Live surgery of a total hip arthroplasty (DAA) with Dr. Rothenberg that demonstrates surgical draping, the value of TraumaCad® data, how the software assists with leg length and offset assessment, and provides an in-depth overview of the RI.HIP surgical workflow.
Next, we'll do a surgical video and I'll try to highlight the tips and tricks throughout the procedure if something comes up. Um I apologize if I take a little slow, it's a little, a little bit of a lag, but I'll be glad to pause uh the video to talk about it further or go back through. Essentially. Uh Here's an I do an anti approach with a, a table. I think there's a mixed bag of here of uh users on the call. We could talk about the post your approach differences at the end if you want, I prep circumferentially around the thigh. Uh This is just a sterile 10 10 dr to block out the, our S CD and, but my assistants will prep the thigh and then that way we can gain exposure to the knee. Um You don't need to go any dis more distant than that, but you really don't want to be too high on the thigh. Um Because you have a minimum distance between the pelvic array and the femoral pless array. So this is a sterile cob band. Um You initially, I was doing this while I was gown but I decided to go ahead and do this with sterile gloves before just to avoid any contamination uh on the skin, I think helps uh as an intermediary layer helps uh avoid any loss of uh you know, kind of movement at the plate. And then the knee cap sometimes can be um difficult in terms of like being an obstacle for getting a stable position. So oftentimes I'll just bring it a little bit to the medial side that helps with camera view because I'll have the camera set up on the other side of me. Um And so, you know, just getting a robust layer so that, that plate is well fixed. Um That's now a, you know, sterile plate that I'm gonna uh perforate the drapes to play, put on the array. And here we're just putting um our uh drapes on to, for our, you know, routine anti or hip approach heater approach uh marking out the skin. Um You definitely, I expanded a little bit here. I can see the Iliac Crest and the A SI S and that's just the, you know, the exposure you need for the, the pelvic pens and the, the pelvic T array. And I use a shower curtain drape. Uh you can use other drapes. Uh Same thing I've done it with uh kind of more standard blue drapes too, but I find this to be really nice and uh easy for our team to use. We're just setting up here. Um So here's our template. This is I I templated the trauma ca like we did before polar uh size five uh standard offset with a 54 R three cup um shooting for three millimeters of length and uh roughly the three millimeters of offset roughly. And then this set of 43 degrees of inclination and my neck cut was 16.5. So we've got this baseline leg length. We've got a, the report that I went over earlier. You can see it in two different ways. A lot of the information is on the templated one or you can pull up the report. So here we made a perforation. There's that, that um sterile, uh pless fem ray, um I orient, there's a kind of a t to it and I put orient the bottom part of the um t towards the toes. I keep that consistent and that, that actually keeps this array. Um I think it maximizes the distance that there's kind of an asymmetry to that point. And so I try to be consistent with that. I recommend that for anyone that's doing this, just make sure that's consistent, whoever's placing it. Now, I'm using the 40 pens, um the in the Iliac crest. I like to um initially when you're doing it, get the guide there. And so you know the distance and then you kind of get used to how far you're gonna do it. And then I use the uh this base clamp. It's really, really critically important that you get that really tight and that the bone they're well fixed in bone, you check rotational stability, you check uh depth that those pens aren't moving. Because if those move during the case, you're not gonna get any useful information. And then here's uh adding the, the removable pless array, uh they're sorry, the removable uh T array. Um I just tighten that down really tight to make sure it's not off uh Here, I'm getting the first point of the registration. So I've got the s the surgical side A SI S and then off screen here, then my assistant got the other side. Uh Next, we've moved on, we have the template here where um now just looking to mark the neck resection. So I have that based on the trauma cat, I marked my neck for a section and now I'm putting uh a cobra, uh we're over the tensor muscle. And what I'm trying to show here is the gluteus, medius and gluteus minimus tendons coming into the proximal femur. Uh always a little tricky to show that. And we can, but we can share some anatomy images. You guys all know this spot, but there's usually a nice little gap here between the vases latter Alice and the men that where the media and minimus come in. There's usually a nice little bald spot there. And if you can, that's that in my hands has been a little bit of a compromise to get it as far lateral as possible for this to make it as accurate as possible from an anti approach. It's not quite as um you know, direct lateral as you can get with a poster or a harding approach. But um uh