Surgical techniques 2022, Dec, 21 | 12:00 am

Uncemented Total Hip Arthroplasty

 

Chapter 2

Uncemented Total Hip Arthroplasty

 

Matthew S. Austin and Brian A. Klatt

 

DEFINITION

  • Total hip arthroplasty is the standard of care for symptomatic degenerative joint disease of the hip that is unresponsive to nonoperative treatment.

  • Cementless total hip arthroplasty has demonstrated excellent mid- to long-term results.

  • The acetabular component obtains initial fixation through a press-fit and has a surface that allows for in- or on-growth of bone.

  • The femoral component obtains intial fixation through a press-fit in either the metaphysis or diaphysis and has a surface that allows for in- or on-growth of bone. The metaphyseal-fit prosthesis may be either wedge-shaped or fit-and-fill.

    ANATOMY

  • The acetabulum must be exposed so that the anterior and posterior walls, superior dome and rim, and teardrop are visualized.

  • The proximal femur must be exposed so that the periphery of the proximal femoral neck cut is visualized.

    PATHOGENESIS

  • Degenerative joint disease of the hip is the endpoint of many hip disorders, including osteoarthritis, inflammatory arthritis, dysplasia, osteonecrosis, trauma, and sepsis.

    NATURAL HISTORY

  • Degenerative joint disease of the hip often follows a variable symptomatic course. It is unknown why some patients progress more rapidly than others and why some patients are more symptomatic than others.

    PATIENT HISTORY AND PHYSICAL FINDINGS

  • The history should be directed to determine whether the pa-tient‘s pain is extrinsic or intrinsic.

  • The patient‘s pain may be extrinsic (eg, lumbar radiculopathy, intrapelvic pathology), and hip arthroplasty may fail to relieve the patient‘s pain completely, even in the face of severe degenerative changes of the hip.

  • Pain usually is located in the groin but may be located in the medial thigh, buttock, or the medial knee.

  • Range of motion (ROM) should be observed. Normal ROM of the hip is an arc of motion of 120 to 140 degrees of flexion–extension, 60 to 80 degrees of abduction–adduction, and external–internal rotation of 60 to 90 degrees. Loss of motion may be due to pain, contracture, or abnormal biomechanics.

  • Nonoperative treatment must be optimized before consideration is given to surgery.

  • Leg lengths should be measured and recorded preoperatively, and the patient should be counseled as to reasonable postoperative expectations.

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  • Examinations to perform include:

    • Trendelenburg test. The test is positive if the contralateral hip drops inferiorly; this may indicate that the hip abductors are compromised.

    • Hip flexion–internal rotation. The test is positive if the patient‘s pain is recreated. Pain that is not recreated with this examination may be from an extrinsic source.

      IMAGING AND OTHER DIAGNOSTIC STUDIES

  • Plain radiographs, including anteroposterior (AP) views of the pelvis and AP and true lateral views of the hip, should be obtained to evaluate the anatomy, assess for deformity, and devise an adequate plan preoperatively (FIG 1).

    DIFFERENTIAL DIAGNOSIS

  • Lumbar radiculopathy

  • Spinal stenosis

  • Sacroiliac degenerative joint disease

  • Intra-abdominal pathology

  • Intrapelvic pathology

  • Neuropathy

  • Meralgia paresthetica

  • Complex regional pain syndrome

  • Vascular claudication

  • Primary bone tumors

  • Metastasis

  • Infection

     

     

     

     

     

    FIG 1 • AP radiograph of the hip demonstrates advanced degenerative changes of osteophytes and joint space obliteration.

     

     
     

     

     

    NONOPERATIVE MANAGEMENT

Acetaminophen

  • Nonsteroidal anti-inflammatory drugs

  • Glucosamine

  • Chondroitin sulfate

Physical therapy

SURGICAL MANAGEMENT

  • The primary indication for cementless total hip arthroplasty is painful, severe degenerative joint disease of the hip that has been nonresponsive to appropriate nonoperative treatment modalities.

    Preoperative Planning

  • Preoperative planning for routine cementless primary total hip arthroplasty can be accomplished with plain radiographs at standard magnifications.

