The Use of Photodynamic Nails for Bone Reinforcement in Combination with Complex Total Hip Arthroplasty in the Setting of Radiation Osteitis

CHAPTER 1

My name is Santiago Lozano. I'm one of the orthopaedic oncologists at the Massachusetts General Hospital in Boston, Massachusetts. Thank you for taking the time to review this surgical technique video describing the use of photodynamic nails for bone reinforcement in combination with complex total hip arthroplasty in the setting of radiation osteitis. The case is the one of a patient with history of a large B-cell lymphoma that affected the left acetabulum. The patient presented with hip pain, and with imaging studies and a biopsy, we confirmed the diagnosis of the large B-cell lymphoma. The patient was staged with a PET-CT scan and then started to receive his treatments with the traditional chemotherapy treatment with consolidation radiation after six cycles of R-CHOP. The patient did well for some time, but unfortunately because of the radiation osteitis and the axial loading of the left lower extremity, he has started to present proximal migration of the right femoral head with the subsequent shortening of the left lower extremity. The patient has history of degenerative lower lumbar spine disease that requires surgical treatment, with fusion between the L4 and S1 levels. The patient, in addition, started to develop osteoarthritic disease of the left hip with significant acetabularization of the proximal iliac bone and medialization of the femoral head. Due to the shortening, decreased range of motion, and pain, the patient decided to opt for a complex total hip arthroplasty. It was clear that the patient will require augments to bring the center of rotation of his left hip down into the acetabulum, in addition to an extensive dissection of the sciatic nerve in order to avoid neurological symptoms and neuropraxia in the process of bringing down his center of rotation. As mentioned, it was clear also that the patient will need an augment, but unfortunately the bone quality is not of optimal characteristics because of the history of radiation and the presence of radiation osteitis, in addition to the destruction of bone due to the migration of the femoral head. For this reason, a reinforcement of the periacetabular bone was performed with photodynamic nails, a new tool of a polymer that is injected in a balloon that is inserted percutaneously in the periacetabular area, reconstructing the sciatic corridor in the posterior column. The purpose of these balloons are to give additional biomechanical stabilization to the pelvis and provide a good anchoring system for the screws that will be used for stabilization of the components of the total hip arthroplasty. The surgery is going to be in two stages that are performed in the same surgical event. The patient initially will be in the prone position as the balloons that are going to be inserted are inserted in the prone position. There are two balloons. One of them reconstructs the sciatic buttress, and that is inserted through an incision in the posterior inferior iliac spine. In this particular case, the insertion needed to be more horizontal given the small size of the sciatic corridor given the migration of the left femoral head into the left acetabulum. The second balloon reconstructs the posterior column. That's inserted in a retrograde fashion through an incision in the ischial bone, in this case, on the left hip. These two balloons form a T-construct that supports the acetabular cup and augment. These balloons are at least in diameter eight millimeters, but in the areas where the bone is weak and is compressible, the balloon can obtain a larger diameter until its maximum, which is 22 millimeters. In preoperative planning, we determined that the balloon in the sciatic corridor was going to measure 140 millimeters in length, whereas the one in the posterior column was going to be 120 millimeters in length. This procedure can be performed under fluoroscopy, navigation, or a combination of the two. My preference is to do it in a combination. For this particular case, we place the tracker in the contralateral posterior inferior iliac spine. After obtaining an intraoperative CT scan, under navigation, we proceeded to insert the first balloon in the sciatic corridor in the posterior-to-anterior position, reconstructing that sciatic corridor. The second balloon, as mentioned, is inserted in the retrograde fashion through the ischial tuberosity. These balloons are inserted as any conventional intramedullary device. There is a process of sequential reaming that starts at a 6.0-millimeter coating ream, which is enlarged up to size eight millimeters. There are different brands that offer reamers that are less flexible, and those can be used in settings where a sclerotic bone is observed. I always have available that for my surgical cases in which I'm concerned about the sclerosis of the bone. This is one of them. After the hole reaming is completed, the balloons are inserted after confirming the measurements. Once the balloons are deployed and filled with the polymer, intraoperative fluoroscopic images confirm the position and the filling of the balloons in the way that it has been planned preoperatively. Once the surgeon is satisfied, the balloons start the process of curing, and once they harden, the deployment system is removed with the coating system that the photodynamic nail set has. The incisions are closed, I prefer to use monofilament sutures, and the sterile dressings are applied. Once this first stage is finished, the patient is again repositioned in the lateral decubitus in the same flat Jackson Table with the hip grip and prep and drape in the standard fashion for a total hip replacement. A total hip replacement is going to be performed in the standard fashion. The only difference is that I'm going to use a multihole revision cup and an orange slice augment in order to bring the center of rotation down. Because of the medialization of the cup, I will evaluate the viability of the remaining bone and according to the amount of bleeding that I identified after reaming, I will proceed to bone graft the posterior part of the cup and the medial part of the acetabulum. I will use a standard cementless stem for the femur with metaphyseal fixation with a dual mobility system. The augment will be secured with 6.5-millimeter screws of the maximal length possible, and as many screws as possible will be used to secure the revision cup into the pubic bone, the iliac portion, and the posterior column of the acetabulum, as well as the ischium. Let's see the surgery.

