Left Hip Hemiarthroplasty for Femoral Neck Fracture

CHAPTER 1

My name's Kiran Agarwal-Harding. I'm an orthopaedic trauma surgeon here at Beth Israel Deaconess Medical Center. So the case that we did is a gentleman in his late '70s who has ALL. He received a bone marrow transplant. And unfortunately, was suffering graft versus host disease. Multiple medical comorbidities as a result of his cancer. And unfortunately, is still dealing with a bout of graft versus host disease. In that setting, he unfortunately had a fall directly onto his left hip and sustained a femoral neck fracture. So we discussed this with him and for palliation, and also to allow him to walk and function the most. The best course of treatment was a hip hemiarthroplasty. So that's what we recommended and that's what he consented to do. So the procedure is we will position the patient in the lateral position in a beanbag, pad all their bony prominences. And then do a lateral approach to the hip where we will make a slightly curvilinear incision centered over the greater trochanter. We'll go through the soft tissues and identify the iliotibial band. Iliotibial band will be incised longitudinally and retracted to expose the greater trochanter. Then I like to take an anterolateral approach to the hip, which involves peeling off a sort of confluent layer of the abductors and vastus lateralis as it inserts onto the greater trochanter. So I usually take the anterior one-third and that's peeled off of the greater trochanter as a single sleeve. That's peeled anteriorly until we can identify the hip capsule. That is then incised in a T-shaped fashion with a long limb at the base, and then the longitudinal limb down the length of the femoral neck. We will tag those with number 1 Vicryl sutures in order to allow some retraction. The femoral neck fracture should be immediately visible then. Depending on how long the femoral neck there is remaining for the bone, we'll make a femoral neck cut, and then we'll remove the femoral head. Once that's done, we'll wash away all the bone fragments that are there from the fracture itself. First, we will measure the femoral head on the back table, and then trial a femoral head to make sure that we have the appropriate size for our hemiarthroplasty. Then we'll turn our attention to the femoral canal. We'll use a box cutter to get ourselves lateral on the canal, making sure to protect the insertion of the abductors. We'll pass the reamers, the canal finders, in order to ream the canal to the appropriate size, and we'll feel that chatter and canal fit. And then we'll broach the appropriate size until we have a good nice press fit. Of course, we'll be doing a cemented stem in this case, but this is just in order to get the appropriate size. With the broaches in there, we'll use that as a trial, remove the broach handle, and then put the neck and a trial head with the appropriate neck length. And we may adjust that neck length in order to get the perfect fit. Then we will reduce the trial components and see how that feels. We'll take the patient to a range of motion. We will check the leg lengths with the contralateral limb that will be underneath the sterile drapes. And we may even get a flat plate X-ray to confirm that everything looks perfect. If it looks perfect, we'll take out the femoral component, and then we will wash the inside of the femoral canal. And then pack it in order to stop any bleeding. Then we'll mix the cement, we'll place the cement after we place the cement restrictor at the bottom, we'll fill the femoral canal proximally with that cement, pressurize it so it sort of intercalates with the medullary bone around the edges of the femoral canal. And then we'll insert the femoral stem of the appropriate size and making sure that it doesn't fall into varus. that it's in the appropriate valgus position and at the appropriate version. And I tend to match the patient's version. If anything, go neutral version with the leg straight up and down. Once the cement is hard, we'll then clean off the stem neck, and we will attach the head of the appropriate size that we confirmed with the trial components, removing all the sponges from the acetabulum and cleaning everything. We'll then reduce the hip into position and then take it through range of motion. And probably get another flat plate then to confirm that everything looks perfect. And if it does, then we'll move on to our closure. I typically will tie the two tagging sutures for the two leaflets of the T-shaped capsulotomy together to close the capsular layer anteriorly. And then we take that confluence stem of the abductors and the vastus lateralis, and we put that back onto the greater trochanter. And we usually use horizontal mattress sutures with a number 5 Ethibond, sometimes with bone tunnels through the greater trochanter to really get it to seat down. Then we'll close the iliotibial band and the skin. And that's the hemiarthroplasty. We'll get a flat plate X-ray in the PACU afterwards to confirm everything looks perfect.

CHAPTER 2

All right, 10 blade to my partner. And I will take a Schnidt, please. Thank you. You wanna hang on to that? That's good. Let's get our little bleeders.

CHAPTER 3

Knife back. I'll have a lap as well. I'm gonna grab Adson just for this layer. Got a few little guys here. Thank you. Good. All right, let's keep going. We're gonna use the Norfolk next, the retractors. Seemed like there was some fluid there, huh? Cob please, let's finish this. Nice. Cob it to me, please. I'm gonna need more distal. I think so. Can I have the skin knife, please? Yeah, I think you're gonna need that whole incision that you marked out previously.

