Live surgery of a total hip arthroplasty (DA) direct anterior approach 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.
Unique to this situation with our hip placement, we have to place a ray on the thigh that's pen. And so we uh abduct the leg and positioning on the table and then prep the leg circumferentially including the medial and post to your thigh. So that a sterile Coban and plate can be applied uh prior to application of the grapes, we are with the leg abducted. We place a sterile drape in to prevent any contamination. I'm able to put the uh C DS and leave them in place. But my circulators prep circumferentially. You didn't wrap a sterile co band around the distal thigh to provide a stable base for the plate. I usually position a little bit medial so that the patella doesn't make it ride, it makes it more stable, really want this to be secure so that you have the leg length and the offset measurements accurately true. So we use a standard shower curtain drape, we uh impervious stripes underneath it. Uh I've expanded my field to include the pelvis here so that we can have access for the pens. This patient has great hip osteoarthritis. He's a 73 year old male um it's fairly routine. Uh I templated him preoperatively and saw that he's 6 mm short on this operative side. Um It's pretty imperceptible for him uh that shortness, but uh we discussed that in the preop area and in the clinic, um generally to see if we want to lengthen them by a certain number of millimeters based on if they're symptomatic or not. I believe it's an uh 8° posterior uh tilt to the pelvis. OK. So we cut through and then we have the sterile drape here, you know the stereo base plate. So now we'll place the, I don't know if it's, I have not, not certain if this is important, but I always keep the orientation the same for consistency with the t the bottom part of the T facing the foot and then line this array, make sure it's well secured and the balls are tight. And you're for a pelvic pin fixation, we use a 40 Pelvic pin. We'll know right away if that's not going to work for this patient. There is a minimum distance between the two points that's well secured, it's rotationally stable, it's not going anywhere here. And then that, that enhances visibility uh for the camera system have this tea there. So we measure the distance from the lesser on the trauma cab and then we just double check it here, mark it out. OK. So now we're gonna um place this retractor over the tensor Oh, so that it's under going around the trope, then we'll internally rotate the hip. And so here we can see the vast is here, here's the femoral neck, here's capsule here, poster capsule, abductors are behind me. Tensors here. So we want to get as far lateral as we can to place this checkpoint to be accurate. And so does that feel about maximal internal for you? OK. And so there's usually a bar area here. So I'm, I'm going behind in front of the media here and then I just kind of push the tensor down and we'll get that far in later here. And I like to tag it just so we know especially people with a lot of fat or muscle where to go. So now we'll put the arrays back on a little bit of artistry here from Taylor trying to work around their tractors, but we want a leg to be in neutral position. And now we've got a blue and all the Pelvis femur and point probe berat. So click that button and then move forward on the screen. Mhm Yeah. Put a cork in the head and neck and then go ahead and come out with this one Taylor. So uh we we, we want to map the articular cartilage. This patient doesn't have a tremendous amount of osteophytes in some situations where there's lots of osteophyte build up. Or uh you might want to remove those as part of the technique but the goal is to get a good uh uh cone or sphere, I guess from the articular surface here. So now I'm going to depress the the button here and then I'm going to take points around the periphery just like the image shows. So I'm just trying to map this existing a tabular portion and it's that quick. Now we're going to come down and map the media wall here. So again, I click that and then I want to make just kind of circles to get a foundation and a base of how far medial we are so we can get our numbers on offset and there it went, it went through. So I template a 54, I usually shoot for uh 4 mm over the uh native a tabular size. And so um this is saying 51. So we're, we're definitely in the ballpark here. This is a 51 Remer. Yeah. Mhm Just traditional raining here. I just want to get the osteophytes, get a sense of their size and then make sure everything is what we want it to be before we get our final rumor in. So looks like I can go a little deeper here. I re one under for most cases, I would say 2/3 or three quarters of cases, but for a good solid bone, a lot of resistance, I'll go line to line here are the hip seven software is right. The monitor is right in front of me so I can see my template. So this is our offset inserter. There's a offset and a straight inserter option with the arrays here, I like the offset for my approach. I generally uh place the opening for the liner for removal tool here at the corner of this uh inserter. So they're in line that way my screw positions are in the right orientation and then I've got enhance this visualization of the uh of the liner if I need to remove it uh during the case or in any future date. So now uh it's visualizing the pelvis, we have a eight degree post to your tilt and then I'm gonna bring the cup in here. Yeah, maybe just for a second first, I'm just clearing out some soft tissue and then I, I try to put it where I, I think I want it based on anatomy and positioning and uh where I'm used to seeing it in relationship to the thigh. And then I then come to the screen here. Uh We've got this patient two numbers. The left is the anti essentially the anterior pelvic plane uh which is kind of our standard reference point. And then the right is the functional plane which is a corrected number based on his post, your pelvic tilt. Um And so here we've got inclination of 46 47. You can see there's a difference in the Anna version based on pelvic tilt it doesn't affect inclination nearly as much. So