Pre operative planning

for total hip arthroplasty

Dr. Ahmed Sabeeh Abd Ali.

Al-Nahrain University.
College of Medicine
Iraq-Baghdad
Updated in sep. 2018
Learning Outcome
• 1/How to select the right patient
for total hip replacement.
• 2/Enumerate the benefits of
radiological templating.
• 3/Stepwise radiological templating.
Pre operative planning:
• -It involves the following:
• 1/ Assessment of the patient generally.
• 2/ Assessment of the hip joint and lower limb
• 3/ Radiological assessment (templating).

• IT IS NOT ONLY
TEMPLATING
1/ Assessment of the patient generally.


• -Age.
• - Functional demands and occupation..
• -Weight and BMI.(morbid obesity is a relative contraindication)
• -Any cardiopulmonary and other serious medical illnesses.
• -Can the patient withstand such a major operation?
• -What is /are the chief complaint? :
• - Is pain severity necessitate arthroplasty?
• -Is it genuine hip pain? Or it is referred.
• - Replacement should not be done for painless LLD.
• - Replacement should not be done for painless limited
ROM.

• -Any focus of infection, local or remote. UTI, prostate, chest

infection, URTI………etc.
2/ Assessment of the hip joint and lower limb.


• -Skin : focus of infection, previous scar.

• -Muscle power: especially hip abductors.
• -ROM,
• *Adduction contractures lead to pelvic obliquity
and false shortening of the limb.
• *Externally rotated limb gives false impression on X-
ray radiograms.
• *Flexion contracture may affect the operative
approach, (anterolateral for flexion contractures).also give false
impression of LLD
•  
• -Limb length (true and apparent).
• -Lower limb vascularity.
• -Limb neurological examination and sensibility.
3/ Routine Radiological assessment.


•1/- AP pelvis X-ray showing the whole

hips,
bilaterally and upper femurs.

2/Lateral hip X-ray (Frog view).-

AP pelvis radiograph.
• -AP view with the hip in internal
rotation to eliminate the anteversion.
• -Assess the magnification of the
images by putting radio opaque
spheres.
• -Nowadays , soft wares are available
from the manufacturers of hip
prosthesis for application on
computerized digital x ray images.
• - Four feet distance=10 %
magnification,
• -Forty inches gives 20%.
magnification.
• -But patient distance from the
cassette also affect magnification.
2/Lateral hip X-ray (Frog view).
Optional views:
1/Lateral pelvis,for suspected lordotic pelvis.
2/Obturater oblique view if we suspect posterior
wall effects.-
• 3/LS spine if we suspect other sources for

the pain.-
• 4/Optional pelvis CT for post traumatic and

dysplastic hips.
Why templating?
• 1/Medial wall?
• 2/Osteophyte.
• 3/Limb length
restoration.
Why templating?
• 1/Osteophyte
removal.
• 2/Is it easy to
dislocate?
Why Templating?
• -Cemented vs
cementless.

• -Risk of fracture
peroperativly.
Cortical thickness index and Dorr
classification .
Why Templating?
• -Restore center of
rotation.
Why Templating?
• Bone deffects
detection
Why Templating?
• Medial offset
restoration
Why Templating?
• Difficult replacement
like dysplasia and
traumatic hips.
Why Templating?
These imagings are important for:


• 1/ Assess bone quality, it will affect the type of prosthesis .

• 2/Assess any osteophytes and their position.,to remove them

intraoperativly.

• 3/Assess medial wall thickness,to avoid floor penetration during

reaming.

• 4/Assess bone defects ,the need for bone grafts or augments.

• 5/Assess size and position of acetabular cup.

• 6/Restore proper center of rotation for proper hip biomechanics.

