Role of primary bipolar arthroplasty or total hip arthroplasty - Punjab ...

Walia et al
Surgery was done under general or spinal anaesthesia
depending upon the choice of anaesthesiologist. All patients
were operated in lateral decubitus via posterolateral
approach. The fascia was incised in line with the skin incision.
After blunt dissection of gluteus maximus the gluteus medius
was retracted to expose the short external rotator muscles of
the hip. The abductor-greater trochanter-vastus lateralis
complex was kept intact. Short external rotators were divided
close to their insertion and an inverted T shaped incision was
made on the joint capsule. The femoral neck was osteotomised
and the femoral head was removed. Patients were subjected to
either hemiarthroplasty, with cemented bipolar prosthesis, or
total hip arthroplasty depending upon condition of the
acetabulum
Hemiarthroplasty - Once the head-neck fragment has been
removed the medullary canal of the femur is readily accessible.
The canal was rasped with an appropriately sized broach and
trial prosthesis was inserted. A helpful guide used for the
appropriate height of calcar reconstruction is the relationship
between the centre of femoral head and tip of the greater
trochanter: It should be essentially coplanar. Although this
may be difficult to assess in presence of trochanteric fracture,
usually, the greater trochanter fragments are still somewhat
attached and can be used as a gross guide for evaluating the
appropriate level for prosthesis. Following an acceptable trail
fit, leg length and hip stability are assessed. The head was redislocated
and a permanent bipolar prosthesis was cemented
into the femur at the proper level. After reduction the movements
of the hip were checked.
Figure 1: Pre and post operative X-ray of bipolar case
Total Hip Replacement - The acetabulam was prepared by
excising the ligamentum teres and removing the articular
cartilage with acetabular reamer till raw cancellous bleeding
bone was exposed. The fitting of the acetabular component
was checked. Acetabular cup was placed in a position of 45-55 0
abduction and 10-15 0 anteversion. Femoral preparation was
done as already mentioned above for bipolar hemiarthroplasty.
Trail reduction was done and soft tissue tension
checked. Following an acceptable trail fit, leg length and hip
stability are assessed. The head was re-dislocated and a
permanent prosthesis was cemented into the femur at the
proper level. After reduction the movements of the hip were
checked.
Figure 2: Pre and post operative X-ray of THR case
Trochanteric reconstruction: Displaced trochanter was
fixed accordingly as per geometry, comminution of fracture with
the help of SS Wire or vicryl numbrt 1 reinforced with bone
cement. Femoral head was used for reconstructing the medial
bone loss wherever required.
After reattachment of capsule and short external rotators,
closure in layers was done over drain.
Physiotherapy was started on the first postoperative day.
On the second postoperative day, patients were allowed
to sit on the side of the bed or upright in a chair. Gait training
was begun and weight-bearing was permitted earliest, as
tolerated. As all the patients were elderly, they required a walker
for balance during gait training.
Patients were discharged 5-12 days after surgery and were
advised to continue physiotherapy until they could return to
independent living.
Patients were evaluated clinically according to the Harris
hip score 5 and Salvati-Wilson hip score 6 in out-patient facilities
at follow-ups.
Pb Journal of Orthopaedics Vol-XII, No.1, 2011
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