Documente Academic
Documente Profesional
Documente Cultură
Editor
Ran Schwarzkopf MD MSc
Head of the Joint Replacement Service
Assistant Clinical Professor
Department of Orthopedic Surgery
University of California
Irvine Medical School
California, USA
Headquarters
Overseas Offices
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
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viii
Preface
The importance of constantly striving to improve our surgical knowledge and technique is exacerbated by the large
anticipated increase in patients requiring total hip arthroplasty in the coming decades. After spending many years
in the operating room and being challenged with a variety of difficult hip reconstruction cases, we felt that a useful
technique text was missing. With this need in mind, we formulated a guide that underlines the fundamentals of hip
arthroplasty and reinforces the techniques for performing complex and primary total hip arthroplasty.
Both patients and surgeons should remember that a successful outcome after total hip arthroplasty is the result
of both faultless surgical skills and properly designed implants. We should also have in mind that most importantly,
patient engagement starting preoperatively and continuing on through the perioperative and rehabilitation process is
fundamental in order to achieve patient satisfaction. This unique technique book about total hip arthroplasty covers
all aspects of surgical reconstruction of the hip in adults. This comprehensive text focuses on primary, complex and
conversion total hip arthroplasty. This text is not meant to be just a reference and didactic text. The book is intended
to be used as a clinical and surgical guide with step-by-step explanations of the various procedures and conditions.
It is a reference to be used while planning and preparing for both routine and less common surgical cases.
We envision surgeons and surgeons in training using the text for surgery planning and management of difficult
hip reconstruction cases.
The book contains 18 chapters that are organized in a way that allows quick and easy access while preparing for
a difficult and challenging case.
The emphasis of the text is on technique and may fall short on the amount of references cited, but each chapter
is accompanied by many images, radiographs and illustrations that help highlight the important points and skills
demonstrated. The authors of the various chapters were invited to contribute their knowledge and expertise in the field
of hip arthroplasty. The authors were selected based on their interest and skill related to the specific surgical technique
illustrated in their respective chapters. Each chapter includes a thorough background of the specific technique as
well as indications, contraindications, possible pitfalls and complications, and treatment options including both non-
surgical and surgical options. A step-by-step surgical technique is included in each chapter detailing and explaining
the procedure in depth.
We hope this textbook will become a reference in the ever-expanding toolbox of the hip arthroplasty surgeon.
Ran Schwarzkopf
Acknowledgments
I would like to express my deepest thanks to my many mentors at NYU Hospital for Joint Diseases for their continued
effort and excellence in teaching me the fundamentals of orthopedic surgery. Among my many outstanding teachers,
I would like to especially thank Dr William Jaffe, Dr Fredrick Jaffe, Dr Nirmal Tejwani, and Dr Toni McLaurin for
their special support. My highest gratitude goes to Dr Kenneth Egol and Dr Joseph Zuckerman; I would not be the
physician and educator I am today without them giving me a chance.
After experiencing many long days and evenings in the operating room, I came to recognize the remarkable
training I received during my fellowship at Brigham and Women’s Hospital in Boston. I would like to thank my
teachers and mentors there, who patiently and skillfully taught me cutting edge total joint arthroplasty and revision
surgery. Among which are Dr Estok, Dr Brick, Dr Ready, Dr Fitz, Dr Scott, and Dr Thornhill.
I am grateful to Ms Chetna Malhotra Vohra (Senior Manager–Business Development), Saima Rashid (Development
Editor) and all the staff of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, for hard work and
patience.
Last but not least, I would like to acknowledge my current colleagues at University of California, Irvine, who
strongly support my work and passion.
Contents
Contents
15. Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures 134
Behnam Sharareh, Ran Schwarzkopf
• Authors’ Preferred Technique 140
xv
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
17. Complications after Total Hip Replacement 155
Carlos M Alvarado, Ran Schwarzkopf
• Venous Thromboembolic Disease 155
• Instability 156
• Limb-Length Discrepancy 157
• Periprosthetic Fractures 158
• Postoperative Infection 159
• Peripheral Nerve Injury 162
• Vascular Injury 162
18. Pain Management and Regional Anesthesia for Total Hip Arthroplasty 167
Leslie Garson, Kyle Ahn
• History of Pain Management for Total Joint Arthroplasty 167
• Pain 168
• The Multimodal Analgesia Concept 169
• Regional Anesthesia for Total Hip Arthroplasty 173
• Evidence-Based Medicine 175
Index 179
xvi
Drivers of Hip
Replacement
Surgery
S Samuel Bederman
Rates of total hip arthroplasty have been steadily increasing over the past several decades and the current trends of
healthcare costs are unsustainable. While total hip arthroplasty is a cost-effective procedure, there is considerable
regional variation that cannot be explained by the variation in disease prevalence alone. Other factors, therefore,
must play a role in driving surgical rates in specific geographic areas. A systematic review of 28 articles focused on
drivers for surgery on the degenerative hip, knee, and spine found that arthroplasty rates were associated with health
service utilization factors, namely, demographic, social structure, health beliefs, personal and community resources,
and medical need.1
Age followed an inverted U-shaped distribution (peak age 60s–70s) and higher rates were found for female gender.
Postsecondary education, higher income, obesity, nonminority race/ethnicity, and rural residence were social structure
factors associated with higher arthroplasty rates. The willingness of patients to consider surgery was associated with a
more than 3-fold higher arthroplasty rate (health beliefs).2 Several studies evaluated the influence of insurance status
on the likelihood of undergoing arthroplasty.3-5 The authors concluded that insurance coverage (personal resources)
was a strong predictor of surgical treatment.1 Several community resources, such as surgeon supply, hospital volume,
supply of operating rooms, and hospital costs, were associated with higher arthroplasty rates while supply of other
physicians (including anesthesiologists) and regional hospital supply predicted lower surgical rates.1 While surgeon
enthusiasm to recommend surgery was associated with higher knee arthroplasty rates, no studies looking at hip
arthroplasty have been performed.6 A history of degenerative osteoarthritis and the presence of physical limitations
were two factors of medical need both found to be associated with higher arthroplasty rates.1
Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies
that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates
may be reduced.
References
1. Bederman SS, Rosen CD, Bhatia NN, et al. Drivers of surgery for the Degenerative Hip, Knee, and Spine: A Systematic
Review. Clinical Orthopaedics and Related Research 2012;470(4):1090-105.
2. Hawker GA, Guan J, Croxford R, et al. A prospective population based study of the predictors of undergoing total joint
arthroplasty. Arthritis Rheum. 2006;54:3212-20.
3. Dunlop DD, Manheim LM, Song J, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries.
Med Care. 2008;46:200-208.
4. Dunlop DD, Song J, Manheim LM, et al. Racial disparities in joint replacement use among older adults. Med Care.
2003;41:288-98.
5. McWilliams JM, Meara E, Zaslavsky AM, et al. Medicare spending for previously uninsured adults. Ann Intern Med.
2009;151:757-66.
6. Wright JG, Hawker GA, Bombardier C, et al. Physician enthusiasm as an explanation for area variation in the utilization
of knee replacement surgery. Med Care. 1999;37:946-56.
Chapter
Early Development of
1
Total Hip Arthroplasty
William C McMaster
“Those who cannot remember the past are condemned to repeat it.”
George Santayana (1863-1952)
The Life of Reason, Volume 1, 1905
In his essay on the development of arthroplasty, FR The Steinbergs cited in their monologue that T Gluck in
Thompson made the case that it was Lister’s introduction 1890 performed a hip arthroplasty using ivory femoral
of aseptic surgery in 1888 that set the stage for all and acetabular components cemented by resin/pumice
subsequent innovation in the field.1,2 Jones eloquently and plaster of Paris.6,11 Others performed arthroplasty
memorialized Lister’s contributions in 1948.2 Previous procedures but with various soft tissues interpositions of
attempts of joint arthroplasty were performed at great fat, muscle and fascia. In the US, JD Murphy in Chicago
risk. While those surgeons were indeed brave, they can began with interposition arthroplasty in 1902 and
hardly be described as heroic and their patients must have reported satisfactory results that established this practice
been desperate.3 As early as 1826 in the US, JR Barton in the US and Europe.12,13 He included trochanteric
performed a subtrochanteric osteotomy on an anklyosed osteotomy, the use of reaming instruments and wiring
hip in a sailor in an attempt to promote a pseudarthrosis.4 the trochanter during repair which portended to current
To read this chronicled account is a fascinating insight techniques. This concept development continued with
into the art of surgery of the time.5 Resection of the hip contributions from Baer14 using chromicized pig bladder,
as a solution was also attempted to address this issue Campbell15 and Mac Ausland16 who employed fascia
and was performed by White in 1821 and later by Fock lata. However, reviews of the clinical results of these
in 1859.1 The Steinbergs have chronicled the continued procedures and pathologic assessment of these interface
evolution of this technique.6 Early advocates in the US results raised further questions and stimulated efforts to
included Bigelow in 1852 who performed this procedure innovate. Allison and Brooks17 in the US observed in the
for tuberculosis7 and then later by New York surgeon, laboratory that the interposition material did not survive
Sayre.8 It was GR Girdlestone at Oxford who perfected but was replaced by connective tissue originating from
this procedure which carries his name today. Popular in the host bone. These observations were corroborated by
Europe for the management of arthrosis, the persistent Phemister and Miller.18
disability following this technique was not broadly Surgical operations to address failures in the treatment
accepted in the US.9 The presence of a mobile supportive of femoral neck fracture led to a number of arthroplasty
hip was a likely impetus to continued search for a surgical surgeries whereby the truncated femoral neck was
approach to preserve that functionality. Both Thompson articulated within the acetabulum and the trochanter was
and Scales cited Carnocham with the first arthroplasty variably repositioned. These included the procedures of
attempt for ankylosis with a prosthetic material, in this Albee,19 Whitman,20 Colonna,21 Luck,22 and Wilson,23 all of
case wood in the temporomandibular space in 1840.1,10 which were variably successful but often left much residual
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
disability. Similarly, congenital hip dysplasia, often long in 29% and an additional 17.2% with constant awareness
undiagnosed, provided a demanding challenge and yet of the implant. The series revision rate was 22.5%.31 The
an opportunity for innovation. The breath of deformity discussers of this report expressed concerns with these
confronting the surgeon reached from simple dysplasia outcomes which were echoed by other reports in the
to frank dislocation and a lack of acetabular bone stock literature. The microscopic histology of the glistening
which can be daunting even today. Simple dysplasia was layer initially described by Smith-Peterson was well
treated with a variety of acetabular coverage procedures identified by Aufranc’s clear high power micrographs
such as the Albee shelf in 1915, which turned down the as fibrocartilage, which Boyd pointed out is not typical
lateral ileum and blocked it with an autograft.24 When of hyaline cartilage.32 The persistent frustration with
used in the proper indications, the results were often this approach to managing hip arthrosis stimulated
satisfactory. Gill confirmed these results in 193525 as did further efforts to improve patient outcomes and surgeon
Ghormley in 1931,26 and Compere and Phemister in 1935.27 satisfaction. A number of general developmental con
In 1936, Colonna reported on a capsular arthroplasty which cepts addressing hip arthrosis branched out from this
involved deepening the original deficient acetabulum and beginning. Three paths of innovation resulted: surface
transferring the femoral head into it while covered by the replacement, endoprosthesis and total hip arthroplasty.
redundant hip capsule; this is an example of a reversion to Attempts to improve on the cup arthroplasty concept,
the interposition of soft tissue concept.28 which in itself had been a key development, saw some
It is fascinating how ideas evolve into application; interesting iterations many of which were indeed
often quite old concepts reappear, are reintroduced advanced in concept and persist today as boutique
and often with the same old results. One wonders how options. Haboush implanted a double cup concept of
this happens. Is it frank ignorance of past experience separate metal coverings of both for the femoral head
or ego that assures the outcome in one’s hands will be and acetabulum with the implants secured by dental
better? Rather it is the open mind that makes a seminal methyl methacrylate in 1953.33 This appears to be the
connection with a casual observation. So it seems to first human account of the use of acrylate to secure a
have been with Smith-Peterson of Boston who observed joint arthroplasty. Others were also intrigued with this
in 1923 the investing membrane about a foreign body of concept of fixation, and Leon Wiltse in 1952 in the US
glass in the back of a patient. It had been present for began animal experimentation with methyl methacrylate
a year and was surrounded by minimal fibrous tissue identifying its properties, systemic effects, and ability to
lined by a glistening synovial sac that contained clear fix prostheses to bone including a Vitallium total elbow
yellow fluid. This observation led to his initial use of a prosthesis in a monkey subject.34 In 1951, John Charnley
glass mould arthroplasty for the hip.29 Unfortunately, the employed a double cup replacement of the hip with an
brittle nature of glass led to fracturing. However, the gross interposition of a Teflon® cap on a shaped femoral head
anatomy at revision showed a glistening covering to the and a metal acetabular liner without fixation which
femoral head and acetabulum reaffirming his original failed due to inflammatory reaction to wear debris and
observation. Abandoning glass, Smith-Peterson tried loosening of the prosthesis components.35 In 1952, Charles
Viscaloid in 1925 and Bakelite in 1937, but there was too Townley of Michigan developed a metal femoral head
much foreign body reaction, perhaps another clue to the hemiarthroplasty capping a shaped native femoral head
future. Smith-Peterson tried a new hard glass in 1933, and this device achieved credible results.36 In an attempt
Pyrex, theoretically strong enough, but they also broke. to expand this to a total arthroplasty, in 1960 he tried
It was his dentist, Dr John Cooke, in 1937 who suggested unsuccessfully to employ polyurethane to secure a metal
Vitallium, a non-iron-based alloy of molybdenum, cobalt femoral head and to line the acetabulum, but reactive
and chromium.30 He implanted the first so constructed wear debris caused failure of the implant.6,37 Maurice
cup arthroplasty in 1938 and went on to implant 500 by Muller of Berne, Switzerland made an early unsuccessful
1948.29 This operation became the common management attempt in 1968 to produce a double cup arthroplasty
of hip arthrosis in the decades of the 1930s and 40s on of cobalt chrome alloy which failed due to instability
both sides of the Atlantic. Aufranc reported on 1000 cup of the femoral component.35 Others developed similar
arthroplasties in 1957 from the Massachusetts General devices including Gerard who began in 1970 and went
2 Hospital with 85% good results but with moderate pain through several iterations of articular bearing materials.38
Early Development of Total Hip Arthroplasty
Trentani in Bologna, Italy,39 Furuya in Tokyo,40 Freeman whereas that of Moore contained fenestrations to allow
in London,41 and Wagner in Germany42 continued work bone interlocking.52 Other concepts include a stemmed
and implanted devices outside of the US. In the US, two device by Lippmann of New York with a femoral head on
devices gained prominence; the first, developed by Eicher a supporting trunion within the femoral neck.53 As these
was a cemented double cup and was carried forward by devices addressed only replacement of the femoral head and
Capello.43,44 Amstutz was also an early proponent of this not the acetabulum, several modifications were developed
concept and has continued in its refinement up to the to address this. Marshall Urist conceived a device which
present day.45,46 However, because of ongoing outcomes placed a Vitallium liner in the reamed acetabulum; he then
issues, concerns associated with broader dissemination, shaped the femoral head with reamers and articulated the
and possibly the demanding technical nuances, this reamed native head on the acetabular prosthesis.54 Gerard
concept, double cup, continues to struggle to gain wide used a shell for the acetabulum and combined it with
acceptance. a prosthetic head for the femur.55 Murray reported that
The second line of development from cup arthroplasty both Giliberty and Bateman began in 1973 working on a
to managing hip disease and trauma is the femoral device called a bipolar endoprosthesis.56 The device had a
endoprosthesis in which the native acetabulum is femoral stem with a small head which was captured into
preserved. The development history of such devices goes the polyethylene liner of a patient-sized large metal femoral
to the early 20th century. Reports of the use of various head.57,58,59 There were two potential planes of motion
construct materials employed included reinforced in this coupled prosthesis which afforded dislocation
rubber by Delbet in 19199 and Ivory by Hey-Groves in protection of the larger femoral head.60 A self-centering
1927.47 Both were interesting ventures but rudimentary. concept was added later to maintain the larger head
In the late 1930s, Bohlman from Baltimore, who had in a relative valgus attitude preventing it from rotating
gained animal experimental experience with metal hip into varus by slightly offsetting the respective centers
replacements, teamed up with Austin Moore of South of rotation of the two concentric spheres. There was
Carolina to devise a Vitallium replacement for a patient preferential motion during ambulation within the smaller
with a massive giant cell tumor of the proximal femur articulation based on the lesser surface frictional torque
which they then implanted in 1940. This was successful in the smaller head motion plane. Bateman referred to
and survived 1½ years until the patient’s demise and this as “an easy total hip”.61 This type of device continues
led to a groundbreaking report in 1943.48 About the in use today and has gained popularity when used to
same time Thompson reported that Hudeck in New York replace the fixed head endoprosthesis for managing
placed a similar independently developed device for a femoral neck fractures.
case of upper femur malignancy.1 Following World War However, the ultimate challenge was to develop a true
II, a flurry of new concepts appeared including the Judet total hip arthroplasty. This was not only a modern goal, as
brothers of Paris who developed a femoral head device there are accounts of a cemented arthroplasty performed
made of acrylic plastic in 1950,49 and reported on 300 in the late 19th century. T Gluck in 1890 reported
implants in 1952.50 The early results were quite satisfying implanting ivory femoral and acetabular components
with relief of pain and restored range of motion. However, cemented by resin/pumice and plaster of Paris.62 In 1958,
with time, wear debris reactivity, loosening and breakage Wiles reported on six total hip arthroplasties performed
marred the concept of acrylic as a bearing surface but in 1938 with stainless steel components secured with
prompted investigations into devices constructed of screws.63 McKee from Norwich began designing concepts
Vitallium. FR Thompson in 1950 devised such an implant of total hip arthroplasty around 1940.64 However, actual
designed to replace the femoral head and neck with a implants were not done until 1948. The initial two were
short-curved intramedullary stem which was press fit into fabricated in stainless steel and failed within a year
the prepared medullary canal. He began implantations due to loosening. The third employing screw fixation
in 1951 through a Smith-Peterson anterior approach, of the cobalt-chromium metal-on-metal surfaces was
the curved stem facilitated insertion.51 Austin Moore of successful for 3 years.65 McKee reported a later series
South Carolina continuing his earlier work developed a from 1956 to 1960 that had a 54% success rate in
similar device with a longer straight press-fit stem for 40 cases using revision as an endpoint after he modified
stability. The stem of Thompson’s prosthesis was solid and adopted the press-fit femoral component of FR 3
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Thompson following a visit to the US in 1953. The head a reduction in friction at the articular surfaces, a variety of
was articulated against a cloverleaf-shaped acetabular materials were employed for the socket including Teflon
component fixed with a large central screw and two which caused a severe reaction to wear debris. Charnley
or three smaller peripheral screws.64 Later, McKee and then changed materials to filled Teflon® (Fluorosint,
Farrar modified the acetabular prosthesis and adopted Polypenco) in 1963, which also demonstrated poor wear
the acrylic cement fixation method.66 Similarly, Peter resistance. The “filled” Teflon composites contained glass
Ring from Redhill introduced a metal-on-metal total hip fiber or synthetic mica. With the filled material, there was
arthroplasty in 1964 with a long screw fixed acetabular significant wear of the metal head associated with release
component against an uncemented Austin Moore femoral of the abrasive adds-ins that caused blackening of the
endoprosthesis, again an assimilation of a successful surrounding tissues with metal debris. He stated, this
US device.67 Peter Ring noted that it was Scales in 1968 experience emphasizes caution in taking laboratory tests
who established that cobalt-chromium was superior to too much for their face value. This may happen if carbon
other metals or combination of metals as an arthroplasty fibers are incorporated.75 This statement was especially
bearing coupling.68 The original configuration of the prophetic in that this eventually became a commercially
Moore stem with its short neck was too short, and available product, and the results were as he predicted.76
restricted range of motion especially abduction. So, It was in 1962 that Charnley finally began the use of
Ring redesigned the neck to extend its length, employed high molecular weight polyethylene (HMWPE) for the
a 40 mm femoral head diameter and a flange to sit on acetabular component. Initially, these components were
the calcar of the resected femoral neck. By 1974, Ring press fit into the prepared bone. Charnley continued use
reported on 1000 implants with this technology without of the 22 mm stainless steel head, which was the most
the use of cement for the femoral component fixation. His practical way to reduce frictional torque at the bearing
results indicated a low mortality of 1.1%, deep infection surface and minimize loosening of the socket.77
rate of 0.7% and a dislocation rate of 0.3%. His results While the final choice of HMWPE as the socket material
continued to hold, and at a 14-year follow-up review of was an important change, it was the seminal technical
the results, he reported only a 5.5% revision rate.69 He adoption of acrylic fixation of both the acetabular and
too eventually adopted a modified prosthesis to employ femoral components that really began the modern era
the cement fixation concept. However, even then there of total hip arthroplasty. Charnley credits Wiltse34 for the
were concerns about metal reactivity70 and descriptions initial experimental studies that identified the successful
of “large bursae” behind a metal-on-metal prosthesis.69 application of acrylic cement in the animal model to fix
Those concerns were not only his but those of others,71,72 hip prostheses.78 As early as 1951, Kiaer described using
and portend issues we have now revisited in the 21st self-polymerizing acrylate dental cement to fix six Judet
century with metal-on-metal bearing surfaces. acrylic prostheses to bone.79 Haboush in 1953 published
It was John Charnley from Manchester who accounts of its use in securing human arthroplasties.33
championed the concept of low-friction arthroplasty first Smith, working with Charnley in Manchester, recounts
introduced by him in 1961 and emphasized the theory that they later found that Gluck in Germany62 had
of the small 22 mm head against a thick socket.73 This actually cemented total hip and knee components
concept was generated out of a time when fixation of the made out of ivory in 1840 with cement of colophony,
acetabular component was without the stability afforded pumice and plaster of Paris.80 Charnley demonstrated
by acrylic cement and focused on the long-term stability that despite possible shortcomings and concerns about
of the socket component. Charnley became aware of the thermal necrosis or toxicity of the monomer, acrylic
effect of torsional friction and articular surface lubrication cement does not bond chemically to bone but results in
from an observation of a patient with a Judet acrylic a mechanical lock onto the cancellous bone by a durable
prosthesis, which squeaked. Charnley surmised that the interdigitation at the porous bone interface, much as a
high frictional torque under load of the large head against grout, which evenly transfers load from the prosthesis to
the rough acetabular surface was resisting motion within bone.81 Charnley began working with his acrylic cement
that interface, and that the movement of the “joint” was application from about 1957, operated on the first case in
actually occurring between a loosened prosthesis stem Manchester in 1958 and reported his results in 1960 where
4 and the femur.74 In his pursuit of the ideal lubrication and he credits Smith with advice on the formulation of the
Early Development of Total Hip Arthroplasty
cement and eventually in making it radio-opaque.78 The wear debris from the acrylic cement.90,91 This process
original formulation of acrylic resulted in a transparent became known as cement disease although the cement
material that was radiolucent and created some issue was not the only generator of reaction and eventually
when interpreting postsurgical imaging and assessing polyethylene was found to be the main culprit.92,93 The
the cement to bone interface. In the beginning, Charnley significant aggressive consequences of osteolysis led to
used a dental formulation but eventually modified its the emergence of a broad discipline centered on the
setting properties, viscosity, radiopacity to his liking, biologic response to wear particle debris. A separate but
which included adding barium sulfate and resulted in the related study of lubrication, wear of bearing interfaces,
commercial CMW cement in 1966.78 Others working in and the release of material encompasses the discipline
the field developed different formulations and a variety of of tribology.
commercial acrylic cement products. Cementing methods Early on there were reports of intraoperative deaths
evolved over time as assessment of failures identified associated with introduction of the cement.94,95 There were
the technique shortcomings. Johnson chronicled the several possibilities of causation including fat and marrow
progression of technique changes and his very successful contents embolization associated with the intrusion of
results with the Charnley prosthesis from 1971 until the the cement into the opened medullary canal.96,97 The
early 1980s. He began with simple finger packing of the
potential role of the volatile acrylic monomer was also
doughy cement, later he began using a distal plug to
investigated. The circulatory effects of acrylic monomer
contain the cement, and he improved canal preparation.
were investigated in animal models.98-102 Modifications of
Further advancements included pressurization of the
surgical technique to reduce these effects, by venting the
cement, reducing cement porosity during mixing, and
femur shaft with a drill hole or the use of canal aspiration
use of a distal centralizer on the stem.82 William Harris
with a catheter connected to suction, were employed.97
of Boston and others demonstrated optimized cementing
It is probable that either mechanism can induce sudden
technique as the key to long-term successful component
death, and that they may work in concert. The negative
survival.83,84 A standard of evaluating the cement to bone
impact of circulating monomer seemed accentuated by
interface by regional zones in the femur was devised by
a patient’s low blood volume.102
Gruen.85 A similar scheme for the acetabular cement was
Many individuals and centers have introduced inno-
devised by DeLee and Charnley.86 The suggested optimum
cement mantle was defined as 1–3 mm thick in Gruen vations and variations on the original Charnley concept
zones 2–6 and 4–7 mm thick in zones 1 and 7, and that the in order to address unanticipated clinical outcomes.
metallic stem should achieve a canal fill of greater than Examples include: mechanical failure of the cement
50%.87 Poor cement fill of the femoral canal while using bond; osteolysis-induced bone loss; aggressive biologic
the finger packing method seemed to be an issue, as well responses to wear debris; and medical complications
as inclusion of biological material that created voids in such as venous thromboembolism and infection. There
the cement mantle thus weakening it. Once the Charnley will continue to be a constant flow of challenges with each
technique became widespread and longer-term follow-up technical advance or adoption of new implant materials.
surveys were reviewed, a concern about aseptic fixation There is value in knowing the history of the development
failure in total hip components, without evidence of of a surgical success such as total hip arthroplasty and
infection, arose and found to be associated with erosions to appreciate the failures and frustrations that had to
of bone stock (later known as osteolysis).88 Amstutz also be absorbed and solved in order to continue forward to
reported a number of modifications to the cementing a truly breakthrough innovation. Total hip arthroplasty
technique in order to address this issue including: distal has been an enduring and highly successful procedure
medullary canal plugging; cleaning and drying of the providing great value in the challenge to improve the
prepared canal; syringe insertion of the cement; proximal quality of patient’s lives. Knowing this history affords one
pressuring of the cement column; and avoiding motion the perspective that many proposed clinical innovations
of the stem while the cement hardened.89 Willert studied are actually reincarnations of long forgotten failures,
the osteolysis phenomenon and demonstrated it to be and without that knowledge those failures and their
an inflammatory process associated with particulate consequences to society will be re-experienced.
5
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
8
Chapter
Total Hip Arthroplasty—
2
Templating
Steven J Schroder, Ran Schwarzkopf
A B
11
Figs 2.2A and B: Increased femoral offset status post total hip arthroplasty
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 2.3: Acetabular offset is defined as the distance between Fig. 2.4: Combined offset combines femoral and acetabular offset
the acetabular center of rotation and a perpendicular line to the but includes the femoral head center and therefore cannot be used
interteardrop line to decipher moment arms or reactive forces
from a fixed point on both sides of the pelvis and the and less susceptible to positional changes due to pelvic
floor. Although not commonly reported as an absolute rotation and is the recommended reference point
number, LLD can be clinically measured with the patient (Fig. 2.6).56,60,61
in a supine position by using a tape measure from the Discrepancies between leg length and hip length
anterior superior iliac spines to the medial malleoli or should be thoroughly investigated. If these two values are
with the patient standing by inserting blocks of known essentially the same, then the majority of shortening is
thickness under the shortened leg until the iliac crests likely attributable to hip pathology, such as loss of hip joint
have equal heights. However, general consensus states space and migration of the femoral head as well as soft
radiographic measures of LLD are more accurate and tissue involvement including adduction/abduction and
reliable than clinical measures.52,53 Radiographically, LLD flexion contractures.62 On the contrary, a large disparity
can be measured as the difference between the inferior in values should prompt a thorough history and clinical
margin of the teardrop and a line parallel to the floor. examination of the lower extremities to account for the
These measurements are all encompassing and account differences.25 These findings can significantly alter the
for differences in length due to degenerative disease of
the hip to malunions of old lower extremity fractures
(Fig. 2.5).
Hip length, however, is defined as the radiographic
comparison between hips and the shortest distance from
a line intersecting fixed points on both sides of the pelvis
and fixed points on the proximal femora.25 Hip length is
reliably assessed through various measurements taken
from an AP pelvic radiograph.54,55 Commonly used points
on the proximal femora are the most medial prominence
of the lesser trochanters and centers of femoral head
rotation. These points are then typically referenced to
the pelvic interteardrop line or bi-ischial line.55-59 Hip
length defined by the interteardrop line and the lesser
trochanters demonstrates reliable intraobserver55 and
12 interobserver60 agreement within 1 mm. The interteardrop Fig. 2.5: Leg-length discrepancy measured radiographically from
line has been found to be a more consistent landmark the anterior superior iliac spines to the medial malleoli
Total Hip Arthroplasty—Templating
Fig. 2.6: Hip length is defined as the perpendicular distance from Fig. 2.7: The software package automatically detects the circular
the interteardrop line to the most medial prominences of the lesser limits of the marker’s image and prompts the user to input the known
trochanters size to define the image magnification
operative plan, as the disparity may not be appropriately appropriately adjust the scale of the templated implants
addressed solely with total hip arthroplasty. and define laterality. Skipping this step or inaccuracies in
calibration may lead to improper sizing of implants that
may lead to difficulties in the operating room or lack of
DIGITAL TEMPLATING ALGORITHM
appropriate implant sizes.
There are numerous digital templating software packages
currently on the market. No matter the manufacturer, Step 2: Determining Pelvic Axis and
there are a series of general steps that are universal in Hip Length
digital templating. This algorithm was developed using
OrthoView™ version 6 (OrthoView, LLC. Jacksonville, FL). This step is required to appropriately orient the acetabular
component as well as determine any hip length
discrepancy. Through software tools, the user defines
Authors’ Preferred Technique the interteardrop line (Fig. 2.9). This line establishes the
Step 1: Establishing Magnification
The initial step in digital templating is to scale the selected
radiograph. Software packages provide automated tools
that aid in this calibration step. If the radiograph was
taken with a ball bearing magnification marker, the
software can automatically detect the circular limits of the
marker’s image (Fig. 2.7). The computer then prompts the
user to define the known size of the marker and the type
of radiograph, AP, PA, lateral etc. If the scaling is based on
the known distance between magnification markers or a
contralateral prosthesis, the software package provides a
ruler feature that the user can apply to define the straight-
line distance in between points (Fig. 2.8). Similarly for
this feature, the user must input the known distance and
the type of radiograph being templated. Based on this Fig. 2.8: The software package allows the user to scale the image
information, the software is able to calibrate the image, based on known distances; as in this case, a contralateral prosthesis 13
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 2.9: The user must define the interteardrop line establishing Fig. 2.10: The user demarcates the most medial prominences of
the position of the pelvis and creating a frame of reference for the lesser trochanters of both femora and the computer determines
the software to position the abduction of the acetabular component the perpendicular distance from the interteardrop line as well as any
hip-length discrepancy
position of the pelvis and allows a frame of reference for for review. As in acetate templating, the acetabular
the software to position the abduction of the acetabular component is addressed first and verified to be positioned
component. Taken further, the user then can use this in an abducted angle of 40° ± 10°. Optimally, the
tool to demarcate the most medial prominences of the component should be sized to minimize the removal of
lesser trochanters of both femora. Once completed, the subchondral bone with the medial border adjacent to the
software can determine the perpendicular distance from ilioischial line allowing for sufficient lateral coverage and
the interteardrop line and the lesser trochanter points to the inferior edge at the level of the teardrop (Fig. 2.12).
identify any hip length discrepancy (Fig. 2.10). The component can be unlocked resized and manually
manipulated to ensure desired positioning.
Step 3: Determining Femoral Shaft Axis,
Head Size and Center of Rotation
The next step helps establish not only the femoral axis
onto which the prosthesis will rest but also the size of the
component. A software wizard requires the user to place
four points, two along the medial and two along the lateral
borders of the femur, both proximally as well as distally in
the metaphysis and diaphysis of the femur, thus creating
a quadrilateral. A computer algorithm then establishes the
femoral shaft axis. Next, the user is prompted to align three
points along the periphery of the femoral head. This process
allows the computer to employ a circle-of-best-fit operation
to determine the femoral head size and establish the center
of rotation (Fig. 2.11).
Fig. 2.12: The acetabular component should be manipulated to Fig. 2.13: Once the acetabular component is positioned, the
ensure that the medial border is adjacent to the ilioischial line and amount of uncovered lateral edge can be measured and matched
the inferior edge is at the level of the interteardrop line intraoperatively to ensure appropriate cup orientation
Once the positioning is established, the acetabular Step 5: Orienting and Sizing the
offset can be determined from the center of rotation and Femoral Component
compared to the contralateral side. Furthermore if lateral
coverage of the component is not complete, the amount The software recommended femoral component size
of exposed cup can be measured for intraoperative should provide adequate metaphyseal and diaphyseal
comparison and validation of proper cup abduction and fill but can be manually up or downsized as needed. The
position (Fig. 2.13). In more complicated cases, such stem can be maneuvered along the established femoral
as hypertrophic osteoarthritis and acetabular protrusio, axis to accommodate for any inadequacies in canal and
measurements of the amount of medial osteophyte to be metaphysis fit and fill (Fig. 2.14). The amount of hip
removed and the width of the medial void respectively lengthening provided is determined by the vertical distance
can be calculated during preoperative planning and between the center of rotation of the acetabular component
verified at the time of operation. and the center of rotation of the femoral head (Fig. 2.15).
Fig. 2.14: The femoral component size and position can be Fig. 2.15: The amount of hip lengthening is determined by the
manipulated to allow for adequate metaphyseal fit and fill vertical distance between the center of rotation of the acetabular 15
component and the center of rotation of the femoral head
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 2.16A and B: Decreasing the femoral head offset (A) decreases the amount of leg lengthening.
Increasing the femoral head offset (B) increases the amount of leg length
Therefore, a femoral head center of rotation cranial to the Prosthetic femoral offset should attempt to restore
acetabular center of rotation will result in limb lengthening. the native offset. Therefore, analogous to lengthening,
The counter is true when the femoral head center of rotation if the center of femoral head rotation lies medial to the
is caudal to the acetabular center of rotation. The desired acetabular component’s center of rotation then the offset
limb lengthening can be altered by several ways: changing will be increased. Conversely, if the femoral head center
the femoral component size and therefore positional depth of rotation lies laterally to the acetabular component’s
in the femur; increasing or decreasing the amount of center of rotation, the offset will be reduced. These
femoral neck resection; modular neck implant options; and measures can be altered with high-offset neck choices
different femoral head offsets (Figs 2.16A and B). and neck lengthening (Figs 2.17A and B).
A B
Figs 2.17A and B: Standard (A) and high (B) offset necks can be chosen to restore native hip offset and biomechanics
16
Total Hip Arthroplasty—Templating
Fig. 2.18: Scaled measurement from the proposed level of neck Fig. 2.19: Scaled measurements from the head center of rotation to
cut to the shoulder of the lesser trochanter can be matched the tip of the greater trochanter and shoulder of the lesser trochanter
intraoperatively for appropriate prosthesis seating can provide intraoperative verification for restoration of length and
offset
Step 6: Determining the Level of Neck tip of the greater trochanter to the femoral head center
Resection and Other Measures of rotation are taken for intraoperative checks of length
and offset (Fig. 2.19).
Once the femoral component placement is confirmed,
the length of femoral neck resection necessary to
appropriately seat the prosthesis is found. This measure
SUMMARY
is taken either from the greater trochanter or more Successful total hip arthroplasty requires the surgeon to
commonly from the lesser trochanter to the proposed meticulously restore the native hip biomechanics, limb
level of neck cut (Fig. 2.18). Measurements from the length, and hip stability (Figs 2.20A and B). Preoperative
proximal corner of the lesser trochanter and from the templating compels the surgeon to mentally perform the
A B
Figs 2.20A and B: Preoperative and postoperative radiographs demonstrating restoration of native limb length and femoral offset
17
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
operation step-by-step and if done reliably, enhances 11. Gamble P, de Beer J, Petruccelli D, et al. The accuracy of
precision, improves surgical times, reduces the loss of digital templating in uncemented total hip arthroplasty.
bone stock and minimizes preventable complications, J Arthroplasty. 2010;25(4):529-32.
such as prosthetic loosening, instability and limb length 12. Whiddon DR, Bono JV, Lang JE, et al. Accuracy of digital
templating in total hip arthroplasty. Am J Orthop (Belle
discrepancy. Acetate templating remains the gold
Mead NJ). 2011;40(8):395-8.
standard; however, digital radiography has become more
13. Efe T, El Zayat BF, Heyse TJ, et al. Precision of preoperative
prevalent and software packages have become more digital templating in total hip arthroplasty. Acta Orthop
precise and user-friendly. Even with improved planning Belg. 2011;77(5):616-21.
through digital templating, unforeseen intraoperative 14. Shaarani SR, McHugh G, Collins DA. Accuracy of
contingencies may arise and appropriate adjustments digital preoperative templating in 100 consecutive
in the presurgical plan should be made to ensure a uncemented total hip arthroplasties: a single surgeon
satisfactory outcome. series. J Arthroplasty. 2013;28(2):331-7.
