Preventing and Managing Intraop Complications| Anterior Hip Fundamentals| Eric Cohen

Added: 2026-04-29

[00:00:00][Music] What I'm going to talk about today is uh basically the complications that I've had or I've seen and uh hope that you can learn learn from them. Some of them are common sense. Um some of them you've probably never seen before and hopefully never do uh because you learn from this talk and then there's I think a few kind of life lessons that translate from the uh O to life. So I put together the Cohen top 10. I don't know how many in the room actually know who David Letterman is anymore. It's a pretty young room, but uh he had a nice top 10.

[00:00:33]We won't I won't make you do a drum roll or anything at the end. Um so bear with me here. All right, so patient selection. So bigger isn't always better when it comes to direct anterior approach when you're doing your first, you know, 50 cases. I think you should choose uh choose your cases uh appropriately. And uh you know that we already talked about the wide iliac wings, the short various necks, the stiff hips, that's your working distance. Um and so those are the ones you're going to want to watch out for early on. The hip flexion contractions and the hip fusions are going to make femoral exposure uh difficult as you know Matt Darren told us earlier.

[00:01:12]Number two, preop preparation. Success is not about luck. It's about preparation meeting opportunity. And I I believe that in the O and in life. And so really it starts from the very beginning. It starts with setting the patient and family expectations about what the surgery is, what you expect for the recovery, and how you expect them to recover. It starts with pre-operative templating like we saw earlier. Uh knowing the sizes of your implants, discussing with your rep, having them bring everything that you think you might need. And that's not just bringing one of everything, that's bringing two of everything. because one of the complications is that uh one you know 54 cup that you needed hitting the floor and uh now you're in the ASC and the next cup's an hour away. Um so planning ahead is going to be key. I know it's obvious probably doesn't need to be said in this room uh but I I've I've experienced that. And then team team member briefing if I know I have a hard case I'm involving everyone in the room before I start that case. I tell them hey this is going to be a difficult case. this is why this patient's, you know, BMI is 45. They have this it's a it's a fuse tip. It's I might need an augment. Uh this is plan A, B, and C, and this is what I might need. Just by doing that, one engages the entire room.

[00:02:23]It also um m makes them kind of work for you. They'll run, help you, and every time I do that, I find the case goes easy. It's actually the hardest case of my day ends up being the easiest case of my day. It's usually the easy case that maybe you overlook. So maybe do this for everybody.

[00:02:40]Number three, room and table setup. So, we had a lot of information today about the room and table. You'll really want to make sure you're set up for success, and no one's going to care more about this than you. Um, I think the vast majority in the room are using handed table, and there's a lot of dangers with the handed table if you're not careful.

[00:02:55]Uh, you know, make sure the bed is locked. That's the obvious. Make sure you have a safety belt that's above the spar, not under the spar. Uh, you want to make sure that the boot is actually locked in to the to the spar and that nut is tight. So, if you have the nurse or your assistant rotate the leg to 120 degrees and that boot's not locked, it's coming out, it's hitting the floor. Um, and I see that happen a lot with junior surgeons. So, it's something that's really overlooked. It's very hectic.

[00:03:20]You're getting set up for the big case.

[00:03:22]You're excited. Check and make sure the patient's actually locked in on the bed.

[00:03:26]And then finally, uh, do not remove uh, the handed table's a very narrow bed.

[00:03:30]Like it was said earlier, don't remove that post until you're ready to move the patient. Uh it actually happened at one of our hospitals. Someone removed the post, turned around to do something else, turned back, patient wasn't there on the floor. Okay.

[00:03:46]Number four, draping and incision placement. So, I don't care how you drape, you need to drape everything in and plan for the complication. You need access to the iliac wing. You need access to the entire femur.

[00:03:59]And um although I do like a big heating incision, I'll say if you have a difficult case and you're starting out, vertical incision is extensile. You can extend that into a lazy ass incision incision. We're going to hear about that here in a in a minute. How to do an extension. Uh but no no reason to be cute and do the bikini incision in your first 50 100 cases or maybe a complex complex case. Uh you really should be doing a vertical incision. Um there's a lot to be debated about that. There's going to be great debate later, but uh that's my two cents on that.

