Cadmore media player playing video Arthroplasty in Hip Dysplasia for Orthopaedic Exams
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Arthroplasty in Hip Dysplasia for Orthopaedic Exams
Description:
Arthroplasty in Hip Dysplasia for Orthopaedic Exams
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/4741cfcd-81f5-48bf-9caf-85be712e3e8d/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H51M50S
Embed URL:
https://stream.cadmore.media/player/4741cfcd-81f5-48bf-9caf-85be712e3e8d
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4741cfcd-81f5-48bf-9caf-85be712e3e8d/Arthroplasty in hip Dysplasia for Orthopaedic Exams.mp4?sv=2019-02-02&sr=c&sig=XSsZ%2BHOZx3TvidEoLWNW%2Fgh1cq7XAmn12%2FVD6vZAxyo%3D&st=2024-11-24T00%3A12%3A31Z&se=2024-11-24T02%3A17%3A31Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
OK good evening, everyone. Welcome to tonight's teaching session on total hip arthroplasty in the dysplastic hip challenges and solutions. This is a combined session with ORUK. And tonight we're privileged to welcome Mr Satish cootie as our guest lecturer.
Mr Satish is a consultant, trauma and orthopedic surgeon at the princess Alexandra Hospital in Harlow in the UK. He is clinical lead and clinical director of his department. He's been clinical lead since 2014. Mr Scott specializes in all aspects of hip surgery with a particular focus on complex arthroplasty of the hip and knee, including revisions of the hip and young adult hip surgery, including hip arthroscopy. During his training, he has won numerous awards which have and which have contributed to fellowships in Austria, Switzerland, Germany and Canada.
Mr Scott has had numerous publications. That is a reviewer. He's a primary editor for the bone, a Joint Journal. He takes a very keen interest in training and remains active in the regional orthopedic training programs. In recognition for his contribution, he was voted trainer of the year for the personal training program in 2016 and 17.
He's also the Royal College of Surgeons of England surgical tutor. I'm sure Mr. QWERTY has a lot to teach us this evening, and his experience as a clinician and a trainer will be valuable to everyone this evening. We have myself, KneeKG Evans, and we have Ruth and Hannah from duke, as well as our mentors Susan, honey and Samir. The program for this evening will be elected by Mr. curti, followed by an MCC poll and invited questions.
Your answers to the polling or anonymous. And we ask you complete these as promptly as possible so we can move on to the invited questions. And then on to some case discussions and top tips for the Fox exam. If you do have any questions, please write them in the chat box and we will monitor this and ask Mr. Cutty after the polling, when the teaching is concluded will stop the recording and will progress to the vyver practice.
This is a popular session and we ask that you raise your hand and message myself, Ruth and Hannah. If you'd like to participate, please state when you are taking the exam and priority will be given to those sitting in November. Please do this as early as possible and we will confirm with you via the chat. We will try to accommodate as many volunteers as possible within the time frame.
But those candidates who missed out on the Fox five, of course, on September the 19th, we have opened another course on the tenth of October, which has places available, so I'd ask you all to mute your microphones and without any further delay, I will pass you over to Mr. Cutty. Many Thanks to my room Mates, talk about arthroplasty in the dysplastic hip and it's a favorite of mine because I have a keen interest, plus the challenging solutions, especially in this type of problem.
So why is it a problem? If you look at what we see nowadays, you hardly see patients on the left with no operations because young adult hip is certainly a subspecialty on its own and we treat patients. I treat patients with young adult problems and they end up having multiple operations. And at the end, the straightforward hip is no longer there.
They often have severe deformities. The biomechanics are completely distorted, as I will show you with examples later on and a fair amount of these because of the excessive amount of bone changes. The middle ear canal is completely obliterated, making it a very difficult to insert a component. And on top of that, when you have retained metalwork of all multiple years, it's quite hard to remove them.
And that becomes an extreme challenge. So I hope you all know what the lateral center angle is, and the normal is between 25 to 39. If your lateral center dangles, you can see from this. This is how it's measured from the center of the femoral. Had you draw a vertical line and then from the very center to the edge of the acetabulum, that's the tended angle should be between that. If it's less, it's dysplastic and then you have a very high risk of osteoarthritis.
And my mentor, Professor Ganz, has written numerous papers on dysplasia, and it's clearly showed that if you don't assist this and manage this problem, they get arthritis very early. And there's another angle which I'd like to bring to your attention, which is not the lateral, but the anterior one which is taken in a special way. It's called the false profile view. And this anterior edge, if it's also less than 25 and you got to really worry, which is not the case is often the anterior column and the anterior wall, which is really dysplastic, and we need to understand that, especially when you're reconstructing for osteoarthritis.
So that's the young person, and if this patient is not addressed early on, we'll go on to get arthritis, for sure. He is. So this is a patient all four years, how rapidly is progressed from having some cartilage to severe osteoarthritis, so how rapidly they progress, so they're not addressed early on, there's a problem, but by the time they come to you, you have all these issues. Luckily, this patient didn't have any metal working or any operation, so it's a reasonably easy, total hip arthroplasty to perform.
This is the issue. Now this is a young patient, this is not my patient, this is one of my boss's patient. 90 seven, she's 24 years old of severe osteoarthritis and I had a hip replacement. And then within seven years, you can see the police worn out and by 32 years old, he's already had first revision. This is the scale of the problem that we face. But implants have changed.
We for better biomaterials, so we are hopeful that the second the first revision may last because that's a ceramic and highly crossing, poly bearing liberation. So this is Professor flakiness, so he doesn't believe in deed. He said these people are born and he feels it should be named as congenital heart disease, the kind of privilege of working with him. So I've learned a lot from him about his thinking and what you should remember the acetabulum, the femur, even though they are linked.
Each has its own problems. They have deficiencies. You have superior a column. These are the ones that severely affect how you manage these patients. And as a result of where the hip is like, the soft tissues are very contracted, the abductors are not functioning well and sciatic and femoral have issues because they are quite contracted.
And when you lengthen or bring it to where their acetabular component should sit and bring the family component down into it, you're stretching neurological structures and there's a limit to how much, how much you can stretch. These structures. Because they will have a neurological compromise if you stretch it way beyond what you're allowed to. On the family side, again, this hypoplastic, it's a very small canal.
The family head is very small. You have leg length issues. The versions completely changed and with hardware and deformity, it becomes a significant challenge to address this problem. So classification and classification is important, and as we always find out during a training, why do we talk about classification classification essentially to understand the severity of the disease and for each what do you how do you manage each one of in those classified subgroups?
And also to communicate results? And if you don't have some sort of way of doing it, it becomes a problem. So there are two very popular classifications that are used. I'm sure everyone knows these. The first ones are Crawford, and the other one is the heart of L Now Crow. If you type in pubmed, the amount of references to crew is huge, but I have to think this is not that much.
My personal feeling is to do the fact that people find it very difficult to pronounce the name this. And that's why they tend to err on using cruel, which is very cruel. So we're going to come so sorry. So cruel. What he's done is mentioned the proximal migration of the femoral head diameter, and this is in relation to the interchangeable.
So for one, is less than 50% of the diameter. That, too, is 50 to 75 percent, so this is the image this is the one on the left, where you see is the amount of migration of the femoral head in relation to the teardrop. So 50-50 to 70 five, 75 to 100 and over 100 that's one to 4. Uh, where this is classic paper, which has been coated all the way through.
And who is cruel if you Google and find out crows a hand surgeon now and he works in Greenwich Hospital in the US and his fellowship with what resulted in that article. I was fortunate to work with four kids during my training and I visited this hospital in Athens. That's cat hospital and a very busy hospital, and they have a significant amount of dysplasia that they treat.
So it's very simple dysplasia where the femoral head is blocked, but it's still inside the original slap. You know this location where it is outside the true acetabulum in a fault partially overlap. The true acetabulum that's low dislocation and high is where there is no contact and it's way higher up. So those are the images so that a is dysplasia. B is low dislocation where there is still some very little contact, but it's still outside the true acetabulum and high is outside and falls a suitable.
