Anterior Approach. Skills Stations

Transcription

1 Anterior Approach Skills Stations

2 Anterior Approach Draping Option One Extra large drape Clear drape Step 1 Use a clear U drape (non sterile) around operative area and towards the foot. Tip: A towel wrapped over each book reduces the chance of perforation through the curtain. Extra large drape Step 2 Place two extra large drapes over the lower extremities starting distal to operative area. Place two large drapes across the top of the patient. Split drape Towels Split drape Step 3 Staple three towels around operative area, one on each side of the incision area and one medial to the incision area.

3 Anterior Approach Draping Option One Step 4 Apply an impervious U drape with adhesive around the operative area and extending over the legs. Apply another in the opposite direction over the head. Place a split drape with adhesive proximal and distal to the operative area. Cover exposed skin with iodine incise drape. Step 5 Cut a small hole in the drape for the femoral lift, place the hook bracket on the lift and seal with iodine incise drape.

4 Anterior Approach Draping Option Two Step 1: One half sheet, preferably with adhesive (orthobar) Step 2: Two quarter sheets for armboards Step 3: Sterile hand towels and stapler

5 Anterior Approach Draping Option Two Step 4: 1 long ioban (cut 2/3 length) Step 5: Shower curtain drape with bag Step 6: Leftover 1/3 long ioban

6 Preoperative HANA Table Setup Ankle Step 1 Remove liner from boot prior to inserting the foot. Step 2 Apply web roll around the foot, then self-adherent wrap (Coban ) around the foot and the upper ankle. Step 3 With the boot liner out of the shell, position the foot inside, making sure the heel sits all the way into the liner. Each side of the liner will wrap over the top of the foot and ankle. Hold the boot open, slide the lined foot into the shell, and secure with the buckle straps. Tip: If the toes are not sticking out, a smaller sized boot is required. Tip: Test the stability of the boot on the foot by holding the ankle while pulling on the boot handle. Step 4 Transfer the patient to the table. Step 5 Secure groin post, and secure boots to the table.

7 Preoperative HANA Table Setup Patient Positioning Step 1 Raise the legs degrees with slight internal rotation. This will work with the diving board of the table to help reduce lumbar lordosis. Step 2 Ensure that the patient s legs are parallel and in neutral position by lining up the leg spars. Step 3 Add slight gross traction to the non-operative side. FAQ What happens when the leg spar is in the red zone? Use the extension connector to the boot.

8 HANA Table Capsular Exposure, Dislocation, and Femoral Head Resection Steps Step 1 Assistant pulls gross traction (A) and locks the traction knob (B). A B Step 2 Assistant gives 3 4 turns of fine traction (Clockwise). Surgeon should see a gap between the acetabular roof and the femoral head. Step 3 Soft tissue between the acetabular roof and the superior head is loosened by moving the hip skid anterior and medial. Assistant takes off 1 2 turns fine traction (Counter-clockwise). Hip skid is then placed between femoral head and anterior rim.

9 HANA Table Capsular Exposure, Dislocation, and Femoral Head Resection Steps Step 4 Head is mobilized and with the hip skid still inserted, the assistant unlocks the rotation knob, externally rotates the foot approximately 20 degrees, then locks the rotation knob. B A Step 5 Surgeon uses the power corkscrew in an anterior to posterior direction (vertical), and applies the T-handle to the corkscrew. Assistant unlocks rotation knob (A) and uses the rotation wheel (B) as a guide when the surgeon pulls up with the T-Handle and supero-medial with the hip skid to dislocate the hip. A Step 6 Following dislocation, the assistant maximally externally rotates the leg while the surgeon aids in external rotation by pushing the corkscrew handle toward the floor. Assistant locks rotation (A) to maintain this external rotation as the surgeon releases the medial capsule off the femoral neck and the upper base of the lesser trochanter. Assistant releases rotation knob for the surgeon to reduce the hip.

10 HANA Table Femur Steps Step 1 Internally rotate the femur to the neutral position. Place the tip of the bone hook (either the right or left, corresponding to the operative side) just distal to the vastus tubercle and around the posterior femur. A B Step 2 Assistant unlocks rotation knob (A) and externally rotates the handle (B), which moves the foot approximately degrees and the femur 90 degrees. Assistant locks the rotation knob (A). Tip: Additional femoral releases may be necessary to achieve desired external rotation. Note that external rotation should not be forced. To show extra care, the surgeon can grasp the foot while applying external rotation, especially for elderly and osteoporotic patients. Step 3 Surgeon lifts up on the femur with the bone hook and pulls laterally away from the acetabulum. Assistant unlocks gross traction knob (A) to release all traction off the femur. A

