Treatment Options for Femoral Revision

The main objectives of femoral reconstruction during revision hip surgery are to preserve the remaining bone of.
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The quality and quantity of remaining bone helps determine the best method for reconstruction. Extensively porous-coated cylindrical stems or titanium fluted tapered devices that achieve fixation in the diaphysis have both demonstrated excellent long-term survivorship. Titanium fluted tapered stems with a modular proximal body allow for more accurate leg length, offset, and version adjustments independent of the distal stem which may optimise hip biomechanics. Intraoperative fractures are more common with cylindrical stems and subsidence with tapered stems, particularly monoblock designs and in both dislocation continues to be one of the most common postoperative complications.

In salvage situations in which an ectatic femoral canal is unable to support an uncemented device, impaction bone grafting, allograft-prosthetic composite, or a segmental proximal femoral replacement may be required. Skip to main content. View all publication partners. Abdel, and David G. Vol 25, Issue 4, pp. Download Citation If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Via Email All fields are required. Send me a copy Cancel. Request Permissions View permissions information for this article.

Article first published online: August 23, ; Issue published: July 1, Accepted: Sculco , Matthew P.

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Abdel , David G. Mayo Clinic First Street S. Abstract Full Text Abstract.

Revision Total hip Replacement

Keywords Femoral revision , Revision total hip arthroplasty , Titanium modular fluted tapered stems , Extensively porous-coated cylindrical stems , Femoral bone loss. Remember me Forgotten your password? Subscribe to this journal. Vol 25, Issue 4, Modular Fluted Tapered Stems in Aseptic Revision Total Hip Arthroplasty Proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone Tips on citation download. Springer Science and Business Media ; Periprosthetic femur fractures treated with modular fluted, tapered stems.

Clin Orthop Relat Res. Google Scholar , Crossref , Medline. The odyssey of porous-coated fixation. Classification of femoral abnormalities in total hip arthroplasty. Revision of the deficient proximal femur with a proximal femoral allograft. Google Scholar , Medline. Revision total hip arthroplasty: Reduction in cement-bone interface shear strength between primary and revision arthroplasty.

Long-term results of aseptic cemented Charnley revisions. Long-term results of revision total hip replacement. J Bone Joint Surg Am. Results of revision for mechanical failure after cemented total hip replacement, to A two to five-year follow-up.

Revision Hip Arthroplasty

Revision of aseptic loose total hip arthroplasties. Survivorship of uncemented proximally porous-coated femoral components. Google Scholar , Crossref. Points in the technique of recementing in the revision of an implant arthroplasty. J Bone Joint Surg Br. Cement-within-cement stem exchange using the collarless polished double-taper stem. Cement-in-cement revision hip arthroplasty: Arch Orthop Trauma Surg. Recementing a femoral component into a stable cement mantle using ultrasonic tools.

Revision of the cemented femoral stem using a cement-in-cement technique: Engh, CA , Ellis, T.

Background

Extensively porous-coated femoral revision for severe femoral bone loss: Extensively porous-coated stems for femoral revision: Femoral fixation in the face of considerable bone loss: Extensively porous-coated femoral stems in revision hip arthroplasty: Four revision stems required repeat revision. Two patients were reoperated in the immediate postoperative period due to dislocation.

In the first case, the stem was undersized and was revised to a longer one, without dislocation recurrence. In the second case, a high angle of anteversion of both the stem and the cup was corrected. Another patient, with Paprosky type 3B pre-revision bone defects, had a late recurrent dislocation without major subsidence. An attempt to use a longer Wagner component in the distal third of the femur, in mostly cancellous bone, did not provide a safe fixation, even with the largest available stem diameter. A proximal femoral replacement prosthesis was eventually used for the femoral reconstruction.


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  • Management of Femoral Bone Loss in Revision Total Hip Arthroplasty!

The transfemoral approach [ 1 ] and the ETO [ 2 ] facilitate femoral canal exposure, while preserving the hip abductors and vastus lateralis musculature in continuity. The vastus is thought to counteract the pull of the abductors in the coronal plane, thus avoiding proximal migration and promoting osteotomy union [ 10 ]. However, the reported incidence of proximal migration of the ETO fragment is up to 6.