So Bill Harris commented. And this is Professor is slide, where he said that they found this far more effective classification than cruel. So I would encourage you to use this because it's far more easy to understand and to discuss. So in the dysplastic type, what do you do? So it's normally a very ovoid acetabulum, there's good bone quality and you can't put in standard acetabular components without a problem.
Majority of the time, very rarely you do need screw augmentation to just support it for the first six weeks, by which time you get bone growth or in growth to the external component. And then it's fine. But remember, where you place, it is very important. Never try to place it high because it's clear evidence that if you place your a component high up, it will fail to aim for where it should sit and then you need to address how you're going to manage the area, which is uncovered.
And that's how you decide on what sort of components you use. So here's one. In my second year, which was 2011 12, actually dysplastic, straightforward and you can see the amount of coverage that's going to be there. I've kind of usually these components are very small. At that time, we didn't have electronic templating, so it was all hand on a printed X-ray sheets, whereas now we have modern software which tells you what to do and how much of lengthening you need to do a shortening of the femur.
If required. So this is that first case that I showed you, and you can see the area of coverage, the acetabulum, and that's when you put the family component in, you can see the amount uncovered. And this operation very solid. Still, I just felt that there was a slight give. And so I augmented this with screws to support the component.
And that's that patient before and after, and this is a 9 year X-ray. So she's done in 2011, and she's doing extremely well in low dislocation. Now this is the one out of the two that you often find quite difficult. So you end up it's quite easy to put a component in, but you have a significant area which is not covered. How do you address that area, which is not covered.
So you could do its structural grafting with the femoral head that you've taken out? Or you do Control perforation, which is the cultural policy which is hardly done from my understanding. Or you keep where the hip is meant to be at high hip center, which again, I say I would encourage you not to or you use a suitable organs, which is fairly new and it's hardly any literature for primary hip replacement.
There's plenty for revisions, but in primary I haven't seen it much in terms of the use of organs and the results. So here's how you can put in a structural paragraph, which is usually flying buttress, so you shape the aircraft is a figure of seven. So if that's a hemisphere, you cut an L shape off and so that becomes a figure of seven. And that is placed at the edge of the established screwed in place.
And then you remove the socket. And just like this, so that's the femoral head screwed into place. You ream that and then you place your components inside your. It was pretty good, but it's technically quite difficult because you need a fine line between loading it and unloading it, so if it's all loaded, it will disappear.
If it's unloaded, it will disappear. So you've got to be really careful as to how it works. Now I'll show you one of mine, which I thought didn't work initially, but then it seems OK at the moment, so it can fail because it can resolve very quickly. So, so sorry. So here's mine and this patient, as you can see, I place the femoral head first.
Use a choir to place it to make sure it doesn't move. Fix that with screws and then agreement to place your component. So this is what, as I said, was quite poor. I thought initially. But this X-ray is taken nine years, 8 to nine years, and it's still there. So if you don't place it properly and the screw direction should be quite.
Allen to these crews so that it doesn't resolve, and the loading is perfect. So that's an issue. It's a technical problem, so it's very difficult to get right. So I moved away from this, so I tend to use augments as required. So here's one where I've used the much bigger screws and this seems to have worked and it's a much smaller patient.
So it can work and it can fail. Ca2+ is very controversial now. A lot of people in. I've done it, and it has reported quite a lot. And the people that I would credit those to is this is Professor Santos. So that was his right hand man, and he's the one who championed cultural policy.
But as Nicholas Bowler from Vienna, he feels that it was the Austrians, and the Germans who popularized it. So that's parent Purna person is the one who has written a lot about this and how he's shown is that the screw up, how you perforator the media war and is pushed inside and the cup goes into effect? It's quite difficult for me to do, and I think many will find it quite difficult.
And this is another image of how you can buffer the medial cortex and fix that with a cup and some screws. So that is an option, but it's rarely used. This is the one that is quite popular and a lot of revision. Hip surgeons and hip surgeons use this called the flying buttress augment. And it's a revision hip as a classification from the type III segmental defect, which is quite easy to manage with an augment.
So here's a case where in a dysplastic hip, I put the trial in just to see how much is not exposed to the amount exposed used to augment trials, to see what fits best. So you can either put the cup first and then the augment and you can unity's the two either using cement or bone graft. I tend to use graft where possible or in this position where if you feel you can put the augment in first, then you put the external component and then try to utilize that with graft.
And that's the fine position and the case that I showed you before. This is a 44-year-old lady who's had a shelf operation procedure for dysplasia done, but one of my senior colleagues many years ago. And that's how she is, and that's how she is now. That's a seven year follow up, and that augment is done really well. So this is another way of trying to manage these kind of complex scenarios where you need superior support.
So this is for the low dislocation and high dislocation this is challenging not for the acetabular side, but from the femoral side. And the acetabular side is really small. So you've got to make sure that your standard components that you have on your shelf don't usually fit. It's in the 40 millimeter size range that often you have to put in. So you have to get the microsystem in for these procedures and often for 40 to 40 for very rarely, for leaks in high dislocation, it's often 40 42 that you have to use.
And because the size of the external component you end up using, even if the plastic inserts, eyeliners and heads. So I end up using ceramic liners for these patients. And a for the federal side, you because it's quite high, it's quite tight, and you need to really do an osteotomy and this is from the paper I'm going to show and I would encourage you to look at the surgical treatment. Jamie American from Mayo clinic Rochester, which gives you a very good view of how to do it, and it's exactly how I tend to do mine.
And this is from that article how they have done a slap osteotomy. They brought the hips into normal and they've used the allegra, the graph from where they've done the osteotomy to help with further bone healing. And this is from our center in Exeter, where they even cemented cup and stems do work in this kind of situation. And they have got very good results, a small cohort of patients, but just show you that it does work for me.
The biggest problem for is that when you're after, you've done your osteotomy, the diameter of the proximal fragment and the inferior fragment is not the same. And unless you get a very tight seal, you will get cement leaking in between into the osteotomy side and it may not heal. So I find it very difficult as a skill, so I tend not to do this.
So this is Professor Hertel kids's diagram, where he feels that this is how you should do it. The one on the left, where you take the head, the neck and part of the lesson to Canter off and you keep the greater Toronto and then you reattach the grade onto the distal onto the femoral segment. Whereas I feel he feels that this one subsequently shortening osteotomy is not the way to do it, but I find that this is much better because you're abductors are there intact with the shaft and they work very well, and I'll show you how I do that.
So here's one of mine and this is a 46-year-old lady bilateral and this one how you do. That's that's the fault acetabulum. And then you go further down, you find the true acetabulum. So I do the osteotomy first to allow me to see because it's out here that the establishment sits. If you don't do the osteotomy beforehand, sometimes it's quite difficult to see the true acetabulum. And that's how much of segmental removal I've done gradually to see how much I can take off to reduce the hip joint without too much tension.
And that's what it looks like. Immediate post of both sides. And that's an eight year follow up where the bone graft has kind of incorporated really well. So as I've told you, the high hip center is clear evidence that if you leave it there, it will fail because the abductors don't function really well. The loads are pretty high and there's impingement.
The patient is not very comfortable in that kind of position to bomb. Biggest issue is biomechanical, and there is evidence that it will fail. And as I've said again, there's high rate of loosening, and Marc Bookman has shown that, so it is best to place it in its true center. The biomechanics will work. There are some other ways of doing it, so if it's a very dysplastic that you could use a blonde cop, there is some evidence that it does work.
That's one of mine. A gun some time ago. This is during my first year as a consultant. And it did work, but I felt that the augments did a much better job. So this is another option for you to use. Now, the federal reconstruction, I think that's the one was more challenging, especially in the high dislocations, because the other two parts, the other two types, the straightforward, dysplastic one on the low dislocation you can manage reasonably well.
So you need to understand where it is, where you have the deformity. And this is from Dan Berry's paper, and I would encourage you to look at where the site, what sort of geometry there is the geology, and then you can decide how you're going to manage the type of deformity and what sort of components you require. And that is absolutely key because not one component will fit all the types.
