Robotic-Assisted Total Hip Arthroplasty Through the Posterior Approach.

IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques Pub Date : 2025-03-18 eCollection Date: 2025-01-01 DOI:10.2106/JBJS.ST.24.00010
Maria T Schwabe, Joseph T Gibian, Kimberly A Bartosiak, Ilya Bendich, Andrew M Schneider
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引用次数: 0

Abstract

Background: Robotic-assisted total hip arthroplasty (THA) through the posterior approach is indicated in cases of symptomatic hip arthritis. The goal of the procedure is to relieve pain and restore function while minimizing postoperative complications such as dislocation. Dislocation often occurs despite traditionally well placed components1,2. The hip-spine relationship can be a causative factor in postoperative instability, particularly in patients with altered spinopelvic kinematics as a result of spinal fusions or degenerative spine disease, in whom component placement based on anatomic landmarks may lead to functional malpositioning3,4. Therefore, we present our technique for robotic-assisted THA through the posterior approach, which incorporates patient-specific spinopelvic kinematic data to maximize impingement-free range of motion and minimize the risk of dislocation.

Description: Preoperative computed tomography (CT) scans are obtained in order to generate a 3D model of the patient's unique hip anatomy. Lateral lumbar radiographs with the patient in the sitting and standing positions are also obtained preoperatively. The sacral slope is measured in each position, imported into the robotic software, and utilized to aid in positioning the components for optimal leg length, offset, and stability of the hip replacement based on the patient's unique spino-kinematic profile. The procedure begins with 3 partially threaded pins being driven into the ipsilateral iliac crest about 2 cm posterior to the anterior superior iliac spine. The robotic pelvic array is fastened to the pins. A standard posterior approach to the hip is utilized. Skin and subcutaneous tissues are dissected down to the iliotibial band and gluteus maximus fascia. The fascia is longitudinally incised, and a small metallic pin is malleted into the distal aspect of the greater trochanter. Initial leg length and offset values are captured. The short external rotators and posterior hip capsule are elevated. The hip is dislocated, and a neck resection is made at a level determined preoperatively with use of the robotic software. The acetabulum is exposed, and osseous registration is carried out to establish a relationship between the 3D model built with use of the robotic software and the patient's anatomy in vivo. The acetabulum is single-reamed, and the final cup is impacted in the desired position. The proximal femur is broached with increasingly sized broaches until rotational and axial stability has been achieved. A trial femoral neck and head are attached to the final broach, and the hip is reduced. Posterior and anterior hip stability are assessed, and leg length and offset are rechecked via the robotic system. Once the surgeon is satisfied, the hip is dislocated, the broach is removed, and the final femoral stem and head are manually implanted. The hip is then reduced for the final time. Closure is performed according to surgeon preference.

Alternatives: Surgical alternatives include THA with use of manual instrumentation or navigation through other approaches to the hip, including the direct anterior, anterolateral, and direct lateral approaches5-7. Nonoperative alternatives include physical therapy, the use of nonsteroidal anti-inflammatory pain medication, and intra-articular corticosteroid injections8.

Rationale: Robotic-assisted THA is particularly advantageous in patients with abnormal spinopelvic kinematics who require precise and specific component positioning to optimize hip stability9-11. In these patients, manually placing components relative to anatomic landmarks may lead to functional malpositioning and ultimately dislocation. Additionally, cases in which there is an anticipated difficulty in acetabular exposure or preparation because of a large body habitus or large pannus, retained acetabular hardware, or severe acetabular wear or dysplasia may benefit from the use of this technique9.

Expected outcomes: Patients who undergo robotic-assisted THA through the posterior approach should expect excellent clinical outcomes in addition to low rates of complication and revision12. Robotic-assisted THA has been shown to lower the risk of dislocation compared with manual techniques10,11. In a study by Bendich et al., a robotic-assisted THA cohort had a 0.3 odds ratio of reoperation for dislocation compared with a manual THA cohort10.

Important tips: Stable array pins are critical in order to obtain accurate leg length and offset measurements intraoperatively.When registering the acetabulum via the robotic software, aim for maximum spread of captured points to ensure accuracy of cup placement.In large-statured patients or patients with a particularly stiff hip, in whom anterior femoral retraction is difficult, disconnect the reamer from the robotic arm and place it into the acetabulum by hand before reconnecting it to the robotic arm. Remove the anterior acetabular retractor and set the reaming orientation to 50° of inclination and 10° of anteversion. Final cup position is kept in the desired orientation.Remember that the robotic-assistance device is just a surgical tool, and the quality of its output relies on the quality of its input. If there is concern for an error in component placement, intraoperative radiographs should be obtained.

