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Anterior Augment and Trabecular Metal Cup For Revision Total Hip Replacement by Dr. Anoop Jhurani
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Anterior Augment and Trabecular Metal Cup For Revision Total Hip Replacement by Dr. Anoop Jhurani
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T00H12M09S
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https://cadmoreoriginalmedia.blob.core.windows.net/1b957c63-1a2f-4961-8fea-e13c74351f8f/Anterior augment and Trabecular metal cup for Revision Total.mp4?sv=2019-02-02&sr=c&sig=f349aWaPc8%2FVU5%2Fq69eFF6t74beQYWpyxyhFghdPqsM%3D&st=2024-11-23T10%3A00%3A08Z&se=2024-11-23T12%3A05%3A08Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision acetabulum reconstruction. In this patient whose 65-year-old lady who had her first total hip replacement 20 years back with a cemented cup and a cemented stem. The cup needed a first revision about 14 years back, so the cemented cup just lasted six years and the cup needed a revision 14 years back with the uncemented socket, which again failed and again she needed her second cup revision about 10 years back.
ANOOP JHURANI: So this cup that we see on the X-ray was implanted 10 years back and this is the second cup revision. The stem has remained the same in the last 20 years and it still looks good, the cemented stem. Meanwhile, in between, she also had a spinal fusion, as you can see on the AP X-Ray, which has a bearing on hip stability.
ANOOP JHURANI: So let's first analyze the socket, because that's where the main challenge is. You can see that the patient has socket loosening. She has relevant symptoms of pain right in the groin area, which has increased over the past few months. So we can see that the socket is loosened out. There is radial loosens around the screws also, which is a sure sign of the socket being loose.
ANOOP JHURANI: ESR and CRP are normal, there are no covert or overt signs of infection. So basically, we are dealing with the aseptic loosening of a socket. This is a Gription revision cup, so we should know what implants are there when we are wanting to revise a cup. On the stem side, the cemented stem still looks good and we do not need to revise this until and unless there is some evidence of loosening there.
ANOOP JHURANI: So we'll keep a revision stem as a backup, but more or less the stem will remain the same because the cement mantle is good but we'll take a final call during the surgery. The socket here, you can see, is loose. There is all around the sclerotic rim, so basically we are not dealing with a case of pelvic discontinuity, but we have to rule it out on the table. Spine x-rays are also very important.
ANOOP JHURANI: It's a spinal fusion case, so spinal mobility at the lumbosacral junction is not there. That predisposes this patient to instability. So we have to be very careful with our cup version. We have to use a dual mobility or a large head to prevent any instability. The approach is posterior and we will send for operative samples here to rule out any infection. Though, as I said, CRP's are normal, but still we need to send the samples.
ANOOP JHURANI: You can see there is no infection there and that's a ceramic head which you can see is worn out because of loosening and impingement to metal. And the stem looks pretty good, there is no evidence of loosening. It's pretty rock solid, but we still have to check. Remove all the fibrous tissue, we carefully expose through our extensile posterior approach with white capsule
ANOOP JHURANI: load me the cup. So there you can see that the cup is completely loose, we will remove the poly first and then gently take out the cup. The trunnion is protected with a gloved finger. That's very important not to scratch the trunnion because we are retaining the stem. So you can see that there is a gloved finger fixed on the trunnion to prevent any damage to the trunnion because we are retaining the stem.
ANOOP JHURANI: That anterior Hohmann which is retracting the femur away is on the anterior column and these two divers are on the posterior side. We are removing the poly first, so poly comes out and then we will remove the socket very slowly and gradually. The important thing of removing the socket is not to cause any bone loss, that's the important step.
ANOOP JHURANI: So we remove the screws first, there is one screw which is broken, but there are only two screws and then we'll gradually remove the socket without causing any bone loss. We don't need x-plant system here because the socket is loose and you can see the socket comes out very easily, there it is and there is not much bone loss. The most important step after this is to reassess our bone loss situation in the socket.
ANOOP JHURANI: And you can see here that the whole anterior column is missing. So there is loss of the anterior column, the posterior column is intact and there is no pelvic discontinuity. In this case, if there is pelvic discontinuity, then we will need to manage it accordingly with either a cup, head construct or by distraction technique and using a bigger trabecular metal cup.
ANOOP JHURANI: But if there is no pelvic discontinuity but a columnar loss, a segmental loss, then we need to build up with a augment and then put our TMARS scuppered trabecular metal shell well fixed after we have put the augment. So you can see that a segmental loss anteriorly there is complete loss of anterior column. We'll put a augment there and then we will put a t-bar scupp.
