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A second stay suture is now applied to the joint capsule along its free edge after the arthrotomy has been performed.
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The acetabulum is washed and dried and high viscosity cement applied to the socket.
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The Exeter stem is inserted in to the cement at 3 minutes 15 seconds starting at posterolateral corner of the canal with the tip of the implant.
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A retractor is now placed anteriorly on the acetabular margin to mobilise the femur anteriorly and out of the way of the acetabulum, following removal of the femoral head.
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Use the acetabular step drill to drill multiple keyholes into the circumference of the acetabulum – this allows for optimal cementation.
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Confirm the height of the broach to the femoral neck cut, the holes in the broach act as a marker.
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Cementation of the femoral canal.
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A distal Hohmann retractor is placed in the space between the joint capsule superiorly and the quadratus femoris muscle inferiorly.
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Pull the stay sutures taught and ensure the posterior structures return to the greater trochanter in a natural position.
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Cut the tube of your cement gun off and follow with pressurisation of the cement in the femoral canal.
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A Judd pin is inserted in to the ischium.
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Place the same trial head (32+0mm) on the stem. Repeat your tests of stability to ensure the hip joint is as stable as when tested with the broach earlier.
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Apply and carefully impact the definitive femoral head to the cleaned and dried trunnion and reduce the hip.
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Check the patient’s leg lengths once they are stably positioned on the table.
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A trial reduction of the cup is made aiming for anteversion of 15 to 20 degrees and an inclination angle of 45 degrees.
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Place a stay suture in the piriformis tendon.
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A superior Judd is placed into the ilium proximal to the acetabulum.
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Remove the trochanteric bursa and fat off the back of the greater trochanter to expose the piriformis tendon and short external rotators.
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Dislocate the hip by internally rotating it as it is adducted over the lower limb.
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Position a Hohmann retractor superior to piriformis and locate its tip into a small incision made next to the tendon.
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Remove the remnants of the piriformis tendon in the piriformis fossa on the greater trochanter and incise the anterior capsule along the femoral neck under quadratus femoris (Q).
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The cement is pressurised using the rubberised pressuriser until approximately 3 minutes and 30 seconds after the cement mixing started and the definitive acetabulum is implanted.
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Drill two holes into the greater trochanter for the posterior repair.
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A 32mm plus 0 head trial head is applied to the Exeter stem and a trial reduction undertaken.
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A box chisel is utilised to start the femoral canal preparation.
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Stay sutures are pulled through the trochanteric drill holes.
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Remove the Judd pins and and place a protective swab into the acetabular component to protect it from scratches during the rest of the procedure.
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Position the patient in the lateral position.
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The femoral canal is lavaged with a pulsatile long nozzeled jet and suction applied to remove loose bone, debris, blood and fat.
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The femoral canal is then packed with a rolled swab.
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Until the cement has fully cured pressure is applied to the acetabular component using the appropriately sized head.
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Ream the acetabulum with the reamer aligned with the transverse acetabular ligament and an abduction angle of 45 degrees.
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The flange has reference lines of 2mm, 3mm, 5mm, 10mm and 15mm. Cut the flange to fit the patients acetabulum.
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The wound is carefully closed in layers.
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Second stage of canal preparation is to use the pencil reamer.
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An osteotomy is made with the sagittal saw at the level of the neck cut as per pre-operative templating and the femoral head is removed.
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Use serial broaching to prepare the femoral canal, starting with an Exeter 37.5 stem 0.
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A Hardinge cement restrictor is now inserted down the femoral canal to 16cm depth (Exeter canal restrictors are an alternative)
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The fascia lata is identified beneath the fat and a fasciotomy is made with the scalpel
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A retractor is placed under the transverse acetabular ligament inferiorly, which is located inferiorly in the acetabulum.
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A Charnley Bow retractor is applied with an anterior curved leaf under the anterior fascia lata. Posteriorly a "squared" leaf of the retractor is applied under the posterior edge of the fascia lata.
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The skin incision is centred over the tip of the greater trochanter, distally the incision is straight in line with the vastus lateralis fibres and proximally the incision curves towards the posterior iliosacral joint.