• 7/Restore limb length.
• 8/Restore medial offset.
• 9/Restore neck length.
• 10/ Assess level of neck osteotomy.
• 11/Assess type of femoral stem, dysplastic
and dwarfs may necessitate straight and short
stems or custom made prosthesis.
• 12/ Deformed and post traumatic femurs may
necessitate pre or per operative osteotomy.
Information that should be fixed after
templating:


• 1/Cup size.
• 2/Cup orientation.
• 3/Stem size.
• 4/Stem neck-shaft angle( S or H or Special stem).
• 5/Neck length.
• 6/Level of osteotomy.
• 7/What limb length would be gained?
• 8/Offsets(acetabular+femoral)
• 9/Stem type(Cemented ,Cementless or Calcalr
replacing and tumour prosthesis).
These results will affect:
• 1/Limb length.
• 2/Center of rotation.
• 3/ The medial offset.
 Four-step approach for hip templating

on a standardized standing pelvic radiograph
A/. Assess the quality of the radiograph.

B/. Identify anatomical landmarks.

C/. Identify mechanical references.

D/. Optimize implant positioning to

restore hip biomechanics.
A./Criteria for good radiographs are:
• 1/ Low AP pelvic radiograph
with the x-ray beam
centered on the
pubis ,rather than on sacrum.
• The symphysis pubis should
project on a line through the
middle of the sacrum.
• The tip of coccyx is above
the Symphysis upper edge.
• Both obturater foramen are
symmetrical
• 2/ Both femora should be positioned in 15 to
20° of internal rotation.
How to check rotation on AP view?
• When the femoral neck is parallel
• to the film, the lesser trochanter is on
average
• 2.3 ± 3.1 mm broad and in most cases less
• than 5 mm of lesser trochanter should be
visible medially from the proximal femur.
3/Check the magnification
• -The only guaranteed method is when a hip prosthesis
with known dimensions has been implanted on the
contralateral side.

• -Calibration metal spheres of known dimensions objects

can be used. positioned at the level of the hip joint in
the anteroposterior plane.

• -It should be positioned close to the pubis between the

patient’s legs and in the plane of the greater trochanter
Proper AP pelvis radiograph means:
• 1/Proper pelvis side.
• 2/Check femoral rotation.
• 3/Check magnification
B/ Anatomical landmark
• -Anatomical landmarks should be easy to
identify, both on radiograph and during
surgery.
• FEMORAL SIDE: Greater and lesser and saddle
area and femoral canal.
• ACETABULAR SIDE: the acetabular roof and
the“teardrop” are adequate landmarks and
symphysis pubis and obturater foramen
The “teardrop” is:
-The superposition of the most distal part of the medial wall
of acetabulum and the tip of the anterior and posterior horn
of acetabulum.
-During surgery, the most distal aspect of the teardrop
corresponds to the most distal and medial part of the
acetabulum, behind the transverse ligament and at the
superior border of the foramen obturatum.
Normal pelvis criteria and leveling of
the pelvis.
C/DEFINING MECHANICAL REFERENCES
• -Normally the acetabulum and the femoral head have
concentric rotation centre .
• -The hip rotation center can easily be found as the centre of
• a circle fitted to the projection of the femoral head or the
acetabular roof and medial wall
If we have a contralateral normal hip:
• 1/Identify the ARC in the normal
side(fit circle to the acetabulum)
• 2/Draw the inter tear drop line.
• 3/Draw a line from ARC perpendicular
to the inter tear drop line.
• 4/Measure the length if this line.
• 5/Measure the length of a line from
the tear drop to the intersection of the
previous two lines.
• 6/ Transfer these two measurements to
the abnormal side makinguse of the
tear drop as a referance point.
WHAT ABOUT BILATERAL SEVERLY
DISTORTED HIPS?

-These original rotation centers can be found as the
centre of a circle fitted on the most preserved part of the
acetabulum (generally the teardrop and

the medial wall). 

Ideal acetabular cup positioning
Femoral, acetabular and combined
offset
The “hip length”
• -Is the shortest distance between the inferior
tip of the teardrop and a horizontal line
through a fixed point on the proximal femur,
e.g. the upper part of the lesser trochanter.

• -This measurement is influenced by hip

abduction/adduction and flexion/extension.
• -Both hips should be in a similar position.
QUESTION:
• -What to do if we can
not put both limbs in
same position??