15. Carter LW, Stovall DO, Young TR. Determination of
accuracy of preoperative templating of noncemented
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J Bone Joint Surg Am. 2004;86-A(5):963-74. 18. Suh KT, Cheon SJ, Kim DW. Comparison of preoperative
3. Kawasaki M, Hasegawa Y, Sakano S, et al. Quality of templating with postoperative assessment in cementless
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5. Schwartz JT, Mayer JG, Engh CA. Femoral fracture 20. Clarke IC, Gruen T, Matos M, et al. Improved methods
during non-cemented total hip arthroplasty. J Bone for quantitative radiographic evaluation with particular
Joint Surg Am. 1989;71(8):1135-42. reference to total-hip arthroplasty. Clin Orthop Relat
6. Aldinger PR, Jung AW, Pritsch M, et al. Uncemented Res. 1976;(121):83-91.
grit-blasted straight tapered titanium stems in patients 21. White SP, Shardlow DL. Effect of introduction of digital
younger than fifty-five years of age. Fifteen to twenty- radiographic techniques on pre-operative templating
year results. J Bone Joint Surg Am. 2009;91(6):1432-9. in orthopaedic practice. Ann R Coll Surg Engl.
7. The B, Verdonschot N, van Horn JR, et al. Digital 2005;87(1):53-4.
versus analogue preoperative planning of total hip 22. Conn KS, Clarke MT, Hallett JP. A simple guide to
arthroplasties: a randomized clinical trial of 210 total determine the magnification of radiographs and to
hip arthroplasties. J Arthroplasty. 2007;22(6):866-70. improve the accuracy of preoperative templating.
8. Unnanuntana A, Wagner D, Goodman SB. The accuracy J Bone Joint Surg Br. 2002;84(2):269-72.
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arthroplasty. J Arthroplasty. 2009;24(2):180-6. radiographs of the pelvis. A prospective trial of two
9. Gonzalez Della Valle A, Comba F, Taveras N, et al. methods. J Bone Joint Surg Br. 2006;88(11):1508-12.
The utility and precision of analogue and digital 24. The B, Diercks RL, van Ooijen PM, et al. Comparison
preoperative planning for total hip arthroplasty. Int of analog and digital preoperative planning in total hip
Orthop. 2008;32(3):289-94. and knee arthroplasties. A prospective study of 173 hips
10. Iorio R, Siegel J, Specht LM, et al. A comparison of and 65 total knees. Acta Orthop. 2005;76(1):78-84.
acetate vs digital templating for preoperative planning 25. Scheerlinck T. Primary hip arthroplasty templating
of total hip arthroplasty: is digital templating accurate on standard radiographs. A stepwise approach. Acta
18 and safe? J Arthroplasty. 2009;24(2):175-9. Orthop Belg. 2010;76(4):432-42.
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26. White SP, Bainbridge J, Smith EJ. Assessment of 41. Laine HJ, Lehto MU, Moilanen T. Diversity of proximal
magnification of digital pelvic radiographs in total hip femoral medullary canal. J Arthroplasty. 2000;15(1):
arthroplasty using templating software. Ann R Coll Surg 86-92.
Engl. 2008;90(7):592-6. 42. Hananouchi T, Sugano N, Nakamura N, et al. Pre
27. Bayne CO, Krosin M, Barber TC. Evaluation of the operative templating of femoral components on plain
accuracy and use of x-ray markers in digital templating X-rays. Rotational evaluation with synthetic X-rays
for total hip arthroplasty. J Arthroplasty. 2009;24(3): on ORTHODOC. Arch Orthop Trauma Surg. 2007;
407-13. 127(5):381-5.
28. Levine B, Fabi D, Deirmengian C. Digital templating in 43. Charles MN, Bourne RB, Davey JR, et al. Soft-tissue
primary total hip and knee arthroplasty. Orthopedics. balancing of the hip: the role of femoral offset restoration.
2010;33(11):797. Instr Course Lect. 2005;54:131-41.
29. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular 44. McGrory BJ, Morrey BF, Cahalan TD, et al. Effect of
impingement: a cause for osteoarthritis of the hip. Clin femoral offset on range of motion and abductor muscle
Orthop Relat Res. 2003;(417):112-20. strength after total hip arthroplasty. J Bone Joint Surg Br.
30. Giori NJ, Trousdale RT. Acetabular retroversion is 1995;77(6):865-9.
associated with osteoarthritis of the hip. Clin Orthop 45. Rubin PJ, Leyvraz PF, Aubaniac JM, et al. The morphology
Relat Res. 2003;(417):263-9. of the proximal femur. A three-dimensional radiographic
31. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro- analysis. J Bone Joint Surg Br. 1992;74(1):28-32.
acetabular impingement due to acetabular retroversion. 46. Noble PC, Alexander JW, Lindahl LJ, et al. The anatomic
Treatment with periacetabular osteotomy. J Bone Joint basis of femoral component design. Clin Orthop Relat
Surg Am. 2003;85-A(2):278-86. Res. 1988;(235):148-65.
32. Reynolds D, Lucas J, Klaue K. Retroversion of the 47. Lecerf G, Fessy MH, Philippot R, et al. Femoral offset:
acetabulum. A cause of hip pain. J Bone Joint Surg Br. anatomical concept, definition, assessment, implications
1999;81(2):281-8. for preoperative templating and hip arthroplasty.
33. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of Orthop Traumatol Surg Res. 2009;95(3):210-9.
pelvic tilt on acetabular retroversion: a study of pelves 48. Fackler CD, Poss R. Dislocation in total hip arthroplasties.
from cadavers. Clin Orthop Relat Res. 2003;(407):241-8. Clin Orthop Relat Res. 1980;(151):169-78.
34. Watanabe W, Sato K, Itoi E, et al. Posterior pelvic tilt 49. Little NJ, Busch CA, Gallagher JA, et al. Acetabular
in patients with decreased lumbar lordosis decreases polyethylene wear and acetabular inclination and
acetabular femoral head covering. Orthopedics. femoral offset. Clin Orthop Relat Res. 2009;467(11):
2002;25(3):321-4. 2895-900.
35. Tannast M, Murphy SB, Langlotz F, et al. Estimation of 50. Sakalkale DP, Sharkey PF, Eng K, et al. Effect of femoral
pelvic tilt on anteroposterior X-rays—a comparison of component offset on polyethylene wear in total hip
six parameters. Skeletal Radiol. 2006;35(3):149-55. arthroplasty. Clin Orthop Relat Res. 2001;(388):125-34.
36. Tannast M, Zheng G, Anderegg C, et al. Tilt and rotation 51. Blackley HR, Howell GE, Rorabeck CH. Planning and
correction of acetabular version on pelvic radiographs. management of the difficult primary hip replacement:
Clin Orthop Relat Res. 2005;(438):182-90. preoperative planning and technical considerations.
37. van der Bom MJ, Groote ME, Vincken KL, et al. Pelvic Instr Course Lect. 2000;49:3-11.
rotation and tilt can cause misinterpretation of the 52. Cleveland RH, Kushner DC, Ogden MC, et al.
acetabular index measured on radiographs. Clin Orthop Determination of leg length discrepancy. A comparison
Relat Res. 2011;469(6):1743-9. of weight-bearing and supine imaging. Invest Radiol.
38. Eckrich SG, Noble PC, Tullos HS. Effect of rotation 1988;23(4):301-4.
on the radiographic appearance of the femoral canal. 53. Terry MA, Winell JJ, Green DW, et al. Measurement
J Arthroplasty. 1994;9(4):419-26. variance in limb length discrepancy: clinical and
39. Noble PC, Kamaric E, Sugano N, et al. Three-dimensional radiographic assessment of interobserver and intra
shape of the dysplastic femur: implications for THR. observer variability. J Pediatr Orthop. 2005;25(2):
Clin Orthop Relat Res. 2003;(417):27-40. 197-201.
40. Sugano N, Noble PC, Kamaric E, et al. The morphology 54. Williamson JA, Reckling FW. Limb length discrepancy
of the femur in developmental dysplasia of the hip. J and related problems following total hip joint replace
Bone Joint Surg Br. 1998;80(4):711-9. ment. Clin Orthop Relat Res. 1978;(134):135-8. 19
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55. White TO, Dougall TW. Arthroplasty of the hip. Leg length 59. Ranawat CS, Rao RR, Rodriguez JA, et al. Correction
is not important. J Bone Joint Surg Br. 2002;84(3):335-8. of limb-length inequality during total hip arthroplasty.
56. Meermans G, Malik A, Witt J, et al. Preoperative J Arthroplasty. 2001;16(6):715-20.
radiographic assessment of limb-length discrepancy 60. Woolson ST, Hartford JM, Sawyer A. Results of a method of
in total hip arthroplasty. Clin Orthop Relat Res. 2011; leg-length equalization for patients undergoing primary
total hip replacement. J Arthroplasty. 1999;14(2):159-64.
469(6):1677-82.
61. Goodman SB, Adler SJ, Fyhrie DP, et al. The acetabular
57. Konyves A, Bannister GC. The importance of leg length
teardrop and its relevance to acetabular migration. Clin
discrepancy after total hip arthroplasty. J Bone Joint Orthop Relat Res. 1988;(236):199-204.
Surg Br. 2005;87(2):155-7. 62. Sayed-Noor AS, Hugo A, Sjödén GO, et al. Leg length
58. Matsuda K, Nakamura S, Matsushita T. A simple discrepancy in total hip arthroplasty: comparison of
method to minimize limb-length discrepancy after hip two methods of measurement. Int Orthop. 2009;33(5):
arthroplasty. Acta Orthop. 2006;77(3):375-9. 1189-93.
20
Chapter
Direct Anterior Approach for
3
Total Hip Arthroplasty
Evan M Schwechter, Gregory W Brick, John E Ready
DIFFICULT PATIENTS
As in other approaches, obese patients are more difficult
secondary to the larger dissection required. Usually,
however, the extent of fat overlying the anterior thigh is
less than that over the lateral or posterior thigh making
the DAA relatively more direct to the hip joint than other
approaches. Care should be taken in wound management
in patients with a large abdominal pannus that may come
in contact with the surgical wound, as the risk of wound
infection may be higher. Large, muscular males are also a
more difficult and challenging patient population, as the
bulky and taut TFL makes retraction more difficult. Offset
reamers and broaches should be available to assist during
this approach and especially during the more challenging
Fig. 3.1: Positioning in the ARCH table and
cases. Femoral exposure is commonly cited as the most
securing the operative leg
difficult portion of the procedure. This is made more
difficult by a patient with a short varus femoral neck and The operating room should be large enough to
by patients with iliac crests that have further lateral offset accommodate fluoroscopy positioned perpendicular to
than their respective greater trochanters. the long axis of the patient at the level of the hip. The
ipsilateral arm is draped over the chest and secured
with a sling, and the contralateral arm is placed on
EXAMINATION AND IMAGING an arm board placed at a right angle to the patient to
Standard preoperative examination for a patient who is a accommodate the proper C-arm position. The bed is
candidate for a DAA should include an assessment of hip elevated to a height that accommodates lowering of the
range of motion and leg length. This will help to direct C-arm enough to obtain an AP of the pelvis on a single
the extent of surgical exposure and plan for equalization image, but also high enough to be able to lower the leg
of leg lengths. In obese patients, the abdominal pannus enough to facilitate levering of the femoral neck out of
should be inspected to ensure it can easily be retracted or the wound during femoral exposure. In our experience,
taped out of the way during the procedure to allow access this is at least 36–39 inches from the floor to the side rail.
The bed should be slid as far distally as possible to allow
to the anterior thigh. Preoperative radiographs should
C-arm entry over the hip at 90° (Fig. 3.2).
include an anteroposterior (AP) pelvis and lateral of the
affected hip. The radiographs should be preoperatively
templated for surgical planning.
Fig. 3.4: The capsule overlying the femoral neck is exposed Fig. 3.5: The femoral neck is exposed and osteotomy site is marked
of the capsule and create a potential space with blunt template may be used to guide the proper orientation of
dissection with a Cobb elevator. A second cobra retractor the intended neck cut. If confirmation of correct position
is placed over the superior femoral neck and held by the of the femoral neck cut is desired, a fluoroscopic image
ipsilateral assistant (Fig. 3.4). may be used after making a small drill hole just superior
With the anterior capsule fully exposed, perform to the demarcated neck cut and placing a tonsil clamp.
a “T”-shaped capsulotomy initially along the entire The leg is then externally rotated approximately 40–50°,
intertrochanteric line, then proceeding vertically along and the femoral neck cut made perpendicular to the
the superior one-third of the femoral neck to the rim of calcar, taking care to avoid saw blade deflection into the
the acetabulum. Kocher clamps are helpful when placed greater trochanter (Fig. 3.6). A second osteotomy can be
on each capsular flap. Once the superior border of the made parallel approximately 1 cm superiorly, and with
acetabulum is reached, the dissection should proceed 6 cm of traction applied to the leg, this “napkin ring”
both superiorly and inferiorly along the acetabular rim. fragment may be removed with a Cobb and rongeur.
In the manner, the “T” capsulotomy is converted to The anterior MIS retractor is repositioned to lie directly
an “H.” A heavy braided suture, such as a #3 vicryl, is over the anterior acetabular wall. A power corkscrew is
placed in figure of eight fashion in both capsular flaps driven into the femoral head remnant and spun to tear
and clamped. The cobra retractors are now repositioned
intracapsularly. The femoral neck is now exposed as well
as any anterior acetabular or femoral neck osteophytes.
The soft tissue must be cleared off the medial femoral
neck with electrocautery down to the lesser trochanter
(Fig. 3.5).
A B
Figs 3.7A and B: (A) A power corkscrew is driven into the femoral head remnant and spun to tear the ligamentum teres;
(B) The femoral head is removed with inferior and outward pressure on the reamer handle
the ligamentum teres. The femoral head is removed with excised using electrocautery. The transverse acetabular
inferior and outward pressure on the reamer handle ligament may be debulked as needed (Fig. 3.8).
(Figs 3.7A and B).
Acetabular Preparation
Acetabular Exposure The femoral head is sized and the reaming begins several
The cobras are briefly removed and the inferior capsule is sizes smaller, initially directed medially, then in a position
excised or retracted to expose the acetabulum with a Gelpie of 40–45° of abduction and 15–20° of anteversion. An
retractor. A small incision is made with electrocautery offset reamer handle may be helpful. In some cases,
just inferior to the transverse acetabular ligament within inserting the reamer head into the acetabulum and
which the inferior cobra retractor is replaced. The superior then connecting it to the reamer shaft is indicated
cobra is replaced along the posterosuperior acetabular when there is difficulty inserting the entire component.
wall. Circumferential acetabular exposure should now be Correct orientation of the reamer is important to avoid
achieved. A headlamp is helpful for complete acetabular over anteverting the cup (Fig. 3.9). Final reaming, usually
visualization. The acetabular labrum and pulvinar are fully 1 mm less than intended cup size for a hemispherical
Fig. 3.8: Full exposure of the acetabulum is achieved Fig. 3.9: Proper orientation of the reamer is important 25
in order to avoid anteversion
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 3.10: Fluoroscopic image visualizing proper Fig. 3.11: Acetabular cup offset insert handle
acetabular reaming
Fig. 3.13: Starter femoral broach placed in the femoral neck Fig. 3.14: Trial broach, neck, and head are placed
27
in the femur for trial reduction
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 3.15: Fluoroscopic image of trial femoral implant in place Fig. 3.16: Fluoroscopic image with leg length measurement
and leg lengths (Fig. 3.15). Leg length may be assessed level of final femoral component seating, a trial reduction
by using a rod placed along the inferior ischial line, on may be carried out. Otherwise, the selected femoral head
an AP fluoroscopic image, and assessing the relative is impacted onto a clean trunion, and the hip reduced
distances to a point on the respective lesser trochanters. (Fig. 3.17B).
All of these metrics can be compared to the contralateral
hip with fluoroscopy (Fig. 3.16). Anterior hip stability
Closure
can be assessed by extending and externally rotating
the limb. The hip joint is thoroughly irrigated. The inferior capsular
The hip is dislocated by traction and external rotation. flap is either excised or sutured to the undersurface of the
A bone hook around the trunion is helpful. Changes in reflected head of the rectus femoris tendon. A drain may
offset, leg length and component sizing or positioning be placed deep in the joint. The fascia over the TFL is
may be made at this point and the hip retrialed. closed with running suture (Fig. 3.18). Subcutaneous skin
The trial components are removed, and the chosen closure is performed in standard fashion. Skin is closed
femoral stem is impacted (Fig. 3.17A). Depending on the with monocryl and Dermabond (Fig. 3.19).
A B
28
Figs 3.17A and B: (A) Final femoral implant impacted and seated; (B) Femoral head impacted and seated prior to reduction
Direct Anterior Approach for Total Hip Arthroplasty
Fig. 3.18: The fascia over the tensor fascia lata is Fig. 3.19: Final closer of the skin is done with
closed with a running suture monocryl suture and Dermabond
A B
Figs 3.20A and B: (A) Preoperative image of the degenerative hip prior to arthroplasty;
29
(B) Postoperative image after implantation of a total hip arthroplasty
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
community hospital setting, despite a major complication faster walking time, faster recovery of single leg stance
rate of 9%, Woolson described no dislocations in a series and improvement in the use of walking aids for patients
of 247 hips.11 treated with the DAA.5
Fracture CONCLUSION
Exposure of the femur is technically challenging, and The direct anterior approach for total hip replacement
does require stepwise soft tissue releases for adequate is not a new approach, but has seen widespread
visualization. Intraoperative fracture can occur at any acceptance recently by surgeons interested in avoiding
point during femoral preparation, and may involve the the complications of other approaches. Early functional
calcar, the greater trochanter, the femoral shaft or the
return and patient activity level is commonly cited as the
ankle. Femoral canal perforation, usually laterally, can
main reason a surgeon chooses to switch to the DAA.
also occur with broaching in a varus position.12 The
With the proper training and careful attention to detail
incidence of intraoperative fracture decreases as the
during the procedure, the learning curve complications
surgeon’s learning curve progresses.10 Matta reported
can be minimized. Because of the success of total hip
four calcar fractures (during femoral broaching), three
replacement surgery in general, patients can be assured
greater trochanter fractures (broaching, or femoral hook
that whichever surgical approach is chosen will offer an
placement), two femoral shaft fractures, and three ankle
excellent long-term outcome and return to an improved
fractures.4
quality of life.
Lateral Femoral Cutaneous Nerve
REFERENCES
An approach that strays too far medial along the TFL will
transect the LFCN. Care should be taken to incise the 1. Judet J, Judet R. The use of an artificial femoral head
fascia overlying the TFL muscle laterally, and perform for arthroplasty of the hip joint. J Bone Joint Surg Br.
subfascial dissection to approach the interval between 1950;32-B:166-73.
the TFL and sartorius muscle. In his series of 81 hips, 2. Rachbauer F, Kain MS, Leunig M. The history of the
Bhargava had 12 cases of numbness over the distribution anterior approach to the hip. Orthop Clin N Am. 2009;
of the LFCN.13 By 2 years postoperatively, only two 40:311-20.
remained unresolved. Berend reported two cases of LFCN 3. Light TR, Keggi KJ. Anterior approach to hip arthroplasty.
paresthesia which both resolved amongst 258 hips.14 Clin Orthop Relat Res. 1980;(152):255-60.
4. Matta JM, Shahrdar C, Ferguson T. Single-incision
OUTCOMES anterior approach for total hip arthroplasty on an
orthopaedic table. Clin Orthop Relat Res. 2005;441:
Several studies have shown more rapid recovery from 115-24.
total hip replacement performed through a DAA. Berend 5. Nakata K, Nishikawa M, Yamamoto K, et al. A clinical
reported a higher Harris hip score and lower extremity comparative study of the direct anterior with mini-
activity scale scores at 6 weeks postoperative when posterior approach. J Arthroplasty. 2009;24(5):698-704.
compared to a less invasive direct lateral approach.14 6. Sariali EE, Leonard PP, Mamoudy PP. Dislocation after
Restrepo, in a prospective, randomized study comparing total hip arthroplasty using Hueter anterior approach. J
the direct lateral approach with the DAA reported Arthroplasty. 2008;23(2):266-72.
more significant improvement in Short-Form Health 7. Seng BE, Berend KR, Ajluni AF, et al. Anterior-supine
Survey (SF-36) and Western Ontario and McMaster minimally invasive total hip arthroplasty: defining the
Universities arthritis Index (WOMAC) scores up to 1 learning curve. Orthop Clin N Am. 2009;(40):343-50.
year postoperative.15 Bhandari, in a multicenter cohort 8. Anterior Total Hip Arthroplasty Collaborative Investi
study of 1,152 patients reported a dislocation rate of gators, Bhandari M, Matta JM, et al. Outcomes following
0.6%, and early return to function, which plateaued by the single-incision anterior approach to total hip
3 months postoperative.8 In a study comparing the DAA arthroplasty: a multicenter observational study. Orthop
30 with a mini-posterior approach, Nakata et al. found a Clin North Am. 2009;40(3):329-42.
Direct Anterior Approach for Total Hip Arthroplasty
9. Siguier T, Siguier M, Brumpt B. Mini-incision anterior 13. Bhargava T, Goytia RN, Jones LC, et al. Lateral femoral
approach does not increase dislocation rate. Clin cutaneous nerve impairment after direct anterior
Orthop Relat Res. 2004;426:164-73. approach for total hip arthroplasty. Orthopaedics. 2010;
10. Jewett BA, Collis DK. High complication rate with
anterior total hip arthroplasties on a fracture table. Clin 33(7):472.
Orthop Relat Res. 2011;469(2):503-7. 14. Berend KR, Lombardi AV, Seng BE, et al. Enhanced
11. Woolson ST, Pouliot MA, Huddleston JI. Primary total early outcomes with the anterior supine intermuscular
hip arthroplasty using an anterior approach and a approach in primary total hip arthroplasty. J Bone Joint
fracture table: short-term results from a community Surg. 2009;91Suppl 6:107-20.
hospital. J Arthroplasty. 2009;24(7):999-1005.
15. Restrepo C, Parvizi J, Pour AE, et al. Prospective
12. Barton C, Kim PR. Complications of the direct anterior
approach for total hip arthroplasty. Orthop Clin N Am. randomized study of two surgical approaches for total
2009;40:371-5. hip arthroplasty. J Arthroplasty. 2010;25:671-91.
31
Chapter
The Modified Lateral Approach
4
for Total Hip Replacement
Evan M Schwechter, Phuc (Phil) Dang, Ran Schwarzkopf
A B
A B
34 Figs 4.2A and B: (A) Incision marked on the skin prior to incision (leg is to the left, head to the right, and
posterior is to the bottom of the image); (B) Illustration of incision through skin and fascia
The Modified Lateral Approach for Total Hip Replacement
Fig. 4.3: Exposure of the tensor fascia lata (head is to the top and
anterior to the right)
A B
Figs 4.4A and B: The tensor fascia lata is incised and the gluteus maximus is split bluntly
(head is to the right and abdomen to the top of the image)
35
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Dislocation and Acetabular Preparation Acetabular reaming is initially conducted medially, then
in 40–45° abduction and 15–20° anteversion (Fig. 4.10).
Retractors are placed superior and inferior to the femoral The cup is trialed, followed by implantation of the real
neck, and the hip is dislocated with gentle hip extension acetabular cup. Supplemental screw fixation is at the
and external rotation (Fig. 4.9A). The femoral neck discretion of the surgeon based on cup stability, host
osteotomy is made with reference to the lesser trochanter bone, and surgeon preference. Anterior and posterior
using the implant specific neck cutting guide. The head osteophytes, if present, are removed with an osteotome
is removed and retractors are placed to expose the (Fig. 4.11). The polyethylene liner is placed and impacted
acetabulum (Fig. 4.9B). The femur is retracted posteriorly. into place.
A B
Figs 4.6A and B: (A) A clamp is directed proximally beneath the fibers of the vastus lateralis and into the interval between the anterior
and middle thirds of the gluteus medius (abdomen to the bottom and feet to the left of the image); (B) A clamp is directed proximally
beneath the fibers of the vastus lateralis and into the interval between the anterior and middle-third of the gluteus medius (abdomen to
the top and feet to the left of the image)
36
The Modified Lateral Approach for Total Hip Replacement
A B
A B
Figs 4.8A and B: Subperiosteal dissection is then continued anteriorly along the femoral neck, and a capsulotomy is made, cobra 37
retractor placed under the inferior aspect of the femoral neck; (B) Superior capsulotomy with or without anterior capsulectomy
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 4.9A and B: (A) Dislocation and inferior capsulotomy; (B) Acetabular exposure
(head to the right and abdomen to the top of the image)
Fig. 4.10: Acetabular reaming angle is demonstrated Fig. 4.11: Acetabular cup placement and screw fixation
38
The Modified Lateral Approach for Total Hip Replacement
Fig. 4.12: Femoral preparation, broach handle with trial stem Fig. 4.13: Trial head and stem relocated in the acetabulum
impacted, the extremity is in an adducted, flexed and external
rotation position
Fig. 4.14: The real stem is impacted and seated; Fig. 4.15: The real head is impacted and 39
the trunnion is prepared for head placement seated on the stem
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 4.16: Three drill holes are made in the greater trochanter and Fig. 4.17: Three 20-gauge wires are brought through the drill
directed anteriorly and medially just off the anterior border of the holes and around the greater trochanteric osteotomy fragment
implanted prosthesis
Closure towel clamp. The wires are tightened, cut, and the ends
twisted and impacted down to avoid soft tissue irritation
Three small caliber drill holes are made in the greater
trochanter and directed anteriorly and medially just off (Figs 4.18A and B). The fascia directly adjacent to the
the anterior border of the implanted prosthesis (Fig. 4.16). wires is oversewn to prevent local tissue irritation by the
Three 20-gauge wires are brought through the drill holes sharp wire ends. The remainder of the wound closure
and around the greater trochanteric osteotomy fragment is carried out in standard fashion. Postoperative X-rays
(Fig. 4.17). The fragment is reduced and secured with a show a well-fixed osteotomy site (Figs 4.19A and B).
A B
40 Figs 4.18A and B: The wires are tightened, cut, and the ends twisted and impacted down to avoid soft tissue irritation
The Modified Lateral Approach for Total Hip Replacement
A B
Figs 4.19A and B: (A) Preoperative anteroposterior pelvis X-ray; (B) Postoperative X-ray view
REFERENCES 7. Baker AS, Bitounis VC. Abductor function after total hip
replacement. An electromyographic and clinical review.
1. Zhan C, Kaczmarek R, Loyo-Berrios N, et al. Incidence J Bone Joint Surg Br. 1989;71(1):47-50.
and short-term outcomes of primary and revision hip 8. Foster DE, Hunter JR. The direct lateral approach to
replacement in the United States. J Bone Joint Surg Am. the hip for arthroplasty. Advantages and complications.
2007;89(3):526-33. Orthopaedics. 1987;10(2):274-80.
2. Masonis JL, Bourne RB. Surgical approach, abductor 9. McFarland B, Osborne G. Approach to the hip: a
function, and total hip arthroplasty dislocation. Clin suggested improvement on Kocher’s method. J Bone
Orthop. 2002;405:46-53. Joint Surg Br. 1954;36B:364-7.
3. Cohn RM, Schwarzkopf R, Jaffe F. Heterotopic ossi 10. Hardinge K. The direct lateral approach to the hip. Brit
fication after total hip arthroplasty. Am J Orthop. 2011; J Bone Joint Surg. 1982;64-B:17-9.
40(11):E232-5. 11. Pai VS. A modified direct lateral approach in total hip
4. Morrey BF, Adams RA, Cabanela ME. Comparison of arthroplasty. J Ortho Surg. 2002;10(1):35-9.
heterotopic bone after anterolateral, transtrochanteric, 12. Archibeck JM, Rosenberg AG, Berger RA, et al.
and posterior approaches for total hip arthroplasty. Clin Trochanteric osteotomy and fixation during total hip
Orthop Relat Res. 1984;(188):160-7. arthroplasty. J Am Acad Orthop Surg. 2003;11:163-73.
5. Eggli S, Woo A. Risk factors for heterotopic ossification 13. Masterson LE, Masri BA, Duncan CP. Surgical approaches
in total hip arthroplasty. Arch Orthop Trauma Surg. in revision hip replacement. J Am Acad Orthop Surg.
2001;121(9):531-5. 1998;6:84-92.
6. Soong M, Rubash H, Macaulay W. Dislocation after 14. Dall D. Exposure of the hip by anterior osteotomy of the
total hip arthroplasty. J Am Acad Orthop Surg. 2004;12: greater trochanter. A modified anterolateral approach.
314-21. J Bone Joint Surg. 1986;68:382-6.
41
Chapter
Posterolateral
5
Approach to the Hip
Jason H Lee, Ran Schwarzkopf
A B
Figs 5.2A and B: Skin incision. The incision is centered over the greater trochanter, proceeds distally along the lateral aspect of the femur
44 for 5 cm and proximally 5 cm in a posterosuperior fashion (patient’s head is to the left). (A) The leg is extended at the hip; (B) The leg
is flexed at the hip
Posterolateral Approach to the Hip
Fig. 5.3: Deep exposure. The iliotibial band is split and the gluteus
maximus is divided along its fibers proximally. Distally, the insertion
of the gluteus maximus tendon can be visualized (patient’s head is
to the right)
capsule and retracted superiorly. The remaining short Fig. 5.4: Short external rotators. The piriformis tendon as well as
external rotators are divided off the bony insertions and the superior and inferior gemelli, obturator internus and quadratus
femoris muscles form the short external rotators
swept posteriorly off the capsule and preserved as a cuff
to protect the sciatic nerve. A posteriorly based capsular
flap is developed sharply and tagged for later repair (Fig. 5.8). Any soft tissue remnants of the ligamentum
(Fig. 5.6). The hip is dislocated and the femoral neck teres and pulvinar are excised. The acetabulum reaming is
is marked with a resection flag, and the femoral neck performed using hemispherical reamers. Initial reaming
osteotomy may proceed with an oscillating saw (Fig. 5.7). is carried out medially until the floor of the medial wall
Retractors are placed to facilitate acetabular exposure. is met (Fig. 5.9). After satisfactory subchondral bleeding
The acetabular labrum is excised circumferentially and bone is created, the acetabular shell is placed into 40–45°
the transverse acetabular ligament is debulked as needed of abduction, 20–25° of anteversion, and fully seated
Fig. 5.5: The piriformis tendon. The robust piriformis tendon is Fig. 5.6: Capsulotomy. The femoral capsular insertion is elevated
identified and elevated from its insertion on the greater trochanter and tagged for later repair (patient’s head is to the right)
(patient’s head is to the left)
45
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 5.7: Femoral neck osteotomy. The hip is dislocated with the Fig. 5.8: Acetabular exposure. Appropriate retractor placement
leg held perpendicular to the horizon. The femoral neck osteotomy allows for circumferential visualization of the acetabulum in order to
is performed with an oscillating saw using the resection flag as a visualize the acetabular rim and floor (patient’s head is to the right)
guide down the femoral axis
(Fig. 5.10). Cancellous acetabular screws can be placed for planer is used to make the residual neck flush to the
further stability at this time if desired. The polyethylene implant. A trial reduction is performed and hip stability is
liner is impacted into place and seated. Overhanging assessed. The hip stability is tested in full extension to its
anterior and posterior osteophytes are identified and limits of external rotation to assess impingement and risk
removed as needed. of dislocation. The hip is then hyperflexed to 100°, and
The femur is then addressed. A box osteotome is used then flexed to 90°, neutral with the horizon and internally
to create a lateral entry point followed by a Charnley awl rotated to again check for impingement and dislocation
to identify the canal (Fig. 5.11). The lateral entry point is risk. The position of sleep is also assessed.
enlarged using a lateralizing reamer. The femoral canal X-rays may be taken intraoperatively and if found to
is reamed by hand until there is good endosteal contact. be acceptable, final implants may be inserted (Fig. 5.13).
The proximal femur is sequentially broached with The hip is reduced and again taken through its stability
approximately 15° of anteversion (Fig. 5.12). The calcar testing. After irrigation for 3 minutes with a Betadine
Fig. 5.9: Acetabular preparation. Initial acetabular reaming is done Fig. 5.10: Acetabular reaming. The acetabulum is reamed until ade
46 until the medial wall is visible quate subchondral bleeding bone is seen. The appropriate shell
placement is 40–45° of abduction and 20–25° of anteversion
Posterolateral Approach to the Hip
Fig. 5.11: Femoral preparation. A box osteotome is used to Fig. 5.12: Femoral broaching. The femoral canal is sequentially
create a lateral entry point at the proximal femur broached while maintaining 15° of anteversion
solution of 3.5%, the hip is irrigated with 1 liter of saline Box 5.1: Intraoperative pain regimen (100 mL)
solution.46 In preparation for wound closure, hemostasis
• Clonidine 80 mcg
is achieved. Periarticular injections are given (Box 5.1).
• Epinephrine 0.5 mg
The wound is irrigated with copious amounts of saline
solution. The capsular flap and the external rotator tendons • Ketorolac 30 mg
are repaired through bone tunnels to the piriformis fossa • Ropivicaine 0.5% 49.25 mL (246.25 mg)
(Fig. 5.14). The deep fascia is reapproximated using a • Sodium chloride 0.9% 48.45 mL
barbed suture in a running fashion. The subcutaneous
tissue is reapproximated using absorbable suture in an
POSTOPERATIVE MANAGEMENT
interrupted fashion. The skin edges are reapproximated
using a subcuticular suture. Skin glue is applied and a All patients receive 24 hours of prophylactic intravenous
sterile dressing is placed over the hip (Fig. 5.15). antibiotics (Cefazolin or an antibiotic that is tailored to their
Fig. 5.13: Intraoperative image. Image taken while the femoral Fig. 5.14: Capsule and tendon repair. The capsular flap and external
broach is in place, in order to assess adequate canal fill and limb rotator tendons are repaired through bone tunnels within the piri
length formis fossa (patient’s head is to the right) 47
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
acetabular fracture rate. Higher intraoperative femoral
fractures have also been reported with press-fit femoral
stems. Cemented stems fracture rates are reported as low
as 0.3%52 and ranging from 0.4% to 5.4% in uncemented
stems.52-54 Dislocation is also one of the most common
complications with reports documenting dislocation rates
from 1% to 10% in primary total hip arthroplasty and
up to 27% following revision total hip arthroplasty.9-14,55
Approximately 60–70% of the dislocations occur within
the first 4–6 weeks following surgery.56 Limb length
discrepancy is one of the most common causes of patient
dissatisfaction, and as such, is one of the most common
reasons for litigation.57 Infection continues to be a
devastating complication with infection rates reported
at roughly 1–2% for primary total hip arthroplasty.58-61
Fig. 5.15: Postoperative image. Postoperative image
showing a well-positioned cup and stem However, a two-stage revision total hip arthroplasty can
be an effective treatment for infection with success rates
of 80–95%.62 It is important to assess the preoperative
risk factors and accurately educate the patient of post-
specific allergies). Some form of venous thromboembolism operative expectations to provide an appropriate
chemoprophylaxis, as well as sequential mechanical pumps, informed consent.
is recommended by the American Academy of Orthopedic
Surgeons for thromboembolic disease prevention.47
Physical therapy begins the day of surgery. Patients are SUMMARY
always weight bearing as tolerated, with emphasis on Multiple surgical approaches to the hip are available
transfers and ambulation. Ambulation with an assistive for total hip arthroplasty including the anterior, antero
device usually begins on postoperative day 1 and the lateral, direct lateral, transtrochanteric and posterolateral
patient receives two sessions of physical therapy every approaches. Each approach has its own advantages and
day. When the patient can safely transfer and ambulate disadvantages and all with documented success. Each
under adequate pain control, they are discharged home surgeon should be aware of the benefits, dangers and
or to a rehabilitation facility, usually on postoperative day complications of each approach and try to minimize
2 or 3. Hip precautions that include avoiding hip flexion potential complications. The posterolateral approach, with
beyond 90°, avoiding hip adduction and internal rotation the formal repair of the posterior capsule and external
are kept for a period of 3 months. rotators, provides a dislocation rate that is comparable
to the other approaches. The posterolateral approach
provides excellent visualization for primary and revision
COMPLICATIONS total hip arthroplasty and can be performed safely and
Total hip arthroplasty has proven to be one of the most efficiently with reproducible results.
successful orthopedic procedures performed, providing
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incision technique in total hip arthroplasty does not 54. Berend KR, Lombardi AV. Intraoperative femur fracture
improve early postoperative outcomes: a prospective, is associated with stem and instrument design in
randomized, controlled trial. J Bone Joint Surg. primary total hip arthroplasty. Clin Orthop Rel Res.
