for the inferior limb
  • Both suture limbs are passed through drill holes in the greater trochanter and tied in neutral rotation, ensuring that the myocapsular sleeve attaches directly to bone
  • The piriformis tendon is repaired with drill holes or a mattress suture at the superior aspect of the greater trochanter
  • Additional sutures are used to repair any gaps as needed

5

Fascial Closure

  • The TFL and gluteal fascia are re-approximated in a simple interrupted fashion
  • A running quill suture is used to reinforce the repair

6

Superficial Closure

  • Absorbable sutures are placed in simple interrupted fashion in the subcutaneous layer
  • A running subcuticular monocryle suture is placed
  • place steristrips or staples

7

Dressing Application

  • Surgical dressings applied per surgeon preference
  • place TED hose and SCDs to surgical leg

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • perform neurovascular exam
  • check range of motion
  • identify medical co-morbidities that might impact surgical treatment

2

Screen medical studies to identify and contraindications for surgery

3

Order basic imaging studies

  • radiographs
  • AP pelvis
  • AP/Lateral of affected hip

4

Perform operative consent

  • describe complications of surgery including
  • leg length discrepancy
  • infections
  • dislocations
  • thromboembolic dz
  • neurovascular compromise
  • peri-prosthetic fracture
  • deep hip sepsis
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT Prophylaxis
  • inpatient PT
  • weight bear as tolerated
  • posterior hip precautions

2

Appropriate medical management and medical consultation

3

Discharges patient appropriately

  • prescribe outpatient physical therapy
  • pain meds
  • DVT prophylaxis
  • schedule follow-up appointment in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • assess for risk of thromboemblotic disease

2

Orders and interprets required diagnostic studies

  • order and interpret AP pelvis, AP and lateral of the hip

3

Prescribes and manages nonoperative treatment

  • physical therapy
  • Nsaids
  • injections
  • activity modification

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
  • remove sutures
  • check radiographs
  • start resisted abductor exercises at 6 weeks
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI
  • CT
  • nuclear medicine imaging
  • advanced radiographs views

2

Appropriately recommends surgical intervention

3

Modifies and adjusts post-operative treatment plan as needed

4

Provides prophylaxis and manages thromboemblotic disease

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

  • treat infections
  • dislocations
  • neurovascular compromise
 

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