• TRACING.
D/CHOICE AND POSITIONING OF THE
IMPLANTS
• -First step, the cup is chosen as follows:
• 1/restore the original acetabular rotation centre.
• 2/The template of the acetabular component is
positioned with an abduction angle of 40°to 45°
between the longest axis of the cup and the
interteardrop line.
• 3/insertion depth is compared to the medial
acetabular wall.
• 4/ the insertion height compared to the inferior
border of the teardrop and the cup containment or
overhang compared to the lateral border of the
acetabular roof .
45
Femoral template description.

• -Stem type(cemented)
• -Magnification factor.
• -medullary line.
• -level of osteotomy.
• -Neck lengths(three small
circles fit with center of
rotation of future hip
prosthesis.
• -Standard or high offset.
• -Magnified scale to measure
the height of osteotomy frpm
the lesser trochanter.
Super impose the femoral template
over the femur on the radiograph
• -Align femur medulary line with
stem longitudinal axis.

• -Insertion depth=bone geometry.

• -One to two mm around stem.

• -Mark center of rotation.

• -Mark all neck lengths

-Super impose a radiolucent tracing paper over the template and radiograph.



-Align the tracing paper with the template.



-Draw ( ON TRACING PAPER )all the lines on the TEMPLATE+ RADIOGRAPH
including the center of rotation and osteotomy site and femur on the
radiograph.

-Align the tracing paper with the line of the symphysis pubis(pelvis
leveling).

-Align the FRC drawn in tracing paper with ARC on the radiograph.

-Draw all the lines in pelvis side in the radiograph.

-we do this method of tracing to counteract any hip adduction
contracture(look to the picture) ,if we did templating in adducted
hip it will end in error in hip length measurement .

On the final Tracing paper we fix the
following criteria:
• 1/Cup size.
• 2/Cup orientation.
• 3/Stem size.
• 4/Stem neck-shaft angle( S
or H or Special stem).
• 5/Neck length.
• 6/Level of osteotomy.
• 7/What limb length would
be gained?
• 8/Offsets(acetabular+femoral)
• 9/Stem
type(Cemented ,Cementless
or Calcalr replacing and
tumour prosthesis).
Compensating for failure to restore the original

hip anatomy


• -it is important to restore the combined femoro-acetabular

offset and the hip length.
• -When acetabular offset is decreased and the hip rotation
• centre is medialised, femoral offset should be increased .

• - On the contrary, a lack of femoral offset can be

compensated for by increasing the acetabular offset, i.e. by
lateralizing the hip rotation centre

• .
• Start the Workshop
 Four-step approach for hip templating

on a standardized standing pelvic radiograph
A/. Assess the quality of the radiograph.
(pelvic+femur+check magnification)

B/. Identify anatomical landmarks.

C/. Identify mechanical references.(center of

rotation)

D/. Optimize implant positioning to restore

hip biomechanics.
Step 1: On sheet no. one
fix the followings:

• Mark the criteria for proper AP pelvis

radiograph.

• How you can predict the both hip lengths

are normal?

• Mark pelvis leveling lines.

Guides for proper AP pelvis
The criteria are:
• Pelvic side: • Femoral side:
• - Symphysis =mid sacrum • -Lesser trochanter
• -Symetrical obturater width .
foramin.
• -Greater troch.max.
• -Tip of coccux above the
symphysis. visualized.
• -The whole film is
centered on symphysis
pubis.
Pelvic leveling lines
Check proper limb lengths,Trans-ischeal
line pass through both lesser trochanters
Step 2 On sheet no. 2
perform:

• Drawthe relevant boney

landmarks to templating.

• Femoral+Pelvic sides
Pelvic and femoral landmarks.
 Requested boney landmarks:
• Pelvic side: • Femoral side:
• -acet roof. • -Femur medullary line.

• -Tear drops ,bilaterally. • -Lesser trochanter.

