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Name:
'How to Do' - Uncemented Femur
Description:
'How to Do' - Uncemented Femur
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https://cadmoremediastorage.blob.core.windows.net/5748f504-e98b-47b3-8c0c-730444f89f01/videoscrubberimages/Scrubber_1.jpg
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T00H09M13S
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https://cadmoreoriginalmedia.blob.core.windows.net/5748f504-e98b-47b3-8c0c-730444f89f01/Video033-008.mp4?sv=2019-02-02&sr=c&sig=CuHfeBfi0MSs2%2Bz%2FXy3u5jRtPj7VIzVAR9PK14jVcA8%3D&st=2025-01-22T17%3A01%3A21Z&se=2025-01-22T19%3A06%3A21Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DOMINIC MEEK: There's various steps if you're doing a cementless stem. You're going to have to template it first. It's important you get the neck cut right to protect the cementless stem entry point, and then we'll go a bit over how you impact. It's different to how you do for a cemented one, so that's the real aspect. For all your stems, trial reduction. In the cementless stem you'll need to do calcar reaming, do a rotational stability test, and then insert the stem.
DOMINIC MEEK: So first thing, templating. You can't not do it. OK? So particularly what you're going to be looking in this case is to where their lesser trochanter is mapped because you're going to measure that so that you know when you're intraoperatively assessing it for leg length, and the offset reproduction for your cementless stem, and the relation of the greater trochanter to the center of the head.
DOMINIC MEEK: And you're going to use all those as landmarks intraoperatively. But a little bit about the neck cut. It's important you get that correct, because that determines you access to get your entry point. And this is one actually from Martin Stone demonstrating on a dry bone where you actually have to make a cut so you can access out to the side. If you don't, you're going to put it down into varus.
DOMINIC MEEK: In the cemented stem you get a varus stem in your X-ray. In the cementless stem, you'll get a fracture. So it's important that you get out to that lateral side. And you can see that there where he's putting it down now, and he's getting down the middle of that because you can't really be too lateral. So this is just demonstrating intraoperatively. Don't go in at that.
DOMINIC MEEK: You've got to make sure you've got access out into the pyriform fossa, and you're going to make sure that you're going down. At that point you're beginning to turn your anteversion. So you're looking at the leg assistant's holding, making sure it's vertically up and making sure you start at that point, because unlike a cemented stem, you don't have the advantage of being able to tweak that anteversion at the end when you actually insert it.
DOMINIC MEEK: You at this point, when you're preparing it, are determining what the anteversion is going to be. And if you look at it and it's a retroverted neck, stop at that point and go to cemented stem. That would be one of the take home messages. So you should always have a cemented back up for your cementless stem. But in the young patients who have narrow canals you obviously templated it for doing this particularly.
DOMINIC MEEK: So you see how you start at the beginning with the rasps, and you're just going to gradually-- and in this case you're compressing the bone out, so you want to stabilize it that way. So you just keep gently going at it. And the taps are very right. We'll come to that in a second. You don't want to be banging it with a 2 pound mallet. OK?
DOMINIC MEEK: It's just gently upsizing it. And one particular thing is when you put the rasps down, put them down after the first one by hand. Don't hit them from the very beginning. You want to actually get it close. And if you're less than one finger breadth from the neck, you know you're going to go up to the next broach up. If you're more than a finger breadth, go back because you're not going to get that stem down.
DOMINIC MEEK: You're going to cause an interrupted fracture. So we're continuing to go up. You're just checking for your finger, making sure that the calcar distance to the broach is right before you start doing that next stem. Just keep repeating it. And the point of this is you have to be patient. You can't just leap up and go onto the next one. So we're just checking again, and you can look at the metaphysis and see how much bone there is left there as well so that there's also enough room to get the next one onto it.
DOMINIC MEEK: So again checking it's still small so we can do that. What you don't want to do as well is when you're putting it down, you mustn't wiggle. OK? You're compressing the bone. If you wiggle it you're going to destroy all that compressed bone, and you're not going to get a proper press fit. And equally, you want to have started out lateral.