if I internally rotate the femur and you know, go to that bald spot or even give a little bit of a longitudinal split of part of the anterior half of the media tenant. Um It, it works really well. So I had taken off the T the T A A and my assistant put it back on here for this part. And what we're doing is just capturing the proximal fem checkpoint. You really wanna make sure that your leg is in a neutral position. Uh I use the HOA table so I have it at that zero up, right? My rep double checks that um that way you can go back to that position at the end per consistency. Um Here we're doing the neck resection based on the landmarks that we picked on the uh trauma cat image. So just uh routine flow here, I've tagged my checkpoint. You can see that here. I like to make sure if it, you know, if it goes anywhere. Um I, I could find it really easily during the procedure. If it were to fall out for some reason, it's not gonna get lost in soft tissue. And then, um, it also is a reminder to take it out at the end, we put it on a, um, a sharp count. So that way he didn't get left behind. I like to save anterior capsule too. And so that's what's tagged here. That's the other tag. So there's two tags on my wound here. Um, you can see that the Pless fero light was off and now it's back on because we're, we're at this point, we're gonna, um we can take it on and off, uh which is really nice versus other systems and it gets out of your flow and you don't have to be on the other side of the pelvis. But here we're gonna doing registration and it's pretty quick. I mean, it, it probably takes 10, 15 seconds to register the Aceta Bum and then the media wall. Um And so here I'm just painting here, you can see it, I'm painting it and so it's getting feedback. It's showing me where it wants me to get additional points. And as an anti surgeon, it usually is wanting more anti rama. So I'd rather focus on that just because that's where my exposure is. Least you can see that's done. And now we're moving on the medial wall, I think at that point and it's uh here uh 456789, 10 seconds. So, um it's probably one of the slower ones. Um my templated size was a 54 and my tale saying 51 mm. So I shoot for 4 mm over my thermal head size and that's right on spot because we've got a 51 ounce taulli. And I think the head measured 50. I think uh one of the nice things here is you get to ream your own on your own. Uh So here I'm reaming uh with our usual something enough you reamer here, I like to use offset uh get my own feedback. Um And you can see, I, I know on the top part of the screen that the array is still in and on the um on the base there. So it's definitely um something where you can work around it if you want to even with your assistant there. So thus far, I mean, it's from a workflow standpoint, it's added, I don't know, a few minutes to my case. And I think you'll see throughout this, we'll get confidence in terms of what measurements we're getting and an ability to fine tune the final implant knowing that you're going to restore the initial goals of, you know, version inclination um offset and length. Here's the uh inserter, there's a uh a uh offset inserter which you can see I use the R three cut out there on the, the cup. I try to put that at the corner there. So it's aligned with the outer edge of the offset inserter. Uh So that the screws are in the post your super quadrants. Um uh then we have the array um for the R I hip system facing away from me, towards the side for the camera tracker. And so now it's gonna show what the screen is showing. It's here, it's um seeing the inserter, it's seeing the pelvis and we're gonna get it in and it's gonna start to show us numbers as we get closer. So here, real time you're getting feedback. I'm just trying to go, what I, what I like to do is, you know, use a standard workflow, use a standard technique. Put it where I think it's close to being where I want it. Um And then uh double check. So initially, it's giving me a little bit more inclination than I shoot for a little more less Anna version, I think, uh you know, literature would say mostly 40 20 but notice how close, you know, 46 48. So inclination is pretty tight there. Uh Anna versions 12 and 18. So, you know, if you're just gonna play averages, uh you could be at a right now. This is a 46 and a 15 cup no matter what uh pelvic plane you're gonna use. So, you know, I I'd say as an anterior surgeon, it's kind of 40 20 for me. If anything I might back off to like um I think in this one, we, we were, I think somewhere in the eighteens we'll see at the end here. Um, but, uh, here just moving that you get real feedback, you see it in the live, I'm moving the cup, I'm adding a little an aversion. I dropped the inclination. Um, it, there, it's storing it. So once it's orange, that's one of those things. You gotta make sure it catches if you move too quick and you don't let the system catch it and with a store or have your rep, press the button for a store. You might move past um getting a final report or, you know, if you change the cup and then move quickly on without getting that stored. Um I, I've been frustrated at the end of the case because I didn't get that. So, um it's easy enough. You just have to be aware that you need to do that. Um