---
title: 'Intra-operative Overview'
type: 'lesson'
url: 'https://doc.social/courses/robotic-total-hip-arthroplasty/intra-operative-overview'
course: 'Robotic Total Hip Arthroplasty'
course_url: 'https://doc.social/courses/robotic-total-hip-arthroplasty'
position: '3 of 4'
author: 'Cory Calendine, MD'
transcript: 'yes'
---

# Intra-operative Overview

## Summary

_This lesson is a recording without a written summary._

## Transcript

2,234 words · 11 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: So we're gonna, we're gonna go into Surgery. So this is, you know, direct anterior. We use a hand to table. Uh, the, the obvious thing, I, I mark out the Hip, uh, beforehand because someone drapes for me and the last thing I wanna do is have my iliac crest under the drape. Um, so there's an iliac crest, greater trope, and then pretty much straight incision.
[0:21] Speaker 1: In the back of my head. Sorry about that. Um, we'll pause it here cause we skipped a whole bunch of things, which is OK. It's just a routine direct anterior.
[0:31] Speaker 1: Approach. Uh, it's a close-up, so this is a retractor above the femoral neck. This is kind of over the front.
[0:39] Speaker 1: This is inferior femoral neck.
[0:42] Speaker 1: The tensor is right here. It's being retracted by a cobra.
[0:47] Speaker 1: This is your vastus.
[0:50] Speaker 1: And I've created a little spot right there where we're gonna put a femoral pin. So we're gonna do enhanced. Enhanced means we're gonna put a femoral array in and that's tabular array. Uh, and so in order to do that, you need to put a, a site where you can put a femoral array, and what's unique about the femoral array is you'll see we'll put a screw here, but the array is removable, so you can put it in, use it while you need it. The screw stays behind.
[1:15] Speaker 1: Work on the, the femur, work on the cup, come back, put the array in. So it's a removable array. It's.
[1:20] Speaker 1: The only one that is removable. So it's just a little starting hole.
[1:25] Speaker 1: And uh the key here is you can, the trochanter is up here buried underneath all this, so you kind of aim it towards the troch. You don't wanna be out in the canal because you don't wanna broach into the screw, you'll lose your array. So again,
[1:39] Speaker 1: In Faac, Superac had.
[1:42] Speaker 1: Back of my hand, uh, lateral femurs right there and just kind of aiming towards where you think the troch is.
[1:50] Speaker 1: And the screw has a little slot in it.
[1:53] Speaker 1: We'll let it keep going.
[1:56] Speaker 1: And you'll see the array has, you know, a stem with a little post on it that locks right into it.
[2:02] Speaker 1: That stitches just so I don't lose it.
[2:07] Speaker 2: And I assume those go in your counts, you know, so you don't leave that little screw in.
[2:11] Speaker 1: Yeah, so there's a good, good view of the screws. So it's a regular screw. It's got a slot here and here. So the femoral array is going to lock into it, and it's going to retain that position if you put it on the back table and you can drop it back in that screw and.
[2:24] Speaker 1: And regain all your, all your data and never lose any of your data.
[2:27] Speaker 1: Uh, like everything Mako, there's a checkpoint, and that makes sure that you haven't bumped the array. It's like a little thumbtack, and we put it right above the, the, uh, screw we just placed.
[2:37] Speaker 1: Uh,
[2:38] Speaker 1: We put them in the same spot every time, so it's easy to find. And again, that's part of your account that's retrieved at the end.
[2:48] Speaker 1: Any
[2:49] Speaker 2: issues, I mean this is, this is low enough on the trochanter you're not worried about Fracture or
[2:56] Speaker 1: everyone, everyone worries about that, but it's, it's not on the trochanter, it's
[3:00] Speaker 1: It's kind of lateral to the, I'll pause it for a minute.
[3:05] Speaker 1: See what we get. That
[3:05] Speaker 2: may
[3:05] Speaker 2: be a better illustration,
[3:07] Speaker 1: right? Yeah, so your, your femoral head's here, superior neck, inferior neck, lateral femur is going down here. Vastus is this big muscle right here. There's an inner trochanteric ridge that goes right along there. And if you go just lateral to it, it's kind of a flat area and your troch is way up there. Um, so, you're in the anterior lateral femur. Yup.
[3:31] Speaker 1: So the arrays in, the camera's over my left Shoulder here.
[3:36] Speaker 1: And what we're doing with this probe is