CHAPTER 2

So, this is a surgical video for the surgical technique photodynamic nail stabilization in bone with radiation osteitis, with the aim of reinforce the bone for a complex total hip arthroplasty. The patient is a 70-year-old male that approximately five years ago was diagnosed with a large B-cell lymphoma. He was treated with radiation and chemotherapy and had a very good response to treatment. He had already at the time some osteoarthritic disease, but his symptoms were very mild. Because of the radiation in the weight bearing, he presented progressive migration of the left femoral head causing limb-length discrepancy and a reduction in terms of range of motion. Because of the radiation osteitis, we're going to use the photodynamic nails to improve the grip of the screws that we're going to use as well as the augment. The patient is under general anesthesia. He's in the prone position with chest rolls. All bony prominences were padded. The patient has a Foley catheter. His knees are mildly flexed. The rolls are flexing his hips as we're going to put the balloons from posterior to anterior and these are going to reinforce the sciatic corridor, which we'll see incisions in a few minutes, and with a retrograde balloon that will go from the bottom of the ischium and that's why it's important to flex the hips. The arms are forward in the superman position. It's important to move the arm boards proximally because we're using the O-arm in navigation for the insertion of these balloons and if the arms are lower, they affect the position of the O-arm. The patient is prepped in the usual fashion. Have that guy. Do you have a sterile towel, please? Open it? Yep, that's perfect. A sterile towel is placed in the intergluteal fold. We're going to be working on the left side, so I'm going to leave the ischial area of that part exposed. Do you have a down drape? Do you have a plastic U? We will need two of those. Do you have the paper one? Perfect. You want the drapes to be low on the lateral side in case you wanna do an anterior column balloon that you can do in an antegrade fashion. Do you have more Ioban, please? Can you cut it in four pieces? Four quarters. Very good. And may I have another pair of eights, please? Okay, let's do our timeout. We're doing a photodynamic nail stabilization of the left side and a complex total knee arthroplasty afterwards. Site is marked, consent is signed and reflects the procedure, images are up. He has allergies to sulfasalazine. He's getting for antibiotics, Ancef, two grams. He's under general, has an endotracheal tube, Foley catheter, compression boots in both lower extremities, two peripheral axises in the prone position with chest rolls, or bone prominences well padded. We also padded his port. We have navigation, we have the photodynamic nail set. Risk of fire is low, some charts in the bottom left corner of coffee's table. We're going to close with 0 PDS, 2-0 PDS, 3-0 Monocryl, Dermabond, Telfa, and Tegaderms. And when we're done with this part, we will position the patient the lateral decubitus with a hip grip for the total hip. Any concerns? We're good? Perfect. Yes. Is there contraindication to dexamethasone from your standpoint? He can have dexamethasone. That's fine.

CHAPTER 3

Do you have a marking pen, please? So, even in patients that are very obese, the posterior inferior iliac spine is easy to palpate and I can feel it here. I'm going to feel the contralateral side and that's where I'm going to insert my pin for the navigation. Usually it is a short pin. The closest the pin is to the bone, the more accurate the navigation is. Do you have a 15 blade, please? So you make a small incision. Basically with this needle you go down to bone and you feel the contralateral posterior inferior iliac spine. This is the device for the short percutaneous pin. This is the device to hammer the device into the bone. Have a mallet, please. You want to be sure that the arrow points towards the navigation device. This procedure can be performed with fluoroscopy only or with a combination of navigation and fluoroscopy, which is my preference. You want to be sure that the pin is well secured and you want to be sure that the soft tissues are relaxed around the pin. Then you insert your tracker and you want it in a position that matches the navigation. Are you ready to calibrate this? We've already calibrated. Perfect. So for calibration purposes you calibrate your chicken foot. The other thing that I use is the cannulated drill and you calibrate that, this is already done. And at this point we need two, three-quarter sheets, please. Then we're going to proceed with the O-arm spin. So you're going to get this on the side, we're going to put it all the way there and you're going to keep the top part to cover and then drop the lower part. And you want to cover this table too. So go over the table. And just secure them here. Okay. You want to move the lights from the field. Okay. Okay, you're all the way down and okay, let's take an X-ray again and then let's do north a little bit. And then can you come south. So you can put this line over the iliac crest. A little bit more down. That's perfect. Then let's check the lateral. The should be good. That's okay. Perfect. That looks good. You can just scroll down. You can take it out. I just wanna scroll, like... So, Adam, you're welcome to open right now. You wanna see on the axial? Yeah, that's good. Perfect. We're good.

