Modern Techniques in Total Hip Arthroplasty From Primary To Complex

Modern Techniques in
Total Hip Arthroplasty

From Primary to Complex
Modern Techniques in
From Primary to Complex
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
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Modern Techniques in Total Hip Arthroplasty: From Primary to Complex

First Edition: 2014
ISBN 978-93-5152-082-5
Printed at:
Dedicated to
My wife Aude and son Matan
for all the love and support they gave me
during long nights and weekends of work.
I hope to make them proud.
Contributors
Kyle Ahn MD Wei-Ming Chen MD Snir Heller MD

Assistant Clinical Professor Professor Orthopedic Surgeon
Department of Anesthesiology and Department of Orthopedics and Division of Arthroplasty
Perioperative Care Traumatology Department of Orthopedic Surgery
UC Irvine Medical Center Taipei Veterans General Hospital  Rabin Medical Center, Beilinson
Orange, California, USA Department of Surgery Campus, Sackler School of
National Yang-Ming University Medicine,Tel-Aviv University
Carlos M Alvarado MD Taipei, Taiwan Tel Aviv, Israel
NYU Hospital for Joint Diseases Nir Cohen MD
Bang H Hoang MD
New York, NY, USA Vice Chairman
Associate Professor
Amir Amitai MD
Director, UC Irvine Multidisciplinary
Rabin Medical Center
Sarcoma Center
Orthopedic Surgeon Beilinson Campus, Sackler School of
Division of Spine Surgery Medicine, Tel-Aviv University
University of California, Irvine
Department of Orthopedic Surgery Tel Aviv, Israel
Orange, California, USA
Rabin Medical Center
Beilinson Campus, Sackler School of Nicholas Colacchio MD
Medicine, Tel-Aviv University Department of Orthopedic Surgery Seth A Jerabek MD
Tel Aviv, Israel Tufts Medical Center Assistant Attending Orthopedic
Boston, Massachusetts, USA Surgeon, Hospital for Special Surgery
S Samuel Bederman MD PhD FRCSC Instructor of Orthopedic Surgery
Assistant Clinical Professor Phuc (Phil) Dang MD Weill Cornell Medical College
Department of Orthopedic Surgery Department of Orthopedic Surgery New York, NY, USA
University of California, Irvine University of California, Irvine
Orange, California, USA Orange, California, USA Tao Ji MD
Orthopedic Surgeon
Gregory W Brick MBCHB Derek J Donegan MD
Musculoskeletal Tumor Center
Assistant Professor Assistant Professor of
People’s Hospital, Peking University
Harvard Medical School Orthopedic Surgery
Beijing, China
Department of Orthopedic Surgery Department of Orthopedic Surgery
Brigham and Women’s Hospital Division of Orthopedic Traumatology
Boston, Massachusetts, USA University of Pennsylvanian Yona Kosashvili MD
Philadelphia, Pennsylvania, USA Orthopedic Surgeon
Cheng-Fong Chen MD Division of Arthroplasty
Assistant Professor Leslie Garson MD MIHM Department of Orthopedic Surgery
Department of Orthopedics and Assistant Clinical Professor Rabin Medical Center
Traumatology Department of Anesthesiology and Beilinson Campus
Taipei Veterans General Hospital Perioperative Care Sackler School of Medicine
National Yang-Ming University UC Irvine Medical Center Tel-Aviv University
Taipei, Taiwan Orange, California, USA Tel Aviv, Israel
Julius K Oni MD Bryan M Saltzman MD Neil P Sheth MD
Adult Reconstructive Surgery Faculty Department of Orthopedic Surgery Assistant Professor of
Einstein Medical Center Philadelphia Rush University Medical Center Orthopedic Surgery
Philadelphia, Pennsylvania, USA Chicago, Illinois, USA Adult Hip and Knee Reconstruction
Division
Steven J Schroder MD
Jason H Lee MD
Department of Orthopedic Surgery University of Pennsylvania
University of California, Irvine Philadelphia, Pennsylvania, USA
University of California, Irvine
Ran Schwarzkopf MD MSc

Eric L Smith MD
William C McMaster MD Assistant Professor of
Head of the Joint Replacement Service
Clinical Professor Assistant Clinical Professor Orthopedic Surgery
Department of Orthopedic Surgery Department of Orthopedic Surgery Department of Orthopedic Surgery
University of California, Irvine University of California Tufts Medical Center
Orange, California, USA Irvine Medical School Boston, Massachusetts, USA
Chief, Orthopedics, Long Beach VAMC California, USA
Long Beach, California, USA
Richelle C Takemoto MD
Evan M Schwechter MD Assistant Clinical Professor
Brian F Moore MD
Clinical Instructor of Orthopedic Department of Orthopedic Surgery
Department of Orthopedic Surgery Surgery Kauai Medical Clinic
Allegheny General Hospital Albert Einstein College of Medicine
Pittsburgh, Pennsylvania, USA Wilcox Hospital Lihue
Montefiore Medical Center Hawaii, USA
New York, NY, USA
Stephen B Murphy MD
Associate Professor of L Sean Thompson MD
Orthopedic Surgery Marwin E Scott MD
Chief of Adult Reconstruction
Department of Orthopedic Surgery Clinical Associate Professor
North Shore Long Island Jewish
Tufts University School of Medicine Department of Orthopedic Surgery
Health System
New England Baptist Hospital NYU Hospital for Joint Diseases
Forest Hills
Boston, Massachusetts, USA New York, NY, USA
Assistant Clinical Professor
North Shore Long Island Jewish
Jonathan D Nyce BA Jeffrey J Sewecke DO
Health System
Department of Orthopedic Surgery Director of Adult Reconstruction
Lenox Hill, NY, USA
Tufts University School of Medicine Co-Director of Orthopedic Trauma
Boston, Massachusetts, USA Department of Orthopedic Surgery
Allegheny General Hospital Steven Velkes MBChB
John E Ready MD FRCS(C) Pittsburgh, Pennsylvania, USA Chairman
Chief, Orthopedic Oncology Service Department of Orthopedic Surgery
Department of Orthopedic Surgery Behnam Sharareh BS Rabin Medical Center, Beilinson
Instructor, Harvard Medical School Department of Orthopedic Surgery Campus, Sackler School of Medicine
Brigham and Women’s Hospital University of California, Irvine Tel-Aviv University
Boston, Massachusetts, USA Orange, California, USA Tel Aviv, Israel
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
Drivers of Hip Replacement Surgery xvii

S Samuel Bederman
1. Early Development of Total Hip Arthroplasty 1

William C McMaster
2. Total Hip Arthroplasty—Templating 9

Steven J Schroder, Ran Schwarzkopf
• Radiographs 9
• Digital Templating Algorithm 13
3. Direct Anterior Approach for Total Hip Arthroplasty 21

Evan M Schwechter, Gregory W Brick, John E Ready
• Indications 21
• Difficult Patients 22
• Examination and Imaging 22
• Authors’ Preferred Technique 22
• Complications 29
• Outcomes 30
4. The Modified Lateral Approach for Total Hip Replacement 32

Evan M Schwechter, Phuc (Phil) Dang, Ran Schwarzkopf
• Authors’ Preferred Technique: Modified Dall Technique 33
5. Posterolateral Approach to the Hip 42

Jason H Lee, Ran Schwarzkopf
• The Posterolateral Approach 42
• Authors’ Preferred Surgical Technique 44
• Postoperative Management 47
6. The Northern Approach for Total Hip Arthroplasty 51

Carlos M Alvarado
• Direct Anterior Approach 51
• Anterior Lateral Approach 53
• Lateral Approach 54
• Posterior Approach 54
• The Author’s Preferred Approach (Minimally Invasive Approach to the Hip: The Northern Approach) 55
7. Cemented Total Hip Arthroplasty 59

Yona Kosashvili, Amir Amitai, Snir Heller, Nir Cohen, Steven Velkes
• Basic Principles of Cementation 59
• Cemented Femoral Stem Design 60
• Cemented Acetabular Design 61
• Authors’ Preferred Technique of Cementation of the Femoral Stem 62
• Authors’ Preferred Technique for Acetabular Cup Cementation 64
• Surgical Pearls and Pitfalls 67
8. Uncemented Total Hip Arthroplasty 69

Cheng-Fong Chen, Tao Ji, Bang H Hoang, Wei-Ming Chen
• History 69
• Surgical Techniques 71
9. Computer-Assisted Hip Arthroplasty 80

Eric L Smith, Nicholas Colacchio, Jonathan D Nyce, Stephen B Murphy
• General Principles of Computer-Assisted Navigation: Image-Based and Image-Free Systems 80
• Procedural Overview of Computer-Assisted Surgery in Total Hip Arthroplasty 81
• Results of Free-Hand Versus Image-Based Versus Imageless Navigation Systems 82
• Minimally Invasive Total Hip Arthroplasty with Computer-Assisted Surgery 83
• Specific Instructions on Performing CT Image-Based Computer-Assisted Surgery 83
• Return to Mechanical Navigation 84
10. Proximal Femoral Reconstruction in Hip Arthroplasty 89

Tao Ji, Cheng-Fong Chen, Bang H Hoang
• Indications 89
• Preoperative Planning 90
• Authors’ Preferred Surgical Technique 90
• Outcomes 95
11. Treating the Degenerative Dysplastic Hip 97

Seth A Jerabek
• Indications 97
• Evaluation 97
• Classification 98
• Treatment and Outcomes 100
• Surgical Technique 100
xiv
• Author’s Technique Highlights 106
Contents
12. Acetabular Protrusio 109
Julius K Oni, Bryan M Saltzman, L Sean Thompson
• Classification/Types 109
• Natural History/Etiology 109
• Diagnosis 110
• Treatment 111
• Outcomes 114
• Future Research Directions 115
• Illustrative Case 115
13. Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures 117

Marwin E Scott, Ran Schwarzkopf
• Indications 118
• Examination and Imaging 118
• Classification 118
• Treatment 119
• Outcomes 127
14. Total Hip Replacement for Treatment of Acetabular Fractures 129

Richelle C Takemoto, Brian F Moore, Jeffrey J Sewecke
• Indications for Combined Open Reduction Internal Fixation and Total Hip Arthroplasty for
Management of Acetabular Fractures 129
• Examination/Imaging 130
• Surgical Treatment of Acute Acetabular Fractures with Total Hip Arthroplasty 131
15. Total Hip Arthroplasty for Treatment of Displaced Femoral Neck Fractures 134
Behnam Sharareh, Ran Schwarzkopf
• Authors’ Preferred Technique 140
16. Conversion Total Hip Arthroplasty for Treatment of Failed

Hip Fracture Fixation 143
Neil P Sheth, Derek J Donegan
• Clinical Evaluation 143
• Preoperative Planning 145
• Arthroplasty Treatment Options and Clinical Results 149
• Authors’ Preferred Treatment 151
xv
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
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
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
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
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
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7
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8
Chapter
Total Hip Arthroplasty—
2
Templating
Steven J Schroder, Ran Schwarzkopf
INTRODUCTION agreement was found to be as high as 87% for acetabular

implants and 76% for femoral components.7 Digital
Total hip arthroplasty has long been accepted as a templating predicted acetabular cup size within one
reliable and cost-effective means to improve quality of size in 60–80% and femoral stem size within one size in
life and function.1-3 Precise sizing and placement of the 82–98% of cases.9-13 These studies illustrate that digital
prosthesis to restore joint biomechanics is imperative to templating is comparable to acetate templating and can
optimal outcome. Failure to appropriately position the reliably and safely predict proper implant sizes.
components can result in abnormal and accelerated wear
as well as instability. Oversized acetabular components
risk excessive bone removal, fracture or impingement.4 RADIOGRAPHS
Likewise, oversized femoral stem placement may The foundation of reliable preoperative templating is
compromise the femoral shaft whereas an undersized based on standardized radiographs. A supine antero
prosthesis may subside and loosen.5,6 posterior (AP) film is obtained with a tube-to-film
Preoperative templating allows the surgeon to select distance of 1 meter, the film 5 cm below the table and
the appropriate-sized implants and to contemplate the the beam aimed at or just below the pubic symphysis.
components’ three-dimensional placement. Moreover, This perspective results in a “low” AP pelvis and provides
this exercise can help expose and minimize potential adequate visualization of the proximal femora for virtual
intraoperative complications. Classically, templating was component positioning. The patient’s legs should be
carried out manually with acetate overlays on hardcopy internally rotated 15–20° in order to account for femoral
X-rays. However, the increased popularity of digital neck anteversion and orient the femoral necks parallel to
radiography has made the use of acetate templates not the cassette; therefore, maximizing the projected femoral
only physically challenging but also potentially inaccurate neck length.15-18 A stiff, arthritic hip may not rotate
due to magnification mismatch. Digital templating and adequately as a result of external rotation contractures;
dedicated software packages afford flexibility and can therefore, analysis of the contralateral, potentially more
increase precision. flexible hip can provide the necessary anatomic detail.19
Acetate templating has been shown to reliably predict All radiographic images undergo some degree of
the appropriate-sized acetabular implant 42–69% and magnification and the previously described radiographic
femoral stem 68% of the time.7,8 This agreement increases configuration produces magnification of roughly
to 60–97% and 77–98% if one size above or below the 20 ± 6%.20 Radiographic magnification is a result of the
templated size is considered for acetabular cup and divergence of the X-ray beam from the source and a
femoral stem sizing respectively.9-12 Digital templating function of its distance to the imaged bone and the film
has been somewhat less precise and predicts the exact cassette. If this orientation is maintained then the image
acetabular component size in 33–38% and femoral stem magnification is reliable. Even though the X-ray beam to
size in roughly 35% of hips.11,13,14 In one series, this film cassette distance is fixed, varying patient morphology
changes the distance of the pelvis from the source and sign.31-33 A misaligned pelvis with excessive tilt can
the film, altering the magnification. For example, an falsely portray increased anterior head coverage and
obese patient will have more distance between his perceived retroversion by a normal acetabulum.33,34
pelvis and the film cassette, thereby increasing the Numerous parameters have been proposed to determine
captured image magnification. The opposite would be the degree of pelvic tilt. Raw radiographic measurements
true for a thinner patient. Traditional acetate templating include the vertical distance between the symphysis and
assumes magnification of 15–20%, hence making precise the sacrococcygeal joint, a line between femoral head
calibration during radiographic examination imperative. centers or a line between the sacroiliac joints.33,35,36 Ratio
White et al.21 demonstrated that digitally obtained images relationships of the vertical and horizontal obturator
were inclined to decrease the average magnification, thus foramen dimensions or pelvic foramen dimensions as
reducing the reliability of standard templates when used well as the ratio between the most caudal point of the
with digital radiographs. obturator foramen and the distance between the teardrops
Digital templating software enables the user to have also been advocated.35 Similarly, the horizontal
manipulate the magnification based on an individual distance between the symphysis and sacrococcygeal
assessment of magnification for each radiograph. joint, and the ratio of the obturator foramen widths
Digital radiographs can be scaled by measurement of have been developed to quantify the amount of pelvic
known distances or calibration markers on the image rotation. Examination of these calculations determined
as determined with software tools. These embedded that the horizontal and vertical distances between the
magnification markers include a 25 mm radio-opaque symphysis and the sacrococcygeal joint to be the strongest
ball bearing, a coin, or manufacturer’s markers such as determinants of pelvic rotation and tilt, respectively.33,35-37
two ball bearings placed at a fixed distance apart.22,23 To Not only does femoral rotation greatly affect the
ensure that the regions of interest and the magnification projected femoral offset, it significantly impacts the
marker experience the same magnification, they must be perceived dimensions of the medullary canal on standard
placed in the same plane, and at the same distance from radiographs. The morphology of the femoral canal varies
the X-ray beam.24 This factor makes the placement of the from a pear-shape proximally to more elliptical toward the
marker essential. Besides scaling from a contralateral diaphysis with its maximal metaphyseal medial to lateral
prosthesis of known size, the optimal placement of a dimension externally rotated out of phase 20–40° from
magnification marker is close to the pubis between the femoral anteversion, and maximal diaphyseal medial to
patient’s legs, and in the plane of the greater trochanter.23 lateral dimension in phase with femoral anteversion.38-41
A reliable and more socially preferred method is In an attempt to achieve maximal metaphyseal fill, this
positioning of the magnification marker laterally in factor must be accounted for as it may explain significant
plane with the greater trochanter prominence.22,25-28 This discrepancies between templated and implanted
method, however, can be difficult with obese patients femoral stem sizes. However as the femur undergoes
as the marker’s projected image may be outside the increasing external rotation, the projected distal femoral
captured field.23 canal becomes narrower resulting in a more proximal
Radiograph evaluation should be performed to not placement of the templated femoral stem.42 Hananouchi
only ensure the quality of the films but to also identify et al.42 demonstrated that femoral rotation could reliably
any pathologic conditions that may present operative be assessed by measuring the projected thickness of the
challenges or alter the operative plan. A thorough lesser trochanter, and the risk posed by inappropriate
understanding of radiographic pelvic tilt and rotation is femoral rotation could be minimized with less than
necessary to identify pelvic malpositioning, which enables 5 mm of visible lesser trochanter.
appropriate assessment of acetabular morphology and
ultimately dictates treatment. Acetabular retroversion is Femoral, Acetabular and
a recognized cause of femoroacetabular impingement
Combined Offset
and a potential source of osteoarthritis.29-31 Acetabular
retroversion results from relative overcoverage of the Femoral offset is defined as the perpendicular distance
femoral head and is characterized by the anterior rim from the center of rotation of the femoral head to
aligned more cranially and laterally in relation to the the longitudinal axis of the proximal femoral shaft
10 posterior rim resulting in the radiographic crossover (Fig. 2.1).43,44 The interplay between multiple morphologic
Total Hip Arthroplasty—Templating
arm increase, the force required to move a certain load
decreases. Optimally during surgery, femoral offset should
be restored. However, failure to restore native offset results
in deficient abductor tensioning requiring increased
muscle work requirement leading to increased muscle
fatigue, discomfort, abnormal gait and joint instability.48
Furthermore, the necessary increased force generated
by the surrounding hip musculature is transferred to the
prosthesis leading to accelerated polyethylene wear and
component loosening.49,50 Conversely, excessive femoral
offset can lead to pain about the greater trochanter
(Figs 2.2A and B).51
Acetabular offset is defined as the distance between
the acetabular center of rotation and a perpendicular
line to the interteardrop line (Fig. 2.3).25 Acetabular
Fig. 2.1: Femoral offset is defined as the perpendicular distance
component positioning establishes the hip’s center of
from the center of rotation of the femoral head to the longitudinal rotation and acetabular offset helps determine abductor
axis of the proximal femoral shaft tensioning as well as the body weight lever arm. Much like
femoral offset, insufficient acetabular offset can result in
parameters determine femoral offset. For instance, hip instability and gait disturbances whereas lateralized
grossly larger femora, and those femora with varus neck cup placement increases the body weight lever arm and
shaft angles tend to have greater offset.45,46 Femoral can lead to overload of the acetabular component.43
neck anteversion dictates the “physiologic offset” and Combined offset sums the femoral and acetabular
as anteversion increases, the greater trochanter and the offsets together (Fig. 2.4). The combined offset determines
attached abductors are posteriorly displaced, thereby the axis of activity as well as the tension on the abductor
decreasing the overall functional offset. A line tangential musculature. This incorporates the hip’s center of rotation
to the lateral margin of the greater trochanter and iliac and therefore cannot be used to decipher moment arms
crest characterizes the tract of the abductor musculature.47 or reactive forces.25,47
This line of pull, femoral offset and abduction strength
have been shown to be significantly correlated.44 Femoral Leg-Length Discrepancy
offset tensions and establishes the moment arm on Leg-length discrepancy (LLD) is defined as the
which the abductors act.43,44 As the offset and moment comparison between legs, by evaluating the distance
A B
11
Figs 2.2A and B: Increased femoral offset status post total hip arthroplasty
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
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
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).
Step 4: Orienting and Sizing the

Fig. 2.11: A computer algorithm requires the user to define the
Acetabular Component femoral canal boundaries with a quadrilateral and demarcate the
edges of the femoral head with three points. The computer then
After the required operations are complete, the computer determines the femoral shaft axis and the femoral head center of
14
then produces images of the proposed components rotation
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
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
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
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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20
Chapter
Direct Anterior Approach for
3
Evan M Schwechter, Gregory W Brick, John E Ready
INTRODUCTION The direct anterior approach is performed supine,

which allows for fluoroscopic feedback on acetabular
The direct anterior approach (DAA) for hip reconstruction and femoral component positioning. This translates
surgery was originally proposed in 1947 by Robert Judet to more accurate component placement5 and lower
as a modification of the Hueter approach in which dislocation rates,6 as compared to posterolateral and
Judet performed an acrylic hemiarthroplasty.1 Originally anterolateral approaches. An additional contributing
described by Carl Heuter in 1881, and later popularized factor with regards to hip stability is that the primary hip
by Marius Smith-Peterson at the Massachusetts General stabilizers, including the abductors and short external
Hospital,2 the anterior approach is the only true rotators, are left undisturbed. Postoperative limp, a
internervous and intermuscular approach to the hip reported complication with the anterolateral approach,
joint. The internervous interval is between the femoral is rare in the anterior approach, as the abductors are not
and superior gluteal nerves, and intermuscular interval released. Limb-length discrepancy is avoided with direct
is between the sartorius and tensor fascia lata (TFL) leg measurement or computer navigation if the DAA is
muscles superficially, and the rectus femoris and gluteus done without an orthopedic table and by fluoroscopic
medius muscles in the deeper layer. This approach to the evaluation of the relative distance between the lesser
hip joint has been used to treat hip disorders including trochanters to the interischial line if an orthopedic table
is used.
developmental dysplasia of the hip, femoral neck, femoral
The reported learning curve is about 40 cases for a
head, and acetabular fractures and femoroacetabular
high volume total joint surgeon.7 A more conservative
impingement.2 Although Judet successfully described its
estimate may be around 100 cases.8 It is recommended
utility in hip hemiarthroplasty, other surgical approaches
that the surgeon become very familiar with the approach
to the hip became more popular.2 With a burgeoning before employing it clinically. Opportunities include
interest in more minimally invasive surgery (MIS), the cadaver courses, surgeon visitation programs, and surgical
Judet brothers began performing total hip replacement technique videos. There are many technical nuances to
through the DAA with the assistance of an orthopedic the procedure, which are difficult to appreciate from a
table.2 written description of the technique.
Kristops Keggi3 and Joel Matta4 are largely responsible
for introducing and popularizing the approach in the
INDICATIONS
United States. Interest in the DAA has gained momentum,
largely based on trying to avoid known complications Any patient indicated for total hip replacement may
with other surgical approaches to the hip joint, as well be considered a candidate for the DAA. Matta, however,
as trying to achieve a quicker postoperative patient cautioned against its use in patients with posterior ace
recovery. tabular wall defects that require bone graft and plate fixation.
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.
AUTHORS’ PREFERRED TECHNIQUE