[3:39] Speaker 1: Registering the femur and basically, the computer will prompt you to give it 40 points and this, this probe is a bone to bone model so it goes through soft tissue, goes down the bone cause it's gonna match your CAT scan.
[3:53] Speaker 1: Versus, you know, a navigated system where a navigated system is not bone to bone, it's all soft tissue or some bone or some cartilage. It's, it's somewhat inaccurate. Um, well,
[4:04] Speaker 2: it's, it's checking you, right, but it's checking you back to three dimensional truth, if you will. So, you know, if you're wrong, it's gonna tell you you're wrong, right?
[4:14] Speaker 2: Yeah.
[4:15] Speaker 1: So, so there's, you know, so we're just running a foot pedal and basically there's the little blue dots and you just capture these points, confirm it.
[4:23] Speaker 2: Yeah, when I had residents come down with me, they're 40 points. I, I would tell them they have 40 seconds, right? I mean, this is pretty quick, otherwise I'm gonna, I'm gonna take over.
[4:32] Speaker 1: Yeah. And so in part of the discussions, you know, a lot of guys say, well, enhanced is too long versus expressed. So we've actually, we time everything. If you guys tell me it's too long, and we're gonna get it timed. So we time putting in the array registration and doing the osteotomy, and the average is about 2 minutes.
[4:52] Speaker 1: Um, so you get a really high level of accuracy for about a 2 minute.
[4:56] Speaker 1: 2 minutes extra on the case.
[5:00] Speaker 2: Yeah, not, not crippling, and I know you have a great system there, but obviously you're high volume, nothing's slowing you down, um, you know, with this, um, and, and you don't have X-ray or anything. You're not bringing it in. You know, a lot of guys, they'll bring X-ray in to mark their neck cut or something. Obviously, those steps are all gone.
[5:16] Speaker 1: Yeah, no, there's no X-ray. I hate lead. Do you like operating in
[5:18] Speaker 2: lead? No, it's hot. I'm, uh, I'm a little chubby, and so I don't like the extra weight. Yeah,
[5:25] Speaker 1: it's awful. And, you know, the Other thing with X-ray, unless you have a dedicated team.
[5:29] Speaker 1: You get like a new X-ray tech every time and then you get the student who comes in. It's just like, just, it just shoot me, it's terrible.
[5:36] Speaker 2: Yeah, you're talking about before and after 3 o'clock and during lunchtime and break. Oh, no,
[5:39] Speaker 1: just anytime you do X-ray. I hate doing X-ray. So I haven't, so since we started this, I mean, I haven't used X-rays since, I don't know, 2012.
[5:48] Speaker 2: Yeah.
[5:50] Speaker 2: Mako doesn't take breaks, right? I mean,
[5:53] Speaker 1: doesn't take what
[5:54] Speaker 2: doesn't take breaks,
[5:55] Speaker 1: doesn't take breaks. They're always there. So there's a registration. So again, remember the 3D plan. There's that osteotomy, that green line.
[6:03] Speaker 1: So it's not robotically cut, it's just robotically guided. So you take the probe and you
[6:10] Speaker 1: Take a bovie and do a little line and then you cut on the, on the line. And you can see there, the femoral array is removed, the, the screw is in place, but the array is removed. So we do the osteotomy. Um.
[6:22] Speaker 1: So you basically you, you cut on the Bovie, on the Bovie mark, and I can tell you right now I cut a little long on this Bovie mark. So, and, oh, let's give you a quick pause. How much time do we have? We doing all right for time or am I killing? OK,
[6:35] Speaker 2: we're
[6:35] Speaker 2: about 5:30 and we got uh 10 minutes and 54 seconds left in the video, so we're good. All
[6:40] Speaker 1: right, so we'll keep going. So one of the things is I'll let it keep going. I'll keep talking over it is, um, I do broach first and
[6:50] Speaker 1: And that's kind of different. Most anterior guys put in the cup. You put in a cup first,
[6:54] Speaker 2: Corey? Yeah, cup
[6:55] Speaker 2: first for me. Yeah,
[6:56] Speaker 1: yeah, that's kind of traditional. I do brooch first, and, and then my thought on it was, well, there's a lot of thoughts on it, but the most recent thought is if I do the brooch first and I measure my version.
[7:08] Speaker 1: And I like my version or I don't like my version, I still have the opportunity to change the cup a little bit, um, for that concept of, um, combined an aversion.
[7:18] Speaker 2: I, I, I like that. I like that a lot, and you and I have obviously talked about that, um, because, you know, you have more flexibility in the cup side than probably the stem like we were talking, uh, there is some flexibility but not eternal flexibility. I was always worried about, uh, you know, bleeding in the canal, but you just put the brooch in and leave it in, right? I mean,