So here's one of mine, and this is the problem, because this patient is about eight operations on the right, and this one has had this done when she was a child and she's now in her 40s. How are you going to find this metalwork? This is a blade plate put in, and often the screws are so buried in. You're going to think hard. How are you going to take this off?
And the patient from the first one on the left, as soon as you and I went and I did the osteotomy, I couldn't see the canal. It was completely obliterated. So it was a hard round segment of bone not like what you would see normally. So the majority canal can be very difficult to manage if you have this sort of problem. So a CT scan you can do to help you, especially to assess the torsion or rotational aspect and leg lengths to see how much you can length, how much you need to lengthen to equalize these patients.
So planning is an absolute must. And CT scan of the hip and the knee, I feel, does add a significant amount of information and 3D reconstructions to help. So this is a story that patient from before. And if you look at her 3D seats, if it plays, is going to play. So the amount of deformity this patient has and how are we going to address this with a standard stem is the question.
So this is her fema, she's had about 4 to five operations on both sides, the established side and the federal side. And if you take the cross section of her acetabulum, you can see there's hardly any interior wall and then to column is quite hypoplastic. And when it is externally rotated. So this patient has severe torsional abnormality.
And in fact, if you add the two together where the foot, the knee and the hip sits, you can see how much of retribution she has. So you may need to consider how you're going to place a component because if you place it anatomically, there is a chance that these could dislocate and that's the planning and the type stem you could use. I decided to use a special design stem for her because I didn't think I could manage the deformity with a straight stamp.
So it was a custom designed for this lady. And that's how she is on the table. And you can clearly see that the knee is pointing up in a lateral position so the amount of torsional abnormality she has. So this is where you need to think outside the box, and I tried to fit the implant to the patient and not the patient to the implant. So these are unique solutions.
They are expensive and that you need that something. You need to have a conversation with your commissioners because if they get sent to especially center, often the cost is even higher. So that's how you can justify doing it in centers where you have a fair amount of volume. So that's the stem I used, and that's the rasp. Both are kind of custom designed ones and and that's how she is. It's a little rotated view, but it is another view where you can see that it sits in the middle.
And because of the torsion abnormality, it was abutting the lateral cortex. But this is three years old, so I'm pretty happy with how she is. First time she walked with a foot pointing forwards, which never happened since her childhood. So you need to evaluate how much of torsion abnormality there is, and if it is a total abnormality, straight terms don't work, so you need to consider really logical.
So consider alternative stems to help with this problem. And if it's more than 40 five, when we do total hips, we do a combined activation of about 45 between the established component and the femoral component. That combined version is way more. You need to consider rotational osteotomy to address the defect, and that's through the sub tocantins region, and it can be achieved using various components and the most versatile component that I was always taught with the asaram, but it's got two different parts, and that's the problem for me.
So it it is quite useful to address version and I'll show you how, for example, this patient, that's a female, that's a leg, that's the femur and the neck is pointing a So when you place the sleeve of the stem, it's quite and when you put your if you put a straight stem, you can't address that problem. So that's where the sleeve helps. And then you can rotate where you want to place the femoral component.
And this is the very same patient where the sleeve is actually pointing at us and pointing anteriorly. So that's why I think these kind of modulus items are useful. Now this is the it's a moral block. So this is where I think this tapered fluted stem play is much easier to use compared to the rest room because the trauma has different parts. This one is useful.
It's just got splints and actually catches or engages the two parts of femur. Should you do it with an osteotomy? I think that's where this plays a significant part for me. And as you can see in this, this patient is a low dislocation and you can link the two parts with a separate country osteotomy. You can use wires if you want to, and a bone graft superior to augment fixation.
The things that I was always taught was do not lengthen more than centimeters. And I really can't find a reference for this centimeters and that's what is quoted. Some say five. Some say four. I tend to keep it at four with more than four. There is evidence that sciatic nerve can be compromised, so shortening is necessary.
And that neurological compromise is a significant problem that you need to understand when dealing with lengthening procedures. This is historic or knot is debatable now. In case you have proximal, you want to avoid anything going distal so you can just consider the proximal femur resurfacing or the meathead resection or even a metatarsal bearing type device.
Now, a lot of these metal and metal is more or less gone, although some centers still do it. I'm not saying it doesn't work, but it does in certain groups which have still this has been removed from the market. It was doing quite well, but for some reason it's been removed. And in this kind of situation, it is useful. So whether it's historic or knot is a question that many people can ask and debate or use amid head.
And this patient had severe femoral neck deformity that one of my bosses decided to imitate, and it worked in this patient. You may think how the hell is going to work, and this is a three year radiograph of a heterosexual. And I thought he was bonkers trying to do this, but it did work. Or a metaphysical type. This is one of my patients.
This patient had this plate put in 2021, 30 years ago, and it's quite anterior and the screws is very difficult to remove because they were really welded in. So an option was to consider a proximal capsule and managed to remove to the others were difficult. So I did plan on a proximal metatarsal bearing. Now this is an eight year X-ray for these patients, a long term follow UPS that I've shown you.
So they do work, or you can use a very short stem. Again, this patient. This is a silent prostheses which has been removed from the market. But this did work really well, especially if you proximal femoral deformity so you can think outside the box and just look at the proximal segment to use in resurfacing. It has been reported.
And this is from Holland aptitudes group and there was also really good. The thing that you need to worry about is because of a lack of weight bearing the bones for osteopenia, so they don't do well in these. So here are had this work made, had a section say like this one, you can consider dysplastic socket and have had a femoral component. So in summary, use a modern hip armamentarium is very important, and if you don't plan, you run into problems and you should always have bailout options and you may have to resort to traditional methods.
And I can show you one of my examples later on. Thank you. And thank you very much, Mr Casey, that was an excellent lecture. I don't know how the other mentors feel, but I think, you know, dysplastic hips. It's one of those topics that you can just learn. And then if it comes up in an exam, it's a gift because you can talk about all the different ways to manage the acetabular deficiencies and the proximal femoral problems.
So that was excellent. If you missed part of the lecture or if you want to watch it again, which I think would be worth doing, it will be available on both the mentor website and the UK website. So what we're going to do next is the MSCI polling, so Ruth is going to share the polls and we just want you to answer the correct answer. It's all anonymous, so if you do it as quickly as you can, then we can move on to the case based discussions.
If you look at if those who joined initially will note that my second or third slide, I did mention that the lateral sandridge Angelo peel-back is 25 to 39. So 25 34 is wrong and now you can debate why 39. But that's the figure quoted in the literature. Less than 25 dysplastic and over 39 degrees is over coverage, so it's 25 to 39 is the right answer.
And we want the next question, if you want. Yes, please. Out of the work. You just scroll down, there's a little toolbar to the right hand side if you just pull that down. Yeah, OK. So the yes, second question, my dislocation. Yes, centimeters.
Absolutely right. As I said, they some do say five, but I think 4 is what's quoted in the literature. So that's correct. Majority, if you got that right. And high dislocation. What segment? Yes, it is the anterior wall on the anterior column. That's the segment which is hypoplastic.
And this is what you should really consider and be very careful, especially when you are preparing to insert your tablet component. That's the first question, I think the other two people have done really well, which is good. OK, that's great, thank you, Mr. cutie. So I think we're going to move on to some questions that were asked.
One so the first question I think you've already answered is lengthening. How much anything you can do before you can get sciatic nerve injury. You've answered that before centimeters. And the next question is, how do you decide how much shortening or do you do to? So that's essentially planning and operatively assessment. So if you if you would, with your regular amount of force that you use to reduce the hip and you can't, then you have to consider shortening.
So because you do want to put excessive traction on the neurological structures. So in pre-op planning, you will find the amount of where the femoral head sits on the dislocated hip and where the true acetabulum is. So that distance is the distance you're going to bring the hip center down. So that's when you can decide if it is 4 centimeters or less, you should be OK.