Prepping and Draping
The patient is positioned supine on a standard sliding
operating room table. A well-padded perineal traction post
is placed, and the nonoperative leg is positioned using a
well leg holder in extension and slight external rotation to
aid in visualizing the lesser trochanter during assessment
of leg length changes during component trialing. Slight
traction to the contralateral leg is applied to keep the pelvis
level. The operative leg is secured into the ARCH (TRUMPF,
22 Farmington, CT) table boot (Fig. 3.1). Fig. 3.2: Proper C-arm position in relation to the patient and bed
Direct Anterior Approach for Total Hip Arthroplasty
In addition to the operating surgeon and the used to separate the fascia from the tensor muscle. Care
anesthesiologist, the surgeon’s primary assistant should is taken to ensure that the dissection remains overlying
stand adjacent to him, and a secondary assistant may the TFL and has not strayed too far medial overlying the
stand on the contralateral side to hold the anterior sartorius. Subfascial dissection that remains relatively
retractor. A scrub tech is also on the contralateral side lateral ensures that the lateral femoral cutaneous nerve
with the instrument table. A circulating nurse, or in (LFCN) is not encountered. With sustained elevated pull
some institutions, an implant company representative, is on the fascia, blunt finger dissection is carried medially
available to make adjustments to the positioning of the over the muscle belly of the TFL, and then proceeds
operative leg using the ARCH table levers. immediately posteriorly. The Allis clamps are removed and
The operative leg is then prepped with a chlorhexidine a Hibbs retractor is placed anteriorly and medially. Gelpie
gluconate-impregnated scrub stick. A ¾ sheet is placed retractors may now be placed in this interval between TFL
superior to the pelvic brim and below the knee. and sartorius for further retraction. Care should be taken to
Two split “U” drapes are then placed beginning just avoid lacerating the tensor fascia muscle.
within the margins of the previous drapes. Anatomic The deep TFL fascia is now encountered, in which
landmarks are then palpated and marked, including the the ascending branch of the lateral femoral circumflex
anterior superior iliac spine (ASIS), and, if possible, the vessels is buried. Often, the vessels are quite obvious.
anteromedial border of the tenor fascia lata. The incision They are most often encountered in the mid portion of
is demarcated, beginning at a point about 2 cm distal and the dissection. Open the deep TFL fascia distally with
2 cm lateral to the ASIS. This extends about 30° posteriorly an electrocautery. The vessels generally become more
in the direction of the lateral femoral epicondyle, and obvious at this point. Long right angle tonsil clamps
continues for about 10–12 cm. Hash marks are drawn, should be used to isolate and clamp the vessels, which
and an ioban occlusive dressing is placed over the entire are then transected and tied with #2 silk suture. The
exposed portion of the ipsilateral limb (Fig. 3.3). dissection then proceeds proximally until the deep TFL
fascia has been fully released.
At this point, precapsular fat is routinely encountered
Exposure in the interval between the rectus femoris superiorly
The skin incision is made and dissection is carried and anteriorly, the vastus lateralis distally, and the TFL
through the subcutaneous fat until the fascia overlying posteriorly and laterally. This triangle of fat should be
the TFL is reached. The fascia is incised and the anterior excised using electrocautery to expose the anterior hip
flap is clamped with two Allis clamps which are elevated capsule. Blunt palpation of the inferior and superior
superiorly. The deep TFL fascia is opened distally with borders of the femoral neck is useful at this point. A
an electrocautery. Finger or Cobb elevator dissection is Cobb is used to gently elevate the rectus femoris off the
inferior aspect of the anterior hip capsule and a cobra
retractor is placed extracapsularly overlying the inferior
femoral neck. The Cobb is then replaced into the rectus
femoris/anterior hip capsule interval and brought
superiorly to continue elevating the capsular rectus off
the capsule. Occasionally, electrocautery may be helpful
to initially create this interval before continuing with
blunt dissection. An anterior MIS or Hibbs retractor
is positioned overlying the anterior hip capsule and
beneath the rectus tendon to expose the remainder of
the anterior hip capsule. The contralateral or superior
assistant holds this retractor. Care must be taken to
ensure this retractor is placed in the correct interval to
avoid inadvertent placement into medial neurovascular
structures (femoral nerve). Overly aggressive retraction
with the anterior MIS retractor may cause injury to the
Fig. 3.3: The patient is prepped and draped and incision marked LFCN or femoral nerve. Identify the superior border
23
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).
Femoral Neck Osteotomy

Anterior acetabular osteophytes should be removed
with a rongeur to completely expose the femoral neck.
The intended femoral neck cut is now demarcated with
a Bovie knife. Reference landmarks should include the
lesser trochanter, the intertrochanteric line, and the
sulcus between the greater trochanter and superolateral
24 aspect of the femoral neck. Posterior to the sulcus is the Fig. 3.6: The femoral neck osteotomy is performed with an
piriformis fossa. An implant specific femoral neck cutting osculating saw perpendicular to the calcar
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
Fig. 3.10: Fluoroscopic image visualizing proper Fig. 3.11: Acetabular cup offset insert handle
acetabular reaming
press-fit cup, may be checked for correct orientation Femoral Exposure

under fluoroscopic imaging (Fig. 3.10). Trial implantation
should be checked with fluoroscopy to ensure adequate Traction is released from the operative leg. The leg is then
orientation, coverage, and proper seating. Cup stability externally rotated and the capsular soft tissue release is
should be checked. Either a solid or cluster hole performed in a stepwise fashion. Initially, soft tissue is
acetabular cup may be implanted. If a cluster hole cup is released in a subperiosteal fashion starting from the
chosen, screw position should be in the posterior superior anteromedial aspect of the calcar and continuing both
acetabular quadrant. An offset insertion handle may be medially around the calcar posteriorly, as well as slightly
helpful (Fig. 3.11). Acetabular bone screws are placed distally. The next release begins at the anterior aspect of
according to surgeon preference. Final cup position may the immediate lateral portion of the femoral neck, and
be checked using fluoroscopic imaging. Any remaining continues posteriorly initially, then continuing around
acetabular osteophytes are removed using a combination the posterior aspect of the femoral neck. This should
of osteotomes and rongeurs. The final acetabular liner is release the posterior capsule off the posterior aspect of
impacted, and checked for complete seating (Fig. 3.12). the femoral neck. In some cases, it may be necessary to
release the short external rotators or piriformis tendon.
Care should be taken to stay entirely within the greater
trochanter as the abductor tendon can be confused
with the piriformis tendon in the exposure. The greater
trochanter is not always well palpated. Care should
also be taken to maintain the insertion of the obturator
externus tendon, as this is thought to impart significant
hip stability due to its direct medial pull. The leg is further
externally rotated as far as the soft tissues will allow,
usually about 120–130°. The medial-lateral axis of the
femoral neck should be in line with the long axis of the
patient (i.e. 90° externally rotated relative to the patient’s
body). As the leg is being externally rotated, lateral pull
with a bone hook or Hibbs retractor should be exerted
on the femoral neck. This maneuver aids in bringing
the greater trochanter away from the posterior aspect
26 Fig. 3.12: Acetabular cup and liner impacted and
seated in the acetabulum of the acetabulum and avoid an inadvertent fracture.
Overzealous retraction also can result in a femoral fracture. to use a broach only system, and an implant that is
A two-prong retractor should be placed just behind the tapered in its medial and lateral dimensions to facilitate
greater trochanter and held by the primary assistant. The its insertion.
leg is then lowered toward the floor and adducted. A wide A rongeur or box osteotome is used to remove any
blade retractor should be placed on the posterior aspect residual lateral aspect of the femoral neck. A rat tail rasp
of the femoral neck and held by the secondary assistant is used to locate the femoral canal, and should be inserted
to aid in keeping the femur in a position to accept the along the medial calcar. Once penetrated, the direction
broach handle without impingement on the anterior skin of the femoral canal usually forces the rasp handle in a
and soft tissues. A retractor may be placed within the slightly posterior direction (counterclockwise if surgeon
medial border of the TFL to prevent inadvertent injury is standing anteriorly). A starting broach, such as a
by the broaches. “chili pepper” is used in the intended stem anteversion
(Fig. 3.13). Standard broaches are then successively used
Femoral Preparation to prepare the femur in standard fashion. A double-offset
broach handle is helpful to avoid skin and soft tissue
The surgeon may stand either anterior or posterior to impingement. Broaches should be impacted in line with
the femoral neck for femoral preparation. In general, we the femoral canal. This usually necessitates maneuvering
have found it helpful to stand anterior and prepare the the broach handle toward the floor (away from the
canal “backwards” if using a broach only implant system. surgeon if standing anteriorly) and medially toward the
In this manner, the surgeon can make, if needed, slight patient’s midline. This will help avoid impingement of the
adjustments to the exposure of the femoral neck in the tip of the broach on the posterolateral femoral cortex,
wound by using his hip to push against the ipsilateral and potential inadvertent canal perforation (Fig. 3.14).
knee, generally into slightly more adduction. These slight
maneuvers may help to facilitate broach entry without
skin and soft tissue impingement.
Trialing and Implantation
If excellent exposure is achieved, almost any type of With the final broach seated firmly in the metaphysis,
femoral implant may be used. In general, however, it is a trial neck is connected to the trunion according
quite difficult, or in some cases, impossible, to bring the to preoperative templating. The leg is brought out of
femur laterally enough away from the lateral border of adduction and elevated. The femoral head is connected
the ilium to pass straight reamers into the canal without and the hip reduced by traction, internal rotation and
deflection from the ilium for a ream and broach implant occasionally manual pressure with a head pusher. Traction
system. In these cases, flexible reaming only, followed by is then released. Fluoroscopic images are very helpful at
broaching is an option. In general, however, we prefer this point to assess component sizing, positioning, offset,
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
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
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
Postoperative Care is due to several factors. First, the posterior stabilizing

structures of the hip are generally left undisturbed. The
The patient is mobilized with physical therapy on
piriformis and short external rotators are only released
postoperative day 0 or 1, and made weight bearing as
in selected cases in which femoral exposure is difficult.
tolerated. No specific hip precautions are made (Figs
The obturator externus, felt to be a key component in
3.20A and B).
hip stability, is left intact. Second, acetabular component
positioning is more reliable as acetabular cup positioning
COMPLICATIONS may be verified easily using fluoroscopy. In his consecutive
series of 496 hips, Matta reported a dislocation rate of
Dislocation 0.61%.4 Siguier reviewed his case series of 1037 hips
The direct anterior approach has become popularized, in and found a dislocation rate of 0.96%.9 Other large
part, because of its lower reported dislocation rate. This series report dislocation rates of 1.5%6 and 0.88%.10 In a
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
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.
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
INTRODUCTION osteoarthritis or avascular necrosis, the incidence of

severe heterotopic ossification was lower with a posterior
Total hip replacement surgery is a common and approach (22%) than with an anterolateral (29%) or a
successful operation that is performed for a variety of hip transtrochanteric (28%) approach.4 Similarly, Eggli and
pathologies. It is estimated that more than 200,000 total Woo found that incidence of heterotopic ossification was
hip replacement surgeries are performed every year.1 8.1% higher with an anterior or anterolateral approach
To be successful, an operation’s benefits (relief of pain, than with a posterior approach.5
quality of life, etc.) must outweigh the risks (infections, This chapter will discuss the lateral approach to the
dislocations, scarring, implant malposition, etc.). An hip. The direct lateral approach is thought to facilitate
appropriate surgical approach is essential in minimizing cup positioning by allowing an uninhibited view of
these risks by allowing adequate exposure as well as ease the acetabulum, which may decrease rates of hip
of component implantation while limiting the damage to dislocation and diminish sciatic nerve injury. Previous
surrounding structures, such as muscles, nerves, vessels reports of the lateral approach included a higher rate
and bone. of trendelenburg limp as well as an elevated rate of
There are many different approaches to the hip for heterotopic ossification.7,8 The direct lateral approach
total hip arthroplasty, each with its own risks and benefits was first described in 1954 by McFarland and Osborne,
including but not limited to dislocation, heterotopic based on the observation that there is a thick tendinous
ossification, and incidence of limp.2-6 periosteum connecting the vastus lateralis and gluteus
Although many reasons can contribute to dislocation medius.9,10 They detached the entire gluteus medius from
after total hip arthroplasty (alcoholism, female sex, the greater trochanter while preserving the periosteal
neuromuscular and cognitive disorders, etc.), surgical tissue overlying the greater trochanter and its connection
approach is of key importance. A recent meta-analysis to the vastus lateralis. This approach requires the patient
involving 13,203 procedures found a dislocation rate of to be positioned in the lateral decubitus position and
0.55% after a direct lateral approach compared with 1.27% involves detaching a thin shell of bone from the greater
after a transtrochanteric, 2.18% after an anterolateral, and trochanter.
3.23% after a posterior approach.2 As for incidence of In 1982, Hardinge modified the approach by
postoperative limp, the study showed 0–16% incidence emphasizing the detachment of only the anterior half of
for patients who had a posterior approach and 4–20% the gluteus medius while preserving the posterior
for patients who had the lateral approach.2 Heterotopic attachment of the gluteus medius to the greater
ossification is a prevalent problem in total hip arthroplasty, trochanter.10 In the modified approach described by
with a wide range of clinical consequences (mild pain, Hardinge, the patient is positioned supine, which offers
loss of motion, ankylosed joint, etc.).3 In a study by advantages during implant insertion due to easier surgical
Morrey and colleagues on 507 consecutive patients with orientation and an enhanced ability to judge leg length.10
The Modified Lateral Approach for Total Hip Replacement
In 2002, due to a continued high rate of hip dislocation roll placed. A hip positioner is used to secure the pelvis,
after total hip arthroplasty among patients with femoral with a posterior bolster placed over the sacrum, and
neck fracture using the lateral approaches, Pai described an anterior bolster placed over either the symphysis
a modified direct lateral approach to the hip.11 In this pubis or the anterior superior iliac spines. Care is
approach, the patient is placed in a lateral decubitus taken to reproduce the patient’s preoperative leg length
position and only the anterior one-third of the gluteus discrepancy, if applicable, with adjustment to pelvic tilt
medius is split. The superior extension is only 3 cm in length before tightening the hip bolster. The down leg is well
and the T-shape capsulotomy is repaired in the end of the padded (Figs 4.1A to C).
procedure. The approach offers a low rate of dislocation and
a low incidence of postoperative trendelenburg limp.11 Exposure
For better visualization and access to the hip joint,
The greater trochanter is demarcated and an incision
especially in revision hip arthroplasty, a trochanteric
is made from spanning an area about one-third distal
osteotomy is often required. Routinely done in the
to the tip of the trochanter in a curvilinear fashion
1970s by Sir John Charnley,12,13 trochanteric osteotomy
extending proximally about two-thirds the distance (Figs
as part of a primary approach to hip arthroplasty was
4.2A and B). Dissection is carried through the skin and
essentially abandoned due to the added surgical time
subcutaneous tissue until the tensor fascia lata is reached
and complications (e.g. nonunion, proximal trochanteric
(Fig. 4.3). Soft tissue is swept off the fascia to further
migration, symptomatic hardware, increased blood loss,
expose it for later closure. The fascia is incised in line with
trendelenburg limp).
the incision, and the fibers of the gluteus maximus are
In 1986, taking advantage of the fact that the gluteus
split with electrocautery (Figs 4.4A and B). Retractors are
medius, gluteus minimus and vastus lateralis tendons
placed to expose the gluteus medius, trochanteric bursa
attach mainly to the anterior part of the greater trochanter,
and vastus lateralis fascia (Fig. 4.5). A depression in the
Dall described a technique which involves only partial
proximal muscular fibers of the vastus lateralis can be
anterior osteotomy of the greater trochanter.14
palpated just distal to the vastus ridge. In this depression,
By osteotomizing only the anterior part of the greater
two opposing cobbs are used to alternatively retract and
trochanter, the continuity of the tendinous junction
dissect the fibers of the vastus lateralis until the lateral
between the gluteus medius and vastus lateralis is
femoral cortex is reached. A joker is brought into this
preserved, thus preventing upward displacement.
intramuscular interval and directed proximally beneath
Reattachment of the anterior fragment is simpler
than fixing the whole trochanter when a trochanteric the fibers of the vastus lateralis and into the interval
between the anterior and middle-third of the gluteus
osteotomy is performed, and since the tendons are still
medius. The tip of the joker is exposed within the gluteus
attached to the osteotomized piece of bone, the strength
medius by using the same opposing cobb technique (Figs
of the fixation is improved and allows maintenance of
good abductor function immediately after surgery. In 4.6A and B).
his case series of 69 hips, Dall reported that there were Subperiosteal dissection is initiated at the lateral
no patients with proximal migration of the osteotomized aspect of the greater trochanter and continued both
fragment.14 Union of the osteotomy was seen in all cases proximally and distally until the ends of the joker are
after 2 months along with no significant heterotopic reached. Dissection should continue a few millimeters
ossification or trochanteric bursitis. Abductor power and posteriorly along the length of the greater trochanter (Fig.
gait returned to normal within 2–3 months. 4.7A). An oscillating saw is then used to osteotomize a
wafer of greater trochanteric bone from posterior to
anterior leaving the anterior cortex intact. A large broad
AUTHORS’ PREFERRED TECHNIQUE: osteotome is used to propagate the osteotomy through
MODIFIED DALL TECHNIQUE the anterior cortex. The anterior one-third of the gluteus
medius remains attached to the bone wafer and is
Prepping and Draping retracted anteriorly (Figs 4.7B and C). Subperiosteal
After the induction of general anesthesia, the patient is dissection is then continued anteriorly along the femoral
turned to the lateral decubitus position and an axillary neck, and a capsulotomy is made (Figs 4.8A and B). 33
A B
Figs 4.1A to C: Patient positioned in the lateral decubitus position,

all bony prominences are well padded. (A) Anterior view; (B) Inferior
C view; (C) Posterior view
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
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
Fig. 4.5: Exposer of the gluteus medius, trochanteric bursa and

vastus lateralis fascia (head to the top and abdomen to the right
of the image)
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
A B
Figs 4.7A to C: (A) Incision of the tendinous junction between

gluteus medius and vastus lateralis; (B) The anterior one-third of the
gluteus medius remains attached to the bone wafer, and is retracted
anteriorly (feet are to the left of the image); (C) Trochanteric fragment
C mobilized anteriorly and medially
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
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
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
Femoral Preparation according to the preoperative templating, and the hip is

reduced (Fig. 4.13). Hip stability is assessed, particularly
Femoral exposure is achieved by placing the operative
anteriorly in hip extension and external rotation. The
leg in a leg bag across the contralateral side of the table final femoral stem is implanted, and the hip reduced
in near 90° hip adduction, slight external rotation, and with a trial femoral head (Fig. 4.14). Hip stability
knee flexion. Bennett retractors are placed lateral, medial and leg length are again assessed. The trial head is
and posterior to the greater trochanter. Femoral stem disimpacted, and the trunnion cleaned and dried. The
preparation is carried out in standard fashion according real femoral head is impacted onto the femoral stem
to the implant specific stem specifications (Fig. 4.12). The trunnion (Fig. 4.15). The hip is reduced and stability
trial stem is paired with a trial femoral neck and head is examined one last time.
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
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
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
INTRODUCTION THE POSTEROLATERAL APPROACH

