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Total Hip Replacement for Neglected Posterior Fracture Dislocation by Dr. Anoop Jhurani
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Total Hip Replacement for Neglected Posterior Fracture Dislocation by Dr. Anoop Jhurani
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T00H11M41S
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https://cadmoreoriginalmedia.blob.core.windows.net/0a6eac38-f096-47fa-9622-c37c294df76c/Total Hip Replacement for Neglected Posterior Fracture Disl.mp4?sv=2019-02-02&sr=c&sig=%2B%2BFGfh1Uf7Uncz7Z9xhl1efQa2O6B7bWte9uBvz0Slc%3D&st=2024-11-21T13%3A33%3A43Z&se=2024-11-21T15%3A38%3A43Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. It's common to get posterior fracture dislocations, neglected ones in our country. Some patients have a head injury, some patients have multiple injuries and hence posterior fracture dislocation is missed, neglected and presents less like in this patient, a 30-year-old guy who had multiple fractures and actually his posterior fracture dislocation was completely missed.
ANOOP JHURANI: And he presented one year later with arthritic hip shortening and a posterior fracture dislocation. If we analyze this BBH correctly, then there is a posterior wall defect that is also the posterior column defect. As you can see, the posterior column fragment is rotated posteriorly. So there is a wall and there is a minor column defect, of course there is shortening. The head has formed a pseudo acetabulum like a type 2 dysplasia with the ilium there because it's been there for about a year.
ANOOP JHURANI: And the patient is about an inch and a half short. So this is a young man with a tibial fracture on ipsilateral side. There is no infection in the tibia that we have to see. CRP is normal, and you can see there is a posterior wall and a column defect and a dislocation along with shortening. That's the lateral view. We can also take due reviews to accurately analyze the column and the wall defect.
ANOOP JHURANI: So here the iliopectineal line was intact, the ilioischial line is also intact but as you can see here, there is a part of column that is defective. You can see that there is a wall fragment and there is some defect in the posterior column as well. So we need to build that up, we need to get the hip down, we need to restore the center of rotation of the hip.
ANOOP JHURANI: We need to build the posterior wall in a young patient, we should always use a head as autograft. When we're doing revisions, we don't have head, then we use augments. But in young patients, 30 year old, we have the autograft, we have the femoral head, we'll build it up with the posterior wall and column. And then we'll ream it to put our highly porous carpet, multiple screws.
ANOOP JHURANI: So this video essentially will be about restoring the center of rotation in a posterior fracture dislocation hip, building the posterior wall in column with the autograft reaming technique, and then finally insertion of a highly porous cup with multiple peripheral screws. So that's the principle by which we have to reconstruct as outlined on this X-ray.
ANOOP JHURANI: That's where our cup is, we don't have to follow the original acetabulum, otherwise we'll go very high up. It's a common mistake to chase the pseudoacetabulum, and then the center of rotation really goes high, if the center of rotation goes high there will be shortening, there will be altered biomechanics, and there will be risk of dislocation. So we have to restore the center of rotation.
ANOOP JHURANI: We have to bring it near the teardrop, and we have to build the posterior wall and the posterior column with the head autograft. So that's the principle with this surgery will be done and we'll be using the posterior approach. We'll be first taking the head out, preserving it, reshaping it to form our posterior wall and column, fixing it with the screws. First reaming gently and carefully to get a press fit between the anterior and the posterior column and also the wall, which we'll build with the head autograft.
ANOOP JHURANI: So that's the principle, he's a 30-year-old man and we'll be approaching it through posterior. The plan is to do a proximally coated and uncemented stem and a highly porous cap on the acetabular side. So let's now go on to this surgical technique where we'll outline all these principles. Of course, we need to analyze the CT scan, especially the 2D films, to see the posterior wall and column defect.
ANOOP JHURANI: And sometimes we only see the 3D CT films, but we should always see the 2D CT films to see where the defect is in the lateral position. This is the posterior approach. And I wanted to mention here was that the patient already has a sciatic nerve because of old posterior fracture dislocation. So be careful with the sciatic nerve and hopefully with the restoration of center of rotation and with the head not pressing against the nerve the sciatic nerve may recover.
ANOOP JHURANI: So that's a femoral head dislocated from posterior approach. We always measure the offset and the limb length, the femoral side by marking the center of rotation with the trial acetabular component. That's the mark for the center of the femoral canal. That is the top of the lesser trochanter. And this is the center of rotation of the hip or the center of the femoral head.
