TEMPLATING IN

TOTAL HIP
REPLACEMENT
Dr. Abhishek Garg
MS orthopaaedics
 Operation of the century- THR
 Total Hip Replacement is a procedure in which diseased
and destroyed hip joint is resected and replaced with a
new bearing surface.
 The indications for THR have increased because of
excellent functions and longevity of implant with
improved wear and fixation issues.
 More attention should be given to hip biomechanics to
restore function.
 Templating is an essential part of implantation process.
 Hip templating-Process of anticipating size and
position of implants prior to THR.
 Traditionally, pre-operative planning for THR is
performed by superposing acetate implant drawings
on pelvis and hip (AP) radiographs.
 It is often a misconception to believe that templating
is only about guessing size of acetabular and femoral
hip components prior to surgery.
 It is difficult and inaccurate as radiographs are a two-
dimensional projection of a three-dimensional
structure.
 This could explain why in some series (22) inter- and
intra-observer reliability is suboptimal [k(w)-value :
022-0.54 and 0.48-0.79respectively] and why exact
implant size is difficult to predict [correct cup size
prediction : 16-62%; stem size prediction : 30- 69%;
cemented stems 78%; cementless stems 42%].
 Yet, within a range of +/- one size, templating is more
accurate in predicting 52 to 98% of cup and stem size.
 The accuracy of hip templating is clearly related to
experience and practice.
 Orthopaedic departments with a long tradition in hip
templating, using cemented stems and cups, can reach
an agreement between planned and implanted
component size of 90% or more.
 What does template mean?

 A pre formed pattern made of metal, plastic, or paper,

used for making many copies of a shape or to help cut
material accurately.
 Templating in THR is a radiographic exercise using
preformed templates in the preoperative planning
process.
 By combining clinical data with careful templating, the
surgeon has the best chance of achieving successful,
reproducible results and minimizing perioperative
complications.
 GOALS of Templating:

 To estimate the position and insertion depth of

acetabular and femoral components.
 To anticipate potential difficulties to reproduce hip
biomechanics with the available implants.
 Helps recognising “difficult hips” where restoration of
the original hip anatomy is difficult.
 To predict implant size.
 According to Maurice Müller, hip templating “forces
surgeon to think in three dimensions, greatly improves
precision of surgery, shortens length of procedure, and
greatly reduces incidence of complications”.
 In a survey by Knight et al, templating was useful to
anticipate peroperative problems in 20% of cases.
 At acetabular side it allows mainly to recognize
protrusion and need for bone grafting or osteophyte
removal.
 At femoral side it allowed mainly to recognize coxa vara.
 Nevertheless, hip templating allows to restore stem
offset in 58-86% of cases, restore position of hip
rotation centre within 5 mm, and leg length within 3
mm in 87-91% and 89% respectively.
 METHOD OF TEMPLATING