2005;87(4):701-10.
2010;468(9):2377-81.
42. Imamura M, Munro NA, Zhu S, et al. Single mini-
55. Alberton GM, High WA, Morrey BF. Dislocation after
incision total hip replacement for the management of
revision total hip arthroplasty: an analysis of risk
arthritic disease of the hip: a systematic review and
factors and treatment options. J Bone Joint Surg Am.
meta-analysis of randomized controlled trials. J Bone
Joint. 2012;94(20):1897-905. 2002;84(10):1788-92.
43. Berry DJ, Berger RA, Callaghan JJ, et al. Development, 56. Ali Khan MA, Brakenbury PH, Reynolds IS. Dislocation
early results, and a critical analysis. The Annual Meeting following total hip replacement. J Bone Joint Surg Br.
of The American Orthopaedic Association, 2003. J Bone 1981;63(2):214-8.
Joint Surg Am. 2003;85-A(11):2235-46. 57. Hofmann AA, Skrzynski MC. Leg-length inequality and
44. Woolson ST, Mow CS, Syquia JF, et al. Comparison nerve palsy in total hip arthroplasty: a lawyer awaits!
of primary total hip replacements performed with a Orthopaedics. 2000;23(9):943-4.
standard incision or a mini-incision. J Bone Joint Surg 58. Eftekhar NS, Tzitzikalakis GI. Failures and reoperations
Am. 2004;86-A(7):1353-8. following low-friction arthroplasty of the hip. A five to
45. Graw BP, Woolson ST, Huddleston HG, et al. Minimal fifteen-year follow-up study. Clin Orthop. 1986;211:65-78.
incision surgery as a risk factor for early failure 59. Fitzgerald RH, Peterson LF, Washington JA, et al.
of total hip arthroplasty. Clin Orthop Relat Res. Bacterial colonization of wounds and sepsis in total
2010;468(9):2372-6. hip arthroplasty. J Bone Joint Surg. 1973;55-A:1242-50.
46. Brown NM, Cipriano CA, Moric M, et al. Dilute
60. Garvin KL, Hanssen AD. Infection after total hip
betadine lavage before closure for the prevention of
arthroplasty. Past, present, and future. J Bone Joint
acute postoperative deep periprosthetic joint infection.
Surg. 1995;77-A:1576-88.
J Arthroplasty. 2012;27(1):27-30.
47. Jacobs JJ, Mont M, Bozic KJ, et al. Preventing venous 61. Maderazo EJ, Judson S, Pasternak H. Late infections of
thromboembolic disease in patients undergoing total joint prostheses. A review and recommendations
elective hip and knee arthroplasty. J Bone Joint Surg. for prevention. Clin Orthop. 1988;229:131-42.
2012;94:746-7. 62. Cui Q, Mihalko WM, Shields JS, et al. Antibiotic-
48. Hozack WJ, Rothman RH, Albert TJ, et al. Relationship impregnated cement spacers for the treatment of
of total hip arthroplasty outcomes to other orthopaedic infection associated with total hip or knee arthroplasty.
procedures. Clin Orthop Relat Res. 1997;344:88-93. J Bone Joint Surg. 2007;89A:871-82.
50
Chapter
The Northern Approach for
6
Total Hip Arthroplasty
Carlos M Alvarado
described a 6–10 cm incision over the sartorius-tensor anterior joint capsule should be excised. The femoral neck
fascia lata interval with a patient supine on the operating should now be completely visible in the surgical field. At
room table. Care must be taken when making this this point, the posterior capsule must be released to allow
incision and dissecting this intermuscular plane as the for easy hip dislocation. The hip is dislocated by adducting,
lateral femoral cutaneous nerve (LFCN) can be injured. extending and externally rotating the hip. Flexion of the
Moving the skin incision laterally while utilizing the same foot of the bed and placing the nonoperative leg on a
plane may result in less LFCN injury. padded Mayo stand will ease extremity positioning during
Once the sartorius-tensor fascia lata interval is the surgery. Upon dislocation, the femoral head and neck
identified, this interval should be developed with careful should be delivered out of the wound allowing for femoral
attention to hemostasis as several perforating veins can neck osteotomy with a reciprocating saw. Once this is
be found in this compartment, lateral femoral circumflex complete, the operative leg is brought back to neutral
vessels. They should be ligated thoroughly to avoid position and the acetabular retractors are placed to allow
significant blood loss. Once this is complete, the interval for acetabular preparation. At this point, careful placement
between the rectus femoris and the gluteus medius of anterior acetabular retractors is necessary to avoid injury
should be identified. This interval directly overlies the to the femoral nerve. The femoral preparation is undertaken
femoral neck, and palpation of the femoral neck should once the acetabulum is complete. This is done once again
be used to orient oneself during this dissection. A with the hip in extension, adduction and external rotation
Holman retractor can be placed above and below the to deliver the femoral canal out of the wound and help with
femoral neck to assist in blunt dissection through this femoral canal preparation. If there is difficulty with exposure
layer. Once again, very careful attention should be paid of the femoral canal, more of the posterior hip capsule should
to hemostasis while dissecting through this layer; careful be released (Figs 6.1 and 6.2).
dissection will result in decreased blood loss. There are After successful placement of components, many
two to three perforating vessels within the layer that must surgeons will verify positioning with an intraoperative
be cauterized. radiography or fluoroscopy, especially early in the sur
Once the deep dissection is complete, the pericapsular geon’s learning curve. Wound closure only requires a
fat and hip joint capsule should be visible in the operative fascia and superficial layer closure. There is no capsular
52
field. Once again, palpation of the femoral neck should closure necessary. Postoperative hip precautions include
help with orientation. The pericapsular fat and the avoidance of extension and external rotation.
The Northern Approach for Total Hip Arthroplasty
Fig. 6.1: Skin incision for direct anterior approach Fig. 6.2: Superficial dissection for the direct anterior approach
ANTERIOR LATERAL APPROACH complete, the anterior aspect of the femoral neck should
be palpable. In order to gain access to the hip joint, the
The anterior lateral approach or Watson-Jones approach
anterior 1/3 of the gluteus minimus insertion must be
has been used for many decades for the management of
reflected. This should be done through the tendinous
hip arthritis. It was described formally by Sir Reginald
portion of the insertion to allow for repair during closure.
Watson-Jones in 1956.8 The benefits of the approach are
A stay stitch placed into the musculotendinous junction
that it does not disrupt the posterior capsule resulting
will assist in reapproximation during closure. Once this
in reduced dislocations. However, the tensor fascia lata-
part is complete, the anterior hip capsule is removed;
gluteus minimus interval does result in some disruption
to the abductor mechanism resulting in possible abductor the hip can be dislocated by adduction and external
weakness and postoperative limp.9 rotation. The femoral head and neck should then be easily
The anterior lateral approach can be done with the visible in the center of the operative field. The femoral
patient in a supine or lateral decubitus position. The neck osteotomy can then be easily completed using
skin incision is centered over the greater trochanter. The a reciprocating saw. While preparing the acetabulum,
incision should start 2.5 cm proximal to the posterior 1/3 the leg remains in a neutral position and is retracted
of the greater trochanter and then extend down the center posteriorly. The preparation of the femoral canal follows
of the femur. The underlying fascia is then incised in line the acetabulum. This is done with the hip in adduction,
with the skin incision. The interval between the tensor flexion and external rotation (Fig. 6.3).
fascia lata and the gluteus medius is identified. Careful After successful placement of components, the
hemostasis must be done in this layer as perforating abductor mechanism must be repaired. This can be done
vessels are commonly encountered. Once this is using a series of running stitches that incorporate the 53
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
line with the skin incision. The gluteus medius is then
identified and split at the 1/3 anterior and 2/3 posterior
margin. A fatty raphe is usually discernible along this
margin. Care must be taken not to split the gluteus medius
greater than 5 cm proximal to the greater trochanter as
this can result in injury to the superior gluteal nerve
resulting in paralysis of the abductor mechanism. The
dissection should be continued distally elevating the
vastus lateralis off of the vastus ridge of the femur. Once
this is complete, the anterior joint capsule should be
visible in the operative field. A T-shaped capsulotomy
allows access to the joint and eases hip dislocation. The
hip is dislocated with extension, adduction and external
rotation of the hip joint. Once this is complete, the
Fig. 6.3: Surgical dissection of the anterior lateral approach femoral neck osteotomy can be completed allowing for
acetabular preparation. The acetabulum is prepared with
the hip in neutral position and the femoral neck retracted
previously placed stay stitch. Once the abductor mecha posteriorly. The femur is prepared with hip in flexion,
nism has been reapproximated, the tensor fascia lata is adduction and external rotation.
closed. The subcutaneous tissue and skin is closed in Once components have been placed successfully,
layers. The postoperative course does not require any the abductor mechanism must be repaired. Once this
posterior hip precautions, as the posterior capsule has is complete, the wound is closed in layers. There are no
not been violated. postoperative hip precautions required during the post-
operative setting.
LATERAL APPROACH
The direct lateral approach to the hip was first described
POSTERIOR APPROACH
in 1954 by McFarland and Osborne.10 It was then popu The posterior approach to the hip was originally popu
larized by Hardinge as a less invasive approach for larized by Moore and then expanded upon by Gibson,
total hip arthroplasty.11 It is commonly used for total Marcy and Fletcher.15,16 The posterior approach continues
hip arthroplasty, hemiarthroplasty and resurfacing pro to be the most common approach to the hip used in
cedures. The direct lateral approach is looked upon the United States due to simplicity, and the ability to
favorably as it boasts the lowest rates of dislocation.12 successfully complete the surgery with only one assistant.
For this reason, the direct lateral approach is preferable While its ease allows for convenient surgical procedures,
in patients with high risk of dislocation including the posterior approach is not without its critics. This
patients with history of alcohol abuse or neuromuscular is mostly due to the higher associated dislocation rate,
disorders. However, the stability gained by the direct 1–9%.17 The increased risk of dislocation is due to the
lateral approach comes at a price. The lateral approach disruption of the posterior capsule and reflection of the
requires the interruption of the abductor mechanism, short external rotators that supply intrinsic stability to the
resulting in slower clinical recovery and prolonged limp hip. Capsular repair and reattachment of short external
postoperatively.13 In addition, the direct lateral approach rotators has resulted in decreased reported dislocation
has been associated with the formation of postoperative rates, with current rates of less than 1%.17-21 However,
heterotopic ossification; however, the clinical significance this remains one of the main criticisms of the posterior
of this is unclear.14 approach.
The direct lateral approach can be performed in the The posterior approach is done with the patient in the
supine or lateral position. The skin incision is centered lateral decubitus position. The skin incision is a curve-
over the greater trochanter and begins 5 cm proximal to linear incision starting 5 cm proximal to the greater tro
54 the greater trochanter. The fascia lata is then incised in chanter, passing over the posterior 1/3 of the greater
The Northern Approach for Total Hip Arthroplasty
trochanter then continuing down the lateral aspect THE AUTHOR’S PREFERRED
of the femur for a 10–15 cm skin incision. The gluteal APPROACH (Minimally Invasive
fascia and tensor fascia lata are incised in line with the
incision, and the gluteus maximus is split in line with
Approach To The Hip: The
its fibers. Once this is complete, the trochanteric bursa Northern Approach)
is visible in the surgical field. The bursa is removed and Minimally invasive approaches to the hip involve modified
the short external rotators are visualized in the surgical surgical dissection that utilizes internervous planes and
field. The interval between the gluteus minimus and the minimizes any tendon or muscle trauma during the
piriformis tendon are identified and blunt dissection is exposure.22 Minimally invasive techniques have become
used to open the interval between the two. The piriformis commonplace in the current arthroplasty landscape.
tendon is then reflected from its femoral insertion and Early efforts focusing on MIS techniques attempted to
tagged. The short external rotators are then reflected from demonstrate improved postoperative clinical outcomes
their femoral insertion while being careful to avoid the including faster recovery and decreased postoperative
vasculature within the quadratus femoris muscle belly. pain.23 While several case series have demonstrated dec
A T-shaped posterior capsulotmy is then completed, reased postoperative pain or a trend toward improved
allowing for easy dislocation of the hip with forward clinical outcomes, this has not been demonstrated in
flexion, adduction and internal rotation. The femoral level-1 studies.24-27 However, the continued push for
neck osteotomy is then completed. The acetabulum is less invasive surgical techniques continues in spite
then prepared with the hip in slight flexion and neutral of level-1 evidence. While no statistical improvement
rotation. The femoral neck is retracted anteriorly. Attention in postoperative pain or clinical outcomes has been
and care to protect the sciatic nerve during acetabular demonstrated, MIS techniques can result in improved
preparation is paramount. Posterior retractors should be cosmetic results, which can be desirable by patients. We
placed carefully after identification of the sciatic nerve. will discuss the results and the technique to the northern
Sharp dissection posteriorly should be limited. The approach to the hip.
femur is prepared with the hip in flexion, adduction and The northern approach is a minimally invasive app
internal rotation to allow for access to the femoral canal roach to the hip that approaches the hip joint via the
(Figs 6.4 and 6.5). piriformis fossa. The approach does not call for hip dis
The postoperative care includes 3 months of posterior location prior to femoral neck cut, but allows for an in situ
hip precautions, where flexion above 900, adduction femoral neck cut allowing for the limb to be maintained
across midline and internal rotation is avoided. Patients in an anatomic position throughout the procedure.
must be instructed to avoid any low chairs, crossing This approach spares a significant amount of the short
legs or bending at waist to pick up objects off the floor external rotator muscles and underlying capsule. The
as these put the hip into a position that increases the northern approach is the combination of two described
dislocation risk. techniques, the “PATH” or percutaneous acetabular total
Fig. 6.4: Skin incision for the posterior approach to the hip 55
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 6.5: Deep dissection for the posterior approach to the hip Fig. 6.6: Illustration demonstrating the short external rotator muscle
release during the northern approach compared to the posterior-
lateral approach
hip by Dr Brad L Penenberg (Los Angeles, California) the piriformis fossa. A box is then cut out of the inferior
and the “Supercap” femoral preparation by Dr Stephen lateral aspect of the femoral head using an osteotome
Murphy (Boston, Mass). and chisel. This maneuver also allows easier access
The northern approach to the hip superficial dissection for instruments to the piriformis fossa. All tendinous
is the same as the traditional posterior- lateral approach. remnants are removed from the piriformis fossa and
Once the short external rotators are exposed, only the the femoral canal is opened through the piriformis fossa
piriformis is reflected and tagged, the remainder of the using a box osteotome followed by the canal finding
short external rotators remains intact (Fig. 6.6). reamer and then the power opening lateralizing reamer
The femoral canal is prepared prior to acetabular (Figs 6.7 to 6.9).
preparation, and the hip remains reduced during the A long ball-tipped guide wire is then used to inspect
femoral preparation. The hip is brought into flexion, the canal checking for any cortical breaches. Once this
adduction, and 10° of internal rotation maintaining the is complete, the canal is broached sequentially. Once
knee flexed to ease tension on the sciatic nerve. The the appropriate size is determined, the broach is left in
abductors are protected. This position allows access to position and the broach handle detached. The depth of
56 Fig. 6.7: Opening of the femoral canal, removing a box from the Fig. 6.8: Preparation of the femoral canal; note that the hip joint
femoral head to allow proper access remains reduced throughout the preparation
The Northern Approach for Total Hip Arthroplasty
Fig. 6.9: Illustration presenting the superior approach to the femur Fig. 6.10: Illustration presenting the percutaneous approach to the
as part of the northern approach to total hip arthroplasty acetabulum as part of the northern approach to total hip arthroplasty
the broach is measured with regards to the superior tip of removing each successive reamer with the cup hook and
the greater trochanter. This should match the measured placing the next reamer with the cup hook. Anteversion
preoperative template distance. and abduction are checked against anatomic landmarks,
Once the appropriate-sized broach is determined including the posterior wall and transverse ligament, to
and placed within the femoral canal, the broach handle ensure proper placement of the reamers. The targeting
is removed and the femoral neck osteotomy is made device has 45° of abduction built into its targeting arm;
along the proximal edge of the broach. Holmans are however, the importance of checking reamer placement
placed anterior and posterior to the femoral neck. The against the anatomic landmarks cannot be stressed
2 cm sagittal saw blade is then used to make the femoral enough. Once reaming is complete, the appropriately
neck cut in situ. The medial cortical cut is completed sized implant is placed.
using the one-inch osteotome. The corkscrew is then The hip is then reduced and leg lengths are checked.
used to evacuate the femoral head. The cut should then The capsule and the piriformis tendon are then reapproxi
be inspected; the cut surface should be flush with the mated. Both the fascia and subcutaneous tissue are then
broach. closed in layers. Postoperative course includes posterior
Once the femoral preparation is complete, attention hip precautions for 1 month. As with other minimally
is turned to the acetabulum. The hip and knee are flexed
to allow easy access to the acetabulum. The labrum is
removed and the pulvinar is cleared from the base of the
acetabulum. The targeting device is then placed into the
acetabulum (Figs 6.10 and 6.11).
The targeting device arm is oriented in line with
the femoral shaft. The skin is incised in line with the
cannula and obturator. The obturator and cannula are
then advanced through the tensor fascia lata and vastus
lateralis into the acetabulum. The targeting device is then
removed leaving the cannula into the acetabulum in place.
The reamers are then placed into the acetabulum, and
the shank of the reamer is passed through the cannula
and placed into the reamer head which is inserted from
the more proximal incision and is connected to the shaft Fig. 6.11: Location for the acetabular reamer targeting device. 57
in situ. The acetabulum is then reamed sequentially An incision is marked with the appropriate targeting device
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
invasive approaches, there is a lack of level-1 evidence 11. Hardinge K. The direct lateral approach to the hip.
for the superiority of the northern approach over the J Bone Joint Surg. 1982;64(1):17-9.
traditional posterior approach; however, as much 12. Kwon MS, Kuskowski M, Mulhall KJ, et al. Does surgical
approach affect total hip arthroplasty dislocation rates?
more cases are competed using MIS techniques, slight
Clin Orthop Relat Res. 2006;447:34-8.
improvements may be elucidated. 13. Masonis JL, Bourne RB. Surgical approach, abductor
function, and total hip arthroplasty dislocation. Clin
CONCLUSION Orthop Relat Res. 2002;(405):46-53.
14. Horwitz BR, Rockowitz NL, Goll SR, et al. A prospective
The debate over the best surgical approach to the hip randomized comparison of two surgical approaches
in the setting of arthroplasty continues. Each one has to total hip arthroplasty. Clin Orthop Relat Res.
its own benefits and setbacks; however in light of that, 1993;(291):154-63.
there is a paucity of level-1 literature that demonstrates 15. Moore AT. The self locking metal hip prosthesis. J Bone
Joint Surg Am. 1957;39:811-27.
a significant clinical superiority of one over the other.
16. Marcy GH, Fletcher RS. Modification of the
The most important factor appears to be the surgeon’s posterolateral approach to the hip for insertion
comfort with the approach, as all seem to be useful and of femoral head prosthesis. J Bone Joint Surg Am.
capable of delivering exceptional clinical outcomes. 1954;36:142-3.
17. Suh KT, Park BG, Choi YJ. A posterior approach to
primary total hip arthroplasty with soft tissue repair.
Acknowledgment Clin Orthop Relat Res. 2004;(418):162-7.
The images 6.7 to 6.11 were provided by Dr Patrick Meere 18. Pellicci PM, Bostrom M, Poss R. Posterior approach to
total hip replacement using enhanced posterior soft
(New York, NY, USA).
tissue repair. Clin Orthop Relat Res. 1998;(3):224-8.
19. Ko CK, Law SW, Chiu KH. Enhanced soft tissue repair
REFERENCES using locking loop stitch after posterior approach for
hip hemiarthroplasty. J Arthroplasty. 2001;16(2):207-11.
1. Gomez PF, Morcuende JA. Early attempts at hip 20. Hedley AK, Hendren DH, Mead LP. A posterior approach
arthroplasty—1700s to 1950s. Iowa Orthop J. 2005;25:25-9. to the hip joint with complete posterior capsular and
2. Smith-Petersen M. Evolution of mould arthroplasty of muscular repair. J Arthroplasty. 1990;5 Suppl:S57-66.
the hip joint. J Bone Joint Surg Br. 1948;30B(1):59. 21. Osmani ON, Walz B, Baker D, et al. Posterior capsular
3. Moore AT, Böhlman HR. The classic. Metal hip joint. A repair decreases incidence of dislocation following
case report. By Austin T. Moore and Harold R. Bohlman. primary total hip arthroplasty. Presented at the
1943. Clin Orthop. 1983;(176):3-6. 71st Annual Meeting of the American Academy of
4. Smith-Petersen MN. A new supra-articular subperio Orthopaedic Surgeons, San Francisco, CA, 2004.
steal approach to the hip joint. Am J Orthop Surg. 22. Berger RA, Duwelius PJ. The two-incision minimally
1917;15:592-5. invasive total hip arthroplasty: technique and results.
5. Barrett WP, Turner SE, Leopold JP. Prospective rando Orthop Clin North Am. 2004;3(2):163-72.
mized study of direct anterior vs postero-lateral 23. Berry DJ. “minimally invasive” total hip arthroplasty.
approach for total hip arthroplasty. J Arthroplasty. J Bone Joint Surg Am. 2005;87(4):699-700.
2013. pii: S0883-5403(13)00161-7. doi: 10.1016/j.arth. 24. Kennon RE, Keggi JM, Wetmore RS, et al. Total hip
2013.01.034. arthroplasty through a minimally invasive anterior
6. Hallert O, Li Y, Brismar H, et al. The direct anterior surgical approach. J Bone Joint Surg Am. 2003;8(Suppl
approach: initial experience of a minimally invasive 4):39-48.
technique for total hip arthroplasty. J Orthop Surg Res. 25. Mears DC. Development of a two-incision minimally
2012;7:17. doi: 10.1186/1749-799X-7-17. invasive total hip replacement. J Bone Joint Surg Am.
7. Light TR, Keggi KJ. Anterior approach to hip arthroplasty. 2003;8(11):2238-40.
Clin Orthop Relat Res. 1980;152:255-60. 26. Duwelius PJ, Berger RA, Hartzband MA, et al. Two-
8. Hart FD, Watson-Jones R. Arthritis of the hip. Trans incision minimally invasive total hip arthroplasty:
Med Soc Lond. 1956;72:33-44. operative technique and early results from four centers.
9. Bertin KC, Röttinger H. Anterolateral mini-incision J Bone Joint Surg Am. 2003;8(11):2240-2.
hip replacement surgery: a modified Watson-Jones 27. Ogonda L, Wilson R, Archbold P, et al. A minimal-
approach. Clin Orthop Relat Res. 2004;(429):248-55. incision technique in total hip arthroplasty does
10. McFarland B, Osborne G. Approach to the hip: a not improve postoperative outcomes: a prospective
58
suggested improvement on Kocher’s method. J Bone randomized controlled trial. J Bone Joint Surg Am.
Joint Surg. 1954;36(B):364-7. 2005;87(4):701-10.
Chapter
Cemented Total Hip
7
Arthroplasty
Yona Kosashvili, Amir Amitai, Snir Heller, Nir Cohen, Steven Velkes
Fig. 7.1A: Charnley type stem, fixed 20-mm head. Fig. 7.1B: Charnley-Muller type stem, fixed 32-mm head.
“Round back” design, collard Several neck length options, collard
inserted in an earlier phase of cement polymerization, only a thin mediolateral cement mantle.26 This philosophy
whereas a polished stem should be inserted in a more that is based on a tight fit of a highly polished femoral
doughy state, usually 6 minutes after the cement is stem in the femoral canal, leaving as little cancellous
mixed. However, one should note that this time is highly bone as possible on the mediolateral plane and the thin
dependent on the cement design and room temperature. incomplete cement mantle acting as a filler of the voids
Therefore, it is prudent that smooth stems are used with between the implant and the host bone has been coined
cement with a longer doughy phase, whereas rougher as the “French Paradox” and has shown excellent long-
stems are used with cement with a longer liquid phase. term outcomes when used with bulky polished stems and
A third philosophy of stem design has been introduced doughy cement.26,27 Consequently, there is a relatively
by Marcell Kerbaul who noticed a higher incidence thin layer of cement and a close contact of the stem to
of medial cement cracks and stem subsidence of the the bone’s mediolateral side, with a 2–4 mm of a cement
Charnley stem in regular patients compared to dysplastic mantle anteroposteriorly around the stem (Fig. 7.3).
hips, where the stems were tightly fitted, leaving room for
Fig. 7.3: Cement mantle around the stem Fig. 7.4: Femoral canal after final broaching
AUTHORS’ PREFERRED TECHNIQUE inserter (Fig. 7.5). The cement plug improves the ability
to pressurize the cement and limits the extent of the
OF CEMENTATION OF THE FEMORAL cement column. Modern restrictors are sized and have
STEM various fins and prominences, which improve the ability
A cemented femoral stem needs to be inserted in a to match the appropriate restrictor to the particular canal
proper alignment, avoiding a varus position, which can geometry. There is no advantage to having the cement
column extending more than 2 cm beyond the stem.29
lead to excessive forces on the proximal medial cement
The preparation of the bony bed for cementation
mantle and tensile forces on the lateral cement mantle.
follows the basic principles of cementation. Hence,
Therefore, the femoral canal should be sufficiently
the bone must be thoroughly cleaned. As mentioned
opened both laterally and posteriorly. Typically, this
requires broaching the cortical bone of the piriformis
fossa. The femoral canal is then opened with a sharp T
handle while maintaining contact with the posterolateral
bone. Reaming with cylindrical or tapered reamers in the
femur is often performed to remove the loose cancellous
bone, leaving a remnant of cancellous bone (Fig. 7.4).
Overzealous broaching should be avoided to prevent
denuding of the inner cortical bone, unless one chooses
to use cementation according to the “French Paradox”
principles. Broaching, which compacts the bone rather
than removing it, as a reamer does, creates a reproducible
larger cavity that allows a circumferential envelope of
2–3 mm around the stem. This allows for a uniform thickness
of the cement mantle around the stem. In some implant
systems, all the femoral bone preparation is performed only
with a broach, without any use of reamers.
After the femoral component is sized according to
the final broaching, the femoral canal is plugged with a
cement restrictor 2 cm distal to the tip of the implant.
This can be readily performed by marking a line 2 cm
62 proximal to the femoral stem’s shoulder on the plug Fig. 7.5: Marking the depth of insertion for the canal plug
Cemented Total Hip Arthroplasty
Fig. 7.6A: Note the cement gun nozzle reaching Fig. 7.6B: The cement working its way back,
the cement plug, allowing for retrograde injection pushing the cement gun
before, pulsatile lavage is a very effective adjunct for There is no consensus regarding the true incidence
removing further loose bone and fat content. Pulsatile of cardiopulmonary complication due to cement use.
lavage was found to significantly increase penetration of Few studies reported hypotension, hypoxia, cardiac
cement into the bone and improve clinical outcomes of arrhythmias, increased pulmonary vascular resistance,
cementation.18,19,30 Once the bone has been cleaned, it and cardiac arrest in response to cement introduction.33,34
should appear almost white, indicating that most blood Therefore, the anesthetist should be notified that cemen
and fat have been removed. Frequent packing of the tation is about to begin and he should take adequate
canal with sponges with or without hydrogen peroxide precautions regarding hydration and elevation of the
will keep the bony bed dry and clean until the cement is blood pressure to diminish the risk for cementation-
ready for application. associated circulatory crush.
Centralization via proximal and distal centralizers, The timing of cement introduction depends upon
which is part of the third-generation cementing technique, the type of cement being used. The doughier cements
must be introduced right away, while the lower viscosity
should be regularly used as they were found to allow a
cements must be placed later in their setting cycle to
more uniform circumferential cement mantle around
avoid the fluid cement running out of the canal. The ideal
the stem. If the stem is consistently placed in the center
time for cement introduction is when the cement is just
of the cement mantle, the chances for uneven cement
becoming doughy with a matt appearance and not sticky.
distribution and cement mantle defects leading to stress
This phase can be clinically recognized when the cement
risers on the cement mantle and cracks are decreased.31,32 stops dripping from the cement gun nozzle (Figs 7.7A
Usually, 80 grams of cement (2 packs) are sufficient and B).
for adequate stem fixation. The mixed cement should Once the cement has been injected, it should be
be collected into a cement cartridge that is afterwards pressurized in order to increase interdigitation and
mounted into a cement gun. A long nozzle is used to microlock of the cement. Pressurization of the cement is
reach the cement plug for retrograde cement placement. done by placing the thumb or a preformed pressurizer
While pressing the cement gun handle, the cement over the top of the canal (Fig. 7.8).
works its way out, gently pushing the cement gun out Shortly after the cement has been pressurized, the
in return (Figs 7.6A and B). The cement gun consistently stem is inserted accurately into the envelope, which had
delivers cement at pressures that can decrease the been created by the broach. The stem is inserted with
chances of blood mixing with the cement at the bone- a stem introducer, which can control the version of the
cement interfaces and have been shown to decrease the stem while it is being introduced (Fig. 7.9). Gentle steady
incidence of air voids. manual pressure should be applied with the version 63
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 7.7A: The cement is too liquid, dropping from the nozzle Fig. 7.7B: The cement is doughy enough, not dropping
from the nozzle anymore
controlled by the inserter. It is imperative to hold both Grade D: A radiolucent line surrounding the entire
the leg and implant still while the cement cures to avoid bone-cement interface in any projection.
the creation of cement voids. All excess cement can be However, this grading of femoral stem cementation
removed at this time. technique has a low interobserver reproducibility.36,37
The cementation of the femoral component can be
evaluated via the following classification:35
AUTHORS’ PREFERRED TECHNIQUE
Grade A: The medullary canal is completely filled with
cement—“white out” (Fig. 7.10). FOR ACETABULAR CUP
Grade B: A radiolucent line surrounding the bone- CEMENTATION
cement interface for less than 50% of its circumference.
Grade C: A radiolucent line surrounding the bone- Several principles should be emphasized in regards to
cement interface for more than 50% but not its entire acetabular implant cementation. The acetabular compo
circumference. nent needs to be completely contained under the roof
Fig. 7.8: Cement pressurization technique Fig. 7.9: Control of the stem version during insertion
64 by using a stem inserter
Cemented Total Hip Arthroplasty
Fig. 7.10: Postoperative radiograph of a medullary canal Fig. 7.11: Primary medial reaming of the acetabulum.
which is completely filled with cement—“white out” Note the vertical direction of the reamer
of the acetabulum in order to maximize fixation and the surrounding infra-acetabular soft tissues. Reaming
avoid edge loading on the liner’s periphery. This can be should be 2–4 mm more than the ultimate cup size in
readily achieved by deepening the acetabulum medially order to allow for a circumferential equal 2–3 mm thick
(Fig. 7.11) until the cancellous bone just lateral to the cement mantle. It is important to ream the acetabulum
inner table is encountered (Fig. 7.12). The medial (central) as close as possible to the true anatomical location in
osteophytes are reamed away, while the transverse order to minimize excessive stress forces on the cup if
ligament is preserved to allow pressurization during positioned too proximally. Therefore, the first reaming
the cup cementation and avoid leakage of cement into is directed perpendicular to the patient until reaching
the acetabular floor on the inner table. Once the medial
border of the acetabulum at the anatomical location is
established, the acetabular bed can be gradually reamed
in 45° of abduction and 15° of anteversion (Figs 7.13A
and B). The acetabular bone should be reamed until
cancellous bone is visualized.38,39
Drill holes in the superior and medial walls are added
to augment the cement fixation (Fig. 7.14). These holes
should not penetrate the acetabulum so as to prevent
cement leaking into the pelvis. All pelvic cysts should be
meticulously curetted, cleaned, and grafted with reamed
bone or bone graft from the femoral head.
The cancellous acetabular bed should be effectively
cleaned of all residual marrow, fat and free bone
and then dried. Drying of the bone in the acetabular
Fig. 7.12: Lateral side of the acetabular inner table bed is not easily achieved. Sponges with or without 65
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 7.13A: Final reaming in the appropriate abduction Fig. 7.13B: Final reaming in the appropriate anteversion
hydrogen peroxide should be repeatedly packed into glove to pressurize the cement. An all-polyethylene cup
the acetabulum; a wide bore needle may be placed into is implanted with a technique that may further pressurize
the acetabular roof and suction applied to it to decrease the cement, using an introducer that attaches to the cup,
the pressure in the acetabular bone bed and thereby which helps maintains accurate position of the implant
decrease bleeding. The surgeon should place high- in the cement mantle, while the cement cures. Insert
viscosity cement in its doughy state into the acetabulum. the cup in a fully perpendicularly position until it is
The cement is doughy enough when “wrinkles” can be completely medialized, and only then it is brought into
created when it is slightly pressed over the surgeon’s its final abduction and version alignment; this further
hand (Fig. 7.15). The cement should be pressurized pressurizes the cement into the socket as the implant is
in the acetabulum, especially into the well-contained “closed” into its final position. Solid patient positioning
drill holes prior to implantation by various techniques; cannot be underemphasized, since the surgeon needs
it can be done by manual pressure, by pressurization to reliably assess appropriate version and abduction
instruments or by improvising and using an acetabular using both extraoperative and intraoperative anatomical
trial at the size of the last reamer covered with a surgical landmarks. In contrast to cementless cup fixation, once
Fig. 7.14: Drill holes in the acetabulum to increase Fig. 7.15: Acetabular cement with positive “wrinkle” sign
66 the fixation of the cement mantle
Cemented Total Hip Arthroplasty
the cement has cured, it is not possible to change the cup • Use vacuum mixing to improve the qualities of the
alignment without performing a formal revision. Finally, cement
extruded cement must be removed carefully to prevent • Apply the right cement at the correct time for the stem
impingement or third-body wear, especially from at the design in use
recess between the cup and the transverse ligament. • Retrograde filling
The overall survivorship of cemented THA depends • Pressurize the cement and use centralizers
on multiple factors including patient selection, implant • Avoid varus—maintain the stem alignment during its
design as well as the cementation technique. Below is insertion
a list of pearls and pitfalls regarding the cementation • Keep cemented developmental dysplasia of the hip
technique. (DDH) stems as a bailout if the cement cured too fast
and the stem is too proud, so it can be replaced with
a tap-out tap-in technique.
SURGICAL PEARLS AND PITFALLS
REFERENCES
General
1. Wroblewski BM. 15-21-year results of the Charnley
• Choose the right patient (older, low-demand, low-friction arthroplasty. Clin Orthop Relat Res. 1986;
osteoporotic) (211):30-5.
• Make sure your patient and the anesthetist are ready 2. Joshi AB, Porter ML, Trail IA, et al. Long-term results
for cementation of Charnley low-friction arthroplasty in young patients.
• Choose your stem and understand its mechanical J Bone Joint Surg Br. 1993;75(4):616-23.
philosophy. 3. Schulte KR, Callaghan JJ, Kelley SS, et al. The outcome
of Charnley total hip arthroplasty with cement after a
minimum twenty-year follow-up. The results of one
Cementation
surgeon. J Bone Joint Surg Am. 1993;75(7):961-75.
• Know the qualities of the cement that is used in your Erratum in: J Bone Joint Surg Am. 1993;75(9):1418.
institution 4. Garellick G, Herberts P, Strömberg C, et al. Long-term
• Be familiar with cementation instrumentation results of Charnley arthroplasty. A 12-16-year follow-up
• Remove loose cancellous bone, leaving only the dense study. J Arthroplasty. 1994;9(4):333-40.
bone nearest to the cortex 5. Wroblewski BM, Siney PD, Fleming PA. Charnley low-
• Meticulously clean and dry the cancellous bone friction arthroplasty: survival patterns to 38 years.
J Bone Joint Surg Br. 2007;89(8):1015-8.
• Use pulsatile jet lavage.
6. Garellick G, Malchau H, Herberts P. Survival of hip
replacements. A comparison of a randomized trial and
Acetabulum a registry. Clin Orthop Relat Res. 2000;(375):157-67.