[00:04:30]Number five, the correct interval. So this is for life and in the Os. The two most important requirements for major success are first being in the right place at the right time and second doing something about it. And so what I mean by that is you get very excited to get down and do the case, but you want to make sure you're in the right spot. Uh the elderly thin female that's sarcopenic with a small tensor, it's an easy case, right? Well, what's not easy about it is their tensor is actually about this big. And it's very easy to overlook the tensor and actually get caught medial. Uh, so a couple things I'm always checking on these cases is I'm making sure I'm lateral to the ASAS.

[00:05:06]If you're medial, you're lost. So remember, if you're you're lost if you're medial. So palpate asas, make sure you're lateral. And then you can see here there's a little fascia over top of the sartorius. So the tensor and the storius look very different. The tensor is just straight muscle fibers.

[00:05:23]And the storius actually has a fascia and aims it does aim a little medial, but can be difficult to tell in a very thin sarcopenic patient. But that fascia, if you're medial to that fascia over top, you're heading in the wrong direction. You're heading into trouble.

[00:05:35]So those are my two big checks when I'm trying to make sure I'm in the correct interval to start.

[00:05:41]Number six, careful anterior retractor placement. You do not want to get on the femoral nerve. So if you are placing an anterior retractor, always use two hands. I'm going perpendicular to the ilinguo ligament and uh making sure I'm staying on bone. So that's going to be on a right hip in the 30 to 60 degree mark. Um if you're heading directly medial or 90 degrees, the femoral nerve is 16.6 millimeters away. And while femoral nerve pauses are rare, they're not impossible. I've had them in my own practice and they are they actually present kind of subtle. It's not like a foot drop that you see in a posterior approach from a satic nerve injury. you know foot drops pretty pretty obvious to everyone. These patients will present with some medial thigh numbness and some even buckling of their knee or their knee will give way. They may actually fall um with a femoral nerve pausy and it may present a day or two later and like slowly progressive from swelling.

[00:06:35]Say you got the retractor too medial and got a bleeder that's right next to the femoral nerve. So be aware of that. So it's the number one causes are aberant retractor placement, excessive traction.

[00:06:45]So, um, again, the small female, uh, with the gener degenerative spine, you know, if you have your assistant, again, communication, if you say, "Okay, pull traction," and they're pulling as hard as they can, you know, they're going to pull that whole leg off, well, what's going to happen is you're going to have basically a double crush phenomenon. So, they're going they have already some lumbar spine disease and now you're pulling traction on the nerve and and they'll present with a nerve pausy and then being in the wrong interval. The treatment has ruled out other causes.

[00:07:14]So, I'm always thinking, can this be a disc? Is this an acute disc that's treatable, right? The vast majority aren't caused by any anything else but uh your error and so it's, you know, patient counseling discussion. Most of these resolve in about a year, unlike sciatic nerve pauses. Um so, you just kind of have to be patient and uh counsel them. I treat this with a knee immobilizer if their knee is buckling and then uh steroids IV decadron um 10 milligrams Q6 while they're in the hospital then send them out on a medal dose pack uh to minimize uh femoral nerve swelling and also to treat concominant uh spine disease.

[00:07:52]If you get way medial or loss, this is probably like the worst complication you can think of uh in the anterior approach um is the femoral artery like a femoral artery injury. Um it's uh if it happens it's an emergency. You need to notify the anesthesiologist up top. They need to get blood in the room. You need a vascular surgeon to come. If you're an ASC or a vascular surgeon's not available, I mean you literally have minutes. So I think anyone who's doing anterior approach, and this may not sound extreme, you should at least know how to do a femoral artery cut down.

[00:08:23]We're all orthopedic surgeons. uh you should know how to get control of the vessels until someone can come help because this would be a patient's life on the line if you got into a femoral artery. So how do you do a femoral artery cut down? So you're going to palpate the pubic tubacle in the SAS.

[00:08:37]You're going to go midline in between about 8 incision. Remember it's a trauma situation. So bigger is better. We're not going for small incisions here. Uh you're going to head towards the medial knee and you're going to be proximal.

