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Takedown of a Fused or Stiff Hip in Ankylosing Spondylitis
Description:
Takedown of a Fused or Stiff Hip in Ankylosing Spondylitis
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Duration:
T00H17M52S
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https://cadmoreoriginalmedia.blob.core.windows.net/8c3e2d75-6df1-49da-a6a8-f00ba784897b/Takedown of a fused or stiff hip in Ankylosing Spondylitis.mp4?sv=2019-02-02&sr=c&sig=IJAR8PtMFD2yoVhGxM1u%2BdZjaUAdwNlDAABvI9yx6SI%3D&st=2024-12-04T08%3A32%3A44Z&se=2024-12-04T10%3A37%3A44Z&sp=r
Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. Taking down a fuse hip can be pretty challenging, especially in cases with ankylosing spondylitis. Before we talk of the surgical tips, tricks, principles, philosophy and practice of taking down a fuse hip, we should understand the influence of the spine on the pelvis. If the spine is fused in a particular direction, its influence on the pelvis can be profound.
ANOOP JHURANI: And we need to analyze that very carefully in a case with ankylosing spondylitis. So this is a patient, 50-year-old of ankylosing spondylitis. He doesn't have bone-on-bone fusion, but he has fibrous ankylosis. So there is only a very, very minimal jog of movement on the left hip, practically nothing on the right hip.
ANOOP JHURANI: Now, whenever we see a patient with ankylosing spondylitis, before we start planning the hip, we should look at the spine very carefully, because the spine has a big influence on the pelvic deformity. So let's understand it like this, that in ankylosing spondylitis the spine loses its lumbar lordosis, and becomes in flexion. So when the spine goes into flexion, the pelvis moves forward, and we need to decrease our anteversion.
ANOOP JHURANI: So we'll detail that further, but essentially with a fused spine in flexion, the pelvis is moving forward. So essentially the angle may become 35-40. Now, if you put your cup in this, it will dislocate anteriorly. So we need to decrease our anteversion. Now, the problem of dislocation in ankylosing spondylitis primarily has been anterior dislocation, as reported by Marnster [?[ study way back in 1990s, and all the other studies have reported this problem of dislocation mostly anteriorly, because the spine is fused in flexion.
ANOOP JHURANI: So the pelvis moves anteriorly. And when you put your cup here, the combined anteversion becomes very high, so you need to decrease your version. Usually what we do in ankylosing spondylitis or any other normal case is that we bang in our cup as a primary fixation. But in ankylosing spondylitis we should put a trial cup in decreased version, decreased version.
ANOOP JHURANI: If the spine is fusion flexion, do a trial reduction and then put our cup if our combined anterversion is 35-40. So it's very important to get your combined anteversion right. So unlike a normal situation where we put our cup parallel to the {INAUDIBLE} in about 15 to 20 degrees of anteversion, here we will decrease our anteversion so that our combined anteversion does not become too much so as to risk an anterior dislocation.
ANOOP JHURANI: So it's important to see this is spinal deformity and its influence on the pelvis. Another hint that you may get is by seeing the obturator foramen. Now when you see a normal pelvis x-ray, your obturator foramen are like semi-open. But when you see this big obturator foramen opening, your hip is in flexion deformity certainly. But also your spine has a flexion deformity and that's what makes the obturator foramen really open up, and that means that the hip is in flexion and so is your spine.
ANOOP JHURANI: It's also important to take into account the spinal deformity in the sagittal plane. So you need to see whether the spine has a scoliotic curve, and if it is a fixed scoliotic deformity on the concave side of the deformity, the pelvis is going to move up. So what that means is so say for example, this concavity is on the right side.
ANOOP JHURANI: So pelvis has moved up. Now here you have to decrease the anteversion, decrease the inclination of your cup. Otherwise if you put it at 45 degrees, your inclination when the patient sits up will be very high. So because this pelvis is up, you need to decrease the inclination, so that your cup is well, your head is well covered and you don't risk a posterior superior dislocation.