A four-step approach for templating as proposed by

Scheerlinck Thierry consists of :
 Identifying anatomical landmarks.
 Evaluating the quality of the radiograph.
 Defining mechanical references.
 Selecting/positioning the acetabular and femoral
implants.
 Anatomical landmarks
 Anatomical landmarks should be easy to identify, both
on AP pelvic radiograph and during surgery, even in
cases where anatomy has been distorted by pathology.
 At femoral side, the medullary canal, the lesser and
greater trochanter & “the saddle”, i.e. most distal part
of junction between superior aspect of femoral neck
and greater trochanter. It can be used to transpose the
position of planned femoral neck cut.
 The saddle point is most useful for minimally invasive
procedures.
  At acetabular side, acetabular roof and “teardrop” are
adequate landmarks.
 The “teardrop” is a radiographic landmark created by
superposition of most distal part of medial wall of
acetabulum and tip of anterior and posterior horn of
acetabula.
 The most distal aspect of teardrop corresponds to most
distal and medial part of acetabulum, behind transverse
ligament and at superior border of foramen obturatum.
 The ilioischial line (Kohler's line) has been used to
estimate degree of protrusio acetabuli radiographically.
This line extends from sciatic notch to lateral edge of
obturator foramen.
Evaluating quality of
radiographs:
 Well exposed, well oriented, good quality standardized
AP pelvic radiographs are mandatory for hip templating.
 Rather than standard pelvic radiographs, which are
generally centred on sacrum, a low AP pelvic radiograph
with x-ray beam centred on pubis is preferred for hip
templating.
 Both iliac spines should be at same distance from the
film.
 The symphysis pubis should project on a line through
middle of sacrum.
 The natural pelvic tilt in sagittal plane can be
estimated by distance between projection of
sacrococcygeal joint and upper border of the
symphysis.
 When pelvis is in neutral inclination, distance
between sacrococcygeal joint and symphysis is 32
mm (range : 8-50 mm) in women and 47 mm (range :
15-72 mm) in men
 To estimate length of femoral neck, both femora
should be positioned in 15 to 20° of internal rotation,
corresponding to femoral anteversion.
 When femoral neck is parallel to film, the lesser
trochanter is on average 2.3 ± 3.1 mm broad and in
most cases less than 5 mm of lesser trochanter
should be visible medially from the proximal femur.
 The standard distance from the x-ray tube to table
top is 40 inches.
 Template X-rays are 120% magnified.
 If a grid cassette is placed directly beneath hip,
magnification of bones of approximately 10% is seen
in an average-size patient
 But in most radiology departments, x-ray tray is
placed in a compartment approximately 2 inches
below table top, resulting in magnification of 15% to
20%.
 Degree of magnification is directly related to distance
from bone to cassette.
 To be less dependent on an accurate radiographic set-
up, calibration objects can be used.
 Ideally these objects (generally metal spheres of
known dimensions) should be positioned at level of hip
joint in anteroposterior plane, in order to achieve the
same magnification
 Patients with degenerative disease tend to develop
external rotation contractures.
 If pathologic hip cannot be internally rotated 15°,
templating can be done on the contralateral normal or
less involved side.
 In many cases, however, both hips have external rotation
contractures.
 In such cases, a PA radiograph can be obtained with the
patient placed prone, with the affected limb in 15° to 20°
of external rotation and hip directly against the table top.
 In case of flexion
contracture, radiographic
technique should be
modified.
 In presence of flexion
contracture, typically femur
will be off the table top
with patient supine, or
there will be increased
lumbar lordosis.
 These inaccuracies can be
minimized by obtaining the
AP radiographs in a
semisitting position.
 If there has been a previous fracture or osteotomy,
long films of the entire femur are advisable.
 A standing film that includes the hip, knee, and ankle
will give a more accurate assessment of the effect of
the angular deformity on the overall limb alignment.
 In patients with posttraumatic arthritis subsequent to
acetabular fractures, further radiographic evaluation is
advisable like Judet views and CT scans.
 Radiographs should be examined for bone quality.
Dorr
classification:
 Dossick et al. described a method of classifying proximal
femoral geometry based on the calcar-to canal ratio. It
corresponds to Dorr classification of femoral medullary
canal.
1. Type A bone : ratio <0.5, champagne type.
Favours the use of uncemented stem
2. Type B bone : ratio 0.5- 0.75.
Thinning of posterior cortex on lateral view.
3. Type C bone : ratio >0.75
Thinning of cortices on both views
Typical of a stovepipe femur.
Favours use of cemented stem.
Defining mechanical
references:
1. FEMORAL AND ACETABULAR ROTATION CENTRE;

 The hip rotation centre can be defined as point around

which all hip movements occur.
 If acetabulum and femoral head are preserved, the
acetabulum and the femoral head are concentric and
both acetabular and femoral rotation centre project on
hip rotation centre.
 As such, hip rotation centre can easily be found as
centre of a circle fitted to projection of femoral head or
the acetabular roof and medial wall.
 On the other hand, if pathology has deformed acetabulum
and/or femoral head, hip rotation centre may be difficult to
find and its position may vary during hip movements
 For this reason, it is easier and more useful to define the
“original” femoral and the “original” acetabular rotation
centres, i.e. the rotation centre of the femoral head and
acetabulum before deformation occurred.
 These original rotation centres can be found as the centre of
a circle fitted on preserved part of femoral head (generally
the inferior 1/3) and preserved part of acetabulum (generally
the teardrop and the medial wall).
 Fitting both rotation centres on each other, generally gives a
good idea of how the hip joint must have looked like before
deformation.
 Identifying the Center of Rotation;

 The ideal position for acetabular template (and

component) is achieved by placing inferomedial edge
adjacent to lateral margin of teardrop.
 In most patients, this will restore center of rotation
very close to an anatomic and desirable location.
 This can be checked by measuring horizontal and
vertical distances from teardrop to template center of
rotation, and comparing them to coordinates from
teardrop to center of normal or unaffected
contralateral hip.
 If distances are equal and there is no difference in limb
length, then this point can be utilized as the point
about which reconstruction can be planned.
 2. FEMORAL,ACETABULAR AND COMBINED OFFSET