One of the things that we, we really harp on is making sure that those arrays are clean, the balls are subject to water and blood uh disrupting our um visualization. So I, I'll keep those really clean assistants. We uh clean them if, if necessary, if there's any splatter on them. And then um with the impactor, sometimes you'll, if you hit it with, you know, a bigger mallet or a bunch of times the balls will loosen a little bit subtly and then it won't read. So you just want to tighten those back up with clean hands or with a lap on it. And so I was just checking here on the anatomy just seeing where the version was, inclination, et cetera. And I just really find choosing to fine tuna there. I'm just holding it steady. Um Just decided, uh I remember this case. Well, I just decided to add a little bit more aversion. Uh just to scotch more at the end before I uh put some screws in. Then I released that inserter. Um It stored the number. OK. We're gonna add a um screw again. I've kept that orientation. I think that's a nice way to hold, to place that for the draft interior approach. Um In my hands with that offset inserter, sometimes I'll use the straight, I'll go to the straight after I've impacted. If there's a little bit, a few millimeters left and you need to the force of a straight impactor, I'd screw it in and put it down, but it's, it's pretty rare that I need to do that. Um And I, I'm, I'm usually uh a 1 or 2 screw this guy there. Is there any, is there any questions coming across right now before we move on to the next part of the flow? I don't wanna um Yeah, sure, sure. The, the question that's uh in the chat right now is can you talk through your pin preference? Uh as far as the size chosen? Yeah, so you can use any kind of screw point. Um We went through using like a 35 cortical screw. And then I end up actually starting to use the core checkpoint. Um So that with the magnetic holder. So for those of you guys who are gonna be using this with Coy, I, um I would disclaim that it's not part of the official technique, but that would be, I found that to be the most helpful. Um Perfect. And then, um as far as the amount of x-ray that you use for cup placement, have you seen a reduction in the amount of x-ray used in these cases? Yeah, absolutely. I, I for this demo, I mean, I took, I took images um you know, including this one here, I'm checking cup depth and cupping, checking cup screw placement. And I still take that x-ray routinely. I'll get a quick shot. What I don't do anymore is make sure the x-ray is perfect because we all know that fluoroscopy lies. And so I've gotten, I've just, I just wanna see, I just kind of generally wanna see depth screw placement and I'm not like uh meticulously changing to match their functional uh pelvic position for when they had their x-ray. Um So that's taken a limited multiple shots of when you want to take a shot. And also during the pro you're having control over what your x-ray tech is delivering to you on the screen. Um The other shot I take it will be if on the femur side, the template is off if I'm, if I'm undersized or for certain reason, oversized, um, I'll check my Barris Fuss alignment, my sizing. Um, and, and, uh, but I mean, generally say I would take, I take 1-2, 40 shots now and where I was using it a lot more. So, uh, once cut position again, that I thought that was right where I wanted it to be, I mean, maybe, um, it looked a little bit more introverted than what normally would have. I would have scrutinized that before I had this system and then, you know, made sure the x-ray was perfect because it's counting for her anatomy. But that cup placed me on the floor shot was great for me with the one screw, put my neutral liner in. And now, you know, skipping had ephemeral preparation. So I, I use all of the offset tools um uh for polar, double offset inserter. And uh that was the double offset box chisel. Um I think for femoral replacement, I wanna or the I take off the removable T A ray when I'm approaching the femur. So it's out of the way, um, the pins, you know, there's plenty of distance as you can see there. Uh especially if you angle them more towards the head and a little bit away from you. So it's like midline to out with your pelvic pin placement, then they're gonna be away from you, your broaching. Um You know, it's a little harder with the single offset broach if you prefer that, but the double offset get swings it away, um, away from the pin array. And uh, it's, it was already what I was using before. Um, Doctor Rothenberg in the chat. There's another pin question specific to the arrays. Um, asking is there a reason that you choose to use 4.0 versus 3.2? Yeah, with only two pins, the four oh is just way stronger and less apt to have flex in the pens so that you, which would introduce air. So, um I, I I'll even make a third incision if I have my first pin placement on the 40 P I don't like. And it, the bone is a little softer on some part of the crest than the other part because if you don't have those pins well fixed and secured the bone and then that base tightened and then that if you all of the links matter, um the system is only as good as we can make it by, you know, making sure the tools are not used properly. So the four Os just with, especially