Name:
Metal on Metal Revision Hip Surgery by Dr Anoop Jhurani
Description:
Metal on Metal Revision Hip Surgery by Dr Anoop Jhurani
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/9eee3ae0-7bde-4337-b22f-37738196127d/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H09M27S
Embed URL:
https://stream.cadmore.media/player/9eee3ae0-7bde-4337-b22f-37738196127d
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9eee3ae0-7bde-4337-b22f-37738196127d/Metal on Metal Revision Hip Surgery by Dr Anoop Jhurani.mp4?sv=2019-02-02&sr=c&sig=xYQxICVX8s6ZQjfAxLEbzB6PrD7HsKoO%2FWO9%2BDTkVt8%3D&st=2024-11-21T15%3A24%3A11Z&se=2024-11-21T17%3A29%3A11Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Nearly 1 million metal on metal hips were implanted worldwide, and that led to a big problem of corrosion stenosis and Charcot foot formation and has increased the revision hip burden worldwide. This is a case of a 60-year-old male who had a metal on metal, total hip done, post acetabular fracture and AVN of the hip. He was doing reasonably OK for the first two years, after which he started having pain and limping.
ANOOP JHURANI: He did not heed advice to get his [INAUDIBLE] or an ultrasound, but presented in 2015 with instability and recurrent dislocation. His x-rays here show the dislocated metal on metal total hip, which was reduced once, but it re-dislocated. The patient had recurrent dislocation and instability.
ANOOP JHURANI: The component positioning is obviously flawed and the cup is not well seated, though it looks well fixed, but it is not well secured near the trochlear drop and is vertical as well, so is the stem in varus. So the plan in this case is to do his Mars MRI first, analyze whether the patient has a pseudo tumour formation and then plan the revision. Morris MRI, or a metal artifact reduction sequence MRI, which clearly shows the shouldn't do what formation there with the big cyst,
ANOOP JHURANI: and that has led to destruction of the abductors and the greater trochanter and that is causing the patient to dislocate and that is the cause of recurrent instability. And there you can see the cyst and the shoulder tumor. This is his post-op X-ray. He is nine months post-op follow up and you can see we have used a highly porous shell with multiple screws and a modular restoration type of a stem.
ANOOP JHURANI: Preparing the metaphyseal separately from the diaphysis, so we account for the metaphyseal diaphysis mismatch in revisions because that stem that we removed was approximately quarter the stem, which enlarged the metaphysis. So we have prepared the metaphysis separately with a cone and the diaphysis separately and this is a modular stem. We also wired the trochanters in the abductors well
ANOOP JHURANI: so that there is no late trochantic fly off. The patient has no link now, no pain, no instability and he's had having a good hip function. We can also see sport variants here. That means that this porous cone is, well ingrown now and we'll see the whole revision in this surgical video that follows. This is the revision for metal on metal pseudo tumor formation and instability with which the patient presented.
ANOOP JHURANI: The patient is in lateral decubitus position and the approach is standard posterior. We are dissecting through the fibrous tissue. The original approach was anterolateral, so we have a fresh plane. It's very important to rule out infection and hence we take three to five samples and send it to the biochemistry lab to rule out infection. The stem here is a Zimmer proximally coated stem and the stem is well ingrown.
ANOOP JHURANI: It's important to be patient with the stem removal use 10 millimeter very thin osteotomes to break that bone that you see there and then gradually take out the stem. You can see that the stem was well integrated but because it was proximally coated we could remove it with 10 osteotomes. Coming to the cup which is also well ingrown, here we can't use the exploring system because this is a very large metal cup
ANOOP JHURANI: so the exploring system typically comes in 32/36 sizes and 28 millimeters. So here, this is a large cemented cup of Zimmer. And again, the trick is to use 10 millimeter curved osteotomes, very thin, go all around, especially inferior where there is good bone. Gradually tap it out and then use this cup holder to pry it out without causing much loss of bone.
ANOOP JHURANI: So here we are taking out the cup after very gradual removal and breakage of the bone. Here the cup was well ingrown, but the patient had tendonosis and psuedo tumor formation. Because of the tendonosis, there was extensive corrosive reaction and the patient had persistent instability. Now the preparation of this socket, you can see that we prepared this socket up to size 64 and in divisions we should oversize the cup by at least 2 millimeters.
ANOOP JHURANI: This is a multi hold, highly porous cup and we are inserting it in 20 degrees of anti version and 40 degrees of inclination, gentle tap at the top to seat it at the bottom and then gradual blows to see that it is well fixed. Our in-revision situations, we should always augment our fixation with the screws, two or multiple going into the ilium into the strongest part of the bone pointing towards the SI joint
ANOOP JHURANI: and we should be careful not to put the screws in to the posterior side so that they come out in the sciatic notch so it's important to follow the safe zone. A 36 liner in and now the preparation of the stem. Because this was a proximally coated stem and we took it out causing some loss of bone, we are choosing for a restoration type of stem which is modular and the preparation of the proximal and the distal part is separate.
ANOOP JHURANI: It's good to start the initial reaming with a guidewire and see on the c-arm that we are not perforating and prepare with reamers the distal part, we ought to have absolute press fit and the commonest mistake in preparation of revision stem is to under size it so it's important to see in the c-arm that we are absolutely correct in our sizing of the stem.
ANOOP JHURANI: So here we are, preparing for the cone now and the cone comes in 70, 80, 90 and 100 millimeters. So here we can anti-vert as per our judgment of command anti-version. That's the insertion of the final stem, which is modular. So it has a proximal body and a distal stem which can be inserted together
ANOOP JHURANI: and then finally this screw is lodged at the end and the stem, you can see is about 15 to 20 degrees anti-verted so that the combined anti-verted is 35/ 40 degrees. There you can see it's a stable reduction, not very tight, not very loose and patient can get extension. The combined anti-version is roughly 40 degrees and the hip is very stable. We have also resected the pseudo tumor membrane all around the glutei and that membrane was causing insufficiency of the abductors and hence patient was presenting with instability.
ANOOP JHURANI: So we resected all the psuedo tumor there under the glutei and kept the hip slightly a little more tight, and you can see that the abductor, the greater trochanter, along with the abductor, was crushed by the or destroyed by the psuedo tumor formation and we have to wire the trochanter very well so that there is no trochantric fly off. So the hip is very stable after wiring the trochanter back
ANOOP JHURANI: and you can see that the patient has very good range of movement, has about 40 degrees of combined antiversion. The shuck test, two to three millimeter opening and flexion, no opening in extension on the shuck. On the slip test flexion, internal rotation, adduction, he is not dislocating, so it's very stable and the pseudo tumor, as you can see, we have resected out the membrane from under the glutei and the patient has a very stable reconstruction.
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