1. The document discusses various techniques for performing total hip arthroplasty in difficult primary cases such as dysplastic hips, ankylosed hips, and hips with fractures or previous failed surgery. 2. Key factors discussed are implant selection, surgical approach, restoration of hip biomechanics, addressing bone defects, and postoperative care to prevent complications. 3. The goal of these surgeries is to restore a biomechanically sound and stable hip joint with the femoral head in a normal center of rotation.

1. 1
Dr VAIBHAV BAGARIA
Joint Replacement Surgeon
Sir HN Reliance Foundation Hospital
Mumbai, India
Uncomplicating Complications:
Your First Difficult Hip

2. What Constitutes a difficult Primary?
⬥ Protrusio Hip
⬥ Dysplastic Hip
⬥ Failed Osteosynthesis/ Bipolar
⬥ Ankylosed Hip
⬥ Fracture Acetabulum

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5. Key points
⬥ Implant Selection
⬥ Approach
⬥ Techniques
⬥ Anticipating complications
⬥ Post Operative Care

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7. GOAL
• Bio-mechanically sound, stable hip joint with
restoration to normal centre of rotation of
femoral head

8. Restoring Hip Biomechanics

9. Restoring Hip Biomechanics

10. Restoring Femur Biomechanics

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IMPLANT SELECTION

15. IMPLANT SELECTION
• Patients Condition
• Anticipated Longevity & Level of Activity
• Bone Quality & Dimensions
• Ready availability of Implants
• Experience of the Surgeon

16. General Tips -Implant Selection
• Have all inventory -‘Overprepare’
• Remember ‘Bail Out Buddies’ talk
• Hedge your bets: Involve different Co.
• Try Innovation but be conservative
• Check Instrumentation a day prior yourself!

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Different Approach

18. Approach Consideration -Tips
⬥ Every Approach - own pros an Cons
⬥ Choose - one that you are trained in
⬥ Approach should help in majority!
⬥ In short Choose Posterior approach
⬥ However do not be ‘dogamatic’

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Charnley: Anterolateral approach; Supine:Troch Osteotomy
Amstutz: Anterolateral, Lateral;Troch Ostotomy
Muller: Anterolateral, Lateral, Release anterior Abductors
Hardinge direct lateral: Muscle Splitting G Medius & Min
Posterolateral: Cut Rotators, lateral, Posterior dislocate
Approaches

20. Dysplastic Hips - Fact Sheet
⬥ Like a revision scenario
⬥ Native Acetabulum - Shallow,
Abducted & Anteverted
⬥ Adaptive Changes - Hyper lordosis,
Adduction contracture & LLD
⬥ Risk of component dislocation high

21. Known the anatomy & Pathology

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24. Dysplasia - Acetabular side
⬥ Restore
Centre
of
Rotation
⬥ Un-­‐cemented
Fixation
⬥ In
Subluxation
-­‐
Slight
medialization
⬥ In
Low
hip
dislocation-­‐
Socket
uncoverage
to
be
tackled
with
femoral
head
autograft
augmentation
⬥ High
Dislocation:
Small
un-­‐cemented
without
graft
is
usually
obtained
or
High
Hip
centre
⬥ Medial
Wall
fracture
Technique

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27. Technical Consideration for femur in DDH
⬥ Significant ante version up to 40 -
warrants derotation osteotomy at
subtroch level
⬥ Narrow canal
⬥ Previous Osteotomies?
⬥ Short Femoral Neck
⬥ LLD
⬥ Femoral Shortening: Carried out as
step cut or inverted Y subtroachanteric
osteotomy

28. Femoral Side - Implant Selection
⬥ Cementless Modular Stem
⬥ Long stem
⬥ Height & Offset options
⬥ Calcar options
⬥ Sleeve - ? HA Coated
⬥ Keep wires ready for osteotomy

29. Osteotomy
⬥ Identify the need
⬥ Just Shortening or angular correction or
rotational correction - usually
combination
⬥ Step Cut/ ( Valgus Subtrochanteric)
Schanz osteotomy
⬥ Fixation Wires and SROM stem

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31. Technical Consideration
⬥ Secure distal fit, Intimate proximal Fit
⬥ Optimise Version, Offset
⬥ Optimise Length - Based on Osteotomy &
Trialing
⬥ Choose appropriate Head Size

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33. Protrusio Hip -Key facts
⬥ Head Medial to Ilioischial Line
⬥ Plan: restoration of offset both
acetabular & Femoral
⬥ Primary defect is medial acetabular
defect - managed by Head graft

34. Protrusio - technique
⬥ Surgical Exposure not to be taken for
granted
Options for Exposure:
⬥ Controlled Dislocation with Hook
⬥ Insitu Neck Osteotomy
⬥ Trochanteric Osteotomy followed by
neck osteotomy

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Bone Hook technique

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Insitu Osteotomy

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Morselized Graft for Medial defect

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Restore lateral Offset - Prevent Impingement
Neck with Liner
Neck with
Acetabulum
Bone to Bone
( Trochanter
with Pelvis)

39. Protrusio - 3 key Points
Controlled Dislocation
Build Medial Wall
Restore Lateral Offset

40. Ankylosed hip - Facts
⬥ Anesthesia: Upper Airway issue & PFT
⬥ Preoperative Orthopedic Considerations
⬥ Exposure Issues
⬥ Implant Issues

41. Ortho Assesment - Ank Spond
⬥ Spinal Involvement: Fusion/ Anderson’s
Lesion
⬥ Pelvic Obliquity
⬥ LLD; Opposite Hip, Both Knees
⬥ Integrity of Sciatic Nerve

42. Pre operative consideration
⬥ Templating is of paramount importance
⬥ MTx is fine
⬥ Anti TNF stop
⬥ Spinal Osteotomy before Hip???

43. Key Issues
⬥ Positioning
⬥ Exposure & Adequate Releases
⬥ Neck Cut
⬥ Joint Line identification & Correct
Acetabular positioning
⬥ Post op HO

44. Key Tips
⬥ Positioning: Be present yourself/ Opp
Hip and Spine
⬥ In case of external rotation fixed
deformity, identifying neck may be
difficult.
⬥ Can go anterior to neck and identify
the structure. May need to sacrifice
acetabular post wall & do osteotomy

45. Identifying Joint line
⬥ Insitu reaming
⬥ Foveal soft tissue
⬥ Incomplete grey ossifying cartilage
⬥ Intraoperative flurosocpy

46. Acetabular Component positioning
⬥ Remember Kyphotic Spine makes them
hyper extend & Pelvic Obliquity
⬥ Malpositioning -> Anterior dislocation
⬥ For each 10° of sagittal pelvic
malrotation above 20°, the cup position
should be modified so that it is 5° less
inclined and anteverted

47. Adequate Soft tissue Release - Ank Spond
⬥ Adductor Tenotomy
⬥ G Max release
⬥ Illiopsoas tenotomy
⬥ Anterior capsule release
⬥ Do not forget over friend ‘Sciatic Nerve’

48. Primary Hip for Acetabular fracture
⬥ Should be done for right Indication
⬥ Reduce and Fix well: Posterior column
Integrity is critical
⬥ Use TM cup - multi holed ( Revision
Shell)
⬥ For Large Bone Defect - Consider
Cages

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Post Operative Care
Do not Forget:
Check X Ray
Limb Positioning
DVT
Mobilization Schedules
HO Prevention

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Uncomplicate: OrganiseYour thoughts
Preoperative Planning :Well begun is half done
Inventory: Be liberal in ordering
Exposure: Comfort is a priority
Biomechanics: Hip Surgery is understanding mechanics
Remain Cool, Calculated & Finally…
TAKE HOME MESSAGE

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Un-complicate Complications!!!