Live surgery of a total hip arthroplasty (DAA) with Dr. Rothenberg that 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.
next we'll do a surgical video and I'll try to highlight the tips and tricks throughout the procedure if something comes up, I apologize if I take a little slow, it's a little a little bit of a lag, but I'll be glad to pause the video to talk about it further go back through essentially. Here's an I do an anterior approach with a hana table. I think there's a mixed bag here of users on the call. We could talk about the post, your approach differences at the end if you want. I prepped circumferential around the thigh. This is just a sterile 10 Drake to block out R. S. C. D. And but my assistants will prep the thigh and then that way we can gain exposure to the knee. Um You don't need to go any more distant than that, but you really don't want to be too high on the thigh um because you have a minimum distance between the pelvic array and ephemeral painless array. So this is sterile carbon. Initially I was doing this while I was gown but I decided to go ahead and do this with sterile gloves before just to avoid any contamination uh on the skin I think helps uh as an intermediary Larrier helps avoid any loss of, you know, kind of movement at the plate and then the kneecap sometimes gonna be difficult in terms of like being an obstacle for getting a stable position. So oftentimes I'll just bring it a little bit to the medial side. That helps with camera view because I'll have the camera set up on the other side of me. Um and so you know, just giving a robust layer so that that plate is well fixed. Um That's now a, you know, sterile plate that I'm gonna perforate the drapes to put on the array. And here we're just putting our drapes on for, you know, routine anterior hip approach here approach marking out the skin. Um You definitely, I expanded a little bit here, you can see the iliac crest and the A. S. I. S. And that's just, you know, the exposure you need for the the pelvic pins and the pelvic T. R. A. And I use the shower curtain drape, you can use other drapes. Same thing. I've done it with kind of more standard blue drapes too, but I find this to be really nice and easy for our team to use. We're just setting up here. Um so here's our template. This is I template the trauma kid like we did before polar uh size five standard offset with 54 are three cup shooting for three of length and roughly three of offset roughly. And then this had a 43° of inclination and my neck cut was 16.5. So we've got this baseline leg length, we've got the report that I went over earlier, you can see it in two different ways. A lot of the information is on the template ID one or you can pull up the report. So here we made a perforation there is that that sterile, painless femoral ray. Um I orient there's a kind of a. T. To it and I orient the bottom part of the T. Towards the toes. I keep that consistent and that actually keeps this hooray um I think it maximizes the distance that there's kind of an asymmetry to that point. And so I try to be consistent with that. I recommend that for anyone that's doing this just to make sure that's consistent. Is placing it. Now I'm using the four oh pens in the iliac crest. I like to um initially when you're doing it, get the guide there and so you know the distance and then you kind of get used to how far you going to do it. And then I used the here the space clampetts really really critically important that you get that really tight. And at the bone there well fixed and bone, you check rotational stability, check depth that those pens aren't moving because if those moved during the case, you're not gonna get any useful information. And then here's adding the removable painless array there. Sorry, the removable T array. I just tighten that down really tight to make sure it's not off here. I'm getting the first point of the registration. So we've got the absolute the surgical side A. S. I. S. And then off screen here. Then my assistant got the other side. Next we've moved on we have the template here where now just looking to mark the necro section. So I have that based on the trauma cat. I marked my next section and now I'm putting a cobra. Uh we're over the tensor muscle. And what I'm trying to show here is glorious medias and gluteus minimus tendons coming into the proximal femur. Always a little tricky to show that. And we can but we can share some anatomy images. You guys all know this spot. But there's usually a nice little gap here between the vast slaughter Alice and the men where the media's and minimus come in. There's usually a nice little bald spot there and if you can that's that in my hands has been a little bit of a compromise to get it as far lateral as possible for this to make it as accurate as possible from an anti approach. It's not quite as you know direct lateral as you can get with the posterior harding approach. But if I internally rotate the femur and you know, go to that bald spot or even give a little bit