Even more commonly, intraoperative split fractures of the paper-thin, proximal cortices during implant and cement removal can occur. Although the osteotomized anterolateral bone flap is folded back, the contralateral interface surfaces remain unexposed. What is more important is that these fractures concern the more distal portion of the proximal femur, as this is the usual area of remaining fixation [ 8 ]. Furthermore, they are uncontrollable, because there is nothing to stop them extend peripherally [ 3 , 8 ].


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In many cases, the attempt to remove a well-fixed prosthesis results in further loss of proximal bone stock and an uncontrolled fragmentation of the distal femur, which usually necessitates a longer revision stem. We propose an alternative to these trochanteric osteotomies, when anything else than a completely loose implant is anticipated. It comprises of a transverse femoral osteotomy just below the stem tip and a subsequent preplanned segmentation of the proximal femur to quickly remove the old prosthesis. It combines the advantages of an extremely wide exposure of component fixation surfaces with the preservation of soft tissue attachments to cut bone.

Revision Hip Arthroplasty - an overview | ScienceDirect Topics

The technique is based on the fact that proximal femur fractures do not interfere with the ultimate stability of a distally anchored component, as long as the hip abductor mechanism remains efficient. For this purpose, the GT is kept intact and the continuity of the abductors to the quadriceps is retained to avoid proximal trochanter migration. The fragmentation extends up to, but excludes, the vastus lateralis origin. To further minimize the possibility of GT migration, its continuity with the lesser trochanter is preserved at least to one femoral cortex.

On the other hand, the transverse osteotomy serves primarily to protect from the distal extension of the fractures; it also, however, allows the surgeon to correct any proximal deformity and gain a straight trajectory down a bowed femur. Through the osteotomy, the canal machining and the intimacy of the implant-bone contact can be unimpededly checked under direct vision. We attribute the abolition, despite the normal weight-bearing protocol, of gross subsidence seen with tapered, fluted stems [ 3 ] and the absence of intraoperative distal fractures in our series to this appropriate femoral preparation and accurate sizing.

This feature of proximal bone reconstitution was behind our decision to use the proximal femur segmentation technique also for revision of solidly bonded stems. Among various techniques described in the literature [ 11 , 12 ], a two-stage removal is invariably advocated for these revisions: Then, the proximal segment is removed using tools such as Gigli saws and burrs, and the distal is trephined with reamers 0.

Our rationale against this approach is that to the shortcomings of the ETO those related with trephining are added. These include not only the intraoperative risks of femoral perforation and trephine breakage [ 13 - 15 ] but also the thermal damage to the cortex, which can extend to a greater area [ 13 , 15 , 16 ]. These dangers are exacerbated with older non-tapered cylindrical designs, which due to large distal dimensions require the use of larger reamers [ 14 ]. In these cases, since the trephines are cylindrical in shape, but also with the newer tapered but rectangular self-locking cross sections, unnecessary removal of the host bone takes place and the theoretical advantages of bone preservation of trephining are eliminated [ 15 ].

In any case, the disruption of completely ingrown surfaces with tools at the proximal implant has a high rate of iatrogenic fragmentation of the femur, which irreversibly compromises the potential of the revision prosthesis for fixation, either proximal or distal. In many cases, this attempt results in frail primary stem stability, which ultimately requires a re-revision with all relevant risks and complications. We consider the results of our approach more predictable, and although the method appears initially to be destructive of uninvolved bone, proximal bone reconstitution is eventually achieved.

Only for the broken stems we favor trephining over the segmentation technique. In these cases, the proximal part is usually loose and can be easily removed without the need for disruption of fixation surfaces. The risks of distal part trephining, however, remain. The major limitation of the proximal femur segmentation technique is that it can only be performed in combination with a posterior approach, as, to avoid a postoperative proximal trochanteric migration, the integrity of the vasto-gluteal sling is a conditio sine qua non.