CHAPTER 4

At this point we're going to identify the starting point for the inferior balloon. So it looks on this that we are aiming too posterior, so - in too little, we want actually to be more medial. So we are still too inferior, so we're going to come up more superior. That looks like a better view. A little lateral and superior lateral. I'm going to start a little bit more inferior. Okay, do you have a marking pen, please? So this is where it's going to be. So we're going to make our incision here. Do you have the 10 blade, please. Buzz here, Bovie. Then you want to make hold your dissection down to bone. You can feel the bone there. Then you're going to take your 3-2 drill bit. I use it in a wire driver and I know like by choking it in this junction overlapping it with the navigation guide, it's going to give me nine centimeters of exposed drill bit. I shorten it to identify the starting point. I'm down to bone. I want to go a little lateral and I want to come a little superior. We may have to start a little bit more inferior just because his head has migrated proximally too much. But this trajectory will let me go to the anterior part of the acetabulum. So I'm going just to come a little bit more superior. Going to aim a little bit more lateral to make more room. And that's going just to the anterior inferior iliac spine. Yeah, can you save that one, please? So his bone is very sclerotic. Have the marking pen too, please. Can I have the 10-blade again. So this is just to save some time. We're opening the portal for the retrograde posterior column balloon. The sciatic nerve is going to be localized more lateral. Do you have a Schnidt, please? And then can you go and drape the C-arm? So usually this trajectory goes more down and lateral, but because he has had his femoral head migrating superiorly, technically his supra-acetabular area has migrated superiorly. So that's why the pin doesn't have this inclination has this, if you have a normal acetabulum, what you can use like with fluoroscopies to feel the greater tuberosity and the greater tuberosity is going to give you the angle for that sciatic corridor. So you see the, the drill bit is exactly in the supra-acetabular area. Can you see back 45 degrees away from you? Somewhere in there. Right there? Yep. Can you see over a little more towards me? Yeah. That's good. And then can you tilt back this way a little bit? Yeah. Okay. X-ray there. So that's going your obturator, oblique view and you see we are spot on in what will be a sciatic corridor. Now can you go back to neutral? Yeah. And then see 45 degrees over me. And I think you have to push in with your machine a little more to see his hip. Very good there but push in more. Okay, let's try that. Can you come a little south, please? So we know that we are there above the sciatic notch and we can advance this more. Do you have the driver, please? X-ray. X-ray. X-ray. X-ray. Do we have the awl, please? Straight awl. So once there, can you come back to neutral and tilt all the way down to get an inlet view. So the projections are the opposite of the usual supine position of the patient as the patient is prone. So tilt all the way down to the feet. So you can see there how the trajectory of the drill bit is in the wide. Can you go a little bit distal? Okay. And you can see how it is in between the inner and outer table of the iliac bone. So now we're going to get our hole. So this basically goes around the drill bit and there's going to be a tool to exchange the drill bit, do you have the wire driver? For the 2.0 ball-tip. Guidewire. X-ray there. Can you go back to the AP. X-ray there? So this is again the iliac oblique view. Can you go a little north, please? Which is the workhorse for this trajectory. X-ray again. Or can you split the difference? Go distal a little bit. X-ray again, you see how the guidewire is in the supra-acetabular area. X-ray there. X-ray there. Okay, do you have the reamer? The 6.0 first. So let's start with the coating one. X-ray there. X-ray. Good. X-ray there. X-ray. Because his bone is sclerotic, this is going to take more time to do the reaming. You do a sequential reaming from size six to size 8.0 millimeters. X-ray there. Do you have the Sima reamers? What do you wanna start with? Can I get the 8.0 straight? So an alternative, you can use a different set of reamers that is less flexible for cases of sclerotic bone. These are the cannulated reamers from Sima. X-ray there. X-ray. X-ray. Do you have fine needle driver, please. X-ray there. X-ray again. X-ray. X-ray. X-ray there. X-ray. X-ray. X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray. X-ray. X-ray. Do you have the lollipop, please? X-ray there. Do you have the 6? Yeah, the luminous. See if it goes a little better. X-ray. X-ray. Do we have a needle driver, please? Nevermind. X-ray. Good. X-ray. X-ray. X-ray. X-ray there. X-ray. Do you have the 6.5? X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray there. Do you have the size 8. Straight. X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray. I will give you that guy back. X-ray there. Do you have another ball-tip? This one is all crooked. Just give you that one. X-ray there. X-ray. X-ray there. Okay. Do you have another wire to measure? And do you have a paper ruler, please? It's going to be 22 by 140. Oh! You have 140? Yeah. So now we're going to use the first one you have there. Okay, so going to start a little bit more dorsal and more lateral. Do you have coronal view and can you zoom out? Yes. So it looks like I'm starting too lateral. So that's more medial. Looks good there. I have to... Yes. Can you raise the... And, we still have to come more... So what I'm trying to get is the anterior column. Okay, can you shoot an X-ray there? Yep. Can you come more distal, please? Right about there? Yep. X-ray there. Can you actually drop down the machine so we see more of the... Can you come to an AP first? Then pull back towards you a little bit. Pull back a little bit more. Try that. X-ray. Can you go north, please? And can you drop even the machine more? Sorry, raise? Sorry, we're about to hit the frame. Oh, you still have space? You can come a little bit more down. That's good. Going to start more here. X-ray there. Okay, can you see 45 degrees over. Like it there. If anything, I'm starting too dorsal, so - X-ray there. X-ray. X-ray. X-ray there. X-ray. X-ray. X-ray there. X-ray. X-ray there. X-ray. X-ray. Good. X-ray. X-ray. Can you go more north, please? X-ray. Okay, do you have the awl, please? Then can I take a ball tip. X-ray there. Can you come south a little bit? Yep. X-ray there. X-ray. Good. X-ray there. Can you go a little north, please? X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray. Good. X-ray. X-ray there. X-ray. X-ray there. X-ray. X-ray. Can you come a little distal, please? X-ray there. The wire is totally bending. X-ray there. X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray. Can you go north, please? X-ray. X-ray. That's it. X-ray. X-ray. Can you come to an AP, please? So I was going too close to the joint so I used the wire and I drilled behind the wire to come more dorsal. So now I'm outside what is going to be the socket. X-ray there. And that looks good on the AP. Can you take an X-ray there again? Okay. Can you see 45 degrees? X-ray there. Do you have another ball tip? Yep. X-ray there. X-ray. X-ray. X-ray. Good. X-ray. X-ray. X-ray. X-ray there. X-ray. X-ray. X-ray. X-ray there. You have another wire to measure. X-ray there. I can use this one, just for a ballpark. Can you come more distal, please? X-ray there. Can I have the ruler. So it is 22 by 120. X-ray there. X-ray. Can you go more proximal, please? X-ray. X-ray. X-ray. Do you have the holder for the reamer? Yep, it's gonna be in this tray. Scissor-looking handle closest to you. That way. Yep. Thank you. X-ray. X-ray. Can you hold this guy, please? X-ray. X-ray. X-ray. Okay. You can let go with that one. Yep. Hold it. X-ray there. The same thing, put your guide there. Not pinching the skin and then go all the way in. X-ray. 6.5, 7. X-ray. Secure that. X-ray. X-ray. 7.5. X-ray there. X-ray. Last but not least, 8. Then slide in. X-ray. X-ray. Okay. X-ray there. Actually we're good in there. X-ray there. X-ray. X-ray. Okay you have them ready? Yep we're ready. Balloon time. Can we turn off the overhead light, please?