DOMINIC MEEK: You don't want to keep rasping away at it from that point of view. So again, you can see there is little bit of movement still present there, but now we're going to tap it down. And we're beginning to get what looks like a solid fit. And the whole femur moved when you did that there. So we just to go to next page. So at this point we're just going to quote one from Steve Young who actually did a good paper of actually the noise production.
DOMINIC MEEK: So that's another feel you can get from this. And then actually the femur acts as a resonance. So when you're actually tapping it down, if you look at the difference when you're beginning-- [CLATTER] You've got a lower tone. When you're getting close, you're getting your resonance up. [CLATTER] A lot of woodpecker sound, but you don't want to go much beyond that.
DOMINIC MEEK: So that's a sweet sound, so get some feel for that as well. So just to carry on to the next bit, where we're actually putting it down. So again we're trialing it now. So we think-- we're actually putting on the neck pieces. But we're going to check where that seems in relationship to the greater trochanter. OK. We knew it should be a slightly varus neck so we should be below the tip of the trochanter.
DOMINIC MEEK: And we're also checking the neck in terms of the calcar. So once we put that on we're looking where that is and checking across to the greater trochanter. And we are feeling it's a little bit too long. So at that point, we're feeling that that's going to produce too long a neck length. So at that point we'll decide to advance the broach a little bit more. So we're just actually just checking where the position of the broach is at the moment relative to the greater trochanter.
DOMINIC MEEK: So we're taking that and advancing it another few millimeters. You can do the approach with the broach the grim hope to tell where the paper from Exeter that wrote it up about of your templating marking it onto the broach, and then you can actually check that against the greater trochanter. So at this point, we're now going to check again. We're just going to mill it down, and then that would mean that we've actually got the few millimeters down from the position we actually need to do.
DOMINIC MEEK: And there's two sizes for this. So you can actually start with always the smaller one before, and then expand it up to the larger one at that point. And now you've done that, you can actually finally check it. And it's important that you're checking it for stability as well as leg length. The tests that I would always do, once you've actually reduced it, is that you'll see how easily it reduced.
DOMINIC MEEK: So the sort of shuck test. And that gives you an idea of the tissue tension, which is a combination of the offset and the leg length. You want to flex it right up and make sure there's nothing impinging when you flex it and internally rotate it. Sometimes there can be a little bit of osteophyte at the top. Sometimes it became a little bit of hypertrophic capsule or rectus, and so you may need to just remove that to stop it doing that.
DOMINIC MEEK: The other thing is to bring it back into extension when you're doing that. And at that point, if it kicks out, you know it's too tight as well. But at this point we're just going through all the motional tests of it here, and we're happy that the balancing of the hip replacement is correct. We just do another final couple of millimeters.
DOMINIC MEEK: It's important you know the design of the cementless stem you have. In this particular one it's slightly bigger than the broach. So if you've just got it flush, it might sit slightly proud. So in this case, we're just doing another 1 or 2 millimeters down further so it'll actually go down. So we're just taking this out.
DOMINIC MEEK: In this case, you don't do all the pulse lavage. You want to preserve all the bone that's there. And all the osteocytes, you're not pulse lavaging because we're not using acrylic to fix it. And at this point, we just obviously-- you've got a good exposure. At this point, when you put it in by hand, again, check that you're within a finger breadth. If you're not within a finger breadth, you may have put it in at the wrong orientation and it's going to catch.
DOMINIC MEEK: And then just finally tap it home. But again, just gentle taps until the collar engages with your milled point to your neck. And once you've done that really the operation is over. You can then just expose the trunnion. Important thing about the trunnion, it must be clean. Anything in between the femoral head and the trunnion will cause the possibility of corrosion or at least not allow it to implant onto it, and you can get abnormal wear from that point of view.
DOMINIC MEEK: So it's, again, vital that you actually do keep it as clean and as dry as possible. And at this point then you would check that there's no retained material in the acetabular component. You would then reduce it and again do your final check of rotational movements for stability, tissue tension, and the leg length at that point of view.
