- Email: [email protected]
Avoiding your next extended trochanteric osteotomy: An alternative for femoral component removal
SE
M I N A R S I N
A
R T H R O P L A S T Y
] (2017) ]]]–]]]
Available online at www.sciencedirect.com
www.elsevier.com/locate/sart
Avoiding your next extended trochanteric osteotomy: An alternative for femoral component removal Mustafa Citak, MD, PhDn, Akos Zahar, MD, and Thorsten Gehrke, MD Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
article info
abstra ct
Keywords:
The removal of well-fixed implants can be challenging for every orthopedic surgeon. The
Solid implant
most commonly used methods for the removal of solid implants are the transfemoral
Total hip arthroplasty
osteotomy and the extended trochanteric osteotomy (ETO). However, those techniques are
Trochanteric osteotomy
often associated with various complications such as non-unions or migration of the
Complication
osteotomy fragment and persistent abductor weakness. Therefore, the authors present the endofemoral technique for the removal of well-fixed cemented and uncemented femoral stems. For a successful and efficient implant removal, it is of enormous importance to have proper instruments available. & 2017 Elsevier Inc. All rights reserved.
1.
Introduction
Revision total hip arthroplasty (THA) is a challenging procedure and the removal of well-fixed femoral stems can be compounded by several pitfalls. In such cases, several removal techniques have been presented in the current literature. The most commonly used techniques are the transfemoral osteotomy presented by Wagner [1] and the extended trochanteric osteotomy (ETO) described by Younger et al. [2]. Those techniques provide an increased exposure of the fixation surfaces and were originally developed for the removal of well-fixed prosthesis stems. Despite the advantage of better intraoperative exposure, the complication rates are not unremarkable [3]. Therefore, it is always a good decision to avoid an extended trochanteric osteotomy if alternative techiques exist. In this context, the current authors present the endofemoral technique for the removal of well-fixed cemented and uncemented femoral stems and illustrate the advantages of endofemoral removal. n
Corresponding author. E-mail address: [email protected] (M. Citak).
http://dx.doi.org/10.1053/j.sart.2017.03.015 1045-4527/& 2017 Elsevier Inc. All rights reserved.
2.
Methods
The authors perform routinely the endofemoral removal of cemented and/or uncemented cases. In 2015, a total of 6832 arthroplasty procedures have been performed at the authors’ institution (Helios ENDO Klinik, Hamburg, Germany). From those, revision THA was done in 1190 cases and a total number of 487 cases had received one-stage septic exchange procedure. Using the endofemoral technique, 99% of stems could be removed successfully without the need for osteotomy. In the remaining cases, the authors created a cortical window of the anterior part of the femur or made a splitting osteotomy to remove the implant.
2.1.
Preoperative planning and surgical approach
Preoperatively, we use a digital image analysis system (mediCADs Classic Version 4.0.0.7; Hectec, Niederviehbach, Germany) to determine the appropriate stem length and cup position. Prior revision THA, we perform an aspiration of synovial fluid to
2
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
femur and enables easy endomedullary and periosteal preparation. The vastogluteal muscular flap is kept in place as a unit, but submuscular preparation along the intermuscular septum is often needed in order to expose the diaphysis of the femur. Cautious preparation allows for controlled ligation of the perforans vessels from the femoris profunda artery. Nevertheless, the removal of well-fixed femoral components can be very tricky also for high-level arthroplasty surgeons.
2.3. Figure 1 – An overview of required instruments. Forceps, long forceps, curetting instruments, and long drills are not presented. exclude a periprosthetic joint infection (PJI) in all patients according to the modified MSIS criteria. The patients are positioned on the operating table in the lateral position and the exposures are performed through a posterolateral approach. First, preparation and detachment of the gluteus maximus muscle, which allows for a better exposure to the posterior aspect of the joint and reduces rotational forces and prevents from periprosthetic femoral fracture. Then, the joint capsule is opened and all capsule and/or synovia are excised.
2.2.
Surgical procedure
In general, the posterolateral approach delivers excellent exposure to all parts of the acetabulum and to the whole
Figure 2 – The technique to disrupt the bone ingrowth between implant and bone in the proximal part of the femoral stem.
Removal of solid femoral implants
For a successful removal of well-fixed implants, it is crucial to have a wide range of diverse special instruments on the operating table. For removal of long and cemented stems special instruments such as curved chisels, long forceps, curetting instruments, long drills or burs, and cement taps are needed. Figure 1 gives an overview of required instruments. In general, different types of uncemented stems are available on the market. There is a difference in design between proximally coated and fully coated uncemented stems. Usually, proximally coated stems are not designed for diaphyseal ingrowth. Nevertheless, the removal of proximally coated stems should not be underestimated since the bone fixation in the distal portion of stem can also be very solid. First, all osteophytes around the collar have to be removed. The proximal part of the femur is chiseled using different sizes and types of osteotomes and chisels (Fig. 2). It is very crucial to go in the interface very carefully to avoid fractures of the femur. Cancellous bone is removed and the cortex is prevented from lever forces. Thin flexible osteotomes are useful to break the bony bond between the coated cementless stem and bone. In uncemented cases, it is of tremendous importance to disrupt the bone ingrowth between implant and bone. Then, a special explantation device (Waldemar Link GmbH & Co. KG, Hamburg, Germany) is attached by drill holes using 5 mm widia drill bit and small sharp screws to the taper of the solid implant (Fig. 3). The removal can be performed usually by sliding mallet taps. In some cases, the interface has to be further mobilized using K-wires before final explantation (Fig. 4). In the vast majority of cases, the stems can be removed using the special explantation device without the need for osteotomy (Fig. 5). The leg must be held carefully, because in the case of combination of poor bone quality in the distal femur and well-fixed uncemented stem
Figure 3 – The attachment process of the specific explantation device. (A) Creating drill holes in the taper of the implant. (B) Fixation of the explantation device using screws.