But even if that is too tight, then you need to consider shortening. But beyond centimeters you have to consider shortening from that by templating. OK another question how would you manage a mild or early stage dysplasia of the hip when they are not arthritic? Uh, so if under the age of 40, if they have a dysplastic literature shows that by denotation osteotomy of the acetabulum, which is a period loss tenotomy depending on what type it is, they do really well, so they have to be under 40 beyond 40.
What happens is the articular cartilage results do tell us that they don't do really well, and that's from the burn burn group, so above the age of 40. So you need to consider be very careful whether or not your team is going to work or not. OK and so how do you overcome leg discrepancies? Intra operatively. So again, the shortening osteotomy, the pelvis is so compensated already so that when you have done your shortening osteotomy, you'll be surprised that they often equalize, even though one leg is short.
And after a while, the pelvis to settle bilateral hits perfect because both your shortening for the same amount, so they do really well. So you can with pre-op templating, leg length scan, you can assess how much you need to change there, how much you're going to shorten to equalize ligaments. OK and again, another question I think you've already answered this. How do you make it?
Well, I know you've answered this. How do you make your decision whether to use a male or female head bone grafts? So I use very young patients. If the fighting the femoral head is pretty good in good quality, then I can use that. And I think that this biologic and I use it in older patients above the age of 50 at the femoral head when I feel is not of great quality, I use an augment.
OK, and just one more question, if you mind the discussion about hip resurfacing dysplastic, if there are kind of recommendations about when to use hip resurfacing and they include large head size and male bone. Does dysplastic fit this category? I have told you before, it. Yeah, as long as the resurfacing, the femoral head is very flattened or because if there's not weight bearing, that particular part of the femoral head is very soft and osteopenia.
And so resurfacing doesn't work very well in that situation. So there you need to consider mid head resection where you can take the head off and then put the metal mid head type of prostheses in a dysplastic hip. If you see the femoral head quality is pretty good, then it will work. Resurfacing as Holland absence has shown that you have to be very selective in what kind of patients and in young fit.
It does work very well. And I would qualify. That's exactly the way you qualified the statements only in a certain select criteria patients with deformities. Just in case the candidates were misunderstood, that's OK. So that's all the questions, if there's any of the mentors have any questions.
And if the questions we proceed to the next. OK, great, thank you so much, so we're going to move on to a couple of case based discussions, and we've got two volunteers for Mr Coffey to go through the case discussions with. So I think our first one is, is it Lang ang? And we'll get you ready. And I am.
Hi Hi. All right, so Mr Cutty is ready for you. Have you yet? We can see you. Excellent right? So this is your department. This is a 75-year-old female who is sitting in front of you and she's coming with obviously, right? Can you just describe what you see on the X ray?
In this AP video graph of the patient's pelvis, there is a pathology in the right hip. I can see that there's arthritic change with the decreased joint space also formation. The very suggestion that this could be a dysplastic hip with a shallow acetabulum, though. How can you want to play an X ray? Just looking at that, do you think that's dysplastic? It will be I will need to quantify that with various radiographic measurements, I will use the center each angle.
Yes, as a rough guide, if you see the femoral head edge sitting outside the edge, that's when you should think that this is dysplastic. So as soon as you start saying dysplastic, you're going into different paths and you could go down a slippery slope where the examiner would feel that you're not talking. You are. You don't understand the a normal and a dysplastic hip.
OK, so familiarize yourself to what is more or less normal and what is a dysplastic hip. OK so I can show you this plaster keeps later on, as I've shown you in my talk, but this is not this plastic. All right. Thank you. OK, so go on. So you told me you you've described the features of lack of joint space ossified formation.
And the other thing that you could think, so she's sitting in front of you and she says, doc, what are you going to do for me? What would you say? Well, I would like to find out her symptoms. And if she has and how the symptoms are troubling her and her expectations as to what she needs to do on a functional basis. OK, that's good.
So you want to find out more about her and what sort of options you're going to offer for her. So in terms of her co-morbidities, she's fit lady. No issues. She's not on any significant medications. She's living alone. She's a non-smoker. And these are the radiographs.
Mason these radio, these findings, I would recommend a course of non operative treatment with seats and physiotherapy to make sure that she is well optimized before discussing surgical options with her. OK yeah, that's a good way of going about it. You try to understand more, whether she can manage what sort of things she can do and she can't do. So have a plan in terms of her activities of daily living.
So the way I used to think about was, can she sleep? OK, think about from sleep, get up early in the morning. Can she put her shoes and socks on? Can she go down the stairs? Can she make her own breakfast? Can she go outside and use the public transport? Does she need a stick? How far can she walk? So that kind of way told me that I wouldn't miss out on any activities.
So that is how I used to. It's how you want to do it as up to you. But it's one way of trying to have ways of describing activities of daily living. So you don't miss anything. So do you foresee? So she's failed conservative management. Now, what do you do? Well, I would discuss with her the option of a joint replacement surgeries in this case, seeing how she has felt non operative, she can ask me, so what sort of joint replacement are you going to put in me?
In her, I would consider a total hip arthroplasty with I would template to see what was my question. Oh, I'm sorry. Was sort of total hip replacement. Would I perform for her? Yes so I was very precious because if you start dithering, the problem is then you lose time and then you go down areas where you don't want to. So templating is not what I asked.
I asked you, what sort of hip replacement would you offer this lady? I would offer this lady a cement, a total hip arthroplasty. That's fine. That's OK. That's all I wanted. So it's quite straightforward when you try to think what sort of answers.
I think we leave this at that because we can go to other things later on. Is that ok? Isn't perfect, so I think the next person for the case based discussion is c.y., who we know quite well, so see why I hand you over to Mr Cutty. So hi, see, boy.
So here this is a 60-year-old lady who now presents with bilateral hip pain and difficulty walking. Can you describe the radiograph to me, please? OK this is an AP pelvis video of a mature patient that can see the temperature hip, Patricio. So what do you mean? What is the definition of tattoos you show? The show is where the caller's line or the ego is still align.
The blood go beyond the ego is the line or the policy line? No no. Where the femoral head goes beyond the low-skill line, not the acetabulum. OK, the femoral head goes beyond the eliska line. If you're acetabulum is gone beyond that, that's of profunda. It's a different term. OK, so remember, terminology is very important.
So when the femoral head crosses, that's true you. That makes sense. Yeah OK. OK she's got she's got the so gone. So tell me, what else do you see on the X rays? So actually changes over the hip joint the second time I can see that the bones are still as well. So this is a case of how can you how can you say the bone and osteopenia on an X ray?
I would not go down that route. So then the examiner will ask you define osteopenia. So the subpoena is the best to be assessment. So is this a bone mineral density scan? This is a. Yes, so don't go down areas where you're not asked to go to OK. OK, just stick to what the examiner has asked you, and that's very important.
So you talked about the earlier skin line. War on the landmine. Other landmarks. That you honor on plane X rays, do you look for? You talked about kill line. OK, tell me, tell me other things that you would look in a plain radiograph. In the paragraph, I also look up for other features, I think for this case, I would look for the integrity of the different columns and the war within the stability.
What what columns are you looking for? And here in the post column, so what landmark would you associate with the 90 day column? You're getting a line like this for the posterior column. I will check for the anterior and the posterior. Also, very good. And I will check your drop as well. Yes what does the teardrop signify?
Do you see any fights or a representative of I think, yes, a media war is need to be aware of could true the true floor of this. That's what many people associate the teardrop as. OK, so the other thing is, you could if you were to do a central angle, what would be the central angle for this patient? It would be increased. Yes so these are the things I would look at.
So you would look at a the Illinois skyline, which in normal see where it sits to the femoral head. This is the Indian line, as you rightly said, for the anterior column, the center edge angle and normal is 25 to 39 and a protrudes you. It's way over 39. And as you said, as we said, the femoral head, it goes medial to the alioski's line.
And that's when it's defined as Patricio. If the femoral head sits lateral to the skin line and the flow of the acetabulum is actually medial to the skin line, that is cork profunda, OK, then we leave it at that. Now OK, excellent talk, Doctor Satish. Very, very succinctly exactly what we need for these folks.