• Medialize the cup so it is fully covered with bone 7. Furnes O, Lie SA, Espehaug B, et al. Hip disease and
• Stay at the true acetabulum—avoid proximalization the prognosis of total hip replacements. A review of
53,698 primary total hip replacements reported to the
• Respect the transverse ligament to prevent cement
Norwegian Arthroplasty Register 1987-99. J Bone Joint
leakage and assist in cup positioning
Surg Br. 2001;83(4):579-86.
• Use reliable extraoperative and intraoperative 8. Malchau H, Herberts P, Eisler T, et al. The Swedish
landmarks for alignment Total Hip Replacement Register. J Bone Joint Surg Am.
• Place the acetabular cement when it gets its “wrinkles”. 2002;84-A Suppl 2:2-20.
9. Havelin LI, Espehaug B, Engesaeter LB. The performance
Femur of two hydroxyapatite-coated acetabular cups compared
with Charnley cups. From the Norwegian Arthroplasty
• Broach the bone at the piriformis fossa to avoid varus Register. J Bone Joint Surg Br. 2002;84(6):839-45.
malalignment 10. Ajmal M, Ranawat AS, Ranawat CS. A new cemented
• Carefully prepare the bone with broaching, cleaning femoral stem: a prospective study of the Stryker
and drying accolade C with 2- to 5-year follow-up. J Arthroplasty.
• Occlude the canal with a cement plug
67
2008;23(1):118-22.
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
11. Lindahl H. Epidemiology of periprosthetic femur 25. Ek ET, Choong PF. Comparison between triple-tapered
fracture around a total hip arthroplasty. Injury. 2007; and double-tapered cemented femoral stems in total
38(6):651-4. hip arthroplasty: a prospective study comparing
12. Hailer NP, Garellick G, Kärrholm J. Uncemented and the C-Stem versus the Exeter Universal early results
cemented primary total hip arthroplasty in the Swedish after 5 years of clinical experience. J Arthroplasty.
Hip Arthroplasty Register. Acta Orthop. 2010;81(1):34-41. 2005;20(1):94-100.
13. Wykman A, Olsson E, Axdorph G, et al. Total hip 26. Langlais F, Kerboull M, Sedel L, et al. The ‘French
arthroplasty. A comparison between cemented and paradox’. J Bone Joint Surg Br. 2003;85(1):17-20. Review.
press-fit noncemented fixation. J Arthroplasty. 1991; 27. Kerboull L, Hamadouche M, Courpied JP, et al. Long-
6(1):19-29. term results of Charnley-Kerboull hip arthroplasty in
14. Charnley J. The long-term results of low-friction patients younger than 50 years. Clin Orthop Relat Res.
2004;(418):112-8.
arthroplasty of the hip performed as a primary
28. Shelley P, Wroblewski BM. Socket design and cement
intervention. 1972. Clin Orthop Relat Res. 1995;(319):
pressurisation in the Charnley low-friction arthroplasty.
4-15.
J Bone Joint Surg Br. 1988;70(3):358-63.
15. Rasquinha VJ, Dua V, Rodriguez JA, et al. Fifteen-year
29. Estok DM 2nd, Orr TE, Harris WH. Factors affecting
survivorship of a collarless, cemented, normalized
cement strains near the tip of a cemented femoral
femoral stem in primary hybrid total hip arthroplasty component. J Arthroplasty. 1997;12(1):40-8.
with a modified third-generation cement technique. 30. Kalteis T, Pförringer D, Herold T, et al. An experimental
J Arthroplasty. 2003;18(7 Suppl 1):86-94. comparison of different devices for pulsatile high-
16. Buckwalter AE, Callaghan JJ, Liu SS, et al. Results of pressure lavage and their relevance to cement intrusion
Charnley total hip arthroplasty with use of improved into cancellous bone. Arch Orthop Trauma Surg.
femoral cementing techniques: a concise follow-up, at 2007;127(10):873-7. Epub 2007.
a minimum of twenty-five years, of a previous report. 31. Ranawat CS, Ranawat AS, Rasquinha VJ. Mastering the
J Bone Joint Surg Am. 2006;88(7):1481-5. art of cemented femoral stem fixation. J Arthroplasty.
17. Hirose S, Otsuka H, Morishima T, et al. Outcomes 2004;19(4 Suppl 1):85-91. Review.
of Charnley total hip arthroplasty using improved 32. Goldberg BA, al-Habbal G, Noble PC, et al. Proximal
cementing with so-called second- and third-generation and distal femoral centralizers in modern cemented hip
techniques. J Orthop Sci. 2012;17(2):118-23. doi: arthroplasty. Clin Orthop Relat Res. 1998;(349):163-73.
10.1007/s00776-011-0180-x. Epub 2011. 33. Patterson BM, Healey JH, Cornell CN, et al. Cardiac
18. Majkowski RS, Miles AW, Bannister GC, et al. Bone arrest during hip arthroplasty with a cemented long-
surface preparation in cemented joint replacement. stem component. A report of seven cases. J Bone Joint
J Bone Joint Surg Br. 1993;75(3):459-63. Surg Am. 1991;73(2):271-7.
19. Breusch SJ, Schneider U, Reitzel T, et al. Significance of 34. Donaldson AJ, Thomson HE, Harper NJ, et al. Bone
jet lavage for in vitro and in vivo cement penetration. cement implantation syndrome. Br J Anaesth. 2009;
Z Orthop Ihre Grenzgeb. 2001;139(1):52-63. 102(1):12-22. doi: 10.1093/bja/aen328. Review.
20. Gozzard C, Gheduzzi S, Miles AW, et al. An in-vitro 35. Barrack RL, Mulroy RD Jr, Harris WH. Improved
cementing techniques and femoral component
investigation into the cement pressurization achieved
loosening in young patients with hip arthroplasty.
during insertion of four different femoral stems. Proc
A 12-year radiographic review. J Bone Joint Surg Br.
Inst Mech Eng H. 2005;219(6):407-13.
1992;74(3):385-9.
21. Dunne NJ, Orr JF, Beverland DE. Assessment of cement
36. Kelly AJ, Lee MB, Wong NS, et al. Poor reproducibility in
introduction and pressurization techniques. Proc Inst
radiographic grading of femoral cementing technique in
Mech Eng H. 2004;218(1):11-25. total hip arthroplasty. J Arthroplasty. 1996;11(5):525-8.
22. Churchill DL, Incavo SJ, Uroskie JA, et al. Femoral stem 37. Harvey EJ, Tanzer M, Bobyn JD. Femoral cement grading
insertion generates high bone cement pressurization. in total hip arthroplasty. J Arthroplasty. 1998;13(4):
Clin Orthop Relat Res. 2001;(393):335-44. 396-401.
23. Davies JP, Jasty M, O’Connor DO, et al. The effect 38. Ranawat CS, Deshmukh RG, Peters LE, et al. Prediction
of centrifuging bone cement. J Bone Joint Surg Br. of the long-term durability of all-polyethylene cemented
1989;71(1):39-42. sockets. Clin Orthop Relat Res. 1995;(317):89-105.
24. Davies JP, O’Connor DO, Burke DW, et al. The effect 39. Crites BM, Berend ME, Ritter MA. Technical consi
of centrifugation on the fatigue life of bone cement in derations of cemented acetabular components: a
68 the presence of surface irregularities. Clin Orthop Relat 30-year evaluation. Clin Orthop Relat Res. 2000;
Res. 1988;(229):156-61. (381):114-9.
Chapter
Uncemented Total Hip
8
Arthroplasty
Cheng-Fong Chen, Tao Ji, Bang H Hoang, Wei-Ming Chen
Fig. 8.1: Mecring macrolocking stem with screw-in cup Fig. 8.2: AML full-coated stem extensive porous-coated stem
(Mecron, Berlin, Germany) (anatomic medullary locking prosthesis, DePuy, Warsaw, Indiana)
was designed and launched in 1984 (Fig. 8.3). The reported interspaces between the patchy coatings increased the
series revealed good short- to mid-term results.13-15 so-called effective joint space, thus providing channels
However, in the long-term follow-up, the HGP-I stem had that allowed extensive wear particle migration down
unacceptable rates of osteolysis, wearing and loosening, the femur, resulting in osteolysis and ultimately stem
compared to the better durability seen in the HGP-I loosening (Fig. 8.4), thus leading to the circumferential
acetabulum component.16-20 The main cause of failure porous-coated stem designs, which became the gold
was related to the noncircumferential coating. The smooth standard to prevent migratory osteolysis.
Fig. 8.3: Harris-Galante prosthesis type I with Fig. 8.4: Extensive osteolysis resulted from
70 noncircumferential coating over proximal part noncircumferential coating of Harris-Galante stem
Uncemented Total Hip Arthroplasty
Today, to reduce the stress shielding and thigh pain, developmental dysplasia of the hip (DDH), conversion
titanium alloy is usually used to fabricate most femoral THA from failed intertrochanteric fractures, anatomically
stems instead of the previously used cobalt-chrome alloy. deformed hips, and ankylosed hip joint. Traditional
The titanium alloy has the advantages of lower modulus templating can be done by conventional radiographs
of elasticity and better biocompatibility with femoral at standard magnifications or by digitalized form.
bone. In addition, the tapered stem was designed to allow Templating should be performed routinely to enable
for better stress transfer to the metaphyseal area instead
surgeons to predict the approximate size, position of
of the diaphyseal area, thus reducing proximal stress
implants, and the leg length discrepancy (Figs 8.5A to C).
shielding. Press-fit, porous-coated and hydroxyapatite
Over-reaming or oversizing should be avoided to preserve
prosthesis have been designed as ways to achieve
biological fixation via bony in- or on-growth. the bone stock of both the femoral and acetabular bone.
Meanwhile, under-reaming or undersizing may result in
SURGICAL TECHNIQUES malposition of implants or inadequate match between
prosthesis and bone. Therefore, if the intraoperative-
Preoperative Planning preferred implant size is different from the templated
An accurate preoperative evaluation is essential size, care should be taken by the surgeon to determine
for cementless THA, especially for severe cases of the potential problems.
A B
Fig. 8.6: Secur-Fit® HA stem with metaphyseal locking, Fig. 8.7: U2® hip system with dual metaphyseal-diaphyseal fitting
72 circumferential stems (Stryker, Mahwah, New Jersey) femoral stem with hydroxyapatite coating on the metaphyseal portion
(United, Taiwan)
Uncemented Total Hip Arthroplasty
A B
C D
Figs 8.8A to D: An incision lines is marked at the anterior quarter of the greater trochanter parallel to the line extending 1.5 cm proximally
and 4.5 cm distally from the tip of the great trochanter (A). Identify the gluteal medium (B) and a 2.5–3 cm incision is made in the tendinous
portion of the gluteus medius, then continued anteriorly into the muscle portion as mark shown (C). Elevate the gluteal minimus and expose
the joint capsule (D)
minimus for complete exposure of joint capsule. During adduction and external rotation (Figs 8.9A and B). Care
this procedure, care must be taken to preserve some should be taken when treating an osteoporotic patient
fibers for reattachment (Figs 8.8A to D). or ankylosed hip. Difficult dislocation of the hip may
result in iatrogenic femoral shaft fracture during external
Dislocation of the Hip and Osteotomy rotation. In this situation, two parallel cuts should be
performed on the femoral neck, to produce a bony disk
of the Femoral Neck
about 1–1.5 cm in size. After removal of the disk, the
An inverted T-shaped capsulotomy is performed to expose hip external rotation could be done safely and the head
the femoral head and neck for hip dislocation. Then, two could be removed easily with a corkscrew device without
narrow sharp-ended retractors are placed on each side of dislocation of the hip joint.
the femoral neck. Following gentle leg traction by the first Once the joint has been dislocated, mark the cutting
assistant, another blunt-end curve retractor is inserted line with electrocautery. The femoral neck osteotomy
to the created space between the femoral head and should be completed by power saw at the appropriate
acetabulum. Under the leverage of these three retractors, level, usually 1–1.5 cm above the lesser trochanter and
73
the hip could be dislocated anteriorly using gentle flexion, perpendicular to the intertrochanteric line (Fig. 8.10).
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 8.9A and B: Photograph of three retractors (A) and application over femoral neck and head to enhance hip dislocation (B)
Inappropriate cutting level will lead to a change in the osteotomy. The first retractor is placed at the edge of
hip offset. Inadequate neck cutting will leave a longer the acetabulum posterior-inferiorly to separate it from
femoral neck and make the stem difficult to be implanted the femur. The second retractor is placed superior to
in the desired position, and a head with a standard neck the acetabulum, whereas the third retractor is placed
is usually necessary in order to preserve an equal leg anteriorly and inferiorly. The fourth retractor is placed in
length. Inversely, a shorter femoral neck cut can make various positions as required for the subsequent steps of
the stem deeper and a head with a longer neck is needed the procedure. Proper placement of the three retractors
in order to achieve the same leg length. However, the should allow direct visualization of the acetabulum
offset is completely different under these two different (Fig. 8.12).
conditions, even though the leg length is equal (Fig. 8.11). As the acetabulum is completely exposed and the
labrum removed, sequential acetabulum reaming
Acetabulum Preparation and starting from size 40 mm diameter is performed. The
aim of the initial reaming is to remove the residual
Cup Implantation
acetabulum cartilage and to expose the underlying
For acetabulum preparation, four narrow sharp-ended subchondral cancellous bone (Fig. 8.13). Therefore, great
cobra retractors are placed after the femoral neck care should be taken in patients with poor bony quality.
74 Fig. 8.10: After anterior dislocation of femoral head, the Fig. 8.11: Illustration revealed the offset difference in
osteotomy of femoral neck is performed by power saw inappropriate cutting level of femoral neck
Uncemented Total Hip Arthroplasty
Fig. 8.12: Photograph showing the four retractors Fig. 8.13: Bleeding over the acetabulum
applied around the acetabulum bone bed after sequential reaming
Hasty and overpressured reaming may result in severe of anteversion. For patients with ankylosing spondylosis
acetabular bone loss and cup medialization. Subsequent or Parkinsonism, greater anteversion is allowed to prevent
reamers are gradually enlarged in 2 mm increments. The posterior dislocation due to their tendency for hip flexion
reaming process is completed when exposure of bleeding posture. The cup should be firmly press fit into the acetabular
cancellous bone over the entire acetabulum socket is socket and an intimate contact between the cup and the
achieved. Meanwhile, the cup size is also determined.
underlying cancellous bone should be confirmed through
In general, line-to-line reaming of the acetabulum
the cup central hole (Figs 8.14A and B). Insertion of two
is recommended for normal bone quality and under-
reaming is allowed for osteoporotic bone. Over-reaming or three screws in the cup is recommended for ancillary
(usually 1 mm larger than the determined cup size) is fixation. Screws should be placed in the posterosuperior
generally reserved for patients with relatively sclerotic quadrant to avoid possible neurovascular injury.24 The trial
or dense bone. The cup implant should be placed in an liner is then inserted and the elevated lip of the trial should
anatomic orientation with 45° of inclination and 15–20° be adjusted to neutral position.
A B
Figs 8.14A and B: Using a curve cup holder to apply the acetabular component (A) and implant
the metal cup to the acetabulum with 45° inclination and 15–20° anteversion (B)
75
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Femoral Preparation and advance, and when good cortical contact is achieved. The
last broach is left within the femoral canal and the stem
Stem Implantation
is assembled with a corresponding standard neck and
During preparation of the femoral canal, the first head trial. The trial reduction is then performed. During
assistant should maintain the operated leg at maximal the procedure of trial reduction, care should be taken
external rotation position and keep the thigh as low as not to reduce the hip via directly internally rotating the
possible. This position could make the osteotomy site of operated leg. Hasty internal rotation of hip may lead to
femoral neck well exposed and elevated out the wound an iatrogenic proximal femoral fracture.
with additional two retractors placed properly under the The stability of the hip is assessed by some
greater and the lesser trochanter. The entire cortical rim of maneuvers. First, the hip should be very stable without
the femoral neck osteotomy site must be well visualized any dislocation event within the whole range of motion,
to assess the version, axial/rotational stability and early including hip flexion over 90° with 45° of adduction (for
detection of calcar fracture. posterior dislocation) or with maximal external rotation
First, an osteotome is inserted laterally toward the (for anterior dislocation). If any dislocation exists,
greater trochanter to remove a piece of cancellous bone all positions of the components must be reassessed
from the femoral neck, and opening a space will provide and adjusted if necessary. For example, a posterior
an adequate entry point for reaming and broaching. dislocation may result from inadequate anteversion of
The starter reamer is then applied through the pilot the acetabulum component, and readjustment of the cup
hole made by the osteotome. Lateralization toward the position is recommended instead of utilizing an elevated
greater trochanter during reaming is essential to avoid liner lip posteriorly.
subsequent malposition of the femoral stem, especially Second, to evaluate the tension of hip, the assistant
for patients with osteonecrosis of the femoral head, who should apply a constant traction force on the operated
received previous core decompression. The sclerotic leg, and the surgeon can evaluate the extent to which the
bone created by the decompression tract may influence head can be distracted from the liner. If the hip is found
the direction of the reamer and broaching and could to be too loose, a modular head trial with longer neck
lead to stem malposition, undersizing or proximal femur could be replaced and the test repeated, and the hip is
fracture. The femoral canal is then reamed sequentially assessed again. If the hip is too tight, the femoral trial
to the appropriate size (Figs 8.15A and B). The previously can be implanted deeper or a head with a shorter neck
templated size could be a reference for surgeon. can be tried. Although the adjustment of neck length can
Sequential broaching could be performed carefully and modulate the leg length and tension of the hip, the offset
the last broaching is complete when the broach stops to of hip is also altered simultaneously.
A B
76 Figs 8.15A and B: Sequential reaming of femoral canal (A) and followed by stem implantation (B)
Uncemented Total Hip Arthroplasty
Third, impingement could occur at flexion, extension THA due to the broaching and impacting procedures
or abduction and must be carefully assessed at extreme done to achieve a tight press fit as well as the wedge-
positions. Bony impingement should be resolved by shaped design of the stem. Careful attention should be
removal of any osteophytes. If impingement occurs paid to avoid hasty and violent manipulation during
between the neck and the elevated liner, adjustment of broaching and hip reduction.
the lip to a safe position or reinsertion of the acetabular Periprosthetic osteolysis in cementless stems that
component must be done. occurs due to wear particles could lead to loosening and
If the stability is acceptable, dislocate the hip by instability of the hip components. The various annual
traction, external rotation and remove all trial components. rate of liner wear following cementless THA was reported
The modular liner is placed with an elevated lip (surgeon’s from 0.10 mm/yr to 0.19 mm/yr.3,28 The wear rates are
preference) at the chosen position and implanted into related to the materials of bearing surfaces, head size and
the acetabular component firmly. After exposure of the stem design.
proximal femur, the femoral stem is inserted into the
canal manually and gently impacted by mallet using a Outcomes
constant force. The implantation is complete when the
stem ceases to advance, good cortical contact is obtained It has been reported that a higher prevalence of thigh
and the audible pitch changed. Following the stem pain (5.6–11.5%) is experienced after cementless
implantation, the selected metal head is assembled to THA.3,29-32 In some instances, thigh pain after cementless
the neck and hip is carefully reduced and assessed in THA may arise from other causes such as spinal
the same fashion done during the trial reduction. pathology. It is essential to clarify those factors before
attributing the pain to the stem. Potential causes of thigh
pain following cementless THA are related to the shape of
Soft Tissue Repair
the prosthesis, especially the diaphyseal fitting stem, and
After adequate irrigation and placement of a drainage stem instability.33,34 Excessively tight distal fit of a rigid
tube, the soft tissue should be repaired layer by layer. stem can also lead to anterior thigh pain. It is believed
The capsule, gluteal minimus and medius should be that the pain from the distal end of a rigid stem usually
repaired to the anatomic footprint using multiple number occurs after exercise and the pain from fibrous fixation
5 nonabsorbable sutures. due to inadequate fitting usually occurs after initial
weight-bearing. However, most thigh pain will improve
Postoperative Care within 2 years postoperatively. If the thigh pain persists,
There is no universal postoperative protocol for cementless loosening of stem should be considered.
THA. According to the author’s preference, protective Stress shielding is also an important cause of
weight-bearing is recommended for 2 weeks and followed periprosthetic osteoporosis after cementless THA.35 Engh
by full weight-bearing. Due to the reattachment of the et al. reported that 67.3% of patients revealed proximal
abductor muscles, abduction activity is allowed only after femoral resorption at 10 years after surgery.36 However,
6 weeks postoperatively. A pillow between the thighs they also reported that bone resorption due to stress
could limit hip adduction and internal rotation, thus shielding did not increase either the fracture rate or
help prevent hip dislocation. If an intraoperative calcar significant problems in cementless THA.37
fracture or unsatisfactory fixation is noted, nonweight- The success of cementless THA depends on
bearing for at least 6–8 weeks is recommended. careful preoperative planning, implant design, surgical
techniques, and patient compliance. The results of
current cementless THA are excellent with a 95–99%
Complication survivorship in mid- and long-term follow-ups.1,4,6-8,12,38
Periprosthetic fractures are among the major compli Even in patients with underlying systemic disease such as
cations of hip arthroplasty. Previous studies have rheumatoid arthritis, there is no evidence to indicate that
reported a cumulative incidence of about 0.3–0.6% of cementless components perform worse than cemented
postoperative periprosthetic fractures following THA.25-27 components.39 Optimal canal fit and fill with adequate
The incidence has been shown to be higher in cementless primary stability is the major factor to enhance the 77
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
primary osteointegration and avoid early loosening of 14. Maloney WJ, Harris WH. Comparison of a hybrid with
cementless components. an uncemented total hip replacement. A retrospective
matched-pair study. J Bone Joint Surg Am. 1990;72:
1349-52.
REFERENCES 15. Woolson ST, Maloney WJ. Cementless total hip
1. Springer BD, Connelly SE, Odum SM, et al. Cementless arthroplasty using a porous-coated prosthesis for bone
femoral components in young patients: review and meta- ingrowth fixation. 3 1/2-year follow-up. J Arthroplasty.
analysis of total hip arthroplasty and hip resurfacing. 1992;7 Suppl:381-8.
J Arthroplasty. 2009;24:2-8. 16. Tanzer M, Maloney WJ, Jasty M, et al. The progression
2. Hungerford MW, Hungerford DS, Jones LC. Outcome of femoral cortical osteolysis in association with total
of uncemented primary femoral stems for treatment hip arthroplasty without cement. J Bone Joint Surg Am.
of femoral head osteonecrosis. Orthop Clin North Am. 1992;74:404-10.
2009;40:283-9. 17. Woolson ST, Comstock CP. Porous pad separation and
3. Kang JS, Moon KH, Park SR, et al. Long-term results of loosening of Harris-Galante femoral hip components.
total hip arthroplasty with an extensively porous coated J Arthroplasty. 1996;11:474-7.
stem in patients younger than 45 years old. Yonsei Med 18. Clohisy JC, Harris WH. The Harris-Galante uncemented
J. 2010;51:100-3. femoral component in primary total hip replacement at
4. Pospula W, Abu Noor T, Roshdy T, et al. Cemented and 10 years. J Arthroplasty. 1999;14:915-7.
cementless total hip replacement. Critical analysis and 19. Cruz-Pardos A, Garcia-Cimbrelo E. The Harris-Galante
comparison of clinical and radiological results of 182 total hip arthroplasty: a minimum 8-year follow-up
cases operated in Al Razi Hospital, Kuwait. Med Princ study. J Arthroplasty. 2001;16:586-97.
Pract. 2008;17:239-43. 20. Hallan G, Lie SA, Havelin LI. High wear rates and
5. Makela KT, Eskelinen A, Paavolainen P, et al. Cementless extensive osteolysis in 3 types of uncemented total hip
total hip arthroplasty for primary osteoarthritis in arthroplasty: a review of the PCA, the Harris Galante
patients aged 55 years and older. Acta Orthop. 2010; and the Profile/Tri-Lock Plus arthroplasties with a
81:42-52. minimum of 12 years median follow-up in 96 hips. Acta
6. Kirsh G, Kligman M, Roffman M. Hydroxyapatite-coated Orthop. 2006;77:575-84.
total hip replacement in Paget’s disease: 20 patients 21. Noble PC, Box GG, Kamaric E, et al. The effect of aging
followed for 4-8 years. Acta Orthop Scand. 2001;72: on the shape of the proximal femur. Clin Orthop Relat
127-32. Res. 1995;(316):31-44.
7. Rothman RH, Cohn JC. Cemented versus cementless 22. Noble PC, Alexander JW, Lindahl LJ, et al. The anatomic
total hip arthroplasty. A critical review. Clin Orthop basis of femoral component design. Clin Orthop Relat
Relat Res. 1990;(254):153-69. Res. 1988;(235):148-65.
8. Hofmann AA, Feign ME, Klauser W, et al. Cementless 23. Chen WM, Wu PK, Chen CF, et al. No significant
primary total hip arthroplasty with a tapered, proximally squeaking in total hip arthroplasty: a series of 413 hips
porous-coated titanium prosthesis: a 4- to 8-year in the Asian people. J Arthroplasty. 2012;27:1575-9.
retrospective review. J Arthroplasty. 2000;15:833-9. 24. Wasielewski RC, Cooperstein LA, Kruger MP, et al.
9. Beckenbaugh RD, Ilstrup DM. Total hip arthroplasty. Acetabular anatomy and the transacetabular fixation of
J Bone Joint Surg Am. 1978;60:306-13. screws in total hip arthroplasty. J Bone Joint Surg Am.
10. Judet R, Siguier M, Brumpt B, et al. A noncemented total 1990;72:501-8.
hip prosthesis. Clin Orthop Relat Res. 1978;(137):76-84. 25. Cooper HJ, Rodriguez JA. Early post-operative
11. Engh CA Jr, Culpepper WJ 2nd, Engh CA. Long-term periprosthetic femur fracture in the presence of a non-
results of use of the anatomic medullary locking cemented tapered wedge femoral stem. HSS J. 2010;
prosthesis in total hip arthroplasty. J Bone Joint Surg 6:150-4.
Am. 1997;79:177-84. 26. Lindahl H, Malchau H, Herberts P, et al. Periprosthetic
12. Engh CA Sr. Pioneering in the first century of hip femoral fractures classification and demographics of
replacement: experiences of a surgeon-designer. Clin 1049 periprosthetic femoral fractures from the Swedish
Orthop Relat Res. 2003;(407):35-49. National Hip Arthroplasty Register. J Arthroplasty. 2005;
13. Martell JM, Pierson RH 3rd, Jacobs JJ, et al. Primary 20:857-65.
total hip reconstruction with a titanium fiber-coated 27. Lewallen DG, Berry DJ. Periprosthetic fracture of the
prosthesis inserted without cement. J Bone Joint Surg femur after total hip arthroplasty: treatment and results
78 Am. 1993;75:554-71. to date. Instr Course Lect. 1998;47:243-9.
Uncemented Total Hip Arthroplasty
28. Livermore J, Ilstrup D, Morrey B. Effect of femoral head 35. Martini F, Sell S, Kremling E, et al. Determination of
size on wear of the polyethylene acetabular component. periprosthetic bone density with the DEXA method after
J Bone Joint Surg Am. 1990;72:518-28. implantation of custom-made uncemented femoral
29. Kim YH, Kim VE. Results of the Harris-Galante cement stems. Int Orthop. 1996;20:218-21.
less hip prosthesis. J Bone Joint Surg Br. 1992; 74:83-7. 36. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip
30. Kim YH, Kim VE. Uncemented porous-coated anatomic replacement. The factors governing bone ingrowth,
total hip replacement. Results at six years in a consecutive stress shielding, and clinical results. J Bone Joint Surg
series. J Bone Joint Surg Br. 1993;75:6-13. Br. 1987;69:45-55.
31. Engh CA, Gloss FE, Bobyn JD. Biologic fixation arthro 37. Engh CA Jr, Young AM, Engh CA Sr, et al. Clinical
plasty in the treatment of osteonecrosis. Orthop Clin
consequences of stress shielding after porous-coated
North Am. 1985;16:771-87.
total hip arthroplasty. Clin Orthop Relat Res. 2003;
32. Hastings DE, Tobin H, Sellenkowitsch M. Review of
(417):157-63.
10-year results of PCA hip arthroplasty. Can J Surg.
1998;41:48-52. 38. Theis JC, Ball C. Medium-term results of cementless
33. Bobyn JD, Glassman AH, Goto H, et al. The effect of hydroxyapatite-coated primary total hip arthroplasty: a
stem stiffness on femoral bone resorption after canine clinical and radiological review. J Orthop Surg (Hong
porous-coated total hip arthroplasty. Clin Orthop Relat Kong). 2003;11:159-65.
Res. 1990;(261):196-213. 39. Zwartele RE, Witjes S, Doets HC, et al. Cementless total
34. Campbell AC, Rorabeck CH, Bourne RB, et al. Thigh hip arthroplasty in rheumatoid arthritis: a systematic
pain after cementless hip arthroplasty. Annoyance or review of the literature. Arch Orthop Trauma Surg.
ill women. J Bone Joint Surg Br. 1992;74:63-6. 2012;132:535-46.
79
Chapter
Computer-Assisted Hip
9
Arthroplasty
Eric L Smith, Nicholas Colacchio, Jonathan D Nyce, Stephen B Murphy
Fig. 9.1: A preoperative 3D CT scan is templated for optimal fit Fig. 9.2: Preoperative planning of the femoral component
(anteversion and inclination) of the acetabular component (superior
panels). An intra
operative comparison to the preoperative plan is 83
shown in the inferior panels
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 9.3: A simulated range of motion is performed using company- Fig. 9.4: Optical arrays are securely fixed to bone and optical
specific software. Adjustments to optimal acetabular and femoral arrays point directly to the infrared camera
compo nent position, as well as impinging bony structures are
analyzed
Following this, acetabular reaming proceeds using and offset are chosen. A trial reduction is performed, and
optical tracking on the reamer as well as the cup inserter. leg length, offset, ROM and stability are tested (Fig. 9.10).
This allows for real-time socket preparation and insertion Following confirmation of adequate trial components,
(Figs 9.7 and 9.8). final implants are seated. A final check for offset and leg
The cup is then inserted and the actual position is length is completed.
compared to the planned position (Fig. 9.9).
The femoral component is then prepared in the RETURN TO MECHANICAL
desired technique, and a trial femoral component is
inserted. Preoperative templating guides the surgeon on
NAVIGATION
the expected size and position of the femoral component. Although there is compelling evidence that CAS has the
The desired neck angle and length as well as head size potential to reduce the rates of acetabular component
malposition, these navigation technologies have not mechanical navigation devices has continued. One such
been widely adopted. The primary reasons for this are smart mechanical device, the HipSextant, is a novel
the investments of time and money associated with leader in the field.
purchasing the equipment as well as training the surgeons The HipSextant patient-specific mechanical navigation
and support personnel to use the technology. Given that system allows the hip surgeon to quickly and reliably
surgeons desire a simple, efficient, effective and low-cost determine the appropriate orientation of the acetabular
alternative for improved navigation, the development of component during THA and hip resurfacing. This device
Fig. 9.9: Following insertion of the acetabular component, the Fig. 9.10: Following placement of the femoral and acetabular
final position is checked compared to the preoperative plan components, a determination of the leg length and offset is compared 85
to the preoperative plan
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
is currently designed for THA performed with the patient through another cannula and percutaneously onto the
in the lateral decubitus position. A patient-specific plan surface of the ilium to determine the second HipSextant
is provided for each surgery. In planning for surgery, CT plane point adjacent to the ASIS. The surgeon confirms
data are used to create a 3D model and to define the APP. the appropriate location of this point by percutaneously
A patient-specific HipSextant docking coordinate system probing the lateral ASIS using the trocar. Finally,
is then determined by three points: one just behind the another trocar is placed through a third cannula and
posterior acetabular rim; a second on the lateral side of percutaneously onto the surface of the ilium to determine
the ASIS; and a third on the surface of the ilium (Fig. 9.11). the landing point. With the HipSextant docked on the
The HipSextant itself has two adjustable orthogonal ipsilateral hemipelvis, a removable direction indicator
protractors (in-plane and off-plane angle) and two is applied to demonstrate the planned cup orientation
adjustable arms so that the instrument is adjusted for each during component implantation. The surgeon then
patient based on their specific anatomy. The instrument impacts the acetabular component with the insertion
docks directly to the pelvis so the recommended orien handle aligned visually with the direction indicator. The
tation of the acetabular component is based on the system maintains intraoperative flexibility by allowing the
actual position of the pelvis at the time of component surgeon to change the desired cup orientation goal and
implantation. A direction indicator points in the direction instrument setting during surgery, based on knowledge
of the planned cup orientation. of femoral component anteversion, for example. The
The surgeon uses the software application to open the instrument can be readjusted either just before or even
patient-specific plan and can designate the desired cup after it is docked on the patient.
orientation, which determines the specific settings for the
instrument so that when the instrument is docked to the
CONCLUSION
patient, the direction indicator points in the direction of
desired cup orientation (Fig. 9.12). Total hip arthroplasty is one of the most common
During surgery, the surgeon exposes and prepares the and successful orthopedic operations. However, there
cup as usual. Just prior to cup implantation, the point continues to be variations in inter- and intrasurgeon
behind the posterior rim (the base point) is identified results. Given the innate uniqueness of patients (size,
using a calibrated drill guide and threaded guidewire. shape, body habitus, acetabular anatomy, lifestyle and
The cannulated base point leg of the HipSextant is then socioeconomic status), it should be no surprise that
placed over the guidewire. A sharp trocar is placed patients might benefit from patient-specific surgical
Fig. 9.11: The HipSextant patient-specific docking coordinate system Fig. 9.12: Using the HipSextant patient-specific mechanical navi
is based on three points, one just behind the posterior rim of the gation device, the surgeon aligns with cup handle to be parallel to
acetabulum, one just adjacent to the ipsilateral anterior superior iliac the direction indicated by the instrument
86 spine, and one on the surface of the ilium, a fixed distance from
the other two points
Computer-Assisted Hip Arthroplasty
techniques and component placement. The ultimate 4. Padgett DE, Hendrix SL, Mologne TS, et al. Effectiveness
goal is to place the femoral and acetabular components of an acetabular positioning device in primary total
in the optimal orientation for each individual patient to hip arthroplasty. HSS J. 2005;1(1):64-7. [Online]
maximize their function and hardware survivorship with Available from http://www.pubmedcentral.nih.gov/
minimal risk of complications. articlerender.fcgi?artid=2504141&tool=pmcentrez&ren
dertype=abstract.
The main benefits of CAS in THA are the ability to
5. Saxler G, Marx A, Vandevelde D, et al. The accuracy of
provide real-time information during acetabular reaming
free-hand cup positioning—a CT based measurement
and component insertion to help a surgeon determine of cup placement in 105 total hip arthroplasties. Int
component position, leg length and offset. Overall, CAS Orthop. 2004;28(4):198-201. [Online] Available from
in THA has been shown to consistently improve the http://www.pubmedcentral.nih.gov/articlerender.fcgi?
chances of placing acetabular components within the artid=3456929&tool=pmcentrez&rendertype=abstract.
desired target safe zone, with less variation in implant 6. González Della Valle A, Slullitel G, Piccaluga F, et al.
position when compared to non-navigated techniques. The precision and usefulness of preoperative planning
As such, CAS in THA has the potential to help create for cemented and hybrid primary total hip arthroplasty.
a THA with more physiologic biomechanical function, J Arthroplasty. 2005;20(1):51-8. [Online] Available from
and to decrease the risk of complications, such as http://www.ncbi.nlm.nih.gov/pubmed/15660060.
dislocations, leg-length discrepancy, component wear, 7. Kelley TC, Swank ML. Role of navigation in total hip
arthroplasty. J Bone Joint Surg Am. 2009;91 Suppl
and impingement. There are also increased applications
1:153-8. [Online] Available from http://www.ncbi.nlm.
for improving minimally invasive techniques, which may
nih.gov/pubmed/19182044.
further enhance the above benefits. 8. Renkawitz T, Schuster T, Herold T, et al. Measuring leg
Despite these benefits, it must be recognized that at length and offset with an imageless navigation system
the present time, these technologies are imperfect and do during total hip arthroplasty: is it really accurate? Int
come with relative drawbacks. Specifically, investments in J Med Robot. 2009;5(2):192-7. [Online] Available from
new equipment, time associated with preparing for and/ http://www.ncbi.nlm.nih.gov/pubmed/19253907.
or performing surgery, as well as training a surgeon and 9. Dorr LD, Malik A, Wan Z, et al. Precision and bias of
staff, has made the adoption of these CAS technologies imageless computer navigation and surgeon estimates
slow. for acetabular component position. Clin Orthop Relat
Further innovation in the field of CAS, as well as Res. 2007;465(465):92-9. [Online] Available from http://
investigation of its clinical and economic merits, must www.ncbi.nlm.nih.gov/pubmed/17693877.