ANOOP JHURANI: So then we measure the offset and we measure the femoral side of the limb length and we restore it. So we have to restore the offset and we have to get the limb length right so that the patient does not have that shortening. That's important. And on the acetabular side, when we'll restore the acetabular offset, the combined offset of the femoral and acetabular side will restore the combined offset.
ANOOP JHURANI: That's a neck cut and will preserve the femoral head. Of course, that's the most important thing, is to preserve the femoral head, reshape it, remove all the cartilage and use the thick part of the neck, along with the cortical cancellous part for rebuilding the posterior wall and column. So there you can see the socket. There is a big posterior wall in column defect.
ANOOP JHURANI: The original socket is filled with fibrous tissue because the head had really gone high. So we have to really remove all the fibrous tissue, change the transverse acetabular ligament, remove all the fibrous tissue to come at the base of the operator for them and we have to palpate the base, otherwise we'll chase the pseudo acetabulum and put a very high socket, that will be disaster for the biomechanics of the hip.
ANOOP JHURANI: So it's very important to check under C-arm that you have come to the base, identify the transverse acetabular ligament, see the operator forearm and palpate it, and then identify the posterior wall column defect and build it up with head autograft. So here we have reshaped the part of the head, the part of the head autograft. And we have put it on the posterior wall and fixed it with two screws so there you can see the head fragment is nicely fixed.
ANOOP JHURANI: We are putting two grafts, one posterior and one posterior superior, just like two augments or one large augment. So here you can see the posterior wall and column and we'll put one more at the posterior superior. So we have full coverage from 6 o'clock to 12 o'clock where the deficiency is. Two screws we'll always check under C-arm, the screws will usually be 30 to 40 millimeters. So those are two grafts, one posterior superior, one posterior covering from almost 7 o'clock to 11-12
ANOOP JHURANI: o'clock position. And we have come to the base, you can see the transverse acetabular ligaments, very important to come to the base. Otherwise, we'll put a higher center of rotation if we just chase the original pseudo acetabulum. Then we gradually start reaming because the autograft will also be reamed. So we have to ream very gently, very carefully. The anterior wall is very thin, posteriorly
ANOOP JHURANI: we have graft, so we have to ream very gently. We don't have to ream away the anterior wall and column. Very gentle reaming, very carefully the autograft will also take the shape of the socket. We can put a trial liner and see that we are coming to the teardrop. Now here we can see we are still higher than teardrop, so we'll really come down. Still, those two screws are in the graft, two superior to inferior screws.
ANOOP JHURANI: The defect at the base we can fill by remnant of the head. We can use it as impaction grafting, taking small pieces from the head, and then impacting really nicely at the base and the small defect in the posterior column. So here you can see a reamed socket That's the anterior wall where the Hohmann is, the two grafts, posterior and posterior-superior, and some impaction bone grafting, then we have to put a highly porous cup there, which will take a nice purchase between the anterior and the newly formed posterior wall and column.
ANOOP JHURANI: It's important to give a few taps from the top so that the socket really comes down to the base of the teardrop and then fix it with multiple screws. So there goes the socket in 40 degree inclination and 20 degree anteversion. It's important to maintain the inclination and the anteversion of the cup.
ANOOP JHURANI: So we put our cup from the anterior side, I do my reaming from the anterior side and putting the cup also from the anterior side. So that one is never in retroversion, always in anteversion of about 20 degrees. Fixation with multiple screws is critical, and we try and put at least four screws in a case like this. We try and get two or three screws in the ilium, one ischium or the superior pubic ramus.
ANOOP JHURANI: So that's a nicely fitting cup. You can see that anterior wall is visible posteriorly, the cup is visible, so it's about 20 degree anteversion. It's taken a fixation, an anterior column, posterior column, and now you can see we really add the teardrop. Those two screws, superior and inferior 4 millimeter screws are of the graft. The thicker 6.5 millimeter screws you are seeing are in the cup.
ANOOP JHURANI: So there are three screws here in the cup and it's nicely fixed. There is a posterior elevated liner. The fixation of the stem is very standard. The preparation is for approximately coated, uncemented stem, and we ensure that the stem is never in varus. We have to maintain our limb length and offset. There goes the proximally coated, uncemented stem, a ceramic head and
ANOOP JHURANI: there is a reduction. The reduction has to be snug and not tight, and there you can see that the graft is posterior, posterior-superior, maybe some extra graft, a posterior-superior, but usually it gets absorbed well fixed along the line of weight bearing. There you can see early follow-up and the graft is consolidating.
ANOOP JHURANI: The head is nicely at the center of rotation. The screws fixed with multiple screws, the center of rotation and the limb length is restored. So this is the way we reconstruct the posterior wall fracture, dislocation, neglected case with head autograft and highly porous cup. And it's important to restore the center of rotation. I think there is a message of this video is to come down to the teardrop, restore the center of rotation.
