Additional surgical approaches can also be utilized for retrieval of the femoral trial head if other measures fail. Callaghan and colleagues7 describe a separate surgical approach that can be used to retrieve the trial component after losing the trial head during a posterolateral approach for THA. This technique is commenced by making a 6-cm to 7-cm incision along the iliac crest to the anteromedial aspect of the anterior superior iliac spine.7 The interval between the iliacus and the inner table of the iliac wing is developed, and an attempt is made to locate the femoral trial head and guide it distally along the pelvis toward the hip. Fingers or napkin forceps can be used to accomplish this advancement of the trial head distally toward the hip, and once reaching surgical site, the trial can then be retrieved.7 Further extension of the incision can be made distally if this limited approach is unsuccessful.7 In the event the femoral trial head is still unable to be retrieved, the authors suggest considering a dedicated retroperitoneal approach for trial retrieval after the arthroplasty procedure has been completed.7
Another method for retrieval of the femoral trial head has been described specifically in the setting of a direct lateral approach.8 Kalra and colleagues8 describe a case in which the trial femoral head dislocated anteriorly, and although it was unable to be visualized, the component was able to be palpated posterior to the superior pubic ramus. With the trial head still disassociated within the pelvis, the final implants were implanted. Although the trial was unable to be viewed, using the same incision for the direct lateral approach, the trial femoral head was guided posteriorly toward the sciatic notch. A posterior approach to the hip was then performed using the same initial direct lateral incision used. Subsequent exposure and release of the external rotators and posterior capsule was performed, as was release of the insertion of the gluteus maximus in order to facilitate better visualization and to prevent excessive tension on the sciatic nerve. Blunt finger dissection of the soft tissues was then performed, and the trial head was retrieved from the sciatic notch with a Kocher clamp.8
Madsen and colleagues1 highlight two different cases in which the trial head was lost into the pelvis when using an anterolateral (modified Watson-Jones) approach to the hip to perform THA. As previously alluded to, the trial heads traveled along the patients’ psoas muscle and stopped directly anterior to their sacroiliac joint. In both cases, the trial head was retrieved using a large Satinsky aortic clamp, which enabled the surgeons to drag the trial head to the pelvic brim where it could be removed with a hemostat.1
Multiple authors have discussed the decision to leave the component within the pelvis if the femoral trial head cannot be retrieved.2,4,7 Batouk and colleagues4 noted that in a case of loss of the femoral trial head, the component would be unlikely to disrupt any of the structures within the pelvis, and in the absence of compression of any vital structures, leaving the implant in the patient could be considered. Although the short-term follow-up of 3 months noted in this particular case did not yield any obvious detriment to the patient in regard to symptomatology, the authors note that the long-term effects of such a practice is unclear.4 In another case, in which the decision was made to leave the femoral trial head, the patient at postoperative week 6 began to hear clicking in the hip with an associated loss of range of motion.7 This subsequently prompted removal of the trial component.
DISCUSSION
Although not a particularly common complication, loss of the femoral trial head can occur; therefore, a plan of action should be in place to prevent its loss or to retrieve it if prevention is ineffective. Given the modularity of various arthroplasty systems in regard to the different trial components or even the final implantable prosthetic devices, component loss is a possibility. An understanding of this complication and the appropriate steps to approaching it could aid in preventing patient morbidity. Because of this, it is imperative that surgeons who perform THA be aware of the potential complications and the measures that can be taken to address them.
Continue to: CONCLUSION