Case Study: Robotic Left Hip Total Replacement

for Arthritis secondary to Avascular Necrosis of the Hip

The patient was a 59-year-old male presenting as a new patient for consultation regarding his left hip pain. The hip pain started insidiously 2 years ago and progressed gradually. He was previously diagnosed with avascular necrosis of the left hip by an outside physician.

He was working as a security officer at an airport but was currently on leave secondary to hip pain. He denied any history of fall or trauma or long term steroid intake. He was a nonsmoker and consumed alcohol socially.

He reported the pain as a dull ache located in the left groin radiating to the left knee. The pain was moderate to severe in intensity (7/10). The patient reported increased severity of pain on activities such as walking, bending, sitting, squatting and going up or down the stairs.

The patient used a cane for ambulation and received two hip cortisone injections with minimal relief. He also had a trial of physical therapy with no relief. The patient was distressed having not been able to do his daily activities. He had given up riding his bicycle, a hobby he enjoyed for the past many years.

His past medical history included coronary heart disease, liver dysfunction, benign prostate hypertrophy, and dyslipidemia. All his medical conditions were well controlled with medications. His past surgical history included a right shoulder arthroscopic surgery and laparoscopic cholecystectomy done 6 years ago.

On physical examination, his gait was antalgic with a decreased stance phase on the left side. Both the shoulders, iliac spines, patella, and medial malleolus were at the same level. There was no evidence of any exaggerated lumbar lordosis and scoliosis.

There were no enlarged inguinal lymph nodes or any fullness in the groin region. The skin overlying the left hip was normal with no scar, sinus or redness. There was tenderness over the left hip anterior joint line. The range of motion was restricted in the abduction and internal rotation.

The bulk and power of both the extremities were intact. There was no deficit of light touch in all sensory dermatomes of the lower extremities. Examination of the right hip, both knees and ankles were normal. Bilateral dorsalis pedis and posterior tibial pulses were palpable and good volume.

Imaging revealed severe osteoarthritis of the left hip and an MRI suggested avascular necrosis changes in the left hip. In view of lifestyle limiting hip pain and patients’ comorbidities, a robotic total hip replacement was advised to the patient. Risks, benefits, and alternatives were discussed at length with the patient. He agreed with the plan. A preoperative CT scan was also obtained.

Preoperative X-ray showing the AP and the lateral views of the left hipPreoperative X-ray showing the AP and the lateral views of the left hip - img 2

Preoperative X-ray showing the AP and the lateral views of the left hip.

PREOPERATIVE DIAGNOSIS(ES): Left hip arthritis secondary to avascular necrosis.

OPERATION: Robotic left total hip arthroplasty.

IMPLANTS USED: Size 58-cup and liner, screw size 6.5 x 30 mm with a 127-degree size 11 stem with a 36 mm head.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining the informed consent, signing on the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient as well as with her husband prior to the procedure. The patient was then anesthetized by the anesthesiologist and the left hip was then draped and prepped in the usual sterile manner.

Robotic arrays were used by placing the external fixator over the iliac crest. The incision was made over the hip and the skin and subcutaneous tissues were incised. The fascia was then divided. The posterior soft tissue structures were then taken down and the hip was then dislocated. The microdissection was made over the correct level.

The head was removed. The acetabular rim was then exposed. The remainder of the labrum was then debrided. The acetabulum was then sequentially reamed after making robotic calibration and the cup was then placed into position in the correct abduction and anteversion. A screw was placed for additional fixation, the poly was then placed over the shell. Thorough lavage was given. Attention was then turned towards the femur. The femur was then sequentially broached.

The final broach was placed into position, and the trunnion and head were then placed and hip was then reduced and trialed through a full range of motion. Hip was found to be stable in all physiological range of motion. A preoperative CT scan was then compared to the final measurements and the measurements on the robotic system were found to be accurate.

The hip was then dislocated. Trial components were then removed. Final components were then placed into position and the hip was then reduced. The robotic system measurements were then again measured and were found to be correct. Screws for the markers were then removed from the femoral as well as the acetabular part of the hip.

Thorough lavage was given. Posterior soft tissue structures were then packed with intertrochanteric through transverse tunnels. The fascia was closed with Ethibond. Cutaneous tissues were closed with O Vicryl. Subcuticular tissues were closed with 2-0 Vicryl. The skin was closed using Monocryl. Sterile dressing was then applied over the wound, and the patient was returned to the postoperative care in stable condition.

Postoperative X-ray of the pelvis with both hip joints in the AP view

Postoperative X-ray of the pelvis with both hip joints in the AP view.

The patient’s pain was well managed with medications. An abduction pillow was given to the patient and hip precautions were explained. Thrombotic-Embolic-Deterrent (TED) stockings and aspirin were prescribed to prevent deep vein thrombosis. Weight-bearing was allowed as tolerated with support. Physical therapy was started to increase range of motion and strengthen muscles.

The patient’s recovery was excellent in three months. He was walking with no pain and with no support. He had successfully concluded his physical therapy. He was advised to stop aspirin and wean off hip precautions gradually. He was back riding his bicycle and happily back to his job. The patient expressed great satisfaction at the outcome of the procedure.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
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22:18 25 Sep 20
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T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
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23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.