Bradford Ms

Extended proximal femoral osteotomy: A new technique for femoral revision arthroplasty

Abstract An osteotomy technique for removal of distally fixed cemented and cementless femoral components is described. The anterolateral proximal femur is cut for one third of its circumference, extended distally, and levered open on an anterolateral hinge of periosteum and muscle. This creates an intact muscle—osseous sleeve composed of the gluteus medius, greater trochanter, anterolateral femoral diaphysis, and vastus lateralis, and exposes the fixation surface as well as distal cement. This technique combines the advantages of an extremely wide exposure of component fixation surfaces and preservation of soft tissue attachments to cut bone. In addition, it allows alteration of the proximal femur to facilitate accurate and safe distal cement removal and canal machining under direct vision. The possibility of placing the component in varus is eliminated. The proximal femur is allowed to conform more accurately to the revision prosthesis, a weakened or damaged trochanter is protected from iatrogenic injury, and soft tissue tension can be adjusted. The osteotomy is then repaired with cerclage wires or cables. The first 20 patients treated with this technique are reviewed. Excellent cement and component removal and optimal revision component implantation were obtained with no change in postoperative regimen and reliable healing.

Bone Stock Loss and Allografting: Acetabulum

Reconstructive surgery of the failed acetabulum in revision arthroplasty is increasingly difficult to perform because of the increased bone loss as compared with that in a primary procedure. Being able to predict the bony defect preoperatively allows the surgeon to create the appropriate armamentarium for successful reconstruction. As the number of joint replacements and the time they remain in vivo increase, bony defects also increase.1–7 A historical and clinical perspective of the patient must be combined with a radiographic assessment to determine a protocol for the appropriate reconstructive procedure.

Management of Segmental Deficiencies

Extensive acetabular bone loss in the revision setting is becoming an increasing problem. Bone loss can occur from the patient’s premorbid condition, previous operative procedures, infection, and osteolysis. This degree of loss can be massive, secondary to the asymptomatic nature of the osteolytic process. Once the acetabular defect has been assessed, one must then collect the armamentarium of instruments, prostheses, and bone graft required to remove the old components, reconstruct the bony acetabulum, and reinsert the new prosthesis. This entails a technically demanding process that becomes more complex as the acetabular bone defect increases.