CHAPTER 5

X-ray. Pass you the trash too. X-ray there. X-ray. Yeah that's okay. Okay, inflating. X-ray. X-ray. X-ray. X-ray. X-ray. Okay can you come to an AP, please? X-ray. I like that. Can you see back towards you 45 degrees. There we go. Can you see back more, like to 45? Yep. Yep. X-ray there. And can you come to AP neutral but all the way down. X-ray there, push in more. X-ray. Can you go back to the neutral and 45 degrees over towards me? Actually come to an AP first. X-ray there. X-ray there. Come more distal, please. X-ray. Can you go more proximal and see over 45 degrees. X-ray there. Can you come lower with the machine or get closer so we can get both? X-ray there. Can you go a little north? X-ray there. X-ray. Perfect. And we can get the lights back on. So we basically confirm the position of the balloons in the iliac oblique view, in the inlet view and the obturator oblique view. You can see on the floor shot how the sciatic corridor even though it is superiorly migrated, has been reinforced by the photodynamic nail. And you see the posterior column also reinforced, in this iliac oblique view. You can see that they form a T, which is what is going to reinforce our total hip arthroplasty.

CHAPTER 6

So at this point the balloons were curing, the time is variable and depends on the size of the balloon and the amount of polymer that the balloon receives during injection. At this point we have one that is completely off and we still have the posterior column one lighting up. Once the curing process finishes, these wires will come out easily. That's an indicator that the balloon has cured. Do you have scissors, please? The heavy scissor is used to cut the deployment system and then this device is used to trim down the deployment system, basically put it over the tube that connects with the balloon and then eat the edges. Kind of like to loose up that piece that goes into the balloon. Then next we take this slap hammer that you connect into the remaining balloon, secure it and when you push down so the balloon doesn't back out, you hammer it and then you touch and then there is nothing that is prominent. At this point we're done with navigation too. You have the slap hammer for the navigation? You remove the tracker. And with the same mechanism the tracker is removed. Do you have some irrigation, please? Get the suction. Do you have the 0 PDS, please? We're going to take final shots just almost. So I will use a 3-0 Monocryl there. You want it inside stitched or just outside? You can do it one inside and then one out. And I'll take the 0. Do you have an Adson, please? Leave a little tail. Yep, that's good. Have a clean lap, please. Nope, we'll use the... Just the glue? The glue. Do you have the 2-0 next, why you don't come in close. So the same steps are done to remove the last deployment system. You can come on that on this side. Or you can close this one, and I can close that one. Do you have the slap hammer, please? Have more irrigation, please. And I will take a clean lap. Can you give me some counter traction with your hand? Can I have the 0 PDS, please. 0 PDS. Yep. May I have another pair of eights, please? Santi, you're all set now if we take away all the stuff? Yep, you can remove everything. Alright, perfect. Do you have the 2-0 PDS, please. Okay, let's come for the final X-rays. So if you could get first an AP. Lorraine do you mind to bring the table up, please? Perfect. That's good. Can you come a little distal, push in a little bit more. Okay, X-ray there. Push in more. And come south. That's pretty good. X-ray there. Can you trace the table a little bit more, please? X-ray there. Can you see 45 degrees over and then pull back towards you. Let's try that. X-ray. Can you pull back more? X-ray there? Good. Can you change the contrast on that one a little bit, then do 45 degrees the other way or 40. X-ray there. Push in a little more. You have to push in way more. So maybe take a little bit off the angle and then push in more. X-ray there. And can you go to that inlet? X-ray there. Go north. X-ray. You go a little bit more north. X-ray. We're good. Thank you. Can we get a wet and dry, please? And then we'll take the Dermabonds. Let's pull these guys. Take all the top. Can you take the drapes down, please, Lorraine?

CHAPTER 7

So look, 'cause I'm short, I go like this... and then you do a matador move. And then you put it all the way up there. Let me go that way. That goes to me. That goes to you. Contrary to last time you were doing it like this, you did like this. You can go and keep pulling and then all the way up here. Make sure that you are - going to run short 'cause I use all that. So it goes up, then you have to bring it diagonal. Okay, bring the leg down. Okay, do you have another one, please? And do you have that other piece of Ioban that you have? That's good. Okay. Have a marking pen, please. Going to put a massive augment there. So we'll go up. It is here.

