Primary Hip Arthroplasty Case Title: Hybrid Primary Hip Arthroplasty
Case Title: Hybrid Primary Hip Arthroplasty
-
Demographics
Age: 76
Sex: Female.
BMI: 26
-
Relevant Past Medical History
Principal pathologies: Mild cognitive impairment, osteoporosis and hypercholesterolemia.
Previous surgical procedures: Bilateral total knee arthroplasties, appendectomy and hysterectomy.
Medication: Citalopram, donepezil and acetaminophen.
History of presenting complaint: 76-year-old female presented with bilateral hip and thigh pain which limited her daily activities for the past 2–3 years. She had failed nonoperative treatment methods which included anti-inflammatory medication and steroid injections.
-
Clinical Examination
Symptoms: Bilateral hip and thigh pain.
Range of motion: Extension-flexion, 0–100°; limited internal rotation due to pain.
Main disability: Pain and difficulty with ambulation.
Scoring: Harris Hip Score = 45.
Neurovascular evaluation: Normal motor and sensory exams of both her feet. She also had palpable pulses which included the dorsalis pedis and posterior tibial arteries.
-
Preoperative Radiological
Assessment/Imaging (Figs. 3.9,
3.10 and 3.11)
![]()
![]()
Fig. 3.9 Anteroposterior pelvic X-ray demonstrates significant osteoarthritis in both hips
![]()
![]()
Fig. 3.10 Anteroposterior view of the right hip shows prominent osteoarthritis of the right hip
![]()
Fig. 3.11 Cross-table lateral X-ray further demonstrates the significant osteoarthritis, especially anteriorly
-
Preoperative Planning
Diagnosis: Bilateral hip osteoarthritis (Figs. 3.9, 3.10 and 3.11).
Possible treatment options: Staged total hip arthroplasty (THA), cemented versus uncemented femoral stem.
Chosen treatment method: Staged THA beginning with the right side which was more symptomatic.
Selection of implants if applicable and rational: Press-fit uncemented acetabular component and a cemented femoral stem. A cemented femoral stem was chosen as the patient’s bone quality was deemed to better fit a cemented stem. In addition, the risk of periprosthetic fractures is lower when compared to press-fit stems [30]. The cemented femoral stem of choice was the Exeter cemented femoral stem (Stryker Howmedica, Kalamazoo, MI, USA).
Expected difficulties: Femoral bone preparation should be meticulous trying to avoid removing cancellous bone that is required for proper cement/bone interdigitation. Obtaining good cement mantle/bone interdigitation.
Strategies to overcome difficulties: Hand reaming and broaching, leaving 3 mm of cancellous bone in zone 1. Removing soft tissue from zone 7. Maintenance of pressurization within the femur during the cementing process which is important for cement penetration into the surrounding cancellous bone.
Templating: This patient was templated for a 52 mm uncemented acetabular shell and a 37.5, 0 cemented Exeter femoral component.
-
Surgical Note
Patient’s position: Lateral decubitus position Type of anaesthesia: Regional anaesthesia Surgical approach: Standard posterior
approach
Main steps:
-
Exposure and dislocation of the hip joint.
-
Femoral neck resection according to a preoperatively templated neck length.
-
Exposure and preparation of the acetabulum underreaming by 1 mm.
-
Implantation of a press-fit uncemented acetabular shell and screws as needed.
-
Preparation of the proximal femur with hand reamers and broaches.
-
Placement of an appropriately sized cement plug.
-
Irrigation of the femoral canal with a pulsa-tile lavage.
-
Insertion of a plastic suction catheter deep into the femoral canal.
-
Epinephrine-soaked swabs are placed into the femoral canal followed by dry swabs.
-
The proximal femur is then filled with cement in a retrograde fashion using a cement gun and long nozzle.
-
The plastic suction catheter is removed early as the cement is being placed.
-
Once the proximal femur is completely filled, it is pressurized with an excellent seal for a few seconds.
-
The dried 60-degree preheated stem is placed with one hand on the stem and the thumb from the opposite hand over the medial neck to increase the pressure during stem insertion.
-
Excess cement is removed and a horse collar is placed around the neck of the stem until the cement fully cures.
-
A trial of range of motion and stability is completed with a trial femoral head.
-
The final femoral head is placed.
Reconstruction techniques: Uncemented acetabular shell and maintenance of pressure within the femoral canal during cementing of the femoral component (Figs. 3.12 and 3.13).