of a longitudinal split part of the anterior half of the media's tenant, it works really well. So I had taken off the T. O. The T. R. A. My assistant put it back on here for this part and what we're doing is just capturing the proximal femoral checkpoint. You really want to make sure that your leg is in a neutral position. I use the haunted table. So I have zero upright. My rep double checks that um That way you can go back to that position at the end per consistency. Um Here we're doing the neck dissection based on the landmarks that we picked on the trauma cat image. So just routine flow here, I've tagged my checkpoint. You can see that here. I like to make sure if it if it goes anywhere, I I could find it really easily during the procedure. If it were to fall out for some reason it's not going to get lost in soft tissue. And then um it also is a reminder to take it out at the end. We put it on a sharps counts that way he didn't get left behind. I like to save anterior capsule too. And so that's what's tagged here, that's the other tag. So there's two tags on my wound here. Um you can see that the penniless family was off and now it's back on because we're at this point we're gonna um we can take it on and off, which is really nice versus other systems and gets out of your flow and you don't have to be on the other side of the pelvis. But here we're doing registration and it's pretty quick. I mean it probably takes 10/15 to register the A. C. Tabula. Um And then the media wall. And so here I'm just painting here, You can see it. I'm painting it. And so it's getting feedback. It's showing me where it wants me to get additional points. And as an anti surgeon it usually is wanting more anterior ramus. I'd rather focus on that because that's where my exposure is. Least. You can see that's done. And now we're moving on the medial wall I think at that point and it's here 45,678,910 seconds. So, um, it's probably one of the slower ones. Um My template id size was a 54 and my last album saying 51 mm. So I shoot for four over my federal head size. And that's right on the spot because we've got 51 ounce tabula and I think the head measured 50 I think one of the nice things here is you get to ring your own on your own. So here, I'm reaming uh with our usual something, if you remember here, I like to use offset, get my own feedback. Um and you can see, I don't know the top part of the screen that the array is still in on the base there. So it's definitely something where you can work around it if you want to even with your assistant there. So thus far, I mean it's from a workflow standpoint, it's added. I don't know, a few minutes to my case and I think you'll see throughout this, we'll get confidence in terms of what measurements were getting and an ability to fine tune the final implant, knowing that you're going to restore the initial goals of version inclination. Also in length, here's the insert, er there's a a offset insert er Which you can see, I use the R. three cut out there on the copper pipe. Try to put that at the corner there so it's aligned with the outer edge of the offset insert, er so that the screws are in the post, your superior quadrant. Then we have the array for the our hip system facing away from me towards the consulate, outside for the camera tracker. And so now it's going to show what the screen is showing, It's here, it's seeing the insert, er it's seen the pelvis and we're gonna get it in and it's going to start to show us numbers as we get closer. So here, real time you're getting feedback. I'm just trying to go. What I like to do is, you know, use a standard workflow. Use a standard technique. Put it where I think it's close to being where I want it. Um And then uh double check. So initially it's giving me a little bit more inclination than I shoot for A little more less an aversion I think literature would say mostly 40, 20, but notice how close, You know, 46, So inclination is pretty tight there and aversions 12 and 18. So, You know, if you're just gonna play averages, you could be at a right now this is a 46 and a 15 cup no matter what pelvic plane you're gonna use. So you know, I I'd say as an anterior surgeon it's kind of 40 20 for me. If anything I might back off to like um I think in this one We were I think somewhere in the 18th we'll see at the end here, but here just moving, you get real feedback. You see it in the live, I'm moving the cup, I'm adding a little anti version. I dropped the inclination um mm mhm there it's storing its own so it's orange. That's one of those things you got to make sure it catches if you move too quick and you don't let the system catch it and with the store, have your rep, press the button for store, you might move past getting a final report or you know, if you change the cup and then move quickly on without getting that stored. I've been frustrated at the end of the case. I didn't get that. So um it's easy enough, you just have to be aware that you need to do that. Um One of the things that we, we really harp