Sir John Charnley popularized total hip arthroplasty in Today, the most commonly performed approach remains
the early 1960s when he introduced the concept of low- the posterolateral approach. The posterolateral approach
friction arthroplasty.1 It has since become one of the is considered to be technically “simpler” than the other
most common and successful orthopedic procedures approaches described in the literature with a shorter
performed today, allowing those with arthritis of the hip learning curve. According to Mehlman,3 the posterolateral
to regain function and return to their daily activities. As approach was initially described by von Langenbeck and
the population of the world ages, the number of total hip then by Kocher, who added subsequent modifications to
arthroplasties will continue to increase. In 2005, nearly the approach, which provided excellent visualization of
209,000 primary total hip arthroplasties were performed both the acetabulum and the femur. In comparison, the
in the United States with a projected increase to roughly modified lateral approach offers the widest exposure of
590,000 by 2030.2 In the same time frame, revision total all the nontranstrochanteric approaches. However, with
hip arthroplasty is estimated to double from 41,000 to detachment of the gluteus medius in the transtrochanteric
and modified lateral approaches, there has been an
over 96,000 cases.2 A firm understanding of hip anatomy
increased incidence of postoperative abductor limp and
and approaches to the hip are necessary for reproducible
heterotopic ossification.
outcomes and for limiting perioperative complications.
In the posterolateral approach, the hip abductors are
Total hip arthroplasty requires complete visualization
spared during the exposure in comparison to the modified
of the proximal femur and the acetabulum for the correct
lateral approach that requires the partial detachment of
placement and orientation of the prosthetic components.
the anterior portion of the gluteus medius and minimus
Various surgical approaches have been described, each
from the greater trochanter.4 Henry5 described the
with their advantages and disadvantages. Yet, even glutei muscles, tensor fascia lata, and iliotibial band as
amongst hip surgeons, the debate regarding the optimal a functional unit called the “pelvic deltoid”, and that
approach still remains controversial. Most agree, the disruption of this mechanism would result in weakened
ideal approach should provide excellent reproducible abductor function. Lees et al.6 performed a cadaveric
visualization, respect the surrounding soft tissues, study comparing the anterolateral, direct lateral and
minimize complications, and allow for a rapid recovery posterior approaches, and concluded that the posterior
to a functional level. The choice of a specific surgical approach had the least impact on the pelvic deltoid.
approach by the surgeon is largely a matter of personal By maintaining the integrity of the abductors in the
preference and training with patient characteristics taken posterolateral approach, there is a reduction in the
into account. incidence of postoperative limp and an increase in
Posterolateral Approach to the Hip
patient satisfaction, while associated with a decreased of the sciatic nerve when retracted. All other structures
need for walking aids in the late postoperative period.7,8 in the region run perpendicular to the sciatic nerve and
Dislocation is a common complication of total hip are easy to localize. Other structures at risk during the
arthroplasty. As such, the choice of surgical approach posterolateral approach are the superior gluteal nerve
on dislocation rates has been a large focus of many and vessels. A split between the gluteus maximus and
studies.9-11 The posterolateral approach historically was gluteus medius muscles taken too proximally can damage
described to have a higher relative risk of postoperative the superior gluteal nerve, which supplies the gluteus
dislocations with studies claiming the rate of dislocations medius and minimus and tensor fascia lata muscles.
being anywhere from 5.8% to 9.5%.12-14 Recent data from a This can result in notable abductor weakness and gait
systematic review of 11 studies revealed dislocation rates impairment. To prevent injury to the inferior branch of
associated with the anterolateral and modified lateral the superior gluteal nerve, care must be taken to avoid
approach to be 0.70% and 0.43% respectively.10 Palan the proximal extension of the abductor split beyond three
et al., after 1089 total hip arthroplasties at the 5-year to five centimeters of the greater trochanter,29-31 and
follow-up showed no difference in the change in Oxford particularly less than three centimeters in the dysplastic
hip score and in dislocation or revision rates between the hip.32
standard anterolateral approach and the posterolateral
approach.15 A meta-analysis of over 13,000 total hip The Mini-incision Posterolateral
arthroplasties found a dislocation rate of 3.2% after the
Approach
posterolateral approach compared to 0.6% with the direct
lateral and direct anterior approaches, and 2.2% with With improvements in instrumentation and training,
the anterolateral approach.16 However, by performing there has been a trend to perform total hip arthroplasty
an enhanced posterior musculocapsular closure, the through shorter incisions. Yet, the principles of adequate
incidence of dislocation with the posterolateral approach exposure remain essential as well as the protection of the
has been reported as less than 1%.10,17-20 Hip precautions soft tissue structures, particularly damage to the abductor
should still be maintained until the posterior wound muscles, which may result in heterotopic ossification
heals and the formation of a pseudocapsule has occurred. and a postoperative limp.33 Mini-incision or “minimally
With adequate soft tissue repair, the posterolateral app invasive” total hip replacement has commonly been
roach has comparable dislocation rates with the other defined as surgery being performed through an incision
common approaches with potentially improved surgical of 10 cm or less.34,35 The mini-posterolateral approach is
visualization. Currently, dislocation rates appear to be a modification of the standard posterolateral approach
more related to femoral head size, component placement, utilizing specially developed instrumentation to facilitate
and soft tissue repair than the specific surgical approach visualization.
used.21 With a smaller incision, proponents argue that there
The major structure at risk with the posterolateral is a reduction in postoperative pain, decreased blood loss
approach is the sciatic nerve. The reported incidence and improvements in early postoperative function.36-38
of sciatic nerve palsy associated with primary total However, patient selection plays a monumental role
hip arthroplasty range from 0.05% to 1.9% across all in its success. Most patients with a body mass index (BMI)
approaches.22-27 The incidence is as high as 8% in of less than 30 (kg/m2) will qualify as good candidates
revision total hip arthroplasty.22,28 Schmalzreid et al.22 for a mini-incision approach. Relative contraindications
reported that patients with developmental dysplasia of include patients with a BMI greater than 35, and those
the hip, and those undergoing revision surgery were at undergoing revision total hip replacements, as they will
significantly increased risk of neurologic injury. Navarro likely require larger incisions and a wider dissection in
et al.23 Johanson et al.24 and Weale et al.25 concluded that order to remove the current implants. Patients with prior
anatomic variation and reconstruction complexity, and reconstructive surgeries and Crowe type IV developmental
not surgical approach were associated with neurologic dysplasia will also likely require larger incisions.
injury. The sciatic nerve lies medial to the insertion of Multiple studies have found no significant differences
the external rotators, which can be elevated as a sheath, in acetabular cup position or femoral position between the
during the exposure of the hip, and used for protection mini-posterior and standard posterolateral approaches.39 43
Yang et al. noted no significant differences in complication
rates including dislocation, nerve injury, periprosthetic
infection, proximal femur fractures and revision rates
between the mini-incision and the standard posterolateral
approaches.39 Chimento et al. performed a prospective
study and found no difference in surgical time between
the mini-incision and standard posterolateral approach;
however, intraoperative blood loss was significantly
less in the mini-incision group.40 Multiple prospective
randomized trials show that minimally invasive total hip
arthroplasty can be performed safely.39-42 Critics caution
the broad acceptance of the mini-incision approach
due to the increased level of difficulty, limited exposure
resulting in malpositioned implants, and unnecessary
soft tissue traction.43-45 Fig. 5.1: The lateral decubitus position. The patient is placed in the
Regardless of exposure type, adequate visualization lateral decubitus position with all bony prominences well padded
is a necessity. The desire for a cosmetically appealing
incision should never take precedence to adequate is carried through the dermis and subcutaneous tissue.
visualization. The fascia lata is split along the length of the incision
between the gluteus maximus and tensor fascia lata
AUTHORS’ PREFERRED SURGICAL interval and carried distally to the level of the gluteus
maximus insertion (Fig. 5.3). Proximally, the fascia
TECHNIQUE overlying the gluteus maximus is incised and split
The patient is positioned in the lateral decubitus position bluntly. The greater trochanteric bursa is identified and
with the assistance of a hip lateral positioner; always resected off the back of the greater trochanter to expose
take time to well pad all bony prominences (Fig. 5.1). the short external rotators (Fig. 5.4). The sciatic nerve is
A modified Kocher-Langenbeck incision is made on identified posteriorly and protected during the course of
the lateral aspect of the hip starting approximately five the surgery. The piriformis tendon, easily identified by its
centimeters distal to the tip of the greater trochanter distinct tendon, is isolated and elevated from its insertion
proceeding proximally for five centimeters in a curved (Fig. 5.5). The piriformis tendon is tagged for future
posterosuperior fashion (Figs 5.2A and B). The incision repair. The gluteus minimus is elevated off the superior
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
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
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
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
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
reliable patient satisfaction and a reproducible return REFERENCES
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a retrospective review of 5359 uncemented acetabular history: the Kocher-Langenbeck surgical approach.
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paedics: The Anatomical Approach, 3rd edition. Phila femoral head diameter and operative approach on
delphia, PA: Lippincott Williams & Wilkins; 2003. risk of dislocation after primary total hip arthroplasty.
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24. Johanson NA, Pellucci PM, Tsairis P, et al. Nerve
385:95-9.
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9. Berry DJ, von Knoch M, Schleck CD, et al. Effect of after posterior and direct lateral approaches for hip
femoral head diameter and operative approach on replacement. A clinical and electrophysiological study.
risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Br. 1996;78(6):899-902.
J Bone Joint Surg Am. 2005;87:2456-63. 26. Ferrell CM, Spinger BD, Haidukewych GJ, et al. Motor
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approach affect total hip arthroplasty dislocation rates? J Bone Joint Surg. 2005;87(12):2619-25.
Clin Orthop Relat Res. 2006;447:34-8. 27. Nercessian OA, Piccoluga F, Eftekhar NS. Postoperative
11. Hedlundh U, Hybbinette CH, Fredin H. Influence of sciatic and femoral nerve palsy with reference to leg
surgical approach on dislocations after charnley hip lengthening and medialization/lateralization of the
arthroplasty. J Arthroplasty. 1995;10:609-14. hip joint following total hip arthroplasty. Clin Orthop.
12. Woo R, Morrey B. Dislocations after total hip arthro 1994;(304):165-71.
plasty. J Bone Joint Surg. 1982;63A:1295. 28. Barrack RL. Neurovascular injury: avoiding catastrophe.
13. Robinson R, Robinson H, Salvati E. A comparison of the J Arthroplasty. 2004;19(4):104-7.
transtrochanteric and posterior surgical approaches 29. Basarir K, Ozsoy MH, Erdemli B, et al. The safe
for total hip replacement. Clin Orthop Relat Res. distance for the superior gluteal nerve in direct lateral
1980;147:143-7. approach to the hip and its relation with the femoral
14. Vicar AJ, Coleman CR. A comparison of the anterolateral, length: a cadaver study. Arch Orthop Trauma Surg.
transtrochanteric, and posterior surgical approaches in 2008;128(7):645-50.
primary total hip arthroplasty. Clin Orthop Relat Res. 30. Eksioglu F, Uslu M, Gudemez E, et al. Reliability of the
1984;188:153-9.
safe area for the superior gluteal nerve. Clin Orthop
15. Palan J, Beard DJ, Murray DW, et al. Which approach
Relat Res. 2003;(412):111-6.
for total hip arthroplasty: anterolateral or posterior?
31. Ince A, Kemper M, Waschke J, et al. Minimally invasive
Clin Orthop Relat Res. 2009;467(2): 473-7.
anterolateral approach to the hip: risk to the superior
16. Masonis JL, Bourne RB. Surgical approach, abductor
function, and total hip arthroplasty dislocation. Clin gluteal nerve. Acta Orthop. 2007;78(1):86-9.
Orthop Relat Res. 2002;405:46-53. 32. Ikeuchi M, Kawakami T, Yamanaka N, et al. Safe zone for
17. Dixon MC, Soctt RD, Schai PA, et al. A simple the superior gluteal nerve in the transgluteal approach
capsulorrhaphy in posterior approach for total hip to the dysplastic hip: intraoperative evaluation using a
arthroplasty. J Arthroplasty. 2004;19:373-6. nerve stimulator. Acta Orthop. 2006;77(4):603-6.
18. Pellici PM, Bostrom M, Poss R. Posterior approach to 33. Hu HP, Slooff TJ, Van Horn JR. Heterotopic ossification
total hip replacement using enhanced posterior soft following total hip arthroplasty: a review. Acta Orthop
tissue repair. Clin Orthop Relat Res. 1998;355:224-8. Bel. 1991;57(2):169-82.
19. Hedley AK, Hendren DH, Mead LP. A posterior approach 34. Sculco TP, Jordan LC, Walter WL. Minimally invasive
to the hip joint with complete posterior capsular and total hip replacement: the hospital for special surgery
muscular repair. J Arthroplasty. 1990;5 Suppl:S57-66. experience. Orthop Clin N Am. 2004;35:137-42.
20. Pelluci PM, Bostrom M, Poss R. Posterior approach to 35. Levine BR, Klein GR, DiCesare PE. Surgical approaches
total hip replacement using enhanced posterior soft in total hip arthroplasty: a review of the mini-incision
tissue repair. Clin Orthop Rel Res. 1998;355:224-8. and MIS literature. Bull NYU Hosp Jt Dis. 2007;65(1):5-18.
49
36. Khan RJ, Fick D, Khoo P, et al. Less invasive total 49. McElfresh EC, Coventry MC. Femoral and pelvic
hip arthroplasty. Description of a new technique. J fractures after total hip arthroplasty. J Bone Joint Surg
Arthroplasty. 2006;21(7):1038-46. Am. 1974;56(3):483-92.
37. Nakamura S, Matsuda K, Arai N, et al. Mini-incision 50. MacKenzie JR, Callaghan JJ, Pedersen DR, et al. Areas
posterior approach for total hip arthroplasty. Int of contact and extent of gaps with implantation
Orthop. 2004;28:214-7. of oversized acetabular components in total hip
38. Goldstein WM, Branson JJ, Berland KA, et al. Minimal- arthroplasty. Clin Orthop Rel Res. 1994;298:127-36.
incision total hip arthroplasty. J Bone Joint Surg Am. 51. Haidukewych GJ, Jacofsky DJ, Hanssen AD, et al.
2003;85(Suppl 4):33-8. Intraoperative fractures of the acetabulum during
39. Yang B, Li H, He X, et al. Minimally invasive surgical primary total hip arthroplasty. J Bone Joint Surg.
approaches and traditional total hip arthroplasty: 2006;88(9):1952-6.
a meta-analysis of radiological and complications 52. Berry DJ, Lewallen DG, Hanssen AD, et al. Pelvic
outcome. PLoS One. 2012;7(5):e37947. discontinuity in revision total hip arthroplasty. J Bone
40. Chimento GF, Pavone V, Sharrock N, et al. Minimally Joint Surg Am. 1999;81(12):1692-702.
invasive total hip arthroplasty: a prospective randomized 53. Schwartz JT, Mayer JG, Engh CA. Femoral fracture
study. J Arthroplasty. 2005;20(2):139-44. during non-cemented total hip arthroplasty. J Bone
41. Oganda L, Wilson R, Archbold P, et al. A minimal- Joint Surg. 1989;71(8):1135-42.
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
Carlos M Alvarado
INTRODUCTION be chosen. The approach must also be done in such a

way to maximize visibility in the surgical field, and allow
Surgical approaches to the hip have been described for appropriate delivery of the implants. This chapter will
throughout modern medical history. These surgical discuss technical aspects of each approach, highlight
approaches were born out of a need to treat numerous the benefits of each surgical approach and lastly discuss
ailments including infections, arthritis and deformity.1 the benefits of MIS techniques for total hip arthroplasty
However, in the more modern era of joint replacement, (Table 6.1).
many new surgical approaches have been added to
facilitate arthroplasty techniques. This chapter will review
the currently accepted surgical approaches to the hip. It DIRECT ANTERIOR APPROACH
will also discuss some minimally invasive surgical (MIS) The anterior, or Smith-Peterson approach to the hip is
techniques for total hip replacement. a useful approach for numerous surgeries about the hip
While many surgeons performed hip surgery prior to including total hip replacement. It was described by
Dr Marius Smith-Peterson (1886–1953), he was the first Marius Smith-Peterson in 1917.4 As of late, there has been
to successfully perform interpositional hip arthroplasty, renewed interest in the direct anterior approach for total
or mold an arthroplasty using a Vitallium resurfacing hip arthroplasty as it may be used for MIS techniques.
component in 1923.2 However, the modern era of hip The benefit of the direct anterior approach is that it takes
arthroplasty was ushered in by Dr Austin Moore (1899– advantage of a true internervous and intermuscular plane
1963) who performed the first hip hemiarthroplasty in between the sartorius and tensor fascia lata allowing for
1940, using an implant very similar to those still widely sparing of muscles during the approach. This has resulted
used today.3 During the next 30 years, hip replacement in significant clinical improvements that are limited to the
surgery was catapulted into the modern era by the first 3 months of the postoperative course.5 However, the
efforts of Dr John Charnley (1911–1982), Dr Kenneth approach can be technically challenging and has been
Mckee (1905–1991) and Dr Peter Ring. The efforts of associated with intraoperative femur fractures, femoral
these surgeons help to make total hip arthroplasty one nerve injuries and difficulty with implant positioning,
of the most successful and most common surgeries especially in obese patients.6 When deciding to use the
in all of medicine. While many things account for the direct anterior approach, careful attention should be
success of total hip arthroplasty including improved given to patient selection as obese body habitus can
materials, improved antibiotics and sterile technique, make visibility very difficult with the anterior approach.6
the importance of improved surgical approaches and However, when this approach is done in the right patient,
an understanding of the management of the soft tissues it can result in very successful results with rapid recovery.
of the hip cannot be underplayed. In order to ensure The direct anterior approach gained widespread
surgical success, the appropriate surgical approach must notoriety due to work by Light and Keggi.7 This work
Table 6.1: Comparing the different surgical approaches to the hip

Approach Skin incision Muscular interval Nervous interval
Direct anterior Between GT and ASIS Superficial—Sartorius and Sartorius—Femoral nerve
tensor fascia lata Tensor fascia lata—
Deep—Gluteus medius Superior gluteal nerve
and rectus femoris
Anterior lateral Centered over GT Tensor fascia lata and Tensor fascia lata—
gluteus medius Femoral nerve
Gluteus medius— Superior
gluteal nerve
Modified lateral Centered over GT Superficial—Split tensor Gluteus medius—Superior
fascia lata gluteal nerve
Deep—Split gluteus
medius at the anterior 1/3
posterior 2/3 interval
Posterior lateral Centered over GT Superficial—Split gluteus Piriformis—Sciatic nerve
maximus Gluteus minimus—
Deep—Piriformis and Superior gluteal nerve
gluteus minimus
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
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
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
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
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
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
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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
INTRODUCTION fractures.11-13 Therefore, the ability to perform a cemen

ted THA is still very relevant today in an age where
Cemented total hip arthroplasty (THA) has a well- cementation is becoming somewhat a “forgotten art”.
documented success for over 3 decades.1-5 Although This chapter presents the principles of implant design
cementless fixation of hip implants have become the and techniques for THA cementation with a special focus
standard of care in North America, registry reports on the surgical technique of proper cementation with
from Australia, New Zealand, Scandinavia and the helpful tips and pearls.
United Kingdom do not show improved longevity for
cementless over cemented implants.6-9 These registries
and other studies indicate that long-term survival of a
BASIC PRINCIPLES OF
cemented implant is dependent on patient selection,
CEMENTATION
surgical experience, cementation technique, and implant In the past 4 decades, since it was initially intro
design.10 duced by Charnley,14 the cementation technique and
Cemented femoral stems are more favorable than instrumentation had evolved through three distinct
cementless ones in patients over 75 years of age and in generations, as presented in Table 7.1.
patients undergoing hemiarthroplasty for fractures of the Today, the surgeon can choose from a variety of
femoral neck. Moreover, cemented femoral stems are polymethylmethacrylate (PMMA) formulations that
particularly useful in certain patient populations, such as are available on the market. Thus, the surgeon needs
patients with large canal diameters or patients with thin to be familiar with the details of the particular cement
cortices. Cementation of the femoral stem in these patient formulation that is being used in terms of viscosity, working
groups may preclude end of stem pain, and reduce the time and setting time, as these qualities may influence
risk of periprosthetic fractures, especially intraoperative the cementation technique and clinical outcomes.
Table 7.1: Generation techniques

Generation Cement mixing Canal preparation Insertion Centralization
First Hand mix Rasp only Manual with finger No
packing
Second Hand mix More aggressive Cement gun No
rasping Distal canal plug
Third Vacuum mix More aggressive Cement gun + Yes
rasping + brushing distal canal plug +
pulsatile lavage pressurization
These properties of the cement vary according to the cement mantle; these are: retrograde cement application,
composition of its basic elements and influence the and vacuum mixing of the cement. Retrograde filling of the
cementing technique adopted. Accurate application of dried femoral tube avoids creation of air and blood voids
the respective cementation technique is a critical factor in the cement that may become loci of cement cracks and
that determines the mechanical durability of the cured failure. Vacuum mixing is highly recommended as it has
cement mantle.15-17 been shown to increase the cement strength by 17%.23,24
The ultimate goal of good cementation is to create
a strong stable interface between the cement and host CEMENTED FEMORAL STEM DESIGN
bone by maximizing the amount of cement interlocking
with cancellous bone, in other words, to get as much soft Two predominant design philosophies exist as to a
cement to penetrate into the cancellous bone bed of the cemented stem. The first is the taper load philosophy
acetabulum or femoral canal. This is achieved by providing where the implants’ highly polished surface and tapered
a clean, stable bony bed for cement interdigitation into design allow the implant to slide within its cement
the remaining lattices of well-fixed cancellous bone. All mantle that is well fixed to the surrounding femoral
loose bone spicules and all fatty marrow in the bone bed bone producing hoop compression forces on the cement
needs to be removed, leaving only the remaining dense mantle. This design “offloads” the bone implant interface
bone nearest to the cortex to enhance interdigitation of and allows compression of the cement mantle. The first
the cement into the bony lattice. This increases the shear generation of Charnley stems, the flat-back design, was
strength of the cement bone interface by attaining the polished implants with a single straight taper in the
maximal surface contact area of the cement mantle to coronal plane (Figs 7.1A and B). More modern designs
the remaining bone stock. It is imperative not to ream such as the Exeter stem are tapered along both the
away all cancellous bone, as this will leave a smooth coronal and sagittal planes to allow a superior controlled
inner cortex and diminish the ability for the cement micromotion of the stem within the cement mantle. The
to achieve adequate fixation via interdigitation into the C-stem implant design (Depuy, Warsaw, Indiana) even
bone and lessens the surface area available for cement has an additional taper, as the stem narrows from lateral
bone contact. to medial to better resist torsional forces.25 The second
Correct adequate bone interface preparation in philosophy of femoral stem designs is the composite
itself is essential for long-term survivorship of both the beam philosophy, where the implant itself bonds to the
cemented stem and the cup.18 The residual cancellous cement mantle via appropriately roughened surfaces
bone needs to be properly cleaned of bone debris and and the cement is well fixed to the surrounding bone
marrow fat and then meticulously dried from blood prior (Fig. 7.2). This design “stresses” both the implant-cement
to cementation. Pulsatile jet lavage is a useful tool in interface as well as the cement-bone interface.
this respect as it significantly improves the “cleansing” Despite the fundamental differences between cement
of the bone surface in preparation for cementation and loading and implant design to accommodate these
thereby improving the cement’s ability to penetrate the philosophies, there are still fundamental design issues
cancellous bone both in vitro and in vivo.18,19 Cement that are similar to these two philosophies. The stem used
fixation is also enhanced by cement pressurization and should be fabricated from a high-strength superalloy,
rapid application as this reduces the risk of contamination such as cobalt-chrome, because its higher modulus of
of the well-prepared bony bed with blood that is caused elasticity may reduce stresses within the proximal cement
by interface bony bleeding and therefore blood cement mantle. The cross-section of the stem should have a broad
mixing that may cause blood lamination at the cement medial border and even a broader lateral border in order
bone interface.20-22 to better load the cement mantle in compression. Femoral
The cement mantle should be continuous, with a stem design should prevent sharp edges to avoid stress
2–3 mm thickness without large voids or cracks as they concentration between the implant and cement mantle
expose the arthroplasty to early loosening by cement that can lead to cement cracks and cement failure with
microfractures and catastrophic failure. catastrophic loosening. Data have shown that different
There are mechanical manipulations that may be used types of femoral stems should be inserted with different
60 to reduce the cement porosity and thereby strengthen the types of cements. For example, a rougher stem should be
Cemented Total Hip Arthroplasty
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
CEMENTED ACETABULAR DESIGN

The cemented acetabular cup designs have evolved in
order to improve fixation and longevity. The original
acetabular cup designs were thick-walled polyethylene
sockets without any grooves or cement spacers.
Horizontal and vertical grooves were added to the outer
socket surface to improve the stability of the socket within
the cement mantle. In order to assess cup positioning,
metal wires were placed on the polyethylene cups. In
addition, cement spacers were added to allow a uniform
3-mm thick cement mantle around the cups and avoiding
“bottoming out” of the cup which resulted in a thin
or discontinuous cement mantle and early loosening.
Pressure-injection flanges were later added to enhance
Fig. 7.2: HS1/HS2 roughened surface stem, fixed head pressurization of the cement.28
61
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
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
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
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
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
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
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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
INTRODUCTION understanding of hip biomechanics and surgical

techniques. Sir John Charnley developed the complete
Total hip arthroplasty (THA) has been a reliable treatment
concepts of low-frictional torque hip arthroplasty,
method for most hip pathologies including advanced
biomechanics and surgical procedures. In the 1960s,
osteoarthritis, osteonecrosis of femoral head, rheumatoid
cement fixation was introduced as a major advance in
arthritis and hip fracture. Along with the improvement of
THA. Until the 1970s, cemented polyethylene cup and
materials, implant designs, and surgical techniques, the
the Charnley stem became the benchmark of other
results of THA are encouraging in the past decades.1-3
arthroplasties.
However, in addition to the surgical exposures, one of
It is generally believed that the cemented THA has
the major issues encountered by surgeons is the type of
been the treatment of choice for elder patients with hip
fixation. The choice of approach is based on the surgeon’s
problems such as advanced osteoarthritis. Postoperative
preference and results have not shown significant
immediate weight-bearing, early functional recovery and
difference among different approaches. However, the
pain relief remain the major advantages of cemented total
choice of fixation has been shown to be a major factor
hip replacement (THR). However, both the cemented
in the survivorship of hip prosthesis.
In most reported series, cementless THA shows cup and the cemented stem revealed higher failure rates
promising results at mid- to long-term follow-up.2,4-6 in young active patients due to the aseptic loosening,
Rothman et al. reviewed a large series comparing the so-called cement disease.8,9
results between cemented versus cementless THA and In order to resolve the cement-related problems,
found that cemented THA are satisfactory in short-term including cement disease, difficulty in future revision
follow-up but the results deteriorated with time. This is surgery, and significant bone loss, Judet et al.10 first
in contrast to cementless THA, which shows excellent utilized a cementless stem with irregular macrotexturing
results at mid- to long-term follow-up. They suggested for fixation. A variety of designs were subsequently
that cementless THAs are the treatment of choice for developed (Fig. 8.1).
younger, active patients.7 Through press-fit techniques, The first-generation cementless, extensive porous-
the acetabular and femoral components can achieve coated stem [anatomic medullary locking (AML)
good initial fixation, followed by bone on- or in-growth prosthesis, DePuy, Warsaw, Indiana (IN)] (Fig. 8.2.) was
to the prosthesis that can ultimately result in durable designed by Engh et al. in the 1980s with excellent long-
skeletal fixation. term results.11,12 However, thigh pain and stress shielding
that resulted from these diaphyseal fitting, stiffer cobalt-
chrome alloy stems remains a major concern. To address
HISTORY these problems, proximal porous-coated implants
Total hip arthroplasty evolved as a result of many with noncircumferential coating, such as the Harris-
improvements of implant design and materials, better Galante prosthesis type I (HGP-I, Zimmer, Warsaw, IN)
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
Figs 8.5A to C: Preoperative templating includes acetabulum