    • Standard templates are available for the components, and many are available for digital templating as well.

  • The acetabular component is placed so that the inferomedial edge of the cup is at the radiographic “teardrop.” The inclination is 35 to 45 degrees, and the cup should contact the super-olateral rim of the acetabulum.

  • The femoral component is placed so that the center of rotation is at the level of the greater trochanter. The femoral offset should be reproduced. However, the femur must be

    internally rotated 10 to 15 degrees on the radiograph to bring the femoral neck into the plane of the radiograph. Externally rotated femora will appear to be in coxa valga.

  • Proximal-fit femoral prostheses are designed to obtain fit in the metadiaphyseal region.

  • Diaphyseal-fit femoral prostheses are designed to obtain fit in the diaphysis.

    Positioning

  • The patient is positioned according to surgeon preference and in accordance with the surgical approach.

    • The hip should be draped in such a fashion as to allow a wide surgical exposure should an extensile approach be required in the event of a complication.

  • The pelvis must be stabilized in a secure fashion to avoid pelvic tilt, which may affect the surgeon‘s perception of the acetabular position.

    Approach

  • The hip can be exposed for primary routine arthroplasty via a variety of approaches:

    • Anterior

    • Anterolateral

    • Direct lateral

    • Posterior

    • Two-incision

    • Small-incision variants of these approaches

       

       

      ACETABULAR EXPOSURE

      • The approach to the hip is chosen according to the sur-geon’s preference. The approach illustrated here is the direct lateral (modified Hardinge) approach in the supine position.

      • Retractors are placed in the anterior, superior, and inferior positions, thereby exposing the entire periphery of the acetabulum (TECH FIG 1).

         

      • The labrum is resected.

        TECHNIQUES

         

      • The soft tissue in the cotyloid fossa is removed, allowing exposure of the medial wall and teardrop.

         

         

         

         

         

         

        A B C

        D
        E

         

         

         

         

        TECH FIG 1 • Acetabular exposure.

        A. Supine position for modified Hardinge approach. B. Completed acetabular exposure. The medial wall and native acetabular anatomy are easily visualized. C. Labrum is resected. D. Osteotome removes osteophytes from cotyloid fossa. E. Currette removes remaining tissue to expose teardrop.

         

        TECHNIQUES

         

        ACETABULAR PREPARATION

        • Before reaming, the entire periphery of the acetabulum, medial wall, and teardrop must be directly visualized (TECH FIG 2).

        • The initial reaming must be done with moderate pressure until the quality of bone is assessed.

          • The goal of the initial reaming is to medialize the reamer fully. The cotyloid fossa should be eliminated without penetrating the medial wall.

        • Reaming then proceeds sequentially. The goal is to recreate the center of rotation by placing the inferomedial aspect of the socket at the level of the teardrop with the component inclined at 35 to 45 degrees and with 10 to

           

          20 degrees of anteversion and with good initial fixation obtained through a press-fit.

      • The templated size should be used as a guide; intraoperatively, an increase or decrease in cup diameter may be found to be appropriate.

        • Failure to recognize the need for a different cup diameter may lead to iatrogenic fracture or a failure to achieve initial fixation.

      • The bony bed should be bleeding but not devoid of scle-rotic bone.

      • The pelvis must remain in a stable position to avoid mal-positioning of the acetabular component.

         

         

         

         

         

         

         

         

        A B C

         

        TECH FIG 2 • Acetabular preparation. A. Initial reaming to medialize acetabulum fully. B. Reaming completed to medial wall. C. Reaming proceeds sequentially at 35 to 45 degrees of abduction and 10 to 20 degrees of anteversion.

         

        ACETABULAR COMPONENT IMPLANTATION

        • The position of the pelvis is reassessed. Any tilt is corrected.

        • The trial component or reamer is used to assess bone coverage of the component and position (TECH FIG 3). If the trial or reamer is not seated properly, then further

          reaming may be necessary. If deemed appropriate, implantation of the actual component may proceed.

