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The Prevention and Treatment of Femoral Trial Head Loss in Total Hip Arthroplasty

March 28, 2018 | Surgery
Douglas Navasartian, MD, MS ; Paul Allegra, MD ; Benjamin Giliberti, MD ; David Chalnick, MD
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. 

Dr. Navasartian and Dr. Giliberti are Orthopaedic Surgery Residents, and Dr. Chalnick is an Attending Orthopaedic Surgeon, Monmouth Medical Center, Long Branch, New Jersey. Dr. Allegra is an Orthopaedic Surgery Resident, University of Miami, Miami, Florida.

Address correspondence to: Douglas Navasartian, MD, MS, Monmouth Medical Center, Department of Orthopaedic Surgery, 300 Second Ave., Long Branch, NJ 07740 (tel, 732-222-5200; email, douglas.navasartian@rwjbh.org).

Douglas Navasartian, MD, MS Paul Allegra, MD Benjamin Giliberti, MD and David Chalnick, MD . The Prevention and Treatment of Femoral Trial Head Loss in Total Hip Arthroplasty. Am J Orthop. March 28, 2018

TAKE-HOME POINTS

  • Femoral head trial loss is a complication that can occur during THA.
  • This event can be a source of avoidable morbidity.
  • Preventative measures can be taken to avoid this complication.
  • If preventative measures fail, retrieval of the femoral trial head can be performed.
  • A thorough understanding of preventative and retrieval methods is essential for surgeons that perform THA.

Case reports have cited the tension of the soft tissues as a definitive factor in trial head loss.1,4,6 These reports discuss the notion that more tension within the soft tissue can increase the likelihood that the trial head will dislodge during reduction or dislocation. Surgeons should therefore consider taking special care when manipulating the trial joint when the soft tissues are particularly tight and offer significant resistance. It has been suggested that the incision be packed with gauze during reductions when the soft tissue is under significant tension in order to keep the femoral trial head from entering the pelvis.6

A simple technique that can be utilized in the prevention of femoral trial head loss is the placement of a suture through the apical hole in the trial head to aid in the retrieval of the implant if it is lost.1 Madsen and colleagues1 suggest the placement of a No.1 (or thicker) suture through this hole. Although this takes some time to perform, it could prove useful in the prevention of complicated implant loss.

Lastly, and perhaps most importantly, it is essential that there is communication and understanding between the surgeon and any assistants. This has been noted to be particularly important during posterior or lateral surgical approaches when the trial head can be lost during attempts at reduction with traction and internal rotation.2 Given the possibility of losing the trial head during this reduction maneuver, communication between the team during the reduction is instrumental.

RETRIEVAL

If the femoral trial head dissociates from the trunnion of the femoral trial manipulation, there are some techniques that can be used to aid in retrieval. It has been described that when the trial head is lost within the surgical wound, it can travel underneath the rectus femoris muscle and cross the pelvic brim, subsequently entering the pelvis along the psoas tendon, as the psoas bursa offers little resistance to the smooth femoral trial head.1 The trial head has been found to follow this path along the psoas tendon until it is located in the posterior pelvis within the retroperitoneal space.1,7 What follows is a compilation of techniques for approaching loss of the femoral trial head when it occurs.

The femoral trial head is round and smooth, which complicates its retrieval. If the surgeon tries to simply grab the component with fingers, it may slip away into the pelvis. When trialing the hip to assess for anterior stability, if the femoral trial head is lost, the leg should not be moved.7 At this point, a manual attempt to recover the trial head before it moves into the pelvis along the psoas tendon should be made.7 It is possible that the femoral trial head may spin when trying to retrieve it, however this should still be attempted before a formal additional surgical approach is employed.7 It has also been noted that one can manually simultaneously press down on the hypogastrium toward the iliac fossa in order to inhibit the movement of the disarticulated trial head from advancing proximally.3 After performing this maneuver, the femoral trial head can be retrieved through the inguinal canal.3

Continue to: Additional surgical approaches...

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