(A), femoral component (B), and leg length measurement from 71
C radiography (C)
Implant Selection system, United, Taiwan) (Fig. 8.7) were developed. It

provides a theoretically perfect dual locking mechanism
Implant selection should be based on the implant design to achieve good stability. Each proximal stem size has
rationale, geography of the patient’s bony structure several corresponding distal stem sizes for choice to
and surgeon’s preference. For a cementless prosthesis, obtain the ideal geometric fit over both metaphyseal and
achievement of initial stability by press fit is quite diaphyseal areas.
important.
However, the morphology of the proximal femoral
canal varies among individuals. The concept of canal flare
Approach
index (CFI), defined as the ratio of the width of the canal A variety of traditional approaches are described in other
proximal to the lesser trochanter and at the isthmus, was chapters of this book. Basically, the choice of approach
first described by Nobel et al.21,22 The femoral canal was depends on the surgeon’s preference. Today, the
classified into three types including normal, stovepipe traditional approaches have been promoted as “minimal
and champagne-flute. For those patients who have invasive” approaches for cosmetic incisions, less soft
larger CFI (champagne-flute canal type), or unreliable tissue damage and proposed better functional recovery.
metaphyseal bone quality due to previous fracture or The approach illustrated here is the minimal invasive
failure of treatment, the longer diaphyseal fitting stems anterolateral approach in the lateral decubitus position
(e.g. AML®, DePuy, Warsaw, IN) are more suitable to proposed by the senior author (WMChen).23 An incision
obtain initial stability at the diaphyseal area. Conversely, line is marked at the anterior quarter of the greater
if the plain radiography reveals a small CFI (chimney trochanter parallel to the line extending 1.5 cm proximally
canal type) or increased anterior bowing of the femoral and 4.5 cm distally from the tip of the great trochanter. A
shaft, the metaphyseal fitting stems [e.g. Secur-Fit® hip 5–6 cm incision is made along the previous mark.
arthroplasty stem, Stryker, Mahwah, New Jersey (NJ)] (Fig. Following the subcutaneous tissue, the tensor fascia lata
8.6) should be first considered to achieve a better fit in is dissected to expose the gluteus medius, a 2.5–3 cm
the proximal femur. To obtain a closer match between the incision is made in the tendinous portion of the gluteus
femoral canal and the femoral stem, dual metaphyseal- medius, then continued anteriorly into the muscle
diaphyseal fitting femoral stems with hydroxyapatite portion with a 30° curve starting from the superior border
coating on the metaphyseal portion only (e.g. U2® hip of the greater trochanter to expose and detach the gluteus
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)
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).
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
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
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)
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
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.
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
INTRODUCTION the surgeon’s ability to determine changes in leg length,

offset and version with the goal to improve physiologic
Proper positioning in total hip arthroplasty (THA) has biomechanics, and decrease the risk for complications
been shown to be one of the most important factors and revision surgery.3,8-10,13-16
in determining short- and long-term outcomes after
surgery. Improper acetabular component orientation
has been correlated with increased dislocation rates, GENERAL PRINCIPLES OF
altered hip biomechanics, component impingement, COMPUTER-ASSISTED NAVIGATION:
bearing surface wear, pelvic osteolysis, and revisions IMAGE-BASED AND IMAGE-FREE
in the long term.1-10 A “safe zone” for acetabular cup
SYSTEMS
alignment has been proposed.11,12 However, more recent
studies have suggested that the safe zone for instability The primary goal of CAS is to improve surgical accuracy,
is patient-specific and narrower for anteversion than and thus to optimize implant orientation and minimize
for inclination.13 Traditional conventional techniques to complications. The principal benefit of CAS is that it
determine acetabular orientation include conventional provides real-time data on acetabular cup position during
external alignment guides, free-hand placement, the use cup reaming and insertion, regardless of the patient’s
of anatomic bony and soft-tissue landmarks, and com position on the operating table. Other benefits of CAS
bined techniques including radiographic preoperative in THA include improved patient-specific cup size and
templating, intraoperative stability and radiographic depth selection, adjustment for patient’s pelvic tilt, and
evaluation. These techniques have been repeatedly facilitation of intraoperative measurement of leg length
demonstrated to lead to cup malposition rates of 50% or and offset.
more.1 This is due to variables including poor visualization, Computer-assisted hip replacement is typically
a wide variation in the position of anatomical landmarks categorized as image-based or image-free. Image-based
between patients, variation in patient position during techniques rely on either preoperative and/or intra
surgery with resulting mechanical guide imprecision, operative imaging. Classically, with preoperative image-
inaccuracies in templating, and imprecise radiographic based navigation, a computed tomography (CT) study is
interpretation.1-6,11 performed and a 3D model of the patient’s anatomy is
Computer-assisted surgery (CAS) methods have been determined. This involves both developing 3D models of
developed to help provide real-time information on the the existing anatomy and also the proposed postoperative
relative position of the femur, pelvis, instruments, and anatomy including implant sizes, position and orientation.
implants to help guide surgery and implant placement.3 Intraoperatively, after trackers are affixed to the bones,
With this “live” information, the use of CAS decreases data are input to “register” or match the preoperative
variation in acetabular cup orientation and can improve bone models to the actual bones being tracked. The data
Computer-Assisted Hip Arthroplasty
for the registration process can be input using various PROCEDURAL OVERVIEW OF
methods including a digitizing probe, an ultrasonic
COMPUTER-ASSISTED SURGERY IN
digitizing probe, intraoperative fluoroscopic imaging, or
even intraoperative small-field CT or magnetic resonance TOTAL HIP ARTHROPLASTY
(MR). The first procedural step for both image-based and
Alternatively, intraoperative image-based navigation imageless navigation techniques is to affix trackers to
may be performed. Using these methods, the trackers are the bones to be tracked and to teach the system the
affixed to the bone first and then imaging is performed relationship between the affixed tracker and the bone
with trackers affixed to the imaging device. Fluoroscopic being tracked. For tracking the pelvis, for example, the
intraoperative image-based navigation is well established. anterior pelvic plane (APP) coordinate system, comprised
In addition, intraoperative 3D data acquisition can be of the two anterior superior iliac spines (ASIS) and the
obtained using specialized fluoroscopic CT or MR tech pubic symphysis, is typically used.
nologies.
Image-free navigation involves first affixing trackers Image-Free Computer-Assisted
to the bones and then establishing coordinate systems
Surgery
using kinematic acquisition and directly digitizing pal
pable bony landmarks. For imageless systems, the tracker is affixed and then
these bony landmarks that define the APP coordinate
Tracking Methods system are directly input using a digitizing probe. The
advantage of this image-free method is its simplicity. One
All computer-assisted surgeries involve tracking techno major disadvantage is that digitization of landmarks in
logy. Most commonly, infrared stereoscopic optical asymmetric or otherwise distorted pelvises and inaccu
tracking is used. Alternatively, electromagnetic, inertial or rate input of the landmarks in general may lead to the
mechanical tracking, as in the case of smart mechanical inaccurate establishment of a coordinate system, and
navigation, may be used. For optical tracking, the stereo there is no method of confirming the accuracy. Another
scopic camera both emits and receives infrared light. For disadvantage for surgery in the lateral position is that
active optical tracking, the trackers affixed to the bones image-free navigation requires a two-step process: affi
and instruments use infrared light emitting diodes (LEDs). xing the tracker and digitizing the landmarks in the
For passive optical tracking, the trackers passively reflect supine position and then repositioning and reprepping
infrared light from the camera back to the camera. in the lateral position.
The primary advantages of optical tracking systems
are their exceptional accuracy and ability to track large Fluoroscopic Computer-Assisted
volumes. Individual markers can be located within less
than 1 mm, and instrument tips within 1–2 mm. The
Surgery
main disadvantage of optical tracking is the requirement Fluoroscopic CAS is a common technology used for
for a direct “line of sight” from all cameras to all targets intraoperative identification of bony landmarks to regis
on the patient and instruments. As such, while navigation ter the APP. An advantage of fluoroscopy for laterally-
is being employed, no person or object can be between positioned surgery is that registration of the APP is
the camera and the optical trackers, and the trackers performed by taking multiple fluoroscopic images with
must be visible outside of the patient’s skin. Thus, the the patient in the lateral position. This eliminates the
navigation system must be incorporated into the overall logistical and time inconveniences of having to register
surgical orchestration as another important member of the patient supine and then reposition and reprep the
the surgical team. patient as in an imageless CAS performed in the lateral
Regardless of the tracking technology, the relative position. Fluoroscopy can be useful in revision THA
positions of the trackers are relayed to the processor so where deformity can distort imageless navigation and
that the positions of the bones and instruments being metal artifact from prior hardware can compromise the
tracked can be displayed to the surgeon. accuracy of CT-based navigation. The main disadvantage
81
of fluoroscopic CAS is the use of a C-arm intraoperatively, or cases of hip fusion may preclude the use of these
which can be disruptive to the flow of the surgery and methods.
can also be bulky and cumbersome in the operating
theater. It also often requires a radiolucent table, which RESULTS OF FREE-HAND VERSUS
may not be readily available. Further, patient habitus
can be a limiting factor, as an obese abdomen can cause IMAGE-BASED VERSUS IMAGELESS
challenges for landmark visualization. As with CT, but to NAVIGATION SYSTEMS
a lesser degree, radiation exposure is another factor to The results of CAS as compared to standard non-
be considered. computer-assisted surgery (N-CAS) have been studied
extensively over the last decade. Consistently, CAS has
Computed Tomography-Based demonstrated superior acetabular placement accuracy
Computer-Assisted Surgery for both anteversion and abduction, with lower variability
and higher rates of “safe zone” placement.9,10,14-20 Safe
Computed tomography-based CAS requires that a zone placement has been shown to be upwards of
preoperative CT scan is obtained, which is used not only 97.1% in minimally invasive THA CAS procedures.19
intraoperatively but also for more extensive preoperative Three studies showed improved accuracy of cup place
planning than is done with other techniques. During the ment with respect to anteversion and abduction com
preoperative planning phase, the expected femoral and pared to experienced surgeon’s placement without
acetabular components, leg length, and the postoperative navigation.9,10,18 Furthermore, a meta-analysis by Beck
range of motion (ROM) can be planned and templated man et al. that screened 363 citations found five high-level
in three dimensions. As with other techniques, the first studies totaling 400 patients, and found that navigation
intraoperative step is to determine the relationship of significantly reduced the variability in cup positioning
the tracker to the pelvis itself. This process is called and the risk of placing the acetabular component
registration. Unlike other methods of navigation, the beyond the safe zone.20 When comparing different CAS
registration process for CT-based CAS can determine techniques, the results between imageless navigation and
the location of the APP without having to digitize or CT navigation have shown both to have similar accuracy.10
image those landmarks during surgery. Rather, the Fluoroscopy has been shown to improve the variability in
registration process can use data from other parts of the cup abduction, but not for cup anteversion.21
pelvis to determine the position of the tracker to the APP Sugano reported a significant difference in dislocation
coordinate system. Many registration algorithms exist, but rates between CAS and N-CAS at 0% and 6%.14 However,
most involve a combination of matching a point on the some surgeons have experienced negligible dislocation
computer model to a point on the patient (paired-point rates with either technique.10,22 Leg-length discrepancy, a
matching) and matching a surface on the computer model cause of impaired hip biomechanics and low back pain,
to a surface on the patient’s pelvis (surface matching). has shown to be different between standard techniques
Geometric modeling is another technique whereby the and computer-assisted techniques.23,24 In the study by
center of the acetabular surface is calculated on the CT Sugano, the CAS THA were significantly more likely than
scan and then points on the patient’s acetabulum are non-navigated hips to result in a normal leg length.14
registered at surgery. The accuracy of the registration Despite the encouraging results of CAS in THA, there
process can be confirmed by measuring the distance of are potential concerns associated with the pelvic and
two points on the actual bone surface compared to the distal pin placement, such as increased risk of infection
computer model. This ability to confirm the accuracy and blood loss secondary to longer surgical time, pain
of the intraoperative registration is a unique advantage after removal of pins and soft-tissue damage.3 There is
to CT-based CAS compared to imageless CAS. Further, also a significant learning curve both when learning
CT-based CAS can be the fastest navigation method, as the new technology and when developing experience
one-stage setup is possible, eliminating the time and at free-hand placement. Najarian et al. demonstrated a
energy of repositioning. The drawbacks to this system significant difference in the accuracy of cup placement in
compared to other technologies are the added time of surgeons performing the first 50 CAS THA versus those
82 preoperative planning and radiation exposure. Further, more experienced. The accuracy, however, of his group
cases with severe metal artifact due to existing hardware was still significantly better than manual methods to
position the acetabular component.25 Lin et al. reported SPECIFIC INSTRUCTIONS ON
three cases of intraoperative conversion from a navigated
PERFORMING CT IMAGE-BASED
hip to a manual hip due to unreliable registration of the
pelvis.22 COMPUTER-ASSISTED SURGERY
Parratte on the other hand reported no difference A preoperative CT scan is performed and the 3D
in intraoperative complications even with an average of images are uploaded to the company-specific software
12-minute longer operative time.17 Consistently, however, for planning purposes. The planning phase allows
no difference between intraoperative blood loss has been the surgeon to identify the best fit of the femoral and
noted.14,17 acetabular components. This includes the acetabular
orientation, depth and size (Fig. 9.1).
MINIMALLY INVASIVE TOTAL HIP The femoral planning allows for positioning and
sizing of the femoral component to adjust for offset and
ARTHROPLASTY WITH leg length, as well as optimal neck osteotomy (Fig. 9.2).
COMPUTER-ASSISTED SURGERY Following the best-fit templating, a ROM application
Since minimally invasive surgery (MIS) has been asso is applied to the software to better understand and adjust
ciated with an increased risk of component malposition, the acetabular and femoral components to achieve the
the combination of MIS with CAS has great potential maximal ROM. Osteophytes and impinging structures are
benefits. In a series by Woolson et al. comparing non- visualized, and intraoperative planning to address these
navigated conventional and minimally invasive THA, the is considered (Fig. 9.3).
mini-incision group had a higher percentage of acetabular Using an image-based CAS, the patient is positioned
component malposition compared to standard incision.26 in the desired position, in this case lateral. The arrays
Combining CAS with MIS offers the potential to gain the are securely fixed to bone using 5.0 mm Schanz pins.
advantages of tissue preservation while simultaneously The pins are placed into the distal femur and the ASIS,
improving rather than worsening component positioning. with the optical trackers pointing directly to the infrared
Several studies have shown that MIS combined with monitor (Fig. 9.4).
CAS can produce component positioning that is similar Once the arrays are placed, the desired approach
or better than conventional THA.19,27,28 Murphy et al. to the hip is completed. Following this, the pelvis is
reported superior functional outcomes of 185 consecutive registered to verify accuracy of the probes palpating bone
CAS minimally invasive THAs compared to controls at with that of the CT scan (Fig. 9.5).
6 and 24 weeks.28 Ideal accuracy is less than 2.0 mm (Fig. 9.6).
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
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
Fig. 9.5 Fig. 9.6

Figs 9.5 and 9.6: Pelvic registration is undertaken to link the CT images uploaded on the computer with the actual patient anatomy.
84 Ideal accuracy between the bony landmarks and the CT images is less than 2.0 mm. This ensures accurate intraoperative tracking
Fig. 9.7 Fig. 9.8

Figs 9.7 and 9.8: Acetabular reaming using optical trackers ensures real-time information on depth and orientation
of the prepared socket. Acetabular cup insertion using optical trackers further ensures proper placement
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
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
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
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11. McCollum DE, Gray WJ. Dislocation after total hip
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parison of a mechanical acetabular alignment guide Res. 1990;(261):159-70. [Online] Available from http://
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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
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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
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88
Chapter
Proximal Femoral
Reconstruction in
10
Hip Arthroplasty
Tao Ji, Cheng-Fong Chen, Bang H Hoang
INTRODUCTION fracture around a femoral stem is the third most common

reason for reoperation following total hip replacement.3
Resection and reconstruction of the proximal femur are Regardless of the indication, the challenges of such
usually performed for malignant diseases (Figs 10.1A and B). treatment are loss of considerable bone lengths, loss of
Non-neoplastic conditions may also require such important soft tissue attachments, instability of the joint,
procedure for reconstruction for segmental proximal and alternation in the normal function of the hip.4 The
femoral bone loss.1 These include complications of total goals of hip revision surgery are to create a stable construct,
hip arthroplasty including periprosthetic fracture, aseptic preserve bone and soft tissues, augment deficient host
loosening, osteolysis, chronic infection, stress shielding, bone, improve function, provide a foundation for future
metabolic bone disease, and failed conventional surgery, and create a biomechanically restored hip.5
treatment of proximal femoral fracture.2 Periprosthetic Current options for treatment of severe femoral defects
include megaprosthesis replacement, allograft prosthetic
composite (APC), and resection arthroplasty.
Following successful application of the megaprosthesis
in patients with neoplastic conditions, the indications
for using this reconstruction method were expanded
to patients with severe proximal femoral bone loss.6
In recent years, modular megaprostheses have been
widely used with the advantage of flexibility in
restoration of limb length, and major tendomuscular
structure reattachment. The main advantages of APC
are the effective soft tissue reattachment and bone stock
restoration. Currently, reconstruction of the proximal
femur with an endoprosthesis or allograft prosthesis
composite has become a reasonable, reliable and
commonly used salvage option in complex periprosthetic
femoral fractures with bone loss, and failed conventional
internal fixation of proximal femoral fractures.7,8
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
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
Fig. 10.3: Sliding osteotomy of greater trochanter should be considered 91

if the greater trochanter is not involved by tumor extension
as far as the lesser trochanter. The hip can be internally is determined after the proximal femoral reconstruction
rotated to provide better exposure of the posterior is completed, because constrained liners may be chosen
capsule. When the capsulotomy is completed, the hip to decrease dislocation in patients with poor soft tissue
joint can be dislocated and retracted laterally. The psoas tension and instability. The constrained liners can be
tendon underlying most of the medial part of the capsule inserted either snap-fit or cemented into the shell.6
is tagged with tendon sutures for later repair.
Prosthetic Reconstruction
Adductor Release Once the femur is exposed, the distal portion of the
After femoral osteotomy and hip joint dislocation, the canal is prepared by serial reaming (Fig. 10.6). Flexible
femur is retracted laterally and externally rotated. The reamers are recommended. To permit an adequate
remaining medial adductors and psoas are now exposed. cement mantle, the canal should be reamed to 2 mm
The muscles are serially dissected and clamped with a larger than the selected stem of the prosthesis. Preserve
vessel sealer, while carefully protecting the vessels in the the cancellous bone for better cement interdigitation.
adductor canal lying on the adductor magnus muscle. Trial reduction is done in order to determine the ease of
The perforator branches of the profunda femoris vessels insertion of the femoral prosthesis, and stability of the hip
are directly under the adductor magnus muscle and care joint before cementing, as well as to determine whether
should be taken to identify them. It is important not to the length of the prosthesis is appropriate. The range of
distract the extremity after removal of the proximal femur motion of the hip joint is tested. The prosthesis should
in order to avoid distraction of the sciatic nerve and be stable in flexion, adduction and internal rotation.
femoral vessels (Fig. 10.5). A cement restrictor is then placed in the canal 2 cm
distal to the anticipated end of the prosthetic stem. The
Proximal Femoral Reconstruction femoral canal is thoroughly irrigated. Then the prosthesis
can be assembled and cemented into the distal femur.
The acetabulum is first to be reconstructed. This can
Alternatively, a press-fit stem can also be used for the
be done with either a cemented or a cementless cup
endoprosthesis. Align the rotational alignment mark
depending on the bone stock and the oncological status.
on the prosthesis with the rotational reference mark
Constrained liners should be considered only if the risk of
postoperative dislocation is high.12 Bipolar implants can previously made on the anterior cortex of the femur,
be used, providing immediate stability and minimizing the and antevert the prosthesis 10–15° if no femoral neck
chance of socket failure. A trial femoral head prosthesis anteversion angles are available in the prosthesis
is used to test the suction fit. If a previous acetabular design.
component is in place, the stability and positioning is In patients with confirmed infection, a two-stage
scrutinized. Consider changing only the acetabular liner procedure should be performed. The first stage consists of
if the component is found to be stable. If the previous a comprehensive debridement, irrigation and metal-work
acetabular component is found to be unstable or absent, removal. An antibiotic-impregnated spacer is used. The
a new component should be inserted. The type of liner second stage is to replace the spacer with endoprosthesis.
92 Fig. 10.5: Typical defect after proximal femoral resection Fig. 10.6: Serial reaming of the residual medullary canal of the femur
Allograft Prosthetic Composite capsule can be reinforced by using remnants of hip

Reconstruction muscles, including the pectineus, external rotators, and
psoas.16 It can also provide initial mechanical support
First, the distal femoral canal is prepared. Then the needed for healing and scar formation.
allograft is prepared by cutting the femoral neck at, or The abductors can be reattached to the prosthesis
1 cm proximal to, the lesser trochanter. The medullary using wires or cables if a greater trochanter osteotomy
canal is reamed to accommodate either a cemented was performed. If no fragment of greater trochanter
or press-fit stem. The allograft should be slightly over- is preserved, a strong or nonabsorbable suture can be
reamed to allow it to toggle and the osteotomy to self- woven through the tendon of the gluteus medius and
align during reduction. Press fit is considered to be safe then fixed to the trochanteric holes on the prosthesis.
when there is at least 6 cm of prosthesis-shaft contact This can be reinforced by suturing the gluteus medius to
bypassing the allograft-host junction.13 The approximate the vastus lateralis muscle.
length of the graft required is assessed by a trial reduction. Various materials17-19 have been used to form
Stability and any preoperative limb-length discrepancy a biocompatible scaffold for the reattachment of
should also be taken into account in determining the surrounding muscles, including the gluteus maximus
allograft length. The prosthesis is then cemented into tendon, vastus lateralis, vastus intermedialis, adductor
the allograft. To prevent the cement from getting onto
magnus tendon and psoas. Tendomuscular reconstruction
the porous surface of the stem, a latex rubber digit, cut
will enhance the stability of the entire reconstruction.
from a surgical glove, can be placed as a sheath protector
over the porous surface of the stem. The stem can then be
passed through the cement, after which the latex rubber POSTOPERATIVE MANAGEMENT
protector can be removed.14 The composite is then Postoperatively, all patients are treated with intravenous
inserted into the host femur. If using a step or oblique antibiotics until the drainage tubes are removed,
cut, the host-graft junction is then secured with cerclage normally for 3–7 days. Patients are allowed to commence
cables, wires, or plate and screws. The junction can be protective weight-bearing on postoperative day 1 after
reinforced by placing two strut grafts with one on each a bipolar implant. However, when an acetabular cup
side and stabilized by wires or cables.5
is implanted together with the femoral reconstruction,
foot-flat weight-bearing is recommended for 4–6 weeks in
Soft Tissue Reconstruction order to allow acetabular bony ingrowth, especially when
Re-establishing hip stability and soft tissue reattachment a constrained liner is used, as well as to prevent possible
are imperative for a successful reconstruction. The dislocation until complete healing of the scar tissue
remaining capsule is sutured tightly with strong sutures around the hip joint occurs. Postoperative mobilization
by a purse string fashion to capture the femoral head and with an abduction brace and weight-bearing as tolerated
provide immediate stability (Fig. 10.7).15 The reconstructed are continued for 12 weeks until adequate soft tissue
healing occurs.
If an allograft is used for reconstruction, unprotected
weight-bearing is prohibited until there is evidence of
radiographic allograft-host union, which usually takes
between 3 and 6 months.
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
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
Table 10.2: Brief literature review of proximal femoral replacement

Study Duration Patient Number Mean Complications (%) Revi- Implant survival
group of follow-up sion
implants (months) Aseptic Dis- Infec- (%)
loosen- location tion 5- 10-
ing year year
Bernthal20 1982–2008 Oncologic 86 65.3 4.7 4.7 1.2 5.8 93% 84%
23
Potter 1993–2003 Oncologic 61 55.4 3.3 6.6 4.9 9.8 92.5% –
29
Finstein 1981–2003 Oncologic 62 59.2 9.7 4.8 4.8 19.4 79%
Menendez24 1992–2003 Oncologic 62 18.1 0 4.8 6.3 7.3 82% 82%
22
Ogilvie 1992–2002 Oncologic 53 36.0 – 5.7 3.8 7.5
30
Farid * 1974–2002 Oncologic 52/20 146/76 10/0 6.9 3.9 7.7/ 85.7/ 81.8/
5.0 100% 85.7%
McLean7 2000–2009 Non- 20 48.0 – 15.0 10
noncologic
Dean8 2001–2008 Non- 8 17.0 – 0 0
noncologic
*The study included both endoprosthetic and APC reconstruction. Detailed results are presented in form of endoprosthetic/APC.
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
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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
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
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1998;80(4):502.
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total hip replacement or hemiarthroplasty? Injury.
reconstruction by an allograft prosthesis composite.
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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.
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and early results. J Arthroplasty. 2011;26(1):161. affecting nonunion of the allograft-host junction. Clin
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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
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Chapter
Treating the Degenerative
11
Dysplastic Hip
Seth A Jerabek
INTRODUCTION onto having advanced degenerative changes requiring

total hip arthroplasty (THA).
Developmental dysplasia of the hip (DDH) describes a
spectrum of hip pathology where there is incongruence
between the femoral head and acetabulum due to INDICATIONS
undercoverage of the femoral head, which can lateralize The indications for THA are similar to that of osteoarthritis,
the center of rotation of the hip and increase contact which is pain not controlled by anti-inflammatory agents,
pressures.1,2 The acetabulum is often shallow and physical therapy, weight loss, and activity modification.
depending on the severity of the acetabular dysplasia, This chapter focuses on arthroplasty options for the
it may be deficient laterally, superiorly and anteriorly.1 degenerative dysplastic hip. However, joint preserving
The femur usually has a narrow canal with excessive surgery, such as periacetabular osteotomies and femoral
neck anteversion, a posteriorly located greater trochanter, osteotomies, is typically the treatment of choice in young
and a valgus neck-shaft angle.3-5 The femoral head can patients (< 35 years) with minimal cartilage damage and
subluxate or even dislocate from the true acetabulum good joint congruity.6
resulting in an articulation with the iliac wing forming a
pseudoacetabulum (Fig. 11.1). Many dysplastic hips go
EVALUATION
The incidence of DDH is approximately 1–2/1,000. However,
DDH is seen in 54% of degenerative hips.7 Patients with
DDH are most often diagnosed in their early thirties when
they develop pain, typically related to degeneration of the
true or false acetabulum and femoral head. Nakamura
reported that nearly 90% of patients will have groin pain,
but it is not uncommon to have pain in the buttock (38%),
anterior thigh (33%), knee (29%), greater trochanter (27%),
low back (17%), and lower leg (8%).8
The physical exam is critical when assessing a patient
with DDH. Adults with unilateral DDH typically feel
shorter on their affected side; however, they have often
compensated for the discrepancy with a scoliosis or
other resultant deformity. In approximately 30% of cases
Fig. 11.1: Anteroposterior view of a pelvis with bilateral Crowe
type IV development dysplasia; the femoral heads articulate with
where the hip is dislocated, the affected femur will be
pseudoacetabuli longer than the contralateral side.9,10 Performing leg-length
testing with block correction in the office determines the with and without block correction will indicate how
perceived leg-length discrepancy, which is often less than flexible the patient’s pelvis is and where it will correct to
the radiographic discrepancy. Hip motion is typically after reconstruction, which will give some insight to the
preserved until advanced degeneration develops. Extension, “ideal” acetabular abduction angle to plan for surgery as
abduction and external rotation can lead to apprehension the ideal leg-length correction.
secondary to instability/subluxation of the femoral head In more severe cases, computer tomography (CT) with
in the anterosuperior direction.2 A careful neurovascular images through the knee is helpful when templating prior
examination should be documented in every case. to surgery. This allows for measurement and potential
Standard radiographs include a standing antero correction of acetabular and femoral anteversion. The
posterior (AP) pelvis, frog lateral of the hip, and false acetabular bone stock can be assessed and help plan for
profile views. The Tönnis angle or acetabular index and the need of bone graft or augmentation. The femoral canal
lateral center-edge angle of Wiberg are measurements is often narrow in patients with dysplasia; thus, the CT
commonly used to diagnose the presence of dysplasia scan can be used to accurately measure canal diameter.
(Fig. 11.2). The Tönnis angle is a measurement of the Using computer software, advanced three-dimensional
weight-bearing zone of the superior acetabulum to a templating can be performed where the acetabular and
horizontal reference (i.e. a line connecting the center of femoral components can be sized prior to surgery. This
the femoral heads, interteardrop line, etc.) with dysplasia is particularly helpful when the acetabular bone stock
is deficient. The sizing and placement of the acetabular
measuring 10° or more.11,12 The lateral center-edge angle
component can be accurately determined as it is critical
is formed by a vertical line from the center of the head,
to maintain anterior and posterior bone stock when there
and a line from the center of the femoral head to the
is deficient bone superiorly (Fig. 11.3).
lateral aspect of the acetabular sourcil, with the apex
at the center of the femoral head (Fig. 11.2). A normal
lateral center-edge angle is greater than 25°, 20–25° is CLASSIFICATION
borderline, and less than 20° indicates dysplasia.12 Murphy In adult reconstruction, the most commonly used
et al. found that a lateral center-edge angle of less than classification systems are those of Crowe and
15° universally leads to symptomatic degenerative joint Hartofilakidis.1,14 The Crowe classification is qualitative
disease at the age of 65.13 as this classification grades the dysplasia based on the
If there is a large leg-length discrepancy, consider degree of hip subluxation relative to the size of the
standing AP hip-to-ankle radiographs with and without uninvolved, contralateral femoral head or height of the
block correction. The pelvis often has obliquity associated pelvis. Crowe et al. noted that the diameter of a femoral
with the leg-length discrepancy. Hip-to-ankle radiographs head was one-fifth of the height of the pelvis measured
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
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
Figs 11.6A to C: Hartofilakidis classification. (A) Dysplasia shows

