Intraoperative challenges in thr
- 1. Intraoperative Challenges in THR
- 2. • Prompt attention required for managing intraoperative problems associated with THR • The operating surgeon should be familiar with treatment options.
- 3. • Intraop problems - Anticipated Unexpected
- 4. Common intraop problems • Gain sufficient exposure • Achieving implant fixation • Correction implant position • Intraop fractures • Intraop limb length • Hip stability
- 5. Exposure Anticipate Challenging exposure • Prior surgery • Deformity • Stiffness • Heterotopic bone • Obesity • Muscle Bulk
- 6. 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
- 7. Exposure – How to get more exposure Acetabular retractors • Anteroinferior - under capsule /iliopsoas • Anterosuperior - anterior coloumn • Posteroinferior – ischium • Posterosuperior – posterior wall Lateral Approach
- 8. Exposure – How to get more exposure Femoral retractors • Curved retractor under gr. troch • Curved retractor under lesser troch. • Pointed retractor – piriform fossae Lateral Approach
- 9. Exposure – How to get more exposure • Posterior Approach Release Quad femoris Release inferior capsule
- 10. Exposure – How to get more exposure Acetabular retractors • Anterior - Retract femur • Inferior - Under transverse ligament • Posterior – Posterior wall Posterior Approach
- 11. Exposure – How to get more exposure Femoral retractors • Femoral elevator under lesser troch • Skid under greater trochanter Posterior Approach
- 12. 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
- 13. Acetabular press fit not good Anticipate • Small acetabulum • Acetabular dysplasia • Osteoporosis
- 14. Acetabular press fit not good Causes for poor fit • Inadequate exposure • Soft tissue interposition • Insufficient bone contact < 40 micron movement
- 15. Acetabular press fit not good Tips To improve implant bone contact • Uncovered cup – ream deeper • Cup has good lateral coverage – ream for larger diameter
- 16. Acetabular press fit not good • Supplemental screws - safe zone
- 17. 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
- 18. 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
- 19. Acetabular press fit not good – Fracture Look for fracture • Greater sciatic notch • Quadrilateral plate • Medial wall • Undisplaced – Multihole cup • Displaced – Supplemental plate fixation
- 20. 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
- 21. Optimizing acetabular component position • Safe zone Anteversion 15 Deg. +/- 10 deg Inclination 40 Deg +/- 10 deg Cup in safe zone Dislocation < 1.6% Outside safe zone – dislocation > 6.1%
- 22. Optimizing acetabular component position • Anticipate increased version Perthe’s DDH • Anticipate Retroversion FAI SCFE Previous osteotomies
- 23. Optimizing acetabular component Anteversion Tips to achieve acetabular component anteversion • Preop planning • Transverse acetabular ligament • Acetabular notch angle • Navigation
- 24. Femoral crack Anticipate • Osteopenia • Femoral deformity • Canal stenosis • Protrusio • Presence of stress riser – core decomp, DHS Nail
- 25. 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
- 26. Femoral crack Suspect if component goes deeper than the broach Expose the entire fracture Undisplaced – circlage Displaced – circlage Locked / Hybrid plate component with distal fit
- 27. Femoral crack Greater Trochanter fracture • Undisplaced - Tension band wiring • Displaced - Tension band wiring Claw plate Advancement plate
- 28. Femoral crack Shaft fracture Anticipate Altered anatomy / stress riser During dislocation – protrusio ( dislocate hip before hardware removal ) Undisplaced longitudinal crack – protected weight bearing Displaced - wiring plating longer stem
- 29. Unstable Hip Anticipate • Morbidly obese • Elderly • Alcohol • Substance abuse • DDH • Parkinsonism
- 30. Unstable Hip • Intraop assessment Leg length Offset Component orientation Range of motion – impingement
- 31. Unstable Hip- Restoring offset • Pre op planning and reproduce in post op X- rays • Intraop fixed devices • Intraop radiographs – supine position • Palpation bony landmark
- 32. 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)
- 33. Short leg • Shuck test – too much acetabulum head displacement • Dislocate easily due to impingement • Intraop – Re-evaluate acetabular component position • Height of femoral cut
- 34. Short leg Tips • Increase neck length – (Affects offset also Skirted neck – impingement) • Upsize the femoral component and leave it proud ( c.f. Fracture )
- 35. Long leg Intraop assessment • Flexion contracture • Cannot extend • Absent schuck test • Hip extended – knee cannot be flexed
- 36. 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
- 37. 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
- 38. Summarize • Intraop complication – ineveitable part of any surgery • Anticipating problems – reduce the event • Understanding treatment strategies – optimize treatment outcomes