10. Acetabular Preparation
The posterior capsule is split at the 5:00 position and the posterior inferior retractor has been placed. The posterior inferior retractor can be placed in either two ways. The point of the retractor can be placed inferior to the transverse acetabular ligament with the wing retracting the posterior capsule, or the point can be placed just posterior to the junction of the inferior acetabular wall and the take off of the ischial ramus with the wing retracting the inferior capsule. It is often helpful to split the capsule at the 5:00 position for retractor placement, although not necessary.

.........................................................................

11. Acetabular Preparation
Soft tissue is removed and reaming is performed in standard fashion until bleeding bone is noted in the periphery.
Tip: The entire acetabulum should be visualized. The transverse acetabular ligament is preserved. The posterior capsular flap can be retracted using a Steinman pin driven into the posterior column.

.........................................................................

12. Acetabular Preparation
Reaming is performed until a bleeding periphery is noted.
Tip: There is no need to move the retractors throughout the acetabulum preparation. Proper placement is obviously the key to visualization.

.........................................................................

13. Acetabular Component
There is adequate room in the distal and anterior portion of the incision to allow for anteversion.
Tip: In a heavy patient, the incision can be moved 1-1.5 cm distally and parallel to the drawn incision to allow for proper abduction of the component.
Tip: Can also use offset positioner/impactor for obese patients.

.........................................................................

14. Acetabular Component
The liner is placed without difficulty. The soft tissue should be removed from the periphery of the component prior to insertion.
Tip: The transverse acetabular ligament is not divided or removed. A 1/2 inch curved osteotome or sharp Cobra are effective inferior soft tissue retractors for liner placement.

.........................................................................

15. Femoral Preparation
The proximal femur is exposed in preparation for a box osteotome and canal finder. The Charnley is not moved. Be sure the patient is paralyzed to ease retraction of the gluteus medius.
Tip: Have your assistant "deliver" the femur into the wound.

.........................................................................

16. Femoral Preparation
The abductors (and piriformis tendon if retained) are retracted with a Hohmann retractor to prevent impingement on the broach during insertion and removal. The canal finder identifies the center of the canal.
Tip: The tip of the Hohmann may be impacted into the anterior column for ease of retraction by the assistant.
Optional: Can use sequential reamers for ream-and-broach femoral preparation.

.........................................................................

17. Broaching
Note the cancellous bone envelope following a broach-only technique. Lateralization of the broach will prevent varus placement.
Tip: The amount of lateralization of the broach should reflect preoperative templating. In a varus hip, the broach should extend further into the trochanter. A canal finder prior to broaching will also help with this decision.
Tip: If a porous-coated prosthesis is selected,
it may be necessary to seat the broach an additional 2 mm to reproduce the height of the trial.

.........................................................................

18. Trial
The trial is placed and the height of the prosthesis should correlate with preop templating. This is measured from the tip of the trochanter. A spinal needle may be used to identify the tip.
Tip: The spinal needle should be parallel to the shoulder of the prosthesis for accurate height measurement.