ANOOP JHURANI: So we are removing the fibrous tissue there all along and exposing the anterior column. You can see there is no bone from 4 o'clock position to 11 o'clock position, so virtually big segmental loss. We are sizing the socket, this is not really reaming, this is just sizing the socket properly, so we are not making any erroneous judgment on the size of the socket after putting the augment.
ANOOP JHURANI: So it's important to size your socket before we put the augment because then we can't ream. Once we do that, we remove all the fibrous tissue, you can see one is gel pin is there to retraction of the soft tissue in the ischium and one is in the ilium. So there are two, two Steinmann pins retracting the soft tissue there. That's the augment and we are putting the augment to build up the anterior defect.
ANOOP JHURANI: So that's the defect and we fixed it with a k-wire first and then put the screws on, it's always more difficult to put an interior augment than a posterior augment, because when you're putting a posterior augment, there is always some supportive bone there. But when we put an anterior augment, we don't have much supportive bone.
ANOOP JHURANI: So we have to manipulate that augment to get one or two good screws in the ilium. So that's the screw that we have manipulated to get it into good iliac bone. And once we get one or two screws and we check on that CR, we can see that we have got one good screw 40 millimeter right into the thick of the iliac bone. And once we get we, we assure that we got that augment and our screw in the right position,
ANOOP JHURANI: then we can focus all our effort and energy on the cup, getting the right size and well fixed component in. So that's the whole thing. Now we put some morselized cancellous bone allograft into the defect antero inferiorly. And then we choose the right size TMARS cup. We can remove this lining of the TMARS cup to put more holes, to drill more holes so that we can try and put some e-shell and superior pubic ramus screw.
ANOOP JHURANI: So the shell has some screws, but if you want to put this e-shell and superior pubic remus screws, you can roughly assess where those screw holes will be and then drill it with a Midas Rex to four additional screw holes. So we drill with the Midas Rex, the trabecular metal you can drill, but you have to ensure that you don't drill too many holes to weaken. So one, two max, three screw holes and divergent positioning, mostly for ischium and the superior pubic ramus can be drilled for that particular patient.
ANOOP JHURANI: It doesn't take much time with the Midas metal cutting, but we can drill those two screws and you can see and we can try and pass this screw through to see that the screw sits in completely. Once we do that, we can position our cup, bang it in and try and put two or three illium screws and one ischium and one superior pubic ramus screw to prevent any early loosening. So an important thing here in revision is to get a trabecular metal shell in after the augment and put in as many screws as possible, not just for the X ray, but good screws into good bone.
ANOOP JHURANI: You can see here there's the TMARS shell. The center of rotation is restored. We are right where the tile is and we are banging it in. And because we removed the peripheral shell, we have to bang it with a poly impactor and then we start drilling these screws in. We try and get as many screws as possible and to take iliac bone, and if possible, if we got it right into the ischial shell and superior pubic ramus screw here, we cannot get a superior pubic ramus screw here because there is no anterior column.
ANOOP JHURANI: But we've got the cup right where it belongs, the center of rotation is restored. It's next to the teardrop, and then once we got our screws, we cement the poly in into the right direction. The beauty of TMARS shell is that we can impact it, fix it in the whatever position we have good bone, and then we can cement the poly into 40 degree inclination and 20 degree anti version.
ANOOP JHURANI: We can also cement the dual mobility cup in, in case we are fearing severe instability situation, but here we are putting a 36 liner in the poly and cup is fixed into wherever the good bone is because that's where the in-growth comes from. We reassess our trunnion and we can see trunnion is not damaged. If the trunnion is damaged, we have to use a sleeve on it. But if it is not damaged, we can retain the trunnion head and put a ceramic head, as you can see here, to minimize wear.
ANOOP JHURANI: So basically, the important thing here is to ensure you're in a stable situation. You can leave it a little tight, you can see that the center of rotation is restored. We have put an anterior augment for the anterior column defect, we could not pass ischium or a superior pubic ramus screw because of bone loss. The limb length is more or less restored, maybe still half a centimeter short, but we restore the center of rotation of the hip, we got some good screws.
ANOOP JHURANI: And because of the spinal pelvic fusion, we have increased our anti version slightly to prevent any instability. The stem was retained because as you seen it was well fixed. And the treatment was also good. So basically to summarize everything, whenever we are planning a revision, we should assess. Bone loss, whether it is contained segmental and if there is pelvic discontinuity or not.
