Peggers’ Super Summary of Hip Hemiarthroplasty

Indications:

Displaced intracapsular in any age

Undisplaced in elderly (young can be treated with DHS or
cannulated screws)

Malunion/non-union/osteonecrosis
Anatomy:
OSSEOUS

Neck shaft angle for the proximal femur is 1300 +/- 70

Anteversion is 100

The weakest bone is anterosuperior region of the femoral neck.
The strongest is the calcar femorale posteroinferiorly.

LT points posteriorly and medially
VASCULAR

Circumflex arteries both medially and laterally

Ligamentum teres from the foveal artery

Medullary bone
N/V LATERALLY

Superior gluteal nerve in posterior surface of gluteus medius, at
risk if dissection is too proximal
N/V POSTERIORLY

Sciatic nerve

Gluteal nerves and vessels
Preoperative planning

Measure leg length radiographically; tip of GT goes through
the centre of the head on contralateral side.

Sernbo score out of 20. Better outcome for THR if score > 15
o
5 Age < 80 (or 2)
o
5 MMTS >8 (or 2)
o
5 <or= 1 walking aid (or 2)
o
5 Independence (RH or NH 2)
Equipment:

Hemiarthroplasty set (Austin Moore / Thompson’s / Exeter
trauma stem)

Cementing technique
Operative room planning:
INTRODUCTION

Confirm Consent / Mark / WHO form / Abx at induction
POSITIONING

Lateral with anterior (superior enough to allow full hip flexion)
and posterior support.

Protect pressure areas

Pillow between knees
DRAPING

Perineal seal

Antiseptic solution to just below knee

Drape sock above knee

Have adequate exposure above & posterior to GT to be central

Ioband for exposed leg
Surgical approach:
ANTEROLATERAL APPRAOCH – (WATSON JONES)

Incision: skin incision is made 2.5 cm behind ASIS to tip of
greater trochanter

Extend incision vertically down along anterior margin of
trochanter and a long line of femur for about 10cm

Interneural Interval: interval between tensor fascia lata &
gluteus medius is identified
Overlying gluteal fascia is divided allowing these muscles to
be separated up to iliac crest

Anterior parts of gluteus medius & minimus are raised from
hip bone & retracted posteriorly

Upper part of Capsule of hip joint will been seen, w/ reflected
head of rectus femoris attached to upper part of acetabular rim

Make a longitudinal incision in the joint Capsule & make a
transverse incision in the anterior margin of the acetabulum

Externally rotate the limb
LATERAL APPROACH

A direct lateral approach over the GT

Cauterise and gentle swab off the bursa to reveal FL

Fascia lata incised over GT directly and released with tissue
scissors proximately and distally

Place scissors over anterior 1/3rd of Gluteus Medius and incise
tendinous insertion with diathermy

Divide rest of gluteal muscles proximately in line with fibres

Diathermy T cut directly down onto femoral neck sticking
directly to bone

Delivery spoon can be sued to stabilise the # head in the
acetabulum then use a corkscrew to remove the head

Circumduct the head to make sure the ligamentum teres is torn
before removal. Cut excessively long ligamentum teres with
diathermy.

Measure the head and choose size to trial in acetabulum.

The femur is delivered out of the wound by adduction and
external rotation ‘figure of 4 position’

For Austin Moore and Exeters aim for 1 finger breath above
LT
MODIFIED HARDINGE

skin incision is similar to that of the posterolateral approach,
except that the incision needs to be shifted anteriorly a few cm

Distally the tensor fasciae lata is split in line with the femur

Proximally the split should curve slightly anteriorly towards
the ASIS

Insert a charnley retractor & use a swab to clear off the bursa
around the GT

medius incision: note the crescent shaped course of the vastus
medialis, with the anterior fibres of the medius lying in a
horizontal position, splitting the most anterior fibres of the
medius provides

note that the superior gluteal nerve enters posterior surface of
this muscle and is at risk for injury (if dissection is carried too
far proximally);

once the dissection, proceeds down to the anterior
intertrochanteric line, flex and externally rotate the hip, so that
the leg
is swung forward over the table, with the leg lying inside the
sterile "saddle bag;"

the hip capsule is identified and incised w/ an inverted "T"
incision;
POSTERIOR KOCHER LANGENBECK

Keep knees flexed to take pressure off sciatic nerve

Skin incision if from PSIS to GT and then down line of
femoral shaft.