CHAPTER 4

All right, now, we'll divide the IT band longitudinally. You wanna do scissors? Yeah, make a nick. And then we can... Yep. Don't go too deep. Good. That's a layer there, I think. You wanna go this way? Super intense. Yeah, he's a - scarred in down there. Yeah, he is. Let me get under there for you. You got it? Yeah. Nice. All right, there we go. May we have the Charnley? Let's not use the Charnley. No? We can just use these guys. Yeah, I like to just use these. Okay. Yeah, these should be enough. One more, please. Thank you. Yeah, just to get all that stuff off of the troch without going too deep. Good. Yeah, let's get all that bursal tissue off. Over that. You can excise all this, just amputate that off. All this. Yep. Yeah, just get that outta there. Hold it up. Good. All right, let's see. We gotta split this up a little bit higher. Okay. I think that'll do. You wanna stick that in there? Use your right hand. Try to get the corner in there so that we can see that front edge. We're gonna do an anterolateral approach, of course. You all right? Yeah, just there we go. Okay.

CHAPTER 5

So, this is where the variation come in - single cuff, double cuff. Let's get some of this stuff off of here still, just so you can see. Yep. Okay. So to me, it looks like you probably wanna take it at that level, yeah? Yeah. So you - that's what I was wondering. So do you do the...? Anterior one-third. But take the... Are you going straight? Are you going through your abductor and capsule? Same layer. Or you like take 'em two? I think here it doesn't matter. It's as you go deeper than you'll find the capsule as a separate layer. I like to take it as a separate layer if you can. Separate layer. Yeah, if you can. If it's all scarred in, which it may be in this guy, you know? From here, we'll go up. This will be our corner. Yeah, Army-Navy. Is that the? Oops, sorry. Is that the right angle? I think it's going off this direction. Army-Navy. Let me show you. You see the fibers, yeah. Yeah. So like take... These ones are going that way. These ones are going like this. Take it this way. Good. Yeah, good. You got that little bleeder. You got a little bleeder there. Good. Try to suction the smoke if you can. Right off the bone all the way down. Take that down. You're gonna need this big sleeve. Come down this way. Just divide the vastus. Longitudinally in line with the fibers. Good. Can I give that back to you? Yep. Keep going. And remember to come up top here. So this is me is where I'm starting to get capsule there, okay. Feel the capsule? Yeah. Good. So one thing you can do to help him is you can externally rotate a little bit. Straighten out the leg, kind of walk that knee kind like you were doing. There it is. That's it, yeah. Take all this off. All this off the bone. This is... Right here I'm talking about, yeah. Because this is what I was talking about where I think... That's starting a capsule, yeah. Yeah, this is capsule there. Good. Trying to release this off the capsule. So we can kind of do a separate capsulotomy. And then back here straightens off. Get the lights up a little bit better. Hold that for me. Yeah, get that little bleeder there. Good. And divide that down here. Hibbs retractor. Thank you. Is that helpful? Yeah. So you just peel this whole layer off. T§his is one nice thick sleeve, Elyse. That's probably capsule. Yeah, that's fine. That's why we need to release it anyway. Just remember to keep releasing all this stuff down. Otherwise, we won't be able to get the hip out. Keep externally rotating the hip. Nice. Good. You wanna just split this stuff here? Yeah, okay. That may be minimus coming in. Yeah. It's kind of nice to see these different layers. Yeah, you're doing a nice job. So yeah, we went through medias. And then you could fill the separate layers of minimus because then you can peel off minimus. That's capsule. And we're at capsule.

CHAPTER 6

All right, I think we're ready for a capsulotomy? Go ahead. Just get the angle right? Yep, just make sure we're centered more or less. Okay, so I think I'm gonna go straight just through my, hang on, I'm gonna aim for 'em. Yeah. Do we have number 5 Ethibonds? We'll just use number 1 Vicryl, I think, for this layer. Just for a tag. The capsular tag. Yeah, a capsular tag, yeah. Yep. Yeah, this is all we got. Mm, okay. You gotta peel all this stuff off here. You got all this stuff to peel off here. Yeah, so you gotta dissect all this stuff off too. Yeah. All right, you gotta divide the capsule way higher than that. You got all the capsule still there. You just go right onto the, yeah, onto the... That all needs to be peeled off here. Snap and a cut, please.

Sorry, I keep hitting you in the head. Let's see. Just right there cut it. Cut it. Cut it. I think you still got a ways to go before you hit the labrum. No, you think you're close? I think tab's all the way here. All the way there. I think you've still got another half a centimeter or so. Is that gonna be a big enough light? Yeah, that seems good. Yeah, you gotta peel off that capsule from the top. Careful of the Bovie. Pull it right there. You can hold that because that will help him. I think you gotta peel this off the top too. I think you're gonna have to, I don't know how else to get in there unless you cut that. I mean, I think we're at a point where... Yeah, you wanna try? Should be able to get it out. Stretch. All right. Shall we see? Yeah. You can come outta there. Right there. Right here. Keep going. Right here. Here, I got the angle. Do you mind if I? You got it? Yeah, I just wanted to follow the superior neck all the way down and release it along the back 'cause I feel like all... I think you got capsule here that needs cutting. Yeah. Yes, that's it. You see this little band here of capsule, right? Yeah, that needs to be divided or peeled. I think that should be it. We can get the head. Do we need to revise our neck cut at all? Yeah, I think so. And that's all the way down here. Pickups, please. I think we need to come through this stuff here just to get a little bit better exposure of the inferior aspect of the neck. No, I'm just trying to get the capsule off the inferior aspect of the neck there. So it's a bit of a funny neck. It is super... A rongeur, please. And we gotta take this stuff off here, huh? Yeah, make sure we just, we can just rongeur this. No, you're right. All right, should we just try and get this out... Yeah. We want…