ANOOP JHURANI: So let me repeat this once again. In case that the spine is fixed in flexion, your pelvis moves anteriorly, and you have to decrease anteversion. In rare cases, if there is exaggerated lumbar lordosis the pelvis moves backwards and you have to increase the anteversion. In case of a scoliotic deformity on the side on which the pelvis is higher, on the concave side of the spinal deformity, the pelvis should be higher, you have to put your cup more horizontal so that your head is covered and you don't risk a posterior superior dislocation.
ANOOP JHURANI: So this is the post-op X-ray of this patient of which you will see the surgical video also, after we have discussed the basics, and you can see that we have taken care of the common anteversion, the inclination very properly, got the cup at the level of the teardrop, not too medial, checked it under C-arm always check in complex cases under C-arm that you are rightly inclined. We put the trial cup first.
ANOOP JHURANI: As you'll see in the surgical video, we have checked the combined anteversion, and when you see that the hip is stable, only then will we put in our final cup. So in cases when you are wondering how the spine has affected the pelvis in coronal and sagittal plane, always put the trial cup first in less anteversion if your spine is fused in flexion.
ANOOP JHURANI: So decrease your version, take a trial reduction, and see that the hip is stable and then put in your final cup as you will see in the surgical video. So in the surgical video you'll see many tips and tricks of taking down the fused hip. But these introductory remarks are to understand the influence of the spine on the pelvis in coronal and sagittal plane. So let's go to the surgical video now.
ANOOP JHURANI: This is a 55-year-old man with ankylosing spondylitis, and as you can see, the spine X rays, the spine is fused and the spine has lost its lumbar lordosis, so it's fused in flexion. What it does is that it takes the pelvis anteriorly, and you can see that the pelvis is opened up, so you can see that the obturator foramen has really opened up. So we have to decrease the anteversion on the cup side in this case where the spine is fused in flexion.
ANOOP JHURANI: Now this hip that we are operating is fused. It's got a fibrous fusion. It's not a bony fusion, but it's a fibrous fusion. And there is no movement at the hip. And the hip is fixed in about 45 degrees of flexion deformity. This is a posterior approach, slightly bigger than usual because it's a tougher case. The plan is to do an in-situ osteotomy and ensure the reaming because we will not be able to dislocate this hip {INAUDIBLE}.
ANOOP JHURANI: We split the Gmax bluntly. That's the insertion of the Gmax, and we mark it so that we can repair it accurately. We don't release the Gmax in all cases, but only in tough cases where it would be difficult to take the femur anterior, we do release this. Then is to release all the external rotators from the posterior aspect of femur right up to the piriformis, and then mark the piriformis and the external rotators so that we can close them accurately after the surgery is finished.
ANOOP JHURANI: The capsule is adherent to the neck, and since the hip is fused, the interval between the acetabulum posterior wall and the trochanter is very less because it's a protusion situation and the neck is all gone inside the socket. So we have to identify the socket and the head very carefully because there can be some confusion. So you can see that the blue mark is the piriformis muscle, the neck is where my finger is, that is the neck.
ANOOP JHURANI: You can see the posterior wall of the acetabulum. I'm making some stress risers through a 2.5 drill bit in the direction of the neck. Once you make the stress risers, it's easy to put your osteotome on all those stress risers and then do an in-situ osteotomy. So multiple drill holes along the neck and then the osteotome, the direction of the osteotome is parallel to the neck and slightly posterior.
ANOOP JHURANI: So we don't hit the anterior wall. We are to prevent damage to the anterior wall. So you can see that the osteotome, which is a 20 millimetre, very thin and sharp osteotome, especially for in-situ osteotomy, so that there is no loss of bone. It goes into the stress risers that we made with the drill bit earlier and then right up to the anterior part of the neck very carefully so as to not damage the anterior wall of the socket.
ANOOP JHURANI: And then we pry open so that the femur goes anteriorly. We dissect the capsule posteriorly, we reflect the, the reflected head of rectus, which is there, so that the femur goes anterior. That is the reflection of the posterior capsule, the inferior capsule, superiorly the rectus and anteriorly very carefully we make a rent between the anterior capsule and the anterior wall with the cautery and then put this Cobra retractor in front to reflect or retract the femur anteriorly.
ANOOP JHURANI: And so we have a full 360 view of the socket, as you can see, and the head is inside the socket. I'm still reflecting some part of the anterior capsule. And you can see that there is a Cobra retractor anterior. There are two different retractors posterior, inferior, and posterior superior and are marked anterior and posterior, which you can see. So this is in-situ reaming. So you take a small 38 reamer and do in situ reaming.
ANOOP JHURANI: So when you do that, gradually you can ream away the head in complete bone effusion. You will need to go right up to the base. Now there is further fibrous fusion and hence we seem to ream the head hollow and then we can take it out. We still have to remove the fibrous adhesions between the head and the acetabular wall, because there is no cartilage there and it is attached with fibrous tissue.
ANOOP JHURANI: Once we release all the fibrous tissue, the shell of the head comes out, as you can see now, and it's completely devoid of any cartilage. Now this is a protrusion situation, and the principle of reaming in a protrusion situation is just in the periphery and don't go right up to the base. So now we are reaming with 48 reamer. We are putting in a trial 50 cup. We are not banging in the final cup, but we are putting in a trial cup in ankylosing spondylitis so that we get our combined anteversion and our stability absolutely right. Now, there are a lot osteophytes in a chronically fused hip and we can again make these drill holes to make a stress riser and then remove all the osteophytes as we planned on the X-ray and which are mostly inferior and some posterior in this particular case.
ANOOP JHURANI: And then we use a 10 millimetre osteotome this time to remove all the osteophytes which overhang the cup so as to prevent any impingement. And impingement from osteophytes is one cause of dislocation and instability. So we remove the anterior osteophytes now, which can cause impingement in flexion. And you can see that it's a big osteophyte and we remove it from the anterior wall so that there is no impingement in flexion.
ANOOP JHURANI: The trial cup is put because if you put the final cup in wrong version, then you have a chance of anterior dislocation, especially in ankylosing spondylitis, because the spine infuses flexion and we have to decrease our anteversion. But we should take a trial reduction first and then finalize our cup position and then put in the cup.
ANOOP JHURANI: So it's now removing the posterior osteophytes, you can see to prevent impingement in extension. Let's go to the femur now with the trial cup in situ, we move on to the femur, clear all the fibrous tissue from the neck, because remember, we have done the in-situ osteotomy, so it's not a classical neck cut. We have to refresh it. And we can take another neck cut if the neck is long. Entry point, just lateral and posterior and prepare for an uncemented proximally coated stem as in this case.
ANOOP JHURANI: And we have to go absolutely lateral to prevent varus malpositioning of the stem. So there's the first femur. Then progressively larger blotches always keep your hand lateral so that we are not in varus and you can see that it's cancellous bone on the medial side of the calcar, which is essential so that your stem is not in varus.
ANOOP JHURANI: That's the final trial and a calcar reamer. We can use a 36 head. And now you can see with the trial cup we see the common anteversion and stability and you can see that the combined anteversion is 35 and we are very stable. There is no posterior dislocation and there is no anterior instability, which we have to prevent more in cases of ankylosing spondylitis.
ANOOP JHURANI: So there is the final shape. Last one, reamer, before we put in our cup and we have decreased our anteversion here by over 10 degrees. So that the combined anteversion is 35 and we do not risk an anterior dislocation because of a fused spine in flexion. A press-fit hemispherical porous coated cup, that's a 54 cup.
ANOOP JHURANI: That's what we templated pre-op. And you can see that we have decreased our anteversion by about 10 or degrees. Screws in the right quadrant. It should go in the thickest part of the ilium. Usually in a man you can put a screw up to 40 millimetres in the good quality ilium bone, and measuring the screw and feeling with this depth gauge that you are in the right quadrant.
ANOOP JHURANI: Always hold the cup while you're putting the screw because when you tighten the screw final few threads, the cup may move. So always hold that. That's the 36 liner. And then we go on to the stem. There is the stem, some release of the anterior capsule there.
ANOOP JHURANI: So the principles of taking down a fused or a fibrous ankylosed hip is right in situ osteotomy in the right plane in situ reaming and then a trial cup first seeing the common anteversion and then putting in your final implants that will ensure that you're stable and you don't dislocate anteriorly, especially in ankylosing spondylitis. There you can see the combined anteversion is 30, 35, very stable anteriorly.
ANOOP JHURANI: We have corrected the deformity, so we are getting...
Segment:0 .
ANOOP JHURANI: Hello, friends. Taking down a fuse hip can be pretty challenging, especially in cases with ankylosing spondylitis. Before we talk of the surgical tips, tricks, principles, philosophy and practice of taking down a fuse hip, we should understand the influence of the spine on the pelvis. If the spine is fused in a particular direction, its influence on the pelvis can be profound.
ANOOP JHURANI: And we need to analyze that very carefully in a case with ankylosing spondylitis. So this is a patient, 50-year-old of ankylosing spondylitis. He doesn't have bone-on-bone fusion, but he has fibrous ankylosis. So there is only a very, very minimal jog of movement on the left hip, practically nothing on the right hip.
ANOOP JHURANI: Now, whenever we see a patient with ankylosing spondylitis, before we start planning the hip, we should look at the spine very carefully, because the spine has a big influence on the pelvic deformity. So let's understand it like this, that in ankylosing spondylitis the spine loses its lumbar lordosis, and becomes in flexion. So when the spine goes into flexion, the pelvis moves forward, and we need to decrease our anteversion.
ANOOP JHURANI: So we'll detail that further, but essentially with a fused spine in flexion, the pelvis is moving forward. So essentially the angle may become 35-40. Now, if you put your cup in this, it will dislocate anteriorly. So we need to decrease our anteversion. Now, the problem of dislocation in ankylosing spondylitis primarily has been anterior dislocation, as reported by Marnster [?[ study way back in 1990s, and all the other studies have reported this problem of dislocation mostly anteriorly, because the spine is fused in flexion.
ANOOP JHURANI: So the pelvis moves anteriorly. And when you put your cup here, the combined anteversion becomes very high, so you need to decrease your version. Usually what we do in ankylosing spondylitis or any other normal case is that we bang in our cup as a primary fixation. But in ankylosing spondylitis we should put a trial cup in decreased version, decreased version.
ANOOP JHURANI: If the spine is fusion flexion, do a trial reduction and then put our cup if our combined anterversion is 35-40. So it's very important to get your combined anteversion right. So unlike a normal situation where we put our cup parallel to the {INAUDIBLE} in about 15 to 20 degrees of anteversion, here we will decrease our anteversion so that our combined anteversion does not become too much so as to risk an anterior dislocation.
ANOOP JHURANI: So it's important to see this is spinal deformity and its influence on the pelvis. Another hint that you may get is by seeing the obturator foramen. Now when you see a normal pelvis x-ray, your obturator foramen are like semi-open. But when you see this big obturator foramen opening, your hip is in flexion deformity certainly. But also your spine has a flexion deformity and that's what makes the obturator foramen really open up, and that means that the hip is in flexion and so is your spine.
ANOOP JHURANI: It's also important to take into account the spinal deformity in the sagittal plane. So you need to see whether the spine has a scoliotic curve, and if it is a fixed scoliotic deformity on the concave side of the deformity, the pelvis is going to move up. So what that means is so say for example, this concavity is on the right side.
ANOOP JHURANI: So pelvis has moved up. Now here you have to decrease the anteversion, decrease the inclination of your cup. Otherwise if you put it at 45 degrees, your inclination when the patient sits up will be very high. So because this pelvis is up, you need to decrease the inclination, so that your cup is well, your head is well covered and you don't risk a posterior superior dislocation.
ANOOP JHURANI: So let me repeat this once again. In case that the spine is fixed in flexion, your pelvis moves anteriorly, and you have to decrease anteversion. In rare cases, if there is exaggerated lumbar lordosis the pelvis moves backwards and you have to increase the anteversion. In case of a scoliotic deformity on the side on which the pelvis is higher, on the concave side of the spinal deformity, the pelvis should be higher, you have to put your cup more horizontal so that your head is covered and you don't risk a posterior superior dislocation.