      • The actual implant should be 1 to 2 mm larger than the last reamer. The surgeon must know the actual

         

         

         

         

         

         

         

         

         

        A B

         

        TECH FIG 3 • Acetabular component implantation. A. Final reamer is used to assess component position, bony coverage, and seating. B. Acetabular component is implanted.

        C. Central hole is used to verify that the cup is fully seated. D. Actual liner is inserted into

        C D the cup.

         

         

         

        diameter of the implant, taking into account any rim or coating.

         

        • Implants that are larger than the size of the last reamer by 4 mm or more are associated with risk of fracture.

      • The acetabular component is then implanted, with care taken to medialize the implant. The inferomedial aspect of the cup should be at the level of the teardrop in 35 to 45 degrees of abduction and 10 to 20 degrees of anteversion.

        TECHNIQUES

         

      • A trial liner or the actual liner is then inserted.

         

        FEMORAL EXPOSURE

        • The femur is exposed by elevating it out of the wound with a retractor (Bennett or double-footed).

        • The periphery of the femur is exposed with another retractor (TECH FIG 4).

        • The soft tissues must be protected so that iatrogenic damage by reamers or broaches is avoided.

           

          TECH FIG 4 • Femoral exposure. The femur is elevated and exposed with two double-footed retractors to allow atrau-matic broaching.

           

          FEMORAL PREPARATION (PROXIMAL-FIT PROSTHESIS)

        • The femur is prepared as delineated by the surgical protocol for each prosthesis (TECH FIG 5). The surgeon should be familiar with the prosthesis and all of the available options and idiosyncrasies.

        • The proximal-fit prosthesis usually requires a starter reamer, which is used as a canal-finder. In addition, the

          reamer should be lateralized to avoid broaching and subsequent varus positioning of the implant.

      • The femur then is broached sequentially, with care taken to lateralize the broach. Broaching is complete when the broach ceases to advance, the pitch of impaction increases, and good cortical contact is obtained.

         

         

         

         

         

         

        A B C

         

         

        TECH FIG 5 • Femoral preparation.

        D E ceeds. (continued)

         

         

         

        TECHNIQUES

         

        TECH FIG 5 • (continued) F,G. Final broach is

        F G seated.

         

        further seating of the prosthesis. ■ A standard or varus neck is selected based on the soft tissue tension and the patient’s anatomy.

        FEMORAL COMPONENT IMPLANTATION (PROXIMAL-FIT PROSTHESIS)

         

        A

        B

        C

         

        TECH FIG 6 • Femoral component implantation (proximal-fit prosthesis). A. Canal appearance before implantation. B,C. Component is introduced in proper orientation until resistance is met. D. Component fully

        D seated.

        SOFT TISSUE TENSION/LEG-LENGTH DETERMINATION

        to 2 mm of toggle (TECH FIG 7). ■ The ROM should be physiologic for the patient.

         

         

         

         

         

         

         

        PEARLS AND PITFALLS

        Preoperative planning Intraoperative decision-making Implantation

         

        Soft tissues

         

         

        B

        A

        C

        D

        TECH FIG 7 • Soft tissue tension and leg-length determination. A. Hip is reduced. Soft tissue tension is evaluated.

        B. Abduction/external rotation. C. Adduction/internal rotation. D. Flexion/adduction/internal rotation.

        ■

        Impingement must be assessed and rectified with removal of any remaining osteophytes.

        ■

        ■

        ■

        Increased offset may aid in decreasing impingement. Proper component position must be verified to exclude positioning as a source of impingement.

        The patient’s leg length is assessed either directly through palpation of the heels or malleoli or indirectly through the use of a pin placed in the ilium and a marker placed on the femur.

        ■

        One must be careful to position the limb accurately to avoid inducing error during the measurement process.

        CLOSURE

        ■

        The wound is thoroughly irrigated.

        Drains are placed at the discretion of the surgeon.

        The capsule is closed meticulously, especially if a posterior approach has been used.

        ■

        ■

        ■

        The soft tissues are closed with absorbable suture. The skin is closed according to surgeon preference.