a shallow acetabulum and mild superolateral deficiency; (B) Low
dislocation where the pseudoacetabulum articulates with the true
acetabulum and there is deficiency superolaterally and anteriorly;
(C) High dislocation where the pseudoacetabulum is located superior
100 and posterior and the true acetabulum is triangle-shaped with
C deficiency superolateraly, anteriorly and posteriorly
and posterior approaches. However, the direct anterior Acetabulum
approach is less forgiving if more advanced femoral
reconstruction is required. Crowe I
These hips can be treated similar to hips with primary
Crowe II, III and IV osteoarthritis. An uncemented acetabular shell is typically
The posterior approach or a transtrochanteric approach used in the United States. Medializing the acetabular
utilizing a trochanteric osteotomy is most commonly component within a few millimeters of the medial wall
used. The majority of Crowe II and III reconstructions will provide better superior coverage. Attention should be
can be performed with a posterior approach. However, paid to the anterior and posterior columns when reaming
performing a trochanteric osteotomy not only provides the acetabulum. The ideal acetabular shell is often smaller
excellent exposure to the acetabulum, but also allows than what would be templated on an AP radiograph. If
for repositioning the greater trochanter at the conclusion the acetabular component is templated to fill the void
of the case, as it can be advanced to improve abductor from the lateral margin of the up-sloped sourcil to the
mechanics or be brought anterior if posterior impingement medial wall, it will often be too large in the anterior to
is a concern. A femoral shortening osteotomy can be posterior dimension, possibly causing the surgeon to
performed through a posterior or transtrochanteric ream away the anterior and/or posterior columns. See
approach. Figures 11.7A to C. Screw fixation of the acetabulum
A B
Figs 11.7A to C: Crowe I templating. (A) Anteroposterior pelvis

with a degenerated Crowe I left hip; (B) Left hip templated with a
54 mm cup filling the acetabulum from the lateral sourcil to the medial
wall; however, it would have been too large in the anteroposterior
dimension and overhanging laterally; (C) Left hip templated with a
48 mm cup, which is unsupported laterally by approximately 20%,
C but fits in the anteroposterior dimension
101
A B
Figs 11.8A to C: Crowe I reconstruction. (A) Preoperative

anteroposterior pelvis; (B) Postoperative anteroposterior pelvis;
(C) Enlarged view of the acetabular shell showing screw fixation,
medialization of the acetabular shell to maximize coverage, and the
lateral aspect of the shell does not contact the superolateral aspect
of the sourcil. Placing a larger acetabular shell would have been too
C large in the anteroposterior dimension
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.
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
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
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
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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39. Wangen H, Lereim P, Holm I, et al. Hip arthroplasty in 52. Wang L, Trousdale RT, Ai S, et al. Dislocation after total
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2008;32(2):203-8. Epub 2008. Epub 2011.
Chapter
12
Acetabular Protrusio
Julius K Oni, Bryan M Saltzman, L Sean Thompson
INTRODUCTION bilaterally, with a marked female to male predominance.

The three main age groups identified at presentation are
Protrusio acetabuli, also known as arthrokatadysis or teens, 35–50-year-old, and 51–85-year-old, although the
Otto pelvis, is a deformity of the hip joint, which involves separation between the two adult groups is not well
invasion of the lesser pelvis by the medial acetabular wall defined.
with associated medial migration of the femoral head.
It was first described in 1824 by a German pathologist,
Primary Protrusio Acetabuli
Dr William Otto.1
This form is thought to be a developmental condition
with hereditary and racial influences.2 It is progressive in
CLASSIFICATION/TYPES
adolescence, prior to fusion of the triradiate cartilage, after
• Idiopathic: This is a diagnosis of exclusion, and which the deformity remains static until superimposed
therefore reserved for patients with no other possible with secondary degenerative changes. Further research is
underlying causative factor. required to identify the exact developmental mechanism,
• Secondary forms: This refers to protrusio caused by but the diagnosis of primary protusio comes only after
any one of multiple conditions (Box 12.1).1 exclusion of such secondary causes as shown in Box 12.1.
NATURAL HISTORY/ETIOLOGY Secondary Protrusio Acetabuli

The exact etiology of protrusio acetabuli is unknown but This form is generally subdivided into inflammatory and
many have been suggested. This condition often presents noninflammatory etiologies.
Box 12.1: Secondary causes of protrusio acetabuli

• Infectious: Gonoccocus, Echinococcus, Staphylococcus, Streptococcus, Mycobacterium tuberculosis, syphilis
• Inflammatory: Rheumatoid arthritis, ankylosing spondylitis, juvenile rheumatoid arthritis, psoriatic arthritis, acute idiopathic
chondrolysis, Reiter’s syndrome
• Metabolic: Paget’s disease, ochronosis, osteomalacia, osteoporosis, hyperparathyroidism, pseudohypoparathyroidism
• Neoplastic: Hemangioma, metastatic disease (breast, prostate most common), neurofibromatosis
• Genetic: Marfan syndrome, trichorhinophalangeal syndrome, Stickler syndrome (hereditary arthro-ophthalmopathy),
trisomy 18, Ehler-Danlos syndrome, neurofibromatosis, sickle-cell disease, homocystinuria, osteogenesis, congenital
contractural arachnodactyly imperfecta, acrodysostosis, arthro-ophthalmopathy
• Trauma/latrogenic: Acetabular fracture, medial acetabular component placement during hip replacement, radiation-
induced osteonecrosis, osteolysis following THA
• Inflammatory etiologies lead to destruction and Clinical Presentation
weakening of the bone surrounding the hip with
resultant migration along the joint-reaction vector At presentation, patients with protrusio acetabuli typically
• Noninflammatory etiologies are usually due to complain of activity-related pain in the groin region and
stiffness. Patients might also occasionally present with
a qualitative deficiency of acetabular bone, a
chief complaint of knee pain, with exacerbation of pain
developmental abnormality or growth disturbance. In
when arising from a seated position. Patients will often
cases with metabolic or connective tissue causative
ambulate with an antalgic and/or Trendelenburg gait.
factors, there is a qualitative deficiency of the bone.
Examination of the affected hip will reveal decrease in
The thin medial acetabular wall has less strength than
both active and passive range of motion, especially in
the better supported bone in the superior portion of
abduction. Also, pain may occur with active straight
the joint, and when it falls below the threshold of
leg raise or at extremes of motion, and there may be a
strength required to withstand the medial component
positive Trendelenburg sign secondary to the shortened
of the joint-reaction force, secondary protrusio
lever arm of the abductors.
occurs. This results in the medial pattern of migration
seen in these cases. Once the joint-reaction vector
has migrated medial to the ilioischial line, the rate of
Radiographic Evaluation
progression increases. Standard anteroposterior (AP)/lateral radiographs of
the pelvis are needed for diagnosis and staging of
protrusio severity (Figs 12.1A and B). Coxa vara is
DIAGNOSIS
frequently associated with protrusio acetabuli. Prolonged
History and Physical Examination protrusio acetabuli can result in secondary osteoarthritic
transformations at the hip joint evident on radiographs.3
A thorough history and physical examination is very Different methods have been described for grading
important. A family history of similar or related problems protrusio but the most utilized are:
should be well documented. Numerous syndromes and • The center-edge angle, originally described by Wiberg
disease states associated with protrusion acetabulum to grade acetabular dysplasia: an angle of over 40° is
may be ruled out with detailed review of systems, diagnostic of protrusio acetabuli (Fig. 12.2).4
and musculoskeletal/neurologic/cardiovascular exami • Armbuster et al.5 considered protrusio to be present if
nations. The symptoms of idiopathic protrusio frequently the medial wall of the acetabulum protruded medial
first develop in adolescence; therefore, this condition to the ilioischial line by 3 mm in males or 6 mm in
should be considered in the differential diagnoses for females, and noted that mild coxa vara is commonly
hip pain in the teenager patient. associated with acetabular protrusio.
A B
110 Figs 12.1A and B: Anteroposterior and frog lateral radiographs illustrating bilateral acetabuli 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.
TREATMENT Preoperative Planning

As with any careful preoperative planning, a thorough
Conservative Treatment
understanding of the deformity is necessary. The medial
Patients with protrusio acetabuli may initially be treated acetabular bone is frequently weakened and at times 111
conservatively to manage various symptoms. This may nonexistent from repetitive remodeling, which may
lead to osteomalacia. Often times, the only barrier Depending on surgeon preference, this may be from a
between the acetabulum and the inner pelvis is the posterior, direct lateral, anterolateral or anterior approach.
obturator membrane. A requirement for concomitant Our preferred surgical technique is described below:
bone grafting with reconstruction of the acetabulum Once anesthesia is administered (spinal is our
is usually necessary. The femoral deformity is often in preferred option), the patient is positioned in a lateral
varus leading to early femoroacetabular impingement. decubitus position with the operative side facing up and
Chronic leg-length inequality results in overlying soft the bony prominences well padded against the operating
tissue contracture, muscular shortening and atrophy room table. A posterior-lateral approach (Kocher-
that can lead to difficulty in surgical exposures, increased Langenbeck) to the hip is then performed. The iliotibial
tension on the sciatic nerve, and difficulty in reduction band is incised and the gluteal fascia is divided bluntly
of the proximal femur. proximal to the trochanteric bursae. The piriformis
Preoperative planning should include consideration tendon is released and tagged for later repair, as well as
for future reconstruction of the contralateral hip, since the rest of the external rotators. The interval between the
this disorder is often bilateral. In these cases, it may piriformis and gluteus minimus is exploited to allow for
be appropriate to leave the index leg slightly longer an L-shaped superior capsulotomy. The external rotators
with the plan to equalize leg lengths during the second and capsule are preserved for reattachment at the end
procedure. Generally, planning for a low-level femoral of the procedure. As previously stated, in patients with
neck resection with a high offset femoral component is chronic disease, soft tissue and capsular contractures
helpful in avoiding over lengthening, while maintaining may be encountered. Release of the anterior capsule,
adequate joint stability. The goal is to avoid offset and gluteus maximus insertion on the proximal femur, and
leg-length discrepancies. As far as acetabular bone stock, occasionally partial longitudinal split of the abductor
a computed tomography (CT) scan may be necessary to insertion on the greater trochanter may be necessary
evaluate defects in the posterior and medial wall prior to to obtain additional length. If the above measures still
surgery. prove inadequate, a trochanteric slide osteotomy may
be necessary. Special care must be taken to protect the
Implant Considerations sciatic nerve, as it is often closer to the field due to medial
migration of the femur associated with this deformity.
The main goal is to select the most stable construct to
Dislocation of the hip can be extremely difficult. If
avoid progressive postoperative medialization of the
necessary, removal of a small overhanging portion of
acetabular component. A porous cluster acetabular cup
the posterior acetabular wall may facilitate dislocation.
that allows for bony interdigitation with various options
However, in severe cases, an in situ femoral neck
for screw fixation is most desirable. Other options may
osteotomy at the pretemplated level may be performed.
include the use of an acetabular cup with a peripheral flare
It is important to realize that an attempted dislocation in
or flange with superolateral flange screw holes to allow
such cases will risk a femoral shaft fracture if significant
for supplemental screw fixation. If the acetabular rim is
medial migration is already present. Blunt retractors are
deficient or severely osteopenic and therefore unable to
used to protect the neck during the in situ osteotomy.
provide adequate support for the cup, then acetabular
If necessary, a double osteotomy may be performed
wedges, buttresses, or other structural augments should
without dislocating the hip joint. The saddle or confluence
be considered and made available. Also, a reconstructive
between the greater trochanter and lateral femoral neck
cage may be needed to gain fixation to the pelvis above
should be cleared of all capsular tissue to visualize the
and below the acetabulum. Femoral stems with enhanced
starting point for this osteotomy. Again a blunt retractor
offset should be available as they help restore offset and
should be placed to protect the greater trochanter. The
also contribute significantly to decreasing the chance of
second osteotomy should be performed one centimeter
bony or component impingement.
proximal to this to remove a section of the femoral neck.
A small sagittal saw is best to perform this osteotomy,
Authors’ Preferred Surgical Approach optimizing visualization and control. The osteotomized
A standard surgical approach to the hip can be used head can then be removed with a corkscrew or threaded
112 for exposure to perform the femoral neck osteotomy. pin while pulling axial traction on the femur. If the head
is firmly fixed in the acetabulum, it may be sectioned and segmental defect in these walls. Any segmental or
removed piecemeal. cavitary deficit that remains medially is grafted. When
Significant capsular release may be necessary to considering grafting of the medial wall defect especially
deliver the end of the femur out of the depth of the in inflammatory arthritis, cancellous autograft is usually
wound. Elevation of the proximal femur using a bone best and can be taken from the femoral head. In larger
hook will allow placement of an anterior acetabular defects, a solid form may be more structurally sound
retractor. Superior and posterior wing retractors can then than morselized graft. A “slurry” of graft material can
be placed. Inferiorly, a cobra retractor can be positioned be created using allograft croutons, demineralized bone
just distal to the transverse acetabular ligament (TAL). matrix, and a 10 cc mixture of the patients blood to
A standard labral resection and removal of the pulvinar pack small defects in the acetabular bone. Autogenous
with electrocautery follows, with care to avoid perforation and/or allograft bone should be placed so that the final
of the medial wall during the debridement, as it may be component will lie outside of Kohler’s line. Be sure
extremely thin and sometimes completely membranous. to remove sufficient osteophyte to allow for insertion
Medial reaming is therefore unnecessary and should be of the reamer basket; however, definitive osteophyte
avoided. This medial defect will necessitate adequate removal should be postponed until final cup placement
lateralization to restore offset when trialing the implants. in the appropriate position. After bone graft placement,
When reaming the acetabulum, medialization should impaction is performed by using a reamer one size smaller
usually be avoided, with the goal to obtain a secure than the last reamer, turning it in the reverse direction for
peripheral fit. Typically, the walls of the acetabular a few turns. A component that is 1–2 mm larger than the
periphery converge in protrusio deformity. The goal final reamer size is then implanted on the prepared rim.
of reaming is, therefore, to progressively reshape Central bone grafting along with cup placement along the
the acetabular rim until a divergent rim that is wide native rim with screw fixation has been shown to lead
enough to support the acetabular component is created to better survivorship. A deep profile or protrusio-type
(Figs 12.3A to D). It is important to palpate the anterior component may also be utilized with some systems. Such
and posterior walls frequently while reaming to avoid a component may maintain adequate rim stabilization
excessive bone removal or creation of a complete while negating the need for medial bone grafting.
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
• 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
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
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
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116
Chapter
Treatment of Total Hip
Arthroplasty Periprosthetic
13
Femoral Fractures
Marwin E Scott, Ran Schwarzkopf
INTRODUCTION to 4% depending on the series reviewed, with higher rates

after revision surgery.1,8-10,25
Total hip arthroplasty has been an extremely effective Periprosthetic fractures (Fig. 13.1) now pose as a
procedure in relieving pain and dysfunction for patients standard problem that the reconstructive and trauma
with varying etiologies of arthritis. However, after decades orthopedic surgeons have to commonly deal with. They
of successful total hip replacements; the substantial are technically demanding to treat, as they require
increase in the number of total hip arthroplasties being the skills of a trauma surgeon as well as those of an
performed; the growing number of patients with a total arthroplasty surgeon.
hip arthroplasty in place for more than 30 years and Such fractures can range from being minor with
with the aging population, we have been encountering minimal effect on patient’s outcome, to being catastrophic
an increasing number of periprosthetic fractures, and this and possibly creating a nonreconstructable problem
number is anticipated to rise even further. The prevalence with an immense effect on the patient’s function.
of postoperative periprosthetic fractures ranges from 0.1% The increasing fracture prevalence is attributed to the
Fig. 13.1: Periprosthetic fracture showing implant in situ

increasing amount of patients who underwent total loose implant, extruded cement, stress risers and varus
hip arthroplasty, increased risk of falling among elderly position. Many periprosthetic fractures occur from low-
patients, the increased number of young patients at risk energy trauma, such as a fall from standing height.27 The
of high-energy trauma and the increased rate of revision treating physician must elicit from the patient’s history
procedures which cause a significant stress transfer near any signs and symptoms that can suggest of implant
the distal tip of the reconstruction. These fractures might loosening prior to the injury such as thigh pain and
be considered sometimes as pathological due to the start-up pain, which is reported when rising from a chair
causative factors, such as aseptic loosening, osteoporosis, or in ambulation initiation.
osteopenic condition like rheumatoid arthritis, Paget’s Preoperative planning should include identifying
disease, polyneuropathies, etc. previous surgical scars and soft tissue condition, review
The economic impact and disabilities associated with of previous operative reports, recording brand and type
these fractures are substantial, thus, having an effective of current implanted prosthesis and further workup if
treatment plan to manage them is crucial. infection is suspected. Patients with fractures around
asymptomatic, well-fixed implants do not usually require
a septic workup.
INDICATIONS
High-quality standard anteroposterior (AP) and lateral
Indications for treatment in total hip periprosthetic radiographs of the affected hip and femur together with
femoral fractures are dependent on a few fracture and a radiograph of an AP pelvis should be obtained. Images
femur bone characteristics such as fracture location, should be reviewed thoroughly to ascertain the type of
stability of the implant, quality of the remaining fracture and the stability of the implant. Signs of a loose
femoral bone, patient’s characteristics like age, medical stem include continuous lucency at the cement-bone
comorbidities as well as surgeon’s experience. Failure to and cement-stem interfaces as well as cement mantle
identify an unstable implant is likely to lead to treatment fractures prior to incurring the periprosthetic fracture.
failure if osteosynthesis rather than revision surgery is We do not include a postinjury cement mantle fracture
chosen. as a sign of stem loosening by itself.
In our practice, we prefer to treat most of the unstable The stability and the condition of the acetabular
femoral periprosthetic fractures surgically rather than component should be assessed as well and if revision is
accepting the inherent risks of nonoperative treatment. warranted, it should be addressed appropriately. We do
Furthermore, most of these fractures occur in elderly not recommend routine use of CT or MRI.
patients for whom the risks of prolonged recumbency If there is any doubt about the implant stability, we
are substantial and the treatment cost is high. recommend intraoperative stability testing utilizing hip
In cases where revision total hip arthroplasty is being arthrotomy and dislocation, when distal testing is not
contemplated as the treatment option for periprosthetic satisfactory.
fractures, the possibility of infection should be considered A complete physical examination with an emphasis
and ruled out. Unfortunately, laboratory studies such as on the injured limp neurovascular status should be
erythrocyte sedimentation rate, white blood cell count carefully documented.
and C-reactive protein are not useful in the presence
of a periprosthetic fracture compared to failed total CLASSIFICATION
hip arthroplasty without a fracture.11 We recommend
obtaining a hip aspiration culture when a suspicion of Several classifications of periprosthetic fractures have
septic loosening prior to fracture is high. been described.1-4 Many are descriptive and provide
information about the site of the fracture but have no
value with regard to the formulation of a treatment
EXAMINATION AND IMAGING strategy.1-4
Assessment of patient’s risk factors prior to treatment The Vancouver classification proposed by Duncan and
is essential in order to maximize the chances of a good Masri is the most widely used system for classification of
outcome. Risk factors include female sex, advanced total hip periprosthetic fractures.1 Besides being simple
118 age, postmenopausal status, osteoporosis, osteolysis, and reproducible, it is useful for devising a treatment
Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures
strategy based on easy-to-determine parameters. The accompanied by a loose implant requires a revision
Vancouver classification takes into account the three most arthroplasty procedure compared to an osteosynthesis
important factors: the site of the fracture; the fixation for a fracture with a stable implant.
status of the femoral component; and the quality of the
surrounding femoral bone stock. Different groups have Type C
validated the Vancouver classification system over the
It includes fractures that are so far below the femoral
years.28 In particular, the Vancouver classification helps
stem that their treatment is independent of the total hip
the surgeon differentiate between a stable and unstable
arthroplasty that is present. Algorithm of treatment by
fracture requiring osteosynthesis, as well as a stable
classification is shown in Flow Charts 13.1 to 13.3.
from unstable implant requiring revision. The choice
of treatment is based upon the type and location of the
fracture, the stability of the implant, and the integrity and TREATMENT
quality of the remaining bone stock.
Historically, nonoperative treatment was the mainstay
for periprosthetic fractures.16 With advances in surgical
Type A techniques and instrumentation, the balance has shifted
It includes fractures involving the lesser trochanter (ALT) much more in favor of surgical management, thus
or the greater trochanter (AGT). These fractures are most avoiding the recognized complications associated with
commonly associated with osteopenia of the proximal prolonged bed rest, such as thrombosis, embolism,
femur (Figs 13.2 and 13.3). pneumonia, pressure ulceration and knee joint
contractures. Nevertheless, there are patients who are
Type B medically unfit with low levels of physical activity who
are not suitable for a prolonged surgical procedure and
It includes fractures around or just distal to the femoral to whom nonoperative treatment is advised.
stem. Type B fractures are further divided into subtypes: When surgical treatment is contemplated, consi
• B1; when adjacent to a well-fixed stem deration should be given to fracture configuration, stem
• B2; in presence of a loose stem but with adequate stability and femoral bone stock. The goals of surgery
bone stock should be fracture union, prosthetic stability, anatomical
• B3; when associated with marked osteopenia and loss alignment, rotation and length, as well as return to
of bone stock. preinjury function. In cases of severe osteopenia,
This subclassification is a critical distinction to osteosynthesis with relative stability techniques such as
be made by the treating physician because a fracture bridging of comminuted segments should be employed.
Fig. 13.2: Image showing type A fracture of trochanter Fig. 13.3: Image showing type ALT fracture of lesser trochanter
119
Flow chart 13.1: Schematic representation of type A fracture
Flow chart 13.2: Schematic representation of type B fracture
Flow chart 13.3: Schematic representation of type C fracture
120
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
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.
Fig. 13.6: Type B1 fracture

Bone Grafts
Bone-graft substitute may also be used to enhance graft
fracture site re-establishes 84% of the femur’s original incorporation, thus augmenting the mechanical strength
strength and stability.18 We recommend using locked of the femur as well as long-term increase in bone mass.
plates wherever possible in this osteoporotic patient It is important to preserve as much blood supply as
population (Figs 13.7 and 13.8). possible by avoiding excessive periosteal stripping and
preserving the patient’s linea aspera intact.
The fracture-healing rate for Vancouver type B1
Strut Grafts fractures, treated with the above techniques, is above
Strut grafts, in the case of stable implants (Type B1), may 90%. Union failure has been associated with varus
be used as the only means of stabilization with either deformity of the stem, insufficient stability and failure to
a single strut or as a double-strut complex in a 90° or detect implant instability.
122 Fig. 13.7: Type B1 fracture with implant Fig. 13.8: Type B1 fracture with strut and plate construct
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).
Authors’ Preferred Treatment Step 3