CHAPTER 8

Okay. So same patient. We're doing the second stage. Now we're in the lateral position. Axillary roll, all bony prominences well padded. When he is due for antibiotics at four hours, if we could, please redose him. And I think that's pretty much it. Can I have the skin knife, please. So this is - the back, this is the top. Need to be a little bit posterior. Knife back. Have another lap, please. Doing a standard posterolateral approach to the hip. Do you have a Cobb, please? Do we have a cerebellar, please? Can we get a second one? Okay. Go back. Open our fascia - center there. Do we have a depth, please? Do we have the Charnley, please? It's not here yet. Oh it's not here. Okay that's fine. Your gluteus medius there. That's it. Let's put the Charnley. You have the medium size, please. I'm just going to take all the external rotators as a single unit. Okay, can you internally rotate the leg with the... Have a long tip, please. So that's piriformis. Trying to stay as close to the bone. Can I have number 551, please. Can I have one more. Can I give you this back. Have some irrigation, please. And I'll take the Jeffs again and take the number five back. Yeah, let's actually just put it for there. Because he had radiation, he's going to have all this stuff like really stuck to his bone. But it is, yeah so I take the external rotators and at the same time with the capsule because it's a much more robust... Have actually another number 551, please. Snap and scissors. So that's the labrum there. Do you have the Cobb, C-O-B-B, COBB. Have a cobra, please. Do you have another one, please? It's because he's heavy. So... No like the acetabulum is kind of like overhanging the head. Do you have a rongeur, please? This one's from the evaluation and get this guy first. So it's further. Have the saw, please. Have another of these, please. Okay, let's come up more with that. So now let's bring it in here. Lancer. Okay, do you have the femoral neck retractor, please? Do you have the coating guide for the neck, please? And I need you to come more like that. Then you have to come under, then you want to like 90 degrees. Have a marking pen, please. Okay, Do you have that... So finger right there. Saw again, please Have the osteotome. Can you get those guys. Do we have that saw again, please. Have the rongeur. Okay, have the femoral neck retractor, please. Have the trochanteric osteotome, please. Have the mallet too, please. You gotta do the femur first? Yes. He's just too tight. Have the canal finder, please. Okay, first approach. Next. Next. Next, four. Four. Have the mallet, please. Looks pretty good. Do we have the planer, please? Sorry about the change of plans. We have to push. So, hold on one second. Put that way and then internally rotate the leg. Let's come on with this. Let's come out with this. I will replace this suture later. Okay, so come down with this. Can we have the acetabular retractors, please. My number two first. Do you have a Jefferson, please? This is the labrum. Do you have a cerebellar, please? Do you have a bone hook? Can you pull that way? Do you have the cork screw, please? Do you have a Cobb, please? Have a curved Mayo, please. Do you have a 10-blade, please? Can I have a short tip, please? Do you have another number 551, please. And a Jeff. Do you have the Cobb? Just pull down with that one one second. Do you have the number seven retractor for the acetabulum, please? Looks like a fork like this. Like a... Oh, the left? Yeah. Do you have the Cobb? Do you have the curved Mayo, please? Have the curved Mayo again. Do you have the Bovie, please. Have the long tip. Do you have the Cobb? Have the curved Mayo again. Actually do you have a rongeur? Going to get a little bit of the acetabulum. Have the curved Mayo again. Just really don't want to break the column. Do you have an osteotome, please. Have a bigger rongeur. Just don't wanna leave it on the acetabulum. Ah! (exhales) Okay. Do you have the number two acetabulum retractor. Okay, now we really have to release all this tightness. So... Can you pull on this one? Do you have a Jeff, please? Do you have a cobra, please? Hold that one and pull on this one like this. Have a rongeur, please. So I'm taking all the ligament and all the smooth studies in the inferior part of the acetabulum because as he migrated superiorly that inferior port filled with a... Do you have a Cobb, please? Do you have the Jeffs again, please? So you can take the Cobb. Have a big curette, please. Can you clean up that tip, please? Have a rongeur, please. Okay, have some irrigation, please. Have another cobra, please. Okay, do you have that Jeff again, please. Do you have a lap, please? Okay, do you have the number seven again, please? You can tow like that. Have the cobra. Okay, that's inferior for... Take a little bit of minimus. Do you have the Cobb, please? Okay. Have the Jeff again, please. This is just anterior labrum. Have a dry lap, please. What reamer do you have there? Okay, just start with that. He looks, but it's impossible because we, so we are pretty medialized already so I don't think we can... Seeing it from here. Do you have the Cobb again, please? Do you have a pituitary by any chance? Do you have the Cobb, please? Do you have the pituitary again? Can I have the rongeur, please. Yeah, it's a pretty decent view of the acetabulum. Do you have cerebellar, please? Do you have the reamer again? Do you have the rongeur, please? He has overhanging walls.

CHAPTER 9

If anything I have to come more... Do you have something smaller than this? Like a 44, or...? Okay, now we're talking. Can have a 46. So now you can feel the floor. So feel this. See the port? Yeah. So what I have to bring is... Okay, do you have the 48? For the dual mobility is 52, for the cup. Have some irrigation, please. On this side. Yes, please. Can you check our suction? Can I have a bulb irrigation. It's a 52? Yeah. Okay. Do you have another cobra, please? Can I have the reamer, please. The balloon. Yeah, that's why we put it. The thing is that... Have irrigation, please. Can I see the 52 again? That's better. That's it. This was what? 52. Can I get a 54, please? Do you have the augments? The orange slice? Yeah, yeah, yeah. Can we get a pulse lavage, please? Let's find the nerve. Do you have a Schnidt, please?

CHAPTER 10

You have a DeBakey? Because they record surgeries. Oh come on. Can you pull on this one. Open with your Bovie. Do you have a right angle, please? And may I have a vessel loop, please? Gimme a little buzz there. Can I have a Jefferson? The vessel loop is coming. Do you have peanuts too, please? Can you open those? Yes please. Can you pull on those guys. Have a cerebellar, please? Do we have fish net again, please? And do you have a DeBakey? I'll take some Metz. Schmutz. Open that fat. Do you have...? Okay. Let's protect these guys here. Do you have a cobra please? Hold that one like that. Nerve is really deep. Have a rongeur, please. What size was the last reamer that I used? Fifty-four. Can I see that again, please? Femoral column? Yes. And I'm going to stay down. Okay, so do you have the 54 augments? Where is the thinnest one of those.

CHAPTER 11

So 54 diameter. See if I can use a 60... Did you have the trial for the 52? For the one that I had, 54? Like that. Do you have a Schnidt, please? Do you have a Kocher. I think he's going to impinge. So that's going down. Do we have the pin. This has to be more inferior. Do you have the 52 outer diameter. Can I see them? Okay. They go by fours. So... Okay, got it. 25. Oh you want the 20? No. Got a 54. 58. Looks like this has to go down. Do you have the Kocher, please? Do you have the pin, please? Yes. Have a Richardson, please. It's not actually sitting relaxed with this one. It's not sitting in bone. Have the 54 again. These wires down. Do you have the driver, please? Do you have the Cobb, please? Do you have a dry lap, please? Can we get a small clips, please? Do you have yellow, please? Or a blue? It's not the blue, it's just a branch. Do you have the pin, please? Have another one? Yes. Problem is he's... Still too high. Have the pin driver, please. Pin driver. So it's better to use it this way, I guess, that is really going to push it down. Just what we need. We really needed, not posterior but just straight superior. So over here. Something like that. The problem is goes anteriorly like that. That version looks pretty good. A little vertical but otherwise... No. If anything we're too flat. This will go like this. Like we were like maybe like there? Yeah. Like it better. We're just here with the posterior lip now. I guess we just... Okay, so can you open the... 15 by... 54? This is a 56. Oh it says, right here, 54-15. So can you open one of these, please? Let's get this guy here. Do you have the number two? Do you have the trial? Blood loss has been, are you on pressors or anything like that or? He's been bouncing around as far as the pressure. Okay. I'm just wondering if there's like 1.70... Oh no we have, this is all irrigation. We use probably we're like around 150 or like yeah. We round up on this service. We like to round up. Think we have to get it there like that. I think that's right. Yep. Augment's here. Can you hold that guy for me there? Do you have a bone tamp and an impactor, please? You wanna put the other retractors back in? We had relaxed the soft tissue. Still there. I think we're good. There is no... Okay. Do you have the K-wire, please? Watch out. Do you have a cerebellar, please? Okay, do you have the thing for the screw, the drill for the augment? This is the drill for the augment? It's the same one? I haven't done one of these in a while, Rich. Just want it going down. There it is, holding the balloon. That's good. That's why I put the balloon. Oh yeah, yeah, yeah. I'm a believer. Do you have a long drill for this? Depth gauge. Oh yes, that's a long one. Have a 40, please. I have lecture at five. Oh you should go to that. No, you should go to that. Oh, he's the professor. You don't want to disappoint him. He's the professor. Sorry. He will be in your interview. Alright, thank you. Thanks, Sam. Sam, just go home after. Okay? Are you sure? Yeah. The femur. Professor. Professor. Do you have a mallet? Have a great day. Thanks, Khofi, have a good one. Alright. Thank you. Wanna put it this way. Do you have the drill again, please? Depth gauge again. 50! So then can we get that, that bone graft that is corticocancellous. That is like... How much? Can we get like 30 ccs of that? Yeah, do you want the one that's completely crushed or that are more like cubes? The one that is all completely crushed and like looks like that. Like 30? Yeah. You want shredded? Shredded. Is this thing all the way down? Looks like it. I think so. Yeah, I'm down. This goes to the sciatic nerve. Do you have the non-articulating screwdriver, please? So you want the straight one? The straight one. You're perfectly co-axial. It's just so quirky. It's still compressing. Oh yeah, it's good. Okay. Do you have the driver, please? To pull the wire driver. And do you have the drill again? I'll take a Richardson. Okay, depth gauge. 50 again. Oh no. Or are we just fully in bone? Doesn't seem like you were just in bone that whole way. Okay. Have the depth gauge again. This screw, it looks like the screw is not going through the augment. Well actually it is going there, but... These are all the same diameter screws, right? Yep. This is user dependent problem. Yeah, can I see them? One second. See, they're small. Yeah, that's the one. Yeah. Can we open those, please? That one is not totally centered and it is stripped already. Have the screwdriver again, please. Have the mallet. No, it's just eccentric with the... Yeah. Eccentric with the TM. Don't feel anything in the notch which is good. Let's get our X-ray and see. Have the mallet, please. I have to secure it with the screws. You have that number two retractor again, please. Have the bone hook, please. We didn't open the cup or did we? I did, but... Yeah. Can I have the 26 trial? The 56 trial, please? That's better. No, that's actually pretty good. Do you have the adapter thing for this? So like this. Thank you. Yeah, thanks. Okay. Have the mallet, please. Can you come out with yours? Yep. Just hold it there. Have the mallet, please. No. Have to put the cup and secure it with the screws. Okay. And take a look and yeah, so we brought it down. If you see like with the augment, like it's all the way down to the bottom of the... I mean that cup looks good, right? What would you change about that? No, I think it's great. It looks good. I don't think we can use a bigger, 'cause he's getting kind of like thin on the side for the stem. Thin on the where? On the lateral, at the junction. Like there is room medially, but... That looks good. What size he's having? Six? I think it was a six. Six. Okay. Think we can fit a seven or no? You could. You could probably work it. It's gonna