10. Kalteis T, Handel M, Bäthis H, et al. Imageless navigation
be continued if these technologies and techniques are
for insertion of the acetabular component in total hip
to be widely embraced by the orthopedic community.
arthroplasty: is it as accurate as CT-based navigation?
J Bone Joint Surg Br. 2006;88(2):163-7. [Online] Available
REFERENCES from http://www.ncbi.nlm.nih.gov/pubmed/16434517.
11. McCollum DE, Gray WJ. Dislocation after total hip
1. Digioia AM, Jaramaz B, Plakseychuk AY, et al. Com arthroplasty. Causes and prevention. Clin Orthop Relat
parison of a mechanical acetabular alignment guide Res. 1990;(261):159-70. [Online] Available from http://
with computer placement of the socket. J Arthroplasty. www.ncbi.nlm.nih.gov/pubmed/2245542.
2002;17(3):359-64. [Online] Available from http://www. 12. Lewinnek GE, Lewis JL, Tarr R, et al. Dislocations after
ncbi.nlm.nih.gov/pubmed/11938515. total hip-replacement arthroplasties. JBJS. 1978;60:217-20.
2. Hassan DM, Johnston GH, Dust WN, et al. Accuracy 13. Murphy WS, Werner SP, Kowel JH, et al. The safe zone
of intraoperative assessment of acetabular prosthesis for acetabular component orientation. International
placement. J Arthroplasty. 1998;13(1):80-4. [Online] Society for Computer Assisted Orthopaedic Surgery.
Available from http://www.ncbi.nlm.nih.gov/pubmed/ 2012.
9493542. 14. Sugano N, Nishii T, Miki H, et al. Mid-term results of
3. Moskal JT, Capps SG. Improving the accuracy of cementless total hip replacement using a ceramic-
acetabular component orientation: avoiding malposi on-ceramic bearing with and without computer
tion. J Am Acad Orthop Surg. 2010;18(5):286-96. navigation. J Bone Joint Surg Br. 2007;89(4):455-60.
[Online] Available from http://www.ncbi.nlm.nih.gov/ [Online] Available from http://www.ncbi.nlm.nih.gov/
pubmed/20435879. pubmed/17463111. 87
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
15. DiGioia AM, Jaramaz B, Blackwell M, et al. The Otto [Online] Available from http://www.ncbi.nlm.nih.gov/
Aufranc Award. Image guided navigation system pubmed/16410235.
to measure intraoperatively acetabular implant ali 22. Lin F, Lim D, Wixson RL, et al. Limitations of imageless
gnment. Clin Orthop Relat Res. 1998;(355):8-22. computer-assisted navigation for total hip arthroplasty.
[Online] Available from http://www.ncbi.nlm.nih.gov/ J Arthroplasty. 2011;26(4):596-605. [Online] Available
pubmed/9917587 from http://www.ncbi.nlm.nih.gov/pubmed/20817389.
16. Murphy SB, Ecker TM. Evaluation of a new leg length 23. Abraham WD, Dimon JH. Leg length discrepancy
measurement algorithm in hip arthroplasty. Clin in total hip arthroplasty. Orthop Clin North Am.
Orthop Relat Res. 2007;463:85-9. [Online] Available 1992;23(2):201-9. [Online] Available from http://www.
from http://www.ncbi.nlm.nih.gov/pubmed/17572632. ncbi.nlm.nih.gov/pubmed/1570134.
17. Parratte S, Argenson JN. Validation and usefulness of a 24. Williamson JA, Reckling FW. Limb length discrepancy
computer-assisted cup-positioning system in total hip and related problems following total hip joint replace
arthroplasty. A prospective, randomized, controlled ment. Clin Orthop Relat Res. 1978;(134):135-8.
study. J Bone Joint Surg Am. 2007;89(3):494-9.
[Online] Available from http://www.ncbi.nlm.nih.gov/
[Online] Available from http://www.ncbi.nlm.nih.gov/
pubmed/729230.
pubmed/17332097.
25. Najarian BC, Kilgore JE, Markel DC. Evaluation of
18. Leenders T, Vandevelde D, Mahieu G, et al. Reduction
component positioning in primary total hip arthroplasty
in variability of acetabular cup abduction using
using an imageless navigation device compared with
computer assisted surgery: a prospective and
randomized study. Comput Aided Surg. 2002;7(2):99- traditional methods. J Arthroplasty. 2009;24(1):15-21.
106. [Online] Available from http://www.ncbi.nlm.nih. 26. Woolson ST, Mow CS, Syquia JF, et al. Comparison
gov/pubmed/12112719. of primary total hip replacements performed with a
19. Ecker TM, Tannast M, Murphy SB. Computer tomo standard incision or a mini-incision. JBJS. 2004;86-
graphy-based surgical navigation for hip arthroplasty. A(7):1353-8.
CORR. 2007;465:100-5. 27. Kelley TC, Swank ML. Role of navigation in total hip
20. Beckmann J, Stengel D, Tingart M, et al. Navigated arthroplasty. J Bone Joint Surg Am. 2009;91 Suppl
cup implantation in hip arthroplasty. Acta Orthop. 1:153-8. [Online] Available from http://www.ncbi.nlm.
2009;80(5):538-44. nih.gov/pubmed/19182044.
21. Tannast M, Langlotz F, Kubiak-Langer M, et al. Accuracy 28. Murphy SB, Ecker TM, Tannast M. THA performed
and potential pitfalls of fluoroscopy-guided acetabular using conventional and navigated tissue-preserving
cup placement. Comput Aided Surg. 2005;10:329-36. techniques. CORR. 2006;453:160-7.
88
Chapter
Proximal Femoral
Reconstruction in
10
Hip Arthroplasty
Tao Ji, Cheng-Fong Chen, Bang H Hoang
A B INDICATIONS
Figs 10.1A and B: Radiographs of a 31-year-old male with recurrent
low-grade fibrous histiocytoma. (A) preoperatively and (B) postoperatively The proximal femur is a common location for a number
following reconstruction with a proximal femoral replacement of primary bone malignancies as well as metastases from
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Table 10.1: Indications for proximal femoral replacement • Limb length discrepancy (≤ 4 cm intraoperative
lengthening can be carried out)
Nononcological extensive bone loss
• Status of the abductors
• Periprosthetic fracture
• Rule out infection
• Failed total hip arthroplasty with segmental bone loss
• Problems with the removal of existing hardware
• Failure of internal fixation • Potential need for insertion of constrained liners
• Chronic osteomyelitis • Length, and canal diameter of the allograft to match
• Highly comminuted fractures with poor bone quality with the host femur if using APC
Oncological bone destruction • Additional screws and plates available (if stem
• Primary bone sarcoma couldn’t bypass the allograft-host junction).
• Metastatic tumors with extensive bone destruction
• Benign aggressive tumors with extensive destruction AUTHORS’ PREFERRED SURGICAL
TECHNIQUE
carcinoma. Like the management of bone tumors, the Position
complexity of proximal femoral reconstruction during
The patient is usually placed in a lateral decubitus position.
revision surgery for failed metallic implants arises when
All bony prominences should be well padded during the
there is significant bone loss.3,6,9,10 The indication for
surgery. An axillary pad and head pad are necessary to
proximal femoral replacement is listed in Table 10.1. For
minimize compression of axillary neurovascular structures
older patients with extensive bone loss, megaprosthesis
and traction of the brachial plexus, respectively. The pelvic
reconstruction allows immediate weight-bearing and
support should be secure for accurate positioning of the
mobilization for the patients. In younger and more
acetabular component. U-drapes are used to isolate the
active patients, reconstruction may be attempted by an
groin outside of the surgical field, and draping should
APC. An important and critical prerequisite for the use
be wide enough to permit an extensile approach to the
of proximal femoral replacement is that there is at least
hip joint and if necessary an arthrotomy of the knee to
10 cm of distal femoral diaphysis available for secure
address intraoperative complications.
intramedullary fixation (3 cm for Compress® Compliant
Pre-Stress Implant, Biomet, Warsaw, Indiana) of the
prosthesis. Incision and Exposure
A long lateral incision that allows exposure to the upper
PREOPERATIVE PLANNING femur passes upward along the midlateral aspect of the
thigh to the greater trochanter then extends proximally
Proximal femur reconstruction is a major surgical 3–4 cm while curving backward slightly, along the interval
procedure that necessitates a detail preoperative plan. between the tensor fascia lata and the gluteus maximus
Both physical examination and imaging studies are muscle (Fig. 10.2). This approach allows exposure of the
imperative to achieve a thorough evaluation. Most proximal third of the femur and the retrogluteal area. It
complications can be avoided by predicting their also permits rotation of the limb internally and externally
likelihood before surgery and modifying the surgical to allow identification of the femoral canal, femoral
techniques accordingly.2 Most patients requiring proximal triangle, superficial and profundus femoral artery, and
femoral replacement have often had numerous previous sartorial canal. The posterolateral approach (Moore) may
surgeries, which makes templating critical. Preopertive be selected for revision arthroplasty.
templating to select the appropriate stem length and
diameter is essential for successful reconstruction. The
following is a general checklist for preoperative planning:
Abductor Detachment
• Feasibility of sparing the greater trochanter (cable or The skin incision is widely retracted using a Charnley
wires for trochanteric reattachment) initial incision retractor. The iliotibial band is opened
• Examine the incision site for previous scar and skin longitudinally to allow adequate anterior and posterior
90 lesions exposure. The abductors are identified with the anterior
Proximal Femoral Reconstruction in Hip Arthroplasty
Fig. 10.2: Lateral incision for proximal femoral replacement Fig. 10.4: Illustration showing exposure of anterolateral aspect of
femur. The vastus lateralis is swept off the fascia lata and followed
down to its attachment to the lateral intermuscular septum
and posterior intervals. A sliding osteotomy of the greater
trochanter is usually done (Fig. 10.3), and the abductors
are reflected superiorly and separated from the gluteus osteotomy, splitting the proximal femur, may be required
minimus muscle. If the greater trochanter cannot be in order to facilitate the removal of the previous
preserved, the abductors are divided with as much of the prosthesis and hardware. Meticulous debridement of
tendon as possible to retain a resilient part to allow later the hip is carried out to remove previous metal debris.
reattachment. If possible, every effort should be made A longitudinal line representing the anterior aspect of
to retain the vastogluteal sling (vastus lateralis—greater the femur should be marked distal to the resection level
trochanter—gluteal medius) in continuity.7 Retrogluteal to aid later in rotational orientation of the prosthesis.
area, including the external rotators, sciatic nerve, Furthermore, certain references should be marked to
abductors, and the posterior capsule can be exposed by restore appropriate limb length. At this point, the femoral
further retracting the gluteus maximus. The sciatic nerve osteotomy is performed at the appropriate location. For
lies directly posterior to the external rotators. APC reconstruction, a step-cut osteotomy can be done to
provide rotational stability at the allograft-host junction
Exposure of the Anterolateral and a large allograft-host contact surface for allograft
incorporation.11
Aspect of Femur
Meticulous soft tissue handling helps the tissue to Access to the Posterior Hip and
heal and minimizes postoperative complications. The
vastus lateralis is swept off the fascia lata with a finger
Hip Dislocation
and followed down to its attachment to the lateral With the retrogluteal area exposed, the external rotator
intermuscular septum. With careful dissection, the muscles are detached from their insertion on the
vastus lateralis along with the vastus intermedialis is proximal femur. The hip joint can be visualized. Then
slightly displaced anteriorly, so that the anterolateral the capsule is incised around the femoral neck passing
aspect of the femur is exposed (Fig. 10.4). An extended anteriorly and medially along the intertrochanteric line
92 Fig. 10.5: Typical defect after proximal femoral resection Fig. 10.6: Serial reaming of the residual medullary canal of the femur
Proximal Femoral Reconstruction in Hip Arthroplasty
COMPLICATIONS
The major complications regarding megaprostheses
in patients with previous failed arthroplasty and after
resection of tumors are early dislocation and aseptic
Fig. 10.7: Illustration showing soft tissue reconstruction after proxi loosening.16,20-22 However, advances in prosthesis
mal femoral reconstruction. Purse string for hip capsule can enhance
design and increased experience has led to reduced
the stability and musculotendinous is reattached to the anatomical 93
position of endoprosthesis being wrapped with synthetic mesh complications. The modularity design allows better
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B A B C
Figs 10.8A and B: Radiograph (A) showed grade II acetabular erosion Figs 10.9A to C: Radiographs showed deep infection after a proximal
(acetabular bone erosion and early migration). The bipolar was then femoral reconstruction (A). Extensive periosteal reaction formed (B) similar
converted to a total hip joint 5 years after initial operation (B) to the process of chronic osteomyelitis. The implant was taken out and the
antibiotic-impregnated articulating cement spacer was used (C)
ability to restore limb length and achieve optimal soft 10% (Table 10.2). In a clinical study of a proximal femoral
tissue tension. replacement fitted with strain gauges and telemetric
Dislocation is a relatively common complication apparatus, Taylor showed that 60% of applied load on a
following proximal femoral replacement, with a wide cemented intramedullary stem was transferred to the region
range reported in the literature of 4.8–15%.15,23,24 The on the tip of the stem.31 As a consequence, continuous
risk may be lower in nonmalignant cases where the growth and an increase in the number of microcracks
resection of soft tissue is much less and with a greater accumulated in the bone cement mantle around the tip of
potential for musculotendinous reattachment. With wide the stem. Cementless stems are being used with increasing
resection of the proximal femur for neoplastic disease, frequency to attempt to achieve a more durable fixation and
surrounding soft tissues may be resected leading to joint decrease the rates of aseptic loosening.6
instability. Besides hip capsule repair, the use of a bipolar Deep Infection is a disastrous complication of
head will also facilitate stability. A study focused on femoral reconstruction with an endoprosthesis or an APC
uncemented bipolar proximal femoral replacement did (Figs 10.9A to C). Neutropenia from chemotherapy and
not show dislocation complications in 23 tumor patients.25 poor soft tissue coverage were thought to have contributed
Acetabular erosion (Figs 10.8A and B) is thought to be the to early deep infection in tumor conditions.32 The duration
major factor influencing clinical outcomes and a leading of antibiotic therapy is usually empirical. Antibiotic-loaded
reason of revision or conversion. Studies regarding cement can be used when cemented fixation is chosen.
acetabular erosion in patients with hemiarthroplasties Minimizing wound hematomas by the judicious use of
show ranges from 2% to 36% for unipolar, and 0% to 26% drainage, careful obliteration and closure of soft tissue dead
for bipolar implants.26-28 Baker27 introduced a grading spaces, and carful application of compressive bandaging
system for acetabular erosion and reported 66% erosion, may also add to the prevention of infection.4
mostly grade I, after only 3 years of follow-up. The incidence of allograft-host bone junction
Aseptic loosening is another common complication nonunion after APC reconstruction is reported to range
94 of megaprosthesis reconstruction in the majority of from 4.7% to 20%.10,11,25 Achievement of adequate and
reported studies. The reported rate ranges from 0% to stable contact at the osteotomy site may sometimes be
Proximal Femoral Reconstruction in Hip Arthroplasty
very difficult. Strut grafts can be placed at the junction of patients who received a modular endoprosthetic
and reinforced by cables, offering additional stability replacement for failed internal fixation of the proximal
and assisting in allograft-host fusion. Many factors may femur following trauma.8
cause an increased risk of nonunion, such as infection
and chemotherapy. Despite aggressive treatment, 30% of CONCLUSION
the patients with a nonunion eventually had removal of
the allograft or amputation.33 Proximal femoral replacement with endoprosthesis is an
effective salvage procedure for both neoplastic and non-
neoplastic conditions. It can provide immediate weight-
OUTCOMES bearing and does not rely on the availability of allograft
There are limited outcome studies on proximal femoral or subsequent bone union. For the sedentary and elderly
replacement in non-neoplastic cases. However, the patients, endoprosthetic reconstruction should be the
initial reviews revealed that the mode of failure of first choice. APC is a useful option for severe proximal
megaprosthesis is similar in patients with or without femoral deficiencies. It can provide excellent soft tissue
neoplastic conditions.6,34 Parvizi reported a series of reattachment and bone stock restoration.
43 patients with a mean age of 73.8 years who had
undergone proximal femoral replacement with a modular
REFERENCES
megaprosthesis for severe proximal bone loss. The implant
estimated 5-year survival was 73%. Ten patients (23.3%) 1. Sternheim A, Rogers BA, Kuzyk PR, et al. Segmental
required a reoperation or revision because of at least proximal femoral bone loss and revision total hip
one complication.9 McLean7 recently reported a total of replacement in patients with developmental dysplasia
of the hip: the role of allograft prosthesis composite.
20 patients with a mean age of 73 who were managed
J Bone Joint Surg Br. 2012;94(6):762.
with a proximal femoral replacement (15) or total
2. Bickels J, Malawer M. Proximal and total femur resection
femoral replacement (5) for salvage of a periprosthetic
with endoprosthetic reconstruction. In: Malawer M,
femoral fracture with severe bone loss. During a mean Wittig JC, Bickels J (Eds). Operative Techniques in
follow-up of 48 months, dislocation was found to be the Orthopaedic Surgical Oncology. USA: LWW; 2012. p.
most common complication (15%). Other complications 223.
included two deep infections and one distal femur 3. Maury AC, Pressman A, Cayen B, et al. Proximal femoral 95
fracture. No complication was reported in a small group allograft treatment of Vancouver type-B3 periprosthetic
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
femoral fractures after total hip arthroplasty. J Bone 20. Bernthal NM, Schwartz AJ, Oakes DA, et al. How long
Joint Surg Am. 2006;88(5):953. do endoprosthetic reconstructions for proximal femoral
4. Choong PF. Proximal femur. In: Sim FH, Choong PF, tumors last? Clin Orthop Relat Res. 2010;468(11):2867.
Weber KL (Eds). Orthopaedic Oncology and Complex 21. Zeegen EN, Aponte-Tinao LA, Hornicek FJ, et al.
Reconstruction. USA: LWW; 2011. p. 101. Survivorship analysis of 141 modular metallic endo
5. Mayle RE Jr, Paprosky WG. Massive bone loss: allograft- prostheses at early followup. Clin Orthop Relat Res.
prosthetic composites and beyond. J Bone Joint Surg Br. 2004; (420):239.
2012;94-B(11 Suppl):61. 22. Ogilvie CM, Wunder JS, Ferguson PC, et al. Functional
6. Parvizi J, Sim FH. Proximal femoral replacements with outcome of endoprosthetic proximal femoral replace
megaprostheses. Clin Orthop Relat Res. 2004;(420):169. ment. Clin Orthop Relat Res. 2004;(426):44.
7. McLean AL, Patton JT, Moran M. Femoral replacement 23. Potter BK, Chow VE, Adams SC, et al. Endoprosthetic
for salvage of periprosthetic fracture around a total hip proximal femur replacement: metastatic versus primary
replacement. Injury. 2012;43(7):1166. tumors. Surg Oncol. 2009;18(4):343.
8. Dean BJ, Matthews JJ, Price A, et al. Modular 24. Menendez LR, Ahlmann ER, Kermani C, et al.
endoprosthetic replacement for failed internal fixation Endoprosthetic reconstruction for neoplasms of the
of the proximal femur following trauma. Int Orthop. proximal femur. Clin Orthop Relat Res. 2006;450:46.
2012;36(4):731. 25. Donati D, Zavatta M, Gozzi E, et al. Modular prosthetic
9. Parvizi J, Tarity TD, Slenker N, et al. Proximal femoral replacement of the proximal femur after resection of a
replacement in patients with non-neoplastic conditions. bone tumour a long-term follow-up. J Bone Joint Surg
J Bone Joint Surg Am. 2007;89(5):1036. Br. 2001;83(8):1156.
10. Clarke HD, Berry DJ, Sim FH. Salvage of failed femoral 26. Hedbeck CJ, Enocson A, Lapidus G, et al. Comparison
megaprostheses with allograft prosthesis composites. of bipolar hemiarthroplasty with total hip arthroplasty
Clin Orthop Relat Res. 1998;(356):222. for displaced femoral neck fractures: a concise four-year
11. Hejna MJ, Gitelis S. Allograft prosthetic composite follow-up of a randomized trial. J Bone Joint Surg Am.
2011;93(5):445.
replacement for bone tumors. Semin Surg Oncol.
27. Baker RP, Squires B, Gargan MF, et al. Total hip
1997;13(1):18.
arthroplasty and hemiarthroplasty in mobile, indepen
12. Goetz DD, Capello WN, Callaghan JJ, et al. Salvage of
dent patients with a displaced intracapsular fracture of
a recurrently dislocating total hip prosthesis with use
the femoral neck. A randomized, controlled trial. J Bone
of a constrained acetabular component. A retrospective
Joint Surg Am. 2006;88(12):2583.
analysis of fifty-six cases. J Bone Joint Surg Am.
28. Squires B, Bannister G. Displaced intracapsular neck
1998;80(4):502.
of femur fractures in mobile independent patients:
13. Donati D, Giacomini S, Gozzi E, et al. Proximal femur
total hip replacement or hemiarthroplasty? Injury.
reconstruction by an allograft prosthesis composite.
1999;30(5):345.
Clin Orthop Relat Res. 2002;(394):192. 29. Finstein JL, King JJ, Fox EJ, et al. Bipolar proximal
14. Abdeen A, Healey JH. Allograft-prosthesis composite femoral replacement prostheses for musculoskeletal
reconstruction of the proximal part of the humerus: neoplasms. Clin Orthop Relat Res. 2007;459:66.
surgical technique. J Bone Joint Surg Am. 2010;92 Suppl 30. Farid Y, Lin PP, Lewis VO, et al. Endoprosthetic and
1 Pt 2:188. allograft-prosthetic composite reconstruction of the
15. Henderson ER, Jennings JM, Marulanda GA, et al. proximal femur for bone neoplasms. Clin Orthop Relat
Purse-string capsule repair to reduce proximal femoral Res. 2006;442:223.
arthroplasty dislocation for tumor—a novel technique 31. Taylor S, Perry J, Adler J, et al. The telemetry of force in
with results. J Arthroplasty. 2010;25(4):654. vivo developed in massive orthopedic implants: the first
16. Bickels J, Meller I, Henshaw RM, et al. Reconstruction 18 months results from walking. In: Tan SK (Ed). Limb
of hip stability after proximal and total femur resections. Salvage: Current Trends. Singapore: ISOLS; 1993. p. 560.
Clin Orthop Relat Res. 2000;(375):218. 32. Guo W, Ji T, Yang R, et al. Endoprosthetic replacement
17. Henderson ER, Jennings JM, Marulanda GA, et al. for primary tumours around the knee: experience from
Enhancing soft tissue ingrowth in proximal femoral Peking University. J Bone Joint Surg Br. 2008;90(8):1084.
arthroplasty with aortograft sleeve: a novel technique 33. Hornicek FJ, Gebhardt MC, Tomford WW, et al. Factors
and early results. J Arthroplasty. 2011;26(1):161. affecting nonunion of the allograft-host junction. Clin
18. Trieb K, Blahovec H, Brand G, et al. In vivo and in vitro Orthop Relat Res. 2001;(382):87.
cellular ingrowth into a new generation of artificial 34. Parvizi J, Javad Mortazavi SM, van de Leur T, et al.
ligaments. Eur Surg Res. 2004;36(3):148. Megaprosthesis for non-neoplastic conditions of the
19. Gosheger G, Hillmann A, Lindner N, et al. Soft tissue proximal femur. In: Sim FH, Choong PF, Weber KL (Eds).
96 reconstruction of megaprostheses using a trevira tube. Orthopaedic Oncology and Complex Reconstruction.
Clin Orthop Relat Res. 2001;(393):264. USA: LWW; 2011. p. 115.
Chapter
Treating the Degenerative
11
Dysplastic Hip
Seth A Jerabek
Fig. 11.2: The lateral center edge angle of Wiberg is demonstrated Fig. 11.3: Example of 3D templating where the surgeon can template
on the right hip and the Tönnis angle or acetabular index on the left the size and location of the acetabular component making sure to
98 hip. The interteardrop line serves as the horizontal plane medialize the acetabular component while maintaining anterior and
posterior bone stock
Treating the Degenerative Dysplastic Hip
from the superior iliac crests to the ischial tuberosities
and that the medial femoral head-neck junction was
approximately located at the level of the interteardrop
line (Fig. 11.4). Thus, in a dysplastic hip, the distance
from the interteardrop line to the medial head-neck
junction could be measured and compared to the size
of the contralateral femur or the height of the pelvis.
Subluxation greater than the diameter of the contralateral
femoral head or one-fifth of the height of the pelvis
represented a dislocation and at least 100% of proximal
subluxation. Given this, the following classification was
introduced to grade dysplasia based on subluxation:
Crowe I was less than 50% subluxation; Crowe II was
50–74% subluxation; Crowe III was 75–100% subluxation;
and Crowe IV was greater than 100% of proximal Fig. 11.4: The diameter of the uninvolved femoral head measures
one-fifth of the height of the pelvis. The distance from the inter
subluxation. Figure 11.4 depicts the landmarks used in teardrop line to the medial head-neck junction is divided by the
the Crowe classification while Figures 11.5A to D show diameter of the femoral head (or one-fifth pelvic) height to determine
radiographic representations of each stage. the Crowe classification
A B
C D
Figs 11.5A to D: Crowe classification. (A) Crowe I right hip; (B) Crowe II right hip; (C) Crowe III left hip; (D) Crowe IV bilateral hips 99
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
The Hartofilakidis classification is a qualitative the iliac wing is hypoplastic and the entire hemipelvis
grading system primarily based on the anatomy of the anteverted. See Figures 11.6A to C.
acetabulum. Three types of dysplasia were described: Both of these classification systems are reliable
(1) dysplasia; (2) low dislocation; and (3) high dislocation. and reproducible in multiple studies and can be used
In dysplasia, the femoral head is located within the true to help guide treatment.15-17 For simplicity, the Crowe
acetabulum, but there is a superior segmental defect classification will be used going forward.
and the fossa is occupied by an osteophyte making the
acetabulum shallow (Fig. 11.6A). In a low dislocation, the TREATMENT AND OUTCOMES
femoral head articulates with a false acetabulum, but the Once conservative treatments have failed and advanced
interior rim of the false acetabulum contacts the superior degenerative changes have developed, THA is the only option.
lip of the true acetabulum. There is a segmental defect in
the bone of the superior and anterior true acetabulum, SURGICAL TECHNIQUE
narrow acetabular opening of inadequate depth, and
often increased anteversion (Fig. 11.6B). Lastly, a high Exposure
dislocation is when the femoral head migrates superiorly
and posteriorly. The entire acetabular rim is deficient
Crowe I
from anterior to posterior, and the true acetabulum is In general, any standard hip exposure will work for
hypoplastic with a triangular opening (Fig. 11.6C). Often Crowe I dysplasia including direct anterior, anterolateral,
A B
A B
A B
should be considered to supplement fixation. Figures more durable results than cemented fixation whether
11.8A to C show the reconstruction of a Crowe I hip. used alone or with augmentation.20-25
When using cementless acetabular components, it
Crowe II, III and IV was historically thought that greater than 70% of the
Crowe II, III and IV hips will have progressively more native bone should be in contact with the shell to obtain
superolateral, anterior, and ultimately posterior acetabular reliable ingrowth.21,26,27 This percentage may be less now
bone loss. Most surgeons agree that it is ideal to restore the that porous metal acetabular shells are available, but it
center of rotation of the hip to the true acetabulum and not does serve as a guide one when to consider advanced
leave patients with a high hip center.18-20 This is particularly reconstructive techniques.
true if the contralateral hip is unaffected, as restoring the If there is inadequate acetabular coverage to place a
hip center of rotation will equalize leg lengths in addition primary cementless shell, reconstructive options include
to improving the mechanics of the hip. placing the acetabular component in a superior location
Both cemented and cementless acetabular compo (high hip center), acetabular component medialization
nents have been used in DDH reconstruction. Over time, through the medial acetabular wall, and superolateral
102 it has become clear that cementless fixation provides augmentation with bone graft or metallic augments.
Treating the Degenerative Dysplastic Hip
Placing the acetabular component superiorly and more lateral coverage and decreasing the need for lateral
leaving a high hip center is a good option if there augmentation. Although 100% (24 of 24) of the acetabular
is very little bone surrounding the true acetabulum, shells placed by this method survived at midterm
which would require placing an acetabular shell with follow-up, this technique has not been universally
little native bony contact. Today, the exact percentage accepted.
is unknown, but 40–50% of uncoverage or coverage Augmentation of the superolateral acetabulum can be
by augmentation has been suggested as a possible achieved with autograft from the femoral head, femoral
indication to leave a high hip center.28 Another indication head allograft, or metallic augments. Autogenous femoral
for leaving a high hip center may be the lack of a leg- head is favored, as it is available as an inexpensive
length discrepancy. Thus, if the patient has bilateral DDH byproduct of a hip replacement, reliably incorporates,
and only one side is symptomatic or if the contralateral and restores pelvic bone stock if future revision is
side has been reconstructed with a high hip center, needed.22,31-34 Cementless acetabular components placed
bringing the hip center down on the operative side would with bulk femoral head autograft have had greater than
cause a leg-length discrepancy and may necessitate a 90% survival and incorporation at 8-year follow-up in two
femoral shortening osteotomy. With modern cementless separate studies.31,33 Figures 11.10A to D demonstrate
acetabular shells, the results of a high hip center may be acetabular reconstruction with a cementless acetabulum
similar to restoring the true center of rotation. Murayama and femoral head autograft.
et al. reported 15-year follow-up comparing 10 hips
placed at an anatomical center and 33 placed at a high
hip center; the polyethylene wear rate and Harris hip
Femur
scores were similar and cup survivorship in the anatomic On the femoral side, there are many options for
group was 100% while the high hip center group was 97% reconstruction, but difficult to subdivide by a classification
(one failure for aseptic loosening).29 Figures 11.9A and B system. All of the common classification systems for DDH
demonstrate a case with a right high hip center due to are predictive of acetabular anatomy and leg lengths,
previous high hip center placement. but none of them are predictive as to the severity of
Dorr et al. proposed a technique where the medial femoral deformity.4,35 Thus, severe acetabular dysplasia
wall was intentionally reamed through to cause a defect (Crowe IV or high dislocation) does not always have a
of approximately 25% of the acetabular area.30 This severe femoral deformity. Alternatively, relatively mild
allowed for further medialization of the shell resulting in acetabular dysplasia can have more advanced femoral
A B
Figs 11.9A and B: (A) The patient has a complex reconstruction on the left that has been in stable position and asymptomatic for the
last 8 years. Her right hip is dysplastic and painful with severe degenerative changes after a pelvic osteotomy as an adolescent, and she
perceives her leg lengths as being equal; (B) A cementless reconstruction with a high hip center was performed to maintain leg lengths. 103
Care was taken to medialize to the medial wall
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
C D
Figs 11.10A to D: (A) and (B) represent preoperative anteroposterior and lateral radiographs of a Crowe III or low dislocation of the left
hip; (C) and (D) are the postoperative radiographs showing acetabular reconstruction with a cementless acetabulum and bulk femoral head
autograft and modular stem
deformities. The best femoral option depends on the geometry. The femoral version is difficult to determine
size, version and morphology of the femur. The most prior to surgery without a CT scan. The surgeon should
common femoral deformities are a narrow canal with have a “back-up” plan in the event that there is more
the mediolateral dimension smaller than AP, excessive anteversion than expected, the canal is too small for
anteversion, posteriorly located greater trochanter, and the smallest stem, or if the geometry does not accept a
a valgus neck-shaft angle.3,5 standard stem.
Cemented stems have several advantages in that they
Crowe I and II are smaller than uncemented stems, do not depend on
Femoral shortening osteotomy is typically not needed the precise fit that press-fit stems do, and can be rotated
in Crowe type I and II hips. Cemented or uncemented to an extent to compensate for excessive anteversion.
stems can be used. Given the relatively young age at Numair et al. reported on 136 cements femoral stems in
reconstruction in many DDH cases, proximally coated Crowe I, II and III DDH and found there was 97% survival
monoblock stems are commonly used. However, careful without loosening at 9.9 years.36 Sochart and Porter
attention should be paid to the overall geometry, size followed 60 THAs done for DDH and using the Kaplan-
104 and version of the femur. Templating before surgery Meier method, 89% of the femoral stems survived to
can indicate how well a stem will fit, both in size and 25 years.37 However, Stans et al. reported on 90 total hips
Treating the Degenerative Dysplastic Hip
done for Crowe III DDH and noted that 40% of cemented There are varying reports of how much a hip can be
femoral stems were loose at 16.6 years.20 acutely lengthened without causing a femoral or sciatic
Some surgeons advocate for monoblock fully coated nerve palsy, which ranges from 1.7 cm to 7 cm.43-46 In
stems or tapered stems in the setting of DDH. These stems practice, most surgeons consider performing a femoral
bypass the dysplastic proximal femur and achieve fixation shortening procedure when planning to lengthen 3 cm
distally in the diaphysis. Thus, the femoral version can be or more.47,48
corrected to some degree and they do not rely on exact In 1976, Dunn and Hess described a proximal femur
fit in the proximal femur. Two series report 100% survival osteotomy of the greater trochanter and metaphysis
of diaphyseal fitting stems (one straight cylindrical and sequentially resecting up to 2–3 cm of bone to allow
the other straight tapered) without loosening at midterm reduction and reduce tension on the sciatic nerve.43
follow-up.38,39 This technique requires the greater trochanter to heal
Modular stems have several advantages as they allow to the cortical diaphysis, failure results in a nonunion.
the surgeon to gain cementless fixation while being Then in 1998, Sponseller and McBeath published a
able to freely adjust version and can often account for case report performing a total hip replacement and a
the metaphyseal/diaphyseal mismatch caused by the subtrochanteric osteotomy to correct leg length and
relatively narrow femoral canal. However, there are rotation in Crowe IV dysplasia.49 Various methods
concerns regarding the strength and potential corrosion of subtrochanteric osteotomy have been described
at the modular junctions. Biant et al. reported 10-year utilizing various combinations of osteotomy geometries
results on 28 hips reconstructed with a cementless (transverse, oblique, chevron and step-cut). A multitude
modular proximal sleeve; they demonstrated excellent
of different stems have been utilized for these complicated
results without loosening or need for revision.40 Since
cases (cemented, modular proximal sleeve with distal
modular stems with a proximal sleeve gain fixation
flutes, and fully coated monoblock cylindrical).47,49-51
proximally, allow for resolution of the metaphyseal/
Transverse osteotomies allow for simpler adjustment of
diaphyseal mismatch, and have reports of intermediate
rotation but may have higher nonunion rates, as there is
to long-term survival with few complications, it is the
less rotational stability. Figures 11.11A and B highlight a
stem of choice when modularity is required (Figs 11.10C
case of subtrochanteric osteotomy.
and D).40-42
The use of electromyographic monitoring during
A custom femoral component can be manufactured
surgery of the sciatic and femoral nerves has been
if none of the above stem options work. A femoral canal
proposed but yet to be proven to improve outcomes.
narrower than commercially available stems is the most
common reason to consider a custom implant. However,
custom implants are expensive and if during surgery, the COMPLICATIONS
custom implant does not fit perfectly, there are limited
The complications associated with Crowe I reconstruction
salvage options.
are not well documented but likely similar to those of
routine THA. Complications unique to reconstructing
Crowe III and IV more severe deformities include aseptic loosening of both
All of the considerations above apply to Crowe III and IV, the acetabular and femoral components, dislocation,
but the additional consideration of excessive lengthening femoral or sciatic nerve palsy, and femoral osteotomy
can become problematic. This is not a problem if the hip nonunion. Wang et al. reported the Mayo Clinic
is left with a high hip center. However, if the acetabulum experience with dislocation after THA in DDH where
is placed at the level of the true acetabulum, the surgeon 820 THAs were performed and they were subdivided by
should be prepared to perform a femoral shortening Crowe classification.52 The overall dislocation rate was
osteotomy. This may need to be done for several reasons: 2.93% with minimum follow-up of 6 months. There was
the rectus femoris and hamstrings become tight not no difference between Crowe classification subtype or
allowing femoral head reduction into the acetabulum; if a subtrochanteric osteotomy was performed. 69.6% of
risk of undue tension on the femoral and sciatic nerves; the dislocations were anterior and it was noted the safe
and need to correct extremes of anteversion. zone of combined anteversion is 30–45°. Dislocations
105
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 11.11A and B: (A) Preoperative anteroposterior pelvis showing bilateral Crowe IV or a high dislocations; (B) Postoperative anteroposterior
pelvis status post left hip reconstruction with a small acetabular shell and transverse femoral shortening osteotomy with bivalved femoral
diaphyseal strut autograft at the osteotomy site
were significantly less when heads larger than 28 mm which is usually smaller than the superior inferior
were used. diameter
• Femoral head autograft should be used to provide
reliable bony support to a cementless shell.