11 HANA Table Femur Steps Step 4 A B Assistant holds the leg spar handle (A), unlocks the leg spar (B) and extends the leg down to the ground and slightly adducts the leg under the non-operative leg. The leg spar does not have to be locked when the leg is extended to the ground. The surgeon can now place the bone hook into the bracket on the table. The surgeon manually lifts the femur and raises the jack to bring the bracket up to hold the hook. FAQ B A Step 5 Once it is time to raise the leg back up, the assistant grabs the leg spar handle (A), raises the leg up to neutral position, and locks the leg spar (B). What do I do if it seems like the table isn t working? First ensure that the Red Emergency Stop button has not been pressed inadvertently. Turn the knob clockwise to turn off Emergency Stop and check that the table function lights are illuminated on the control base. If this is not the issue, turn off the table and unplug the power cord. Wait 30 seconds and then plug in the table and turn the power on. What do I do if it seems like the lift pedal isn t working? B A Step 6 Assistant unlocks the rotation knob (A), then in one move, pulls gross traction and internally rotates (B) the handle to reduce the hip back into the acetabulum. Assistant can then lock the rotation knob back into neutral position. Make sure the switch at the head of the table is turned on to the right or left side. Double check that the table is plugged in. The foot pedal light and femur lift light will both be illuminated.

12 Anterior Approach Acetabular Reaming Step 1 With the first reamer, begin reaming medially towards the teardrop. Aim the reamer anterior to posterior, and proximal. Tip: Remember that reaming too deeply in the direction of the cup can cause the center of rotation to move too superiorly.

13 Anterior Approach Acetabular Reaming Step 2 With the next size reamers, begin to rotate the handle more distally so that there is slight overhang superiorly. Tip: Stay aware that excessive overhang may impinge on the iliopsoas tendon. Step 3 With the final reamer, ream a full hemispherical cavity to prepare for the trial. The reamer should now be in the final cup position for inclination and anteversion angles.

14 X-Ray Interpretation Patient Positioning Flexed pelvis (Inlet view) Characteristic: Thin Obturators Abduction decreases Anteversion decreases Solution Cephalad Move C-Arm beam toward the head Extended pelvis (Outlet view) Characteristic: Wide Obturators Abduction increased Anteversion increases Solution Caudad Move C-Arm beam toward the feet Laterally tilted pelvis Characteristic: Uneven Obturators Solution Rainbow Move C-Arm beam toward the more narrow obturator

15 X-Ray Interpretation Overlay Technique Step 1: Level pelvis to take shot of AP Pelvis. Step 2: Take AP hip shots of nonoperative and operative sides. Print both. Step 3: Match up pelvis and check offset and leg length. Step 4: Match up femurs and check offset and leg length. Step 5: Make informed decision based on both views. FAQ What can I expect to see on a standing x-ray versus a sitting x-ray? Most patients go into extension, creating an outlet view What s the approximate impact of pelvic movement on the x-ray? Anteversion changes more than abduction when changing pelvic positioning (about.8 degree for anteversion per degree of change, and.3 degree for abduction).

16 Anterior Approach Broaching Challenge Stem is undersized & varus Challenge Broaches entered valgus & created wide proximal opening Solution Lateral neck remnant is removed for femur access Solution Broaches entered centered for proper placement Intraoperative View Lateral neck remnant highlighted

17 Anterior Approach Broaching Challenge Lateral perforation of the femur on first broach Challenge Posterior perforation of the femur on first broach Solution Broach handle is dropped for proper placement Solution For straight access down the femur, ensure that the broach handle is against the patient s side. Assistant can push on the patient s thigh to adduct the leg for proper access as well. Intraoperative View Broach handle angle change shown

18 Anterior Approach Retractor Placement Cutting The Neck 2 1 Hibbs Placement: Laterally retracting the tensor, protecting it from the oscillating saw 2 Blunt Cobra Placement: Medial and lateral to the neck Cobra with sharp pointed tip Placement: Over the mid portion of the posterior rim with the tip outside the labrum, but inside the capsule Tip: Can be held by Hana table lift rack 2 1 3

19 Anterior Approach Retractor Placement Releasing The Capsule Long Hohmann Placement: Over the tip of the greater trochanter, outside the hip capsule Tip: Move further behind greater trochanter after release 2 Mueller Retractor Placement: Along the posterior medial cortex of the femur Bone Hook Placement: Just distal to the vastus tubercle and around the posterior femur 3 1 Tip: Use the table bracket as a shelf, not as a lift for the bone hook and femur. Tip: Place the bone hook into the bracket on the table and manually lift the hook. Lift the femur and raise the jack to bring the bracket up to hold the hook. 3

20 DePuy Orthopaedics, Inc. 700 Orthopaedic Drive Warsaw, IN USA Tel: +1 (800) Fax: +1 (574) DePuy Synthes All rights reserved. DSUS/JRC/0916/1801h 02/17 The third party trademarks used herein are the trademarks of their respective owners. See the Anterior Approach Surgical Technique for a full description of the surgical steps. Dr. Joel Matta receives royalties as the designer of the HANA table which is manufactured by Mizuho OSI.