        ■

         

         

        TECHNIQUES

         

        POSTOPERATIVE CARE

        1. Rongeur is used to clear tissues and lateral cortical bone. B. Curette used to find canal. C,D. Canal is reamed to open canal, and care is taken to lateralize. E. Broaching pro-

        • Improper broaching can lead to fracture, malposition, ■ The templated size should be used as a guide, and an inor undersizing. crease or decrease in stem size intraoperatively may be

        • The component should be anteverted 10 to 15 degrees. appropriate.

        • The greater trochanter can be used as a reference to ■ Failure to recognize the need for a different size may recreate the center of rotation. lead to iatrogenic fracture or failure to achieve initial

        • It may be necessary to adjust the neck cut to allow for fixation.

        • The implant chosen usually matches the size of the last ■ The implant is impacted until it ceases to advance, the broach. pitch of impaction increases, there is good cortical con-

        • The proximal-fit femoral component is inserted, with tact, and the implant has reached the level of the last care taken to avoid varus positioning (TECH FIG 6). broach.

        • The hip is trial reduced and assessed for soft tissue ten- ■ The hip should be stable within the patient’s physiologic sion, stability, ROM, impingement, and leg length. ROM. If instability exists, the position of the components

        • The soft tissue tension should allow for no more than 1 must be reassessed.

        • Preoperative radiographs must be evaluated for any unusual findings (eg, dysplasia) that may require techniques or implants not routinely performed or available.

        • The templated component size must be used as a guide. Proper implant sizing must be guided by visual, auditory, and tactile feedback.

        • The components must be implanted properly. Failure to achieve soft tissue tension, physiologic range of motion, stability, and reasonable leg lengths must be followed by reevalua-tion of the component positioning.

        • Care must be taken to perform gentle dissection and thorough closure of the capsule and soft tissue to minimize pain, instability, and limp.

        • Weight bearing after cementless total hip arthroplasty is controversial. Some surgeons routinely restrict weight bearing for 6 weeks, whereas others allow weight bearing as tolerated.

        • Hip precautions are prescribed according to the approach.

          • Posterior approaches avoid flexion, internal rotation, and adduction, whereas anterior approaches avoid extension, external rotation, and adduction.

          • The hip precautions are discontinued at 6 weeks.

          • Some surgeons who perform the anterior approach have discontinued the use of traditional hip precautions.20

          • The patient ambulates with the aid of crutches or a walker for several weeks, then progresses to use of a cane. Generally, the cane is discontinued at 6 weeks.

             

            OUTCOMES

          • The survivorship of cementless total hip arthroplasty components generally has been excellent, although isolated reports of high failure rates exist for certain designs, which have subsequently been abandoned. Most modern, uncemented acetabular and femoral components have reported survivorship of 95% to 100% at mid- to long-term follow-up.1–19, 21–23

             

            • Overall survival of cementless acetabular components has ranged from 83% to 99.1% at 8.5 to 16.3 years of follow-up.1,3,6,7,10–12,15,21,23

            • The reported survivorship of cementless femoral components has ranged from 82% to 100% at 6.6 to 17.5 years of follow-up.1,2,4,5,8,9,12–14,16–18,19,22

            • The main limitation to long-term clinical success has been wear and subsequent osteolysis.

              COMPLICATIONS

            • Iatrogenic fracture

            • Stress shielding of proximal bone

            • Blood loss

            • Infection

            • Neurovascular injury

            • Anesthetic and medical complications

            • Loosening

            • Osteolysis

              REFERENCES

              1. Archibeck MJ, Berger RA, Jacobs JJ, et al. Second-generation cementless total hip arthroplasty: Eight to eleven-year results. J Bone Joint Surg Am 2001;83A:1666–1673.

              2. Bojescul JA, Xenos JS, Callaghan JJ, et al. Results of porous-coated anatomic total hip arthroplasty without cement at fifteen years: A concise follow-up of a previous report. J Bone Joint Surg Am 2003;85:1079–1083.

              3. Callaghan JJ, Savory CG, O‘Rourke MR, et al. Are all cementless acetabular components created equal? J Arthroplasty 2004;19(4, Suppl 1):95–98.

              4. Capello WN, D‘Antonio JA, Feinberg JR, et al. Ten-year results with hydroxyapatite-coated total hip femoral components in patients less than fifty years old: a concise follow-up of a previous report. J Bone Joint Surg Am 2003;85:885–889.