Furthermore, it cannot be combined with proximally coated revision implants. When reconstruction of the deficient bone stock is selected and press-fit fixation of the new prosthesis is intended, the proximal femur should be circumferentially kept intact and the older osteotomies appear to remain the only viable option. Another consideration is that we have used so far this technique only with tapered, fluted, grit-blasted stems. Although we do not have the relevant experience, we believe that it can be also combined successfully with other distally fixated revision systems, such as the extensively porous-coated cylindrical stems [ 17 ].

The most frequent postoperative complication encountered was dislocation. All of them, however, were due to initially undersized or malpositioned stems and not due to subsidence. As these failures were recorded early in our series, we attribute them to the learning curve in implanting this system. Similarly, Sharma et al. Our practice is to cross-match 4 blood units before revisions with this technique, which have been proved enough in the majority of the cases.

The proximal femur segmentation technique facilitates the removal of the old prosthesis and the implantation of the revision component, even when proximal femoral bone deformity is present. With the steep increase in the prevalence of failed total hip arthroplasties, the speed and safety of this technique may be proved invaluable to the femoral revision surgery.

Panagiotis Karonis, staff member of our unit and painter, for the line art drawings of this manuscript. PM carried out all the operations and designed and applied the technique. He had also critically reviewed the final draft of the manuscript. CSG collected the clinical and radiological data and wrote the manuscript. AP conceived of the study and participated in its design and coordination and found and organized the literature. AK was an independent researcher who followed up clinically the patients and performed the final clinical evaluation.

All authors read and approved the final manuscript. Christos S Georgiou, Email: National Center for Biotechnology Information , U. J Orthop Surg Res. Published online Dec Received Aug 22; Accepted Dec 8. This article has been cited by other articles in PMC. Abstract Background The transfemoral and the extended trochanteric osteotomies are the most common osteotomies used in femoral revision, both when proximal or diaphyseal fixation of the new component has been decided.

Methods The procedure includes a complete circular femoral osteotomy just below the stem tip to prevent distal fracture propagation and a subsequent preplanned segmentation of the proximal femur for better exposure and fast removal of the old prosthesis.


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    5. Conclusions This new osteotomy technique may seem aggressive at first, but, at least in our hands, has effectively increased the speed of the femoral revision, particularly for the most difficult well-fixed components, but not at the expense of safety. Proximal femur segmentation technique, Femoral osteotomy, Stem removal, Wagner revision stem, Hip revision arthroplasty, Surgical technique.

    Introduction The transfemoral osteotomy described by Wagner [ 1 ] and the extended trochanteric osteotomy ETO popularized by Younger et al. Surgical technique The hips to be revised are templated to determine the appropriate stem length and the exact point of osteotomy. Open in a separate window. Materials and methods We retrospectively reviewed the 47 consecutive patients who underwent the proximal femur segmentation technique by the first author in our tertiary university department between and Table 1 The reasons for revision for our study group.

    Table 2 Distribution of pre-revision bone defects. Results During surgery, no fracture of the trochanters or the distal femur occurred. Discussion The transfemoral approach [ 1 ] and the ETO [ 2 ] facilitate femoral canal exposure, while preserving the hip abductors and vastus lateralis musculature in continuity. Conclusion The proximal femur segmentation technique facilitates the removal of the old prosthesis and the implantation of the revision component, even when proximal femoral bone deformity is present.

    Acknowledgements We thank Mr. Footnotes Competing interests The authors declare that they have no competing interests. Contributor Information Panagiotis Megas, Email: Revision prosthesis for the hip joint in severe bone loss. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty.

    Femoral revision with the Wagner SL revision stem: J Bone Joint Surg Am. A new technique to reattach an extended trochanteric osteotomy in revision THA using suture cord. Clin Orthop Relat Res. Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty. Results of revision for mechanical failure after cemented total hip replacement, to A two to five-year follow-up.

    Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Extended femoral osteotomy for revision of hip arthroplasty: Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. Trochanteric osteotomy in primary and revision total hip arthroplasty: