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Chapter 05 Video 1: Primary Total Hip Arthroplasty Through the Direct Anterior Approach With the Use of a Specialized Surgical Table

November 07, 2016

Contributors: Richard A Berger, MD

This video is a demonstration of a total hip replacement in a 67 year old female. There is severe osteoarthritis of the hip with superior migration and lateral subluxation of the femoral head in the acetabulum. The surgery is performed through a direct anterior approach utilizing the ARCH table. The incision is made lateral and posterior to the anterior superior iliac spine to avoid the lateral femoral cutaneous nerve. The dissection is carried out down to the fascia overlying the tensor fascia lata muscle. The lateral circumflex femoral vessels are clamped, cut and ligated with #2 silk. Adipose tissue is resected from the anterior hip capsule. This is located just proximal to the quadriceps muscle and lateral to the rectus femoris muscle. The capsule is exposed below and above the femoral neck using a cobb elevator followed by cobra retractors above and below the femoral neck. The rectus femoris is mobilized off the anterior acetabulum, retractors are placed (modified Charnley), and a T incision is made in the capsule. This becomes an “H” incision when the superior capsular flap is incised. The femoral neck is exposed, and the cut is marked according to templating. The leg is externally rotated 40°, and the femoral neck is first cut through the calcar. A segment of the femoral head and neck is taken out, and the femoral head is removed with a corkscrew device. The ligamentum teres is removed. The labrum is excised and any osteophytes removed. The acetabulum is reamed sequentially until bleeding cancellous bone is achieved. If difficulty is experienced exposing the acetabulum the surgeon should check:

  1. That the femoral neck cut is not too long.
  2. There is adequate traction on the limb.
  3. There are no large overhanging osteophytes.

The acetabular component is trialed. If the trial is stable, a no-hole acetabular component is implanted. If the trial is not completely stable, a sector acetabular component is implanted with three screws. The final component is implanted, and the screw positions are checked fluoroscopically. The femur is released and inflamed capsule and synovium are released. It is important to release all posterior capsule as well as some external rotators leaving the obturator externus tendon intact. The posterior trochanter is exposed and soft tissue lying medial to the tip of the greater trochanter is released. Traction is released on the table and the leg is externally rotated between 100 and 120 degrees. The leg is then placed in extension and adducted 40-50 degrees. The femur is broached and calcar reamed to get the neck edge flush with the broach. The femoral broach is trialed. The size, component orientation and leg length is checked. The real femoral component is implanted and the real femoral head is impacted. The inferior capsular flap is repaired to the reflected head of the rectus femoris. A drain is inserted, and closure proceeds with a continuous number one suture in the fascia. Post-operative protocol is discussed.

Results for "Advanced Reconstruction Hip 2"