Dr. Adam Rothenberg delivers key insights based on his experience performing RI.HIP cases.
I'll just try to run through those a little bit for those D. A surgeon out here and I think there's some that have a general applicability. Um I think um you want to remove barriers to visualizations, You want drapes that aren't cumbersome. You want drapes that don't pull or tug at your a racist, you know your raise. I think that getting the painless femoral ray is a little one of those learning curves that you just wanna avoid my mistakes and just go ahead and throw a co ban on it. I think the oven has a little play in it. I like to have co ban on the leg then rapid but you know to each their own plus taking the band off of it. If you were trying to use that it's a real pain for your to get it clean. Um You want to get your A. S. I. S. Points right? So you really want to harp at the beginning of making sure on your trauma cad that your basis points are consistent and something that you can palpate and feel. You can double check this work early on. There's a caliper that comes with the trauma cad system and what you do is you you add on, it doesn't wanna do this automatically. When you're doing the trauma cad, you measure between the two S. S. Points you picked and then you will go to your patient put the calipers on them while their position and get that distance between the two S. I. S. Points to double check kind of cheat a little bit to know exactly where you want to feel it on the patient there's a bypass for this on the lateral approach. But I would recommend use this information on the anterior approach. You know, I like to again just make sure I'm being consistent about sterility, wrap the leg. Use double check your drapes, then it's not gonna pull Use four. Oh pins. Like we talked about to make sure the T. R. A. is strong, angle your placement of the pelvic pins slightly towards the midline and cephalopod. That way you get it away from your broaching and out of your assistance area of placing retractors for short patients, you want to get that you want to move the base towards the head. There's a way you can either point towards the toes or towards the head, visibility makes it better to have it pointed towards the toes and it avoids the abdomen but there's a minimum distance for the system to work where you would if you're not it won't pass at the beginning if you're too close and in that case you can switch it so that it's pointing towards the head. Which I believe is the technique officially I just like if I have a regular tall patient, I don't like five ft 10 or taller, they can usually point it so that if the array is more visible. Um I've had it where the teeth were teeth were on teeth and if you're not fully engaged, just like with Corey, you know something slides, it's gonna just make it useless later so make sure it's totally engaged and then rotate your maximize your internal rotation. So you can get that that trip point as far lateral as possible. That's gonna make your offset and length measurements that much more accurate. Um You want to collect your A. S. S. Points on the skin, don't, you don't need to make an incision like you might in other systems. Um Really important that whatever whether you're doing a lateral approach based approach or an anterior approach that you know where the leg is in position. So you can go back to that and double check that your where you're putting the leg is where you have it at the beginning. Um I've had some cases where I was tipped off that something moved during the case because I had to put the leg in a totally different position to get the measurements at the end and for like a you know a heavy B. M. I. 40 to post your approach patient and I've got a padded mayo stand and then I, you know, maybe the leg drops or something moved. You don't want to use those numbers for some reason something moved. So it's really good feasibility, you know, double check during the case. Um One little thing if you've got lots of Oslo fights or there's something throwing it off, You can do a little bit of a gentle ring um, to kind of start the process of getting sizing airplane, the bed to see better for mapping. Um, if you're head diameter is way off from your template, just really consider just getting doing the points one more time. It's not that hard time consuming. Just make sure you're getting a good range of points. Um, you may um, you wanna definitely hear that this is important using the store button or giving your time, the system time enough to have the orange lights kind of set up so that you make sure you're getting the numbers that you want to double check at the end of the case. Um and then, um, if you're a straight impactor guy, there's a kind of a, you can kind of leave the tracking rails a little bit loose and then put the cup where you want it and then put it where the camera can see it and then tighten it. Um mhm. And then, uh, here's one literally just knowing that you put the clicker over the shortest peg of the point pro because there's, you can put it in other places and it won't work and you get really frustrated and like why isn't this working? And that's why they're just making sure there's a little attention to detail to get the system that works smoothly. Um and then really keeping those clean and free of debris and having your assistance do that throughout the case, you're not wasting time as you go just having your search, your scrub tech just be like, okay, I'm gonna make sure that they're titan secured clean throughout the case and ready to go with a wet drive. You need it. Excellent question. I think we need more us, you know, us users using the system to study this into make a final determination of which way we should go with it. I think that my reading from the leaders that have led us to um you know in the literature too understand that adjusting for public tilt is an important component is that post your public tilt, especially in the setting of lower lumbar spine stiffness is a more concerning um tilt and so in post your pelvic tilt patients. I tend to use I use the functional pelvic plain for my cup positioning for anterior pelvic tilt patients. I tend to essentially work between the anterior as the an atomic pelvic plain and the poster functional public, Sorry though, for anterior pelvic tilt, I tend to work between the two different plane options and view them simultaneously. Um there's some literature to see us that anti republic tilt up to 13 degrees can be due to hip flexion contractors. And so uh the you know dr vic George check summary recently has pushed me away from being too aggressive in the anterior tilt patients. Um there uh I think especially with small cups, you'll be surprised about how you can get into and out of a safe zone very quickly. Um and if you see both screens you can feel confident that if you if you're kind of navigating to a 45, or 45, 20 or wherever you feel comfortable based on the literature, you can definitely get that within a few degrees both ways to make sure you're not hitting an outlier for your patients. So that's one of those things that provides, I would when you start this I would have both screens up so you get feedback about where you're headed with your tilt. I would say it took me about 20-25 to but I would say um I didn't have any of these tips and tricks, These are all a list of things that um coming online with this system early in the middle of Covid not having um the rep support that we could have had to launch the system and having to kind of figure it out with charlie early on. Um It probably took a little longer, it might have doubled the learning curve a little bit because there was you know, really stupid things like that. We weren't doing like that clicker disrupting our case or flow. So um I think the curve is probably mostly at consistency of how you template and getting the A. S. I. S. Points that's important. I wouldn't hand this off to someone that's gonna do this variably. I would do it yourself or supervise it. I think double checking your rays are stable and not stressed and by drapes or you know your personnel in the room and that you're just, you're totally secure and where those checkpoints are and then um making sure your leg positions are are you're confident in those positions and your hand position where you're putting the point bro, if you are reproducible e doing those things throughout each case, then I think that everything will flow. Um And I think that one of the things that the attention of keeping things clean and visible if you, you know you can get your P. A. And your or whoever you're working with your fellow, your resident, your scrub techs just making sure that they are aware that these are important things and they can help you so that you cut time out of the system. And I think all of us, you know, should as you start this, you know use your regular workflow in a sense that be confident with um that you you're comfortable with where that cup is going and where the and then double check it and then just start to see that you're getting the information you need and then just start to give away that control to let the system work