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Steinmann pin is vertically at the 5
o'clock position into the cotyloid groove and a mark is made on the greater trochanter.
The hip is then dislocated by flexion, adduction, and internal rotation. The center of the femoral head is then
marked using a trial acetabular component that matches the femoral head circumference; which is placed over
the head and the center of the femoral head is identified and marked (Fig. 3.7), and the distance from the center
of the femoral head to the highest point of the lesser trochanter is identified, measured, and recorded. From the
center of the head to the greater trochanter, a reference mark is made and the distance is measured to
reproduce offset. The femoral neck cut
is made perpendicular to the neck at a level based on preoperative templating, using an oscillating saw; care
should be taken not to cut into the greater trochanter. The cut neck should be left a few millimeters more than
predicted to allow for templating measurement errors. Excess bone can be removed after femoral broaching
using a calcar reamer.
Figure 3.7. An appropriate trial acetabular component that matches the femoral head circumference is used to
mark the center of the femoral head for measurement of leg length and offset.
Acetabular Exposure
Femur is retracted anteriorly using a C-shaped retractor that is placed over the anterior acetabular wall above
the anterior-inferior acetabular spine after releasing the capsule and oblique head of rectus. A small bent
Hohmannn retractor is placed intracapsularly posterior to the labrum, an Aufranc retractor is placed inferiorly
under the transverse acetabular ligament, and finally a Steinmann pin is placed superiorly retracting the gluteus
medius, but not the minimus (Fig. 3.8). The labrum is removed. The pulvinar is then cleaned from the fovea using
electrocautery to allow visualization of the medial wall of the acetabulum (Fig. 3.9). The foveal artery (a branch of
the obturator artery) is cauterized at this step. Next, sequential acetabular reaming is performed, which is
discussed in Chapter 54.
Figure 3.8. Final acetabular retractor placement. A C-shaped retractor is placed over the anterior acetabular wall
above the anterior-inferior acetabular spine, a bent Hohmann retractor is placed intracapsularly posterior to the
labrum, an Aufranc retractor is placed inferiorly under the transverse acetabular ligament, and a Steinmann pin is
placed superiorly retracting the gluteus medius.
Figure 3.9. Before reaming, the labrum is removed, the pulvinar is cleaned, and the transverse acetabular
ligament is identified.
Intra-Articular Injections and Wound Closure
Intra-articular injections using a combination of local anesthetic and corticosteroid have been shown to
significantly decrease postoperative pain and narcotic requirements (28,29). After final femoral component
placement, injection of the deep soft tissues is performed. The locations of deep injection include the anterior
capsule, iliopsoas tendon, and gluteus medius and minimus insertion sites. After reduction, superficial injection is
performed in the iliotibial band, the gluteus maximus muscle–tendon unit, and the subcutaneous tissue (28).
After copious irrigation of all exposed tissues, an extended posterior soft tissue repair is performed. The
quadratus femoris is repaired to its insertion using a nonabsorbable suture, along with repair of the gluteus
maximus insertion. The SERs and posterior capsule are then repaired to the trochanteric fossa, very close to
their insertion, through two drill holes, approximately 2 cm apart. A nonabsorbable suture is passed through the
superolateral portion of the posterior capsular flap and the piriformis tendon. A second nonabsorbable suture is
passed through the inferolateral portion of the capsule and the conjoint tendon (Fig. 3.10) (21,30). With the help
of a suture passer the sutures are passed through the drill holes and tied with the leg in slight external rotation
and neutral abduction to bring the femur close to the posterior structures and to take tension off the flap. The
interval between the superior border of the piriformis and gluteus minimus is closed with absorbable sutures (Fig.
3.11).
Figure 3.10. The quadratus femoris is repaired to its insertion using a nonabsorbable suture, along with repair of
the gluteus maximus insertion. The short external rotators and posterior capsule are repaired to the trochanteric
fossa through two drill holes, approximately 2 cm apart, using nonabsorbable sutures.
Figure 3.11. Final deep closure after the interval between the superior border of the piriformis and gluteus
P.59
minimus is closed with absorbable sutures.
Postoperative Rehabilitation
Physical therapy program is essential to the success of THA. We initiate physical therapy the day of surgery with
weight bearing as tolerated. Hip precautions to prevent dislocations are maintained and include avoidance of hip
flexion beyond 90 degrees and adduction to neutral
position with the use of an abduction pillow. A raised toilet seat can be used to avoid excessive hip flexion past
90 degrees. Healing of the SERs and capsule can be assessed via the internal rotation (IR) test, with 15 degrees
or less internal rotation at 90 degrees of hip flexion with the patient lying supine, at 6 weeks postoperatively. With
a positive IR test, patients can return to all activities of daily living (21). After full recovery, patients can engage in
sporting activities such as walking, bicycling, bowling, swimming, golf, tennis, and skiing. Avoidance of high-
impact activities, such as jogging, running, and jumping are strongly recommended.
Tips, Tricks, and Pitfalls
Patient positioning and table orientation is key to component placement and the coplanar test.
Adequate length of incision (15 to 20 cm based on the patients' body habitus) is essential for optimum
exposure without excessive soft tissue trauma.
The gluteus maximus tendon insertion is partially released to prevent sciatic nerve palsy.
During release of the gluteus maximus insertion, the first perforator branch of the profunda femoris artery may
be encountered.
A bent Hohmannn retractor is placed between the plane of the gluteus medius and minimus to visualize the
piriformis tendon.
Electrocautery is used to detach the SERs and the posterior capsule as a single soft tissue sleeve.
A Steinmann pin is placed at the level of the infracotyloid groove and used as a reference to measure the leg
length.
The reflected head of the rectus femoris muscle is released for further acetabular exposure.
A bent Hohmannn retractor is placed posteriorly, intracapsularly, to expose the labrum to avoid sciatic nerve
injury.
The SERs and posterior capsule are repaired to the trochanteric fossa through two drill holes using
nonabsorbable sutures and tied over the greater trochanter.
Hip precautions for the first 4 to 6 weeks are maintained for proper posterior soft tissue healing. The IR test
can be used to assess healing.
References
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 4th ed.
Philadelphia, PA: Lippincott; 2009;443–455.
2. Langenbeck BY, Kocher D. Ueber die Schussverletzungen der Huftgelenks. Arch Clin Chir. 1874;16:236.
3. Kocher T. Chirurgische Operationslehre. 4th ed. Jena, Germany: Gustav Fischer; 1907;922.
4. Tronzo RG. Surgery of the Hip Joint. 1st ed. Philadelphia, PA: Lea & Febiger; 1973;53–56.
5. Gibson A. Posterior exposure of the hip joint. J Bone Joint Surg Br. 1950;32-B:183–186.
6. Moore AT. The Moore self-locking Vitallium prosthesis in fresh femoral neck fractures: A new low posterior
approach (the southern exposure). In: American Academy of Orthopaedic Surgeons Instructional Course
Lectures. Vol 16. St Louis, MO: CV Mosby, Co; 1959:309–321.
7. Mehlman CT, Meiss L, DiPasquale TG. Hyphenated-history: The Kocher-Langenbeck