• -Inter tear drop line (or • -Greater trochanter.

other reference lines).
• -Saddle area.
• -Line via symphysis
pubis,perpenducular to inter
tear drop line.
Step 3: Mark the Center of rotation
• Normal other hip: • Abnormal both
• -depend on femur hips:
head or acetabulum • -Depend on tear
on normal side, then drop or obturator
transfer to abnormal foramen, or on the
side. reminants of
inferomedial
acetabulum
Finding the normal side center of rotation(
depend on femur head or the acetabulum)
Transfer the center of rotation to the
abnormal side.
• Transfer the
dimentions of both
right angle
triangles ,to be
symmetrical on both
sides
Step 4: Perform Templating for both
pelvic and femoral parts:
• Template example for
acetabulum.( some are
desiged with lip offset of
10 degrees (not showen in
this slide)

• -The circular template is to

localize the center of
rotation according to head
of femur
How to template the acetabular side?
• -Align the center of rotation of
the template with that on
radiograph.
• -Angulate the acetab. Template
45 degrees to inter tear drop
line.
• Inferior angle aligned with inter
teart drop line.
• The medial aceta.rim aligned
with the line perpendicular to
inter tear drop line via the
lateral lip of the tear drope..
• -Assess the remaining medial
bone.
• -Assess the superior
uncovering(max.10%)
Templating the femoral side.
Criteria for proper templating the
femoral side.
• -Align the medullary line of femur for both the
radiograph and template.
• -Shift the template gradually downward till you
get ideal position with one mm canceolus
bone remaining arround the stem in diaphysis
and two mm arround the stem in metaphysis.
• -Check the stem fitness to the contour of the
calcar.
• -Cementless stem is not forgiving, regarding
its position(guided by bone geometry).
Start the Tracings
• -WHY TRACING?
• -TO ABOLISH THE EFFECT OF HIP ADDUCTION
IN BOTH THE NORMAL AND ABNORMAL HIPS
Tracing the whole pelvis.
• -Done after acetabular
implant templating.
• -Apply the tracing paper
over the radiograph and
acetabular template.
• -Draw the whole pelvis
with the
acetab.implant(Green
color)
Trace the normal femur
• Fix the acetabular center
of rotation(by the tip of a
pencil).
• -Rotate the tracing
paper ,so the edge of it is
parallel to medullary line.
• -Trace the whole femur
including
lesser,greater,saddle and
medullary line
Template the femur for the abnormal
side
• -Apply the selected size
template which is either
cementless or cemented.
• -Align the medullary line
with the stem axis.
• -Apply the stem so that
about 1-2 mm of
cancelleus bone still
remaining arround the
stem.
• -Stem seating is guided by
bone geometry,pay
attention to the calcar
• -N.B The arrow refer to
stem center of rotation
 Do tracing for the femur of abnormal
side
• -Apply the tracing paper over the
radiograph and the femur
template still in place.
• -Coincide selected stem length
(eg M) in the femur template
over the acetab center of
rotation previously marked in
tracing paper.
• -Rotate the tracing paper so the
edge parallel to femur medullary
line.
• -Trace the whole femur+stem
including osteotomy level
(prefferaly in different colors)
Remove the tracing paper
• -Assess hip lenghs
bilaterally.it should be
equall on both sides.
• -You can increase or
decrease the hip
lengths by choosing
different neck
lengths(but this will
change the offset as
well)
Assess the femoral offset bilaterally.
• -It should be equal
on both sides.
• -If the offset is less
in the replaced side,
we can choose the
H stem(127
degrees).
Measure the level of osteotomy.
• Take the lesser
trochanter or the
greater trochanter as a
refference point.
Fix all the results and make the
available in theatre.
Fix your final results on the tracing
paper
• 1/Cup size. • 6/Level of osteotomy.
• 2/Cup orientation. • 7/What limb length would
be gained?
• 3/Stem size.
• 8/Stem
• 4/Stem neck-shaft type(Cemented ,Cementless
angle( S or H or or Calcalr replacing and
Special stem). tumour prosthesis).
• 5/Neck length. • 9/
Offsets(acetabular+femoral)
Take Home Message

• Failure to
plan is
plan to
failure