Osteosynthesis technique for Vancouver type B1 fracture: Around the stem, we use nonlocked screws or polyaxial
Our current recommendation for type B1 fractures is locked screws positioned anterior and posterior to the
osteosynthesis, with a locking combination plate applied stem, augmented when needed with circumferential
with minimal soft tissue stripping. Newer polyaxial cables (Fig. 13.13).
locking screw designs allow screw angulation, which is For the above mentioned reasons, we prefer
very useful around well-fixed stems. The surgeon should combination plates that enable us to use either locked
be prepared for a possible revision arthroplasty if an or nonlocked screws and it also allows for compression
unstable stem is found intraoperatively. at the fracture site, when nonlocked screws are used.
Positioning Postoperative Care

We currently utilize the lateral decubitus position with Weight-bearing status is individualized based upon
a direct lateral approach to the femur; this approach fracture stability and patient characteristics. We tend to
123
Fig. 13.10: Lateral decubitus position
Fig. 13.11: X-ray of type B1 fracture Fig. 13.12: X-ray of type B1 treatment
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
124 Fig. 13.13: Intraoperative image of B1 fracture Fig. 13.14: Type B2 fracture

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
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
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
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
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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;
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element modelling of femoral shaft fracture fixation 29. Bhattacharyya T, Chang D, Meigs JB, et al. Mortality
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128
Chapter
Total Hip Replacement for
Treatment of Acetabular
14
Fractures
Richelle C Takemoto, Brian F Moore, Jeffrey J Sewecke
INTRODUCTION INDICATIONS FOR COMBINED OPEN

Total hip arthroplasty (THA) is a reliable and effective REDUCTION INTERNAL FIXATION
surgery in relieving pain and dysfunction for arthritis. AND TOTAL HIP ARTHROPLASTY
Indications for THA have expanded over the last two FOR MANAGEMENT OF
decades and are routinely used for the treatment of ACETABULAR FRACTURES
fractures, particularly femoral neck fractures. THA used for
the treatment of femoral neck fractures has demonstrated Approximately 21% of all patients with operatively
treated displaced acetabular fracture were reported to
superior results compared to internal fixation in both
undergo conversion to THA within 20 years.2 Half of
short- and long-term outcome studies. Acetabular
the conversion surgeries occurred within the first 1.5
fractures are potentially life-threatening injuries that often
years, with a slow and steady rate of THA conversion
occur in young adults with high-energy mechanisms of at longer follow-up. Factors that were predictive of the
injury. However, given the growing number of active need for early conversion to THA were increased age,
elderly, the number of acetabular fractures in older anterior hip dislocation, posterior wall involvement, a
patients sustaining low-energy mechanisms of trauma femoral head cartilage lesion, marginal impaction, large
is increasing. The incidence of acetabular fractures is initial displacement, nonanatomical reduction, failure to
3/100,000 per year in the United States.1 restore a congruent acetabular roof, and utilization of the
Treatment of these fractures is technically demanding extended iliofemoral surgical approach.2
and often requires skills of both an orthopedic trauma Restoration of a congruent hip joint in acetabular
surgeon as well as an arthroplasty surgeon. Such fractures is essential in reducing post-traumatic
fractures can range from minimally displaced, lower- arthritis.3-8 In younger, active patients with adequate
energy injuries amenable to nonoperative management bone stock, acetabular fractures can successfully be
treated with open reduction, internal fixation with good
to major fractures posing a catastrophic problem to the
to excellent outcomes. However, in elderly patients,
patient. The optimal treatment should allow patients to
treating acetabular fractures in the same fashion may
obtain early mobilization and prevent common medical
lead to fixation failure, acceleration of arthritis and need
complications associated with prolonged bed-rest and for reconstructive surgery.2
periods of nonweight-bearing. The economic impact Acetabular fractures in the elderly commonly occur
and disability that these fractures cause is immense and via moderate- to low-energy mechanisms in the setting
the treating surgeon must have a surgical plan in place of osteoporosis or osteopenia.9,10 Treatment of acetabular
before undertaking treatment of these complicated fractures in this patient population has evolved over the
fractures. last 10 years to include treatment modalities other than
open reduction internal fixation (ORIF) in a similar way EXAMINATION/IMAGING
that the treatment of femoral neck fractures has evolved
to include THA in a specific elderly patient population. Acetabular fractures are evaluated using the five
Treatment of acetabular fractures in the elderly can standard views described by Letournel and Judet. A
range from nonoperative management, acute primary thin-cut computed tomography (CT) scan is often
arthroplasty, delayed or staged arthroplasty or a combined obtained to determine the amount of articular impaction
procedure with open reduction and internal fixation of and acetabular bone stock. Three-dimensional
the fracture and hip arthroplasty.11 However, poor bone reconstructions can be helpful in determining fracture
quality and an unstable anterior or posterior column geometry and surgical planning of bone grafting. It
may result in a poor outcome. A complex approach to is also useful in determining the column stability,
management of these fractures is essential to restoring particularly in cases in which a combined surgery of
function to this patient population. column stabilization and arthroplasty is anticipated
Primary THA for the treatment of acetabular fractures (Figs 14.1A and B).
should be considered in patients in whom early joint A thorough clinical examination must be performed
degeneration is highly probable. However, accurate in patients with acetabular fractures. Approximately
fracture reduction, particularly of the involved column is
10–15% of patients will present with peripheral nerve
essential even when primary THA is planned. The decision
palsy, most commonly involving the sciatic nerve.2 About
regarding the choice between ORIF and THA must also
one-fourth of patients with an acetabular fracture will
take into account factors such as the invasiveness of
also have a concomitant hip dislocation, most of which
the procedure, the associated morbidity, and the costs
associated with a second surgery. can be reduced using skeletal traction in the emergency
Patients with marginal impaction of the dome (gull room or trauma bay. However, closed reduction of the
sign), intra-articular fragments, lesions of the femoral hip in transtectal T-type fractures or transverse fractures
head, suboptimal reductions of the fracture, with or may sometimes place the femoral head against a fracture
without the presence of osteoporosis, and patients fragment, thereby causing sustained pressure on the
older than 55 years of age who are active community articular cartilage. In these cases, closed reduction is
ambulators with normal cognitive function may benefit not recommended prior to surgery; skeletal traction may
from a single combined open reduction, internal fixation be applied until the patient is medically optimized and
and THA.9 surgery is performed.
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
SURGICAL TREATMENT OF ACUTE series of 22 patients with acetabular fractures treated

with a combined approach; three were treated with an
ACETABULAR FRACTURES WITH
IL approach for fracture fixation and then repositioned
TOTAL HIP ARTHROPLASTY during the same anesthesia for the THA using the
The goals in treating acetabular fractures with a combined posterior approach.8 The Kocher-Langenbeck approach
approach are primarily to restore column stability in is typically selected for posterior wall, posterior column,
preparation for cup implantation in THA. This is different and posterior column plus posterior-wall fractures. The
than treating acetabular fractures with a single ORIF surgical approach for treatment of transverse, T-shaped,
procedure whereby more attention is paid to treating transverse plus posterior wall, and both-column fractures
marginal impaction and restoring a congruent joint is individualized based on the fracture pattern, but in
surface. Combined procedures must be well planned most cases where a concomitant arthroplasty is planned,
and patients must be counseled on the length of the the KL approach can be used. The KL approach can be
procedure, the higher rate of complications and the likely extended distally to accommodate the femoral implant.
need for blood transfusion. Loss of bone stock secondary to osteoporosis or
In the combined procedure, column stability should osteopenia and marginal impaction may be managed
be addressed first. Operative management may consist of with bone graft from the femoral head. It is the surgeon’s
ORIF, and THA during the same anesthesia. The Kocher- preference whether or not to cement the femoral
Lagenback (KL) approach is preferred; however, the component. In Hercovic’s series of 22 patients, half of the
fracture pattern dictates the approach for fixation and femoral components were cemented. The dislocation rate
if the column cannot be stabilized with a KL approach, was 11%; two cases of instability required revision to a
the ilioinguinal (IL) approach should be used for fracture constrained acetabular component.
fixation to restore column stability. A lateral decubitus When treating posterior column fractures, connection
position is preferred when performing a combined ORIF, of the ilium to the ischium is required to obtain posterior
and THA using the KL approach (Fig. 14.2). columnar stability when attempting to treat these
An IL approach is typically utilized for anterior wall, fractures with a THA (Fig. 14.3).
anterior column, and anterior column plus posterior In general, a Kocher-Langenbeck approach is
hemitransverse fracture patterns. In instances where preferred. The sciatic nerve is visualized and protected.
the anterior column is compromised, a dual approach Osteotomy of the femoral neck will allow visualization of
may be necessary to stabilize the anterior column and the fracture planes. If the posterior column is not stable,
perform the arthroplasty. Herscovici et al. reported a it can then be plated using a reconstruction plates and
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
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
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)
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)
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).
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
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
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
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
INTRODUCTION arthroplasty treatment options, technical considerations

during conversion, as well as clinical results of different
Intracapsular femoral neck fractures are common available treatment options.
injuries seen in the elderly population as a result of low-
energy falls and are often treated with endoprosthetic
replacement, either hemiarthroplasty or total hip CLINICAL EVALUATION
arthroplasty (THA). However, these fractures also occur
History and Physical Examination
in younger patients and are more common following
high-energy mechanisms, requiring anatomic reduction Thorough preoperative patient assessment is critical when
and stable internal fixation to achieve clinical success. performing arthroplasty conversion of previously failed
Intertrochanteric hip fractures are similar in their osteosynthesis of a hip fracture. Patient history is a key
etiology with regards to the mechanism of injury in component of the patient evaluation; all prior procedures
the respective age groups; however, these fractures are and a detailed history of all perioperative complications
commonly treated in both age groups with open reduction (i.e. postoperative issues with wound healing) must be
and internal fixation (ORIF). Primary endoprosthetic obtained. Since pain is the most common complaint
replacement is not routinely performed for comminuted requiring conversion, the history must document the
intertrochanteric fractures, even in the elderly, due to location, type (i.e. sharp, dull, radicular, etc.), duration,
disruption of the calcar femorale, the distal femoral neck temporal nature (i.e. onset of symptoms in reference
and the greater trochanter. The femoral component used to the timing of the ORIF), exacerbating and remitting
in THA for this clinical scenario must account for calcar factors (i.e. activity-related symptoms), and previous
bone loss and provide a site for reattachment of the treatments for pain (i.e. bone stimulator). A detailed
greater trochanter and the overlying abductor complex. history can often help determine the cause of failure.
Failure of ORIF for hip fractures presents a challenging The lack of a pain-free interval following ORIF of a hip
clinical problem. In young patients, femoral head salvage fracture increases the suspicion for nonunion and deep
operations are performed in order to maintain the native space infection. A diagnosis of deep infection must be
hip through revision ORIF in conjunction with some type ruled out in all patients with previous retained hardware,
of proximal femoral osteotomy. Arthroplasty conversion is especially in patients with nighttime pain or pain at
preferred in older patients, or patients who have evidence rest. When deep space infection is of higher likelihood,
of articular damage or proximal femoral bone loss that erythrocyte sedimentation rate (ESR) and C-reactive
renders the hip nonreconstructable. This chapter reviews protein (CRP) must be obtained. Elevated serum
the clinical and radiographic evaluation of patients with inflammatory markers should prompt a preoperative
a failed internal fixation of a hip fracture, both intra- and hip aspiration. Synovial fluid analysis including a white
extracapsular, critical features of preoperative planning, blood cell count with differential as well as aerobic and
anaerobic cultures should be performed. White blood inequality may result from femoral head collapse, failure
cell counts of 1,100–3,000 with a differential greater than of hardware, malunion, or soft tissue contracture. It is
60%, typically used for the diagnosis of periprosthetic imperative to understand the presence of soft tissue
infection may not be valid in this scenario; however, any contractures around the hip, as these contractures must
suspicion of infection should be treated with hardware be addressed at the time of arthroplasty conversion.
removal and a staged procedure with placement of an A Thomas test should be performed in order to rule
antibiotic spacer.1,2 out a flexion contracture of the anterior soft tissues
Physical examination includes an assessment of that may result in shortening of the limb. An adduction
the patient’s general health, the lumbosacral spine and contracture may result in the limb appearing equal in
contralateral limb, followed by a detailed examination of length or shorter than the contralateral uninvolved limb.
the affected hip and lower extremity. Documentation of It is difficult to differentiate external rotation contractures
all prior hip incisions and the current state of the wound about the hip as being a result of soft tissue contracture
is required; a draining sinus tract may be seen with (i.e. short external rotator contracture), secondary to
chronic deep space infection. A detailed motor, sensory malunion, or due to patient compensation for painful/
and neurovascular examination must also be performed. protruding hardware. A mechanical block to hip range of
Patients with failed ORIF often also present with some motion and crepitus on physical exam may be indicative
degree of leg-length discrepancy and may present with a of proximal femoral deformity due to malunion or
circumduction gait of the longer limb or compensation protruding hardware making contact with the acetabulum
with a shoe lift on the foot of the shorter limb. Leg-length (Figs 16.1A to C).
A B
Figs 16.1A to C: (A) Preoperative anteroposterior hip radiograph of a

failed open reduction and internal fixation and valgus intertrochanteric
osteotomy; (B) Intraoperative image demonstrating posterior wall
acetabular wear (white arrow) from protruding hardware; and
144 (C) Intraoperative image of the resected femoral head with protruding
C lag screw
Conversion Total Hip Arthroplasty for Treatment of Failed Hip Fracture Fixation
The state of the soft tissues play a critical role in etiology of failure of ORIF. The most common reasons for
optimizing hip biomechanics following arthroplasty failure of hip fracture fixation include inadequate fracture
conversion, which includes restoration of the center of hip reduction resulting in failure of fixation; hardware failure
rotation, leg length, and femoral offset.3 Understanding (i.e. broken screw) and protruding hardware; fracture
the role of soft tissues in the presenting deformity around nonunion or delayed union (based on time from fixation);
the hip is essential prior to arthroplasty conversion since fracture malunion; femoral head collapse secondary to
radiographs only offer a two-dimensional view of a three- osteonecrosis; and post-traumatic osteoarthritis. Serial
dimensional problem. radiographs are helpful in identifying these etiologies
The patient’s gait must be evaluated for the presence as they provide a temporal course over which these
diagnoses develop.
of painful ambulation (antalgic gait) and presence of
Computed tomography (CT) is useful as an adjunct
weakness resulting in a compensatory gait pattern (i.e.
for further defining proximal deformities and proximal
trendelenburg gait secondary to abductor absence/
femoral bone loss.4 In situations where hardware may have
weakness; extensor lurch secondary to hip extensor
protruded through the native femoral head, CT scans can
weakness; lack of terminal knee extension at heel strike also help further delineate any degree of acetabular bone
due to femoral nerve dysfunction; and/or high steppage loss that must be addressed at the time of conversion and
gait due to common peroneal/sciatic nerve injury). may result in a more complex reconstruction. In addition,
multiplanar CT scan sequences have been shown to be
Radiographic Evaluation useful in diagnosing fracture nonunion (Figs 16.2A to C).5
Preoperative radiographic assessment includes standard
projections: anteroposterior (AP) pelvis; AP of the PREOPERATIVE PLANNING
involved hip; and frog-leg lateral of the involved hip.
Medical Optimization
Concerns regarding the acetabulum should prompt the
addition of a shoot-through lateral X-ray. The AP pelvis Patients scheduled to undergo arthroplasty conversion for
X-ray should be centered over the symphysis pubis failed ORIF of a hip fracture require medical optimization
and aligned with the coccyx. This projection allows for prior to undergoing operative treatment. A formal
assessment of leg length as compared to a horizontal line preoperative medical clearance should be obtained,
regardless of patient age, due to the risk for significant
across the ischial tuberosities of the pelvis and a fixed
blood loss at the time of conversion. Most elderly patients
point on the lesser trochanters. The AP Pelvis and AP
also present with significant comorbidities that may need
hip X-rays should be performed with the use of a marker
to be addressed preoperatively to optimize their ability to
ball in order to allow for either digital or manual acetate tolerate the stress of surgery.
preoperative templating.
An AP of the affected hip is performed in a standing Preoperative Templating
position with the lower extremity internally rotated 10–15º
to avoid the natural tendency of the limb to externally Preoperative templating is a very important part of the
preoperative planning process. Preoperative templating
rotate. This may be difficult in certain cases where a
can be done digitally or manually with the use of acetate
mechanical block to motion exists due to malunion or
templates. Proper templating requires appropriate sizing
protruding hardware or a significant external rotation
of radiographs, typically magnified by 20%. A marker ball
contracture.
can be used as a radiographic marker for templating; the
An adequate length of the proximal femur must be marker ball is 25 mm in diameter and can be used to
radiographically visible in order to assess the presence determine the X-ray magnification (Fig. 16.3). Accurate
of proximal femoral deformity in both the AP and lateral templating allows you to formulate a plan as to the size of
planes. A full-length lower extremity X-ray should be the devices that are going to be implanted. This exercise
obtained to assess the mechanical axis of the limb in should be looked at as a guide since femoral external
severe deformities that require femoral osteotomy at the rotation on the X-ray will lead to an underestimation
time of arthroplasty conversion. of femoral offset and femoral canal diameter as well as
Plain radiographs are an essential adjunct to the causing the femoral neck to appear more valgus.3 In most 145
history and physical examination in determining the cases where previous surgeries have been performed
A B
Figs 16.2A to C: (A) Plain radiographs and biplanar computed

C tomography of a left hip femoral neck nonunion (white arrow)
on the proximal femur, the proximal femur tends to

remodel and thus templating allows for identification of
this remodeling and assists in proper implant selection.6
In addition, when there is significant deformity of the
proximal femur, templating of the unaffected hip may be
more accurate with regards to proper sizing of implants
as well as identifying the proper center of hip rotation,
femoral offset and leg length (Fig. 16.4).3
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.
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
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.
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
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
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
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.
SUMMARY 8. Sikes C Van, Lai LP, Schreiber M, et al. Instability after

total hip arthroplasty: treatment with large femoral
Despite some of the reported complications, conversion heads vs constrained liners. J Arthroplasty. 2008;23(7
to THA remains an excellent secondary treatment Suppl):59-63. Available from http://www.ncbi.nlm.nih.
of the failed osteosynthesis of a femoral neck and gov/pubmed/18922375.
intertrochanteric hip fracture. Successful conversion THA 9. Weeden SH, Paprosky W. Minimal 11-year follow-up
can be performed with careful preoperative planning of extensively porous coated stems in revision total hip
and attention to detail before and during the surgical arthroplasty. J Arthroplasty. 2002;17(4 Suppl 1):134-7.
procedure. A strict postoperative rehabilitation protocol/ 10. Dorr L, Gruen A, Bognar B, et al. Structural and cellular
schedule is critical to achieving clinical success. Stressing assessment of bone quality of proximal femur. Bone.
patient compliance as well as aligning expectation will 1993;14:231-42.
11. Dalury DF, Kelley TC, Adams MJ. Modern proximally
help achieve favorable clinical outcomes.
tapered uncemented stems can be safely used in Dorr
type C femoral bone. J Arthroplasty. 2012;27(6):1014-8.
Disclaimer Available from http://www.ncbi.nlm.nih.gov/pubmed/
The authors have not received any financial support 22325961.
for the work. Dr Sheth performs consulting services for 12. Levine BR, Della Valle CJ, Hamming M, et al. Use of the
extended trochanteric osteotomy in treating prosthetic
Zimmer. Dr Donegan performs consulting services for
hip infection. J Arthroplasty. 2009;24(1):49-55. Available
Synthes.
from http://www.ncbi.nlm.nih.gov/pubmed/18534433.
13. Pellicci PM, Bostrom M, Poss R. Posterior approach to
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2. Valle CJ Della, Bauer TW, Dicesare PE, et al. Diagnosis
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7. Lombardi AV, Skeels MD, Berend KR, et al. Do large 21. Bjorn S, Hansson LI, Nilsson L, et al. Hook-pin fixation
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154
Chapter
Complications after
17
Total Hip Replacement
Carlos M Alvarado, Ran Schwarzkopf
INTRODUCTION Box 17.1: List of postoperative complications in order