 The femoral offset is defined as perpendicular distance

from neutral long axis of femur and femoral center of
rotation. Restoring normal degree of offset is a primary
goal of hip replacement, thus making this measurement
valuable.
 If pathology has deformed the femoral head, the original
femoral offset can be estimated as distance between the
original femoral rotation centre and the longitudinal axis
of the proximal femur.
 The femoral offset is important because it controls
tension and moment arm of abductor muscles, the
tension of soft tissues , the wear of acetabular
component and load imposed on both, the acetabular
and femoral implants .
 Failure to restore femoral offset may lead to excessive
wear, limping and/or hip instability .
 Excessive femoral offset has potential to overload the
femoral implant, to generate micromotion at implant-
bone interface and to cause pain in abductor muscles
and region of greater trochanter
 The acetabular offset can be defined as shortest
distance between acetabular rotation centre and a
perpendicular to the interteardrop line, drawn along the
projection of the most distal part of the teardrop .
 The acetabular offset is important because it controls
tension of abductor muscles and the soft tissues as well
as lever arm of the body weight and thus load
transmitted to the acetabulum.
 Decreasing the acetabular offset by excessive
medialisation of the acetabular component may lead to
limping and/or hip instability.
 Increasing the acetabular offset may overload the cup.
 The combined offset can be defined as the sum of the
femoral and acetabular offset.
 3. LEG AND HIP LENGTH

 The “leg length” can be defined as the distance

between a fixed reference point on the pelvis, e.g. the
inferior tip of the teardrop, and a horizontal line
parallel to the floor.
 The “hip length” can be defined as the shortest
distance between the inferior tip of the teardrop and a
horizontal line through a fixed point on the proximal
femur, e.g. the upper part of the lesser trochanter.
 This should be correlated with clinical measurements.
 The amount of desired lengthening should be well
established preoperatively and incorporated into the
plan.
Choice and positioning of
implants;
 The main goal is to restore as nearly as possible the
anatomic or premorbid centre of rotation and femoral
offset, while equalizing limb length.
 If anatomy of hip to be replaced is well preserved,
templating can easily be performed on the
pathological side.
 However, when pathological hip is deformed or
radiographed in an inappropriate position, it can be
easier to template healthy contralateral hip and to
mirror results to the pathological side.
 ACETABULAR SIDE

 Templating appropriately begins with the acetabular

side, because this is the sequence that is followed in
surgery.
 The acetabular template is placed just lateral to
lateral edge of teardrop at a 40-45° angle between
longest axis of cup and interteardrop line.
 Ideally, the cup should be completely covered by bone
and should span distance between the teardrop and
the superolateral margin of the acetabulum.
 The component size that best accomplishes this with
minimal removal of subchondral bone is selected.
 With acetabular template in place, the insertion depth
compared to medial acetabular wall, the insertion height
compared to inferior border of teardrop and cup
containment or overhang compared to lateral border of
the acetabular roof are noted.
 For cemented sockets, a uniform 2- to 3-mm space must
be left for cement. This is often indicated on templates
by a dashed line.
 The center of rotation is marked through the template.
 In dysplastic hips, the goal is to restore the original
rotation centre whenever possible.
 However, as acetabulum is often shallow with a vertical
roof, obtaining sufficient lateral coverage may be
difficult.
 This may require bone grafting of the lateral and
superior portion of the acetabulum.
 In some cases, when cup coverage is insufficient and
cannot be solved with bone grafting, a small cup
inserted in a medialised position or even a high
rotation centre may have to be considered.
 PROTRUSIO ACETABULI

 Protrusio acetabuli is present in a number of primary hip

replacements, particularly in cases of rheumatoid
arthritis, ankylosing spondylitis, Paget's disease, and
metabolic bone diseases
 Leaving hip center in medialized location is not
advisable, because there is often not optimal structural
support for component in that position, and opportunity
to restore medial bone should be utilized.
 In case of protrusio acetabuli, femoral head projects
medially from Köhler’s line, lateralising acetabular
component and grafting medial acetabular wall can allow
to restore original acetabular rotation centre, avoiding
impingement and increasing bone stock.
 The femoral head can be morselized and used as a
medial graft to lateralize component to a more normal
anatomic position
 Lateralizing the component in cases of protrusio
acetabula has the additional advantage of increasing
combined offset.
 Because the cup is contacting bone graft medially rather
than structurally supportive subchondral bone, a large
acetabular component is needed to achieve peripheral
rim contact.
 Significant lengthening occurs through acetabulum in
protrusio acetabuli cases. This is often desirable, since
the limb is often short in these cases.
 LATERALISED ACETABULUM