[7:37] Speaker 1: so.
[7:37] Speaker 1: Yeah, so the challenge, so what I was learning, uh, I always thought getting the goddamn femur up is really hard. So why not do the hard thing first, right? So I started doing femur first long before I could measure brooch. And, and then the next phase was, all right, now you put the brooch in.
[7:53] Speaker 1: How are you gonna put a cup in around the brooch? Um, but with the Hana table, I'm gonna pause it here for a minute. With the Hanna table, you can move the leg and that brooch gets right out of the way. Now, a perfect brooch would not have this little dimple. That would be really great. But even with the dimple, you'll see you can get, you can get around it.
[8:11] Speaker 1: So this is the view. If you look in the top right, that's the broach version view and so if it looks like this, it should be 17 degrees. So you can kind of visually look at this and say, well, I think it's 17 or I think it's 15, or you can measure it.
[8:28] Speaker 1: So
[8:30] Speaker 1: I, the MPS always ask me what, you know, Dave always asks what do I think it is. I give him a number, he writes it down, and then they, then the brooch, you know, we measure and it proves me wrong or proves me right sometimes. So what we'll do is we'll put the neck on and if you look at the neck.
[8:46] Speaker 1: Here we go. It's got 3 little dimples. So if you put the neck on, put the femoral array back, and you give it 3 points, you can measure the plane of the brooch really easily. So we'll do that.
[9:00] Speaker 1: So we'll bring the leg back over and up a little internal rotation. Yeah,
[9:05] Speaker 2: you're at your final size here, so you, you're not intending to change the stem, I guess you could put a smaller stem in and see where you were and then, you know, broach up, but you're, you're not doing that
[9:15] Speaker 2: here.
[9:15] Speaker 1: No, so I, I would do that. That's a good point. So if, if I had some crazy introversion, that's, you know, 30 degrees introverted and I'm gonna get up to a 6 stem, I would have tested like the 2 stem, see if I can dial it back. If I'm in the right plane, then I would, you know, try to get all the way up to a 6.
[9:30] Speaker 1: So, here's what I did. Let's pause it. I'll show you.
[9:35] Speaker 1: Maybe I can pause it. So if you look over here, I gave it 3 points and the roach version, my eyes are fading to. I think it says 18 degrees, right? So we, our visual is 17, we measured 18.
[9:50] Speaker 1: But if you look down here, my cut was off. Look at the difference. I'm 11 long, so my osteotomy, even though it was robotically guided, my eyes cut a little long, so I'm a little long. So it gives me preliminary data on my broach version and where my
[10:04] Speaker 1: Length is on my osteotomy.
[10:06] Speaker 1: Um,
[10:09] Speaker 2: Yeah, it's interesting to think about just to be clear, there's no cup in there, it's just going based on your femoral position because we're doing a femur side first so you're getting a lot of information from this pathway.
[10:21] Speaker 1: So what I'm gonna do is go back and I'm gonna bury the cup just a little bit, and I know I'm gonna bury the brooch or the brooch, bury the final stem just a little bit to make up that difference. You could go back and recut it, but I thought the cup was OK, so when we change it around, I move the cup, I go back and check and some 7 longer, 3 increased, and we'll keep it for now. So here's the, the view of the, I'm gonna pause, the view of the Stum.
[10:47] Speaker 1: So there's your femur. There's your ostemo up here, one retractor, one cerebellar. Checkpoint goes on this side. It's about, uh, it's about 1 o'clock, and the checkpoint is a little bigger than the one we put in the femur, and that has the number 5 at the bottom on it too, so I don't lose that.
[11:05] Speaker 1: And then we'll go ahead and register the tabammen and put on the ostabular array. So this is a 33 pin, uh, procedure. It's right in the iliac crest. It's just 3 parallel pins.
[11:17] Speaker 1: And with an S t array.

## In this course

- [Previous: Pre-operative Planning](https://doc.social/llms/courses/robotic-total-hip-arthroplasty/pre-operative-planning.md)
- [Next: Summary Discussion](https://doc.social/llms/courses/robotic-total-hip-arthroplasty/summary-discussion.md)
- [All lessons: Robotic Total Hip Arthroplasty](https://doc.social/llms/courses/robotic-total-hip-arthroplasty.md)