of incidence
Total hip arthroplasty (THA) has become the gold
standard treatment for patients with end-stage arthritis.1 Complications after total hip arthroplasty
The benefits of THA as a treatment for arthritis have been • Venous thromboembolic disease
well documented. Multiple studies have demonstrated • Hip instability
that, following THA, patients experience significant • Limb-length discrepancy
quantitative and qualitative improvement in both their • Periprosthetic fracture
physical function and quality of life.2-4 Current projections • Periprosthetic joint infection
in the United States predict an increase of 174% to nearly • Neurovascular injury
600,000 THA procedures annually by 2030, with an
estimated increase of 673% to an outstanding 3.48 million
procedures globally per year.5-7 who have undergone THA are at significant risk for
Despite the great advancements and success of postoperative venous thromboembolic (VTE) disease.
THA, perioperative complications still occur and are Without prophylaxis, the rates of VTE are as high as
an inevitable risk when undergoing surgery. Numerous 40–60% with a rate of fatal pulmonary embolism (PE) of
studies have demonstrated that postoperative compli approximately 1–3.4%.15,16 With current recommended
cations are a risk associated with THA,8,9 and perioperative prophylaxis regimens, the rate of fatal PE is reduced
complications are the leading factors that influence to 0.13–0.5% and symptomatic VTE to 3–4%.17 There
the success of THA.10-13 As more and more patients are multiple prophylaxis regimens available including
undergo THA for the treatment of hip arthritis, it is our pharmacologic and nonpharmacologic methods. The
goal to try and minimize the incidence of perioperative combined use of the two demonstrates synergistic utility,
complications in order to decrease the risk of poor and they should be used in concert.15 Nonpharmacologic
outcomes for our patients. Thus, a thorough understanding methods include sequential compression devices and
of the most common perioperative complications, and early mobility protocols. There are multiple agents for
the knowledge of their treatment options is a cornerstone chemoprophylaxis including aspirin, warfarin, unfrac
in preventing and minimizing morbidity to our patients tionated heparin, fondaparinaux, low-molecular-weight
(Box 17.1). heparin and rivaroxaban. All have been demonstrated as
being effective prophylactic agents and there is no single
universally accepted prophylactic agent of choice.18 In
VENOUS THROMBOEMBOLIC DISEASE
addition to being efficacious, all anticoagulants have a
After every major orthopedic surgery, there is a transient similar risk profile with the most common complication
period of hypercoagulability.14 For this reason, patients being minor bleeding events at 3.7%.19 Minor bleeding
incidences include bruising at the injection site and mild Box 17.3: Summary of clinical recommendations
wound oozing. Major bleeding rates have been reported at
• Preoperative evaluation with specific questioning
2.5% which is not significantly higher than placebo.15,20,21 regarding VTE risk factors
In essence, what can be determined is that multimodal • Combined nonpharmacological and pharmacological VTE
prophylaxis is effective in preventing postoperative VTE, prophylaxis
and a reasonable safety profile is achieved regardless of • Postoperative monitoring for patients with significant risk
what medication is selected as treatment. for VTE
There are several risk factors, which have been • Prolonged postoperative prophylaxis for a minimum of
demonstrated to increase the risk of postoperative VTE. 4 weeks after THA
Age over 85 has been associated with a mild increase in
(THA: Total hip arthroplasty; VTE: Venous thromboembolic
postoperative VTE.22 Female gender is weakly associated disease)
with symptomatic VTE.23 Prior VTE is associated with
a threefold higher risk.22 Thrombophilia including the 4 weeks demonstrated a significant reduction in the rates
presence of lupus anticoagulant and anticardiolipin of VTE after THA (Box 17.3).26
antibody increase the rate of VTE by five- to tenfold.24
Malignancy has been demonstrated to increase risk;
INSTABILITY
however, there are no specific studies pertaining
specifically to incidence of VTE after THA. Body mass index The goal of THA is restore the anatomical and biomechanical
(BMI) over 30 has been demonstrated as an increased function of the hip. Instability is among the most common
risk factor for VTE after THA.22,25 Medical comorbidities early complications with dislocation rates ranging from
including dementia, renal failure and cerebrovascular 0.2% to 7% after primary THA, and up to 25% in revision
disease have also demonstrated significantly higher rates surgery.27-29 Most incidences of hip dislocation occur in the
of VTE.25 It is important to remember these risk factors first 3 months after the index procedure but can also occur
many years after a successful THA. Instability after THA
during the postoperative period as many of the patients
can be caused by many factors. We can divide the etiology
undergoing THA will have several of these risk factors
of instability into two main categories: patient-related and
simultaneously, thus requiring prudent postoperative
surgical technique.
follow-up (Box 17.2).
The length of prophylactic treatment after THA should
be prolonged as well when compared to total knee
Patient-Related
replacement. It has been demonstrated that VTE after Compliance with postoperative “hip precautions” in
THA can occur as far out as 60 days postoperatively.23 the early postoperative phase is paramount in avoiding
A randomized clinical trial by Comp et al. demonstrated early dislocation; such precautions are necessary until
that prolonged chemoprophylaxis for a minimum of the healing of the hip pericapsular tissues is complete
(Fig. 17.1). Risk factors for noncompliance with “hip
Box 17.2: Risk factors for postoperative venous
precautions” include: cognitive impairment from both
thromboembolic disease postoperative confusion and age-related degradation;
• Age > 85 years
alcoholism; neuromuscular disorders; epilepsy; and
Parkinson’s disease. Other risk factors include: revision
• Female gender
and conversion surgery; femoral neck fracture; obesity; high
• BMI > 30
preoperative range of motion; and cerebral palsy.27,30,31
• History of VTE
• Medical comorbidities: dementia, renal, cerebrovascular
disease
Surgical Technique and
• Malignancy
Component Position
• Thrombophilia: anticardiolipin antibody, lupus anti- Traditionally, the surgical approach to the hip entailed a
coagulant specific risk of dislocation. The posterior-lateral approach
156 (BMI: Body mass index; VTE: Venous thromboembolic) has been historically associated with a relative high rate
Complications after Total Hip Replacement
thorough history and physical examination is important
in order to determine the mechanisms and direction
of the dislocation. Early postoperative dislocations can
be treated in a nonoperative fashion as long as the
components are accurately placed, and the patient is
informed that there is an increased risk of redislocation
with such treatment.27,30 An abduction brace that limits
flexion, internal rotation, and adduction can be used in
cases of posterior dislocation. Weight-bearing can be
resumed immediately after closed reduction as long as
the neurovascular status of the limb is intact.
Operative treatment is preserved for patients who
have recurrent dislocations. Most common causes for
recurrent dislocation are: implant malposition; implant
wear or loosening; soft tissue or bony impingement; and
weak or absent abductor mechanism. CT scan can be
utilized to determine component orientation and help
with preoperative planning. Operative options include
Fig. 17.1: Schematic demonstrating positions at increased risk of revision and reorientation of the implants, and soft tissue
dislocation after posterior approach for total hip arthroplasty. tensioning, which can be achieved by increased offset
Source: Milliman CareGuidelines: Inpatient and Surgical Care/
on the femoral implant, lateralized acetabular liners,
Recovery Facility Care/Home Care, 1990 to 2010. Exercise Graphics
courtesy of Physio Tools© and trochanteric advancement. Overlengthening of the
femoral neck may lead to limb-length discrepancy (LLD)
and should be avoided. Larger femoral heads, greater
of dislocation (1–7%). Current reports of newer soft tissue
techniques, such as capsular repair and preservation of than 32 mm, cannot be the sole answer for recurrent
the hip abductors, state much lower dislocation rates dislocation, but it has been shown that increased head
(0–2%) that compare favorably with the anterior-lateral, size does decrease the rate of total hip dislocation.36
and lateral approaches (0–3%).27-29,30,32,33 It has been Constrained acetabular liners should not be
shown as well that increased surgeon volume correlates considered as a first-line treatment; the advantage of
with a decreased rate of postoperative dislocations.34 In constrained liners is immediate stability and the ease of
light of this data, it seems that surgical technique and implantation but they incur a high stress transmission to
the surgeon’s experience play a more significant role in the prosthesis bone interface. It has been reported that
dislocation rates than the surgical approach chosen by treatment with constrained liners can prevent recurrent
the surgeon. dislocation in over 70% of the patients.37
Proper component position refers to both the cup Prevention of THA dislocation can be achieved by
and stem orientation. Cup abduction of 40° (± 10°), and accurate surgical technique and implant choice followed
anteversion of 15–20° (± 10°) has been recommended by the patient’s postoperative attention to detail and hip
for stability, and increased cup abduction has been precautions during the recovery period.
associated with increased dislocation rates.27,28,35
Femoral component anteversion of 10–15° (± 10°) is
recommended. More importantly, the accumulative LIMB-LENGTH DISCREPANCY
anteversion of the arthroplasty should be kept around Limb-length discrepancy after THA can be a significant
25–50°. cause for dissatisfaction and concern for the patient.38
Severe cases of LLD may even lead to symptomatic
Treatment and Prevention conditions such as back pain and gait disturbances.39
Initial treatment of THA dislocation includes closed Leg length is measured clinically from the anterior
reduction under sedation, either in the emergency room superior iliac spine (ASIS) to the ipsilateral medial 157
or under general anesthesia in the operating room. A malleolus. Radiological leg length can be measured with
these goals. Preoperative planning with appropriate
radiographical images [anteroposterior (AP) pelvis and
AP/lateral hip] provides the surgeon with the opportunity
to plan the correct restoration of the hip offset, length, and
position of the implants. Proper preoperative planning
will help avoid excessive limb lengthening in order to
achieve stability where soft tissue tension and hip offset
is needed. Intraoperative leg length should be assessed
both during trial component placement and following
insertion of the final components. Many intraoperative
techniques to measure limb length have been described,
ranging from external and internal measurements, to
computer navigation.46
Patients should be informed during the surgical
Fig. 17.2: Postoperative limb-length measurement using consent that limb-length equality is one of the surgical
anterior-posterior pelvic radiograph goals but is not always possible, and that the surgeon will
not risk hip instability in order to achieve limb-length
equality.
a full-length scanogram with a line drawn from the center
of the femoral head to the middle of the tibial plafond.
The incidence of LLD after THA surgery is not
PERIPROSTHETIC FRACTURES
easy to discern, partially due to the fact that no true After years of successful total hip replacements, the
definition exists to classify LLD, as well as the etiology substantial increase in the amount of THA being
for postoperative LLD depends on many preoperative performed, the increasing number of patients with
and intraoperative factors. Leg-length discrepancy of a THA in place for more than 30 years, and with the
greater than 2 cm has been widely agreed upon as a aging population, we have been encountering a growing
threshold beyond which the LLD is clinically significant number of periprosthetic fractures. This number is
(Fig. 17.2).40 Both functional and true LLD may present anticipated to rise even further. The prevalence of
after surgery; true LLD is usually seen during physical postoperative periprosthetic fractures ranges from 0.1%
exam as gait disturbance, flexed knee stance, and pelvic to 4% depending on the series reviewed, with higher
tilt.40,41 rates after revision surgery.47 Periprosthetic fractures can
Functional LLD is a perception of LLD by the patient range from being minor with minimal effect on patient’s
but without a clinical measured LLD.42 Functional LLD outcome, to being catastrophic and possibly creating an
may resolve with time, as an example; a patient with a unreconstructable problem with an immense effect on
previously shortened arthritic hip which was brought the patient’s function.
back to its anatomic length after THA. Functional LLD Indications for treatment in total hip periprosthetic
can result from different soft tissue contractions around femoral fractures are dependent on a few fracture and
the hip, and pelvic and spinal deformity.40,41 femur bone characteristics: fracture location; stability
Patients who present with functional LLD should be of the implant; quality of the remaining femoral
reassured that it most likely will resolve within the first bone; patient characteristics such as age and medical
6 months after surgery.42 True LLD can be addressed comorbidities; and surgeon experience. Failure to identify
with shoe lifts placed inside the shoe, or if larger lifts are an unstable implant is likely to lead to treatment failure
necessary then specialized shoes are needed. Revision if osteosynthesis rather than revision surgery is chosen.
surgery for LLD should be kept as a last resort, and Assessment of patient risk factors prior to treatment is
patients should be counseled about the risks of revision essential in order to maximize the chances of a good
surgery and hip instability.43-45 outcome. Risk factors include: female sex, advanced
One of the major goals of THA is achieving limb-length age, postmenopausal status, osteoporosis, osteolysis,
158 equality and hip stability; proper preoperative planning loose implant, extruded cement, stress risers and varus
and surgical technique are a cornerstone in achieving position. Many periprosthetic fractures occur from
low-energy trauma such as a fall from standing height. shown that patients presenting more than 48 hours
It is important to elicit from the patient’s history any signs after sustaining the fracture were at a higher risk of
and symptoms that can suggest of implant loosening developing deep venous thrombosis.49 We recommend
prior to the injury, such as thigh pain and start-up that all patients treated for periprosthetic fractures receive
pain, which is reported when rising from a chair or in appropriate thromboprophylaxis treatment. Surgical site
ambulation initiation. If there is any doubt about the infection should be avoided by antibiotic prophylaxis.
implant stability, it is recommended to assess stability The advances achieved in the past years, among
intraoperatively utilizing hip arthrotomy and dislocation which are modular uncemented revision femoral
when distal testing is not satisfactory. The stability and stems, and fixed-angle locking plates, have improved
the condition of the acetabular component should be significantly the outcomes of patients afflicted with total
assessed as well and if revision is warranted, it should be hip periprosthetic fractures. The current gold standard
addressed appropriately. A complete physical examination for the treatment of periprosthetic femoral fractures is
with emphasis on the injured limb neurovascular s operative, with the exception of a few stable patterns.
tatus should be carefully documented as well. Consequently, it is essential to classify correctly the
Several classification schemes of periprosthetic type of fracture, the quality of the bone stock, and the
fractures have been described.47,48 Many are descriptive stability of the prosthesis. The patient’s final outcome
and provide information about the site of the fracture is dependent as well on early functional recovery and
but have no value with regard to the formulation of return to preinjury independence.
a treatment strategy.48 The Vancouver classification
proposed by Duncan and Masri is the most widely POSTOPERATIVE INFECTION
used system for classification of total hip periprosthetic
fractures.47 Besides being simple and reproducible, it is Epidemiology
useful for devising a treatment strategy based on easy to
Postoperative infection is one of the most devastating
determine parameters. The Vancouver classification takes
complications that can be encountered after THA.
into account the three most important factors: the site of
During the initial trials with THA, the infection rate
the fracture; the fixation status of the femoral component;
was found to be 9–12%, and the procedure was nearly
and the quality of the surrounding femoral bone stock.
abandoned. However, with improvement in sterile
Historically, nonoperative treatment was the mainstay
procedure and preoperative antibiotic prophylaxis, the
for periprosthetic fractures.17 With advances in surgical
overall risk of infection has been decreased to less than
techniques and instrumentation, the balance has shifted
1%.50 However, it is to be noted that when the Medicare
much more in favor of surgical management, thus
data was scrutinized, there was a 1.63% of infection in
avoiding the recognized complications associated with
THA within the first 2 years, with most cases presenting
prolonged immobilization, such as deep vein thrombosis
in the first 4 weeks postoperatively.50 The difference
(DVT), PE, pneumonia, pressure ulceration and knee
within bearing surfaces and infection incidence must
joint contractures. Nevertheless, there are patients who
also be noted. In a cohort of Medicare patients from
are medically unstable with low levels of physical activity,
2004 to 2007, metal-on-metal primary hip replacements
who are not suitable for a prolonged surgical procedure,
were associated with a slight increase in periprosthetic
and nonoperative treatment is advised. When surgical
infections when compared to ceramic-on-ceramic.51 In
treatment is considered, attention should be given to
addition, in a review of over 50,000 revision THA done
fracture configuration, stem stability, and femoral bone
in the United States, periprosthetic infection was the
stock. The goals of surgery should be fracture union,
third most common cause for revision at 14.8%, behind
prosthetic stability, anatomical alignment, rotation and instability/dislocation and aseptic loosening.52
length, as well as return to previous functional levels.
Many different treatment options have been described in
the literature over the years; no one treatment has been
Classification
shown to be the gold standard. While there has been no formal classification system
The three main complications experienced following applied to periprosthetic hip infections, one convention
treatment of femoral periprosthetic fractures are: aseptic for classification is a system based on chronology. 159
loosening, nonunion and deep infection. It has been This system divides infections into acute and chronic
infections. An acute infection presents within the first 4 While the exact time frame for when a wound should be
weeks after THA, while a chronic periprosthetic infection completely dry has not been completely established, what
presents after 4 weeks. can be said is that wound drainage and postoperative
hematoma have both been associated with higher rates of
Risk Factors postoperative wound infection.57 Unfortunately, the best
method for prevention of prolonged wound drainage has
Risk factors for infections may be divided into hospital not yet been determined. Several important facts have
factors and patient factors. In looking at hospital factors, been demonstrated. The first is that vacuum-assisted
increased hospital volume appears to play a significant drainage of the operative site has not demonstrated
protective role. It has been demonstrated that medical a significant decrease in incidence of hematoma,
centers with a volume exceeding 100 THA procedures periprosthetic infection, DVT/PE, and length of hospital
annually, there is a 69% decrease in postoperative stay. The only significant difference noted in patients with
infections, looking specifically at deep tissue infections.53 vacuum-assisted drainage was an increased incidence of
In addition, the incidence of postoperative mortality and blood transfusion (Table 17.1).58
dislocation were also significantly decreased in centers
with higher volume.
The subject of operative hoods and laminar flow
Etiology
in the operating theater has been discussed at length The origin of the offending agent in periprosthetic
in the literature with studies demonstrating both its infections may be of two separate sources, direct
effectiveness and conversely its ineffectiveness. In a study inoculation at time of surgery or hematogenous
by Hooper et al. looking at a large number of THA done spread. While both are possible and likely in the acute
in hospitals equipped with and without laminar flow in postoperative period, the two most common bacteria
the operating theater, there was no difference found in found in periprosthetic infections are Gram-positive
the incidence of periprosthetic infection at 1 year.54 In organisms Staphylococcus aureus and Staphylococcus
addition, operative hoods had no effect on the number epidermis, both of which are common skin flora.59
of infections encountered.54 Staphylococcus aureus is the isolated organism in
In addition to hospital factors, many patient factors approximately 53% of cases. Gram-negative bacteria are
have been demonstrated to play a significant role in the isolated in approximately 24% of cases. Gram-positive
development of postoperative periprosthetic infections. organisms prove themselves difficult to eradicate, as
In a study by Parvizi et al. that reviewed over nine they are able to form a biofilm glycocalyx on the surface
thousand cases, multiple independent risk factors for of prosthetic implants shielding them from antibiotic
postoperative periprosthetic infections were identified.55 penetration. In addition, there has been a significant
This study demonstrated the distinction between patient increase in penicillin-resistant organisms over the last
factors and hospital factors. The patient factors 10 years.60 While preoperative decolonization and
determined included rheumatoid arthritis, obesity,
dementia, hypercholesterolemia and American Society of Table 17.1: Independent risk factors associated with peri
Anesthesiologists (ASA) score greater than 2. In addition, prosthetic infection after total hip arthroplasty
several studies have demonstrated the detrimental BMI > 40 kg/m2 Allogenic blood transfusion
effect of perioperative hyperglycemia. Perioperative ASA score > 2 Postoperative urinary tract infection
hyperglycemia has been demonstrated to significantly Postoperative Postoperative atrial fibrillation
increase the risk of postoperative deep and superficial myocardial
wound infection.56 However, an important fact that infarction
was demonstrated by this study is that risk of infection Longer hospital
is reduced with strict postoperative glycemic control, stay
highlighting the fact that effective and comprehensive (BMI: Body mass index; ASA: American Society of
postoperative medical care is necessary for a successful Anesthesiologists)
total joint replacement. Source: Pulido L, Ghanem E, Joshi A, et al. Periprosthetic
160 Another risk factor for acute postoperative joint infection: the incidence, timing, and predisposing
periprosthetic infection is prolonged wound drainage. factors. Clin Orthop Relat Res. 2008;466(7):1710-5.
treatment programs have provided some evidence that addition, there may be a role for monitoring the level of
preoperative decolonization may decrease infection risks, interluekin-6 as it has been demonstrated to be a more
more data is required in order to establish evidence- accurate marker of periprosthetic joint infection.66
based guidlines.61 Radiographic evaluation has little use in the acute
postoperative setting, as changes due to infection will
Prevention not be apparent. But radiographs may demonstrate
other causes of postoperative pain including component
It should be stressed that current periprosthetic infection position or fracture.
prophylaxis strategies are successful in approximately Whole body bone scan may be useful in detecting
99% of cases. However, it is important to continue chronic infection after THA, however it is of little
to strive for the eradication of infection, as it is a value in the acute setting, as increased uptake in
devastating complication. Current infection prophylaxis the operative hip may be apparent under normal
consists of strict adherence to sterile procedure as well postoperative circumstances for up to 1 year following
as pre- and postoperative antibiotics. In most centers, THA. In addition, while the sensitivity of bone scan for
antibiotics are given within an hour of surgical incision periprosthetic infection is highly sensitive, specificity
and then continued postoperatively for 24 hours. A single has been demonstrated as low as 28–90%.67 Therefore, a
dose of a second-generation cephalosporin has been positive bone scan should be approached with caution
demonstrated as very effective if given 30–60 minutes as further testing is usually required.
before skin incision.62 With the increasing incidence of Joint aspiration by a radiologist is a routine part of
bacterial resistance, there have been studies investigating the periprosthetic infection workup.68 It should be done
the effectiveness of vancomycin as a prophylactic ideally with the patient off antibiotics for at least 2 weeks.
agent. These have demonstrated no improvement when The aspirate should be sent for cell count, differential
compared to a second-generation cephalosporin.63 and cultures. Sensitivity and specificity of aspirate
More attention has also been given to decolonization cultures have been demonstrated to be 82% and 92%
of nasal passageways prior to total joint arthroplasty (TJA). respectively.69 In evaluation of the aspirate cell count,
These studies have demonstrated that nares cultures and white blood cell counts of greater than 3,000 with elevated
decolonization may decrease surgical sight infections in ESR/CRP, and greater than 80% polymorphic neutrophils
TJA.64 However, results at this time are not significant have been demonstrated as indicative of periprosthetic
which could be due to an underpowered study. hip infection.70
Clinical Evaluation and Workup Treatment

All patients should be watched closely in the postoperative There are five possible treatment modalities for
setting, and wound dressings should be changed only by periprosthetic infections: antibiotic suppression; incision
the primary operative team. There should be a high index and drainage with retention of fixed components;
of suspicion in patients with increased risk of infection. single-stage revision; two-stage revision; and resection
While there is no specific definition of when a surgical arthroplasty. Antibiotic suppression may be used in
wound after THA should be dry, the commonly accepted patients with low demand, indolent infections, and poor
clinical convention is approximately 3–5 days. Other medical status that would preclude further operative
clinical indicators of infection are erythema, worsening procedures. It should be noted that chronic antibiotic
pain and swelling. The role of blood cultures taken in suppression might lead to drug resistance and unwanted
perioperative fevers has been fairly low yield, specifically side effects due to chronic antibiotic usage.
after THA, and it rarely provides useful clinical data.65 Incision and drainage with retention of fixed
Other laboratory tests may in fact provide very components has demonstrated variable success rates,
valuable data. In the acute postoperative setting, elevated 18–90% in the reported literature. However, more
inflammatory markers including C-reactive protein (CRP) consistent results have been found when the infection
and erythrocyte sedimentation rate (ESR) are expected. is an acute postoperative infection. In these instances,
However, these should be followed over the recovery successful eradication of the infection has been
period if there is any suspicion of acute infection. In demonstrated at 75% at 2 years after surgery; success
161
rates decrease with the presence of resistant organisms.71 more than 5 cm proximal to the tip of the greater
In addition, if the infection is solely superficial in nature, trochanter.79 Patients with an injury to the superior
then one can expect 80% success with simple irrigation gluteal nerve present with abductor weakness and a
and debridement with retention of the components.72 Trendelenburg lurch.
It should also be noted that all the patients in the cited Obturator nerve injuries are rare events after THA.
studies underwent irrigation and debridement in addition Although injury can occur with screw placement in the
to prolonged postoperative courses of intravenous anterior inferior quadrant, and with intrapelvic extruded
antibiotics. cement, patients with obturator nerve injury will normally
Single-stage revision with antibiotic-loaded cement present with groin pain and adductor weakness.
has demonstrated variable success rates, 78–90%. Two- Treatment of peripheral nerve injury depends on a
stage exchange revision with antibiotic spacer has swift diagnosis. The patients’ perioperative neurological
become the gold standard with a 92% success rate. status should be evaluated and documented during the
Resection arthroplasty should be reserved for recalcitrant postoperative examination. Prompt treatment of sciatic
cases and patients with very limited functional demands. nerve palsy should include loosening of all compressive
dressings and positioning of the hip in extension coupled
with knee flexion in order to relieve tension from
PERIPHERAL NERVE INJURY
the injured nerve. Patients with residual palsy upon
Peripheral nerve injuries can occur at the surgical site but discharge should be treated with an ankle-foot orthosis
can also occur far from it due to poor positioning of the and followed closely in clinic; nerve conduction studies
upper extremities or the dependent leg. In this section, should be considered at 6 weeks postoperatively.
we will discuss injuries that occur at the surgical site only Treatment of femoral nerve palsy depends on the
because they are the most prevalent. etiology, but observation is usually recommended due to
The reported incidence of peripheral nerve injury the fact that compression from malpositioned retractors
during THA is around 1%;73 some report up to 70% is the most common cause.
incidence of nonsymptomatic neuropraxia.74 The four Prevention of peripheral nerve injuries is the best
most common nerves involved are the sciatic, femoral, approach and to accomplish this, surgeons should be
obturator and superior gluteal nerves. With the new familiar with the relevant surgical anatomy and risk
surge of popularity of the direct anterior approach for factors.
THA, damage to the lateral femoral cutaneous nerve has
been reported as well.
Sciatic nerve injury accounts for more than 90%
VASCULAR INJURY
of the reported peripheral nerve injuries during THA; Vascular injury during an elective THA can be a devastating
the peroneal branch is most commonly affected.75 The complication. Vascular injury during THA has a reported
most common hypothesis to the increased incidence of incidence of 0.1–0.2%, with the femoral and external iliac
peroneal nerve injury compared to the tibial nerve is as the most common injured vessels.80-82 Patient factors
the relative tethering of the nerve between the ischial that have been associated with an increased risk of
notch and the fibular neck.76 Most common risk factors vascular injury include infection, revision surgery, female
are: posterior surgical approach; heterotopic ossification; gender, and protrusio.82,83 Protruded implants or cement
female sex; hip dysplasia; revision surgery; and limb into the pelvis may adhere to the pelvic vessels. And any
lengthening.77,78 attempt to extract the components without an intrapelvic
Femoral nerve injury following THA is much less approach may cause injury and tearing to the vessels. A
frequent than sciatic nerve injury. The femoral nerve is retroperitoneal approach to the hip with the assistant of
positioned posterior to the rectus femoris and is most a vascular surgeon should be the preferred approach for
frequently injured due to malpositioned acetabular such cases.
retractors.73 Knowledge of the vessel anatomy around the pelvis and
The superior gluteal nerve is at risk during a gluteal acetabulum is necessary for avoiding such complications.
splitting approach such as the Harding or modified The femoral vessels, which are the direct extension of the
162 Harding approaches, when the gluteus medius is split external iliac vessels, lie on the anterior-medial aspect of
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
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166
Chapter
Pain Management and
Regional Anesthesia for
18
Leslie Garson, Kyle Ahn
HISTORY OF PAIN MANAGEMENT Traditionally, postoperative analgesia following total

joint arthroplasty (TJA) was provided by either IV PCA
FOR TOTAL JOINT ARTHROPLASTY
or epidural analgesia. However, each technique has its
Total hip replacement (THR) can provide pain relief and advantages and disadvantages. For example, opioids do
restoration of function in individuals with musculoskeletal not consistently provide adequate pain relief and often
impairment. The total joint replacement (TJR) procedures cause sedation, confusion and delirium, constipation,
are extremely successful and unrivaled in the treatment nausea and vomiting, and pruritus. Epidural infusions
of osteoarthritis pain. During the next few decades, containing local anesthetics (with or without opioid)
the demand for TJR in the United States is expected to provide superior analgesia but are associated with
increase significantly. By the year 2030, it is expected that hypo tension, urinary retention, motor block limiting
the number of THRs performed will increase by 174%, ambulation, and spinal hematoma secondary to anti
reaching into the millions of procedures performed coagulation.4
annually.1 Pain, which has become the “fifth vital sign” in the view
In the decade from 2001 to 2010, there have been of the Joint Commission on Accreditation of Healthcare
major innovations in total hip arthroplasty (THA), Organizations (JCAHO), demands consideration in the
including minimally invasive techniques, computer- care of the patient, including taking account of pain in
assisted procedures, advanced rehabilitation protocols the discharge decision as well as in the entire patient
and improved perioperative pain management. However, and outpatient course.4 However, the importance of
it is the opinion of many in the field that recent pain extends far beyond the humanitarian and ethical
improvements in pain management have been the aspects of inadequate pain control. The consequences of
most substantial advances in the practice of total joint severe postoperative pain are prolonged hospital stays,
surgery.2,3 increased hospital readmissions, and increased opioid
Early in the development of joint arthroplasty use with subsequent increase in postoperative nausea
surgery, the mainstay of anesthetic and postoperative and vomiting, resulting in overall low patient satisfaction
pain management was general anesthesia with the and potentially greater cost.5 Not to mention, with the
use of intravenous (IV) opioids postoperatively, and implementation of Hospital Consumer Assessment of
most commonly by patient-controlled analgesia (PCA). Healthcare Providers and Systems (HCAHPS) in 2013
Unfortunately, this regimen was deemed unsatisfactory for as part of Medicare value-based reimbursement, patient
a large percentage of patients due to them still experiencing satisfaction survey scores will have financial repercussions
severe postoperative pain, and/or complications from the to hospitals as well.
use of parenteral opiates (morphine, dilaudid, fentanyl), With this in mind, over the years, there has been an
specifically pruritus, respiratory depression, urinary evolution in the management of postoperative pain for
retention, ileus, or even mental status changes.3 patients undergoing THA. The goals for these patients
Fig. 18.1: Major sensory pathways that carry stimuli to the brain
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
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
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
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
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
Benefits of Neuraxial Block for Total Complications of Neuraxial Anesthesia