CHAPTER 7

Here, watch out for this thing. Lift up the leg for me. Just a hair. There we go. Let's get that outta there. Great. Yeah, you don't wanna try to get out like this. It's better to get it out this way. Rotating. Externally rotate, okay. Could I also have Hohmann. Do you have the Schanz pin on a driver the way the jack likes to do it? What you're trying to do here? You can get off the posterior wall sometimes. Take a Hibbs and just retract that posteriorly. Yep, so that's it right there. So we can be able to get it. So what are we taking - we're taking Schanz pin? Or do we have the corkscrew? Or what do we have? Just trying to spin it so we can see the head. There we go. I think you can get it. Gosh, it really cracked distal, huh? Yeah, it is a... All right, we got that cork screw? Coming. They're still looking. Schanz Pin. Create it like a little joystick. And then you can get the head out. I learned from Jack and he always uses it this way. Trying to fish it out with that? Yeah. All right, thank you. So then you go on the cortical neck. Yeah, I think that's easier. Okay, right there. Should be exposed. Ooh, one more time. Driver. Thank you. Wanna show me that cortical bit again? I got it. I got it. Just hope that's in there better. Yeah, so then you use this guy, sort of lever it from the back. Get a better grip on this. Thanks. What's holding us up here? More of the capsule here, I think. Almost. Almost. Yeah, go ahead. Geez. Again, another one, please. You got the rongeur again? Let's just get this stuff outta there. Hang on, don't lose that piece of bone. I don't think you're getting a good grip in there. Head's spinning there. Yeah? Oh, good. Cobb. Head is spinning. Not that much, yeah. Okay. Got it. It's moving, spinning. You want me to try to retract the femur out the way? Yeah. Let me just feel what's holding us up. I think it's just the capsule here. Yeah, like all this capsule that I'm on here. Just feel it with your finger. Feel what I'm talking about. Any better? Cobb, please. Angling back this way with the head towards the front? Yeah, one sec. Oh. What about taking it, trying to exit it right there? Like from... Yeah, we're just caught up on the femur there. Yeah, what about if we angle it back this way? Just the opposite. Like right this? Yep. Can I take a feel? Yeah, sure. Oh, tragic. Too strong. The what? Charnley. Oh, you want the Charnley? I think we're still getting caught up on capsule here as well. On the superior aspect. Okay. It's basically down to labrum there. Yeah, I mean, I thought I felt the rim Is Paul next door? Don't go into the tab. There's still no room. One more Hibbs retractor to me, please. Oh, you got it now I think. Yeah, put one more Hibbs here. Yep. Is it just getting caught on the neck? Can you actually rotate a little bit like that? Yep, there it is. Almost. Big head. I got that. Yeah, yeah. Nice. There you go. There we go. Big head. That's a big head, yeah. Nice job. Okay, can I have a squirt of irrigation. Didn't get the capsule enough. Yeah, I thought so. I thought that's what it was. Don't divide the abductor layer. All right, there we go. So what Jack sometimes does is just excised this whole anterior capsule right here. Okay. Like all this stuff here. All right. I don't think that does much, you know? Just as long as the abductor layer is okay. Yeah. All right, there we go. Okay. All right, rongeur, please. Rongeur. Really lost our calcar, huh? Yeah, I mean, it's still actually, even though it looks funny, it's like, I'd like a fingerbreadth above the lesser, you know? I feel like it's actually a decent height right there. Decent height. Okay. I don't know if we need to, I mean, but that's... I think we should probably... Clean that up. I can take a Bovie to all this and clear that. Yeah, you'll have to. Probably wanna just go ahead and... Yeah, it's a very low neck break. Yeah. So... Irrigation. Yeah, that's a good height for the neck cut. Yeah, I think you'll need to take a little bit more of this off though. Suction might be clogged. What are 33 cents? New tip. New suction. All right. Good.