ANOOP JHURANI: So this is the post-op X-ray of this patient of which you will see the surgical video also, after we have discussed the basics, and you can see that we have taken care of the common anteversion, the inclination very properly, got the cup at the level of the teardrop, not too medial, checked it under C-arm always check in complex cases under C-arm that you are rightly inclined. We put the trial cup first.
ANOOP JHURANI: As you'll see in the surgical video, we have checked the combined anteversion, and when you see that the hip is stable, only then will we put in our final cup. So in cases when you are wondering how the spine has affected the pelvis in coronal and sagittal plane, always put the trial cup first in less anteversion if your spine is fused in flexion.
ANOOP JHURANI: So decrease your version, take a trial reduction, and see that the hip is stable and then put in your final cup as you will see in the surgical video. So in the surgical video you'll see many tips and tricks of taking down the fused hip. But these introductory remarks are to understand the influence of the spine on the pelvis in coronal and sagittal plane. So let's go to the surgical video now.
ANOOP JHURANI: This is a 55-year-old man with ankylosing spondylitis, and as you can see, the spine X rays, the spine is fused and the spine has lost its lumbar lordosis, so it's fused in flexion. What it does is that it takes the pelvis anteriorly, and you can see that the pelvis is opened up, so you can see that the obturator foramen has really opened up. So we have to decrease the anteversion on the cup side in this case where the spine is fused in flexion.
ANOOP JHURANI: Now this hip that we are operating is fused. It's got a fibrous fusion. It's not a bony fusion, but it's a fibrous fusion. And there is no movement at the hip. And the hip is fixed in about 45 degrees of flexion deformity. This is a posterior approach, slightly bigger than usual because it's a tougher case. The plan is to do an in-situ osteotomy and ensure the reaming because we will not be able to dislocate this hip {INAUDIBLE}.
ANOOP JHURANI: We split the Gmax bluntly. That's the insertion of the Gmax, and we mark it so that we can repair it accurately. We don't release the Gmax in all cases, but only in tough cases where it would be difficult to take the femur anterior, we do release this. Then is to release all the external rotators from the posterior aspect of femur right up to the piriformis, and then mark the piriformis and the external rotators so that we can close them accurately after the surgery is finished.
ANOOP JHURANI: The capsule is adherent to the neck, and since the hip is fused, the interval between the acetabulum posterior wall and the trochanter is very less because it's a protusion situation and the neck is all gone inside the socket. So we have to identify the socket and the head very carefully because there can be some confusion. So you can see that the blue mark is the piriformis muscle, the neck is where my finger is, that is the neck.
ANOOP JHURANI: You can see the posterior wall of the acetabulum. I'm making some stress risers through a 2.5 drill bit in the direction of the neck. Once you make the stress risers, it's easy to put your osteotome on all those stress risers and then do an in-situ osteotomy. So multiple drill holes along the neck and then the osteotome, the direction of the osteotome is parallel to the neck and slightly posterior.
ANOOP JHURANI: So we don't hit the anterior wall. We are to prevent damage to the anterior wall. So you can see that the osteotome, which is a 20 millimetre, very thin and sharp osteotome, especially for in-situ osteotomy, so that there is no loss of bone. It goes into the stress risers that we made with the drill bit earlier and then right up to the anterior part of the neck very carefully so as to not damage the anterior wall of the socket.
ANOOP JHURANI: And then we pry open so that the femur goes anteriorly. We dissect the capsule posteriorly, we reflect the, the reflected head of rectus, which is there, so that the femur goes anterior. That is the reflection of the posterior capsule, the inferior capsule, superiorly the rectus and anteriorly very carefully we make a rent between the anterior capsule and the anterior wall with the cautery and then put this Cobra retractor in front to reflect or retract the femur anteriorly.
ANOOP JHURANI: And so we have a full 360 view of the socket, as you can see, and the head is inside the socket. I'm still reflecting some part of the anterior capsule. And you can see that there is a Cobra retractor anterior. There are two different retractors posterior, inferior, and posterior superior and are marked anterior and posterior, which you can see. So this is in-situ reaming. So you take a small 38 reamer and do in situ reaming.