on is making sure that those arrays are clean. The balls are subject to water and blood disrupting our visualization. So I'll keep those really clean assistance will clean them if if necessary, if there's any splatter on them and then um with the impactor. Sometimes you'll if you hit it with, you know, a bigger mallet or a bunch of times the balls will loosen a little bit subtly and then it won't read. So you just want to tighten those back up with clean hands or with a lap on it. And so I was just checking here the anatomy, just seeing where the version was, inclination, etcetera. And just really find drink choosing to find tuna there. I'm just holding it steady and just decided I remember this case. Well, just decided to add a little bit more an aversion. Just a scotch more at the end before I put some screws in, then I released that insert. Er it's toward the number. Okay, we're gonna add a screw again. I've kept that orientation. I think that's a nice way to hold a place that for the draft into your approach in my hands with that offset insert. Er Sometimes I use the straight, I'll go to the straight after I've impacted if there's a little bit a few millimeters left and you need the force of a strange factor, I'd screw it in and put it down but it's pretty rare that I need to do that. Um And I'm unusually one or 2 screws guy there, are there any, are there any questions coming across right now before we move on to the next part of the flow? I don't wanna Sure. The question that's in the chat right now is can you talk through your pin preference as far as the size chosen? Yeah, so you can use any kind of screw point. Um We went through using a 35 cortical screw and then I went up actually starting to use the quarry checkpoint so that with the magnetic holder. So for those of you guys are gonna be using this quarry. Um I would just claim that it's not part of the official technique but that would be I found that to be the most hopeful. Um Perfect. And then um as far as the amount of X ray that you use for cut placement, have you seen a reduction in the amount of X ray used in these cases? Yeah, absolutely. I for this demo I mean I took I took images um you know, including this one here, I'm checking cups, depth and cupping, checking cup screw placement and I still take that X ray routinely. I'll get a quick shot. What I don't do anymore is make sure the X ray is perfect because we all know that Flora Skopje lies. And so I've gotten I've just I just wanna see, I just kind of generally want to see depth screw placement and I'm not like meticulously changing to match their functional pelvic position for when they had their X ray. Um So that's taken eliminated multiple shots of when you want to take a shot and also during the procedure having control over what your X ray take is delivering to you on the screen. Um The other shot I take will be if on the femur side the template is off. If I'm, if I'm undersized or for certain reason oversized, I'll check my paris, Vegas alignment, my sizing. Um and But I mean generally say I would take I take 1-2 floor of shots now and where I was using a lot more so once cut position again, I thought that was right where I wanted it to be. I mean maybe it looked a little bit more inverted then when I normally would, I would have scrutinized that before I had this system and then, you know, made sure the X ray was perfect because it's counting for anatomy. But that cut placement on the floor shot was great for me with the one screw put my neutral liner in and now, you know, skipping ahead ephemeral preparation. So I I use all the offset tools um for polar double offset in searchers and that was the double offset box chisel. Um I think for ephemeral replacement, I want to I take off the removable T array when I'm approaching the female. So it's out of the way the pens, you know, there's plenty of distance as you can see there, especially if you angle them more towards the head and a little bit away from you. So it's like midline to out with your pelvic pin placement. Then they're going to be away from your, your approaching um you know, it's a little harder with a single offset broach if you prefer that, but the double offset swings it away away from the pen array and it was already what I was using before Dr. Rothenberg in the Chat. There's another pin question specific to the arrays um asking is there a reason that you choose to use 4.0 verse 3.2? Yeah, with only two pins, the 40. Is just way stronger and less apt to have flex in the pens so that you, which would introduce air. So um I'll even make a third incision if I, my first pin placement on the 40 pin I don't like and the bone is a little softer on some part of the crest, on the other part because if you don't have those pins whilst fixed and secured a bone and then that base tightened and then if all of the links matter, um the system is only as good as we can make it by, you know, making sure the tools are not used properly. So The four arrows just with, especially with two pins have