Robotic (Mako) Total Hip Replacement Cases

Speaker 1Thank you, uh, once again, good to be with you all. So in keeping in line with my prior talk today, this is largely a case presentation, not so much what would you do, but look at what I did.

Speaker 1Uh, I actually have 3 cases. The first one's, uh, fairly straightforward. I'm gonna jump to, uh, the third case.

Speaker 1Did those Other ones really fast.

Speaker 1So here's case 3. He's a um.

Speaker 146 year old, uh, gentleman had a motor vehicle accident in 1992, subsequently an acetabular Fracture.

Speaker 1His, uh, preoperative workup for infection was negative, and for me that meant he had normal sed rate and CRP. He did have an aspiration, which we held for 14 days, showed no growth, um.

Speaker 1And his Hip motion is minimal.

Speaker 1Would anyone consider fusing the Hip or something like that?

Speaker 1I didn't,

Speaker 2but.

Speaker 2Solihuna kesha.

Speaker 3So, uh, this is a challenger, uh, cases for the, the older pelvic Fracture and a lot of hardware, uh, stay in the position. And even I think even the, uh, negative ESR and the CRP we still, uh, consider infection for the, uh, if we do the Total hip arthroplasty, and, uh, uh, because we know that there are high infection rates for the hardware staying position. Yeah.

Speaker 1Yes, no history of wound complications, but with prior Surgery, particularly prior Surgery for trauma, I would be especially concerned.

Speaker 1Other thoughts

Speaker 1Would anyone not do a Total Hip Replacement or would that be the standard both in America and China?

Speaker 1Yeah, go ahead, John.

Speaker 4I, I, I was just gonna say that, you know, I would probably would have taken Michael's advice and done a Hip Replacement instead of fixing the acetabulum.

Speaker 4But here we are now.

Speaker 1Yeah. He would have been in his early 30s, but I'm with you. I, I wasn't there. I was in high school.

Speaker 1It was a good year.

Speaker 1I'll discuss that at dinner.

Speaker 1So this is just what a standard digital template setup would look, would look like again with regard to the sizing. In reality, with two dimensional imaging, I have no idea where that cuff is going to be or what bone is truly there. Perhaps not more importantly, but relevant to the mechanics of the Surgery. I also don't have a great appreciation in a two dimensional scan with where all the screws are.

Speaker 1So typically if I did this manually, I'll just make one more comment about the screws. As far as equipment, obviously I've had revision cups of all sizes, etc. but I also have a metal cutting burr. My plan here would be to remove any hardware that got in my way. I would not routinely remove all the hardware.

Speaker 1So again, uh, using a robotic platform has, uh, is my growing tendency. I have the ability to see with a CT scan. I would love to show you the 3D modeling. However, the 3D modeling for the Mako is on a separate operating system. So I've selected some images to hopefully illustrate how you can preoperative plan. Here in these images, you'll see that the green represents the new implant.

Speaker 1Anything pink in this picture represents either a bony landmark or the rim of the bone. You can see in particular how that one screw obviously needs to be removed or shortened because it will interfere with the placement of my cup. You can see it in multiple views to assure you have good bone contact and confirm your cup position.

Speaker 1This stem is fairly straightforward. This is for sizing. You'll note it does say 8 degrees of femoral version. In this case, that's probably not so surprising. But in DDH cases, which seems to be a pattern here in China, perhaps even more than we do, that number is quite valuable. You can see down in the box that versus the opposite Hip, we're only 4 millimeters shorter.

Speaker 1Uh, based on landmarks, uh, high on the pelvis, here we used an ASIS, uh, landmark because he had significant deformity of his pelvis otherwise.

Speaker 1So this is essentially the program software again demonstrating what our plan would be. This is not an X-ray, mind you. This is again the computer making something that looks like an X-ray for me. In reality, I'm going to follow this patient's X-ray for the rest of their life. I want to make sure that I like how the X-ray looks, that if they dislocate, I want to feel like.

Speaker 1The X-ray was my intent.

Speaker 1In this plan, again, uh, this is what we're planning bottom right. Um, we, uh, made him, uh, 10 millimeters longer than pre-op, which leaves him that 4 millimeters shorter.

Speaker 1This is the post-op X-ray. I removed two screws. Uh, well, we, we removed, I did, I, I did this with another surgeon. We removed 2 screws during this case. Uh, we used a single, single staging reaming technique, uh, ream the acetabum, got good press fit.

Speaker 1Um, there is, there is a screw in the acetabulum, although.

Speaker 1I could not convince you of that based on that X-ray, and then femoral sizing was appropriate.

Speaker 1This is just to compare what the computer software did for us with regard to planning and what we should have developed and had, and then of course, you see the true postoperative film on the left.

Speaker 1Any questions or thoughts about utilization of this platform?

Speaker 4Looks like you have the implant a little bit more proud, so he's a little bit more equal in terms of leg length.

