Surgical Techniques
Direct Anterior Cup-Half Cage for Revision and Complex Primary Total Hip Arthroplasty: Surgical Technique
As surgeons' comfort with the direct anterior approach (DAA) for total hip arthroplasty continues to increase, there is a growing interest in performing complex surgeries through this approach. Acetabular bone loss and/or pelvic discontinuity in the primary or revision setting often requires specialized implants such as a cup-cage construct. We describe our surgical technique for implanting modified cup-half cages through the DAA and show 2 case examples of how this technique was utilized in the setting of complex acetabular bone loss.Surgical Technique of a Cement-On-Cement Removal System for Hip and Knee Arthroplasty Revision Surgery
Cement removal during hip or knee arthroplasty revision surgery is technically demanding and prone to severe complications such as periprosthetic fractures, incomplete cement removal, or perforations. Several alternative techniques have been developed to enable complete, accurate, and safe removal of cement from bone, including osteotomies and cortical windows, endoscopic instruments, ultrasound devices, lithotripsy, and laser-assisted removal. We describe a cement-on-cement technique with a sterile, single-use tool for cement removal.Safety and Efficacy of Using Fracture Tables for Prosthetic Hip Dislocations
The incidence of prosthetic hip dislocation continues to increase because of the overall increase in volume of total hip replacement surgery. Closed reduction is often the preferred treatment, particularly in the first few months after surgery. No matter the closed reduction technique, linear traction is a requirement, thus posing a physically demanding stress opening both surgeon and patient to potential injury. We describe a fracture table closed reduction technique along with outcomes and safety data for a sample of patients.Conversion of Hip Arthrodesis Using Robotic Arm Technology
Recent advancements in computer-assisted surgery have led to a renewed interest in robotic-assisted hip arthroplasty. This technology assists with component position which is especially useful in prior trauma or dysplasia cases. We present a case of a surgical hip fusion conversion to total hip arthroplasty with the use of robotic-assisted technology. Enhanced preoperative planning with the ability to manipulate implant position before execution can be invaluable during complex procedures. Further research is warranted before revision cases using computerized navigation systems becomes more prevalent.Complex Primary Total Hip Arthroplasty: Small Stems for Big Challenges
Total hip arthroplasty is one of the most successful operations in all of medicine. Femoral deformities from malunion, prior osteotomy, and retained surgical implants all present unique challenges. Corrective osteotomy and hardware removal add significant morbidity to an operation that typically has a fast recovery. Short stems can be used in these cases to spare patients' increased morbidity. We present a case-based illustration and surgical technique for the use of short stems in complex primary total hip arthroplasty with femoral deformity and retained hardware.The Value of the Direct Lateral Hip Radiograph in an Adult Reconstruction Practice
The specialty evaluation of hip pain, stiffness, and/or dysfunction usually includes patient history, physical examination, and radiographic evaluation. Radiographic views of the hip are not standardized, and basic studies may include an anteroposterior pelvis, anteroposterior hip, frog lateral, and direct lateral of the hip. In this article, we discuss the importance of obtaining a direct lateral radiograph of the hip in all patients being evaluated by a specialist for hip pain and its value in hip arthroplasty care.Robotic-Arm Assistance Simplifies Hip Arthrodesis Conversion to Total Hip Arthroplasty
Hip fusion takedown to total hip replacement is a challenging operation. Neck osteotomy and acetabular component placement are technically demanding and often require fluoroscopic guidance. Robotic arm–assisted total hip arthroplasty enhances accuracy of preoperative planning and provides navigated guidance for neck osteotomy and haptic guidance on acetabular reaming and cup implantation. Fluoroscopic guidance is replaced by real-time navigation and on-screen data. This article describes how robotic arm assistance can simplify this complex operation.Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation
Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ≤−5° on the coronal assessment). We describe our surgical technique, with 4 easily reproducible technical tips to achieve positional consistency of the femoral stem: commencing stem insertion from the piriform fossa entry point, using a femoral stem distal centralizer, aiming the tip of the component to the center of the patella, and placing the thumb between the calcar and inferior neck of the femoral component to prevent the stem from tipping into varus.Rapidly Progressive Osteoarthritis and Acetabular Bone Loss Outcomes for Patients Undergoing Primary Total Hip Replacement
Rapidly progressive osteoarthritis (RPO) is a rare condition which is poorly understood. Limited published literature is available. Reported here is a cohort of patients with RPO and acetabular bone loss who underwent primary THA. Risk factors, degree of acetabular bone loss and outcomes are presented. A typical case of RPO is described and investigations discussed. A retrospective audit was undertaken. 49 patients over an 18-year period were included. RPO patients were significantly older (P < 0.01) and had a lower BMI (P = 0.03).Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient
Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally.Direct anterior approach total hip arthroplasty for Crowe III and IV dysplasia
High-dislocated hip dysplasia is challenging to treat with total hip arthroplasty via the direct anterior approach (DAA). The DAA has potential advantages including optimizing component positioning, enhanced hip stability, and a more rapid postoperative recovery. We present a surgical technique for DAA total hip arthroplasty for hip dysplasia that includes preoperative planning, soft tissue releases, subtrochanteric osteotomy, component placement, and intraoperative nerve monitoring and imaging.Algorithmic soft tissue femoral release in anterior approach total hip arthroplasty
Although the anterior approach for total hip arthroplasty has gained increasing utilization, some studies have suggested a higher risk of femoral complications, as well as difficulty with femoral exposure. Techniques of soft tissue releases have been described to offer better femoral exposure, and to help mitigate complications. The purpose of the study is to describe an algorithmic soft tissue femoral release in direct anterior approach total hip arthroplasty and to assess the clinical outcomes of patients upon which this algorithm of femoral soft tissue releases was utilized.Optimum anatomic socket position and sizing for the direct anterior approach: impingement and instability
A comprehensive strategy is important for ensuring reproducible and safe acetabular component sizing and positioning. Presented here is our approach for anatomic acetabular component positioning in direct anterior total hip arthroplasty. This strategy has evolved with our understanding of the ramifications of socket sizing and positioning on instability and impingement. Data collected by a single surgeon (J.A.R.) between 2009 and 2011 influenced our current paradigm. We compare the sizing and positioning parameters of the anterior and posterior approach, thus demonstrating how the 2 are different.Femoral artery injury during total hip arthroplasty
There are an increasing number of vascular complications after hip replacement, some of which can be life-threatening. However, there are few reports of lower limb ischemic symptoms after undergoing an otherwise uncomplicated classic total hip replacement. We report a patient with low weight who developed postoperative limb ischemia resulting from blood clots caused by insertion of a Hohmann retractor close to small anterior acetabular osteophytes. Ultrasonography and angiography revealed her symptoms to be the result of femoral artery intimal injury with lower extremity arterial thrombosis, which led to pain, numbness, and decreased skin temperature.Antibiotic cement spacer for isolated medial wall acetabular deficiency in the setting of infected hip arthroplasty
Periprosthetic joint infections remain challenging for orthopaedic surgeons. These are typically treated with 2-stage revision with an antibiotic spacer and arthroplasty reimplantation after infection eradication. We report a novel technique to create an antibiotic cement spacer construct in the setting of significant acetabular medial wall destruction due to osteolysis and infection. The medial wall of the acetabulum was reconstructed using antibiotic cement with 2 screws acting as a rebar. An acetabular liner was then cemented into place forming a cement construct similar to a reconstruction cage in function.A simple technique to remove well-fixed acetabular components in revision of total hip arthroplasty
Removing well-fixed acetabular components can be a challenge for orthopaedic surgeons in revision of total hip arthroplasty. Acetabular bone loss, fracture, and other complications occurred in extracting implants may result in instability and fail of revision. Thus, instruments are developed to avoid such complications. We report a simple technique by drilling a tunnel on the superolateral quadrant of acetabulum and using an offset staff to remove acetabular components without many matching units.Concomitant achondroplasia and developmental dysplasia of the hip
Achondroplasia (ACH) is the most common form of hereditary dwarfism and presents with multiple musculoskeletal anomalies but is not normally associated with premature hip arthritis. Developmental dysplasia of the hip (DDH) is a spectrum of disease resulting in shallow acetabular depth and a propensity for chronic femoral subluxation or dislocation; it is among the most common causes of premature arthritis. This case report describes the diagnosis of symptomatic DDH in a patient with ACH and highlights difficulties of primary total hip arthroplasty (THA) as a treatment option.Custom titanium sleeve for surgical treatment of mechanically assisted crevice corrosion in the well-fixed, noncontemporary stem in total hip arthroplasty
Adverse local tissue reaction associated with total hip replacement may occur when mechanically assisted crevice corrosion occurs at metal-metal modular junctions in which at least one of the components is fabricated from cobalt-chromium alloy. Complete removal of components may be associated with significant morbidity; when components are well fixed and in acceptable position, it may be appropriate to consider modular rather than complete revision. We have diagnosed mechanically assisted crevice corrosion in total hip arthroplasty patients with noncontemporary but well-fixed femoral components and found that modular conversion to a ceramic femoral head to remove a source of CoCr corrosion and fretting products was only possible by having a custom titanium sleeve manufactured.Arthroplasty in organ transplant patients
The number of solid organ transplants performed in the United States continues to increase annually as does survival after transplant. These unique patients are increasingly likely to present to arthroplasty surgeons for elective hip or knee replacement secondary to a vascular necrosis from chronic immunosuppression, or even age-related development of osteoarthritis. Transplant recipients have a well-documented increased risk of complications but also excellent pain relief and dramatic improvement in quality of life.