And also, you've demonstrated for the farke's time is very important in your question, in your 5 minute waiver for each question. Also answer the question, which is a very important technique and focus on the key things. So for example, in this one with a profunda. The most important clinical information that you need here is that you're going to have to cut the neck in situ because your at risk of fracturing and you didn't get to that.
So that makes sense. OK, well done, everyone. Thank you very much, KneeKG. Hey, thank you, everyone. So we are going to stop the recording now.
Segment:0 .
OK good evening, everyone. Welcome to tonight's teaching session on total hip arthroplasty in the dysplastic hip challenges and solutions. This is a combined session with ORUK. And tonight we're privileged to welcome Mr Satish cootie as our guest lecturer.
Mr Satish is a consultant, trauma and orthopedic surgeon at the princess Alexandra Hospital in Harlow in the UK. He is clinical lead and clinical director of his department. He's been clinical lead since 2014. Mr Scott specializes in all aspects of hip surgery with a particular focus on complex arthroplasty of the hip and knee, including revisions of the hip and young adult hip surgery, including hip arthroscopy. During his training, he has won numerous awards which have and which have contributed to fellowships in Austria, Switzerland, Germany and Canada.
Mr Scott has had numerous publications. That is a reviewer. He's a primary editor for the bone, a Joint Journal. He takes a very keen interest in training and remains active in the regional orthopedic training programs. In recognition for his contribution, he was voted trainer of the year for the personal training program in 2016 and 17.
He's also the Royal College of Surgeons of England surgical tutor. I'm sure Mr. QWERTY has a lot to teach us this evening, and his experience as a clinician and a trainer will be valuable to everyone this evening. We have myself, KneeKG Evans, and we have Ruth and Hannah from duke, as well as our mentors Susan, honey and Samir. The program for this evening will be elected by Mr. curti, followed by an MCC poll and invited questions.
Your answers to the polling or anonymous. And we ask you complete these as promptly as possible so we can move on to the invited questions. And then on to some case discussions and top tips for the Fox exam. If you do have any questions, please write them in the chat box and we will monitor this and ask Mr. Cutty after the polling, when the teaching is concluded will stop the recording and will progress to the vyver practice.
This is a popular session and we ask that you raise your hand and message myself, Ruth and Hannah. If you'd like to participate, please state when you are taking the exam and priority will be given to those sitting in November. Please do this as early as possible and we will confirm with you via the chat. We will try to accommodate as many volunteers as possible within the time frame.
But those candidates who missed out on the Fox five, of course, on September the 19th, we have opened another course on the tenth of October, which has places available, so I'd ask you all to mute your microphones and without any further delay, I will pass you over to Mr. Cutty. Many Thanks to my room Mates, talk about arthroplasty in the dysplastic hip and it's a favorite of mine because I have a keen interest, plus the challenging solutions, especially in this type of problem.
So why is it a problem? If you look at what we see nowadays, you hardly see patients on the left with no operations because young adult hip is certainly a subspecialty on its own and we treat patients. I treat patients with young adult problems and they end up having multiple operations. And at the end, the straightforward hip is no longer there.
They often have severe deformities. The biomechanics are completely distorted, as I will show you with examples later on and a fair amount of these because of the excessive amount of bone changes. The middle ear canal is completely obliterated, making it a very difficult to insert a component. And on top of that, when you have retained metalwork of all multiple years, it's quite hard to remove them.
And that becomes an extreme challenge. So I hope you all know what the lateral center angle is, and the normal is between 25 to 39. If your lateral center dangles, you can see from this. This is how it's measured from the center of the femoral. Had you draw a vertical line and then from the very center to the edge of the acetabulum, that's the tended angle should be between that. If it's less, it's dysplastic and then you have a very high risk of osteoarthritis.
And my mentor, Professor Ganz, has written numerous papers on dysplasia, and it's clearly showed that if you don't assist this and manage this problem, they get arthritis very early. And there's another angle which I'd like to bring to your attention, which is not the lateral, but the anterior one which is taken in a special way. It's called the false profile view. And this anterior edge, if it's also less than 25 and you got to really worry, which is not the case is often the anterior column and the anterior wall, which is really dysplastic, and we need to understand that, especially when you're reconstructing for osteoarthritis.
So that's the young person, and if this patient is not addressed early on, we'll go on to get arthritis, for sure. He is. So this is a patient all four years, how rapidly is progressed from having some cartilage to severe osteoarthritis, so how rapidly they progress, so they're not addressed early on, there's a problem, but by the time they come to you, you have all these issues. Luckily, this patient didn't have any metal working or any operation, so it's a reasonably easy, total hip arthroplasty to perform.
This is the issue. Now this is a young patient, this is not my patient, this is one of my boss's patient. 90 seven, she's 24 years old of severe osteoarthritis and I had a hip replacement. And then within seven years, you can see the police worn out and by 32 years old, he's already had first revision. This is the scale of the problem that we face. But implants have changed.
We for better biomaterials, so we are hopeful that the second the first revision may last because that's a ceramic and highly crossing, poly bearing liberation. So this is Professor flakiness, so he doesn't believe in deed. He said these people are born and he feels it should be named as congenital heart disease, the kind of privilege of working with him. So I've learned a lot from him about his thinking and what you should remember the acetabulum, the femur, even though they are linked.
Each has its own problems. They have deficiencies. You have superior a column. These are the ones that severely affect how you manage these patients. And as a result of where the hip is like, the soft tissues are very contracted, the abductors are not functioning well and sciatic and femoral have issues because they are quite contracted.
And when you lengthen or bring it to where their acetabular component should sit and bring the family component down into it, you're stretching neurological structures and there's a limit to how much, how much you can stretch. These structures. Because they will have a neurological compromise if you stretch it way beyond what you're allowed to. On the family side, again, this hypoplastic, it's a very small canal.
The family head is very small. You have leg length issues. The versions completely changed and with hardware and deformity, it becomes a significant challenge to address this problem. So classification and classification is important, and as we always find out during a training, why do we talk about classification classification essentially to understand the severity of the disease and for each what do you how do you manage each one of in those classified subgroups?
And also to communicate results? And if you don't have some sort of way of doing it, it becomes a problem. So there are two very popular classifications that are used. I'm sure everyone knows these. The first ones are Crawford, and the other one is the heart of L Now Crow. If you type in pubmed, the amount of references to crew is huge, but I have to think this is not that much.
My personal feeling is to do the fact that people find it very difficult to pronounce the name this. And that's why they tend to err on using cruel, which is very cruel. So we're going to come so sorry. So cruel. What he's done is mentioned the proximal migration of the femoral head diameter, and this is in relation to the interchangeable.
So for one, is less than 50% of the diameter. That, too, is 50 to 75 percent, so this is the image this is the one on the left, where you see is the amount of migration of the femoral head in relation to the teardrop. So 50-50 to 70 five, 75 to 100 and over 100 that's one to 4. Uh, where this is classic paper, which has been coated all the way through.
And who is cruel if you Google and find out crows a hand surgeon now and he works in Greenwich Hospital in the US and his fellowship with what resulted in that article. I was fortunate to work with four kids during my training and I visited this hospital in Athens. That's cat hospital and a very busy hospital, and they have a significant amount of dysplasia that they treat.
So it's very simple dysplasia where the femoral head is blocked, but it's still inside the original slap. You know this location where it is outside the true acetabulum in a fault partially overlap. The true acetabulum that's low dislocation and high is where there is no contact and it's way higher up. So those are the images so that a is dysplasia. B is low dislocation where there is still some very little contact, but it's still outside the true acetabulum and high is outside and falls a suitable.
So Bill Harris commented. And this is Professor is slide, where he said that they found this far more effective classification than cruel. So I would encourage you to use this because it's far more easy to understand and to discuss. So in the dysplastic type, what do you do? So it's normally a very ovoid acetabulum, there's good bone quality and you can't put in standard acetabular components without a problem.