 In many cases of degenerative osteoarthritis, the

presence of hypertrophic osteophytes in acetabulum
causes lateralization of hip's center of rotation.
 This becomes apparent during templating when 1 or 2 cm
of reaming is noted to be necessary to place component
in vicinity of the teardrop.
 Failure to recognize this will result in placement of the
acetabular component in a lateralized position with
incomplete bony coverage and suboptimal stability.
 The most reliable structural landmark is transverse
acetabular ligament that marks inferior border of true
acetabulum.
 If reaming is initiated above transverse acetabular
ligament in a straight medial direction for several
millimeters, location of the cotyloid notch becomes
apparent and it can be curetted of bone, cartilage, and
soft tissue.
 Straight medial reaming to within a few millimeters of the
planned depth of reaming is advisable to avoid superior
placement of the component.
 When template is placed adjacent to the teardrop and the
lateral margin is uncovered, a number of options exist:-
 -Medial reaming to the subchondral plate.
 10% to 20% uncoverage can be accepted, and screws
can be used to augment fixation of cementless
components because there will not be circumferential
peripheral contact.
 In cemented components, cement augmentation of the
superolateral deficiency has been described without
deleterious effects on component fixation.
 The acetabular component can be positioned somewhat
vertically.
 FEMORAL TEMPLATING
 After the planned center of rotation of reconstruction is
marked on radiograph, the femur is templated.
 Femoral implant is chosen to fit the medullary canal.
 The longitudinal axis of implant is positioned parallel to the
longitudinal axis of the femur and the approximate insertion
depth is chosen in order to correctly restore the leg or hip
length.
 Fine tuning to restore the offset and the original femoral
rotation centre, can be done in three different ways :
 (i) medialising or lateralising the femur by using a
standard or offset stem,
 (ii)choosing a stem with a different neck-shaft angle
 (iii) modifying the length of the femoral neck
 The goals and emphasis of femoral templating vary
depending on whether a cementless (proximally or
extensively coated), or cemented stem is planned.
 It is prudent to template for both a cemented and
cementless stem, particularly in cases where any
anatomic abnormality is identified.
 Component size is judged from the AP radiograph of
the hip.
 For proximally coated components, proximal fit and fill
are generally emphasized.
 For cemented stems, it is important to leave adequate
room for a cement mantle. A 2- to 3-mm
circumferential cement mantle is optimal.
 A repeated “trial and error technique” allows selecting
correct stem size and type as well as right neck-shaft
angle and neck length.
 The femoral template is moved vertically until there is
proximal fitting of stem in femur.
 Regardless of the stem type utilized, templates should
be kept centered along the neutral axis of the femur,
rather than in any varus or valgus inclination.
 With appropriate template in place, the insertion depth
and the level and orientation of femoral neck cut are
noted in relation to greater and lesser trochanter.
 Traditionally, the distance between lesser trochanter and
medial border of the femoral neck cut is used as a landmark
to evaluate the height of the neck cut and the stem
insertion depth, which is ideally around 1-2cm.
 If the center of femoral head template lies medial to
planned center of hip rotation when template is at
appropriate height, stem insertion to this level will increase
femoral offset, which is generally an advantage, particularly
if it is a matter of a few millimeters.
 Excessive increase in offset may cause prominence of
trochanter with a tendency toward bursitis and should be
avoided.
 If center of femoral head template lies lateral to planned
center of hip rotation, then reconstruction will decrease
femoral offset, and this is particularly to be avoided.
 LIMB LENGTH DISCREPANCY;
 Shortening, which is present in most of cases.
 2.7- 4 cm of limb lengthening can be done safely.
 The shortening can be compensated by :
i) Using longer neck length
ii) Prosthesis with higher neck- shaft angle
iii) High neck cut +/- with proud stem.
 Lengthening can be compensated by:
i) Using shorter neck lengths.
ii) Prosthesis with lower neck-shaft angle
iii) Low neck cut
 COXA VARA

 Patients with coxa vara have higher than usual femoral

offset. This can be compensated for by utilizing a
component with a lower neck shaft angle, or by making
a lower neck cut and utilizing a longer neck.
 Making a standard-length neck cut can significantly
lengthen the leg without restoring offset.
 To avoid limb lengthening a distal neck cut and a low
stem insertion position are often required.
 COXA VALGA

 The opposite situation exists when the patient's neck

shaft angle significantly exceeds that of the prosthesis.
 There is a relatively low offset and more length.
 To compensate for this with a component with less
valgus, it is necessary to make a higher neck cut and
use a shorter neck to maintain length and offset.
Thank you