Acronyms and abbreviations: THA = total hip arthroplastyCT = computed tomographyDVT = deep vein thrombosisIT = iliotibial.

后路机器人辅助全髋关节置换术。
背景:机器人辅助全髋关节置换术(THA)通过后路是指在病例的症状性髋关节关节炎。手术的目的是减轻疼痛和恢复功能,同时尽量减少术后并发症,如脱位。尽管传统上放置良好的部件,但错位经常发生1,2。髋-脊柱关系可能是术后不稳定的一个致病因素,特别是在脊柱融合或退行性脊柱疾病导致脊柱骨盆运动学改变的患者中,基于解剖标志的组件放置可能导致功能错位3,4。因此,我们提出了通过后路机器人辅助THA的技术,该技术结合了患者特定的脊柱骨盆运动学数据,以最大限度地提高无碰撞的运动范围并最大限度地降低脱位的风险。术前计算机断层扫描(CT)扫描是为了生成患者独特的髋关节解剖的3D模型。术前还应获得患者坐位和站位的侧位腰椎x线片。在每个位置测量骶骨斜率,将其导入机器人软件,并根据患者独特的脊柱-运动学剖面来帮助定位组件,以获得最佳的腿长、偏移量和髋关节置换术的稳定性。手术开始时,在髂前上棘后约2厘米处,将3个部分螺纹的钉入同侧髂骨。机器人骨盆阵列被固定在针上。采用标准的髋关节后路入路。皮肤和皮下组织向下解剖至髂胫束和臀大肌筋膜。将筋膜纵向切开,并将一个小金属钉锤入大转子远端。捕获初始腿长和偏移值。抬高短外旋体和髋后囊。髋关节脱位,在术前使用机器人软件确定的水平处进行颈部切除术。暴露髋臼,进行骨配准,以建立使用机器人软件建立的3D模型与患者体内解剖结构之间的关系。髋臼是单孔的,最后的髋臼杯被压在期望的位置。用越来越大的拉刀拉入股骨近端,直到达到旋转和轴向稳定。将试验股骨颈和股骨头连接到最后的拉针上,并复位髋关节。评估髋关节后侧和前侧稳定性,并通过机器人系统重新检查腿长和偏移量。一旦外科医生满意,髋关节脱位,拔出拉针,人工植入最后的股骨干和股骨头。然后最后一次复位髋关节。闭合是根据外科医生的喜好进行的。其他选择:手术选择包括THA,使用手动内固定或通过其他髋关节入路导航,包括直接前入路、前外侧入路和直接外侧入路5-7。非手术治疗包括物理治疗、使用非甾体类抗炎止痛药和关节内皮质类固醇注射。理由:机器人辅助THA对于需要精确和特定的部件定位以优化髋关节稳定性的脊柱骨盆运动异常的患者特别有利。在这些患者中,手动放置相对于解剖标志的组件可能导致功能错位并最终脱位。此外,对于由于体型较大或腹肌较大、髋臼固定物残留、或髋臼严重磨损或发育不良而预期髋臼暴露或准备困难的病例,也可受益于该技术9。预期结果:通过后路接受机器人辅助THA的患者除了并发症和翻修率低外,还应期待良好的临床结果12。与人工技术相比,机器人辅助THA已被证明可以降低脱位的风险10,11。在Bendich等人的一项研究中,机器人辅助THA队列与人工THA队列相比,脱位再手术的优势比为0.3。重要提示:为了术中获得准确的腿长和偏移测量,稳定的阵列销是至关重要的。当通过机器人软件定位髋臼时,目标是最大限度地扩展捕获点,以确保杯子放置的准确性。对于身材高大或髋关节特别僵硬的患者,其股前回缩困难,应将铰刀从机械臂上断开,用手将其放入髋臼,然后再将其与机械臂重新连接。 取出髋臼前牵开器,将扩孔方向设置为倾斜50°,前倾10°。最后杯子的位置保持在期望的方向上。请记住,机器人辅助设备只是一种手术工具,其输出的质量取决于其输入的质量。如果担心假体放置错误,应进行术中x线片检查。缩略语:THA =全髋关节置换术;ct =计算机断层扫描;dvt =深静脉血栓形成;it =髂胫。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
2.30
自引率
0.00%
发文量
22
期刊介绍: JBJS Essential Surgical Techniques (JBJS EST) is the premier journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, while utilizing online delivery, imagery and video to optimize the educational experience, thereby enhancing patient care.
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