Majority of the time, very rarely you do need screw augmentation to just support it for the first six weeks, by which time you get bone growth or in growth to the external component. And then it's fine. But remember, where you place, it is very important. Never try to place it high because it's clear evidence that if you place your a component high up, it will fail to aim for where it should sit and then you need to address how you're going to manage the area, which is uncovered.
And that's how you decide on what sort of components you use. So here's one. In my second year, which was 2011 12, actually dysplastic, straightforward and you can see the amount of coverage that's going to be there. I've kind of usually these components are very small. At that time, we didn't have electronic templating, so it was all hand on a printed X-ray sheets, whereas now we have modern software which tells you what to do and how much of lengthening you need to do a shortening of the femur.
If required. So this is that first case that I showed you, and you can see the area of coverage, the acetabulum, and that's when you put the family component in, you can see the amount uncovered. And this operation very solid. Still, I just felt that there was a slight give. And so I augmented this with screws to support the component.
And that's that patient before and after, and this is a 9 year X-ray. So she's done in 2011, and she's doing extremely well in low dislocation. Now this is the one out of the two that you often find quite difficult. So you end up it's quite easy to put a component in, but you have a significant area which is not covered. How do you address that area, which is not covered.
So you could do its structural grafting with the femoral head that you've taken out? Or you do Control perforation, which is the cultural policy which is hardly done from my understanding. Or you keep where the hip is meant to be at high hip center, which again, I say I would encourage you not to or you use a suitable organs, which is fairly new and it's hardly any literature for primary hip replacement.
There's plenty for revisions, but in primary I haven't seen it much in terms of the use of organs and the results. So here's how you can put in a structural paragraph, which is usually flying buttress, so you shape the aircraft is a figure of seven. So if that's a hemisphere, you cut an L shape off and so that becomes a figure of seven. And that is placed at the edge of the established screwed in place.
And then you remove the socket. And just like this, so that's the femoral head screwed into place. You ream that and then you place your components inside your. It was pretty good, but it's technically quite difficult because you need a fine line between loading it and unloading it, so if it's all loaded, it will disappear.
If it's unloaded, it will disappear. So you've got to be really careful as to how it works. Now I'll show you one of mine, which I thought didn't work initially, but then it seems OK at the moment, so it can fail because it can resolve very quickly. So, so sorry. So here's mine and this patient, as you can see, I place the femoral head first.
Use a choir to place it to make sure it doesn't move. Fix that with screws and then agreement to place your component. So this is what, as I said, was quite poor. I thought initially. But this X-ray is taken nine years, 8 to nine years, and it's still there. So if you don't place it properly and the screw direction should be quite.
Allen to these crews so that it doesn't resolve, and the loading is perfect. So that's an issue. It's a technical problem, so it's very difficult to get right. So I moved away from this, so I tend to use augments as required. So here's one where I've used the much bigger screws and this seems to have worked and it's a much smaller patient.
So it can work and it can fail. Ca2+ is very controversial now. A lot of people in. I've done it, and it has reported quite a lot. And the people that I would credit those to is this is Professor Santos. So that was his right hand man, and he's the one who championed cultural policy.
But as Nicholas Bowler from Vienna, he feels that it was the Austrians, and the Germans who popularized it. So that's parent Purna person is the one who has written a lot about this and how he's shown is that the screw up, how you perforator the media war and is pushed inside and the cup goes into effect? It's quite difficult for me to do, and I think many will find it quite difficult.
And this is another image of how you can buffer the medial cortex and fix that with a cup and some screws. So that is an option, but it's rarely used. This is the one that is quite popular and a lot of revision. Hip surgeons and hip surgeons use this called the flying buttress augment. And it's a revision hip as a classification from the type III segmental defect, which is quite easy to manage with an augment.
So here's a case where in a dysplastic hip, I put the trial in just to see how much is not exposed to the amount exposed used to augment trials, to see what fits best. So you can either put the cup first and then the augment and you can unity's the two either using cement or bone graft. I tend to use graft where possible or in this position where if you feel you can put the augment in first, then you put the external component and then try to utilize that with graft.
And that's the fine position and the case that I showed you before. This is a 44-year-old lady who's had a shelf operation procedure for dysplasia done, but one of my senior colleagues many years ago. And that's how she is, and that's how she is now. That's a seven year follow up, and that augment is done really well. So this is another way of trying to manage these kind of complex scenarios where you need superior support.
So this is for the low dislocation and high dislocation this is challenging not for the acetabular side, but from the femoral side. And the acetabular side is really small. So you've got to make sure that your standard components that you have on your shelf don't usually fit. It's in the 40 millimeter size range that often you have to put in. So you have to get the microsystem in for these procedures and often for 40 to 40 for very rarely, for leaks in high dislocation, it's often 40 42 that you have to use.
And because the size of the external component you end up using, even if the plastic inserts, eyeliners and heads. So I end up using ceramic liners for these patients. And a for the federal side, you because it's quite high, it's quite tight, and you need to really do an osteotomy and this is from the paper I'm going to show and I would encourage you to look at the surgical treatment. Jamie American from Mayo clinic Rochester, which gives you a very good view of how to do it, and it's exactly how I tend to do mine.
And this is from that article how they have done a slap osteotomy. They brought the hips into normal and they've used the allegra, the graph from where they've done the osteotomy to help with further bone healing. And this is from our center in Exeter, where they even cemented cup and stems do work in this kind of situation. And they have got very good results, a small cohort of patients, but just show you that it does work for me.
The biggest problem for is that when you're after, you've done your osteotomy, the diameter of the proximal fragment and the inferior fragment is not the same. And unless you get a very tight seal, you will get cement leaking in between into the osteotomy side and it may not heal. So I find it very difficult as a skill, so I tend not to do this.
So this is Professor Hertel kids's diagram, where he feels that this is how you should do it. The one on the left, where you take the head, the neck and part of the lesson to Canter off and you keep the greater Toronto and then you reattach the grade onto the distal onto the femoral segment. Whereas I feel he feels that this one subsequently shortening osteotomy is not the way to do it, but I find that this is much better because you're abductors are there intact with the shaft and they work very well, and I'll show you how I do that.
So here's one of mine and this is a 46-year-old lady bilateral and this one how you do. That's that's the fault acetabulum. And then you go further down, you find the true acetabulum. So I do the osteotomy first to allow me to see because it's out here that the establishment sits. If you don't do the osteotomy beforehand, sometimes it's quite difficult to see the true acetabulum. And that's how much of segmental removal I've done gradually to see how much I can take off to reduce the hip joint without too much tension.
And that's what it looks like. Immediate post of both sides. And that's an eight year follow up where the bone graft has kind of incorporated really well. So as I've told you, the high hip center is clear evidence that if you leave it there, it will fail because the abductors don't function really well. The loads are pretty high and there's impingement.
The patient is not very comfortable in that kind of position to bomb. Biggest issue is biomechanical, and there is evidence that it will fail. And as I've said again, there's high rate of loosening, and Marc Bookman has shown that, so it is best to place it in its true center. The biomechanics will work. There are some other ways of doing it, so if it's a very dysplastic that you could use a blonde cop, there is some evidence that it does work.
That's one of mine. A gun some time ago. This is during my first year as a consultant. And it did work, but I felt that the augments did a much better job. So this is another option for you to use. Now, the federal reconstruction, I think that's the one was more challenging, especially in the high dislocations, because the other two parts, the other two types, the straightforward, dysplastic one on the low dislocation you can manage reasonably well.
So you need to understand where it is, where you have the deformity. And this is from Dan Berry's paper, and I would encourage you to look at where the site, what sort of geometry there is the geology, and then you can decide how you're going to manage the type of deformity and what sort of components you require. And that is absolutely key because not one component will fit all the types.
So here's one of mine, and this is the problem, because this patient is about eight operations on the right, and this one has had this done when she was a child and she's now in her 40s. How are you going to find this metalwork? This is a blade plate put in, and often the screws are so buried in. You're going to think hard. How are you going to take this off?