AUTHOR’S TECHNIQUE HIGHLIGHTS
Developmental dysplasia of the hip is spectrum of Femur
disease resulting in incongruence between the femoral
head and acetabulum. These hips often go on to have • Femoral deformity is not predicted by dysplasia
degenerative changes requiring THA. Reconstruction can classification
be challenging on both the acetabular and femoral sides, • Common deformities include a narrow canal,
but the following points should be highlighted for each excessive anteversion, posterior position of the greater
reconstruction. trochanter, and valgus neck angle
• Standard proximal fixation stems may not fit due to
Acetabulum metaphyseal/diaphyseal mismatch and are not able
to correct for excessive femoral neck anteversion
• As the dysplasia classification increases, the more • Cemented stems and distal fixation stems can better
bony deficiency of the acetabulum is present typically correct anteversion and metaphyseal/diaphyseal
progressing from superolateraly to anteriorly to mismatch
posteriorly • Modular stems may be needed in more severe cases
• Restore the center of rotation to the true acetabulum of excessive anteversion and metaphyseal/diaphyseal
when possible mismatch
• Leaving a high hip center is acceptable if the bone • Subtrochanteric femoral shortening osteotomy should
of the true acetabulum is deficient and there is good
be considered when lengthening of 3 cm or more is
bone quality superiorly
anticipated.
• Medialize the acetabular component to gain better
coverage
• Uncemented acetabular fixation is preferred to REFERENCES
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developmental dysplasia of the hip. Mod Rheumatol. 72(10):1536-40. Epub 1990.
2013;23(1):119-24. Epub 2012. 22. Gross AE, Catre MG. The use of femoral head autograft
9. Koulouvaris P, Stafylas K, Sculco T, et al. Distal femoral shelf reconstruction and cemented acetabular compo
shortening in total hip arthroplasty for complex nents in the dysplastic hip. Clin Orthop Relat Res.
primary hip reconstruction. A new surgical technique. 1994;(298):60-6. Epub 1994.
J Arthroplasty. 2008;23(7):992-8. Epub 2008. 23. Inao S, Matsuno T. Cemented total hip arthroplasty
10. Karachalios T, Hartofilakidis G. Congenital hip disease with autogenous acetabular bone grafting for hips
in adults: terminology, classification, pre-operative with developmental dysplasia in adults: the results at
planning and management. J Bone Joint Surg Br. 2010; a minimum of ten years. J Bone Joint Surg Br. 2000;
92(7):914-21. Epub 2010. 82(3):375-7. Epub 2000.
11. Jessel RH, Zurakowski D, Zilkens C, et al. Radiographic 24. Rodriguez JA, Huk OL, Pellicci PM, et al. Autogenous
and patient factors associated with pre-radiographic bone grafts from the femoral head for the treatment of
osteoarthritis in hip dysplasia. J Bone Joint Surg Am. acetabular deficiency in primary total hip arthroplasty
2009;91(5):1120-9. Epub 2009. with cement. Long-term results. J Bone Joint Surg Am.
12. Rogers BA, Garbedian S, Kuchinad RA, et al. Total hip 1995;77(8):1227-33. Epub 1995.
arthroplasty for adult hip dysplasia. J Bone Joint Surg 25. Sternheim A, Abolghasemian M, Safir OA, et al. A
Am. 2012;94(19):1809-21. Epub 2012. long-term survivorship comparison between cemented
13. Murphy SB, Ganz R, Muller ME. The prognosis in and uncemented cups with shelf grafts in revision
untreated dysplasia of the hip. A study of radiographic total hip arthroplasty after dysplasia. J Arthroplasty.
factors that predict the outcome. J Bone Joint Surg Am. 2013;28(2):303-8. Epub 2012.
1995;77(7):985-9. Epub 1995. 26. Anderson MJ, Harris WH. Total hip arthroplasty
14. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement with insertion of the acetabular component without
in congenital dislocation and dysplasia of the hip. cement in hips with total congenital dislocation or
J Bone Joint Surg Am. 1979;61(1):15-23. Epub 1979. marked congenital dysplasia. J Bone Joint Surg Am.
15. Decking R, Brunner A, Decking J, et al. Reliability of 1999;81(3):347-54. Epub 1999.
the Crowe und Hartofilakidis classifications used in the 27. Hampton BJ, Harris WH. Primary cementless acetabular
assessment of the adult dysplastic hip. Skeletal Radiol. components in hips with severe developmental dysplasia
2006;35(5):282-7. Epub 2006. or total dislocation. A concise follow-up, at an average 107
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
of sixteen years, of a previous report. J Bone Joint Surg 40. Biant LC, Bruce WJ, Assini JB, et al. Primary total hip
Am. 2006;88(7):1549-52. Epub 2006. arthroplasty in severe developmental dysplasia of the
28. Dapuzzo MR, Sierra RJ. Acetabular considerations hip. Ten-year results using a cementless modular stem.
during total hip arthroplasty for hip dysplasia. Orthop J Arthroplasty. 2009;24(1):27-32. Epub 2008.
Clin North Am. 2012;43(3):369-75. Epub 2012. 41. Le D, Smith K, Tanzer D, et al. Modular femoral
29. Murayama T, Ohnishi H, Okabe S, et al. 15-year sleeve and stem implant provides long-term total hip
comparison of cementless total hip arthroplasty with survivorship. Clin Orthop Relat Res. 2011;469(2):508-13.
anatomical or high cup placement for Crowe I to III hip
Epub 2010.
dysplasia. Orthopedics. 2012;35(3):e313-8. Epub 2012.
42. Christie MJ, DeBoer DK, Trick LW, et al. Primary
30. Dorr LD, Tawakkol S, Moorthy M, et al. Medial
protrusio technique for placement of a porous-coated, total hip arthroplasty with use of the modular S-ROM
hemispherical acetabular component without cement in prosthesis. Four to seven-year clinical and radiographic
a total hip arthroplasty in patients who have acetabular results. J Bone Joint Surg Am. 1999;81(12):1707-16. Epub
dysplasia. J Bone Joint Surg Am. 1999;81(1):83-92. Epub 1999.
1999. 43. Dunn HK, Hess WE. Total hip reconstruction in
31. Spangehl MJ, Berry DJ, Trousdale RT, et al. Uncemented chronically dislocated hips. J Bone Joint Surg Am.
acetabular components with bulk femoral head autograft 1976;58(6):838-45. Epub 1976.
for acetabular reconstruction in developmental 44. Edwards BN, Tullos HS, Noble PC. Contributory
dysplasia of the hip: results at five to twelve years. J factors and etiology of sciatic nerve palsy in total hip
Bone Joint Surg Am. 2001;83-A(10):1484-9. Epub 2001. arthroplasty. Clin Orthop Relat Res. 1987;(218):136-41.
32. Farrell CM, Berry DJ, Cabanela ME. Autogenous femoral Epub 1987.
head bone grafts for acetabular deficiency in total-hip 45. Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy
arthroplasty for developmental dysplasia of the hip: associated with total hip replacement. Risk factors and
long-term effect on pelvic bone stock. J Arthroplasty.
prognosis. J Bone Joint Surg Am. 1991;73(7):1074-80.
2005;20(6):698-702. Epub 2005.
Epub 1991.
33. Tsukada S, Wakui M. Bulk femoral head autograft
46. Farrell CM, Springer BD, Haidukewych GJ, et al. Motor
without decortication in uncemented total hip arthro
plasty: seven- to ten-year results. J Arthroplasty. nerve palsy following primary total hip arthroplasty.
2012;27(3):437-44 e1. Epub 2011. J Bone Joint Surg Am. 2005;87(12):2619-25. Epub 2005.
34. Schofer MD, Pressel T, Schmitt J, et al. Reconstruction 47. Krych AJ, Howard JL, Trousdale RT, et al. Total hip
of the acetabulum in THA using femoral head autografts arthroplasty with shortening subtrochanteric osteotomy
in developmental dysplasia of the hip. J Orthop Surg in Crowe type-IV developmental dysplasia. J Bone Joint
Res. 2011;6(1):32. Epub 2011. Surg Am. 2009;91(9):2213-21. Epub 2009.
35. Argenson JN, Flecher X, Parratte S, et al. Anatomy 48. Takao M, Ohzono K, Nishii T, et al. Cementless modular
of the dysplastic hip and consequences for total hip total hip arthroplasty with subtrochanteric shortening
arthroplasty. Clin Orthop Relat Res. 2007;465:40-5. osteotomy for hips with developmental dysplasia.
Epub 2007. J Bone Joint Surg Am. 2011;93(6):548-55. Epub 2011.
36. Numair J, Joshi AB, Murphy JC, et al. Total hip 49. Sponseller PD, McBeath AA. Subtrochanteric osteo
arthroplasty for congenital dysplasia or dislocation of tomy with intramedullary fixation for arthroplasty of
the hip. Survivorship analysis and long-term results. the dysplastic hip. A case report. J Arthroplasty. 1988;
J Bone Joint Surg Am. 1997;79(9):1352-60. Epub 1997.
3(4):351-4. Epub 1988.
37. Sochart DH, Porter ML. The long-term results of
50. Becker DA, Gustilo RB. Double-chevron subtrochanteric
Charnley low-friction arthroplasty in young patients
shortening derotational femoral osteotomy combined
who have congenital dislocation, degenerative osteo
arthrosis, or rheumatoid arthritis. J Bone Joint Surg Am. with total hip arthroplasty for the treatment of complete
1997;79(11):1599-617. Epub 1997. congenital dislocation of the hip in the adult. Preliminary
38. Faldini C, Miscione MT, Chehrassan M, et al. Congenital report and description of a new surgical technique.
hip dysplasia treated by total hip arthroplasty using J Arthroplasty. 1995;10(3):313-8. Epub 1995.
cementless tapered stem in patients younger than 51. Sener N, Tozun IR, Asik M. Femoral shortening and
50 years old: results after 12-years follow-up. J Orthop cementless arthroplasty in high congenital dislocation
Traumatol. 2011;12(4):213-8. Epub 2011. of the hip. J Arthroplasty. 2002;17(1):41-8. Epub 2002.
39. Wangen H, Lereim P, Holm I, et al. Hip arthroplasty in 52. Wang L, Trousdale RT, Ai S, et al. Dislocation after total
patients younger than 30 years: excellent 10 to 16-year hip arthroplasty among patients with developmental
108 follow-up results with a HA-coated stem. Int Orthop. dysplasia of the hip. J Arthroplasty. 2012;27(5):764-9.
2008;32(2):203-8. Epub 2008. Epub 2011.
Chapter
12
Acetabular Protrusio
Julius K Oni, Bryan M Saltzman, L Sean Thompson
A B
110 Figs 12.1A and B: Anteroposterior and frog lateral radiographs illustrating bilateral acetabuli protrusio
Acetabular Protrusio
include activity modification, weight loss, and physical
therapy for hip flexor, hip abductor, lumbar spine, and
abdominal strengthening. Intra-articular injections may
also be administered for pain relief.
Operative Treatment
Generally, the recommended surgical treatment for
protrusio acetabuli is total hip arthroplasty (THA).
However, if the disease is unilateral in a patient who is
young or a manual laborer, arthrodesis may be considered
as a treatment option. Recent reports have suggested that
symptomatic bilateral protrusio acetabuli may be feasibly
treated with subtotal acetabuloplasty, femoroplasty, and
circumferential labral surgery through arthroscopic
means, but further evaluation of these interventions is
necessary.8
Fig. 12.2: Radiographic measurements. A: Kohler (Ilioischial)
line; B: Iliopectineal line; C: Acetabular wall; D: Interteardrop line;
E: Normal center edge angle; F: Abnormal center edge angle as Indications
seen in acetabular protrusio
The main surgical indication is typically progression of
symptoms, which presents most commonly as increased
• Sotelo-Garza and Charnley6 also used the ilioischial pain and limitation of motion that have not responded
line on an AP pelvis radiograph as a reference point
to conservative measures. There is often an associated
from which they measured how far medially the
decline in quality of life associated with the progression
acetabular medial wall has migrated. This distance
of disease.
was used to designate the condition as mild
(1–5 mm), moderate (6–15 mm) or severe (>15 mm).
• Gates et al.7 discovered that the teardrop is the Basic Principles of Protrusio
most consistent landmark, varying little with minor Deformity Surgical Reconstruction
degrees of pelvic obliquity. The authors, therefore,
It is important to understand the following basic
recommended utilizing an X-Y coordinate system
principles when preparing an operative plan for a pelvis
based on the hip center in relation to the teardrop as
with acetabular protrusio:
the most useful way to assess and track progression
• The hip center must be restored to an anatomic (more
of acetabular protrusio.
lateral and inferior) position in order to restore proper
joint biomechanics
Laboratory Studies • The acetabular cup implant should be adequately
Basic blood tests, including complete blood cell count, supported by the intact acetabular rim
complete metabolic profile, erythrocyte sedimentation • The medial wall defects, especially larger ones,
rate, rheumatoid factor, and antinuclear antibody, are may require concomitant bone grafting, acetabular
obtained to help identify any possible underlying cause. If augments plus or minus the use of acetabular cages
an inflammatory etiology is suspected, a synovial biopsy • Limb-length restoration should be addressed with
is sometimes required for definitive diagnosis. preoperative templating and intraoperative evaluation.
Cup Placement
Ranawat, Dorr and Inglis9 developed a method of
determining the hip center using the radiographic
relationships of the Kohler and Shenton lines and the
height of the pelvis. However, while this method is useful
A B for radiographic measurement, it is not significantly
helpful during surgical restoration of the anatomical hip
center. Anatomic landmarks to reference for optimal cup
position include the TAL to mark the inferior border of
the true acetabulum, and the teardrop. In general, the
relationship of the acetabular implant to the peripheral
rim and the measurement of the remaining medial and
superior bony deficits in comparison to the preoperative
templating is used to restore the hip center to a more
C D lateral and inferior position.
Figs 12.3A to D: (A) Diagram illustrating an anterior-posterior view
of acetabular protrusio deformity; (B) To lateralize the acetabular Principles of Bone Grafting
component, an oversized reamer is used to enlarge the peripheral
bony rim; (C) Reaming expands the peripheral rim of the acetabulum Ranawat’s10 recommendations:
to fit the acetabular component; (D) Morselized bone graft (dark
• When protrusion is less than 5 mm in either direction
area) is packed into the medial defect, and a cementless cup is
press-fitted on the bony rim, which provides primary mechanical and the medial wall is reasonably strong, bone graft 113
support and an area for biologic ingrowth into the cup. is not indicated
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
• In protrusion greater than 5 mm with a thin but intact COMPLICATIONS
medial wall, autogenous bone graft is indicated but
artificial fixation devices need not be used Intraoperative complications during reconstruction
• A grossly deficient medial wall requires reconstruction of protrusio acetabuli include acetabular fracture,
with bone graft and additional fixation devices to neurovascular injury (sciatic nerve and external iliac
achieve normalization of the center of rotation of the vessels), and visceral injury. The sciatic nerve is closer
hip joint. to the femoral neck in patients with protrusio compared
to normal hips, and therefore more susceptible to injury.
Also, penetration of the pelvic cavity through the medial
Revision Total Hip Arthroplasty
acetabular defect may place intrapelvic structures like the
In revision THA with acetabular protrusio, exposure bladder, ureter, bowel and external iliac artery at risk of
can be more challenging. In this setting, polyethylene injury. The most common postoperative complications
wear, component migration, osteolysis, and acetabular include loosening and medial migration of acetabular
defects leading to pelvic discontinuity may complicate component. Others include dislocation, infection, and
reconstructive efforts. Preoperative evaluation, in this limb-length discrepancies.
setting, might include CT scan for detailed evaluation
of acetabular bone stock, CT angiogram to evaluate OUTCOMES
arterial structures that might be at risk during implant
retrieval, and possible placement of ureteral stents to Many authors have emphasized the importance of
facilitate intraoperative identification and prevent injury medial bone grafting when THA is performed in patients
to this vital structure. During surgery, exposure of the with protrusio acetabuli. A few examples are highlighted
joint may require a standard or extended trochanteric below.
osteotomy. This will facilitate greater visualization for Ebert et al.12 in their midterm follow-up (mean of
bone grafting and cup preparation. Extraction of the cup 4 years), reported no acetabular component failures or
can be performed with an explantation device; however, acetabular bone graft resorption. Chen et al.13 found no
it is important to note that the medial tip of the blades prosthesis loosening or subsidence, and healed bone
may iatrogenically damage the medial ischial membrane graft with no reprotrusion in their cohort of 16 patients at
and perforate into the pelvic cavity. Finally, removing a a mean 37-month follow-up. Mullaji et al.14 also reported
small amount of lateral acetabular bone may help with similar results. Dutka et al.15 demonstrated very good or
implant removal and positioning of the new component. good results at an average of 12-year follow-up in 80–85%
As for the revision procedure itself, recent studies by of their cohort of 135 consecutive cemented THAs, with
Blumenfeld et al.11 have preliminarily supported a “cup- better outcomes achieved by patients using autogenic
in-cup” technique for revision THA which has demon bone grafts. Of note, in a study by Thakkar et al.16 on THA
strated satisfactory short-term follow-up at 28 months in patients with protrusio acetabuli and Marfan syndrome,
postoperatively. In this protocol, a porous tantalum this patient population had a high frequency of revision,
acetabular shell is impacted into supportive medial host infection, loosening and dislocation, but do still report
bone, and a second shell is then cemented into the first improved hip function postoperatively that is comparable
to restore vertical and horizontal offset with its carefully to patients without Marfan syndrome. Some authors have
templated diameter. reported that THA with bone grafting was effective in
arresting the progression of protrusio acetabuli. Gates
et al.17 reported arrest of protrusio progression in 90%
POSTOPERATIVE MANAGEMENT
of their patients at an average of 12.8-year follow-up.
Weight-bearing is usually restricted to touch down for McCollum et al.18 had previously reported similar results.
6 weeks followed by partial (50%) weight-bearing for The importance of correcting the protrusio deformity
another 6 weeks. It is important to remember that these and restoring the acetabular component to an anatomic
guidelines are generally dependent on the quality of location has been highlighted by many authors. Bayley
acetabular fixation achieved with final cup placement. Full et al.19 found an increased incidence of loosening of
114 weight-bearing is allowed by 3 months postoperatively. acetabular components at long-term follow-up when the
Acetabular Protrusio
center of rotation of the hip was not corrected to within posed and preliminarily studied. This concept was initially
10 mm of the anatomical location. Ranawat et al.9 and developed due to the excessively deep acetabulum in
Gates et al.7 reported similar results with 94% and 50% protrusio acetabuli directly contrasting the excessively
loosening rates respectively in patients with cup centers shallow acetabulum in developmental dysplasia of the
more than 10 mm from the anatomic hip center. In the hip, which is a condition that has its proposed etiology in
Ranawat series, none of the reconstructed hips with cup genetics. Ghosh et al.23 analyzed 26 patients with primary
center within 5 mm of the anatomic center was loose at protrusio acetabuli for a R2726W variant mutation of the
an average follow-up of 4.3 years. fibrillin 1 (FBN1) gene—which is related to the unique
For revision total hip arthoplasties performed for skeletal characteristics of Marfan syndrome—to examine
acetabular protrusio, the few existing studies in the literature for a potential role in the skeletal abnormality. Despite
show promising results. In their 3-year follow-up of the relationship between Marfan syndrome and protrusio
19 revision total hip arthroplasties for protrusio caused acetabuli, they reported that this mutation was absent
by large medial bone defect but with intact peripheral in all primary protrusio acetabuli patients. However, the
rims, Hansen et al.20 reported no acetabular loosening in possibility still exists that a different and yet unidenti-
all patients treated with oversized cementless acetabular fied genetic variant of the FBN1 gene or some other
components and medial morselized allograft. With regard genes may contribute to this distinctive acetabular
to cemented versus noncemented acetabular implants, the morphology.
consensus is unanimous that survivorship is decreased
with cemented cups and that cementless prostheses can
ILLUSTRATIVE CASE
effectively restore femoral offset and acetabular center of
rotation.13,21,22 In summary, the results of THA using medial Eighty-three-year-old male complains of chronic, atraumatic,
bone grafting and cementless acetabular components in progressive debilitating right hip pain and stiffness for
patients with protrusio acetabuli have been favorable, with several years. Patient is limited to two-block ambulation
success rates similar to conventional THA. with a walker. Pain is refractory to nonoperative treatment
and patient has significant difficulties with performing
his activities of daily living. Radiographs reveal right hip
FUTURE RESEARCH DIRECTIONS
severe degenerative changes in the setting of acetabular
The idea that a genetic predisposition exists for the protrusion (Fig. 12.4A). Patient was indicated for a right
development of primary protrusio acetabuli has been THA using a lateralized cementless acetabular cup with
A B
Figs 12.4A and B: (A) Preoperative AP pelvis radiographs of patient’s right hip showing severe degenerative changes and acetabular
protrusio; (B) Postoperative AP pelvis radiographs of patient status post right total hip replacement. Note the lateralized acetabular shell
that is supported by the peripheral bony rim
115
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
screw augmentation and morselized bone graft for the 12. Ebert FR, Hussain S, Krackow KA. Total hip arthroplasty
medial defect (Fig. 12.4B). Patient tolerated procedure well for protrusio acetabuli: a 3- to 9-year follow up of the
and experienced complete relief of pain postoperatively. He Heywood technique. Orthopedics. 1992;15(1):17-20.
continues to function well as at the most recent follow-up 13. Chen Z, Yuan J, Cao S, et al. Early effectiveness of total hip
at 2-year status post surgery. arthroplasty in treating protrusio acetabuli. Zhongguo
Xiu Fu Chong Jian Wai Ke Za Zhi. 2012;26(3):292-5.
14. Mullaji AB, Marawar SV. Primary total hip arthroplasty
REFERENCES in protrusio acetabuli using impacted morsellized
1. Van de Velde S, Fillman R, Yandow S. The aetiology of bone grafting and cementless cups: a medium-term
protrusio acetabuli: literature review from 1824 to 2006. radiographic review. J Arthroplasty. 2007;22(8):1143-9.
Acta Orthop Belg. 2006;72:524-9. 15. Dutka J, Sosin P, Skowronek P, et al. Total hip arthro
2. Dunlop CC, Jones CW, Maffulli N. Protrusio acetabuli. plasty with bone grafts for protrusio acetabuli. Ortop
Bull Hosp Jt Dis. 2005;62(3-4):105-14. Traumatol Rehabil. 2011;13(5):469-77.
3. Van de Velde S, Fillman R, Yandow S. Protrusio acetabuli 16. Thakkar SC, Foran JR, Mears SC, et al. Protrusio
in Marfan syndrome: history, diagnosis, and treatment. acetabuli and total hip arthroplasty in patients with
JBJS. 2006;88-A(3):639-46. Marfan syndrome. J Arthroplasty. 2012;27(5):776-82.
4. Hooper JC, Jones EW. Primary protrusion of the 17. Gates HS 3rd, McCollum DE, Poletti SC, et al. Bone-
acetabulum. J Bone Joint Surg Br. 1971;53(1):23-9. grafting in total hip arthroplasty for protrusio acetabuli.
5. Armbuster TG, Guerra J Jr, Resnick D, et al. The adult A follow-up note. J Bone Joint Surg Am. 1990;72(2):
hip: an anatomic study. Part I: the bony landmarks. 248-51.
Radiology. 1978;128(1):1-10. 18. McCollum DE, Nunley JA, Harrelson JM. Bone-grafting
6. Sotelo-Garza A, Charnley J. The results of Charnley in total hip replacement for acetabular protrusion.
arthroplasty of hip performed for protrusio acetabuli. J Bone Joint Surg Am. 1980;62(7):1065-73.
Clin Orthop Relat Res. 1978;(132):12-8. 19. Bayley JC, Christie MJ, Ewald FC, et al. Long-term
7. Gates HS 3rd, Poletti SC, Callaghan JJ, et al. Radiographic results of total hip arthroplasty in protrusio acetabuli.
measurements in protrusio acetabuli. J Arthroplasty. J Arthroplasty. 1987;2(4):275-9.
1989;4(4):347-51. 20. Hansen E, Ries MD. Revision total hip arthroplasty for
8. Matsuda DK. Protrusio acetabuli: contraindication large medial (protrusio) defects with a rim-fit cementless
or indication for hip arthroscopy? and the case for acetabular component. J Arthroplasty. 2006;21(1):72-9.
arthroscopic treatment of global pincer impingement. 21. Garcia-Cimbrelo E, Diaz-Martin A, Madero R, et al.
Arthroscopy. 2012;28(6):882-8. Loosening of the cup after low-friction arthroplasty in
9. Ranawat CS, Dorr LD, Inglis AE. Total hip arthroplasty patients with acetabular protrusion. The importance
in protrusio acetabuli of rheumatoid arthritis. J Bone of the position of the cup. J Bone Joint Surg Br. 2000;
Joint Surg Am. 1980;62(7):1059-65. 82(1):108-15.
10. Ranawat CS, Zahn MG. Role of bone grafting in 22. Berend ME. Acetabular protrusio: a problem in depth.
correction of protrusio acetabuli by total hip arthroplasty. Orthopedics. 2008;31(9):895-6.
J Arthroplasty. 1986;1(2):131-7. 23. Ghosh S, Fryer AA, Hoban PR, et al. Fibrillin 1 gene with
11. Blumenfeld TJ, Bargar WL. A cup-in-cup technique to R2726W mutation is absent in patients with primary
restore offset in severe protrusio acetabular defects. Clin protrusio acetabuli and developmental dysplasia of the
Orthop Relat Res. 2012;470:435-41. hip. Med Sci Monit. 2009;15(5):CR199-202.
116
Chapter
Treatment of Total Hip
Arthroplasty Periprosthetic
13
Femoral Fractures
Marwin E Scott, Ran Schwarzkopf
Fig. 13.2: Image showing type A fracture of trochanter Fig. 13.3: Image showing type ALT fracture of lesser trochanter
119
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Flow chart 13.1: Schematic representation of type A fracture
120
Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures
Many different treatment options have been described femoral component and the quality of the proximal
in the literature over the years; no one treatment has femoral bone.
been shown to be the gold standard. We present common At the time of surgery, the surgeon should be familiar
treatment options and remark on our preferred ones for and feel comfortable with the extensile approaches to the
each fracture type. hip and femur. The surgeon should try to minimize soft
tissue trauma when feasible and preserve blood supply
Vancouver Type ALT to the fracture fragments by limiting surgical dissection.
Intraoperative stability testing can be done without an
Type ALT fractures are rare and usually minor treatment is arthrotomy if the distal stem is exposed in the fracture
required, which is nonoperative, unless they are deemed site.
to compromise the stability of the implant by extending
into the calcar region and thus the medial buttress is lost.
These fractures may need surgical fixation with cerclage
Type B1
wiring in which they may be fixed with cerclage wiring Controversy still exists to which is the preferred fracture
or revision if the implant is deemed unstable. fixation technique for type B1 fractures (Fig. 13.6). Type
B1 fractures should be treated with open reduction and
Vancouver Type AGT internal fixation with or without cortical strut allograft.
It has been shown that cerclage wiring alone has a high
Type AGT fractures (Fig. 13.4) are usually stable due to failure rate when compared to cable plate augmented with
the composite tendons of the vasti and glutei muscles, an anterior-placed strut graft.6 Proximal unicortical screws
and treatment for nondisplaced fractures can be have been shown to be more stable than cerclage wiring
nonoperatively done with protected weight-bearing alone.19 It has been shown that either a trochanteric plate
for 6–12 weeks and avoidance of hip abduction until with proximal unicortical and distal bicortical screws or
fracture union is achieved.12 Displaced fractures may a plate with proximal unicortical screws combined with
require fixation, either with a hook cable plate or cerclage cerclage wires and distal bicortical screws is a sufficiently
fixation with placement of morselized bone graft in order strong mechanical construct.6,13,26 Compared to plates,
to restore the functional leverage moment of the glutei cortical strut grafts express less stress-shielding effect and
muscles (Figs 13.5A and B). are osteoconductive.17 Osteosynthesis utilizing a plate or
strut, which extends at least two femoral widths past the
Vancouver Type B
Subclassification and treatment options depend on the
morphology of the fracture, the status of fixation of the
A B
Figs 13.5A and B: (A) Different greater trochanteric grip cable
Fig. 13.4: Greater trochanter fracture plates; (B) Placement of a great trochanteric grip with locking screws 121
both proximally around the stem and distally
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
180° to each other or in combination with osteosynthesis
(Fig. 13.9). In the presence of osteolysis or severe
osteopenia, it is often necessary to augment implant
stability with cortical structural allograft. Strut grafts
have an advantage of being a biological osteosynthesis
technique and provide reduced stress-shielding due to
their similar modulus of elasticity as the native bone.6,20,22
Emerson et al. reported a 96.6% incorporation rate in
63 cases where strut grafts were used, with a high rate of
fracture healing.23
We recommend that prior to insertion, the strut graft
should be burred down and sculpted to provide optimal
contact with the underlying native bone.
122 Fig. 13.7: Type B1 fracture with implant Fig. 13.8: Type B1 fracture with strut and plate construct
Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures
allows extensive access to the femoral diaphysis and easy
conversion to the modified Harding lateral approach to
the hip (Fig. 13.10). The lateral approach to the hip allows
the most flexibility in our opinion when unexpected
conversion from osteosynthesis to revision arthroplasty
is needed.
Step 1
Exposure of the fracture site should be done with minimal
soft tissue dissection. Stability of the implant is verified
and a hip capsulotomy is performed if stability is in
doubt. Reduction of the fracture can be achieved with
longitudinal traction and reduction clamps.
Step 2
A submuscular locking plate is inserted and percutaneous
locked or unlocked screws, depending on the quality
of the bone, can be utilized to minimize soft tissue
disruption. We use bicortical screws distal to the stem
Fig. 13.9: Plate and strut construct and recommend at least eight cortices of fixation (Figs
13.11 and 13.12).
123
Fig. 13.10: Lateral decubitus position
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
allow weight-bearing as tolerated for the elderly patients cementless, cemented or cement within impaction
to avoid a bedbound condition. In younger patients who allografting are all viable options. The disadvantage of
can handle crutch or walker ambulation, we maintain a cemented implant is the possible excursion of the
foot flat weight-bearing for 6 weeks. cement into the fracture site, which can impede fracture
union and healing. We recommend a cemented stem
Type B2 for older patients, osteoporotic and radiated bones,
where fixation with a cementless stem would be more
Revision arthroplasty is the treatment of choice when the
difficult. Cementless implants with distal fixation have an
prosthesis is loose or when it is fractured. Duncan and
advantage of bypassing the fracture site and having their
Masri reported that 82% of type B fractures occurred in
point of fixation outside the area of injury. This allows the
the presence of a loose implant (Fig. 13.14).
fracture to be bridged and osteosynthesized around the
In essence, the implant may be replaced by a
stem, with cables struts and plates (Figs 13.15A and B).
cemented or cementless prosthesis, whereby the new
implant should have a long femoral component extending
two cortical shaft diameters beyond the fracture and
with at least 5 cm of diaphyseal fit.18,24 Revision with
A B
Fig. 13.16: Type B3 fracture
Figs 13.15A and B: Treatment of type B2 fracture consisted of
revision stem, cable plate and strut graft
Fracture fragments should be separated to enable grafting or strut grafting with cerclage wires are other viable
canal debridement and reaming to provide adequate options. In older and low functional demand patients,
implant fit in patients treated with long-stem bypass a proximal femoral replacement or “megaprosthesis”
fixation. may be used. In contrast to allograft this option allows
Extensively coated stems with diaphyseal fixation are immediate weight-bearing after surgery, which is an
our preferred choice of implant. The ability to achieve essential component of care for this population group.15
biological ingrowth and fixation around the extensively Because of soft tissue deficiency, a constrained
porous-coated stem provides the potential for long- acetabular liner may be needed to prevent instability.
term stability. Distal fixation is achieved by bypassing This is our preferred option in elderly patients because
the fracture site by at least two cortical diameters and of the shortened rehabilitation time and the immediate
by securing a tight diaphyseal fit. If rotational stability weight-bearing status for these patients.
and restoration of limb length are concerns, then a fluted
modular noncemented stem may be utilized. Implant
modularity enables us to intraoperatively correct leg-
length differences and achieve stability by soft tissue
tensioning. Strut allograft may be needed for preliminary
stability of the construct in cases of unstable transverse
fractures.
Type B3
Revision arthroplasty is the treatment of choice
(Figs 13.16 and 13.17). In young patients, restoration of
bone stock is a priority. An allograft-prosthesis composite
is an attractive option. The prosthesis can be cemented
into the allograft and the remaining bone fragments
secured around with cables. Wong et al. reported their
experience with 15 type B3 fractures treated with an A B
allograft-prosthesis composite (Figs 13.18A to D); their Figs 13.17A and B: Treatment of type B3 fracture with revision 125
rate of healing was 93.3%.21 Cancellous bone impaction arthroplasy with a proximal femoral replacing prosthesis
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
a strut allograft may be used to provide a more stable
construct. Care should be taken to avoid leaving a
segment of weak, unprotected bone, between the implant
and proximal end of the plate. Adequate overlap should
be achieved to avoid such stress risers that may lead to a
recurrent fracture. Our concern with intramedullary nail
fixation relates to the possibility of creating a stress riser
between the tip of the nail and the femoral component.
COMPLICATIONS
The three main complications experienced following
A B C D treatment of femoral periprosthetic fractures are:
1. Aseptic loosening
Figs 13.18A to D: Allograft-prosthesis composite 2. Nonunion
3. Deep infection
It has been shown that patients presenting more than
Vancouver Type C 48 hours after sustaining the fracture were at a higher risk
Surgical fixation is our treatment of choice for this pattern of developing deep venous thrombosis.5 We recommend
of fractures. There are numerous types of fixation devices that all patients treated for periprosthetic fractures receive
available to address these fractures among which are: appropriate thromboprophylaxis treatment. Surgical site
locking plates, combo locking plates, screw and cable infection should be avoided by antibiotic prophylaxis.
hybrid plates, and intramedullary devices (Figs 13.19 Stem subsidence is a complication, which has been
and 13.20). connected to inadequate diaphyseal fixation (< 5 cm
Our preferred option is a hybrid plate with unicortical in length), which can be avoided intraoperatively by
screws and cable fixation around the femoral stem and ascertaining adequate fixation length.5 Varus positioning
bicortical screws distal to the femoral stem. Occasionally, of the revised femoral prosthesis, which alters the
126 Fig. 13.19: X-ray of type C fracture Fig. 13.20: X-ray of type C fracture treated with locking plate
Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures
biomechanics at the fracture site, has been shown to be Poor cortical bone quality is a common finding among
associated with an increased risk of failure after revision patients presenting with total hip periprosthetic fractures,
for periprosthetic fractures.13 thus, it is imperative that adequate and sufficient
Mortality among patients who sustained a mechanical fixation be achieved in the treatment of
periprosthetic fracture has been shown to be 11% at 1 these patients. The patient’s final outcome is dependent
year postoperatively compared to 16% among hip fracture on early functional recovery and return to preinjury
patients and 2.9% among primary arthroplasty patients.29 independence. We recommend routine radiological
follow-up of high-risk patients, in order to identify loose
implants and enable early intervention prior to fracture
OUTCOMES
occurrence.
Betheta et al. reported treatment outcomes of 31 total With an expected rise in the prevalence of peri
hip periprosthetic fractures; they have shown a general prosthetic fractures, advancements in surgical manage
poor outcome with nonoperative treatment.2 Reports of ment of these complex patients are warranted. In
treatment of type B1 fractures with strut graft alone or with summary, the most important principle of periprosthetic
a combination of a plate and strut have been promising. fracture treatment is establishing implant and fracture
Haddad et al. reported union in 39 out of 40 patients stability, otherwise the revised total hip arthroplasty
treated with one of the above options; they concluded that construct will fail.
cortical strut grafts enhance the mechanical properties of
the construct as well as the healing potential.7 Springer
et al. reported the Mayo Clinic experience in which they
ACKNOWLEDGMENT
have shown a 90% survival, with revision for any reason I owe a great many thanks to a great many people who
as the end point, at 5 years, and 79% at 10 years with helped and supported me during the writing of this book.
118 hips that had undergone revision total hip arthroplasty My deepest thanks to Dr Kenneth Egol, the guide of the
for Vancouver type B periprosthetic fractures.8 Prosthetic project for guiding and correcting various documents
loosening and fracture nonunion were their greatest long- of mine with attention and care. He has taken pain to
term complications; they have reported better outcomes go through the project and make necessary correction
when using an uncemented extensively porous-coated as and when needed. We thank for his contribution in
stem. supplying us with images.