CHAPTER 8

So what size was our head? So, for me, it's like 54-55. But this 55 is too big. You might want to just trial a 54 and see what you think. Sounds good to me. Okay. Do you want stick a... Do we wanna get it in there and shuck it or? Yeah, do you want to take out all this capsule? You wanna just take it out? I think so. Okay. We were struggling so much. Where's our abductor layer? Well, I think we'll be okay now. You think so? Yeah, I mean, you can actually see it. Here, Lemme borrow that. It's right, I mean, that's labrum right there, we're on the rim. I see it. Yeah. This is out the way. I think we'll be okay. It's, it's gonna be open. I don't think it's blocking us at all. Move your hand. That's labrum there. Squirt of irrigation again. I can actually see the tab. Okay should we squirt and size that? Yeah, we can. Do you have enough space? To get it in there? All right, did you say we're between 53/54? Yeah. Hang on. That's a little too much. There we go, that's it, yeah. It's caught. I got you here. There. All right. How's that feel? That sounds good. That feels pretty good. I'm not feeling much play there. That says a... You wanna try a 56? Oh, okay. Kocher, please. Yeah, I do think that six would be too big based on how that felt, so... You get that guy outta there. Had a good enough suction that it popped this right off. Is there a? Is there anything? No. Think we're good with that? Yeah, I think so. 54. Yeah, that's good. All right, let's get this guy back. Back in the bag. Elevator? Yes, here you go.

CHAPTER 9

And then we'll go with box cutter, canal finder, reamers. First, I'm gonna clear off the corner. Take my pickups. So you're gonna do hip preservation stuff in your grownup career, huh? In my grownup career, yeah. Nice. Sound like what? Sounds like Dr. McCain. Yeah. The same voice. Yeah, almost. You're right. Right. Yeah. I think that's good. Don't go too crazy there. I like to keep the abductors. Yeah. All right, so who's holding the leg? I got the leg. Okay, so leg straight up and down. I got the leg straight up and down. You can just match version. Yes. I'll take the box cutter. Yes, sorry. Yep, I'll take that. Can we go down with the bed of bit? Is that what we got? Okay. Now don't break off, okay? And then is that drop? Does it drop anymore? We good there? How's that? That's good. You want me to hold that? Yeah, if you could. You got the version? I'm gonna go right about there. Yeah, that looks good. That seems a little anteverted to me. That's better. Good. Nice, good job. Okay.

CHAPTER 10

Canal finder. It's got very soft bone, remember? What are you doing to me? Next time, no, just, just use synthes, you know? Just works better. Oh, you want sit right there? Two, three. Remember, we're cementing. I mean, I think we got. Huh? Fall after. What is? The fact that it's handed in so much? This is what? 45. 45. That was 45. Can you hold that for me, Liz? Do you mind? Can you reach it? Yep. Lovely. 7. Thank you. I don't know if we're gonna get through the... I think that's plenty. Yeah, I don't think we're getting to the six. Yeah, yeah. So we went to five, right? Yep. Okay. Went to five.