with two pens uh uh have been great and I haven't had, you know, knock on wood. I haven't had any actually, patients complain about those sites, they don't find them particularly painful. Uh You know, sometimes we get a little bleeding at the end. Um But uh we just use uh, one of my phd S is a mono girl I'll let them choose with and the other one uses a Derma bond. And so, uh, regardless patients haven't really, um, had any issues with it. I, I think you could use a 32, but I'd advise against it. I just think the four rows are way more stout and I use the 32 on my, my knees. So, you know, for different reasons, I think there's fracture risk in the lower extremity and, or the pelvis. I don't, I think it's not an, not an issue. So you just want something as strong as you can. So uh uh put my polar in, I think this is a standard and minus head. Um We're gonna reduce then see what our numbers show. Um I generally do a stress test external rotation, 60°. That's my rep just, you know, taking the range of motion there and then uh check lateral shock just to get the usual feedback that you want um in the system. Um And then we're gonna check with our point probe. I think you can see the pless femoral array in the bottom right hand side of your screen is moving with the leg, it's stable, it's, you know, there's, the drapes aren't pulling on it as you move the leg. So those are things you don't want the drapes to be too tight where it's kind of sliding the array around or rotating it. Um And then there you can see the checkpoint so you, you can do the clicker method. I I prefer um you gotta have the balls visible. Um You also need to have the clicker has a, a radio frequency, I think, I believe communication to the um the camera. So you've actually got to make sure your hands not cut, you know, it's the balls might be visible. The clicker has to be um the transceiver of that needs to be visible uh visually um to the uh camera. And so, you know, this is telling me, hey, I'm too shorter and four lateralized. Uh That's how, what I was seeing and feeling, you know, in terms of it being a little bit um offset. So I just go ahead and I'm gonna go to um I've actually went to a Vagas plus four. Oh sorry is zero. So um I'm expecting to be able to lengthen the patient here. Um And so here I'm gonna get zero change. So relatively I lengthen them and then uh reduced the offset changes. I I think there's differences of philosophy, you know, between surgeons that might want or certain patients err on the side of a little bit of extra offset. Um I try to, for most patients, I try to shoot back to restore their native biomechanics and this patient didn't have a, I think they listed it 6 mm short um on the trauma cad. And then I was shooting for uh if I remember three and three roughly, I love that the conversation becomes millimeters. Yeah, I don't like going to the recovery room and going, oh, you know, I was uh I'm off by 78 millimeters a centimeter. No one likes those surprises. It's not fun for the patient. It's not fun for us as surgeons. So there's the polar, you can see the H A sitting. I use the colored polar, um H A is sitting right where it needs to be based on the approach. Um And then we're gonna, I think one of the time things that's helped is that I just, I, I'll sometimes just measure before I take out the polar, I'll measure at the distance physically between the collar and the uh necker section and then uh go back if it's and then remeasure it when it goes in and if it's sitting right where it needs to be, uh you know, I have confidence to just put the final head in. Don't, I don't try again. That's what we've done here. Be careful with the oxen there. It's precious. So, um you're gonna reduce it here and then um recheck our numbers and see where we're at. So I just uh the stability tests again, that era, uh My assistant's making sure the camera is visible. She was just moving the drape there so that the pen's camera away was not blocked by the camera. And then uh I went to a plus four here with the vagus. Um So I got, I would say, you know, we were 00. And now we're four and three with the plus four. So I think that's, you know, I would have expected, you know, 2.5 2.5 with that plus four. Um So when it, it probably set up a millimeter or two, uh when I put it in or just, you know, we can see, I moved that right, that that point probe around a little bit to show that if you're not putting your, you know, point probe back in the same position, you can move it by a millimeter here or there on your final number. So there's there is, you know, an accuracy of a millimeter affected by the probe in its position. So you want to be consistent. Uh I just took the checkpoint out, that's an important point to remember. We don't like leaving checkpoints in. So I I do recommend having it as part of a account or a a way of checking things. And there you can see the vagus. Um This patient, I didn't because it's vagus, it didn't have a collar on this one. Um But bit him out, bit put post your looking on this patient. I mean, he's got you, you got a standing view, not much of an animal on the pelvis. And um yeah, yeah, pretty much. Here's the you know, final results. I think the patient was really happy and it's doing really well. So.