Speaker 1Uh, in truth, uh, this, uh, this is the, uh, plan. The plan was to put it, uh, uh, making the 4 millimeters different. I did not, um.

Speaker 1I, I, I did not have on here the final intraoperative reduction, uh, but yes, we equalized his leg length intraoperatively. Um, again, let me go back to this screen. This identical screen you can see in the operating room after you capture for leg length and offset. So I know that this is a planned image because it's planned. Typically intraoperatively after I capture, capture my landmarks in that same location, it would say reduced.

Speaker 1And you would capture leg length at offset. So yes, in him, I did equalize his offset. Again, I think it's really important, and we made this point earlier. The, the robot is helping me with the hard tissue, the reconstruction with the parts, but we cannot ignore the soft tissue and particularly stability.

Speaker 2So, I have a question. For, before Surgery, this, uh, x-ray showed a great uh abnormal structure, and then when you do a total Hip, you have to remove a lot of, uh, bone osteophytes, etc. May that time, maybe make the Hip very loose. Then how can you get a very good range of motion? How can you balance the leg length? How, how can you, uh, make this Hip very stable? Uh, what's, what was your plan?

Speaker 1Yes. So it goes back to the comment John was mentioning to me. Our plan was to not regain the full length thinking he would be contracted. However, intraoperatively, we could see, he would tolerate longer length. Now, he had been short at this or he'd at least been contracted since his MBA in the early 90s, so we didn't know how much length we would get back. The one advantage here, I

Speaker 1Like some of my Other colleagues from the US, due to a significant number of anterior approaches, but this was obviously done posterior Approach, with the same Approach used for his Surgery, and I have the ability to on-t test them. Now, they're probably a great discussion to be had about what on-table testing means and how it correlates to dislocation, but I can share with you my routine. They're obviously lateral positioned.

Speaker 1I, I flexed them to 90 degrees and I see how much they'll internally rotate and I, I, I document that obviously. In, in, in this situation, um, by my assessment, he could flex to 90 degrees and inter rotate 70 degrees before he impinged trope on the pelvis and 75 degrees before he dislocated. He was able to achieve full extension with his Hip, but could, but could not hyperextend because we did, uh, lengthen him nearly 14 millimeters here.

Speaker 1Yes. So

Speaker 5just to not lose track of the soft tissues, this guy's short, and he's got a lot of extra bone. I would ask him a lot of questions about his sciatic nerve function at the time of the injury. And I would probably, I'm a typically a nerve avoider. I don't, I don't find the nerve. This would probably be somebody that I would find that nerve on as I'm taking out that bone because we're gonna make him long and it may be encased in bone, and that would make me pretty nervous. So, what, what did you do with the

Speaker 5nerve?

Speaker 1Um, I, I prayed for the nerve, uh, Rob, um, it, it is a, it is an excellent point. Uh, I too do not typically uncover the sciatic nerve. In this case, I could feel his nerve quite readily, uh, and it was not encased in bone. Uh, combining that with my ability to add length, but realized after I removed the bone that I didn't feel like I was over lengthening him, I always also palpate the nerve at the completion of the procedure.

Speaker 1Now the problem with that is lots of people will palpate the nerve with the leg in a neutral position. I think it's very important to flex the Hip up and see what their true functional, for example, sitting tension of the sciatic nerve is. So after completion of the procedure, his nerve was supple, and with a flexed Hip, I did not think he had undue tension.

Speaker 1But yes, I was scared.

Speaker 6Corey, um, I thought, have you, in, I mean, these things do not happen every day, but in some of these post-traumatic reconstructions, uh, are you aware of people or your own experience with regards to the gluteus medius dysfunction?

Speaker 6Maybe some initial injury or from doing these conversions, although using the posterior Approach rather than the harden splitting the gluteus uh medias, maybe injuring the uh superior gluteal nerve in traction and end up with um dysfunction of that and therefore the tension issue.

Speaker 1Yeah, Hip function is so important, of course, uh, after these cases. I'm actually we'll be presenting a case, uh, tomorrow, um, uh, showing a complex Sab reconstruction where you, uh, go high on the, on, on the pelvic wall. I think this is one advantage of knowing exactly where you are in three dimensional space and having a plan on which, you know, I'm going to remove screw number 4, yada yada. Having a plan for screw removal.

Speaker 1Because I do not compelled, I do not feel compelled in this case to do further dissection up the acetabulum or up the iliac wing or, or around the posterior wall. Now, you bring up a good point. It could be scarred in and just lengthening the limb would, would injure the superior gluteal nerve. I do not have much experience with that.

Speaker 1My concern has been when the case required extensive dissection, like in a triflange case, um, and then I feel like I'm getting up to, uh, you know, where up above before it splits and causes a huge functional issue. I think the danger there is less in lengthening, uh, and more in the dissection.

Speaker 1It's been my experience.

Speaker 6Alright.

Speaker 6Great. Thank

Speaker 1you.