I shoot for 40 20 overall. And when they have large post tier tilts, uh, I think we don't, we're not 100% certain whether we should be correcting tilts, uh, either spinal tilts. And so there's a little bit, uh, yet to be decided upon, but here I've got a confident that I'm in a safe zone because I'm at between 40 and 42 on my inclination and uh Unsorrected 13 and 19, uncorrected. So I just want to double check this because it's, it's always, it's been accurate in my hands, but I just want to make sure um am I introverted enough under introverted? Just always good to go back to the foundation of how you train and just check that this s tab is covered here. It's pretty in line with the T A L and I'm at 38 and 18. So with the post year pelvic till I choose to generally pick the functional pelvic plane for these patients. And so I'm gonna just give it a little bit more. OK? I typically my workflow, I'll put a screw in down and we'll just get ac arm shot to just confirm depth and final positioning here. Have a de gauge this time. 35 I think for I used C arm to confirm cup positioning. I would have taken multiple shots here today to get a perfect view to get my inclination inversion where I want it and uh I've skipped that step here because I, I've trusted that this, these numbers have been reproducible for me. Ok. So g will get a shot here. Please predict the airplane out. Yeah, he can come back to you a little bit, a little bit more towards you. Ok. And see where we're at. So here we said we were 40 and 20 on the functional plane, 41 5th, you know, 13 or something like that and 39 13 on the anatom plane, I think, you know, I you could, we could tweak this image to get a perfect reproduction of his preoperative standing view. But this is pretty darn close in my mind. This is enough information to move on screw placement is good. Cup depth is good, cup height is good, it looks like my template. And so I'm gonna go ahead and put a neutral liner here. One question I get asked a lot is, can you eliminate C arm? I think you, I think there's a comfort level, you're going to have to get to in a combination with what you are seeing atomically and then what numbers you're getting with the system. I I do like making sure that I don't have any surprises. The whole point of the technology that we use is to eliminate outliers. And uh for this, I just, I like to make sure my depth is good is right where I want it to be. And my, I like to check my screws. So uh based on placing that cup in alignment with where we were, a screw is easily placed here and then we have our liner removal tool right visible. So if you ever have to pop it off and change to a collateralized liner, if you're coming back in that unfortunate situation, it's easy to access. So I'm gonna start my approach. So I I use the double offset instruments for polar. It's been nice for, I think kind of a game changer for access for me. Um uh Ron, dear, please. Ah, really easy. We've got this base over here. That's not in our way. Even you could even for those of you that want to use a single offset or a straight. Um I don't know why you're, you know, doing that, but you know, if you, if you like to do that, uh You can do that with this system since that array is movable. Oh, we had a five. Yeah, 0345. Can I see the, please? It's gonna get a little bit louder off here. Do we get him? No, hopefully not. Sorry, Doctor Newman. I like that. four looks good, rotationally stable, right where we want it right on our neck cut. So we'll see where we're at was the standard 0 or one of them. I did minus, but I can't remember minus. Got a little bit about what exactly Yeah. So we templated a five standard stem and a 54 cup. I just put a four standard in and felt that that was stable. Uh When I go ahead. So, uh obviously I'll undersize if I think I'm between sizes, Nelson is doing a stability test. So he'll take the leg to 60° of external rotation and drop the leg. You want to do that one more time, Nelson and here she's, he's stable all the way to the bottom there. And then I'll usually test stability at neutral. I'd say I have got a little bit more uh laxity. I'd probably go back to a zero on based on the field. So we're right, basically on template. The four standard with a -3 head was what we did the five standard for templating. And so now we'll take the plant probe. Um I think one of the feasibility checks you want to do is you want the leg to be back in the same position as when you started, which is what we have here. So uh just making sure that the all the system has been stable throughout, just double check. Everything here is rotationally stable. This is rotationally stable and do the numbers make sense to you. And I would say, yeah, I, I felt like there was maybe a little bit chuck but maybe I was just a little short. So uh now we can dial in uh the implant positioning to try to adjust for uh length and offset. We'll see how this looks. The stand went right back to where it was before. Check, stability again. Feels good. Check tension. I like that. And then uh point probe, please. Zero and zero. I think I'm gonna do plus four final and you go, yeah, I think that's nice. It'll be 2 and 2. He started out six maybe, you know, give a little bit more attention. Keep that baugus there and it's got really good bones. So let's do that. OK. That's what the numbers are dictating and we have the option. So let's do it. Yeah, plus four. To me that, that right where I wanted it. I've got the H A coating right at the, right at the level of the osteotomy right above it. It might have sat down a millimeter or two. I like the 00. If I get the two plus two plus two, I'm happy. Yeah, it will reduce stability one more time. Good there. So, yeah, point probe. Oh Got it. There we go. So it sat up just a touch and I, you know, we, we started, we were six shorter. You can see that there is some play. If you move this around a little bit, you might get a millimeter here and there. Uh but I try to put it right back where I started and I think that's, I mean, I'm happy about that and so we will remove the checkpoint at this point that's out. Uh Sarah Bella. So now we'll just check bleeding and get the wound closed.