[00:08:47]You want to be proximal to the groin crease. The femoral artery goes under the inguinal ligament and u ligament is proximal to the groin crease. So you need to make that incision through skin and subcutaneous tissue. You can use two big rakes and and spread pretty aggressively here until you see a fascia. The fascia is going to be white tensor fascia. You make an incision in the tensor fascia and then the neurovvascular bundle is going to be right there. The profunda artery comes off, you can see here, comes off posterior and medial. And so you use a vessel loop and gain proximal control of the femoral artery until you can get your vascular surgeon there. So I've luckily I've never experienced this. Uh I don't want to ever experience this, but I have uh spoken to surgeons that have experienced this and uh it's a dreadful complication.

[00:09:32]Number seven, protect the anterior wall.

[00:09:35]The anterior wall is your friend. It's kind of been discussed a lot. it it is your friend. You need the anterior wall.

[00:09:42]Okay, it not only protects uh from impingement for front of the ios, but it also gives you fixation, right? And so I'm feeling the anterior wall before I start. There's some patients that actually have kind of a small shallow anterior wall. So those are ones you're going to want to be extra careful with.

[00:09:57]The sclerotic posterior bone, uh especially if you're using a single reamer, can push you up anterly and all it takes is just one second. And Charlie was talking about hearing. You'll you'll hear a hear a crack. you'll hear hear cortical bone being missing and then it's over there. There's no there's no more anterior wall after that. So, I'll ream into the posterior posterior bone a little bit to make sure it doesn't push it push me up anterior. A long neck cut uh can push you up anterly and make acetabular access difficult. So, if I'm having issues, I'll actually revise my neck cut uh for those. And then a large tensor and a big muscular male obviously is going to push you up anterior as well. I always ream anterior to posterior. So my hand, the reamer, straight reamer is going like this. Um, so I can tuck the reamer under the anterior wall. So again, so I'm not accidentally going to grab some of that anterior wall. You don't want to oversize the cup. If it's a displacic hip, you know, and you measure the femoral head on the back table, the the cup size is going to be about the size of the femoral head or maybe even a touch smaller on a displacic hip. And for our standard hip, it's usually within four millimeters. So if you're getting way above your templates, um, that kind of means there there's a problem.

[00:11:06]So, how do you recover? If you have room to medialize, you can continue to medialize. That will effectively create more anterior wall. Um, but if that if you don't have a lot of room room for medialization, then you're really relying on a pinch between your anterior and posterior columns and it turns into a revision situation. You need a slightly larger cup. I go multihole cup and then I put my inferior screws in first. So, when I So, when I put the superior screws, the whole cup doesn't just go vertical. So, you'll always need inferior screws to anchor it down and to gain that rotational stability like you can see in this X-ray here.

[00:11:40]Exposure. Everyone's talked about exposure today is certainly the most important and I would argue the femoral neck cut is probably the most important part of the entire case. It is really going to dictate the tone of the case, the cadence of the case. It's going to allow easy acetabular exposure. It's going to allow easy femoral exposure.

[00:11:56]And what I mean by that is I use the anominant tubacle as a as my landmark.

[00:12:01]And very similar to Eric who presented earlier, um I want my neck cut to go directly in front of or proximal to the anomal tubacle into that lateral cortical bone. That allows me to get lateral with my brooing. It also makes it very easy for my bo to go straight across and and do my femoral release. If you have a big lateral shoulder, it's going to be hard to place that retractor. It's going to be hard to use that boi. And then you want to always make sure you complete your neck cut medially. Most importantly, you can't just crack crack it open. If you didn't complete it medially, that's when you're going to calar fracture. And if you cut too deep posterior laterally, that's going to be a greater trocanter tip fracture, which I'll show earlier. Um, doesn't affect patient recovery, but it's kind of style points.

[00:12:44]Another uh advantage, another femoral exposure. If all the resets and releases that um Matt Darren told you didn't work, you can then do a quad snip similar to a quad snip and a total knee and that it gives you better exposure.

[00:12:58]Doesn't change your protocol and um doesn't affect the patient.