take some work. It looks really tight in there. But I think you know how to work that to it. A seven, it's a jump in the neck so I'm not sure where we're gonna be. Oh okay. Maybe we can try out the six and then... And then see how, how it looks. Okay, we're good. Thank you. Do you mind putting the X-ray up in the screen, please. Use it as the Yankauer. Do you have the bone graft, please? Do you want me to give you a reverse reamer? Yeah, we'll use that. You want reverse reamer? Well actually I can just... Give it the old smush. Just packing it on the top. Truly we're good. Okay. Sure. Do you have that cup, please? I have a 54. So we use... One 56. The last size is 56. This is the one that we did with the X-ray? No. Okay. Okay. Give me a 56, please. This one. There is all these soft tissue stuff that... Okay, that's good. The Charnley back in. I feel like we... Charnley? Yeah sure. Can I have the bone hook? Have the mallet, please. Can you hold it there, go on. Hold it, so just... Do you have the drill, please? And universal screwdriver or...? The universal. Wait just one second. This is tensioning the sciatic. There you go. Have the depth gauge. Have 35. So the one that I drilled was that one. I have to hold it really tight because I'm screwing and it's moving. Do you have the straight one? I'm going to fix it first anteriorly. Can you save that screw, please? Like this? So that's vertical. I mean literally, it's actually rotated. I had more of a lip here or version. Do you have the drill again, please? Can I have the depth guage, please? He needs about 1500. Okay. Is he doing okay or...? Yeah, just trying to get a sense of, you know, he's a little tachycardic. It looks like you've got 1950 in the canister. If we wanna take 1600 of the irrigation, that'd be about 350 BDL. Does that make sense? Sure. Seems to be less, but that's fine. Like I prefer that he gets the fluid. Okay. Have a 25, please? You got the bone hook, please? Have the drill again, please. Depth gauge? Have a 30, please. Oh. Have the gauge, please. Suction. Can I have a Schnidt? Have a 45? It's pretty straight. Just go on that side. Put that one. Have another 40, please. Do you have the articulating one for this? Can I have the depth gauge? A 50. Can you give me the 35 that I had? Can you hold the thing, then get inside? No. Have the drill again, please. Do you have the shortie of the drills, please? Depth gauge. What is the shortest Rich? 15. 15. May I have a 15? Okay. That's some. Have the drill again, please. Have depth gauge, please. Have another 15? This is sclerotic bone, so it's going to have an amazing bite. I'm going to strip it. Can we call for an X-ray, please? And last but not least. Can you hold the... Oh it's fine. I will get it. Oh. Okay. Do you have the thing to trial? You want a trial? Yeah, like the head and stuff. Do you have the bone hook again for me? For him. Bone hook. Got it. Do you have - nevermind. Do you have a Schnidt, please? You have a Kocher? This always... Have the impactor. Do you have the neck? The neck. I think we'll need the - so we need the high offset. You got it? Okay. You put it. There's the soft tissues. Then you need to get the, how about that? Better. It's getting into a... Oh it's not that. Let's get rid of this guy. Okay. There you go. Put the ball. Okay, you have the head pusher? Hold on, soft tissue. Hold on. Okay, can you back out that? Cable? Okay, feels tight, which is expected. Sciatic nerve feels pretty loose. Length is money. Knee cap here. You're touching something else. Oh yeah. Yeah. Saying, since you're a spine surgeon. So he's going to to be tight in flexion. Stable on the table there though. And then it has the anterior flexion contracture. We'll release it. Okay. I like it. He couldn't extend before. I think we can try to release. You have a Richardson, please? Let me just make like a transverse incision to like relax his anterior capsule. So get that. Take this guy. Can you get anterior in this part. Feel with your finger? That hard thing. Yeah, you can feel it there, it's hard. Let's get the X-ray first. Look at those screws in the pubic bone. Iliac bone. That's pretty good. Okay, perfect. So you're happy with that? Yeah, we're just going to put a bigger stem on the... Do you have a femoral neck retractor, please? The other one. Do you want try to go up to a seven? Do you have the Brower-Rich holder and the mallet, please? Will it go higher? Yeah. So we'll have to use - you know what? You know what? Let me just - give me the six stem. Yep. The six, yeah. And I don't want to start mucking around with that. So can you come a little bit, actually a little bit that way? Like that. Do we have the trial again? Okay, so now you're going to bring the leg in a little bit and then internally rotate more. Belly booster. One second. Okay. There's your reduction maneuver. Joint sky. There we go. Tranquila! You're good. It's in. That's funny. Tranquila. Sternotomy, pelvectomy by hand. Okay. Femur. It feels good. Not that bad. Feels good. Can we use minus five head instead of the zero? Just to shorten him a little bit. Oh, what's that? Minus four. Minus four. Okay, okay. Minus four. So internal rotation in flexion. Yeah. Okay. Tranquila! Oh, relax. Relax, relax, relax. Just have to keep it like that and bring it down this way. Put your left hand on the knee. Increase your internal rotation a little. We actually should unitize them, the cup and the augment and the cup. In the outside, I guess. No, it's fine. Do you have dry lap, please? Internally rotate more. Nope. No drains. Okay. Reduce. Yep, that's it. Tranquila. There we go. You're good. Do you have scissors, please? Vessel loop back. Put on the same spot, just a little bit more. So let's get the bomb business. Do you have the drill please for the...