There are only scarce reports of treatment outcomes
for Vancouver type B3 periprosthetic fractures. Parvizi REFERENCES
et al. reported in their series outcomes of 29 patients
with type B3 fractures treated with either cerclage 1. Duncan CP, Masri BA. Fractures of the femur after hip
wiring and revision, or revision with a proximal femoral replacement. Instr Course Lect. 1995;44:293-304.
replacement.5 Proximal femoral replacement for these 2. Betheta JS 3rd, DeAndrade JR, Fleming LL, et al. Proximal
fractures has been shown to be effective with a 64% femoral fractures following total hip arthroplasty. Clin
survivorship at 12 years.14 Orthop. 1982;170:95-106.
3. Johansson JE, McBroom R, Barrington TW, et al.
Fracture of the ipsilateral femur in patients with total
CONCLUSION hip replacement. J Bone Joint Surg Am. 1981;63:
The advances achieved in the past years with modular 1435-42.
uncemented revision femoral stems and fixed-angle 4. Kelley SS. Periprosthetic femoral fractures. J Am Acad
locking plates have improved significantly the outcomes Orthop Surg. 1994;2:164-72.
of patients afflicted with total hip periprosthetic fractures. 5. Mont MA, Maar DC. Fractures of the ipsilateral femur
The current gold standard for the treatment of after hip arthroplasty. A statistical analysis of outcome
periprosthetic femoral fractures is operative, with an based on 487 patients. J Arthroplasty. 1994;9:511-9.
exception of a few stable patterns. Consequently, it is 6. Parvizi J, Rapuri VR, Purtill JJ, et al. Treatment protocol
essential to classify correctly the type of fracture and the for proximal femoral periprosthetic fractures. J Bone
stability of the prosthesis. Joint Surg Am. 2004;86:8-16. 127
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
7. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic 18. Larson JE, Chao EY, Fitzgerald RH. By-passing femoral
femoral fractures around well-fixed implants: use of cortical defects with cemented intra-medullary stems.
cortical onlay allografts with or without a plate. J Bone J Orthop Res. 1991;9:414-21.
Joint Surg Am. 2002;84:945-50. 19. Dennis MG, Simon JA, Kummer FJ, et al. Fixation of
8. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral shaft fractures occurring at the
periprosthetic femoral fractures following total hip tip of the stem. A biomechanical study of 5 techniques.
arthroplasty with femoral component revision. J Bone J Arthroplasty. 2000;15:523-8.
Joint Surg Am. 2003;85:2156-62. 20. Brady OH, Garbuz DS, Masri BA, et al. The treatment of
9. Adolphson P, Jonsson U, Kalen R. Fractures of the periprosthetic fractures of the femur using cortical onlay
ipsilateral femur after total hip arthroplasty. Arch allograft struts. Orthop Clin North Am. 1999;30:249-57.
Orthop Trauma. 1987;106:353-7. 21. Wong P, Gross AE. The use of structural allografts for
10. Berry DJ. Epidemiology of periprosthetic fractures after treating periprosthetic fractures about the hip and knee.
major joint replacement: hip and knee. Orthop Clin Orthop Clin North Am. 1999;30:259-64.
North Am. 1999;30:183-90. 22. Head WC, Malinin TI, Mallory TH, et al. Onlay cortical
11. Lowenhielm G, Hansson LI, Karrholm J. Fracture of allografting for the femur. Orthop Clin North Am.
the lower extremity after total hip replacement. Arch 1998;29:307-12.
Orthop Trauma Surg. 1989;108:141-3. 23. Emerson RH Jr, Malinin TI, Cuellar AD, et al. Cortical
12. Spangehl MJ, Masri BA, O’Connell JX, et al. Prospective strut allografts in the reconstruction of the femur in
analysis of preoperative and intraoperative investigations revision total hip arthroplasty. A basic science and
for the diagnosis of infection at the sites of two hundred clinical study. Clin Orthop. 1992;285:35-44.
and two revision total hip arthroplasties. J Bone Joint 24. Namba RS, Rose NE, Amstutz HC. Unstable femoral
Surg. 1999;81A:672-83. fractures in hip arthroplasty. Orthop Trans. 1991;15:753.
13. Pritchett JW. Fractures of the greater trochanter after 25. Lewallen DJ, Berry DJ. Periprosthetic fracture of the
hip replacement. Clin Orthop. 2001;390:221-6. femur after total hip arthroplasty: treatment and results
14. Tandross TS, Nanu AM, Buchanan MJ, et al. Dall-Miles to date. Instr Course Lect. 1998;47:243-9.
plating for periprosthetic B1 fractures. J Arthroplasty. 26. Rosemberg AG. Managing periprosthetic femoral stem
2000;15:47-51. fractures. J Arthroplasty. 2006;21:101-4.
15. Malkani AL, Settecerri JJ, Sim FH, et al. Longterm results 27. Lindahl H, Malchau H, Odén A, et al. Risk factors for
of proximal femoral replacement for non-neoplastic failure after treatment of a periprosthetic fracture of the
disorders. J Bone Joint Surg. 1995;77B:351-6. femur. J Bone Joint Surg Br. 2006;88:26-30.
16. Scott RD, Turner RH, Leitzes SM, et al. Femoral fractures 28. Brady OH, Garbuz DS, Masri BA, et al. The reliability
in conjunction with total hip replacement. J Bone Joint and validity of the Vancouver classification of femoral
Surg Am. 1975;57:494-501. fractures after hip replacement. J Arthroplasty. 2000;
17. Mihalko WM, Beaudoin AJ, Cardea JA, et al. Finite- 15:59-62.
element modelling of femoral shaft fracture fixation 29. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality
techniques post total hip arthroplasty. J Biomech. 1992; after periprosthetic fracture of the femur. J Bone Joint
25(5):469-76. Surg Am. 2007;89:2658-62.
128
Chapter
Total Hip Replacement for
Treatment of Acetabular
14
Fractures
Richelle C Takemoto, Brian F Moore, Jeffrey J Sewecke
A B
Figs 14.1A and B: (A) Anteroposterior pelvis radiograph of a comminuted anterior wall acetabular fracture;
130 (B) Three-dimensional computed tomography reconstruction of the acetabular fracture
Total Hip Replacement for Treatment of Acetabular Fractures
Fig. 14.2: Postoperative radiograph of total hip arthroplasty per Fig. 14.3: Preoperative radiograph of an impacted
formed in an acetabular wall fracture after first stabilizing the anterior posterior wall acetabular fracture 131
column with a reconstruction plate
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Herscovici reports a series of 22 patients treated with
a combined ORIF/THA with an average follow-up of 29.4
months. Surgeries averaged 232 minutes with 1163 mL
average blood loss. Hospital stays approximated 8 days
with full weight-bearing occurring at 3 months. Hip
motion averaged 102° of flexion, 32° of abduction, and
16° of adduction. Harris hip scores averaged 74. Four
patients developed heterotopic ossification, and five
underwent revisions as a result of osteolysis or multiple
hip dislocations.8
Postoperative treatment includes a period of partial
weight-bearing to allow fracture healing and bony
ingrowth of the cup. The results of acute THA for
acetabular fractures have been generally good; however,
Fig. 14.4: Postoperative radiograph after stabilizing the posterior not surprisingly, these are long operations with a
column with reconstruction plates followed by total hip arthroplasty significant amount of blood loss and higher complication
rates when compared to primary THA done for other
3.5 mm screws prior to performing a THA. Care must diagnoses.
be taken so that the screws used in the internal fixation
do not interfere with the cup component of the total hip COMPLICATIONS
(Fig. 14.4).
Reduction and fixation of the anterior column The complications of delayed THA after acetabular
component can be achieved with 3.5 mm lag screws from fracture are well documented in the literature. However,
the KL approach. Low anterior column components can there is little written about complications of combined
typically be ignored. The quadrilateral surface will usually ORIF and THA for acute acetabular fractures. In
follow the posterior column. An anterior approach is cases of delayed arthroplasty after acetabular ORIF,
rarely necessary unless a severe amount of anterior the predominant cause of failure is aseptic loosening
column or wall comminution is present. However, low- secondary to abnormal or incongruent acetabular
energy mechanisms of injury in osteoporotic bone tend to component. Complex fracture patterns have a higher
impact the acetabulum rather than cause a comminuted incidence of bone defects, though this does not seem to
fracture pattern. Once column stability is achieved, the correlate with anatomical restoration of the hip center of
acetabulum is then reamed to size, and autograft from rotation, and complications related to the THA.9
the resected femoral head can be applied to defects if In combined ORIF and THA for acetabular fractures,
necessary. If the bone quality and quantity obtained from the incidence of complications is higher than in primary
the femoral head is not optimal to fill the defect, allograft THA for the treatment of osteoarthritis. Herscovici
bone, calcium phosphate or a demineralized bone reported a 59% postoperative complication rate. About
matrix allograft can be used. An uncemented acetabular one-third of the complications were postoperative
component is then impacted into the pelvis. Fixation medical complications such as urinary tract infections
with multiple screws is essential for immediate fixation (UTI) and transient ischemic attacks (TIA) which
of the cup (see Fig. 14.1A and B). Cemented acetabular were treated conservatively. Long-term complications
components have a high failure and though may seem included heterotopic ossification formation, osteolysis
appealing should be avoided. Haidewich et al. describe and hip dislocation.8
using the cup as a “round plate”, essentially allowing
additional dome and ischial fixation with screws. In some
CONCLUSION
instances, an antiprotrusio device is needed if primary
cup stability cannot be obtained. The femoral component Total hip arthroplasty is a treatment option for acute
of the reconstruction is typically performed in the routine acetabular fractures, particularly in fractures with joint
132 manner and done either with a press-fit or cemented impaction in elderly patients. Total hip arthroplasty
technique depending on surgeon preference. can also be used as a secondary or salvage surgery
Total Hip Replacement for Treatment of Acetabular Fractures
after sequela of acetabular fracture, particularly once 5. Matta JM, Anderson LM, Epstein HC, et al. Fractures of
post traumatic degenerative joint disease and avascular the acetabulum. A retrospective analysis. Clin Orthop
necrosis set in. For both acute and delayed THA for Relat Res. 1986;205:230-40.
6. Matta JM, Mernt P. Displaced acetabular fractures. Clin
acetabular fracture, good results have been documented.
Orthop Relat Res. 1988;230:83-97.
However, complication rates are much higher than those
7. Matta JM. Fractures of the acetabulum. Accuracy of
reported for primary THA and should be expected. reduction and clinical results in patients managed
operatively within three weeks after the injury. J Bone
REFERENCES Joint Surg Am. 1996;78:1632-45.
8. Mears DC. Surgical treatment of acetabular fractures
1. Laird A, Keating JF. Acetabular fractures: a 16-year in elderly patients with osteoporotic bone. J Am Acad
prospective epidemiological study. J Bone Joint Surg Orthop Surg. 1999;7:128-41.
Br. 2005;87-B:969-73. 9. Moushine E, Garofalo R, Borens O, et al. Cable fixation
2. Tannast M, Najibi S, Matta JM. Two to twenty-year and early total hip arthroplasty in the treatment of
survivorship of the hip in 810 patients with operatively acetabular fractures in elderly patients. J Arthroplasty.
treated acetabular fractures. J Bone Joint Surg Am. 2012; 2004;19:344-8.
94:1559-67. 10. Herscovici D Jr, Lindvall E, Bolhofner B, et al. The
3. Melton LJ III, Sampson JM, Mowey BF, et al. combined hip procedure: open reduction internal
Epidemiologic features of pelvic fractures. Clin Orthop fixation combined with total hip arthroplasty for the
Relat Res. 1981;155:43-7. management of acetabular fractures in the elderly.
4. Ragnasson B, Jacobsson B. Epidemiology of pelvic J Orthop Trauma. 2010;24(5):291-6.
fractures in a Swedish county. Acta Orthop Scand. 11. Haidukewych G. Acetabular fractures: the role of arthro
1992;63:297-300. plasty. Orthopaedics. 2010;33(9):645.
133
Chapter
Total Hip Arthroplasty for
Treatment of Displaced
15
Femoral Neck Fractures
Behnam Sharareh, Ran Schwarzkopf
An estimated 250,000 femoral neck fractures are treated partial displacement; stage IV is a complete fracture
annually in the United States with an incidence rate of with total displacement. The reliability of this system
0.16% and 0.28% in men and women over 65, respectively.1 improves when the stages are grouped into nondisplaced
Due to continued increase in life expectancy, this number (Garden type I and II) or displaced (Garden type III and
is expected to rise to greater than 500,000 annually IV) to designate the appropriate treatment (Fig. 15.1).4
by year 2040.2 These injuries are complicated and are Fractures can also be classified based on their anatomic
correlated with a 25% decrease in life expectancy if left location: subcapital, transcervical and basicervical (Figs
untreated.2,3 Patients who are not treated promptly, face 15.2A and B).
the consequence of severe long-term immobility. As Nondisplaced fractures have a good prognosis of
such, goals of treatment are to reduce pain, increase union and are generally treated surgically; methods
mobility and allow patients to return to activity levels include: closed reduction and internal fixation with
prior to their injury. cannulated screws (Figs 15.3A and B), and sliding hip
Femoral neck fractures are classified using the four- screw construct. Displaced fractures have a high rate
stage Garden system: stage I is a nondisplaced partial of osteonecrosis when fracture fixation methods are
fracture (valgus impacted); stage II is a nondisplaced chosen.1 Displaced femoral neck fractures can sever the
complete fracture; stage III is a complete fracture with branches of the medial and lateral circumflex femoral
Fig. 15.1: The four stages of the Garden classification system and the generalized classification
differentiating between displaced and nondisplaced femoral neck fractures4
Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures
A B C
Figs 15.2A to C: Displaced basicervical (A), transcervical (B), and subcapital (C) femoral neck fractures
arteries leading to avascular necrosis of the femoral follow-up compared to only 6% for those that underwent
head and further complications.1 Arthroplasty is the a form of arthroplasty.5 Furthermore, in a recent meta-
recommended treatment for displaced femoral neck analysis of 12 randomized clinical trials monitoring the
fractures given the high rate of reoperation associated with outcomes of internal fixation for displaced femoral neck
internal fixation.1,2,5 In a prospective randomized clinical
fractures, Broderick et al. reported an average failure rate
trial comparing internal fixation versus arthroplasty,
Rogmark et al. reported that patients who underwent of 41% and a 45% rate of revision surgery at 1–15-year
internal fixation had a failure rate of nearly 43% at 2-year follow-up.6
A B
Figs 15.3A and B: (A) Nondisplaced (valgus impacted) basicervical right femoral neck fracture in a 58-year-old woman
before treatment and (B) following treatment with closed reduction and internal fixation.
135
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 15.4A and B: (A) Displaced transcervical right femoral neck fracture in an 87-year-old female before treatment; and
(B) following treatment with hemiarthroplasty (unipolar femoral head and cemented stem)
Different types of arthroplasty exist for the treatment on a patient-specific basis. Important factors to consider
of displaced femoral neck fractures. These can vary include: age; life expectancy; dementia and ability to
based on the use of cement for fixation of the femoral maintain hip precautions; mobility and activity prior to
stem versus press-fit fixation of the femoral stem. They injury; and systemic health.
can vary as well based on whether a partial arthroplasty Hemiarthroplasty allows for preservation of the patient’s
[hemiarthroplasty (HA)] or a total hip arthroplasty (THA) acetabulum and utilizes femoral implants that are either
is performed. The surgical preference for each type of nonmodular (mostly historical), unipolar modular (Figs
arthroplasty has changed over the years and is analyzed 15.4A and B), or bipolar modular (Figs 15.5A and B).
A B
136 Figs 15.5A and B: (A) Displaced transcervical left femoral neck fracture in an 86-year-old male before treatment; and
(B) following treatment with hemiarthroplasty (bipolar femoral head and cemented stem)
Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures
The bipolar implant allows for less stress to be placed significant increase in reoperation rate following HA,
on the femoral head as well as the articulating surface with a relative risk ratio of 0.40 when comparing THA to
during weight-bearing. Several studies have shown HA.2 Pain and quality of life were analyzed by Keating
the benefits of HA compared to THA to include: a less et al., where a significant increase in Johanson hip rating
complex surgery; shorter operation time; less blood questionnaire (HRQ) and EuroQol-5 dimension (EQ-5D)
loss; less costly procedure; and most importantly a scores were documented in patients who underwent
decreased rate of dislocation.1,2,7 However, an increased THA compared to HA at 2-year follow-up.13 Hedbeck
rate of reoperation has also been noted in many long- et al. noted a difference in hip function between the two
term studies analyzing HA for treatment of displaced treatment modalities with an average Harris hip score of
femoral neck fractures.8-10 The increased risk is mainly 89 with THA compared to 75 with HA at 4-year follow-up.11
a result of acetabular erosion, which may necessitate a Long-term follow-up comparison studies have also
conversion to THA.10 While steps have been taken to supported the use of THA to HA in treatment of displaced
minimize acetabular erosion, such as the use of bipolar femoral neck fractures. Ravikumar and Marsh compared
femoral head prosthesis to redistribute weight-bearing, outcomes of 180 patients who were randomized into THA
this complication still remains significant. Hedbeck and HA and noted a 24% failure rate of HA compared
et al. recently reported a 14% rate of acetabular erosion for to 6.75% for THA at 13-year follow-up.14 The latter study
37 patients who underwent bipolar HA at 4-year noted that THA also resulted in the least long-term pain
follow-up.11 As a result, HA is generally indicated for and most long-term joint mobility.14
patients with a lower life expectancy, neurological An increased rate of femoral head dislocation following
comorbidities or other orthopedic comorbidities.1,2,10,12 THA as compared to HA has also been reported.14-16 In
The superiority of THA (Figs 15.6A and B) compared 1986, Dorr et al. reported an 18% rate of femoral head
to HA has been documented in several clinical trials with dislocation (39 patients) following THA as compared to
respect to increased hip function, decreased pain at short- a 4% rate (50 patients) following HA, and Ravikumar and
term and long-term follow-up, and lower rates of revision Marsh, in 2000, noted a 20% dislocation rate (89 patients)
surgery needed.1,2,7,11,9,13 Liao et al. reported meta-analysis following THA compared to 13% for HA (91 patients).14,16
of five randomized clinical trials and noted a statistically The surgical approach and femoral head size appear to
A B
Figs 15.6A and B: (A) Displaced subcapital right femoral neck fracture in a 79-year-old female before treatment; and 137
(B) following treatment with total hip arthroplasty (press-fit stem)
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
A B
Figs 15.7A and B: (A) Total hip arthroplasty using a 36 mm diameter cobalt chrome femoral head component;
(B) Total hip arthroplasty using a 32 mm diameter cobalt chrome femoral head component
play important roles in such rates.17 Studies performing however, have been associated with less postoperative
post displaced femoral neck fracture THA using the thigh pain and increased mobility.23 Rudelli et al. reported
posterior approach noted dislocation rates varying from retrospective results of 86 patients treated with cemented
8% to 20%, whereas studies analyzing the outcomes of THA and noted that increased hip function and a low rate
THA with an anterolateral approach noted rates between of reoperation (4.6%) offset the increased costs, over the
0% and 2% at similar length follow-up.18 Johannson et al. course of a 5-year follow-up.24
reported a dislocation rate of 22% using the dorsolateral While it was initially noted that THA for treatment
approach.19 Regarding femoral head size used in THA, of displaced femoral neck fractures should only be
Bistolfi et al. reported an eightfold increase in dislocation considered for healthy patients under the age of 70, recent
rate in 198 hips operated with a 28 mm implant diameter studies have supported the notion of using THA in older
compared to 259 hips receiving a 36-mm head implant
patients. Chammout et al. reported a 17-year follow-up of
(Fig. 15.7A).20 Furthermore, Amile et al. reported a sixfold
100 patients with a mean age of 78 who underwent THA
increase in dislocation rate using the 28-mm femoral
and noted higher mobility, lower risks of complications
head as compared to the 32-mm model (Fig. 15.7B) in a
and lower long-term pain when compared to patients
retrospective study of 2572 hips.21
of similar age and background that underwent internal
Regarding implant stem fixation, press-fit femoral
implants (Figs 15.8A and B) have been associated with fixation.25 Rudelli et al. reported results of 86 patients
lower operative and anesthetic times and an overall with an average age of 79 and noted that 90.7% of patients
decrease in cost as compared to cemented stems.22 were able to return to preinjury activity levels.24 Overall,
Tripuraneni et al. noted an 18% reduction in total costs, the decreased long-term pain; increased hip function;
an average operative reduction time of 23 minutes, and and lower risk of reoperation along with improved
an average anesthetic reduction time of 20 minutes surgical techniques and instrumentation support the use
associated with press-fit femoral stems when compared of THA for a large proportion of patients who suffer a
138 to cemented femoral stems.22 Cemented femoral stems, displaced femoral neck fracture (Figs 15.9A and B).
Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures
A B
Figs 15.8A and B: (A) Displaced subcapital left femoral neck fracture in a 92-year-old female before treatment; and
(B) following treatment with hemiarthroplasty (unipolar, press-fit stem)
A B
Figs 15.9A and B: (A) Displaced subcapital left femoral neck fracture in an 85-year-old female before treatment; and
(B) following treatment with total hip arthroplasty (press-fit stem) 139
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
Fig. 15.10: Patient positioned in the lateral decubitus position Fig. 15.11: Kocher-Langenbeck incision mark is made on the lateral
with the assistance of a hip lateral positioner aspect of the hip, 5 cm distal to the tip of the greater trochanter
proceeding proximally for 5 cm in a curved posterosuperior fashion
AUTHORS’ PREFERRED TECHNIQUE the fascia overlying the gluteus maximus is incised and
split bluntly. The greater trochanteric bursa is identified
Most femoral neck fractures, especially high-energy and resected off the back of the greater trochanter to
fractures, tend to cause damage to the surrounding soft expose the short external rotators. The sciatic nerve is
tissue, especially the posterior capsule and short external identified posteriorly and protected during the course of
rotators. High-energy fractures may even tear the gluteus the surgery. The piriformis tendon, easily identified by its
maximus insertion off the femur. Due to this, we prefer distinct tendon, is isolated and elevated from its insertion
the posterior-lateral approach to the hip when we intend (Fig. 15.13). The piriformis tendon is tagged for future
to reconstruct the hip with a THA, thus preserving the repair. The gluteus minimus is elevated off the superior
anterior capsule and abductor muscles. capsule and retracted superiorly. The remaining short
On the other hand for patients who suffer a low- external rotators are divided off the bony insertions and
energy trauma and that we suspect that they may be swept posteriorly off the capsule and preserved as a cuff
noncompliant with hip precautions (such as dementia or to protect the sciatic nerve. Frequently, the anatomy may
Alzheimer), we prefer to use the anterior-lateral approach be distorted at this level due to the expanding hematoma
as well as using a HA in order to decrease to minimum
the chances of postoperative dislocation.
After medical optimization and medical clearance
is achieved, the patient is brought into the operating
theater. The patient is positioned in the lateral decubitus
position with the assistance of a hip lateral positioner;
always take time to well pad all bony prominences
(Fig. 15.10). For the posterior-lateral approach, a modified
Kocher-Langenbeck incision is made on the lateral aspect
of the hip starting approximately 5 centimeters distal to
the tip of the greater trochanter proceeding proximally
for 5 centimeters in a curved posterosuperior fashion
(Fig. 15.11). The incision is carried through the dermis
and subcutaneous tissue. The fascia lata is split along the
length of the incision between the gluteus maximus and
tensor fascia lata interval and carried distally to the level Fig. 15.12: Split fascia lata along the length of incision between
140
of the gluteus maximus insertion (Fig. 15.12). Proximally, the gluteus maximus and tensor fascia lata interval
Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures
Fig. 15.13: The piriformis tendon is isolated and elevated Fig. 15.14: The femoral neck fracture is visualized and exposed
from its insertion point on the femur
in the capsule from the femoral neck fracture; possible continued in a similar manner as an elective primary
capsular tear or complete rapture may be encountered. THA (See chapter 5) or Hemiarthroplasty.
The femoral neck fracture is visualized (Fig. 15.14). The
hip is dislocated and a refreshing femoral neck cut SUMMARY
is performed after it is marked with a resection flag.
Attention is transferred to the fractured femoral head, The decision if to conduct a THA or a HA for the treatment
a corkscrew head removal tool is inserted in the center of displaced femoral neck fractures is a complex and
of the femoral head, and the fractured head is extracted multivariable decision. Our “rule of thumb” is that if the
from the acetabulum (Fig. 15.15). If the ligamentum teres patient had come to see us in the clinic complaining of
is intact, curved Mayo scissors may need to be inserted degenerative hip disease, we would indicate him for a
to sever the ligament prior to extraction. total hip arthroplasty than he should be offered such
After removal of the fractured head and completion a procedure at this time. If the patient were medically
of the refreshing femoral neck cut, the procedure is or mentally unsuitable for a THA then a HA would be
performed.
REFERENCES
1. Messick K, Gwathmey W, Brown T. Arthroplasty in the
management of acute femoral neck fractures in the
elderly. Semin Arthroplasty. 2008;19(4):283-90.
2. Liao L, Zhao JM, Su W, et al. A meta-analysis of total
hip arthroplasty and hemiarthroplasty outcomes for
displaced femoral neck fractures. Arch Orthop Trauma
Surg. 2012;132(7):1021-9.
3. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture
morbidity, mortality and costs. J Am Geriatr Soc. 2003;
51(3):364-70.
4. Van Embden D, Rhemrev SJ, Genelin F, et al. The
reliability of a simplified Garden classification for
intracapsular hip fractures. Orthop Traumatol Surg Res.
Fig. 15.15: Extracted fractured head from the acetabulum 2012;98(4):405-8. 141
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
5. Rogmark C, Carlsson O, Johnell O, et al. A prospective 15. Lee BP, Berry DJ, Harmsen WS, et al. Total hip
randomized trial of internal fixation versus arthroplasty arthroplasty for the treatment of an acute fracture of
for displaced fractures of the neck of the femur. J Bone the femoral neck: long-term results. J Bone Joint Surg
Joint Surg Br. 2002;84:183-8. Am. 1998;80(1):70-5.
6. Broderick JM, Bruce-Brand R, Stanley E, et al. 16. Gao H, Liu Z, Xing D, et al. Which is the best alternative
Osteoporotic hip fractures: the burden of fixation for displaced femoral neck fractures in the elderly?:
failure. Scientific World Journal. 2013;2013:515197. A meta-analysis. Clin Orthop Relat Res. 2012;470(6):
7. Fan L, Dang X, Wang K. Comparison between bipolar 1782-91.
hemiarthroplasty and total hip arthroplasty for unstable 17. Hailer NP, Weiss RJ, Stark A, et al. The risk of revision
intertrochanteric fractures in elderly osteoporotic due to dislocation after total hip arthroplasty depends
patients. PLoS One. 2012;7(6):e39531. on surgical approach, femoral head size, sex, and
8. Avery PP, Baker RP, Walton MJ, et al. Total hip replacement primary diagnosis. An analysis of 78,098 operations
and hemiarthroplasty in mobile, independent patients in the Swedith Hip Arthroplasty register. Acta Orthop.
with a displaced intracapsular fracture of the femoral 2012;83(5):442-8.
neck: a seven- to ten-year follow-up report of a 18. Chaudhry H, Mundi R, Einhorn TA. Variability in
prospective randomized controlled trial. J Bone Joint the approach to total hip arthroplasty in patients
Surg Br. 2011;93(8):1045-8. with displaced femoral neck fractures. J Arthroplasty.
9. Blomfeldt R, Tornkvist H, Eriksson K, et al. A randomised 2012;27(4):569-74.
controlled trial comparing bipolar hemiarthroplasty 19. Johannson T, Jacobsson SA, Ivarsson I, et al. Internal
with total hip replacement for displaced intracapsular fixation versus total hip arthroplasty in the treatment
fractures of the femoral neck in elderly patients. J Bone of displaced femoral neck fractures: a prospective
Joint Surg Br. 2007;89:160. randomized study of 100 hips. Acta Orthop. 2000;71:597.
10. Baker RP, Squires B, Gargan MF, et al. Total hip 20. Bistolfi A, Crova M, Rosso F, et al. Dislocation rate after
arthroplasty and hemiarthroplasty in mobile, indepen hip arthroplasty within the first postoperative year: 36
dent patients with a displaced intracapsular fracture of mm versus 28 mm femoral heads. Hip International.
the femoral neck. A randomized, controlled trial. J Bone 2011;21(5):559-64.
Joint Surg Am. 2006;88:2583. 21. Amlie E, Høvik Ø, Reikerås O. Dislocation after total hip
11. Hedbeck CJ, Enocson A, Lapidus G, et al. Comparison arthroplasty with 28 and 32-mm femoral head. J Orthop
of bipolar hemiarthroplasty for displaced femoral neck Traumatol. 2010;11(2):111-5.
fractures: a concise four-year follow-up of a randomized 22. Tripuraneni KR, Carothers JT, Junick DW, et al.
trial. J Bone Joint Surg Am. 2011;93(5):445-50. Cost comparison of cementless versus cemented
12. Atik OS. What is the best choice for displaced femoral hemiarthroplasty for displaced femoral neck fractures.
neck fractures in the elderly? Internal fixation or total/ Orthopedics. 2012;35(10):e1461-4.
hemiarthroplasty. Eklem Hastalik Cerrahisi. 2012; 23. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties
23(3):121. (with and without bone cement) for proximal femoral
13. Keating JF, Grant A, Masson M. Displaced intracapsular fractures in adults (Review). Cochrane Database Syst
hip fractures in fit, older people: a randomized com Rev. 2010;16(6):CD001706.
parison of reduction and fixation, bipolar hemi 24. Rudelli S, Viriato SP, Meireles TL, et al. Treatment of
arthroplasty and total hip arthroplasty. Health Technol displaced neck fractures of the femur with total hip
Assess. 2005;9(41):1-65. arthroplasty. J Arthroplasty. 2012;27(2):246-52.
14. Ravikumar KJ, Marsh G. Internal fixation versus hemi 25. Chammout GK, Mukka SS, Carlsson T, et al. Total
arthroplasty versus total hip arthroplasty for displaced hip replacement versus open reduction and internal
subcapital fractures of femur—13 year results of a fixation of displaced femoral neck fractures: a rando
prospective randomised study. Injury. 2000;31(10): mized long-term follow-up study. J Bone Joint Surg.
793-7. 2012;94(21):1921-8.
142
Chapter
Conversion Total Hip
Arthroplasty for Treatment of
16
Failed Hip Fracture Fixation
Neil P Sheth, Derek J Donegan
A B
A B
Implant Selection
Femoral component selection for conversion is a function
of the type of previous proximal femoral fracture; the
integrity of the greater trochanter and the soft tissue
abductor complex; the type of current hardware in place;
Fig. 16.3: An anteroposterior radiographs of the pelvis depicting a
the type of proximal femoral anatomy; degree of proximal
marker ball at the bottom of the X-ray. This radiography has been
femoral remodeling; and the quality of the remaining
146 templated using digital software for a patient scheduled to undergo
a left total hip arthroplasty bone stock.
Conversion Total Hip Arthroplasty for Treatment of Failed Hip Fracture Fixation
deficiency has more of a direct impact on the acetabular
component being implanted in the case of conversion to
THA. The only indication for the use of a constrained liner
is abductor deficiency.7,8 However, a constrained liner
should be inserted into a well-fixed acetabular component
due to decreased likelihood of biologic ingrowth of a
newly implanted component with a constrained liner. In
these scenarios, use of a large femoral head to minimize
instability should be utilized followed by liner revision to
a constrained liner 3 months postoperatively if instability
becomes an issue.7
The type of hardware currently in place also plays a
critical role in femoral component selection. Typically,
after successful removal of retained hardware, there are
Fig. 16.4: An anteroposterior radiograph of a patient scheduled to residual screw holes traversing the proximal femoral shaft.
undergo left total hip arthroplasty. This patient has had a previous In addition, there is typically a residual large circular
screw and side plate construct which was removed as a separate defect in the greater trochanter from where a lag screw
surgical procedure. In cases such as this, it can be helpful to
template off of the unaffected hip in order to determine the center had been placed for secure fixation within the femoral
of hip rotation, leg length and femoral offset head. The chosen femoral device should bypass the most
distal screw hole by 2 cortical diameters. This typically
Femoral neck fractures are intracapsular and typically will require the use of an extensively porous-coated
do not involve the calcar or greater trochanter, unless it device that can achieve diaphyseal fixation over 4–6 cm of
is a basicervical fracture which may act similarly to an interference fit within the isthmus of the femoral canal.9
intertrochanteric fracture. Intertrochanteric fractures, A metaphyseal fitting component is often inadequate
based on the degree of comminution, may have loss of to bypass cortical stress risers from previous hardware,
calcar support as well as abductor insufficiency due to especially if a side plate was previous implanted with
fracture extension into the greater trochanter. The femoral more than two proximal screws.
component selected for conversion for these fractures Assessment of proximal femoral anatomy is another
require an implant that provides calcar support as well factor that must be incorporated into the decision
as an attachment site for the greater trochanter. process when choosing the femoral component for
Some patients with greater trochanter involvement conversion. Dorr et al. defined three different proximal
may present at the time of failed ORIF with a significant femoral anatomic morphologies (type A, B and C) which
Trendelenburg gait due to fracture nonunion, greater correlate to the type of stem that should be considered
trochanteric escape, or malunion with an associated when choosing a femoral stem for reconstruction.10
lengthened position of the overlying soft tissue abductor Progressing from type A to type C, the femoral canal
complex and resulting biomechanic disadvantage. becomes more capacious, especially in elderly patients,
However, all patients do not present with abductor and an extensively porous-coated or cemented stem
insufficiency. Some patients are able to compensate as becomes a more appropriate choice of implant. Although
long as there is a robust sleeve of tissue in continuity studies have shown that metaphyseal fitting stems can
extending from the origin of the abductor complex on be used in Dorr type C femoral canals, in the setting of
the ilium to the vastus lateralis confluence on the femoral conversion from previously failed ORIF of a hip fracture,
shaft and the lateral intermuscular septum. The greater diaphyseal fitting stems may be more appropriate and
trochanteric fragment is enveloped within this sleeve allow for bypassing of proximal stress risers.11
of tissue, and some patients are spared the disability In line with the type of proximal femoral anatomic
associated with abductor insufficiency. morphology, the degree of proximal femoral remodeling
In cases where abductor deficiency is clinically and quality of the remaining bone stock also factor into
apparent, postoperative instability becomes of real the decision-making of what type of femoral stem to 147
concern following arthroplasty conversion. Abductor utilize. Most commonly, proximal femoral remodeling
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
occurs in varus due to failure of fixation and inadequate which implants are in place can prevent operating room
fracture reduction, and/or retroversion due to previous delays when the patient is already under anesthesia.
surgical violation of the proximal femur. Retroversion of The surgical approach utilized is based upon previous
the proximal femur may require a prosthesis that will surgical incisions, the type of arthroplasty reconstruction
allow for placement of the femoral component version that is planned, and ultimately, the surgeon’s preference
independent of the native version of the proximal femur. based on comfort level and experience. The posterior
This entity has been described following previous THA and approach is most commonly utilized as it affords the
is commonly encountered at the time of revision THA, but most extensile exposure with excellent acetabular and
the concept should still apply to arthroplasty conversion femoral visualization. However, there are concerns
following proximal femoral device implantation for regarding increased instability as compared to direct
fracture fixation; the proximal femur may still undergo lateral and anterior-based approaches. However, with
some degree of remodeling.6 Preoperative planning more femoral component options available to restore
should allow for appropriate implants to be present at the femoral offset, the use of larger femoral heads, and better
time of reconstruction to address any aberrant anatomic posterior capsular repair techniques, dislocation rates
considerations. have significantly decreased.13
The degree of proximal femoral remodeling and any One of the most important components of the surgical
associated femoral bone loss should be recognized at the procedure that needs to be preoperatively planned is the
time of hip templating. Multiple previous hip surgeries order in which the hardware is removed. In general, it is
often render the hip difficult to expose due to significant
safer to dislocate the hip prior to removal of any hardware.
scar formation. The presence of significant hardware
If all hardware is removed prior to dislocation, there is a
may result in substantial proximal femoral bone loss
risk of inadvertent fracture through a stress riser while
and residual proximal femoral fracture upon removal.
using a torsional force during hip dislocation. Certain
The use of an extended trochanteric osteotomy has been
components of the hardware can be removed after
described for the treatment of periprosthetic fractures
dislocation while other components of the hardware may
and may be necessary for enhanced exposure of the
be kept in place until the acetabular component has been
acetabulum and direct access to the femoral isthmus for
successfully implanted as the first step to complete the
diaphyseal fixation in conversion cases.12
conversion to a THA. This allows some protection of the
proximal femur against fracture while a retractor is used
Case Preparation and Technical to anteriorly displace the proximal femur for acetabular
Considerations exposure. After acetabular component implantation
Formulating a detailed preoperative plan is extremely has been completed, the remainder of the hardware
helpful in getting the entire team organized for the is removed from the proximal femur prior to femoral
procedure (i.e. assistants, OR staff, manufacturing reconstruction.
representatives, etc.), having all implants and hardware In most cases, there is compromise of the greater
removal devices available, minimizing the time spent trochanter to some degree. This is more commonly seen
in the operating room waiting for instrumentation, and after ORIF for an intertrochanteric fracture; however, this
preparing for unexpected intraoperative complications. is also seen when a femoral neck nonunion has been
The preoperative planning phase started during the treated with revision ORIF in conjunction with a valgus
previous section, but this section focuses on specifics intertrochanteric osteotomy. In addition, removal of a
pertaining to operating room preparation and how to sliding hip screw and side plate results in a large circular
critically think about the planned procedure. hole at the base of the trochanter which increases the
For all previous procedures performed at an outside risk for intraoperative fracture of the greater trochanter,
hospital, best efforts should be made to obtain an especially if a diaphyseal-engaging stem is being inserted.
operative report to both understand the rationale for Lateral positioning within the proximal femoral canal
the construct used for primary fixation and which is important to avoid varus placement of the femoral
manufacturer’s implants were utilized. Universal screw component, however, this puts excessive stress on the
148 removal sets are now readily available, but knowing greater trochanter and may result in its fracture.