[00:13:05]Now, if you have a fracture um it all depends on what the fracture is. You you have been given the tools to fix it. the greater trocanter fracture actually don't worry about okay the beauty of the anterior approach is you don't violate the abductors you don't violate the vasis lateralis and so that complete soft tissue is intact so this is a complex revision that I did there's a greater troanter fracture and at a gear it it healed in and followup with no fixation this is just a picture of a greater troanter tip fracture that you just have to see every year and follow up when they come back it's just a reminder that uh you kind of kind of messed up on your neck cut Calcar fractures treated just like it would be any other approach uh with a removal of the stem cable and a final stem and then diaphysical fracture.

[00:13:51]You're going to use that extended lazy S incision. We're going to hear about you need a cable and bypass it with a diaphal stem.

[00:13:59]Number nine, the femoral head. Don't lose your head. So don't lose your head in the O and don't lose the femoral head in the O. um those are are two never ever events uh for you in the anterior approach. So if I have a hard case uh like a tight rectus, a hip flexion contraure, or we're trying to gain a lot of length, a patient's really short, I'll go ahead and tag the femoral head uh so I know I can easily retrieve it.

[00:14:24]Or if I'm letting the fellows reduce the hip, I'll usually tag it so I know they won't lose it. And then I always keep my finger on the femoral head as we're reducing it to keep control of that.

[00:14:33]Same with the dislocation as well because if you don't keep track of it then you know it's going to be lost in space and uh that's kind of an oh [ __ ] moment. So uh what happens is the ball will go up under the rectus into the ilosas and go into the inner pelvic brim um up into that iliosus bersa and you're going to need to retrieve it and that's why you need to really drape out the iliac wing not just for a proximal exposure but so you can do a lateral window. Uh you're going to make an incision over the iliac wing through the fascia. you can actually dissect the iliacis off and gain access to the inner pelvis. Now, if it gets pushed retroparanal, that's a whole different story and you got to call general surgery. That's a that's an open abdomen case. Again, another another bad day in the O.

[00:15:17]And then number 10, scrutinize inoperative images. If you're taking fluo, you need to look at it. A picture is worth a thousand words. And I think really what it comes down to is tunnel vision. And you get so focused on one thing, like I'm going to look at the femur. I'm going to look at how good my cup is that you actually miss everything else that's going on. So, really scrutinize your in interoperative images. I think experienced surgeons are doing this kind of naturally, but as you start, if you if you haven't seen a complication, then then you don't know uh what to look for. And so, what I'm looking for on my images, I'm getting AP and lateral images. I'm checking the fit, fill, and alignment of my stem. I'm making sure there's no perforation of the femur by getting the two laterals.

[00:15:58]looking at uh cup position uh and making sure there's no fracture of the acetabulum or the femur. And then I'm making sure the c the cup and ball is concentric. Um you can have bone pieces that can affect you know making it eccentric or maybe the wrong head size was opened and you put a you know a 36 instead of a 32. Uh these things have happened and you can catch this before you leave the O and fix it. And if you don't then you're going to have a bad day in the O. So, this was just an AP was obtained. Um, you can see that something's going on on on the on the PACU X-ray that the stem's kind of over the lateral medial cortex. Let's get another view. Boom. Out the back.

[00:16:41]Posterior cortex perforation. Bad day.

[00:16:44]Need to go back. And how you deal with cortical perforations is um you can graft them and then just bypass them with a with a stem. And then the final bad day in the O. Hope you guys remember all of this so you don't make any of these mistakes. Is this was uh a acetabular revision loose cup. Um you can see on that fluo image it looks like you're kind of seeing a lot of the trunion for a plus five head. Well patient got up the next day. I I think it was uh the ball was pulled off with the reduction from probably a rectus or not enough exposure. again more exposure and a patient stood up and uh well basically dislocated her hip right like the tr the ball's no longer on the trunion so she had to go back there's a 32 plus 5 head looks looks better on the trunion again the ball looks concentric on the in the cup it's not eccentric there's no bone in there and uh that's how the x-ray should look you know that's kind of typical tunnel vision there so I think I'm a little over time but you know thank you all for listening and I hope you can learn from my mistakes and not make the same mistakes again.

[00:17:51][Applause]