-
-
Intraoperative Challenges
Challenges and solutions: Challenge: poor bone quality from conditions such as osteoporosis. Solution: Utilize a cemented femoral component to minimize iatrogenic intraoperative proximal femur fractures. Challenge: Maintenance of constant pressure during cemented stem insertion. Solution: Placement of the contralateral thumb over the medial neck throughout stem insertion.
Unanticipated problems and solutions: Challenge: Iatrogenic fracture of the proximal femur calcar during preparation. Solution: Increase exposure to identify the extent of the fracture. Place wires or cables around the fracture for stability as needed.
Thorough description of decision-making, including the reason for the final decision: Total hip arthroplasties in patients with poor bone quality can be challenging. Press-fit stems in these situations pose a risk for iatrogenic intraoperative fractures [30]. For that reason, we prefer to implant cemented femoral stems in female patients over the age of 70 years and male patients over the age of 80 years given the increased frequency of osteoporotic bone. The patient described was female and over 70 years old with the comorbidity of osteoporosis, which is why we felt a cemented femoral stem would be appropriate.
-
Postoperative Radiographs
(Figs. 3.12 and 3.13)
![]()
![]()
![]()
Fig. 3.12 Anteroposterior X-ray of the right hip demonstrates an uncemented acetabular component with screws for additional fixation and a cemented femoral component. Note the adequate cement mantle
![]()
Fig. 3.13 Lateral X-ray shows the acetabular component with the correct version and the placement of three screws. The cement mantle for the femoral stem can again be seen surrounding the entire portion of the stem within the proximal femur
-
Postoperative Management
Chemoprophylaxis and anticoagulant treatment period: Aspirin 325 mg twice a day and compression stockings for six weeks. The patient also receives omeprazole while on aspirin. Sequential compression devices are also worn during the hospitalization period.
Gait/limb loading until full loading: Weight-bearing as tolerated immediately after surgery with no restrictions.
-
Follow-Up and Complications
No postoperative complications. Harris Hip Score = 85.
-
Discussion
Advantages of the applied method: Primary THA has been a successful operation for most patients. The debate between the superiority of uncemented and cemented femoral stems continues within the literature with no clear answer. There are several advantages to cemented femoral stems which include the decreased risk of iatrogenic proximal femur fractures in weaker bone as they do not rely on a press fit for initial stability and the ability to adjust version as the stem is implanted into the cement mantle. The positive long-term results of the cemented Exeter polished femoral component has been extensively documented [31]. Furthermore, the UK has demonstrated increased survivorship for cemented THAs as compared to uncemented hips [32].
Disadvantages of the method: The main disadvantage with cemented femoral stems is the risk of sudden death during pressurization of the cement within the femoral canal. This is thought to be caused by cement debris, fat and blood that embolizes to the lungs during cement pressurization and stem insertion which leads to cardiopulmonary collapse. The act of judicious lavage and
suctioning of the femoral canal prior to pressurization has been credited with a decreased risk of sudden death [33]. Furthermore, in a recent study, cemented stems were found to have a higher revision rate for any reason at a mean follow-up of
6.5 years in patients less than 70 years old [34].
Alternative evidence-based techniques for the case: An uncemented femoral stem.
Why is the chosen technique better for this case? Press-fit femoral stems pose a higher risk of intraoperative fracture of the proximal femur in patients with weaker bone quality. A cemented femoral stem minimizes this risk because a press fit is not required for initial mechanical stability which is provided by the cement mantle.
Indications and contraindications for your technique: Indications: Any patient with weaker bone quality caused by conditions such as osteoporosis, female patients older than 70 years old and male patients older than 80 years old. Contraindications: Patients with an active infection or with comorbidities that make it unsafe for surgery.
Learning curve and how to manage complications: The most critical part of the learning curve with this technique is adequately preparing the proximal femur with lavage and suction followed by retrograde cement filling and pressurization. This will allow for an excellent cement mantle that interdigitates with the surrounding cancellous bone. Complications include those that are inherent to any primary THA such as acute and chronic infection, dislocation and nerve injury. The most feared complication associated with cemented femoral stems is sudden death during cement pressurization. To prevent this complication, it is crucial to aggressively lavage and suction the femoral canal prior to instrumentation and place a small suction tube into the femoral canal just prior to cementation. It is also advisable to inform the anaesthesiology team during pressurization and involve them early to monitor the cardiac and respiratory status.
Level of evidence concerning the superiority
of this method against others: Level II [35].
