Case Study: Robotic Left Hip Total Replacement

in sequel of Developmental Dysplasia of the Hip

A 56-year-old female presented to our office with complaints of worsening left groin pain and limp. She stated she had left hip pain since she was a child and was treated with a spica-cast and brace as a child in the Dominican Republic.

The pain was better as a child but she had a limp, for which she was using a shoe raise. Over the years, she started noticing pain in the left groin but didn’t seek medical attention. In the past five years, the pain worsened and she was unable to walk for more than 5 blocks. She used a cane for ambulation.

She went to different physicians who advised her hip replacement but told her she was too young to undergo hip replacement surgery. She received hip cortisone injections and received physical therapy but with minimal relief.

The pain was severe in intensity (8/10) located in the left groin and radiating to the left knee. She described the pain as a dull ache. The pain was especially worse on activities such as getting up from a chair, walking, bending and navigating stairs. The limp was worse with the increasing intensity of pain.

She was working as an assistant to a podiatrist and currently out of work secondary to pain. She was the firstborn child and gave a history of a difficult childbirth. She had no family history of hip disorders. She distressed with her limited mobility and increasing hip stiffness interfering in her daily activities.

She was a nonsmoker and nondrinker. She had no known drug allergies. She had a history of treatment for psoriasis in the past. Currently she was taking Lipitor for dyslipidemia and Toprol XL for hypertension. She had a hysterectomy done 15 years ago for uterine fibroids.

On physical examination, she had an antalgic gait with a lurch towards the left side. The stance phase was decreased on the left side. There was no exaggerated lumbar lordosis. There was mild functional scoliosis with convexity towards the right side which disappeared on bending forward.

The right anterior superior iliac spine was at a lower level on standing with both feet on the ground. There was mild atrophy of the buttock on the left side. Both the patella and medial malleolus were at the same level.

On the supine examination, the left anterior superior iliac spine was at a higher level than the right side. On squaring the pelvis, both the apparent and true shortening was similar of 2 cms. There was no fixed adduction or flexion deformity, but the abduction, extension and internal rotation were moderately restricted.

The skin overlying the left groin was normal with no scar marks or sinus tracts. There was no swelling in the left groin or any bony swelling in the left buttock. The left trochanter was at a higher level than the right side on digital palpation. There was no broadening or thickening of the trochanter.

The telescopic test of the left hip was negative and straight leg raise was positive with pain in the left hip. The examination of the right hip, bilateral knee and ankles were normal. There was no distal neurological deficit and bilateral pulses were palpable and comparable.

Imaging revealed severe osteoarthritis of the left hip with subchondral cysts, sclerosis, and osteophytes. The left acetabulum was shallow with a shortened left femoral neck.

After careful consideration of the patient’s condition, she was advised robotic left total hip replacement. Risks, benefits, and alternatives were discussed with the patient at length. She denied any recent intake of immunosuppressants and anticoagulants. She agreed to go ahead with the procedure.

Preoperative X-ray of the pelvis showing AP view of the pelvis with both hips

Preoperative X-ray of the pelvis showing AP view of the pelvis with both hips.

Preoperative X-ray of the left hip in AP and frog-legged lateral views Preoperative X-ray of the left hip in AP and frog-legged lateral views - img 2

Preoperative X-ray of the left hip in AP and frog-legged lateral views.

OPERATION: Robotic left total hip arthroplasty.

IMPLANTS USED: Acetabular shell 62 mm with 10-degree poly 36 mm with 127-degree neck stem size 6 with a ceramic head, 36-mm +O.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining informed consent finding the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient as well as with his wife prior to the procedure.

The patient was brought to the operating room and anesthesia was obtained by the anesthesiologist. The patient was then definitively positioned with the left hip up and the left hip was then draped and prepped in the usual sterile manner. A curved incision centered over the greater trochanter was used for the arthrotomy.

Skin and subcutaneous tissues were incised. The fascia was then divided. The posterior soft tissue structures were then taken down and tagged for future repair. The hip was then dislocated. Lesser trochanter to the center distance was measured and the neck resection was made at the correct level.

The head was removed. Attention was then turned towards the acetabulum. Acetabular exposure was obtained. On dissection of the inferior part of the acetabulum, bleeder was encountered. Because of the significant bleeder, vascular was called in. The vascular surgeon ligated the bleeder and control of the bleeding were achieved.

After the bleeding was controlled, the remainder of the labrum was then debrided. The acetabulum was then reamed and the final shell was placed into position in the correct abduction and anteversion using the robotic arm.

Before starting the procedure, three pins were placed into the iliac crest and the robotic sensors were placed over the pins in the iliac crest. There was also an EKG lead attached to over the anterior part of the patella for registration. Before the dislocation, a probe was placed over the greater trochanter and after the acetabular dissection, a probe was placed over the superior acetabulum for registration.

After the cup was inserted, excellent stability was achieved. It was not necessary to use a screw. A poly was then placed over the cup. Attention was then turned towards the femur. The femur was then sequentially broached. The final broach was left into position along with the head. The lesser trochanter to the center measurement was taken and was found to be correct.

The hip was then relocated, trialed through a full range of motion and excellent stability was achieved . Robotic measurements were compared with intraoperative measurements and it was in acceptable alignment and length. The hip was then dislocated. The final components were then placed into position.

The lesser trochanter distance was found to be correct. The tip of the greater trochanter to the center of the head was also found to be correct according to preoperative evaluation. Through lavage was given.

After the lavage, the drill holes were made at the greater trochanter and posterior soft tissue structures were then tacked to the greater trochanter through transosseous tunnels. The fascia was closed with Ethibond. Cutaneous tissues were closed with 0 Vicryl. Subcuticular tissues were closed with 2-0 Vicryl. The skin was closed using staples.

The external fixator pins over the iliac crest within the wound. Deep tissue was closed with 0 Vicryl. Subcuticular tissues were closed with 2-0 Vicryl. The skin was closed using staples. Sterile dressings were then applied over the wound. The patient was then transferred to the preoperative care unit in stable condition.

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

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

She had an excellent recovery post-op. Her vitals remained stable and she had no distal neurological deficit. She was advised hip precautions and aspirin was given for deep vein thrombosis prophylaxis.

Weight-bearing was allowed as tolerated and sutures were removed post-op day 14 uneventfully. Physical therapy was started to strengthen the muscles. Three months post-op she regained full movements and reported zero pain. She was walking without the support and extremely happy with the outcome. She follows up as needed.

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

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00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
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15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
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!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
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
Ethel Congo
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

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.