been great and I haven't had, you know, knock on wood. I haven't had any actually patients complain about those sites, they don't find them particularly painful. You know, sometimes we get a little bleeding at the end but we just use one of my p ages is a moniker. I let them choose what and the other one uses the term bond. And so regardless, patients haven't really um had any issues with it. I think you could use a 32, but I advise against it. I just think the four of us are way more stout And I use the 32 on my my knees. So for different reasons, I think there's fracture risk in the lower extremity where the pelvis. I don't think it's not a non issue. So you just want something as strong as you can. So uh put my polar in. I think this is a standard and minus head. Um We're going to reduce then see what our numbers show. Um I generally do a stress test external rotation 60°. That's my rep. Just taking the range of motion there and then check lateral shock. Just get the usual feedback that you want in the system. And then we're gonna check with our point probe. I think you can see the painless ephemeral array in the bottom right hand side of your screen is moving with the leg, it's stable, it's, you know, the drapes aren't pulling on it is to move the legs so those are things you don't want the drapes to be too tight where it's kind of sliding the array around or rotating it. Um and then there you can see the checkpoint. So you can do the clicker method. I try to prefer gonna have the balls visible. You also need to have the clicker has a radio frequency, I think I believe communication to the um, the camera. So you've actually got to make sure your hands not, you know, it's the balls might be visible. The clicker has to be um transceiver of that needs to be visible visually um to the camera. And so, you know, this is telling me, hey, I'm to shorter and for lateral. Ized, that's what I was seeing and feeling. You know, in terms of being a little bit um offset. So I just go ahead. I'm gonna go to um I've actually went to a Vegas Plus four, I'm Sorry, Blah Blah zero. So, um, I'm expecting to be able to lengthen the patient here. Um and so here I'm gonna get zero change. So relatively I lengthen them and then reduced the offset changes. I think there's differences in philosophy between surgeons that might want to, there are certain patients there on the side of a little bit of extra offset. I try to, for most patients, I try to shoot back to restore their native biomechanics And this patient didn't have a, I think they listed at six short on the trauma cat. And then I was shooting for if I remember three and three roughly. I love that the conversation becomes millimeters. I don't like going to the recovery room and going, you know I was I'm off by 78 mm a centimeter. No one likes those surprises. It's not fun for the patients. Not fun for us as surgeons. And so there's the polar, you can see the H. A. Sitting. I use the collard polar H. A. Sitting right where it needs to be based on the approach. Um And then we're gonna I think one of the time things that's helped as though I just I'll sometimes just measure before I take out the polar, I'll measure out the distance physically between the collar and the necro section and then go back. It's and then re measure it when it goes in and it's sitting right where it needs to be. You know, I have confidence to just put the final head end. I don't trial again. That's what we've done here. Be careful with the oxen, iem their precious. So um you're going to reduce it here and then recheck our numbers and see where we're at. So just the stability tests again that erase my assistant's making sure the camera's visible. She was just moving the drape there so that the railway was not blocked by the camera. And then I went to a plus four here with the Vegas. Um So I got I would say you know we were 00 and now we're four and 31 at the plus four. I think that's you know, I would have expected you know 2.5 2.5 with that plus four. Um So when it probably set up a millimeter or two when I put it in or just you know we can see I moved that right that that point probe around a little bit to show that if you're not putting your point pro back in the same position you can move it by a millimeter here or there on your final numbers. So there's there is you know an accuracy of a millimeter affected by the probe and its position you want to be consistent. I just took the check point out. That's an important point to remember. We don't like leaving checkpoints in. So I do recommend having it as part of account or way of checking things. And there you can see the Vegas this patient. I didn't because it's Vegas it didn't have a collar on this one. Um but bit about bit of poster tilt looking on this patient. I mean he's got your you got a standing view not much of an inland in the pelvis and um ah yeah pretty much here's the final results. I think the patient was really happy and doing really well. So
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