Conversion Total Hip Arthroplasty for Treatment of Failed Hip Fracture Fixation
It is not uncommon that previous osteotomies or native femoral head with revision ORIF in conjunction
nonunions have undergone incomplete healing and with bone grafting and some type of osteotomy to
thus a fibrous union may be encountered at the time redirect the forces across the hip to enhance healing.
of arthroplasty conversion. All fibrous tissue must be Most commonly, a valgus intertrochanteric osteotomy is
debrided which leaves the residual greater trochanteric utilized in the setting of femoral neck nonunions.
fragment as a mobile entity. The mobility of the fragment In rare cases, patients may undergo removal of
can be used as a trochanteric slide osteotomy which can hardware and be left with a resection arthroplasty due
be safely translated anteriorly and enhance access to the to patient factors that preclude implantation of any type
femoral shaft for component insertion.14 It is imperative of device (i.e. patient with infected proximal femoral
that all soft tissue sleeve attachments to the greater hardware who will never be considered a surgical
trochanteric fragment be maintained if possible in order candidate for arthroplasty conversion due to significant
to maintain the integrity of the vascular supply to the comorbidities). This chapter will focus on arthroplasty
fragment. conversion, the use of either hemiarthroplasty or THA
Fixation of the greater trochanter is performed after as the treatment of failed ORIF of a hip fracture.
successful implantation of the femoral component. There
are several methods by which to reattach the greater Failed Open Reduction Internal
trochanter, of which all exhibit a balance between the
Fixation of Femoral Neck Fractures
time it takes the trochanteric fragment to heal and the
time it takes the hardware to fail. Most options include Hemiarthroplasty
the use of claw plates, proximal femoral locking plates,
trochanteric reattachment constructs, use of cables or Hemiarthroplasty is an option that utilizes a femoral
16-gauge wires, or some combination of all of the above. stem with a large metallic head that articulates with
With regards to greater trochanteric fixation, all of these the native acetabular cartilage. The benefits of this
devices attempt to provide a medially based force to procedure include decreased operative time as well as
prevent abduction failure of the fragment, as well as an increased stability as this construct maximizes the head-
inferiorly directed force to prevent trochanteric escape.14 to-neck ratio. Post-traumatic osteoarthritis of the hip
In the setting of arthroplasty conversion, with a joint, penetration of the acetabulum and pelvis with the
greater trochanteric fragment that requires fixation, there internal fixation device, or femoral head osteonecrosis
are two separate components of healing that may occur. with femoral head collapse typically prohibit the use
Firstly, the constructs listed above attempt to provide of hemiarthroplasty and require resurfacing of the
mechanical stability while the fragment undergoes bone- acetabulum as well (THA). There are far fewer studies
to-bone healing with the remainder of the proximal femur, that evaluate the use of hemiarthroplasty as a salvage
assuming some degree of boney apposition was achieved option for failed osteosynthesis of femoral neck fractures
during fixation. Secondly, there is some degree of bone to since most patients present with one of the previously
implant healing as most of the femoral implants utilized mentioned features that require conversion to THA.
for reconstruction today have proximal porous-coated Nilsson et al. evaluated the functional outcomes
surfaces which may allow for fragment healing to the of patients that underwent Austin-Moore prosthesis
prosthesis. implantation for either primary treatment of displaced
femoral neck fracture or implantation of the device for
salvage treatment of failed osteosynthesis.15 A total of
ARTHROPLASTY TREATMENT 33 patients were in the secondary arthroplasty group. At
OPTIONS AND CLINICAL RESULTS the time of final follow-up, 7 years, long-term functional
capacity was higher in the secondary arthroplasty group.
Available Treatment Options
Roberts and Parker evaluated the largest cohort
There are several treatment options for the treatment of patients undergoing hemiarthroplasty for failed
of failed osteosynthesis of a hip fracture. The option to osteosynthesis of an intracapsular hip fracture (n =
accept the deformity and disability is primarily reserved 100) as compared to patients that were treated with
for nonambulatory patients. In general, for young hemi arthroplasty as primary treatment (n = 730).16
149
patients, every attempt should be made to salvage the An uncemented Austin-Moore monoblock bipolar
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
prosthesis was implanted in each patient. The authors Table 16.1: Reported complications with conversion
demonstrated inferior clinical results in the secondary total hip arthroplasty surgery26
arthroplasty group. They concluded that secondary Conversion THA for displaced
arthroplasty for failed osteosynthesis had higher rates of THA group fracture group
revision, dislocation and overall complications.
Superficial wound 11% 2.8%
infection
Total Hip Arthroplasty Dislocation rates 20% 8%
In the setting of osteonecrosis of the femoral head, Deep infection rates 7.5% 1.9%
conversion to THA has demonstrated favorable clinical
outcomes when used as salvage for failed osteosynthesis
of a failed intracapsular proximal femoral fracture. Most A recent study by McKinley et al. evaluated a match-
patients who present with femoral head collapse following paired group of 107 patients between the age of 60 and
failed osteosynthesis are symptomatic.17 Several studies 80 years who either underwent conversion THA for failed
have demonstrated rates as high as 40% conversion to a ORIF or THA for primary treatment of a displaced femoral
THA in the setting of osteonecrosis, predominantly due neck fracture.26 The authors found a significantly higher
to femoral head collapse.17-21 complication rate in the conversion THA group (36%
Several studies have been published in the literature versus 13%) (Table 16.1). Patients who were converted to
comparing secondary THA with other treatment options. a THA also had inferior clinical results at 2-year follow-up
Franzen et al. reported on 83 patients who underwent with regards to pain, mobility and social dependence.
THA for failed osteosynthesis of a femoral neck fracture.22
These patients were compared to a matched group of
patients who underwent THA for a primary diagnosis of
Failed Open Reduction Internal
hip osteoarthritis. All patients were followed clinically for Fixation of Intertrochanteric Fractures
a minimum of 5 years (range, 5–12 years). The authors Primary arthroplasty treatment for acute intertrochanteric
reported that the risk of revision was 2.5 times greater for hip fractures is more technically demanding and is not
the conversion group than the primary treatment group, often performed due to disruption of the calcar femorale,
but this risk applied to patients over the age of 70 years. the distal femoral neck and the greater trochanter with
Mehlhoff et al. assessed a cohort of 27 patients the overlying abductor complex attachment. Some
retrospectively to determine differences in clinical authors have advocated the use of primary arthroplasty
function between THA performed for primary for the treatment of this fracture pattern based on the
osteoarthritis or for failed osteosynthesis.23 This study premise of early weight-bearing and expedited functional
reported equivalent clinical results for both groups. A recovery.27-29 However, these procedures are associated
similar study was performed by Tabsh et al. recently.24 with longer operative time, increased blood loss and
Fifty-three matched patients underwent either THA for an increased complication rate as compared to ORIF.
failed ORIF or for a diagnosis other than a displaced As a result, arthroplasty conversion is more commonly
femoral neck fracture. At short-term follow-up (2 years), encountered and requires adherence to certain surgical
there was no statistical difference between the groups. principles to achieve clinical success.
However, although THA conversion was an acceptable Patterson et al. introduced two main important
salvage treatment for failed ORIF, it was associated with concepts to incorporate when using arthroplasty
an increased rate of complications. conversion for the treatment of failed intertrochanteric
Skeide et al. utilized the Norwegian Hip Registry data hip fractures.30 The authors recommend hip dislocation
between the years of 1987 and 1994 to identify patients prior to hardware removal since torsional stress may
who underwent THA conversion for failed ORIF.25 There be required for the hip dislocation maneuver and may
was a slightly higher rate of failure in this patient cohort result in femoral shaft fracture through one of the holes
(4.1%) as compared to patients who underwent THA from the previous hardware. In addition, if a cemented
for osteoarthritis (3.7%). The most common recorded prosthesis is going to be implanted for the reconstruction,
reasons for revision surgery were instability and femoral then the removed screws should be replaced in the holes
150 shaft fracture with a relatively low rate of acetabular- until they are flush with the endosteal surface during
related complications. cement pressurization. The screws can be removed after
Conversion Total Hip Arthroplasty for Treatment of Failed Hip Fracture Fixation
the cement has cured, and bone graft from the femoral AUTHORS’ PREFERRED TREATMENT
head can be placed in the remaining holes.
Few studies in the literature have evaluated the clinical The authors’ preferred method for conversion to THA is
results following arthroplasty conversion following failed to start with a thorough preoperative evaluation and plan.
osteosynthesis of intertrochanteric fractures. Haentjens et Every Patient receives a thorough workup for infection
al. reported on a small series of patients (n = 9) following with complete blood count (CBC), ESR and CRP. Any
arthroplasty conversion.31 The mean time to reoperation suspicion for infection should prompt an aspiration of the
after ORIF was 7 months. Clinical results were fair to hip to evaluate for white blood cell count with differential
excellent for all patients at a final follow-up of 41 months. cell count as well as aerobic and anaerobic cultures. If
The authors concluded that early full weight-bearing an infection is present then a two-stage procedure is
resulted in restoration of function and clinical success. performed with an antibiotic spacer placed as the first
Haidukewych and Berry performed an analysis of stage followed by reimplantation once the infection has
60 patients who underwent secondary arthroplasty for been eradicated. Once the infection workup has been
failed intertrochanteric fracture ORIF.32,33 Thirty-two fulfilled, we routinely obtain all operative records to
patients were converted to THA, twenty-seven to a confirm the current implants and manufacture, and the
bipolar hemiarthroplasty, and one patient to a unipolar equipment needed for removal at the time of surgery.
hemiarthroplasty. There were two reported dislocations, Our preferred surgical plan is to position the patient
and Kaplan-Meier survivorship at 7 and 10 years was in the lateral decubitus position on a radiolucent flat
100% and 87.5% respectively. top table in order to utilize fluoroscopy throughout
Other studies have demonstrated differing results. the case. We use an extensile posterior approach. At
Klingman et al. found a very high intra- and postoperative the time of surgery, we critically evaluate the previous
complication rate in a small cohort of patients (n = 16) surgical incision. If it will allow the appropriate access
undergoing arthroplasty conversion.34 The most common then we incorporate the previous incision, if not, then we
complications encountered were femoral fracture, wound do not hesitate to make a new incision. It is important
infection, and aseptic loosening. Zhang et al. found to understand that the more superior and anterior
similar results with patients undergoing arthroplasty the incision, the easier the acetabular visualization.
conversion with a high early complication rate (42%) and Conversely, incisions that are more inferior and posterior
a high incidence of greater trochanter fracture (32%).35 allow for better femoral visualization. Use this knowledge
The authors did report low level of satisfactory clinical as a guide to determine whether a separate incision is
outcomes at 7.4-year follow-up. required for your procedure.
Over the past decade, there has been experienced Once our incision is made, the fascia is clearly
a dramatic increase in the use of cephalomedullary identified and incised in line with the skin incision.
nails over a screw and side plate for the treatment of The plane between the underlying gluteus maximus
intertrochanteric fractures. The purported benefit of and the deep gluteus medius is defined. The gluteus
shorter surgical time and easier implantation has no doubt maximus tendon insertion on the femur is identified
been responsible for the enthusiasm for these devices and transected to allow easier retraction of the femur for
with no real scientific evidence for clinical superiority of exposure of the acetabulum. The posterior borer of the
one device over the other. Bercik et al. recently performed vastus lateralis is then identified and followed proximally
a retrospective review of 76 patients who had undergone into the posterior capsule to expose the femoral neck and
THA conversion for failed osteosynthesis from either a head. The approach is extended over the border of the
cephalomedullary device or a screw and side plate.36 In acetabulum and over the posterior ilium, following the
the perioperative period, patients being converted from posterior border of the abductor complex. The posterior
a cephalomedullary device were more likely to have capsule that was just incised is tagged with three #5
longer operative times (p = 0.02) and increased blood Ethibond sutures. At this point, culture swabs are taken
loss (p = 0.041), demonstrating increased complexity and to assure that there is no evidence of infection. The hip
technical difficulty with conversion to THA after failed is then dislocated using a bone hook.
ORIF with a cephalomedullary device. This may factor Once the hip is dislocated, attention is turned to
into the decision-making of what device to use at the the hardware. If cannulated screws were used, these
time of index internal fixation if arthroplasty conversion are removed using the appropriate screwdriver, and 151
is a consideration for future treatment. the neck osteotomy is performed using a single-sided
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
reciprocating saw. If a sliding hip screw was used, a neck A big concern is the remaining integrity of the
osteotomy is made at the desired level around the lag greater trochanteric bone stock. If an intertrochanteric
screw. Once the osteotomy is complete, the head/neck/ nonunion is present, we will use the fracture nonunion as
lag screw complex is removed in an antegrade direction, a trochanteric slide osteotomy to facilitate access to the
sliding the lag screw out of the barrel of the sliding hip femoral canal. The appropriate starting point is identified
screw. Removing the lag screw with the femoral head and and a large burr is used to lateralize the femoral entry
not back through the lateral cortex prevents a new hole point. The femur is then prepared and fluoroscopy is
from being cut by the threads of the screw and potentially used to determine alignment of the prosthesis within the
causing a stress riser. If a cephalomedullary device was canal to avoid varus placement of the implant. The THA
used, the cephalomedullary screw or blade is removed is then trialed and the appropriate head/neck sizes are
through the nail and lateral aspect of the femur, and a utilized to provide stable hip range of motion. If there is a
neck osteotomy is made. Regardless whether a sliding hip greater trochanteric fracture, our preferred method to fix
the trochanter is to use 16-guage cardiac wires through
screw of a cephalomedullary device was used, the side
the lesser and greater trochanters and through the greater
plate and screws or the intramedullary nail is maintained
trochanter and lateral femoral cortex in a tension band
to provide support for anterior femoral retraction while
construct.
resurfacing the acetabulum and to help avoid fracturing
After completion of the reconstruction, the wound
the greater trochanter during retraction.
is irrigated and a meticulous posterior capsular repair
Once the neck osteotomy is made and the hardware is performed. The wound is then closed in typical layer
into the femoral head is addressed, the acetabulum is fashion over drains. Postoperatively, our preferred
exposed and prepared in routine fashion. We routinely method is to make the patient toe-touch weight-bearing
use a noncemented press-fit acetabular socket. on the affected hip for 6 weeks. If a greater trochanteric
Attention is then turned back to the femur. The fracture occurred, then we will limit active abduction
remainder of the hardware is removed. The femur is for 6 weeks as well. We prefer 14 days of low-molecular-
then prepared for the preoperatively planned implant. weight heparin (LMWH) followed by 4 weeks of twice
In general, if cannulated screws or a two-hole sliding daily aspirin for deep vein thrombosis prophylaxis.
hip screw was used, a standard metaphyseal femoral We routinely see the patients in follow-up at 2 weeks
component can be implanted. If a four-hole or greater for wound check and suture removal as well as X-ray
sliding hip screw or a cephalomedullary device was used, evaluation; if all is well, we see the patient again at the
then a long cementless stem should be utilized to bypass 6-week and 3-month postoperative visit, followed by
residual screw holes and avoid a potential stress riser. yearly visits thereafter (Figs 16.5A and B).
A B
Figs 16.5A and B: (A) Three-week postoperative anteroposterior left hip X-ray following conversion to total hip arthroplasty for treatment
of failed osteosythesis of a femoral neck fracture/nonunion; and (B) cross-table lateral X-ray demonstrating adequate acetabular component
152 anteversion. In addition, positioning of the cup has been implanted without undercoverage by the anterosuperior acetabular wall, minimizing
the risk of iliopsoas impingement.
Conversion Total Hip Arthroplasty for Treatment of Failed Hip Fracture Fixation
154
Chapter
Complications after
17
Total Hip Replacement
Carlos M Alvarado, Ran Schwarzkopf
Fig. 17.3: Schematic demonstrating acetabular Fig. 17.4: Schematic demonstrating vasculature
zones for screw placement in each of the four acetabular zones
(ASIS: Anterior superior iliac spine) (ASIS: Anterior superior iliac spine)
the hip capsule. Injury during THA has been described contrast-enhanced CT imaging prior to surgery in order
throughout the different aspects of the procedure, from to identify the relation of the intrapelvic vessels and
patient positioning, retractor placement, acetabular the components. Consultation with a vascular surgery
screw placement, and implant position. Retractors placed should be considered if an intrapelvic approach is
too far medially may cause compression or direct injury considered.
to both the femoral and the external iliac vessels. The Even though the incidence of vascular injury during
acetabular quadrant system described by Wasielewski total hip surgery is low, the consequences can be
et al. divided the acetabulum into four quadrants devastating; proper prevention is the best approach.
(Figs 17.3 and 17.4) by a line drawn from the ASIS to the
ischium and a second line drawn perpendicular to it.84
CONCLUSION
The posterior superior quadrant is considered the “safe
zone” for screw placement, and screw placement in the Total hip replacement continues to be one of the most
anterior superior quadrant may place the external iliac common and successful procedures performed in the
vessels at risk. orthopedic world and the medical world overall. In
Intrapelvic bleeding is a rare occurrence in total spite of its clinical success, complications can and may
hip surgery; if a vascular injury is suspected, a consul occur. While many times these complications can occur
tation with a vascular surgeon is necessary. Patient’s due to no fault by the surgeon, it remains the duty of
hemodynamic state should be controlled and the the surgeon to have an intimate understanding of risk
procedure terminated until the vessel is repaired or factors for possible complications that may arise in the
embolized. perioperative course. This chapter has presented a basic
Prevention of vascular injury in a high-risk patient can understanding of the more common complications
be achieved with adequate preoperative planning and encountered after THA. By familiarizing ourselves with
proper surgical techniques. Gentle retractor placement these complications, surgeons can identify methods for
and careful attention that the retractors are placed minimization of complications in the future resulting
directly on bone may minimize any vascular injury. in improved clinical outcomes and greater patient
Patients with component protrusion should undergo satisfaction.
163
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
are: (1) early ambulation; (2) minimal to no pain recovery; Major pathways for pain (and temperature) sensation:
and (3) early discharge. Additionally, these goals should (1) the spinothalamic system; (2) the trigeminal pain and
be met with minimum of side effects or complications, temperature system, which carries information about
namely, postoperative nausea and vomiting, deep venous these sensations from the face.7
thrombosis (DVT), renal insufficiency or excessive wound Like the other sensory neurons in dorsal root ganglia,
bleeding. Thus, the concept of a multimodal approach to the central axons of nociceptive nerve cells enter the
pain has developed. spinal cord via the dorsal roots (Fig. 18.1). Axons carrying
information from pain and temperature receptors are
PAIN generally found in the most lateral division of the dorsal
roots, but the cell bodies of these neurons are not discretely
Pain, in itself, is a complex process involving cellular,
localized within the ganglia (although they are generally
humoral and central nervous system pathways.
Additionally, there is a large emotional/psychological smaller than the mechanosensory nerve cells). When
component to the experience of pain as well.6 The these centrally projecting axons reach the dorsal horn,
International Association for the Study of Pain defines they branch into ascending and descending collaterals,
pain as “an unpleasant sensory and emotional experience forming the dorsolateral tract of Lissauer (named after
associated with actual or potential tissue damage or the German neurologist who first described this pathway
described in terms of such damage”.2 in the late 19th century). Axons in Lissauer’s tract run up
The pathways that carry information about noxious and down for one or two spinal cord segments before
stimuli to the brain, as might be expected for such an they penetrate the gray matter of the dorsal horn. Once
important and multifaceted system, are complex. The within the dorsal horn, the axons give off branches that
168 major pathways are summarized in Figure 18.1 which contact neurons located in several of Rexed’s laminae
omits some of the less well-understood subsidiary routes. (these laminae are the descriptive divisions of the
Pain Management and Regional Anesthesia for Total Hip Arthroplasty
spinal gray matter in cross section, again named after
the neuroanatomist who described these details in the
1950s). Both Ad and C fibers send branches to innervate
neurons in Rexed’s lamina I (also called the marginal
zone) and lamina II (called the substantia gelatinosa).
Information from Rexed’s lamina II is transmitted to
second-order projection neurons in laminae IV, V and VI,
the neurons of which also receive some direct innervation
from the terminals of the first-order neurons. The axons
of these second-order neurons in laminae IV–VI (which
are collectively known as the nucleus proprius) cross the
midline and ascend all the way to the brainstem and
thalamus in the anterolateral (also called ventrolateral)
quadrant of the contralateral half of the spinal cord.
These fibers, together with axons from second-order
lamina I neurons, form the spinothalamic tract, the
major ascending pathway for information about pain and
temperature. This overall pathway is also referred to as Fig. 18.2: Dissociated sensory loss
the anterolateral system, much as the mechanosensory
pathway is referred to as the dorsal column—medial
lemniscus system. The presence of nociceptive, or peripheral receptors
The location of the spinothalamic tract is particularly to pain, also has been well established. During peripheral
important clinically because of the characteristic sensory inflammation nociceptors within damaged tissues are
deficits that follow certain spinal cord injuries. Since the readily excited by and show an enhanced response to
mechanosensory pathway ascends ipsilaterally in the noxious stimuli (primary hyperalgesia). This sensitization
cord, a unilateral spinal lesion will produce sensory loss of nociceptors is produced by physical changes in the
of touch, pressure, vibration, and proprioception below damaged tissues and by inflammatory mediators, for
the lesion on the same side. The pathways for pain and example, prostaglandins, serotonin and bradykinin,
temperature, however, cross the midline to ascend on which alter the sensitivity of nerve endings to mechanical
the opposite side of the cord. Therefore, diminished and thermal stimuli. In addition, some nociceptors are
sensation of pain below the lesion will be observed on also directly activated by the inflammatory mediators’
the side opposite the mechanosensory loss (and the presence.8
lesion). This pattern is referred to as dissociated sensory We also know that postoperative pain has a significant
loss (Fig. 18.2). economic impact and is a common cause of delayed
The complexity of the pain pathways (recall that discharge from the hospital or rehabilitation facility
several minor routes are omitted in this account) often and is a common cause for readmission.7 Arthrofibrosis
makes the origin of a patient’s complaints about pain and diminished range of motion are closely related to
difficult to assess. For the same reason, chronic pain the degree of postoperative pain.9 Rehabilitation after
is often difficult to treat. Such pain can arise from THA is directly linked to pain and comfort levels. Early
inflammation (as in neuritis), injury to nerve endings mobilization, ambulation and return of normal gait is
and scar formation (as in the pain that can follow surgical associated with more optimal pain control.9
amputation), or nerve invasion by cancer. Injuries to
the central nervous system structures that process THE MULTIMODAL ANALGESIA
nociceptive information can also lead to intractable
CONCEPT
pain. The common denominator of conditions that
cause chronic pain is irritation of nociceptive endings, With continued understanding of how pain is experienced,
axons, or processing circuits causing abnormal activity and the many pathways involved in determining the
that is interpreted as pain.7 perception of pain, it was only a logical next step to 169
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
consider blocking pain with a multimodal approach. can consent to and participate in the realistic factors
Multimodal analgesia is a multidisciplinary approach to relevant to patient care.12
pain management with a goal to maximize the analgesic Over the past decade, a greater understanding of
effect and minimize the side effects of the medications.2 pain mechanisms has also led to the concept of pre-
To obtain more effective pain control, pain protocols emptive analgesia.3 Pre-emptive analgesia (Flow chart
must act simultaneously on several of the pain pathways 18.1) involves preoperative administration of various
as well as both centrally and peripherally.10 In effect, agents to reduce central sensitization and amplification
the goal is to achieve a peripheral (local wound) effect, of postoperative pain. It is further defined as an
a spinal cord transmission effect, and a brain thalamic analgesic intervention initiated prior to the onset of
effect.11 the noxious stimuli.3 Pre-emptive analgesia should
Multimodal analgesia takes advantage of the additive reduce both neurogenic and inflammatory responses to
or synergistic effects of various analgesics permitting the surgical trauma.10 Multimodal analgesia, pre-emptively
use of smaller doses with a concomitant reduction in side administered, represents a comprehensive approach to
effects. Because many of the negative effects of analgesic postoperative pain management, as such, this strategy
combines analgesics with differing mechanisms of
therapy are related to parenteral opioids, limiting its use
action.13 Recommendations for such an approach starting
is a major principle of multimodal analgesia.3
in the preoperative period are as follows.
Key aspects of a multimodal approach to pain control
Acetaminophen, though a weak analgesia, still forms
after THR are outlined in Box 18.1.10
a basic component of a multimodal analgesia regimen.
Preoperative patient education plays a significant
This drug is a safe and effective form of analgesia and
role in postoperative rehabilitation and functionality for
one of its mechanisms of action is to block the cyclo-
these patients. Patient factors play an important part in
oxygenase (COX)-3 isoenzyme in the thalamus and
postoperative pain perception.10 In successful total joint
programs, patients are enrolled and expected to attend elevate the patients pain threshold.12 Dose reduction
preoperative TJR class in which instructional videos and may be required in elderly patients and its use should
handouts are offered as well as a real-time discussion be limited in patients who have compromised hepatic
of what to expect preoperatively, intraoperatively and function.13
postoperatively. Details of the rehabilitation course with Nonsteroidal antiinflammatory drugs (NSAIDs)
physical and occupational therapy are discussed in detail inhibit the COX-1 and -2 enzymes and thus reduce
at this time also. Patients expectations are tempered the production of inflammatory mediators such as
toward realistic goals and typical timelines for recovery prostaglandins and thromboxane A2. Adverse effects
of function and pain free joint are outlined.10 The overall of NSAIDs include platelet dysfunction, gastrointestinal
goal is to reduce patient anxiety and misconceptions in mucosal damage, and renal dysfunction.13 Substantial
the early postoperative period that can negatively affect evidence supports the efficacy of NSAIDs for perioperative
a patient’s perception of pain. Thus, this approach has analgesia. At our institution, we preferentially use COX-2
been shown to provide a mechanism by which patients inhibitors in the preoperative period. These agents
selectively inhibit COX-2 enzyme and reduce production
of “inducible” prostaglandins while the COX-1 enzyme
Box 18.1: Components of a multimodal approach for total is unaffected and continues to catalyze the synthesis of
hip replacement “homeostatic”prostaglandins.13 Thus, COX-2 inhibitors
• Preoperative patient education/clarification of produce analgesia and have a low incidence of associated
expectations platelet dysfunction, bleeding and gastric ulcers. Several
• Pre-emptive analgesia systemic reviews have shown that COX-2 inhibitors
improve postoperative analgesia and reduce opioid
• Anesthesia technique
consumption in the first 24 hours.14 It is important
• Surgical technique
to recall that some COX-2 inhibitors possess adverse
• Intraoperative agents—specifically, use of periarticular cardiovascular effects.13 Celecoxib and meloxicam remain
injection
in use in the United States because their cardiovascular
170 • Postoperative analgesia
risk profile has been shown to be no higher than that
Pain Management and Regional Anesthesia for Total Hip Arthroplasty
Flow chart 18.1: Multimodal analgesia protocol
associated with nonselective NSAIDs.13 Both classes of Oral opioids are available in immediate release
drugs should be used with caution by individuals who and sustained release formulations. Controlled release
have renal dysfunction.13 oxycodone, a synthetic narcotic analgesic, has been
Gabapentinoids include gabapentin and pregabalin. shown to improve pain control and decrease the need for
These drugs are gamma-aminobutyric acid analogues other narcotic agents while improving functional recovery
and act by binding to alpha-2 delta receptors on voltage- and reducing adverse effects.22 Despite well-known side
gated calcium channels on presynaptic nerves.15 This effects including sedation, nausea and pruritus, opioids
activity reduces the entry of calcium into presynaptic remain an integral component of postoperative pain
nerve terminals and subsequently decreases the release relief via their action on spinal pathway mu receptors,
of excitatory neurotransmitters such as glutamate, supraspinal sites of action, as well as peripheral analgesic
aspartate, substance P and norepinephrine into the effects in inflammatory states.3
synaptic cleft. Thus, postsynaptic transmission of neural Incisional local anesthetic placement is a technique
pain messages is diminished.16 In contrast to other that provides effective analgesia, reduces opioid require
classes of analgesics that affect the transmission of neural ments and decreases the incidence of postoperative
impulses from both normal and traumatized tissues, nausea and vomiting compared to placebo.13
the gabapentinoids selectively affect the transmission By incorporating different pharmacologic agents,
of neural messages from damaged tissue.17 The most regional anesthesia techniques, as well as local infiltration
common side effects of the gabapentinoids include of the surgical site, central nervous system, peripheral
somnolence and dizziness.16 In addition to analgesia pain pathways, and different receptor sites can be blocked
and reduced opioid consumption, the gabapentinoids synergistically and to good effect. Additionally, the
may confer ancillary benefits perioperatively as well. routine use of parenteral opioids is virtually eliminating,
These may include reduction in the incidence of anxiety, thus obviating many of the bothersome, if not outright
sleep disturbance and delirium, as well as enhanced joint dangerous, side effects of narcotic use.
mobility.18-20 Further evidence shows gabapentinoids Anesthesia technique revolves around the use of
may play an important role in the prevention of chronic general anesthesia versus neuraxial anesthesia either
postoperative pain.21 with, or without, the adjunct of a regional nerve block 171
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
as well. This area will be discussed in more depth in the extremity block, and injury to surrounding organs (e.g.
following section. Surgical technique will be addressed in kidney, etc.) as well as deeper structures (e.g. peritoneal).
much greater detail in other chapters. Because the targeted nerves lie deep within the psoas
muscle and closely communicate with the epidural space
Peripheral Nerve Block as Part of medially, precautions regarding anticoagulation status
Multimodal Analgesia are similar to neuraxial blocks.28,29
A fascia iliaca block is an anterior approach to
Peripheral nerve blocks for postoperative pain manage blocking the nerves arising from the lumbar plexus.
ment have the advantage of delivering targeted pain relief This block is a compartment block that aims to deposit
to the surgical site without the adverse effects of systemic a high volume of local anesthetic or to place a catheter
opioids. Many studies have shown that incorporating for continuous infusion immediately deep to fascia iliaca,
single-injection or continuous peripheral nerve block a fascia extending from the lower thoracic vertebrae to
as part of multimodal analgesia reduces IV opioid use the anterior thigh. Compared to a lumbar plexus block
and opioid-related side effects (nausea, vomiting, itching, described earlier, the advantages are that it is easily and
urinary retention, sedation), and improves patient quickly performed, can be done postoperatively with
satisfaction following hip arthroplasty.23-26 Continuous the patient supine, and there is less concern regarding
peripheral nerve block, compared to a single-injection anticoagulation status.
block also allows prolonged analgesia as well as the Although uncommon, patients who have undergone
ability to control the degree of sensory and motor orthopedic surgeries are at risk of fall in the postoperative
blockade. In a dual-center, randomized, triple-masked,
period. In a retrospective analysis of inpatient falls in a
placebo-controlled trial, Ilfeld and colleagues showed
large orthopedic ward, Ackerman and colleagues found
that continuous peripheral nerve blockade extending
1% of patient fell, resulting in minor complications to
beyond the first night reduced time to meet predefined
major injuries requiring additional surgery.30 One factor
discharge criteria (adequate analgesia, independence
loosely associated with falls is motor blockade after
from IV opioids, and sufficient ambulation) by 38%.24 By
peripheral nerve block.31 Therefore, while peripheral
infusing dilute local anesthetic through peripheral nerve
nerve block provides many benefits, multimodal analgesia
block catheters, adequate analgesia can be achieved
that incorporates alternative techniques that minimize
while allowing for early physical therapy.
or eliminate motor blockade, such as periarticular
Commonly used regional anesthesia techniques for
injections, is gaining greater acceptance.
postoperative pain management include lumbar epidural,
lumbar plexus (psoas compartment) block, and fascia At this point, we will address the use of periarticular
iliaca block. The lumbar plexus (psoas compartment) injections as this mode is performed intraoperatively by
block when used as part of multimodal analgesia for the surgeon and has been found to have a significant
THA has been shown to reduce hospital length-of-stay, impact on postoperative pain medication requirements.
improve rehabilitation and analgesia, reduce opioid use For periarticular injections (Flow chart 18.1), at the
and opioid-related side effects.25,26 This block targets the time of surgery, combinations of medications including
lumbar and some sacral nerve roots and provides effective local anesthetics, opiates, steroids, alpha receptor
analgesia after THA.25-27 The block is typically placed blockers, and antiinflammatories are injected into the
with the patient in the lateral decubitus position prior to periarticular soft tissues with investigators reporting pain
placement of neuraxial anesthesia or induction of general relief and decreased use of narcotic pain medications in
anesthesia. It can also be performed postoperatively the perioperative period.32 This combination of agents
for patients whose pain control is inadequate despite is injected into the synovium, joint capsule, periosteum,
noninvasive modalities. Continuous lumbar plexus ligamentous structures, deep fascia, muscle groups
block was found to be superior to IV PCA for pain deep to the fascia, and into the actual arthrotomy site.
management after THA in a randomized controlled Many believe the intraoperative injection to be the most
trial.23 Complications of lumbar plexus block include important and effective component of this pain protocol.10
intraneural injection, local anesthetic systemic toxicity, Direct analgesic effect is produced by long-acting local
172 epidural or subarachnoid block leading to bilateral anesthetic. The addition of epinephrine prolongs the
Pain Management and Regional Anesthesia for Total Hip Arthroplasty
action of the local agents by decreasing absorption by REGIONAL ANESTHESIA FOR
vasoconstriction via its alpha-adrenergic effects. Opiates
TOTAL HIP ARTHROPLASTY
exert their analgesic effects centrally, regionally and
locally by their effect on opioid receptors (µ, k, d).10 Local There is no consensus as to which anesthetic technique is
administration allows sustained effect with a minimum best for patients undergoing THA. While spinal anesthesia
of the typical opioid adverse effects of sedation, nausea with IV sedation is commonly used, THA can also be
and respiratory depression which occur through central reliably and safely performed under epidural, combined
spinal-epidural, general anesthesia, or a combination of
opioid receptors.10 Clonidine exerts its effect via its a-2
neuraxial and general anesthesia.
adrenergic actions. This results in potentiation of the
When choosing an anesthetic technique, the surgeon
actions of local anesthetic agents and local opioids via
and anesthesiologist should take into consideration
synergistic effects.32 Steroids prevent local inflammation
several important factors including patient preference,
as well as reductions in the local stress responses to
surgical procedure, skill of the anesthesiologist, patient
surgical trauma.10,33 Lastly, the antiinflammatories, comorbidities, type of thromboprophylaxis,28,29 and
specifically NSAIDs, act via their well-known anti- availability of equipment. Many patients scheduled to
inflammatory properties by blocking COX-1 and COX-2 undergo THA have coexisting joint disease elsewhere.
enzymes. The technique of periarticular infiltration of Some of these patients may become uncomfortable due
local anesthetic and other drug combinations enhance to pain in other joints, and rarely, surgery under regional
dynamic pain management and improve postoperative anesthesia may require conversion to general anesthesia
mobility.13 intraoperatively (Figs 18.3A and B).
A B
Figs 18.3A and B: Image of spinal anesthesia. (A) Spinal anesthetic being performed under aseptic technique with the patient in the
sitting position. From a technical standpoint, this may be a more easily performed neuraxial block; (B) This is a spinal anesthetic being
performed using aseptic technique. Note the patient is in a right lateral decubitus position, often used in patients who have difficulty moving 173
into a sitting position
Modern Techniques in Total Hip Arthroplasty: From Primary to Complex
178
Index
Page numbers followed by f refer to figure and t refer to table.
181