ANOOP JHURANI: So when you do that, gradually you can ream away the head in complete bone effusion. You will need to go right up to the base. Now there is further fibrous fusion and hence we seem to ream the head hollow and then we can take it out. We still have to remove the fibrous adhesions between the head and the acetabular wall, because there is no cartilage there and it is attached with fibrous tissue.
ANOOP JHURANI: Once we release all the fibrous tissue, the shell of the head comes out, as you can see now, and it's completely devoid of any cartilage. Now this is a protrusion situation, and the principle of reaming in a protrusion situation is just in the periphery and don't go right up to the base. So now we are reaming with 48 reamer. We are putting in a trial 50 cup. We are not banging in the final cup, but we are putting in a trial cup in ankylosing spondylitis so that we get our combined anteversion and our stability absolutely right. Now, there are a lot osteophytes in a chronically fused hip and we can again make these drill holes to make a stress riser and then remove all the osteophytes as we planned on the X-ray and which are mostly inferior and some posterior in this particular case.
ANOOP JHURANI: And then we use a 10 millimetre osteotome this time to remove all the osteophytes which overhang the cup so as to prevent any impingement. And impingement from osteophytes is one cause of dislocation and instability. So we remove the anterior osteophytes now, which can cause impingement in flexion. And you can see that it's a big osteophyte and we remove it from the anterior wall so that there is no impingement in flexion.
ANOOP JHURANI: The trial cup is put because if you put the final cup in wrong version, then you have a chance of anterior dislocation, especially in ankylosing spondylitis, because the spine infuses flexion and we have to decrease our anteversion. But we should take a trial reduction first and then finalize our cup position and then put in the cup.
ANOOP JHURANI: So it's now removing the posterior osteophytes, you can see to prevent impingement in extension. Let's go to the femur now with the trial cup in situ, we move on to the femur, clear all the fibrous tissue from the neck, because remember, we have done the in-situ osteotomy, so it's not a classical neck cut. We have to refresh it. And we can take another neck cut if the neck is long. Entry point, just lateral and posterior and prepare for an uncemented proximally coated stem as in this case.
ANOOP JHURANI: And we have to go absolutely lateral to prevent varus malpositioning of the stem. So there's the first femur. Then progressively larger blotches always keep your hand lateral so that we are not in varus and you can see that it's cancellous bone on the medial side of the calcar, which is essential so that your stem is not in varus.
ANOOP JHURANI: That's the final trial and a calcar reamer. We can use a 36 head. And now you can see with the trial cup we see the common anteversion and stability and you can see that the combined anteversion is 35 and we are very stable. There is no posterior dislocation and there is no anterior instability, which we have to prevent more in cases of ankylosing spondylitis.
ANOOP JHURANI: So there is the final shape. Last one, reamer, before we put in our cup and we have decreased our anteversion here by over 10 degrees. So that the combined anteversion is 35 and we do not risk an anterior dislocation because of a fused spine in flexion. A press-fit hemispherical porous coated cup, that's a 54 cup.
ANOOP JHURANI: That's what we templated pre-op. And you can see that we have decreased our anteversion by about 10 or degrees. Screws in the right quadrant. It should go in the thickest part of the ilium. Usually in a man you can put a screw up to 40 millimetres in the good quality ilium bone, and measuring the screw and feeling with this depth gauge that you are in the right quadrant.
ANOOP JHURANI: Always hold the cup while you're putting the screw because when you tighten the screw final few threads, the cup may move. So always hold that. That's the 36 liner. And then we go on to the stem. There is the stem, some release of the anterior capsule there.
ANOOP JHURANI: So the principles of taking down a fused or a fibrous ankylosed hip is right in situ osteotomy in the right plane in situ reaming and then a trial cup first seeing the common anteversion and then putting in your final implants that will ensure that you're stable and you don't dislocate anteriorly, especially in ankylosing spondylitis. There you can see the combined anteversion is 30, 35, very stable anteriorly.
ANOOP JHURANI: We have corrected the deformity, so we are getting...
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