CHAPTER 11

So then we'll start with our broaches. I think we may need to revise back there a little bit. Good. Or is it okay? Also is it a calcar planer, right? We have a calcar planer, yeah. Cool. I mean, why is it so funky here? I mean... You gotta turn it... You just got like a weird, weird shape to. With the knee straight up and down. They get a little anteverted. Yeah, it's a little anteverted. Yeah, exactly. Makes sense? Yeah. But we want some anteversion. No, not really. Just put it in neutral. We want zero? Just match there. Yeah, I think that's fine here. That, that's it. I think that's it. Yeah. Yep. All right. Then yeah, we're gonna have to... Put knee straight up and down. Flat of the floor. Knees straight up and down, for sure. Can we get a new one of these? It'll cost ya. Laterally. Yeah, I need to rongeur some of that out because see how it's - it sinks in well. Did you rasp all that out? Yeah, just rasp it. Yeah, just rasp that. We have a lateral too, if that would help. I think he's got it. Okay. Does that seem okay? Yeah. Just make sure you're not putting it in varus. Four. Yeah. You want another one? Yeah, let's get it. I think we'll need it, yeah. It's just we've been blocked here. No, no. It's just sitting really funny in there. You got a curette? Thank you. How much more of this bone needs to come out here? Yeah. This should help me. All right. Just don't break the greater troch. You got a new Yankaur? Easy. Easy. All right, that's good. Happy? That looks better. That looks like it's sitting better, huh? Neutral. You want flat? I think so, yeah. If anything, we did an anterior approach, right? Yeah. But you still dislocate posterior, right? Okay. Easy, wait. Got the hoop stresses. Got one more to go too, so... Yeah. All right. It's sitting pretty low. Is it? Yeah. For sure. Like his neck is low? Yeah. I don't know. I could use Appleton's eyes on this. Just make sure that we don't put it too low. Is he gone? Yeah. Oh, okay. All right. That's fine. Do you need an X-ray? No, that's okay. No? Same thing. Is Jack next door? He was here, but I don't know if he's still here. Is anyone next door? Got it. Still getting held up there? Yeah. Pickups, please. That right there. Just this stuff here. Yeah, there's like a little bit of soft tissue there. Can I give it a feel? Do you mind? Yeah, I mean that feels like it... I mean, it just feels like it's clotting down there. I know we - it does. It feels like it's distally clotting but I know we reamed to... Wanna take another run at it with the 5? Yeah, let's do the 5 reamer. Yeah. Yeah, it feels like it's... It looks like it's thrown it into varus, right? Yeah. Yeah, it's thrown into verus, feels like it's falling distally. Yeah, it's falling into varus. Yeah. A lot of the four I feel like is able to get down. And the four. Do you feel like the four slipped into varus? Like it kicked down? I don't think so. I mean, you might want to just go with the four. Yeah, I mean that goes down. Nice and straight, right? No problem. And there is just this... All right. And that's the five. I'll take a four again. I think our neck break is just like super low. 'cause there's the lesser troch, right? Yeah. So it's gonna sit like that. No. Well, that looks straight in. Yeah, I mean, this is not. That sunk deeper than we need it. Too deep. That's the lesser there. Yeah, it's too deep, yeah. You want it just to sit right there, right? There we go. Yeah, that looks good. Right. It looks like it's staying. Yeah, that looks good. I just encountered way more resistance than I should based on how that four felt. I don't know where it's catching that. Curette, please. Can you get a little more like? Let me get a curette. Come on out. Is there too much? There's a lot of bone here. I mean, yeah. Based on how the four goes in, it just feels like... Yeah, I mean, I've never put a stem in flat, but... Yeah, first for everything. Yeah, I usually just match the version. Go ahead and match the patient's version. Yeah. See if that helped you. Yeah. Did that help? That seems pretty good there, huh? Careful, easy. I think that's probably good there. Yeah. So... And that seems like, I think that's plenty of height there, You know? Do you feel like the head is high? I mean, do you feel like it's proud or..? No, take that off. Let's see where our greater troch is, yeah. You know how to do this? Go ahead. Yeah, I just can't do it well from this angle, my hand... Oh, yeah, yeah, that break was just so uneven. Yeah, I think that's gonna be good. Here, let's take some of that bone off. Rongeur, please. Go zero, or do you feel like? I think we're probably gonna need to use a short neck. Well, if that's the case, why don't we just sink it down a little bit. Why a short neck? I think it was just so tight, but we'll see. Let's see how it feels.

CHAPTER 12

Yeah, let's get the minus three. I think that looks good. All right, cut with this. I'm gonna put it on in two. Yeah. Oh, boy. Yeah, that looks good. Yeah. That's lined up, right? Let's see, are we able to show it anymore? That's the, which..?

Okay, all right. Let's see if we can get in. You got the pusher, ice cream cone? Might be too proud. Wait just a sec. Yep. Can we externally rotate it? Yep. Let go. All right. Yeah, we just don't have enough length. I mean, we just need either a lot more traction or lot push in. All right, should we go deeper with it? We should go down deeper with it. That's sitting. I mean, that looks... I got it. Okay, that's probably plenty. All right, rongeur some of this up. We're not going any lower than what that side is. No, no, definitely not. Might as well take this. Just be very careful with it. Hibbs. All right, we able to... Yeah, can you grab the leg? So yeah... Kust hold it like that, yep. Good. Good. All right, we'll take the trial neck and head. Yeah. Yeah. It's like pretty long posteriorly. Pretty short anteriorly. I am gonna get that junk here. I think there's some posterier capsule or junk actually. Not capsule. Can I borrow the suction? Let's get all that stuff out of the acetabulum. Hold that. Let's see. Yeah, are we able to, like... Yes, yeah. Abduct a little bit more? Yeah, yeah. - And then that rotation. How's that? Better. Yeah, very, nice. Okay. Ice cream. Head pusher. For the head pusher. Okay, this one. Get that leg straight in the... Yep. Straight out. Go ahead. Wait here. This is getting pulled in the wrong direction. Okay, so just some traction. More traction. There we go. Let's get this outta here. Wanna get an X-ray of a trial? Sure. I'd like to. Yeah, sure. Let's do it. Yeah, we're very quite short. We're short? Yeah. That's minus three. We're short here? Let's go. Yeah. I don't know. That doesn't seem too short to me. Okay, yeah, you're right. Touch sore. Yeah, yeah. Touch sore. You wanna try it with zero. We could, yeah. You got a bone hook? Can I move this out of the way? No. Oh-oh. All right. Some traction. Yeah, that was a little too easy, huh? Nice. Good save. Okay. Wanna try? What's up? 5-0. 5-0 Let's call for a flat plate. Yeah, it looks great. That seems reasonable. It looks great, yeah. All right. That felt good. Try that, Miles. What do you think? Much better? Yeah. Oh, it that better? Yeah. It feels like something fell over that knee a little bit. I think that might be right. Could be a tiny bit short, but it's very much way better. Yeah, I think he's being a little hard on himself. I think that's pretty good. That's all right, yeah. Yeah, that feels pretty good to me. I'd rather make him long than short. Sure. Let's get a flat plate. I mean, do you know why I say that? I put you on the spot, but it is... Let's got some irrigation, please. You'd rather make them long and short. Yeah. We'll talk about it later. There's a lot of biomechanics of it, but... I have a feeling plus five is gonna be too much. Do you wanna try it? I mean, we're waiting on it. Let's go ahead and do it. Yeah, just do it and feel it. And maybe we won't even get it in and maybe be like, "There's the answer." Bone hook back. That came out pretty easy. Yeah, super easy. This is just swimming in here, unfortunately. It's okay. We're cementing. So just get the version right when we cement. By the way, there's a lap down here in this pocket, yeah. All right, straighten out. Push, push, push. Traction though. Yeah, I got traction. Nice. I mean, that feels pretty much the same. Yeah, let's flex him. I mean, not this one. We probably should have tested the other. No, that's good there. Knee up okay. It's fine there. Yeah, totally. Yeah, that's good. Yeah. Yeah, I mean, that's sitting pretty nicely. Let's just get that flat plate.