Hip Arthroplasty Although neuraxial anesthesia is widely used in
The benefits of neuraxial (spinal, epidural) anesthesia orthopedic surgery, there are several disadvantages
compared to general anesthesia include avoidance of and complications that must be appreciated. Most
airway intubation, eliminating the complications of complications of neuraxial anesthesia are self-limited
general anesthesia, excellent muscle relaxation, good early and include localized backache and postdural puncture
postoperative analgesia, reduction in incidence of venous headache. Their incidence is low in the general
thrombosis and pulmonary embolism, lower anesthetic elective joint arthroplasty population. Rare but serious
cost,34 and decreased incidence of postoperative nausea complications include spinal hematoma (epidural or
and vomiting. In a large meta-analysis, Rogers and subdural), epidural abscess, cardiac arrest, cauda equina
colleagues found that neuraxial anesthesia reduces syndrome, meningitis and persistent paresthesias.
Neurologic complication as a result of spinal
postoperative mortality and morbidity, including DVT,
hemorrhage is often estimated in literature to occur in
pulmonary embolism, blood transfusion requirements,
less than 1 in 150,000 for epidural anesthesia, and less
pneumonia, respiratory depression, myocardial infarction,
than 1 in 220,000 spinal anesthesia.37 However, more
and renal failure in patients undergoing a variety of
recent data suggest that certain patient characteristics,
surgical procedures.35 A meta-analysis by Muermann
such as female sex, advanced age, spinal pathology,
and colleagues also showed that neuraxial anesthesia for
and concurrent use of antiplatelet, anticoagulant, or
elective THA is associated with decreased intraoperative
thrombolytic therapy are associated with significantly
blood loss and number of patients requiring transfusion.36
higher frequency.28,29,38 In a retrospective study involving
Neuraxial anesthesia may also allow the patient to have
more than 1.5 million neuraxial blocks during a 10-year
a choice as to the level of sedation they prefer during
period in Sweden, Moen and colleagues reported an
surgery (although most prefer to be moderately sedated).
incidence of 1:3,600 in female patients undergoing
Compared to epidural anesthesia, placement of
knee arthroplasty.38 In the setting of new or progressive
spinal anesthesia typically requires less time, less local
neurologic deficit suggestive of spinal hematoma, MRI is
anesthetic, provides more rapid, dense and reliable
considered the diagnostic modality of choice.29
sensory and motor blockade, and produces less patient
Sedation during neuraxial procedures is titrated to
discomfort (therefore reduced requirement for sedatives). patient comfort while maintaining meaningful contact.
The advantages of an epidural anesthesia are avoidance This allows the patient to report paresthesias or pain on
of intentional dural puncture (potentially decreasing the injection. This is important because in a retrospective
incidence of postdural puncture headache), and greater review of over 4,700 consecutive spinal anesthetics,
control of block distribution and intensity of sensory and paresthesias during needle placement was associated
motor blockade.10,34 with increased risk of persistent paresthesias.37 Direct
Epidural anesthesia, alone or in combination with spinal cord injury is extremely rare and can be minimized
spinal anesthesia (combined spinal-epidural) typically by performing epidural and spinal anesthesia no higher
involves the placement of a small catheter in the epidural than the L2/3 interspace.
space. This allows the anesthesiologist to administer The incidence of cardiac arrest following neuraxial
additional local anesthetic to extend the duration of anesthesia was reported to be less than 2 in 10,000 by
anesthesia without interrupting surgery. The catheter Kopp and colleagues in 2005.39 The exact mechanism
can be removed at the conclusion of surgery if it will not is unknown and is likely multifactorial. Interestingly,
be used for postoperative pain management. If used for in the same study, those who arrested during neuraxial
postoperative pain management, a continuous infusion anesthesia were more likely to survive without neurologic
of dilute local anesthetic with or without opioid can be compromise compared with those who arrested under
given to providing analgesia with minimal motor block. general anesthesia.
The epidural analgesia can be patient-controlled [patient- Multimodal analgesia is also a critical component of
controlled epidural analgesia (PCEA)] or programmed to postoperative pain management following THR (Flow
174 infuse at a constant hourly rate. chart 18.1). Historically, patients were administered
significant doses of morphine or narcotic pain medication EVIDENCE-BASED MEDICINE
routinely following TJR. Patient-controlled analgesia was
also a common modality for managing in the postoperative The evidence supporting the concept of a multimodal
period.9 However, side effects and complications such as approach to pain management for TJR surgery is
significant. There are studies supporting the idea of
respiratory depression, constipation, delirium and others
preoperative classes and education for patients prior to
are frequently associated with the use of IV narcotics.9
TJR surgery in the literature. The preoperative class is one
Additionally, patient participation in postoperative
of the best techniques available to educate patients and
rehabilitation and physical therapy may be limited by
their families because it provides information on what
the somnolence, nausea, and the physical constraints
will happen to them and eases the “fear of the unknown”
associated with IV PCA, which may promote stiffness,
patients may be experiencing. Patients may experience
poor mobility and greater length of stay.1 To help avoid
less pain because they are better prepared to cope with
these issues, more modern pain management protocols
pain. Anxiety has been shown to increase sensitivity
have focused on oral administration of pain medications
to pain, and a decrease in anxiety leads to a decrease
and multimodal regimens to minimize narcotics and
in pain scores.41 Patients are motivated to mobilize
potential side effects.1 The goal, once again, is to use a
earlier and be discharged to their own home because of
variety of agents that act via different mechanisms and
confidence gained through their education.12 In addition,
exert both local and systemic effects; use of agents with
preoperative education has been shown to influence
combined analgesic and antiinflammatory properties;
the patient discharge rate and decrease the cost of the
early conversion from parenteral to oral agents with
procedure, with a mean savings of $810 per patient.42
prolonged effect; use of baseline analgesia to provide A multimodal analgesic approach to perioperative
more uniform pain control and minimize narcotic management of THR patients incorporates the use of
usage with its associated adverse effects.10 COX-2 analgesic adjuncts with different mechanisms of action.
selective inhibitors and sustained-release oral narcotics Studies have shown that combining acetaminophen and
are continued postoperatively on a scheduled basis COX-2 inhibitors are safe and opioid-sparing. Regular
to provide baseline analgesia and antiinflammatory dosing significantly lowers visual analog pain scores
effects.10 Acetaminophen is also administered on a (VAPS),43 decreases opioid consumption,14,43,44 reduces
scheduled basis. Though it has no antiinflammatory effect, opioid-related side effects45 and enhances postoperative
it provides baseline analgesia and antipyretic effects. mobility. The gabapentinoids are effective postoperative
Acetaminophen’s ability to elevate the pain threshold is analgesics that reduce opioid consumption by up to
believed to be via inhibition of the nitric oxide pathway 50% compared with placebo.46 Oral narcotics are used
via neurotransmitter receptors N-methyl-D-aspartate and as an adjunct to these measures, both preoperatively
substance P or via central inhibition of COX-3.40 The oral as well as postoperatively. There is some evidence that
narcotics are used in the immediate postoperative period some select patients undergoing THR can be successfully
with variable dosages based on patient’s age, weight, and treated with only the non-narcotic measures described
narcotic tolerance from prior use. Patients generally are above.12,47 Periarticular local anesthetic infiltration
administered these medications every 3–6 hours on both provides more comprehensive analgesia than obtained
a scheduled as well as an “as needed” basis for the first with simple surgical wound infiltration.48 By providing
2 weeks following surgery with as rapid weaning from the excellent dynamic pain control, this technique has been
oral narcotics as possible. Pain medication administration shown to have significant advantages in postoperative
is critical for successful physical therapy following joint mobility and rehabilitation.33,49 Periarticular injection
replacement surgery, and overaggressive weaning is (Flow chart 18.1) during THR has demonstrated
avoided because it can be associated with joint stiffness improved early pain management, reduced need for
and delayed rehabilitation.1 Physical therapy following narcotics, and improved recovery with a shorter length
TJR is critical to the immediate and long-term results, of stay.33 In terms of postoperative recovery, one
and therefore appropriate pain management including study10 revealed that in patients who underwent THR,
all pharmacologic modalities should be continued until narcotic pain requirements and the need for prolonged
appropriate range of motion has been restored.1 physical therapy were significantly reduced compared 175
with historical control subjects. Recovery of functional analgesia for hip arthroplasty.13 Over the past 20 years,
milestones was achieved at an earlier period in 90% of multimodal pain management has been beneficial to
patients; overall patient satisfaction was improved; 78% the patient undergoing TJR surgery. Studies have shown
of patients described their recovery “as easy”; by 6 weeks this form of pain management decreases postoperative
postoperatively, 97% of patients had no or mild pain; opioid consumption and the related adverse effects.1 As
66% were walking unlimited distances. There were no well, a multimodal analgesic protocol for TJR decreases
instances of delayed wound healing or wound infections hospital length of stay,3 adverse events,3 costs/patient,42
and no patient required repeat surgery.10
and increases patient satisfaction.2,10 For these reasons, a
A study by Hebl et al. on patients undergoing either
multimodal pain program combined with a periarticular
total knee arthroplasty (TKA) or THA concluded that use
injection has been a substantial advance in perioperative
of a pre-emptive, multimodal analgesic regimen resulted
in clinically significant improvements in postoperative pain care after THA.2 The future goal should be to
analgesia (i.e. >2-point difference in VAPS) with fewer achieve a nearly painless THA using a combination of
opioid side effects.26 Additionally, improved perioperative regional anesthesia and multimodal pain management
outcomes included a shorter hospital length of stay and techniques.
a significant reduction in postoperative urinary retention With the multimodal approach incorporating regional
and ileus formation.26 Skinner and Shintani also have anesthesia, the safety of the operation is enhanced by
shown a reduction in length of stay, opioid use, time the decrease in complications of respiratory depression,
on PCA, and pain scores in their patients receiving TJR nausea, vomiting, ileus, urinary retention, pruritus,
using a multimodal protocol.50 From a study at the Mayo hypotension, bradycardia and cognitive changes. There
Clinic, it is concluded that, “using strict criteria, 90% may also be additional long-term benefits of neuraxial
of patients undergoing minimally invasive total hip or anesthesia for joint replacement surgery. Although
knee replacement using a comprehensive pre-emptive, further studies are needed, in a retrospective study of
multimodal analgesic regimen with conventional over 3,000 patients who underwent primary total hip or
techniques had significantly improved perioperative
knee surgeries, Chang and colleagues found that the odds
outcomes and fewer adverse events, as compared to
of 30-day surgical site infection was more than two times
patients receiving traditional IV opioids during the initial
higher in those who had general anesthesia compared to
postoperative period.”3
those who had neuraxial anesthesia.52
The future for TJR is exciting as the industry, physicians
SUMMARY and hospitals become more aware of the importance
Surgical pain management is considered to fall into of controlling postoperative pain. Newer adjuvant
four distinct phases, namely preoperative (education, therapies and devices will become available. Recently,
building confidence and motivation), pre-emptive patient-activated transdermal analgesic patches have
(utilizing the concepts of a multimodal approach), been released. Other strategies have focused on using
operative (suitable anesthetic technique) and acute anesthetic-coated sutures and implants as carriers. As
postoperative and residual phases. As relates to TJR, it well, newer hemostatic agents and drain systems can help
is the elements designed to manage the pre-emptive minimize the risk of postoperative hematoma formation,
and the acute postoperative pain phase that should be thus mitigating this as a potential cause of postoperative
regarded as key enabling techniques promoting rapid pain as well.6
return to normal activities and facilitating discharge from To see the multimodal analgesia protocol used at our
the hospital.51 Further measures to exploit these benefits, institution for our TJR program, we refer you to Flow
such as reduced invasive interventions (urinary catheters, chart 18.1.
PCA), early mobilization and early discharge can further
improve outcomes and healthcare resource utilization.
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178
Index
Page numbers followed by f refer to figure and t refer to table.
A protrusio deformity surgical Computed tomography 80, 82, 112, 130,

reconstruction 111 145
Abductor detachment 90 Benign aggressive tumors with extensive Computer
Abnormal center edge angle 111f destruction 90 assisted
Acetabular bone 26 Bennett retractors 39 hip arthroplasty 80
erosion 94f Bilateral acetabuli protrusio 110f surgery 80, 82, 83
Acetabular Body mass index 43, 156, 160 tomography 98
cup Bone Congenital hip dysplasia 2
cementation 64 grafts 122 Contralateral prosthesis 13f
offset insert handle 26f hook 26 Conversion total hip arthroplasty surgery
placement and screw fixation 38f 150t
exposure 25, 46f C-reactive protein 161
fracture 131f C Crowe classification 99f
index 98f Cup placement 113
Canal flare index 72
preparation 46f
Cancellous
protrusio 109, 111f
reamer targeting device 57f
acetabular screws 46 D
bone impaction 125 Deep
wall 111f
Capsulotomy 45f infection rates 150
Acetabulum 67, 101, 106
preparation and cup implantation 74 Cement vein thrombosis 159
Acute disease 5 venous thrombosis 168
acetabular fractures 131 mantle around stem 62f Developmental dysplasia of hip 67, 71, 97
idiopathic chondrolysis 109 pressurization technique 64f Digital templating algorithm 13
Allograft prosthetic composite 89, 126f Cementation 67 Dislocation 29, 36
reconstruction 93 Cemented of hip and osteotomy of femoral neck
American acetabular design 61 73
Academy of Orthopedic Surgeons for femoral stem design 60 rates 150
Thromboembolic Disease total hip Displaced
arthroplasty 59 and nondisplaced femoral neck
Prevention 48
replacement 69 fractures 134f
Society of Anesthesiologists 160
fractures 134
Anesthesia technique 170, 171 Cementless acetabular component 103
subcapital
Ankylosing spondylitis 109 Charnley-Muller type stem 61f
left femoral neck fracture 139f
Anterior Chronic osteomyelitis 90
right femoral neck fracture in 137f
acetabular osteophytes 24 Clonidine 47 transcervical
border of implanted prosthesis 40f Cobb elevator 24 left femoral neck fracture 136f
pelvic plane 81 Comminuted anterior wall acetabular right femoral neck fracture 136f
superior iliac spine 23, 81, 157, 163f fracture 30f Dissociated sensory loss 169, 169f
Anteroposterior pelvis 22 Complete blood count 151 Dorsolateral tract of Lissauer 168
Complications
after total hip
B E
arthroplasty 155
Basic principles of replacement 155 Ehler-Danlos syndrome 109
cementation 59 of neuraxial anesthesia 174 Epinephrine 47
Erythrocyte sedimentation rate 143, 161 Hemiarthroplasty 136, 136f, 139f, 143, Minimally invasive
Exposure of 149 surgery 21, 83
anterolateral aspect of femur 91 Hereditary arthro-ophthalmopathy 109 surgical techniques 51
gluteus medius 36f Hibbs retractor 26 techniques 167
tensor fascia lata 35f Hip total hip arthroplasty 83
External iliac vessels 114 fracture fixation 143 Modified Dall technique 33
instability 155 Mycobacterium tuberculosis 109
Homocystinuria 1098 Myocardial infarction 160
F
Failed
open reduction internal fixation of
I N
femoral neck fractures 149 Ilioischial line 111 Neurofibromatosis 109
intertrochanteric fractures 150 Iliopectineal line 111f Neurovascular injury 155
total hip arthroplasty with segmental Implant selection 72, 146 Nondisplaced fractures 134
bone loss 90 Incision of tendinous junction 37f Nonsteroidal antiinflammatory drugs 170
Failure of internal fixation 90 Infrared light emitting diodes 81 Normal center edge angle 111f
Fatal pulmonary embolism 155 Interteardrop line 111f
Femoral Intertrochanteric fractures 143
bone stock 119 Intracapsular femoral neck fractures 143
O
broaching 47f Obturator internus 45f
exposure 26 Ochronosis 109
neck 74f
J Oncological bone destruction 90
fracture 3, 135f, 141f Joint Commission on Accreditation of Open reduction and internal fixation 130,
osteotomy 24, 24f, 46f Healthcare Organizations 167 143
nerve 23 Juvenile rheumatoid arthritis 109 Osteogenesis 109
Femur 67, 103, 106 Osteomalacia 109
Fibers of vastus lateralis 36f Osteoporosis 109
Fluoroscopic computer-assisted surgery K
81 Kocher-Langenbeck
Fracture 30 approach 131
P
of trochanter 119 incision 44, 140f Paget’s disease 109
Kohler line 111f, 113 Pain 168
Peripheral nerve injury 162
G
Periprosthetic
Garden classification system 134f L fracture 90, 117, 155, 158
Gelpie retractor 25 Lateral infection 160t
Gluteus decubitus position 123f joint infection 155
maximus 35f, 45f, 140f femoral cutaneous nerve 23, 30, 52 Piriformis
medius 36f, 37f side of acetabular inner table 65f fossa 47f
Greater Leg-length discrepancy 11 tendon 45f, 141f
trochanter fracture 121f Limb-length discrepancy 155, 157 Placement of great trochanteric grip 121f
trochanteric Lowers visual analog pain scores 175 Polymethylmethacrylate 59
bursa 44 Posterior
osteotomy fragment 40f bone stock 98f
M hip and hip dislocation 91
Postoperative venous thromboembolic
H Management of
acetabular fractures 129 disease 156
Harris-Galante hip arthritis 53 Preoperative anteroposterior pelvis X-ray
prosthesis 70f Marfan syndrome 109 41f
stem 70f Mecring macrolocking stem 70f Preparation of femoral canal 56f
Hartofilakidis classification 100, 100f Megaprosthesis 125 Primary
180
Hemangioma 109 replacement 89 bone sarcoma 90
Index
medial reaming of acetabulum 65f Sequential reaming of femoral canal 76f joint
protrusio acetabuli 109 Short external rotators 45f arthroplasty 161, 167
Principles of bone grafting 113 Sickle cell disease 109 replacement 167
Prosthetic reconstruction 92 Skin incision 44f knee arthroplasty 176
Proximal femoral Sodium chloride 47 Tracking methods 81
reconstruction 92, 93f, 94f Transverse acetabular ligament 113
Spinal anesthesia 173f
in hip arthroplasty 89 Treating degenerative dysplastic hip 97
Staphylococcus
replacement 89f, 90t, 91, 95t Treatment of
aureus 160
resection 92 acetabular fractures 129
Psoriatic arthritis 109 epidermis 160
displaced femoral neck fractures 134
Stickler syndrome 109
total hip arthroplasty periprosthetic
Strut grafts 122
Q Substantia gelatinosa 169
femoral fractures 117
Trichorhinophalangeal syndrome 109
Quadratus femoris muscles 45f Superficial wound infection 150
Trisomy 18 109
Syphilis 109
Trochanteric bursa 36f
R Tumor extension 91
T
Reconstruction of acetabular fracture 130f
Recurrent low-grade fibrous histiocytoma Technique of cementation of femoral U
89f stem 62 Uncemented total hip arthroplasty 69
Reiter’s syndrome 109 Tensor fascia lata 21, 33, 35f, 42, 140f Urinary tract infections 132
Revision total hip arthroplasty 114 Thompson’s prosthesis 3
Rheumatoid arthritis 109 Tönnis angle 98f
Ropivacaine 47 Total V
hip Vastus lateralis 37f, 91
S arthroplasty 1, 9, 11f, 21, 29f, 32, fascia 36f
42, 48, 51, 57f, 69, 80, 81, 97, Venous thromboembolic disease 155,
Sartorius-tensor fascia lata 52
Schanz pins 83 111, 129, 131, 131f, 132f, 134, 156
Sciatic nerve 114 136, 137f, 138f, 143, 146f,
Secondary 147f, 150, 155, 156, 157f, 160,
167, 173, 174
W
causes of protrusio acetabuli 109
protrusio acetabuli 109 replacement 51, 129, 167, 170 Wrinkle sign 66
181

Modern Techniques in Total Hip Arthroplasty From Primary To Complex

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Modern Techniques in Total Hip Arthroplasty: From Primary to Complex

Kyle Ahn MD Wei-Ming Chen MD Snir Heller MD

Ran Schwarzkopf MD MSc

Drivers of Hip Replacement Surgery xvii

1. Early Development of Total Hip Arthroplasty 1

2. Total Hip Arthroplasty—Templating 9

3. Direct Anterior Approach for Total Hip Arthroplasty 21

4. The Modified Lateral Approach for Total Hip Replacement 32

5. Posterolateral Approach to the Hip 42

6. The Northern Approach for Total Hip Arthroplasty 51

7. Cemented Total Hip Arthroplasty 59

8. Uncemented Total Hip Arthroplasty 69

9. Computer-Assisted Hip Arthroplasty 80

10. Proximal Femoral Reconstruction in Hip Arthroplasty 89

11. Treating the Degenerative Dysplastic Hip 97

13. Treatment of Total Hip Arthroplasty Periprosthetic Femoral Fractures 117

14. Total Hip Replacement for Treatment of Acetabular Fractures 129

16. Conversion Total Hip Arthroplasty for Treatment of Failed

REFERENCES 22. Luck JB. A reconstruction operation for pseudarthrosis

INTRODUCTION agreement was found to be as high as 87% for acetabular

Step 4: Orienting and Sizing the

INTRODUCTION The direct anterior approach is performed supine,

AUTHORS’ PREFERRED TECHNIQUE

Femoral Neck Osteotomy

press-fit cup, may be checked for correct orientation Femoral Exposure

Postoperative Care is due to several factors. First, the posterior stabilizing

INTRODUCTION osteoarthritis or avascular necrosis, the incidence of

Figs 4.1A to C: Patient positioned in the lateral decubitus position,

Fig. 4.5: Exposer of the gluteus medius, trochanteric bursa and

Figs 4.7A to C: (A) Incision of the tendinous junction between

Femoral Preparation according to the preoperative templating, and the hip is

INTRODUCTION THE POSTEROLATERAL APPROACH

INTRODUCTION be chosen. The approach must also be done in such a

Table 6.1: Comparing the different surgical approaches to the hip

INTRODUCTION fractures.11-13 Therefore, the ability to perform a cemen­

Table 7.1: Generation techniques

CEMENTED ACETABULAR DESIGN

INTRODUCTION understanding of hip biomechanics and surgical

Figs 8.5A to C: Preoperative templating includes acetabulum

Implant Selection system, United, Taiwan) (Fig. 8.7) were developed. It

INTRODUCTION the surgeon’s ability to determine changes in leg length,

Fig. 9.5 Fig. 9.6

Fig. 9.7 Fig. 9.8

INTRODUCTION fracture around a femoral stem is the third most common

Fig. 10.3: Sliding osteotomy of greater trochanter should be considered 91

Allograft Prosthetic Composite capsule can be reinforced by using remnants of hip

Table 10.2: Brief literature review of proximal femoral replacement

INTRODUCTION onto having advanced degenerative changes requiring

Figs 11.6A to C: Hartofilakidis classification. (A) Dysplasia shows

Figs 11.7A to C: Crowe I templating. (A) Anteroposterior pelvis

Figs 11.8A to C: Crowe I reconstruction. (A) Preoperative

INTRODUCTION bilaterally, with a marked female to male predominance.

NATURAL HISTORY/ETIOLOGY Secondary Protrusio Acetabuli

Box 12.1: Secondary causes of protrusio acetabuli

INTRODUCTION fractures.11-13 Therefore, the ability to perform a cemen

Table 10.2: Brief literature review of proximal femoral replacement

REFERENCES 15. Haas SB, Barrack RL, Westrich G. Venous thrombo