And the patient from the first one on the left, as soon as you and I went and I did the osteotomy, I couldn't see the canal. It was completely obliterated. So it was a hard round segment of bone not like what you would see normally. So the majority canal can be very difficult to manage if you have this sort of problem. So a CT scan you can do to help you, especially to assess the torsion or rotational aspect and leg lengths to see how much you can length, how much you need to lengthen to equalize these patients.
So planning is an absolute must. And CT scan of the hip and the knee, I feel, does add a significant amount of information and 3D reconstructions to help. So this is a story that patient from before. And if you look at her 3D seats, if it plays, is going to play. So the amount of deformity this patient has and how are we going to address this with a standard stem is the question.
So this is her fema, she's had about 4 to five operations on both sides, the established side and the federal side. And if you take the cross section of her acetabulum, you can see there's hardly any interior wall and then to column is quite hypoplastic. And when it is externally rotated. So this patient has severe torsional abnormality.
And in fact, if you add the two together where the foot, the knee and the hip sits, you can see how much of retribution she has. So you may need to consider how you're going to place a component because if you place it anatomically, there is a chance that these could dislocate and that's the planning and the type stem you could use. I decided to use a special design stem for her because I didn't think I could manage the deformity with a straight stamp.
So it was a custom designed for this lady. And that's how she is on the table. And you can clearly see that the knee is pointing up in a lateral position so the amount of torsional abnormality she has. So this is where you need to think outside the box, and I tried to fit the implant to the patient and not the patient to the implant. So these are unique solutions.
They are expensive and that you need that something. You need to have a conversation with your commissioners because if they get sent to especially center, often the cost is even higher. So that's how you can justify doing it in centers where you have a fair amount of volume. So that's the stem I used, and that's the rasp. Both are kind of custom designed ones and and that's how she is. It's a little rotated view, but it is another view where you can see that it sits in the middle.
And because of the torsion abnormality, it was abutting the lateral cortex. But this is three years old, so I'm pretty happy with how she is. First time she walked with a foot pointing forwards, which never happened since her childhood. So you need to evaluate how much of torsion abnormality there is, and if it is a total abnormality, straight terms don't work, so you need to consider really logical.
So consider alternative stems to help with this problem. And if it's more than 40 five, when we do total hips, we do a combined activation of about 45 between the established component and the femoral component. That combined version is way more. You need to consider rotational osteotomy to address the defect, and that's through the sub tocantins region, and it can be achieved using various components and the most versatile component that I was always taught with the asaram, but it's got two different parts, and that's the problem for me.
So it it is quite useful to address version and I'll show you how, for example, this patient, that's a female, that's a leg, that's the femur and the neck is pointing a So when you place the sleeve of the stem, it's quite and when you put your if you put a straight stem, you can't address that problem. So that's where the sleeve helps. And then you can rotate where you want to place the femoral component.
And this is the very same patient where the sleeve is actually pointing at us and pointing anteriorly. So that's why I think these kind of modulus items are useful. Now this is the it's a moral block. So this is where I think this tapered fluted stem play is much easier to use compared to the rest room because the trauma has different parts. This one is useful.
It's just got splints and actually catches or engages the two parts of femur. Should you do it with an osteotomy? I think that's where this plays a significant part for me. And as you can see in this, this patient is a low dislocation and you can link the two parts with a separate country osteotomy. You can use wires if you want to, and a bone graft superior to augment fixation.
The things that I was always taught was do not lengthen more than centimeters. And I really can't find a reference for this centimeters and that's what is quoted. Some say five. Some say four. I tend to keep it at four with more than four. There is evidence that sciatic nerve can be compromised, so shortening is necessary.
And that neurological compromise is a significant problem that you need to understand when dealing with lengthening procedures. This is historic or knot is debatable now. In case you have proximal, you want to avoid anything going distal so you can just consider the proximal femur resurfacing or the meathead resection or even a metatarsal bearing type device.
Now, a lot of these metal and metal is more or less gone, although some centers still do it. I'm not saying it doesn't work, but it does in certain groups which have still this has been removed from the market. It was doing quite well, but for some reason it's been removed. And in this kind of situation, it is useful. So whether it's historic or knot is a question that many people can ask and debate or use amid head.
And this patient had severe femoral neck deformity that one of my bosses decided to imitate, and it worked in this patient. You may think how the hell is going to work, and this is a three year radiograph of a heterosexual. And I thought he was bonkers trying to do this, but it did work. Or a metaphysical type. This is one of my patients.
This patient had this plate put in 2021, 30 years ago, and it's quite anterior and the screws is very difficult to remove because they were really welded in. So an option was to consider a proximal capsule and managed to remove to the others were difficult. So I did plan on a proximal metatarsal bearing. Now this is an eight year X-ray for these patients, a long term follow UPS that I've shown you.
So they do work, or you can use a very short stem. Again, this patient. This is a silent prostheses which has been removed from the market. But this did work really well, especially if you proximal femoral deformity so you can think outside the box and just look at the proximal segment to use in resurfacing. It has been reported.
And this is from Holland aptitudes group and there was also really good. The thing that you need to worry about is because of a lack of weight bearing the bones for osteopenia, so they don't do well in these. So here are had this work made, had a section say like this one, you can consider dysplastic socket and have had a femoral component. So in summary, use a modern hip armamentarium is very important, and if you don't plan, you run into problems and you should always have bailout options and you may have to resort to traditional methods.
And I can show you one of my examples later on. Thank you. And thank you very much, Mr Casey, that was an excellent lecture. I don't know how the other mentors feel, but I think, you know, dysplastic hips. It's one of those topics that you can just learn. And then if it comes up in an exam, it's a gift because you can talk about all the different ways to manage the acetabular deficiencies and the proximal femoral problems.
So that was excellent. If you missed part of the lecture or if you want to watch it again, which I think would be worth doing, it will be available on both the mentor website and the UK website. So what we're going to do next is the MSCI polling, so Ruth is going to share the polls and we just want you to answer the correct answer. It's all anonymous, so if you do it as quickly as you can, then we can move on to the case based discussions.
If you look at if those who joined initially will note that my second or third slide, I did mention that the lateral sandridge Angelo peel-back is 25 to 39. So 25 34 is wrong and now you can debate why 39. But that's the figure quoted in the literature. Less than 25 dysplastic and over 39 degrees is over coverage, so it's 25 to 39 is the right answer.
And we want the next question, if you want. Yes, please. Out of the work. You just scroll down, there's a little toolbar to the right hand side if you just pull that down. Yeah, OK. So the yes, second question, my dislocation. Yes, centimeters.
Absolutely right. As I said, they some do say five, but I think 4 is what's quoted in the literature. So that's correct. Majority, if you got that right. And high dislocation. What segment? Yes, it is the anterior wall on the anterior column. That's the segment which is hypoplastic.
And this is what you should really consider and be very careful, especially when you are preparing to insert your tablet component. That's the first question, I think the other two people have done really well, which is good. OK, that's great, thank you, Mr. cutie. So I think we're going to move on to some questions that were asked.
One so the first question I think you've already answered is lengthening. How much anything you can do before you can get sciatic nerve injury. You've answered that before centimeters. And the next question is, how do you decide how much shortening or do you do to? So that's essentially planning and operatively assessment. So if you if you would, with your regular amount of force that you use to reduce the hip and you can't, then you have to consider shortening.
So because you do want to put excessive traction on the neurological structures. So in pre-op planning, you will find the amount of where the femoral head sits on the dislocated hip and where the true acetabulum is. So that distance is the distance you're going to bring the hip center down. So that's when you can decide if it is 4 centimeters or less, you should be OK.
But even if that is too tight, then you need to consider shortening. But beyond centimeters you have to consider shortening from that by templating. OK another question how would you manage a mild or early stage dysplasia of the hip when they are not arthritic? Uh, so if under the age of 40, if they have a dysplastic literature shows that by denotation osteotomy of the acetabulum, which is a period loss tenotomy depending on what type it is, they do really well, so they have to be under 40 beyond 40.