We didn't really get the other side though, did we? Hey, I'll take that STEM position. Stem looks great. And that calcar's actually more calcar than I thought. Yeah, that looks really good. And it's not in varus. No. Not at all. Yeah, could we try dropping the machine a little bit so we can look at both hips? Sure. Do you want me to get this? I think it just has a weird neck 'cause look how far in you are. It's got a super weird neck, yeah. So I feel like his neck is maybe a little high. Yeah. Right. But I don't wanna take it lower 'cause we already feel short because we already have a plus five on there. Yeah, we're just gonna drop a little bit so we can see the rest of the pelvis. It's not gonna be great though because we're looking at an operator. I know. I know. It's a little awkward, but it'll give us some idea. All right, one more shot guys. Everybody out. Any better? Maybe. Yeah, lessers look kind of good. I think that looks fine. That's good, yeah. Yeah, that's fine. As much as we can tell from that. Yeah. It looks good to me. Yeah, very nice. Okay. Thank you. Thanks. Let's get our Norfolk back. Is this helping us or hurting us before the Norfolk? I think it's helpful right there. That one. This one may be was... Okay. Don't push that. - Pull, pull, pull. I think we need to... Come this way with it a bit. No, that's okay. Just pull up. Broach, please. Broach handle. Yeah, that's okay. All right, you wanna put the cement restrictor in?

CHAPTER 13

We can just put this cement restrictor in. I'll take a marker. Feels good. Yeah. Cement a lot of the thing. No, I don't think so. I think we're good. There you go. Yeah. 54. 54 plus five. Okay. Excellent. Yep. So Elyse, when you wash this, just remember that that's there. So you wanna be gentle. Not gonna push down. Not pushing. Oh, oh, careful. Plug that in. Let go a little bit. Good. Broken. You sure? Yeah, it's not staying. All the way to the top. Good, good. All the way down. Yeah, how's our blood pressure? We're about to start cementing. Can we raise the blood pressure up a little bit? Awesome, thank you. Is it a button or just a knob that you turn? I thought it was just right next to the table, you know? We sure act like it. Let's wait until the pressure comes up. Yeah, I don't know, I do not think that fracture would've done okay with some... I think that's the right thing for 'em. Very nice. All right. Let's mix the cement, guys. Quite well. Okay. But what if you had a... Thank you. Look in the bottom. That's it, you're done, I think. Let's tuck that in there. Let just wait for the cement to be a nice and good consistency. I like the big too. I like to use this. You grab it and push it. Pressure's still good? Yes. Stem ready to go? Yeah. You like to dry put the stem in there or no? Not usually. We can, but we already put the stuff in so... We should have marked it when we had our stem where we wanted. I think I remember where it is. Let me get the leg in the right position. I think we were just aiming for just a touch, probably matched, right there. Yeah, yeah. I think that's good. Good. And I think he does have very weird anatomy. He was like kind of ext- or internally rotated or something. Can I get the long pickups? We still gotta get the stem in there.

CHAPTER 14

Start from the bottom. Okay. The pressurizer ready to go? Alright. All right. All right. That's a bit much. Yeah. We're gonna need another sucker tip. For sure. Other way, right? Yeah. Other way here. Yeah, that's how you do it. All right, that's good. Here, let's hold onto it until after we're done cementing for the day because that's the problem.