ANOOP JHURANI: If there is pelvic discontinuity, we have to use a cup cage or a distraction technique with a TMARS shell. Here there was no pelvic discontinuity but a segmental, big anterior column loss for which we have used anterior augment, fixed it with the screws, and then a trabecular metal shell with multiple screws to restore the center of rotation and hopefully this will work well for the patient.
ANOOP JHURANI: Thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision acetabulum reconstruction. In this patient whose 65-year-old lady who had her first total hip replacement 20 years back with a cemented cup and a cemented stem. The cup needed a first revision about 14 years back, so the cemented cup just lasted six years and the cup needed a revision 14 years back with the uncemented socket, which again failed and again she needed her second cup revision about 10 years back.
ANOOP JHURANI: So this cup that we see on the X-ray was implanted 10 years back and this is the second cup revision. The stem has remained the same in the last 20 years and it still looks good, the cemented stem. Meanwhile, in between, she also had a spinal fusion, as you can see on the AP X-Ray, which has a bearing on hip stability.
ANOOP JHURANI: So let's first analyze the socket, because that's where the main challenge is. You can see that the patient has socket loosening. She has relevant symptoms of pain right in the groin area, which has increased over the past few months. So we can see that the socket is loosened out. There is radial loosens around the screws also, which is a sure sign of the socket being loose.
ANOOP JHURANI: ESR and CRP are normal, there are no covert or overt signs of infection. So basically, we are dealing with the aseptic loosening of a socket. This is a Gription revision cup, so we should know what implants are there when we are wanting to revise a cup. On the stem side, the cemented stem still looks good and we do not need to revise this until and unless there is some evidence of loosening there.
ANOOP JHURANI: So we'll keep a revision stem as a backup, but more or less the stem will remain the same because the cement mantle is good but we'll take a final call during the surgery. The socket here, you can see, is loose. There is all around the sclerotic rim, so basically we are not dealing with a case of pelvic discontinuity, but we have to rule it out on the table. Spine x-rays are also very important.
ANOOP JHURANI: It's a spinal fusion case, so spinal mobility at the lumbosacral junction is not there. That predisposes this patient to instability. So we have to be very careful with our cup version. We have to use a dual mobility or a large head to prevent any instability. The approach is posterior and we will send for operative samples here to rule out any infection. Though, as I said, CRP's are normal, but still we need to send the samples.
ANOOP JHURANI: You can see there is no infection there and that's a ceramic head which you can see is worn out because of loosening and impingement to metal. And the stem looks pretty good, there is no evidence of loosening. It's pretty rock solid, but we still have to check. Remove all the fibrous tissue, we carefully expose through our extensile posterior approach with white capsule
ANOOP JHURANI: load me the cup. So there you can see that the cup is completely loose, we will remove the poly first and then gently take out the cup. The trunnion is protected with a gloved finger. That's very important not to scratch the trunnion because we are retaining the stem. So you can see that there is a gloved finger fixed on the trunnion to prevent any damage to the trunnion because we are retaining the stem.
ANOOP JHURANI: That anterior Hohmann which is retracting the femur away is on the anterior column and these two divers are on the posterior side. We are removing the poly first, so poly comes out and then we will remove the socket very slowly and gradually. The important thing of removing the socket is not to cause any bone loss, that's the important step.
ANOOP JHURANI: So we remove the screws first, there is one screw which is broken, but there are only two screws and then we'll gradually remove the socket without causing any bone loss. We don't need x-plant system here because the socket is loose and you can see the socket comes out very easily, there it is and there is not much bone loss. The most important step after this is to reassess our bone loss situation in the socket.
ANOOP JHURANI: And you can see here that the whole anterior column is missing. So there is loss of the anterior column, the posterior column is intact and there is no pelvic discontinuity. In this case, if there is pelvic discontinuity, then we will need to manage it accordingly with either a cup, head construct or by distraction technique and using a bigger trabecular metal cup.
ANOOP JHURANI: But if there is no pelvic discontinuity but a columnar loss, a segmental loss, then we need to build up with a augment and then put our TMARS scuppered trabecular metal shell well fixed after we have put the augment. So you can see that a segmental loss anteriorly there is complete loss of anterior column. We'll put a augment there and then we will put a t-bar scupp.
ANOOP JHURANI: So we are removing the fibrous tissue there all along and exposing the anterior column. You can see there is no bone from 4 o'clock position to 11 o'clock position, so virtually big segmental loss. We are sizing the socket, this is not really reaming, this is just sizing the socket properly, so we are not making any erroneous judgment on the size of the socket after putting the augment.