CHAPTER 12

So, more superior spot. You got it. Think we got a stray. Open up. Close. Pull. Okay, drill again, please. You wanna do it? Just leave it closed while you push. I get it. Made a big hole so you can see it, needs a spine surgeon, gets to see little holes. Pull back, pull back, push in a little bit. Split the difference. Open up. Can you rotate 90 degrees with the thing in? There we go. Have a DeBakey, please. Okay, close it. Pull. Push it again. Like close it and put it in the same hole. Yeah. Good, okay. Pull back. There you go. Open it. You turn 90 degrees. Open up and pull back towards you. That's good. There you go. That's good. That's gonna work. Okay, close. Do you have a Schnidt, please? Have the scissors, please. Have the drill again, please. Schnidt, pull back towards you. Schnidt. Pull back towards you. Salvator, push in, pull back to where you were. Push the bottom. Oh, okay. Pull back towards you a little bit. That's it. Have a DeBakey, please. Okay, pull back. Okay, so we get that and I'll get this. Yeah, so we'll do one this. Do those two. Have the Schnidt to put in there. And do you just like two to one? Is that good? Yep. And then we will... Not cut them yet. Not cut them yet. Make it flat. So you want to go... Okay. Lock it there. Come out. You can tie those two. Tie those two and then cut these ones. Good. You can cut those. Have a lap, please. Can we get number 1 PDS, please? Excellent. Thank you. You're gonna need a bunch of those, Santi? Oh, just two. Still have some of the gluteal sling. I didn't take the whole thing. Yeah, with impunity. Impunity, yeah. I think it affects a little bit there. You do, but not... No. It's a philosophical thing. Yeah, yeah. Okay. Get another one in. Yeah. The flush. This here? You want to grab the on the port. So for more scar tissue, just get the superficial. Posterior hip propulsion. We'll get an X-ray and a CT tonight. Mhm mm. Ancef. What do you wanna do? Aspirin? Is he on blood thinners? He has a history of DVT, doesn't he? He was not on blood thinners. I think that was long ago that he had the... Are you okay with just treating him, like maybe just asprin and... Are we just doing regular dressing, just...? Yeah, I think so. Kind of like that. His radiation, it was so long ago. What do you have for? Oh but we have the Dermabond and 3-0 Monocryl, so... Do you have a 0, please? We have the Monocryl and the Dermabond. If you space it out just right, you can probably just put one figure-of-eight stitch right there. We're closing. Do you have a - dressing and that's it. Do we have 2-0? And Adsons, please. You can do it as a figure of eight, like grab another... Done, like the double layer. Yeah, yeah. Pass it over. In either direction, whatever. Do you have the zero, please? We were doing so... Yeah. Hold on. Have the 2-0 again, please. We'll take two 2-0s. We're good? Count is good? Thank you. That one specimen? Yeah. Can I have a dry lap, please. You can do a Monocryl. Can I pass you that? Do you have a Monocryl?

CHAPTER 13

As you saw in the surgery, the patient was positioned initially in the prone decubitus with the assistance of chest rolls. This is important to maintain flexion of the hips which facilitate the insertion of the balloon in the posterior column in the retrograde fashion through the ischial tuberosity. As you could see, the incisions were small and the insertion of the balloons was very simple, after advancing the drill bit under navigation and fluoroscopy. As you could see during the surgery, the working horse projection under fluoroscopy are the iliac oblique view, the inlet view, and the obturator outlet view to identify the sciatic corridor. As you saw, the reaming was uneventful, but at some point we needed to use reamers of less flexible characteristics to some areas of sclerosis. We were able to deploy the balloons with excellent length in filling areas of defect, reinforcing the entirety of the posterior column and the entirety of the sciatic buttress. As you notice, absorbable sutures were used for closing, including PDS zero and PDS 2-0. The skin was closed with 3-0 Monocryl continuous suture and a sterile dressing with Telfa gauze and Tegaderms as well as acrylic for the skin was provided to the patient. You saw how we changed the position of the patient into the lateral decubitus and how we used the hip grip. You observed the traditional posteriolateral approach to the left hip. You saw the use of the retractors in order to expose the entirety of the acetabulum. As you noticed, we trialed the orange slice augment in combination with the trial for the multihole cup. The maximum size possible was obtained and intraoperative X-rays were also taken to confirm that the central rotation has been brought down in a satisfactory manner. Ultimately, a 56 multihole cup was used in combination with the corresponding augment of a thickness of 20 millimeters. This brought down the center of rotation, the 20 millimeters that we have planned preoperatively. As mentioned, the augment was fixed with three different screws, 6.5 millimeters in diameter that were as long as possible and located in the sciatic buttress area. These screws had also purchase in the photodynamic nail that was used. A series of different screws were inserted to form a rainbow construct securing the multihole revision cup. We obtained fixation in the pubis, the iliac bone, and the posterior column. As you notice, the length of the screws was substantial, going up even to 50 millimeters in length. During the reaming, we identified bleeding bone in the remaining lower acetabulum, and for this reason, we proceeded to bone graft the entirety of the back of the cup as well as the medial portion. Excellent medialization of the cup was obtained. The femur was inserted in the standard fashion maintaining the patient's anatomic version as a dual mobility construct was being used. We confirmed the lack of impingement in the anterior structures and performed an anterior capsular release in order to increase the extension of the hip. As you noticed, we did a very aggressive neurolysis of the sciatic nerve, being sure that the nerve was free and without any tension, after the center of rotation was brought down to its anatomic position. A standard closure with bone tunnels was performed. As you saw, my preference is to remove the external rotators in the capsule as a single layer, intact with number 551 stitches. Bone tunnels were used for reconstruction of the soft tissues. The standard closure of monofilaments was performed in the way that I use to all my surgeries with zero PDS and 2-0 PDS for the superficial layers. And number one PDS for the fascia layers. I closed the interval between the gluteus minimus and the external rotators, and I closed the skin again with Monocryl and an incisional vac. The patient, as you saw, emerged from anesthesia without any complication. He was started with an immediate weight-bearing status with the assistance of a walker as part of postoperative day one physical therapy. He received preoperative antibiotics for 24 hours and received DVT prophylaxis with aspirin. The patient was discharged on postoperative day number two. Given his comorbidities and the extent of surgery, this was a lot more than a primary total hip arthroplasty. The patient is currently recovering in rehabilitation.

CHAPTER 14

[No Dialogue.]