CHAPTER 15

All right, I got the leg straight up and down. Okay. Keep it out of varus. I'll take this, steer. It seems about right on our version. I think so. That looks pretty good, yeah. Are we down a little? Just a little bit further. Just a little bit further. Just give it a little tap. Mallet. Yeah, that's good. Okay. Schnidt. Falling in there? Another Schnidt to me. Thanks. If getting the head out is the most difficult part, I'll take it 'cause... Yeah, well it's just 'cause we didn't get enough capsule. As awkward as it makes that step, means nothing else went to... Yeah, just 'cause we didn't get enough of the capsule out and that's all. Yeah. Just using the cement to fill in this little gap here that we had, yeah. Hold pressure. Yeah, how we feeling? Pretty soft. We got that. All right, my friend. Your job is to make something out of this. Be as creative as you can. What do you got? A star. Starfish or star. Starfish. Okay. All right. See I don't know how I made it here. When I had to do this as a sub, I just made a snake. Oh, God. That's embarrassing. You guys don't know how to make a rose? What rose? Rose. The rose petal. Oh, you gotta make individual rose pedals and then assemble it. No, it's just a rose. The problem is it doesn't stick to itself so it's hard to stick pieces together. No, you don't have to stick anything. Oh, my God. I just schooled this. Roll it out. You gotta make it flat. I actually reread all the Harry Potter books the summer before I started med school. Really? Yeah. Yeah, I read them and watched each movie after. Who's that person? That's really embarrassing though. Hold it up and roll. How's it feeling? Starting to heat up yet? Little bit. It's getting a little harder to. Pressure's okay. How's he doing up there? He's all good. Excellent. I like the version. That looks really nice. Nice job, man. Like so hard that the test people do sometimes, we'll take the scalpel... That's what we'll do. Push into it and you wait until it won't go in at all. That's how hard if you want. It's almost there. Oh, it's always the most painful part of the procedure for me. Just waiting for the cement to dry. It gets hot. Yeah, it gets hot. We get all this. Yeah, like actually some people don't like cement on the drapes 'cause it can burn the drapes. These are good. I mean, we're trying to prove they are. I always say orthopaedic surgery if nothing else is very good at producing research to... That's it. Meanwhile, gen surg... Doesn't matter. I mean, I'm just gonna, I'm just gonna use it to test the cement. It's pretty solid. Pretty solid, I think we're good. All right, let's get that little bit of cement out of there. Is this worth trying to get out? I don't know. I actually operated with someone recently that purposely packs cement in there. Huh? Purposely does that, huh? Yeah. They wanna make it so no one can get it out. I guess - I was like, well, that's kind of - can't back out if you bulk it in. It's pretty in there. Okay. All right. Just clean it up a little bit. All right, let's get our head. Go ahead and get our little. Let's get our pack out. I was not being helpful to your situation. Sorry. All right. You ready? Ready.

CHAPTER 16

I wanna get that down under there. All right. And off. Okay, I'll take... I'll take another liter of irrigation. I think it's heavy. I wonder how much weight they gain just by having... Who knows? Yep. Get that guy out. Yep. Get that out there. There we go. There we go. All right. Elyse, hold that. Hold these guys, Elyse. Yep. Got it. Oh, nope. Something in there. Okay. Are you not located? Hmm? Doesn't it feel like it's just sitting out more. Or you think it feels okay? It's all against the rim. Just felt like it's was further seated last time, right? I think it feels good. You worried about it? I don't know. I just didn't feel like it... Is it okay? That's fine, yeah. Happy with it? Yeah. All right, let's get another flat plate. Yeah, you want another one? Feeling better.

CHAPTER 17

All right, let's get our retractors back again. All right. Let me get that for you. Yeah, just careful of the nerve. Careful of the nerve. Back here. See this right here? Mm-hm. You don't wanna get that. Do you know what this is? Cutaneous? No. We're in the posterior aspect. You wanna tie these together? Yeah. It's a very large nerve. It's a very large nerve. Femoral. No. Larger. Posterior. The other one I'm thinking is obturator. Even bigger. So, when somebody has really bad bad back pain that shoots down their legs, What do they call it? Sciatica. So that's the sciatic nerve. Yep, exactly. Can I have a pair of suture scissors, please? My sciatic is acting up. Oh, that's pretty good. All right.

Check our lengths. Lengths are great. We called x-ray. Yes. All right, great. All right, cool. Can we start closing this layer down. Please. There's our layer there. Yeah, okay. Number 5 Ethibond. Let's get the Hibbs back, or these things back, I mean. Can I get Bonneys, please? So I like to pound it through the bone so you can take this guy and just reattach that there to the end of the tendon. Okay. And then the rest you can do with, you know, going through the bone. Yep. Good. You can run that down a little bit. Okay. Take one more of these number 5. Just one? Yep. Good. All right, we'll do the same thing thing here. I see that Weaver didn't get you to stop believing in his least favorite myth. Which is? That these have to be cut with a knife. Is that a Weaver thing? Yeah, one of them. He doesn't think that you need to do that. Yeah, He's like, "Scissors." And he cuts these. He's like, "See, tell all your sports friends, you can cut these with scissors. They're not that strong." Can I get a mallet, please? Who's got scissors? I have the scissors. Oh. Just like in Malawi, what would they do for a geriatric femoral necks. Nothing. Nothing? Nothing. And then what happens? They go home and die. Oh, my gosh. How did you first become involved with Malawi of all places? Mentors told me to go there. Yours is good, right? Yeah. Do you wanna finish up? We're almost ready. Yeah, that might just sit on top there, I think. I think that's okay. Oof. Goodness. Breaking the thing that.. We'll need one more number 5. That's working, yeah. Yeah, scar down. Yeah, let's do a couple more on the other side of that. After we do this. Yeah. Oh, is X-ray here? Yeah. Let's start setting up the, oh, it's already set up. We got all of our laps and sponges and all that, right? Yes. All right. I'm just coming in for the X-ray, let's get some irrigation, please. All right, get us a towel. Yep. Thanks. All right. Yeah, just the hip is fine. Yeah, just the hip.