In the same line as the skin incision split gluteus maximus and
FL in line of their fibres

Partially release fibres of Gluteus maximus inserting distally
into the femur NB underlying blood vessels bleed

Identify the Piriformis, internally rotate and adduct leg, the
sciatic nerve may enter (anteriorly / posteriorly or split the
Piriformis)
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Peggers’ Super Summary of Hip Hemiarthroplasty


Identify the short external rotators and quadrates femoris
Divide the tendinous insertion of the Piriformis and external
rotators, place a stay suture and reflect to protect the sciatic
nerve

Obturator internis elevated to reveal posterior column down to
ischium and hamstring insertion
RETRACTORS

Self retainers

Hohmann

Bennetts

Langerbeck
REAMING

Aim posterior & laterally knock out the cancellous cavity
with a box osteotome

Circular reamers aiming down femoral cavity scrape
posteriorly and laterally

Specific set Reamers or Broach with 100 anteversion until
appropriate fit and length looking at measuring points

Trail head and reduce to check for
o
Stability
o
flexion to 900
o
Extension to 00
o
kick back
o
leg length
o
IR/ER
CANAL PREPARATION

Irrigate

Measure and place plug 1-2cm distal to tip

Hydrogen peroxide swab with a knot in situ down canal

Mix cement and introduce when doughy via pressurized
technique sucking any blood proximately

Remove excess cement and place implant in being careful to
place implant in anteversion and up to the measured point.

Hold in situ as cement expands during setting process
Anterior 1/3rd of the Gluteus medius elevated with the capsule to expose
the #
Implant positioning:

LT needs to be cut at appropriate level for implant

Ream to middle hole of implant on neck or tip of neck to GT

100 anteversion
Subcut LMWH injections
Right lateral, spinal, sedation, IV Cefuroxime 1.5g, sterile prep and drape,
WHO checks
Findings :
Procedure :
Femoral stem prepared
Hardinge plug inserted
Washout given
Standard stem Thompson's prosthesis inserted with cement
Acetabulum washed out
Reduction achieved & stable in ROM
Washout given
Closure :
Wound closed in layers, #1 vicryl deep and to fascia, 2/0 vicryl to fat and
subcut caprosyn 3/0 to skin
Opsite, pressure dressings
Post Op Instructions :
Monitor CSM
Keep legs ABDucted with a wedge between the legs
Analgesics
Routine blood check – Hb and electrolytes
Check Xray – Left Hip lateral and AP pelvis to check leg length
Operative note:
Preparation and Position:
Anterolateral approach to the hip joint. All tissues divided in the line of
incision
Head extracted measuring 53mm
Routine post hemiarthroplasty mobilisation
Closure

Irrigate

Haemostasis

No1 vicryl to Piriformis and external rotators via an
intraosseous canal / FL in centre then continuous / No1 vicryl
to deep fat & dermal / 2/0 vicryl to subcutaneous tissues / 3/0
caprisyn to subcuticular closure.
Incision and Approach :
Femoral neck osteotomised
IV fluids for 24hrs
Evidence:

Posterior approach reduces dislocation. Pellicci PM et al.
Clin Orthop Relat Research 1998.

THR better than bipolar. Keating JF et al. JBJS (Am) 2006

THR better than Hemi or bipolar in independent mobile
patients. Bannister GC et al. JBJS (Am) 2006 also supported
by Sernbo score
Complications:
Intraoperative

Instability

Perforation of femoral canal or #
Early

Infection if wound not dry by 10th day return to theatre

Failure of fixation

Dislocation
Late

Septic or aseptic failure

Thrombosis

Mortality 10% at 1 month, 30% at 1 year
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