19. Trial
Once the trial prosthesis is removed, the final prosthesis is inserted.

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20. Final Prosthesis
Again, the depth of the final prosthesis is checked with a spinal needle and ruler.
Tip: Measurement is facilitated by your assistant internally and externally rotating the leg.

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21. Femoral Head
The femoral head is impacted. A sponge protects the head from the flat retractor. The taper is exposed and cleaned meticulously prior to head placement.

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22. Reduction
Prior to closure, final soft tissue tension and stability are checked. It is important to check the acetabulum for soft tissue prior to relocation.
Tip: In a hip with no significant shortening and soft tissue contracture, normal tension is defined by the assistant tensioning the leg until the femoral head subluxates 50%-75% out of the acetabulum.

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23. Capsule Repair
A posterior soft tissue repair is then performed. The piriformis and capsule are sutured to the posterior border of the gluteus medius.
Tip: Not placing the sutures through drill holes in the trochanter will help prevent early postop failure.

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24. Capsule Repair
A posterior soft tissue repair is then performed. The piriformis and capsule are sutured to the posterior border of the gluteus medius.
Tip: Your assistant can externally rotate the leg to facilitate tensioning of the piriformis.

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25. Capsule Repair
The suturing continues along the border of the medius to create a soft tissue sling. Figure of eight sutures are used for the remaining repair.
Tip: Digital palpation of the sciatic nerve will add comfort to completing the repair. Typically 4-5 #2 Vicryl sutures are used.
Alternative Capsule Repair
After implanting the components, 3 #5 sutures are used to repair the posterior capsular flap and external rotators in the following manner: The
capsular sutures are placed so that the posterior flap is advanced superiorly approximately 2 cm and secured to the superior edge of the capsule (under the piriformis tendon and gluteus minimus muscle) using the sutures. When advanced in this fashion, the capsule becomes tightly constricted around the prosthetic femoral head and neck in a noose-like fashion. This closes dead space, provides a significant resistance to dislocation, and yet allows excellent range of motion of the prosthetic hip.

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26. Closure
The gluteus maximus fascia is closed with a running #1 Vicryl suture. Abduction of the leg will relieve tension on the gluteus tissue for repair.
Tip: It’s all downhill from here.

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27. Final Measurement
Final measurement of the incision is made to prove you could do it.
Tip: In heavy patients, bruising of the edges of the incision may be noted. This has not led to any long-term problems.

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28. Postoperative
Postoperative x-ray shows the restoration of length and lateral offset.
Tip: Nothing more to add except weight bearing as tolerated.

steps 1-9  |   steps 10-18  |   steps 19-28  |   Instruments