ANOOP JHURANI: So it's important to size your socket before we put the augment because then we can't ream. Once we do that, we remove all the fibrous tissue, you can see one is gel pin is there to retraction of the soft tissue in the ischium and one is in the ilium. So there are two, two Steinmann pins retracting the soft tissue there. That's the augment and we are putting the augment to build up the anterior defect.
ANOOP JHURANI: So that's the defect and we fixed it with a k-wire first and then put the screws on, it's always more difficult to put an interior augment than a posterior augment, because when you're putting a posterior augment, there is always some supportive bone there. But when we put an anterior augment, we don't have much supportive bone.
ANOOP JHURANI: So we have to manipulate that augment to get one or two good screws in the ilium. So that's the screw that we have manipulated to get it into good iliac bone. And once we get one or two screws and we check on that CR, we can see that we have got one good screw 40 millimeter right into the thick of the iliac bone. And once we get we, we assure that we got that augment and our screw in the right position,
ANOOP JHURANI: then we can focus all our effort and energy on the cup, getting the right size and well fixed component in. So that's the whole thing. Now we put some morselized cancellous bone allograft into the defect antero inferiorly. And then we choose the right size TMARS cup. We can remove this lining of the TMARS cup to put more holes, to drill more holes so that we can try and put some e-shell and superior pubic ramus screw.
ANOOP JHURANI: So the shell has some screws, but if you want to put this e-shell and superior pubic remus screws, you can roughly assess where those screw holes will be and then drill it with a Midas Rex to four additional screw holes. So we drill with the Midas Rex, the trabecular metal you can drill, but you have to ensure that you don't drill too many holes to weaken. So one, two max, three screw holes and divergent positioning, mostly for ischium and the superior pubic ramus can be drilled for that particular patient.
ANOOP JHURANI: It doesn't take much time with the Midas metal cutting, but we can drill those two screws and you can see and we can try and pass this screw through to see that the screw sits in completely. Once we do that, we can position our cup, bang it in and try and put two or three illium screws and one ischium and one superior pubic ramus screw to prevent any early loosening. So an important thing here in revision is to get a trabecular metal shell in after the augment and put in as many screws as possible, not just for the X ray, but good screws into good bone.
ANOOP JHURANI: You can see here there's the TMARS shell. The center of rotation is restored. We are right where the tile is and we are banging it in. And because we removed the peripheral shell, we have to bang it with a poly impactor and then we start drilling these screws in. We try and get as many screws as possible and to take iliac bone, and if possible, if we got it right into the ischial shell and superior pubic ramus screw here, we cannot get a superior pubic ramus screw here because there is no anterior column.
ANOOP JHURANI: But we've got the cup right where it belongs, the center of rotation is restored. It's next to the teardrop, and then once we got our screws, we cement the poly in into the right direction. The beauty of TMARS shell is that we can impact it, fix it in the whatever position we have good bone, and then we can cement the poly into 40 degree inclination and 20 degree anti version.
ANOOP JHURANI: We can also cement the dual mobility cup in, in case we are fearing severe instability situation, but here we are putting a 36 liner in the poly and cup is fixed into wherever the good bone is because that's where the in-growth comes from. We reassess our trunnion and we can see trunnion is not damaged. If the trunnion is damaged, we have to use a sleeve on it. But if it is not damaged, we can retain the trunnion head and put a ceramic head, as you can see here, to minimize wear.
ANOOP JHURANI: So basically, the important thing here is to ensure you're in a stable situation. You can leave it a little tight, you can see that the center of rotation is restored. We have put an anterior augment for the anterior column defect, we could not pass ischium or a superior pubic ramus screw because of bone loss. The limb length is more or less restored, maybe still half a centimeter short, but we restore the center of rotation of the hip, we got some good screws.
ANOOP JHURANI: And because of the spinal pelvic fusion, we have increased our anti version slightly to prevent any instability. The stem was retained because as you seen it was well fixed. And the treatment was also good. So basically to summarize everything, whenever we are planning a revision, we should assess. Bone loss, whether it is contained segmental and if there is pelvic discontinuity or not.
ANOOP JHURANI: If there is pelvic discontinuity, we have to use a cup cage or a distraction technique with a TMARS shell. Here there was no pelvic discontinuity but a segmental, big anterior column loss for which we have used anterior augment, fixed it with the screws, and then a trabecular metal shell with multiple screws to restore the center of rotation and hopefully this will work well for the patient.
ANOOP JHURANI: Thank you very much.
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