              5. Della Valle CJ, Paprosky WG. The middle-aged patient with hip arthritis: the case for extensively coated stems. Clin Orthop Relat Res 2002;(405):101–107.

              6. Della Valle CJ, Berger RA, Shott S, et al. Primary total hip arthroplasty with a porous-coated acetabular component. A concise followup of a previous report. J Bone Joint Surg Am 2004;86:1217–1222.

              7. Duffy GP, Prpa B, Rowland CM, et al. Primary uncemented Harris-Galante acetabular components in patients 50 years old or younger: results at 10 to 12 years. Clin Orthop Relat Res 2004;427:157–161.

              8. Engh CA Jr, Claus AM, Hopper RH Jr, et al. Long-term results using the anatomic medullary locking hip prosthesis. Clin Orthop Relat Res 2001;393:137–146.

              9. Grant P, Nordsletten L. Total hip arthroplasty with the Lord prosthesis. A long-term follow-up study. J Bone Joint Surg Am 2004;86: 2636–2641.

              10. Grubl A, Chiari C, Gruber M, Kaider A, et al. Cementless total hip arthroplasty with a tapered, rectangular titanium stem and a threaded cup: a minimum ten-year follow-up. J Bone Joint Surg Am 2002; 84:425–431.

              11. Herrera A, Canales V, Anderson J, et al. Seven to 10 years followup of an anatomic hip prosthesis: an international study. Clin Orthop Relat Res 2004;423:129–137.

              12. Kim YH, Oh SH, Kim JS. Primary total hip arthroplasty with a second-generation cementless total hip prosthesis in patients younger than fifty years of age. J Bone Joint Surg Am 2003;85A:109–114.

              13. Kim YH, Kim JS, Oh SH, et al. Comparison of porous-coated titanium femoral stems with and without hydroxyapatite coating. J Bone Joint Surg Am 2003;85A:1682–1688.

              14. Marshall AD, Mokris JG, Reitman RD, et al. Cementless titanium tapered-wedge femoral stem: 10- to 15-year follow-up. J Arthroplasty 2004;19:546–552.

              15. Moskal JT, Jordan L, Brown TE. The porous-coated anatomic total hip prosthesis: 11- to 13-year results. J Arthroplasty 2004;19: 837–844.

              16. Park MS, Choi BW, Kim SJ, et al. Plasma spray-coated Ti Femoral component for cementless total hip arthroplasty. J Arthroplasty 2003;18:626–630.

              17. Parvizi J, Keisu KS, Hozack WJ, et al. Primary total hip arthroplasty with an uncemented femoral component: a long-term study of the Taperloc stem. J Arthroplasty 2004;19:151–156.

              18. Parvizi J, Sharkey PF, Hozack WJ, et al. Prospective matched-pair analysis of hydroxyapatite-coated and uncoated femoral stems in total hip arthroplasty: a concise follow-up of a previous report. J Bone Joint Surg Am 2004;86A:783–786.

              19. Parvizi J, Sullivan T, Duffy G, et al. Fifteen-year clinical survivorship of Harris-Galante total hip arthroplasty. J Arthroplasty 2004;19: 672–677.

              20. Peak. EL, Parvizi J, Ciminiello M, et al. The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study. J Bone Joint Surg Am 2005;87A:247–253.

              21. Robertson A, Lavalette D, Morgan S, et al. The hydroxyapatite-coated JRI-furlong hip. Outcome in patients under the age of 55 years. J Bone Joint Surg Br. 2005;87B:12–15.

              22. Teloken MA, Bissett G, Hozack WJ, et al. Ten to fifteen-year followup after total hip arthroplasty with a tapered cobalt-chromium femoral component (trilock) inserted without cement. J Bone Joint Surg Am 2002;84A:2140–2144.

              23. Udomkiat P, Dorr LD, Wan Z. Cementless hemispheric porous-coated sockets implanted with press-fit technique without screws: average ten-year follow-up. J Bone Joint Surg Am 2002;84A:1195–2000.