DOMINIC MEEK: And that's just summarizing the steps you would want to do with that. If you do that, you should get what you expect on your post operative X-ray. Thanks very much
SPEAKER 2: If you've enjoyed these videos, there will be more at future BHS meetings where we'll be running further educational days covering the syllabus for the FRCS T&O exam, which will be of interest to trainees but also to hip surgeons alike. And I hope you enjoy them.
Segment:0 .
DOMINIC MEEK: There's various steps if you're doing a cementless stem. You're going to have to template it first. It's important you get the neck cut right to protect the cementless stem entry point, and then we'll go a bit over how you impact. It's different to how you do for a cemented one, so that's the real aspect. For all your stems, trial reduction. In the cementless stem you'll need to do calcar reaming, do a rotational stability test, and then insert the stem.
DOMINIC MEEK: So first thing, templating. You can't not do it. OK? So particularly what you're going to be looking in this case is to where their lesser trochanter is mapped because you're going to measure that so that you know when you're intraoperatively assessing it for leg length, and the offset reproduction for your cementless stem, and the relation of the greater trochanter to the center of the head.
DOMINIC MEEK: And you're going to use all those as landmarks intraoperatively. But a little bit about the neck cut. It's important you get that correct, because that determines you access to get your entry point. And this is one actually from Martin Stone demonstrating on a dry bone where you actually have to make a cut so you can access out to the side. If you don't, you're going to put it down into varus.
DOMINIC MEEK: In the cemented stem you get a varus stem in your X-ray. In the cementless stem, you'll get a fracture. So it's important that you get out to that lateral side. And you can see that there where he's putting it down now, and he's getting down the middle of that because you can't really be too lateral. So this is just demonstrating intraoperatively. Don't go in at that.
DOMINIC MEEK: You've got to make sure you've got access out into the pyriform fossa, and you're going to make sure that you're going down. At that point you're beginning to turn your anteversion. So you're looking at the leg assistant's holding, making sure it's vertically up and making sure you start at that point, because unlike a cemented stem, you don't have the advantage of being able to tweak that anteversion at the end when you actually insert it.
DOMINIC MEEK: You at this point, when you're preparing it, are determining what the anteversion is going to be. And if you look at it and it's a retroverted neck, stop at that point and go to cemented stem. That would be one of the take home messages. So you should always have a cemented back up for your cementless stem. But in the young patients who have narrow canals you obviously templated it for doing this particularly.
DOMINIC MEEK: So you see how you start at the beginning with the rasps, and you're just going to gradually-- and in this case you're compressing the bone out, so you want to stabilize it that way. So you just keep gently going at it. And the taps are very right. We'll come to that in a second. You don't want to be banging it with a 2 pound mallet. OK?
DOMINIC MEEK: It's just gently upsizing it. And one particular thing is when you put the rasps down, put them down after the first one by hand. Don't hit them from the very beginning. You want to actually get it close. And if you're less than one finger breadth from the neck, you know you're going to go up to the next broach up. If you're more than a finger breadth, go back because you're not going to get that stem down.
DOMINIC MEEK: You're going to cause an interrupted fracture. So we're continuing to go up. You're just checking for your finger, making sure that the calcar distance to the broach is right before you start doing that next stem. Just keep repeating it. And the point of this is you have to be patient. You can't just leap up and go onto the next one. So we're just checking again, and you can look at the metaphysis and see how much bone there is left there as well so that there's also enough room to get the next one onto it.
DOMINIC MEEK: So again checking it's still small so we can do that. What you don't want to do as well is when you're putting it down, you mustn't wiggle. OK? You're compressing the bone. If you wiggle it you're going to destroy all that compressed bone, and you're not going to get a proper press fit. And equally, you want to have started out lateral.
DOMINIC MEEK: You don't want to keep rasping away at it from that point of view. So again, you can see there is little bit of movement still present there, but now we're going to tap it down. And we're beginning to get what looks like a solid fit. And the whole femur moved when you did that there. So we just to go to next page. So at this point we're just going to quote one from Steve Young who actually did a good paper of actually the noise production.
DOMINIC MEEK: So that's another feel you can get from this. And then actually the femur acts as a resonance. So when you're actually tapping it down, if you look at the difference when you're beginning-- [CLATTER] You've got a lower tone. When you're getting close, you're getting your resonance up. [CLATTER] A lot of woodpecker sound, but you don't want to go much beyond that.
DOMINIC MEEK: So that's a sweet sound, so get some feel for that as well. So just to carry on to the next bit, where we're actually putting it down. So again we're trialing it now. So we think-- we're actually putting on the neck pieces. But we're going to check where that seems in relationship to the greater trochanter. OK. We knew it should be a slightly varus neck so we should be below the tip of the trochanter.
DOMINIC MEEK: And we're also checking the neck in terms of the calcar. So once we put that on we're looking where that is and checking across to the greater trochanter. And we are feeling it's a little bit too long. So at that point, we're feeling that that's going to produce too long a neck length. So at that point we'll decide to advance the broach a little bit more. So we're just actually just checking where the position of the broach is at the moment relative to the greater trochanter.
DOMINIC MEEK: So we're taking that and advancing it another few millimeters. You can do the approach with the broach the grim hope to tell where the paper from Exeter that wrote it up about of your templating marking it onto the broach, and then you can actually check that against the greater trochanter. So at this point, we're now going to check again. We're just going to mill it down, and then that would mean that we've actually got the few millimeters down from the position we actually need to do.
DOMINIC MEEK: And there's two sizes for this. So you can actually start with always the smaller one before, and then expand it up to the larger one at that point. And now you've done that, you can actually finally check it. And it's important that you're checking it for stability as well as leg length. The tests that I would always do, once you've actually reduced it, is that you'll see how easily it reduced.
DOMINIC MEEK: So the sort of shuck test. And that gives you an idea of the tissue tension, which is a combination of the offset and the leg length. You want to flex it right up and make sure there's nothing impinging when you flex it and internally rotate it. Sometimes there can be a little bit of osteophyte at the top. Sometimes it became a little bit of hypertrophic capsule or rectus, and so you may need to just remove that to stop it doing that.
DOMINIC MEEK: The other thing is to bring it back into extension when you're doing that. And at that point, if it kicks out, you know it's too tight as well. But at this point we're just going through all the motional tests of it here, and we're happy that the balancing of the hip replacement is correct. We just do another final couple of millimeters.
DOMINIC MEEK: It's important you know the design of the cementless stem you have. In this particular one it's slightly bigger than the broach. So if you've just got it flush, it might sit slightly proud. So in this case, we're just doing another 1 or 2 millimeters down further so it'll actually go down. So we're just taking this out.
DOMINIC MEEK: In this case, you don't do all the pulse lavage. You want to preserve all the bone that's there. And all the osteocytes, you're not pulse lavaging because we're not using acrylic to fix it. And at this point, we just obviously-- you've got a good exposure. At this point, when you put it in by hand, again, check that you're within a finger breadth. If you're not within a finger breadth, you may have put it in at the wrong orientation and it's going to catch.
DOMINIC MEEK: And then just finally tap it home. But again, just gentle taps until the collar engages with your milled point to your neck. And once you've done that really the operation is over. You can then just expose the trunnion. Important thing about the trunnion, it must be clean. Anything in between the femoral head and the trunnion will cause the possibility of corrosion or at least not allow it to implant onto it, and you can get abnormal wear from that point of view.
DOMINIC MEEK: So it's, again, vital that you actually do keep it as clean and as dry as possible. And at this point then you would check that there's no retained material in the acetabular component. You would then reduce it and again do your final check of rotational movements for stability, tissue tension, and the leg length at that point of view.
DOMINIC MEEK: And that's just summarizing the steps you would want to do with that. If you do that, you should get what you expect on your post operative X-ray. Thanks very much
SPEAKER 2: If you've enjoyed these videos, there will be more at future BHS meetings where we'll be running further educational days covering the syllabus for the FRCS T&O exam, which will be of interest to trainees but also to hip surgeons alike. And I hope you enjoy them.
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