ANOOP JHURANI: Otherwise it's very easy to chase the false acetabulum, build up the posterior wall defect with autograft, and initially keep the patient non weight bearing and weight bearing after six weeks to restore the limb alignment and limb length. Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. It's common to get posterior fracture dislocations, neglected ones in our country. Some patients have a head injury, some patients have multiple injuries and hence posterior fracture dislocation is missed, neglected and presents less like in this patient, a 30-year-old guy who had multiple fractures and actually his posterior fracture dislocation was completely missed.
ANOOP JHURANI: And he presented one year later with arthritic hip shortening and a posterior fracture dislocation. If we analyze this BBH correctly, then there is a posterior wall defect that is also the posterior column defect. As you can see, the posterior column fragment is rotated posteriorly. So there is a wall and there is a minor column defect, of course there is shortening. The head has formed a pseudo acetabulum like a type 2 dysplasia with the ilium there because it's been there for about a year.
ANOOP JHURANI: And the patient is about an inch and a half short. So this is a young man with a tibial fracture on ipsilateral side. There is no infection in the tibia that we have to see. CRP is normal, and you can see there is a posterior wall and a column defect and a dislocation along with shortening. That's the lateral view. We can also take due reviews to accurately analyze the column and the wall defect.
ANOOP JHURANI: So here the iliopectineal line was intact, the ilioischial line is also intact but as you can see here, there is a part of column that is defective. You can see that there is a wall fragment and there is some defect in the posterior column as well. So we need to build that up, we need to get the hip down, we need to restore the center of rotation of the hip.
ANOOP JHURANI: We need to build the posterior wall in a young patient, we should always use a head as autograft. When we're doing revisions, we don't have head, then we use augments. But in young patients, 30 year old, we have the autograft, we have the femoral head, we'll build it up with the posterior wall and column. And then we'll ream it to put our highly porous carpet, multiple screws.
ANOOP JHURANI: So this video essentially will be about restoring the center of rotation in a posterior fracture dislocation hip, building the posterior wall in column with the autograft reaming technique, and then finally insertion of a highly porous cup with multiple peripheral screws. So that's the principle by which we have to reconstruct as outlined on this X-ray.
ANOOP JHURANI: That's where our cup is, we don't have to follow the original acetabulum, otherwise we'll go very high up. It's a common mistake to chase the pseudoacetabulum, and then the center of rotation really goes high, if the center of rotation goes high there will be shortening, there will be altered biomechanics, and there will be risk of dislocation. So we have to restore the center of rotation.
ANOOP JHURANI: We have to bring it near the teardrop, and we have to build the posterior wall and the posterior column with the head autograft. So that's the principle with this surgery will be done and we'll be using the posterior approach. We'll be first taking the head out, preserving it, reshaping it to form our posterior wall and column, fixing it with the screws. First reaming gently and carefully to get a press fit between the anterior and the posterior column and also the wall, which we'll build with the head autograft.
ANOOP JHURANI: So that's the principle, he's a 30-year-old man and we'll be approaching it through posterior. The plan is to do a proximally coated and uncemented stem and a highly porous cap on the acetabular side. So let's now go on to this surgical technique where we'll outline all these principles. Of course, we need to analyze the CT scan, especially the 2D films, to see the posterior wall and column defect.
ANOOP JHURANI: And sometimes we only see the 3D CT films, but we should always see the 2D CT films to see where the defect is in the lateral position. This is the posterior approach. And I wanted to mention here was that the patient already has a sciatic nerve because of old posterior fracture dislocation. So be careful with the sciatic nerve and hopefully with the restoration of center of rotation and with the head not pressing against the nerve the sciatic nerve may recover.
ANOOP JHURANI: So that's a femoral head dislocated from posterior approach. We always measure the offset and the limb length, the femoral side by marking the center of rotation with the trial acetabular component. That's the mark for the center of the femoral canal. That is the top of the lesser trochanter. And this is the center of rotation of the hip or the center of the femoral head.
ANOOP JHURANI: So then we measure the offset and we measure the femoral side of the limb length and we restore it. So we have to restore the offset and we have to get the limb length right so that the patient does not have that shortening. That's important. And on the acetabular side, when we'll restore the acetabular offset, the combined offset of the femoral and acetabular side will restore the combined offset.
ANOOP JHURANI: That's a neck cut and will preserve the femoral head. Of course, that's the most important thing, is to preserve the femoral head, reshape it, remove all the cartilage and use the thick part of the neck, along with the cortical cancellous part for rebuilding the posterior wall and column. So there you can see the socket. There is a big posterior wall in column defect.
