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    What the Experts Do to Improve Outcomes of THA

    Dr. Richard Berger, Dr. David Nazarian and Dr. William Hozack share their top moves in the operating room when performing a primary or revision total hip arthroplasty.

    ICJR’s 8th Annual Winter Hip & Knee Course held earlier this year included 4 sessions dedicated to presentations from orthopaedic surgery experts on their top 5 moves for primary and revision total knee (TKA) and total hip arthroplasty (THA).

    In this article, we focus on the top 5 moves in primary and revision THA from Richard A. Berger, MD; David G. Nazarian, MD; and William J. Hozack, MD.

    Primary THA: Richard A. Berger, MD
    Rush Medical Center, Chicago, Illinois

    Dr. Berger shared these top 5 moves for primary THA:

    Restore hip anatomy and equal leg lengths. Dr. Berger plans the surgery “the old-fashioned way”: He templates all hips. His goal is for the acetabular cup to be placed up against the medial wall, “just touching” the superior dome. He then aligns the femoral template with the femoral canal and notes where the femoral head will be. With this done, he determines head length and neck cut. Once in the OR, he can simply follow the templated plan.

    Consider an anterior approach. Dr. Berger uses the Watson-Jones anterior approach as he finds it to be quick and easy even in heavier patients. The anterior approach is intrinsically stable and Dr. Berger has no worries about dislocations, takes no additional precautions, and allows patients to do what they want to do. An additional advantage is that this approach leaves most anatomic structures intact, which means he only has to close the fascia, fat, and skin.

    Don’t forcibly dislocate the hip. After exposure, Dr. Berger makes an in-situ neck cut. He makes this cut in steps, removing slices of the femoral head from the top down until most of the bone is removed. Finally, after externally rotating the hip, Dr. Berger find it easy to get an AP bone cut right at the saddle point. The leg is then put in a figure-4 position, which exposes the lesser trochanter and allows for the templated neck cut.

    Get great visualization. For good visualization of the acetabulum, Dr. Berger uses 1 retractor posteriorly around the ischium, 1 retractor anteriorly, and 1superiorly. After the cup and liner are implanted, Dr. Berger extends, externally rotates, and adducts the leg, which brings the femoral neck into the field. This allows great visualization and almost straight access for the surgical instruments.

    Resume life – immediately. Dr. Berger lets his patients do whatever they want, as soon as they want. A few hours after surgery, patients get out of bed and walk in the hallway. They also climb and descend stairs before they are discharged. Most of Dr. Berger’s primary THA patients go home on the day of surgery.

    Click the image above to watch Dr. Berger’s presentation.

    Revision THA: David G. Nazarian, MD
    University of Pennsylvania, Philadelphia

    Dr. Nazarian had these 5 tips for meeting attendees:

    Preparation. Dr. Nazarian emphasized the importance of preparation and quoted Maurice Müller: “The OR is no place to think, and certainly no place to panic.” Common errors occur commonly, Dr. Nazarian said, so study your own errors and the errors of those referring revision patients to you as a way of preventing them in the future.

    Extensile exposure. The difference between an easy and a difficult case is the exposure, Dr. Nazarian said. His patients are lying supine, as he prefers the lateral approach for revision THA, so in cases with difficult exposure, he frequently uses a trochanteric slide. If more exposure is needed, Dr. Nazarian performs an extended trochanteric osteotomy (ETO), which he demonstrated in his surgical video. Another option that works well with the lateral approach is the Wagner osteotomy, which is also shown in his presentation.

    Workhorse extraction tools. In all his revision THA cases, Dr. Nazarian uses cement taps, an ultrasonic cement removal tool, and explant osteotomes.

    Acetabular reconstruction. Dr. Nazarian believes that acetabular reconstruction has been greatly improved with the newer component options and metals available. He advised meeting attendees to become comfortable with a single acetabular implant system as up to 98% of acetabular cups will be revised with an oversized, multi-hole acetabular component. He also recommended becoming familiar with the use of trabecular metal augments, which he believes have supplanted the need for most bone grafting.

    Femoral reconstruction. Femoral reconstruction, Dr. Nazarian said, has been made much easier by the use of a proximal cone body and splined tapered stems. In particular, the implantation of these implants is almost as easy as in a primary THA. Using a tapered reamer, the isthmus is converted to a trapezoidal shape that perfectly fits the tapered stem, essentially creating a fit similar to that of a primary THA. The surgeon can then build proximally using the appropriate-size proximal cone body to recreate leg length, offset, and stability.

    Click the image above to watch Dr. Nazarian’s presentation.

    Revision THA: William J. Hozack, MD
    The Rothman Institute, Philadelphia, Pennsylvania

    Dr. Hozack made the point that surgeons using a direct anterior approach for their primary THA procedures should become familiar with ways to expand the exposure in case of intraoperative misadventure, such as fracture, or in case a revision is needed.

    Using surgical video Dr. Hozack reviewed his 5 top moves for using the direct anterior approach in revision THA:

    Proximal exposure. Elevating the femur is the most important step in achieving good visualization, Dr. Hozack said. This is accomplished mainly by incising the superior capsule. The muscles are left intact but are allowed to slide with the capsule for full exposure. Once the femur is elevated, further exposure can be achieved by hyperextending the table at the hip. Dr. Hozack also showed a surgical video demonstrating how he releases tensor fascia lata (TFL) proximally to improve exposure.

    Increasing distal exposure. Dr. Hozack extends the skin incision distally and proceeds to incise the fascia between the TFL and the sartorius muscle; he then reflects the TFL posteriorly. This exposure can be continued as far distally as necessary. For additional exposure, Dr. Hozack splits the vastus lateralis laterally. He moves to the lateral aspect of the femur at the trochanter and begins incising the vastus lateralis distally while pulling the vastus lateralis anteriorly. The muscle is incised all the way to the bone and then elevated from the bone.

    Removing a well-fixed stem. Debride soft tissues laterally in the trochanteric bed to visualize the lateral aspect of the femoral stem, Dr. Hozack said. After debridement, he uses a burr to remove bone posteriorly and around the periphery of the stem. He then uses a smaller burr to make small incisions into the bone between the cortex and the prosthesis, and finally, he usesa small saw blade to cut anteriorly and posteriorly between the bone and the prosthesis. These steps are often enough to allow extraction of a well-fixed stem.

    Removing a well-fixed stem that doesn’t budge: episiotomy. If Dr. Hozack is unable to remove the femoral component, the next step is an episiotomy of the femur, making sure the bone is cut to a point distal to the porous coating of the stem. He then uses an osteotome to loosen the bone from the stem. This allows the removal of most stems, and an extended trochanteric osteotomy (ETO) is usually not necessary.

    Removing a well-fixed stem that doesn’t budge: extended trochanteric osteotomy. If the episiotomy is not enough, Dr. Hozack proceeds to an ETO. He noted that because the vastus lateralis is intact and attached to the trochanter, it prevents the trochanteric fragment from elevating after it is re-attached.

    Click the image above to watch Dr. Hozack’s presentation.