COI. Consulting-TJO, United Institutional Support- Smith & Nephew, Acelity-KCI, Stryker, USMI

Transcription

1 Difficult Primary Anterior Hip Replacement RLO November 17 th 2017 Capital City Club George Guild MD

2 COI Consulting-TJO, United Institutional Support- Smith & Nephew, Acelity-KCI, Stryker, USMI

3 Success Avoid Bad Ideas/Make Good Decisions

4 What is a difficult Primary Hip? Dysplasia/Perthes Protrusio Harware Conversions (Hip Resurfacing)* Avantages of DA here?

5 Dysplasia

6 Why Change? Current Problems with Dislocation 1 Sciatic nerve injury 2 Periprosthetic Fracture/perforation 3 Aseptic loosening/high hip center 4 Dysplasia

7 Why the increased complications? Acetabulum Deficiencies anterolaterally and superiorly, small diameter Proximal femur Increased anteversion, shorter necks, smaller canals, coxa vara or valga Soft Tissue Inefficient abductor musculature leading to limp Adductors, hip flexors & extensors shortened in chronic subluxation

8 Can we do better? How? Improve acetabular position- e.g. no high hip center, superior coverage, and versionimaging Avoid the nerve/don t overlengthen-imaging Avoid fracture/perforation intraop-imaging 5

9 DA Tips/Acetabular Dysplasia Take standard incision up onto crest Take down tensor 1 cm off crest for repair later Allows for excellent exposure of lateral ilum for grafting/augments Avoids SGN/Sciatic Prepare for Small Socket

10 Extensile Proximal Exposure Courtesy J Yerasimidies

11 Socket Placement/Dysplasia Access anteversion Prior to neck cut Ream on fluoro to medialize, gain superior coverage Engage A/P Ensure anteversion 20 or less, may have to dial back OK to raise hip center 1cm or <

12 Hip Center Elevation/Simulataneous

13 Good Access Lateral Ilium Courtesy John Yerasimides

14 Case Example

15 Tip assess femoral version preop and prior to neck cut intraop

16 Prepare for Extensile Exposrue

17 Iliac exposure/self retainer

18 Simultaneous Bilat/avoids interim LLD

19 Dealin With Hardware+Dysplasia

20 Prepare for Extensile Exposure

21 Small Stature/achondroplastic dwarf

22 Use accessory lateral incision/can unitize

23 Prepare for fx/rotational issues

24 Femoral Sided Tips for Straight stems Release Capsule to LT Excise superior Capsule Release piriformis/oi Max tredelenberg Rotation Tough to judge, drape with shower curtain to palpate epicondyles/knee

25 Femoral Sided Tips dysplasia (already released 2-3 cm TFL) May need guide wire/reamers Need stem with modularity/dial in version Have long stem available

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27 Protrusio Acetabuli Femoral head medial to ilioischial line Arthrokatydiasis Otto Pelvis Increased incidence RA Repetitive microtrauma anterior and medial

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29 Protrusio Problems Difficult to Dislocate Inability to restore hip center results in early failure Medial wall/anterior column deficient Anterior retractor problematic/hibbs Only

30 Tips Dislocation not necessary Fluoro for hip center Use head in slices/reaming bone graft Consider elliptical socket Hibbs only anterior

31 Case Example

32 Case Example

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35 Converting Failed HWR

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37 Tips Prepare for acetabular bone loss (screws/bone graft) Culture Take nail out like it was put in Remove distal screw after hooking up extractor Need stem with metadiaphyseal engagement Need to Trendelenburg bed Take down 2-3 cm of tensor off ilium Use fluoro

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39 43 y/o active male wants to run

40 Resurfacing? Resurfacing is not the same as MOM THR. There is no modularity and no trunion. The risk of pseudotumor is 0.1 to 0.3 percent. 6,7 In resurfacing, only three scenarios can result in excessive metallosis: A poorly designed resurfacing device. Several devices are no longer on the market. Today, the Birmingham Hip Resurfacing System (BHR) (Smith & Nephew) is the only FDA-approved resurfacing device available in the U.S. It has had the longest and best track record. Component malposition. Malposition of the socket can lead to edge loading and high levels of metal debris. Poor patient selection. We have learned that hip resurfacing is most successful in large individuals, usually men, under age 65. It should be avoided in small females and in patients with avascular necrosis or hip dysplasia. In the series of the designing surgeon (Derek McMinn, MD, FRCS), the success rate at 15 years was 98 percent in males and 92 percent in females, including all ages and diagnoses. 8

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46 Works Cited 1. Linde F, Jensen J. Socket loosening in arthroplasty for congenital dislocation of the hip. Acta Orthop Scand Jun;59(3): Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am Jan;61(1): MacKenzie JR, Kelley SS, Johnston RC. Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip. Long-term results.j Bone Joint Surg Am Jan;78(1): Dunn HK, Hess WE. Total hip reconstruction in chronically dislocated hips. J Bone Joint Surg Am Sep;58(6): Yoshikawa et al JOA 2009 anterior v posterior hip dyplasia

47 6. Canadian Hip Resurfacing Study Group. A survey on the prevalence of pseudotumors with metal-on-metal hip resurfacing in Canadian academic centers. J Bone Joint Surg Am. 2011;93(suppl 2): Garbuz DS, Tanzer M, Greidanus NV, et al. Metal-onmetal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty. Clin Orthop Relat Res. 2010;468: The McMinn Centre. BHR & Other Options: The 15 Year Results. Winter 2013/2014. mcminncentre.co.uk. Accessed Oct. 20, 2014.

48 Thank You