ANOOP JHURANI: The original socket is filled with fibrous tissue because the head had really gone high. So we have to really remove all the fibrous tissue, change the transverse acetabular ligament, remove all the fibrous tissue to come at the base of the operator for them and we have to palpate the base, otherwise we'll chase the pseudo acetabulum and put a very high socket, that will be disaster for the biomechanics of the hip.
ANOOP JHURANI: So it's very important to check under C-arm that you have come to the base, identify the transverse acetabular ligament, see the operator forearm and palpate it, and then identify the posterior wall column defect and build it up with head autograft. So here we have reshaped the part of the head, the part of the head autograft. And we have put it on the posterior wall and fixed it with two screws so there you can see the head fragment is nicely fixed.
ANOOP JHURANI: We are putting two grafts, one posterior and one posterior superior, just like two augments or one large augment. So here you can see the posterior wall and column and we'll put one more at the posterior superior. So we have full coverage from 6 o'clock to 12 o'clock where the deficiency is. Two screws we'll always check under C-arm, the screws will usually be 30 to 40 millimeters. So those are two grafts, one posterior superior, one posterior covering from almost 7 o'clock to 11-12
ANOOP JHURANI: o'clock position. And we have come to the base, you can see the transverse acetabular ligaments, very important to come to the base. Otherwise, we'll put a higher center of rotation if we just chase the original pseudo acetabulum. Then we gradually start reaming because the autograft will also be reamed. So we have to ream very gently, very carefully. The anterior wall is very thin, posteriorly
ANOOP JHURANI: we have graft, so we have to ream very gently. We don't have to ream away the anterior wall and column. Very gentle reaming, very carefully the autograft will also take the shape of the socket. We can put a trial liner and see that we are coming to the teardrop. Now here we can see we are still higher than teardrop, so we'll really come down. Still, those two screws are in the graft, two superior to inferior screws.
ANOOP JHURANI: The defect at the base we can fill by remnant of the head. We can use it as impaction grafting, taking small pieces from the head, and then impacting really nicely at the base and the small defect in the posterior column. So here you can see a reamed socket That's the anterior wall where the Hohmann is, the two grafts, posterior and posterior-superior, and some impaction bone grafting, then we have to put a highly porous cup there, which will take a nice purchase between the anterior and the newly formed posterior wall and column.
ANOOP JHURANI: It's important to give a few taps from the top so that the socket really comes down to the base of the teardrop and then fix it with multiple screws. So there goes the socket in 40 degree inclination and 20 degree anteversion. It's important to maintain the inclination and the anteversion of the cup.
ANOOP JHURANI: So we put our cup from the anterior side, I do my reaming from the anterior side and putting the cup also from the anterior side. So that one is never in retroversion, always in anteversion of about 20 degrees. Fixation with multiple screws is critical, and we try and put at least four screws in a case like this. We try and get two or three screws in the ilium, one ischium or the superior pubic ramus.
ANOOP JHURANI: So that's a nicely fitting cup. You can see that anterior wall is visible posteriorly, the cup is visible, so it's about 20 degree anteversion. It's taken a fixation, an anterior column, posterior column, and now you can see we really add the teardrop. Those two screws, superior and inferior 4 millimeter screws are of the graft. The thicker 6.5 millimeter screws you are seeing are in the cup.
ANOOP JHURANI: So there are three screws here in the cup and it's nicely fixed. There is a posterior elevated liner. The fixation of the stem is very standard. The preparation is for approximately coated, uncemented stem, and we ensure that the stem is never in varus. We have to maintain our limb length and offset. There goes the proximally coated, uncemented stem, a ceramic head and
ANOOP JHURANI: there is a reduction. The reduction has to be snug and not tight, and there you can see that the graft is posterior, posterior-superior, maybe some extra graft, a posterior-superior, but usually it gets absorbed well fixed along the line of weight bearing. There you can see early follow-up and the graft is consolidating.
ANOOP JHURANI: The head is nicely at the center of rotation. The screws fixed with multiple screws, the center of rotation and the limb length is restored. So this is the way we reconstruct the posterior wall fracture, dislocation, neglected case with head autograft and highly porous cup. And it's important to restore the center of rotation. I think there is a message of this video is to come down to the teardrop, restore the center of rotation.
ANOOP JHURANI: Otherwise it's very easy to chase the false acetabulum, build up the posterior wall defect with autograft, and initially keep the patient non weight bearing and weight bearing after six weeks to restore the limb alignment and limb length. Thank you very much.
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