You got it? Yep. Thank you. Beautiful. That's a thing of beauty. All right, thank you so much. You're welcome. Let's get outta here.

All right, let's finish up, guys. A little bit more irrigation, please. And then we'll take number 1 Vicryls. Did we repair that adequately? I think so. Kind a small incision all things considered. Maybe that was another thing we could have done. I like these small incisions. Now that I'm looking at it like this, I'm like yeah, that is pretty small. Make sure you got IT Band there. Not something else stupid. Yeah. Good layer there. Good there, there. Yeah, so, I mean, Drew, take Drew, here approach - look at his anterior hips. Then at MGH, I think, I don't know. It's a whole lot of struggles for three... You got one more of these? The knee infection specialists? Yeah. We will take 2-0 after this one. You finish up distal? No, I'm just going where I can go, squeeze in real quick, and throw one in. You wanna run one over the top or just..? Yeah, you can run it in those tissues up there. That's fine. Yeah. Any questions about anything we did today? Can we get a little basin to hold the knee up? Take some type pressure off of here. It's great. A little towel on there, please. Just hold the leg like that for us. Thank you. Is there any bone that needs to heal here? No bone needs to heal. Right. But you do have the head of the bone. Yeah, I think you got the angle with your right hand. You mind getting that? You got all this? Yeah, I've just been running this too. Oh, okay, great. Keep it down and double... Here you go. Let me hand this back to you. Oh, vancomycin. Should we put vanco powder in? You got it. That's it. Yep. Just tie it off there. I think you're good. All right, push it down, push it down with your finger. Just can you come out with that? Yeah.

Yeah, just in that Scarpa's layer, you see that? Yeah. Bring that together. Close up the dead space. So those are also load-bearing constructs, right? So even though someone has a, they'll have a femoral shaft fracture, and they can weight bear immediately after surgery. All right, we're gonna do 3-0 Monocryls and then staples. Monocryls and a pair of Adsins, please. One more. One more bit of irrigation. Take a little irrigation before you hand me that. One more irrigation. Thank you. You got a smaller needle driver? No, okay, that's fine. Thank you. So for me it's a lot of the same things. There are two things that I really liked. I like surgery and I like palliative care. And you're gonna first say like, well that makes no sense, orthopaedics is not palliative. That makes a lot of sense. Orthopaedics is totally palliative. It actually makes a lot of sense. So from a surgical perspective, I think I really love surgery. And one thing that's amazing about orthopaedic surgery is there's a lot of resection that occurs, there's a lot of times where you take out pathology in fields of surgery, but in orthopaedics there's a lot of focus on reconstruction and using creative materials to try and restore a patient's functional anatomy. Now this is an answer that is like honed by interviews. This is one hell of an answer. So that's part one. The other part is I think that similar to what Miles was saying is that I really like palliative care 'cause I think it's an approach to medicine where you have a lot of different tools in your day... Can I have a lap, please. You talk with the patient about what they care about most and use that answer and those conversations to guide your treatment decisions. Well done, everybody.

CHAPTER 18

So the procedure went as planned. You know, we placed the patient in the lateral position. We did our skin incision as described. Incised the iliotibial band and exposed the abductor and the vastus lateralis, which we peeled off with an anterior one-third sort of sleeve. We got to our capsule. Capsule in his case was quite hypertrophic. So that was one bit of struggle in this case was getting the capsulotomy appropriate so that we could really get the femoral head out. So you'll notice from the video we struggled a little bit to get the femoral head out. Once it was out, we were able to notice that our capsulotomy was not deep enough. We were able to take it all the way down without incising the labrum and protecting that. So that really allowed - facilitated everything for the rest of the case. And once that little struggle was over, then everything was fine. So we trialed our head component and that worked great. The femoral neck fracture was actually quite low, so I didn't need to do an additional femoral neck cut. If anything, we used a little bit of this calcar planer to make the cut perfectly flat. But if anything, we just used the rongeur to bring the femoral neck bone down to the right level so that we didn't need to take any much more with the saw. We broached and we made sure using a curette, and the lateralizor that we were really getting lateral, and making sure the stem was in a valgus, if anything, position rather than into falling into varus. Once that was done, we cemented, we placed the stem, we relocated the hip. It was stable reduction. X-rays looked fantastic and the closure went very smoothly. So I was very happy with how it turned out.