What happens is the articular cartilage results do tell us that they don't do really well, and that's from the burn burn group, so above the age of 40. So you need to consider be very careful whether or not your team is going to work or not. OK and so how do you overcome leg discrepancies? Intra operatively. So again, the shortening osteotomy, the pelvis is so compensated already so that when you have done your shortening osteotomy, you'll be surprised that they often equalize, even though one leg is short.
And after a while, the pelvis to settle bilateral hits perfect because both your shortening for the same amount, so they do really well. So you can with pre-op templating, leg length scan, you can assess how much you need to change there, how much you're going to shorten to equalize ligaments. OK and again, another question I think you've already answered this. How do you make it?
Well, I know you've answered this. How do you make your decision whether to use a male or female head bone grafts? So I use very young patients. If the fighting the femoral head is pretty good in good quality, then I can use that. And I think that this biologic and I use it in older patients above the age of 50 at the femoral head when I feel is not of great quality, I use an augment.
OK, and just one more question, if you mind the discussion about hip resurfacing dysplastic, if there are kind of recommendations about when to use hip resurfacing and they include large head size and male bone. Does dysplastic fit this category? I have told you before, it. Yeah, as long as the resurfacing, the femoral head is very flattened or because if there's not weight bearing, that particular part of the femoral head is very soft and osteopenia.
And so resurfacing doesn't work very well in that situation. So there you need to consider mid head resection where you can take the head off and then put the metal mid head type of prostheses in a dysplastic hip. If you see the femoral head quality is pretty good, then it will work. Resurfacing as Holland absence has shown that you have to be very selective in what kind of patients and in young fit.
It does work very well. And I would qualify. That's exactly the way you qualified the statements only in a certain select criteria patients with deformities. Just in case the candidates were misunderstood, that's OK. So that's all the questions, if there's any of the mentors have any questions.
And if the questions we proceed to the next. OK, great, thank you so much, so we're going to move on to a couple of case based discussions, and we've got two volunteers for Mr Coffey to go through the case discussions with. So I think our first one is, is it Lang ang? And we'll get you ready. And I am.
Hi Hi. All right, so Mr Cutty is ready for you. Have you yet? We can see you. Excellent right? So this is your department. This is a 75-year-old female who is sitting in front of you and she's coming with obviously, right? Can you just describe what you see on the X ray?
In this AP video graph of the patient's pelvis, there is a pathology in the right hip. I can see that there's arthritic change with the decreased joint space also formation. The very suggestion that this could be a dysplastic hip with a shallow acetabulum, though. How can you want to play an X ray? Just looking at that, do you think that's dysplastic? It will be I will need to quantify that with various radiographic measurements, I will use the center each angle.
Yes, as a rough guide, if you see the femoral head edge sitting outside the edge, that's when you should think that this is dysplastic. So as soon as you start saying dysplastic, you're going into different paths and you could go down a slippery slope where the examiner would feel that you're not talking. You are. You don't understand the a normal and a dysplastic hip.
OK, so familiarize yourself to what is more or less normal and what is a dysplastic hip. OK so I can show you this plaster keeps later on, as I've shown you in my talk, but this is not this plastic. All right. Thank you. OK, so go on. So you told me you you've described the features of lack of joint space ossified formation.
And the other thing that you could think, so she's sitting in front of you and she says, doc, what are you going to do for me? What would you say? Well, I would like to find out her symptoms. And if she has and how the symptoms are troubling her and her expectations as to what she needs to do on a functional basis. OK, that's good.
So you want to find out more about her and what sort of options you're going to offer for her. So in terms of her co-morbidities, she's fit lady. No issues. She's not on any significant medications. She's living alone. She's a non-smoker. And these are the radiographs.
Mason these radio, these findings, I would recommend a course of non operative treatment with seats and physiotherapy to make sure that she is well optimized before discussing surgical options with her. OK yeah, that's a good way of going about it. You try to understand more, whether she can manage what sort of things she can do and she can't do. So have a plan in terms of her activities of daily living.
So the way I used to think about was, can she sleep? OK, think about from sleep, get up early in the morning. Can she put her shoes and socks on? Can she go down the stairs? Can she make her own breakfast? Can she go outside and use the public transport? Does she need a stick? How far can she walk? So that kind of way told me that I wouldn't miss out on any activities.
So that is how I used to. It's how you want to do it as up to you. But it's one way of trying to have ways of describing activities of daily living. So you don't miss anything. So do you foresee? So she's failed conservative management. Now, what do you do? Well, I would discuss with her the option of a joint replacement surgeries in this case, seeing how she has felt non operative, she can ask me, so what sort of joint replacement are you going to put in me?
In her, I would consider a total hip arthroplasty with I would template to see what was my question. Oh, I'm sorry. Was sort of total hip replacement. Would I perform for her? Yes so I was very precious because if you start dithering, the problem is then you lose time and then you go down areas where you don't want to. So templating is not what I asked.
I asked you, what sort of hip replacement would you offer this lady? I would offer this lady a cement, a total hip arthroplasty. That's fine. That's OK. That's all I wanted. So it's quite straightforward when you try to think what sort of answers.
I think we leave this at that because we can go to other things later on. Is that ok? Isn't perfect, so I think the next person for the case based discussion is c.y., who we know quite well, so see why I hand you over to Mr Cutty. So hi, see, boy.
So here this is a 60-year-old lady who now presents with bilateral hip pain and difficulty walking. Can you describe the radiograph to me, please? OK this is an AP pelvis video of a mature patient that can see the temperature hip, Patricio. So what do you mean? What is the definition of tattoos you show? The show is where the caller's line or the ego is still align.
The blood go beyond the ego is the line or the policy line? No no. Where the femoral head goes beyond the low-skill line, not the acetabulum. OK, the femoral head goes beyond the eliska line. If you're acetabulum is gone beyond that, that's of profunda. It's a different term. OK, so remember, terminology is very important.
So when the femoral head crosses, that's true you. That makes sense. Yeah OK. OK she's got she's got the so gone. So tell me, what else do you see on the X rays? So actually changes over the hip joint the second time I can see that the bones are still as well. So this is a case of how can you how can you say the bone and osteopenia on an X ray?
I would not go down that route. So then the examiner will ask you define osteopenia. So the subpoena is the best to be assessment. So is this a bone mineral density scan? This is a. Yes, so don't go down areas where you're not asked to go to OK. OK, just stick to what the examiner has asked you, and that's very important.
So you talked about the earlier skin line. War on the landmine. Other landmarks. That you honor on plane X rays, do you look for? You talked about kill line. OK, tell me, tell me other things that you would look in a plain radiograph. In the paragraph, I also look up for other features, I think for this case, I would look for the integrity of the different columns and the war within the stability.
What what columns are you looking for? And here in the post column, so what landmark would you associate with the 90 day column? You're getting a line like this for the posterior column. I will check for the anterior and the posterior. Also, very good. And I will check your drop as well. Yes what does the teardrop signify?
Do you see any fights or a representative of I think, yes, a media war is need to be aware of could true the true floor of this. That's what many people associate the teardrop as. OK, so the other thing is, you could if you were to do a central angle, what would be the central angle for this patient? It would be increased. Yes so these are the things I would look at.
So you would look at a the Illinois skyline, which in normal see where it sits to the femoral head. This is the Indian line, as you rightly said, for the anterior column, the center edge angle and normal is 25 to 39 and a protrudes you. It's way over 39. And as you said, as we said, the femoral head, it goes medial to the alioski's line.
And that's when it's defined as Patricio. If the femoral head sits lateral to the skin line and the flow of the acetabulum is actually medial to the skin line, that is cork profunda, OK, then we leave it at that. Now OK, excellent talk, Doctor Satish. Very, very succinctly exactly what we need for these folks.
And also, you've demonstrated for the farke's time is very important in your question, in your 5 minute waiver for each question. Also answer the question, which is a very important technique and focus on the key things. So for example, in this one with a profunda. The most important clinical information that you need here is that you're going to have to cut the neck in situ because your at risk of fracturing and you didn't get to that.
So that makes sense. OK, well done, everyone. Thank you very much, KneeKG. Hey, thank you, everyone. So we are going to stop the recording now.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode