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Name:
Total Hip Replacement (THR) For Dysplasia Hip With SRom Stem
Description:
Total Hip Replacement (THR) For Dysplasia Hip With SRom Stem
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T00H21M23S
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https://cadmoreoriginalmedia.blob.core.windows.net/6b847d1e-8501-40b6-8620-8528b8664490/Total Hip Replacement (THR) For Dysplasia Hip With SRom Stem.mp4?sv=2019-02-02&sr=c&sig=fFiooB1mSQ%2Bpqs6k8ix2QQKhbcUO%2BMIW7d12nImOfo0%3D&st=2024-11-21T13%3A52%3A44Z&se=2024-11-21T15%3A57%3A44Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Total hip replacement for dysplastic patients is a special challenge. Most of these patients are small in stature. Have got bilateral hip pain and have longstanding arthritis. This particular patient is a 55-year-old lady who has got pain in both the hips for the last 15 years. She got a valgus osteotomy done in the left hip about 20 years back and is now persistently complaining of pain in both the hips.
ANOOP JHURANI: Our range of movement in the right hip is flexion up to 90 degrees. A reduction of to 10 degrees and very limited internal and external rotation. Her problem in the left hip is very similar. Now let's look at the X-rays. It's absolutely important to have a pelvis with both hip X-ray or two sides to see both the hips, the pelvis and the upper fourth of the shaft of femur.
ANOOP JHURANI: So as we can see here, there is bilateral involvement and dysplasia essentially means insufficient coverage of the femoral head, superior laterally and abnormal shape both of the socket and the femoral head. On the right side, there is a big medial osteophyle that is deficient in the superior lateral area, and there's a very tight femoral canal. On the left side, because of the previous valgus osteotomy, there is an angle blade plate which will need removal.
ANOOP JHURANI: There is the small offset, the big medial osteophyte and the acetabular socket. And again, a very tight and narrow femoral canal. If you look at the lateral views, all of these patients have increased anti version. So most dysplastic patients have increased diversion and that needs to be taken account when we are operating. The ideal implant for these cases is the S long from where we can dial the anti version less in these cases
ANOOP JHURANI: so that our combined anti version is about 35 to 40. A conventional implant will not allow us to decrease the anti version and we might have increased combined anti-version leading to an anterior dislocation. So it's important to use the SRom implant in these cases so that the combined anti-version is molded according to the patient and we do not have a problem of instability.
ANOOP JHURANI: Now, let's look at the post op X-ray for the final reconstruction. As you can see on the right side, we have got the socket down the right place. We have restored the offset and we have a well fitting SRom implant. Similarly, on the left side, we've got the socket at the right place, just lateral to the teardrop.
ANOOP JHURANI: It's a uncemented cup, we've got a well fitting sleeve and a very well fitting tight diaphyseal fixation of the AC from stem. This is a surgical technique to demonstrate the use of modular sSRom stem in a dysplasia of the hip. The approach is posterior. The patient is in lateral decubitus position. We after taken the skin, we take the facialata.
ANOOP JHURANI: In this particular case, we have an old angle blade plate which we are removing along with the screws. Close the vastus lateralis, before we start with the reconstruction of the hip. It's important to rule out infection in cases of previous implants that are in or around the hip. In this particular case, the ESR and CRP was normal and the plate removal was pretty much straight forward. That's the gluteus maximus tendon.
ANOOP JHURANI: Along the cautery is the posterior aspect of the shaft and the trochanter. Once you're taking the fibers of the gluteus maximus, we then take the quadratus femoris, the jemeli and the obturator and the piriformis in that order, from distal to proximal of the posterior aspect of the gd, there's the dislocation of the dysplastic head and the head is very much flat. We measure the offset by putting a 44 or 46 millimeter head on this particular femoral head so that we can see the center of the head and then measure the offset and the leg length.
ANOOP JHURANI: We'll try and restore the offset. So from the center of the shaft to the center of the head from these two methylene blue marks is the offset and the distance from the center of the head to the lesser trochanter will tell us about the limb length. So we have to restore the offset, but we have to lend in this patient by about one, one and a half centimeters.
ANOOP JHURANI: And you can see that in this particular case, the offset is four centimeters or forty millimeter, and so is the length from the lesser trochanter to the center of the femoral head. So that is the offset. four centimeters and we have to restore the offset after the hip reconstruction with the SRom implant. And there is the length, which we have to increase. The cut for the SRom implant is horizontal and not oblique, as in a standard uncemented hip.
ANOOP JHURANI: The cut is according to the pre op templating. And that's the cut. And it's a horizontal cut and we take the femoral head out which is flattened, eroded, arthritic and dysplastic.
ANOOP JHURANI: Once we have done that, we take the femur anterior and start exposing the acetabulum so that's the complete exposure of the socket. The bone hook takes the femur anterior and we make a space between the capsule and the anterior wall of the acetabulum so that we can put our Hohmann retractor along the anterior wall like that. This retractor will take the femur anterior.
ANOOP JHURANI: There is one posterior retractor in the ischium and one Steinmann pin in the ilium. So these three retractors give us a three dimensional 360 view of the whole socket. As you can see here, the cup is shallow, dysplastic, and we have to reach the true floor of the acetabulum or the radiological teardrop to sit our cup accurately. We remove the initial scar tissue that we see there
ANOOP JHURANI: and then start preparing the cup with a small acetabular reamer of about four millimeters, which will first ream the medial osteophyte, go to the floor of the acetabulum and then we start with progressive reaming to make it a hemispherical socket. We also identify the transverse acetabular ligament, which you can see now, and this transverse acetabular ligament is a great landmark to see the correct version of the cup and also the inclination of the cup.
ANOOP JHURANI: There's a transverse acetabular ligament. We have to be parallel to the transverse acetabular ligament, which will give us the right anti-version of the cup. We start with the small reamer, first vertical to remove the medial osteophyte and reach the true floor of the acetabulum.
ANOOP JHURANI: Progressively larger reamer. Further reaming to convert a flat ellipsoid middle acetabulum into a hemispherical socket.
ANOOP JHURANI: We do a trial reduction of the cup with the liner and remove the osteophysis. It's important to remove the osteophyle to prevent any impingement. Now we turn our attention to the femur. It's a short, dysplastic femur.
ANOOP JHURANI: We have to dissect the anterior capsule of the shaft, so that femur can be delivered into the wound nicely, and we can prepare the femur for the SRom stem. The purpose of using SRom stem is because all displastic hips have a bigger anti-version than normal and in this hip also you can see that the neck is really pointing towards the floor. So the true anti-version of this hip is roughly 50 to 60 degrees.
ANOOP JHURANI: So we have to decrease the anti version in the shaft so that we have a stable hip. Or if we follow this route for an uncemented hip, we'll have our hip in a lot of anti version with resulting anterior instability. So you can see that the neck is pointing towards the floor with a version of about 50 to 60 degrees. Deeper position starts from just medial to the greater trochanter.
ANOOP JHURANI: We have to be absolutely lateral so that our stem is in straight position and not in varus. We do progressive canal reamings with an SRom reamer. Since this is a very tight canal of only seven/eight millimeters, there is some resistance in reaming and that was the pre-op templating.
ANOOP JHURANI: We have to ensure in dysplastic patients that we have smaller stems of 6 to 8 millimeters because that is what most smaller dysplastic patients get. This is preparation for the cylindrical reaming into the trochanter of size 14b so we'll be using an 8mm stem and plus 6 that is 14 is for the sleeve, preparation for the sleeve.
ANOOP JHURANI: So this is preparation for the sleeve laterally. The sleeves are available for the smaller sizes in size B and D. And each B and D has got further two sizes, which increases the fixation from media to lateral. We have to have good proximal fixation.
ANOOP JHURANI: The proximal sleeves are HA coated and they take fixation proximally. The distal stem is modular and fluted which takes fixation distally. This is preparation for the sleeve in the calcar area. We put this instrument up to the mark for 14b sleeve,
ANOOP JHURANI: and then use a reamer to prepare the calcar like that.
ANOOP JHURANI: We are reaming the calcar area for purchase of the sleeve and the reamer goes till the above mentioned mark of a 14b sleeve. This is insertion of the trial sleeve, which in this particular case goes
ANOOP JHURANI: in about 45 degree of 50 degree aversion, as you can see there. But we put the stem in less version so that is the version which can be adjusted separately of the sleeve so the stem and the sleeve can be adjusted separately in terms of degree of anti version and that is the main advantage of the SRom stem.
ANOOP JHURANI: So here you can see that we are now decreasing the anti version of the stem because that is a lot of anti version and now is the correct anti version of about 15 degrees and that is the final trial reduction. As you can see, the combined anti version is about 45 degrees, which is the way it should be. The movement is very reasonable, the hip is stable and
ANOOP JHURANI: the offset and leg length are restored. That is further final adjustment of the version of the stem, so that our command anti version is right. The patient does not have any anterior or posterior instability.
ANOOP JHURANI: There is the insertion of a fully coated cup in the right anti version, and the cup has to be parallel to the tunnel and just under the border of the tunnel so that we have the right inclination and the right anti-version. Then final adjustment of reaming and the insertion of the cup. The cup looks very solid and stable.
ANOOP JHURANI: The fixation is augmented by two self tapping screws into the ilium so that there is no micro movement and the cup in-grows very fast.
ANOOP JHURANI: The solid purchase of the screw, the insertion of a liner and now the insertion of the sleeve, it has to be really well fixed into the calcar, as you can see there, so that it in-grows and takes very good fixation and the patient can weight bear immediately. So that's the sleeve, which is, as you can see in the neck of almost 60 degrees of anti version, but will decrease the version on the stem to about 15 degrees.
ANOOP JHURANI: And you can see, that is the stem going in about 15 degrees of version while the sleeve is in about 60 degrees of anti version, the sleeve follows the neck, but the stem follows the normal anatomy so that we can have a combined anti version of about 40, 45, 15 degree on the stem and about 25 degree on the socket, you know, in a woman. Women have larger anti version than men.
ANOOP JHURANI: So a woman's pelvis is more anti-verted than a man's pelvis. And you can see that we have restored the offset to about 40 millimeter and we also lend into the patient by about a centimeter. That's the final trial reduction, and you can see that the hip is very stable in all movements, especially flexion, adduction and internal rotation. Has no impingement of the greater trochanter to the ilium.
ANOOP JHURANI: Hip can external rotate and hands offset is restored.
ANOOP JHURANI: The socket is uncovered superior, posterior superior, and that is what happens in displastic because there is lack of coverage of the socket posterior superior. That's not to be worried in a fully coated uncemented cup because they in-grow with about 50% to 60% of contact with the host bone. There is the implementation of the final head which will give a stable, hip reconstruction.
ANOOP JHURANI: And there is the final, final hip reconstruction, which restores the command anti-version. The limb land and the offset. The closure is standard and the patient weight bears on the next day. This lady was being operated about six months back, is doing very well.
ANOOP JHURANI: She walks about one kilometer, is pain free and also doesn't have any limp. So dysplasia is a special challenge in hip replacement surgery and the SRom implant, along with proper exposure, pre-op planning and execution, gives excellent results in dysplastic hips.
Segment:0 .
ANOOP JHURANI: Total hip replacement for dysplastic patients is a special challenge. Most of these patients are small in stature. Have got bilateral hip pain and have longstanding arthritis. This particular patient is a 55-year-old lady who has got pain in both the hips for the last 15 years. She got a valgus osteotomy done in the left hip about 20 years back and is now persistently complaining of pain in both the hips.
ANOOP JHURANI: Our range of movement in the right hip is flexion up to 90 degrees. A reduction of to 10 degrees and very limited internal and external rotation. Her problem in the left hip is very similar. Now let's look at the X-rays. It's absolutely important to have a pelvis with both hip X-ray or two sides to see both the hips, the pelvis and the upper fourth of the shaft of femur.
ANOOP JHURANI: So as we can see here, there is bilateral involvement and dysplasia essentially means insufficient coverage of the femoral head, superior laterally and abnormal shape both of the socket and the femoral head. On the right side, there is a big medial osteophyle that is deficient in the superior lateral area, and there's a very tight femoral canal. On the left side, because of the previous valgus osteotomy, there is an angle blade plate which will need removal.
ANOOP JHURANI: There is the small offset, the big medial osteophyte and the acetabular socket. And again, a very tight and narrow femoral canal. If you look at the lateral views, all of these patients have increased anti version. So most dysplastic patients have increased diversion and that needs to be taken account when we are operating. The ideal implant for these cases is the S long from where we can dial the anti version less in these cases
ANOOP JHURANI: so that our combined anti version is about 35 to 40. A conventional implant will not allow us to decrease the anti version and we might have increased combined anti-version leading to an anterior dislocation. So it's important to use the SRom implant in these cases so that the combined anti-version is molded according to the patient and we do not have a problem of instability.
ANOOP JHURANI: Now, let's look at the post op X-ray for the final reconstruction. As you can see on the right side, we have got the socket down the right place. We have restored the offset and we have a well fitting SRom implant. Similarly, on the left side, we've got the socket at the right place, just lateral to the teardrop.
ANOOP JHURANI: It's a uncemented cup, we've got a well fitting sleeve and a very well fitting tight diaphyseal fixation of the AC from stem. This is a surgical technique to demonstrate the use of modular sSRom stem in a dysplasia of the hip. The approach is posterior. The patient is in lateral decubitus position. We after taken the skin, we take the facialata.
ANOOP JHURANI: In this particular case, we have an old angle blade plate which we are removing along with the screws. Close the vastus lateralis, before we start with the reconstruction of the hip. It's important to rule out infection in cases of previous implants that are in or around the hip. In this particular case, the ESR and CRP was normal and the plate removal was pretty much straight forward. That's the gluteus maximus tendon.
ANOOP JHURANI: Along the cautery is the posterior aspect of the shaft and the trochanter. Once you're taking the fibers of the gluteus maximus, we then take the quadratus femoris, the jemeli and the obturator and the piriformis in that order, from distal to proximal of the posterior aspect of the gd, there's the dislocation of the dysplastic head and the head is very much flat. We measure the offset by putting a 44 or 46 millimeter head on this particular femoral head so that we can see the center of the head and then measure the offset and the leg length.
ANOOP JHURANI: We'll try and restore the offset. So from the center of the shaft to the center of the head from these two methylene blue marks is the offset and the distance from the center of the head to the lesser trochanter will tell us about the limb length. So we have to restore the offset, but we have to lend in this patient by about one, one and a half centimeters.
ANOOP JHURANI: And you can see that in this particular case, the offset is four centimeters or forty millimeter, and so is the length from the lesser trochanter to the center of the femoral head. So that is the offset. four centimeters and we have to restore the offset after the hip reconstruction with the SRom implant. And there is the length, which we have to increase. The cut for the SRom implant is horizontal and not oblique, as in a standard uncemented hip.
ANOOP JHURANI: The cut is according to the pre op templating. And that's the cut. And it's a horizontal cut and we take the femoral head out which is flattened, eroded, arthritic and dysplastic.
ANOOP JHURANI: Once we have done that, we take the femur anterior and start exposing the acetabulum so that's the complete exposure of the socket. The bone hook takes the femur anterior and we make a space between the capsule and the anterior wall of the acetabulum so that we can put our Hohmann retractor along the anterior wall like that. This retractor will take the femur anterior.
ANOOP JHURANI: There is one posterior retractor in the ischium and one Steinmann pin in the ilium. So these three retractors give us a three dimensional 360 view of the whole socket. As you can see here, the cup is shallow, dysplastic, and we have to reach the true floor of the acetabulum or the radiological teardrop to sit our cup accurately. We remove the initial scar tissue that we see there
ANOOP JHURANI: and then start preparing the cup with a small acetabular reamer of about four millimeters, which will first ream the medial osteophyte, go to the floor of the acetabulum and then we start with progressive reaming to make it a hemispherical socket. We also identify the transverse acetabular ligament, which you can see now, and this transverse acetabular ligament is a great landmark to see the correct version of the cup and also the inclination of the cup.
ANOOP JHURANI: There's a transverse acetabular ligament. We have to be parallel to the transverse acetabular ligament, which will give us the right anti-version of the cup. We start with the small reamer, first vertical to remove the medial osteophyte and reach the true floor of the acetabulum.
ANOOP JHURANI: Progressively larger reamer. Further reaming to convert a flat ellipsoid middle acetabulum into a hemispherical socket.
ANOOP JHURANI: We do a trial reduction of the cup with the liner and remove the osteophysis. It's important to remove the osteophyle to prevent any impingement. Now we turn our attention to the femur. It's a short, dysplastic femur.
ANOOP JHURANI: We have to dissect the anterior capsule of the shaft, so that femur can be delivered into the wound nicely, and we can prepare the femur for the SRom stem. The purpose of using SRom stem is because all displastic hips have a bigger anti-version than normal and in this hip also you can see that the neck is really pointing towards the floor. So the true anti-version of this hip is roughly 50 to 60 degrees.
ANOOP JHURANI: So we have to decrease the anti version in the shaft so that we have a stable hip. Or if we follow this route for an uncemented hip, we'll have our hip in a lot of anti version with resulting anterior instability. So you can see that the neck is pointing towards the floor with a version of about 50 to 60 degrees. Deeper position starts from just medial to the greater trochanter.
ANOOP JHURANI: We have to be absolutely lateral so that our stem is in straight position and not in varus. We do progressive canal reamings with an SRom reamer. Since this is a very tight canal of only seven/eight millimeters, there is some resistance in reaming and that was the pre-op templating.
ANOOP JHURANI: We have to ensure in dysplastic patients that we have smaller stems of 6 to 8 millimeters because that is what most smaller dysplastic patients get. This is preparation for the cylindrical reaming into the trochanter of size 14b so we'll be using an 8mm stem and plus 6 that is 14 is for the sleeve, preparation for the sleeve.
ANOOP JHURANI: So this is preparation for the sleeve laterally. The sleeves are available for the smaller sizes in size B and D. And each B and D has got further two sizes, which increases the fixation from media to lateral. We have to have good proximal fixation.
ANOOP JHURANI: The proximal sleeves are HA coated and they take fixation proximally. The distal stem is modular and fluted which takes fixation distally. This is preparation for the sleeve in the calcar area. We put this instrument up to the mark for 14b sleeve,
ANOOP JHURANI: and then use a reamer to prepare the calcar like that.
ANOOP JHURANI: We are reaming the calcar area for purchase of the sleeve and the reamer goes till the above mentioned mark of a 14b sleeve. This is insertion of the trial sleeve, which in this particular case goes
ANOOP JHURANI: in about 45 degree of 50 degree aversion, as you can see there. But we put the stem in less version so that is the version which can be adjusted separately of the sleeve so the stem and the sleeve can be adjusted separately in terms of degree of anti version and that is the main advantage of the SRom stem.
ANOOP JHURANI: So here you can see that we are now decreasing the anti version of the stem because that is a lot of anti version and now is the correct anti version of about 15 degrees and that is the final trial reduction. As you can see, the combined anti version is about 45 degrees, which is the way it should be. The movement is very reasonable, the hip is stable and
ANOOP JHURANI: the offset and leg length are restored. That is further final adjustment of the version of the stem, so that our command anti version is right. The patient does not have any anterior or posterior instability.
ANOOP JHURANI: There is the insertion of a fully coated cup in the right anti version, and the cup has to be parallel to the tunnel and just under the border of the tunnel so that we have the right inclination and the right anti-version. Then final adjustment of reaming and the insertion of the cup. The cup looks very solid and stable.
ANOOP JHURANI: The fixation is augmented by two self tapping screws into the ilium so that there is no micro movement and the cup in-grows very fast.
ANOOP JHURANI: The solid purchase of the screw, the insertion of a liner and now the insertion of the sleeve, it has to be really well fixed into the calcar, as you can see there, so that it in-grows and takes very good fixation and the patient can weight bear immediately. So that's the sleeve, which is, as you can see in the neck of almost 60 degrees of anti version, but will decrease the version on the stem to about 15 degrees.
ANOOP JHURANI: And you can see, that is the stem going in about 15 degrees of version while the sleeve is in about 60 degrees of anti version, the sleeve follows the neck, but the stem follows the normal anatomy so that we can have a combined anti version of about 40, 45, 15 degree on the stem and about 25 degree on the socket, you know, in a woman. Women have larger anti version than men.
ANOOP JHURANI: So a woman's pelvis is more anti-verted than a man's pelvis. And you can see that we have restored the offset to about 40 millimeter and we also lend into the patient by about a centimeter. That's the final trial reduction, and you can see that the hip is very stable in all movements, especially flexion, adduction and internal rotation. Has no impingement of the greater trochanter to the ilium.
ANOOP JHURANI: Hip can external rotate and hands offset is restored.
ANOOP JHURANI: The socket is uncovered superior, posterior superior, and that is what happens in displastic because there is lack of coverage of the socket posterior superior. That's not to be worried in a fully coated uncemented cup because they in-grow with about 50% to 60% of contact with the host bone. There is the implementation of the final head which will give a stable, hip reconstruction.
ANOOP JHURANI: And there is the final, final hip reconstruction, which restores the command anti-version. The limb land and the offset. The closure is standard and the patient weight bears on the next day. This lady was being operated about six months back, is doing very well.
ANOOP JHURANI: She walks about one kilometer, is pain free and also doesn't have any limp. So dysplasia is a special challenge in hip replacement surgery and the SRom implant, along with proper exposure, pre-op planning and execution, gives excellent results in dysplastic hips.
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