CHAPTER 20
Total Hip Arthroplasty

Hybrid and Uncemented

1. The preferred patient position for a posterolateral approach to the hip joint is the lateral decubitus position. Adequate padding of the axilla is necessary to avoid injury to the brachial plexus. While the patient must be secure on the operation room table, avoid excessive tightening of pelvic posts,which can compromise the neurovascular status of the “down-leg” (Fig. 20–1).

2. All pressure points should be padded.

3. The procedure can be done with general, epidural, or long-acting spinal anesthesia. There is some evidence that epidural anesthesia decreases the risk of deep-vein thrombosis as well as decreases blood loss during total hip arthroplasty.

4. Instruments required for total hip arthroplasty include self-retaining retractors, straight and bent Hohman-type retractors, a femoral neck elevator to facilitate exposure of the proximal femur, and battery powered reamers and power saws. In addition, the specific instruments, broaches and trial components unique to the prosthesis to be implanted should be available.

5. Consider using enclosed helmets and body exhausts, which may help minimize the risk of perioperative sepsis.

6. Intravenous antibiotics appropriate for the hospital’s bacterial flora should be administered prior to tourniquet inflation and continued for at least 24 hours after surgery.

Tips and Pearls

1. Extensile exposure is essential for success. The use of short or “mini” incisions is to be avoided as it may compromise component insertion.

2. The inability to anteriorly translate the femur enough to achieve adequate visualization of the acetabulum is usually due to insufficient release of the gluteus maximus tendon at its femoral insertion and/or of the reflected head of the rectus femoris tendon at its insertion site into the supra-acetabulum.

3. Preoperative measurements (level of neck resection, distance from lesser trochanter to center of hip rotation) should be reassessed during surgery since radiographic magnification may vary as much as 10 to 15%.

4. Ensure that all significant osteophytes are identified and removed at the time of surgery. Medial acetabular osteophytes can result in lateralization of the cup that may affect abductor mechanics. Osteophytes located on the acetabular rim or on the femoral neck can cause impingement leading either to decreased hip motion and/or to hip instability.

5. Assess the stability of the hip prior to closure. Pay particular attention to impingement from either osteophytes or the prosthetic femoral neck on the rim of the acetabular component. Stability often reflects the adequacy of reconstruction of both length and offset. Failure to restore offset, especially in large individuals, may result in impingement and hip instability. Hip motions evaluated should include:

a. Hip flexion of 90 degrees without rotation (simulating sitting in a chair)

b. Hip flexion of 45 degrees, hip adduction of 15 degrees, and internal rotation of 15 degrees (simulating sleeping position)

c. Hip extension, abduction and external rotation to assess anterior instability

What To Avoid

1. Because of the problems associated with infection, great care is taken to minimize this complication. Operating room traffic should be minimized, and preoperative antibiotics administered.

2. Avoid a vertical or retroverted alignment of the acetabular component.

3. Avoid over-reaming the acetabulum and removing excessive bone. Conversely avoid under-reaming the acetabulum and using excessive force during component impaction, thereby increasing the risk of acetabular fracture. Controlled acetabular reaming is preferred. If the press-fit stability of the acetabular component is not satisfactory, the use of a supplemental acetabular fixation screw is recommended.

4. Avoid a varus or retroverted alignment of the femoral component.

5. Avoid excessive broaching or reaming of the femur especially when cement fixation of the femoral component is planned. Over zealous removal of cancellous bone will weaken the bone-cement interface and may predispose to early component loosening. Femoral preparation should be performed in a controlled methodical fashion.

6. Avoid excessive force during femoral preparation for an uncemented femoral component. Preparation of the femur for an uncemented femoral component requires patience in order to minimize the risk of fracture.

1. Position the patient in the lateral decubitus position. Pad all pressure points including the axilla. While the patient must be secure on the operation room table, avoid excessive tightening of pelvic posts, which can compromise the neurovascular status of the “down-leg” (Fig. 20–1).

2. Prepare and drape the limb in the hospital’s standard sterile fashion.

3. Make a straight lateral incision approximately 15 cm in length. Center the incision over the lateral shaft of the femur. The incision should start approximately 5 cm proximal to the tip of the greater trochanter and extend distally about 10 cm.

4. Carry the dissection directly through the subcutaneous tissue. Maintain adequate hemostasis. Identify the fascia lata.

5. Incise the fascia lata longitudinally. Bluntly split the fibers of the gluteus maximus at the proximal pole of the fascia lata.

6. Insert a self-retaining retractor. Partially release the femoral insertion of the gluteus maximus tendon with the electrocautery. This greatly facilitates anterior translation of the femur that will be necessary for acetabular preparation. Attempt to avoid the small perforating branches of the profunda femoris artery.

7. While gently rotating the hip internally, identify the piriformis and conjoined tendons. Incise them at their insertion on the posterolateral femur with an electrocautery. Tag the tendon ends with nonab-sorbable suture (Fig. 20–2).

8. Place a cobra (“Aufranc”) retractor around the inferior femoral neck between the posterior hip joint capsule and the quadratus femoris. Retracting the muscle fibers of the quadratus femoris inferiorly helps expose the entire posterior capsule. Retract the gluteus medius superiorly with a thin, bent Hohman or other retractor.

9. Perform a trapezoidal-shaped posterior capsulotomy. Tag the proximal and distal corners of the capsule with nonabsorbable sutures.

10. Dislocate the hip by gently internal rotating and adducting the femur.

11. With the leg held in internal rotation (foot pointing toward the ceiling), use an electrocautery to strip the capsule and soft tissue off the posterior femur (which now points up) until the lesser trocahnter is visible.

12. Determine the optimal site for the femoral neck osteotomy based on both the preoperative radiographic measurements and the intraoperative anatomic landmarks. Use an oscillating saw to make the femoral neck osteotomy (Fig. 20–3). Remove the femoral head and save it on the back table. Occasionally, there is a need for an autogenous bone graft in primary hip arthroplasty, and the femoral head is a convenient bone source.

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