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
3
Figure 4 – The break-down process of the bony bond between the coated cementless stem and bone using K-wires.
Figure 6 – The successful removal of cement using a threaded device (“cork-screw”).
the axial mallet taps may result in supracondylar femur fracture (Vancouver type C).
in the distal part of the femur should be addressed by reversed cutting hooks.
2.5. 2.4.
Osteotomy techniques
Removal of cemented femoral stems and decementing
First, excess cement between the prosthesis and greater trochanteric region must be removed using different sizes and types of chisels and/or osteotomes. Then, the implant– cement interface should be debonded by thin osteotomes. The implant–cement interface loosening can be also done using an oscillating saw. The mobilized femoral stem can be removed using an extraction device or with direct blows using a punch .The stem can also be extracted using the specific explantation device as described above (Fig. 5). Afterwards, the residual cement is then removed step by step using different chisels, osteotomes, rongeurs, taps, and drills. Again, it is essential to go very carefully in the bone–cement interface to avoid fractures or perforations of the femur. First, cement removal of the proximal part can be addressed using different types of chisels and osteotomes. The break-down of cement lamellae should be done with specific curved chisels by twisting in its longitudinal axis. The cement in the distal part of the femur can be shipped away by longer chisels and the cement in the cortical zone can be removed using different sizes of taps by grasping the plug and tapping out in a retrograde manner (Fig. 6). This technique is to be avoided if the cement mantle is wider in the distal portion than the diameter of the femoral canal beyond the isthmic part of the femur, because extracting to proximal may result in a fracture when passing the isthmus. Alternatively, the cement can be milled using a high-speed bur. The remaining cement
In a limited number of cases, the final possibility in case of the femoral stem cannot be removed from proximal, requiring a femoral osteotomy to expose the cement mantle. The current authors institution perform either a splitting osteotomy or create a cortical window to have a better access to the femoral stem (Fig. 7). The cortical window is done in the anterior part of the femur to mobilize the stem (Fig. 7B). In such cases, a revision stem must be available that extends beyond the uppermost extension of the cortical window by at least two cortical diameters of the femur. The splitting osteotomy is made by a longitudinal osteotomy of the entire distance of the shaft with the oscillating saw without opening the medullary canal. Then, the osteotomy is spread with two Lambotte chisels taking advantage of the elasticity of the bone. Afterwards, the stem is mobilized and removed using the explantation device. The osteotomy zone is then fixed with cerclage using the Cable-Readys system (Zimmer Biomet, Warsaw, IN) or any other wire device.
3.
Discussion
The most commonly reported and used techniques in the literature for removal of well-fixed implants are the transfemoral osteotomy and the extended trochanteric osteotomy [1,2]. The main advantage of ETO is the direct access to the distal canal for easier removal, which also results in a lower rate of
Figure 5 – Successful removal of the femoral stem with the explantation device: (A) During removal and (B) after removal.
4
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
Figure 7 – (A) The splitting osteotomy of the shaft. The hole is drilled with a 12 mm diameter at the tip of the stem to mobilize the stem with a mallet. (B) The technique of a cortical window made in the anterior part of the femur.
intraoperative fractures and/or femoral perforations. Another advantage is that those approaches preserve the hip abductors and the lateral vastus muscle in continuity [1,2]. Despite the reported advantages of ETO, we recommend the endofemoral way to remove a solid implant and bone–cement for following reasons. First, the complication rate of ETO should not to be underestimated. As reported by several authors, nonunion of the osteotomy, migration of the osteotomy fragment, wire breakage, trochanteric bursitis, and persistent hip abductor weakness are well-known complications following ETO [3–9]. For instance, the incidence of proximal migration of the ETO fragment is as high as 6.6% [7,9]. The reported non-union rate varies from 5% to 11% [7,8]. Another important consideration that must be taken into account, when using ETO, is the fact that after removing of long cemented and/or uncemented femoral stems, there are limitations regarding implant choice. With the ETO, the removal of solid implants can result in further loss of proximal bone stock in the distal part of the femur, which necessitated longer revision stems for more distal fixation. This can lead to a more challenging revision surgery in case of failure. Especially, the radical debridement in case of a possible periprosthetic infection after ETO is more challenging compared to the endofemoral approach. It must be also noted, that in ETO septic revision, the infected femoral canal could contaminate the uninfected soft tissue outside the femoral canal, which is contradictory to the standards of septic revision surgery. Another disadvantage of ETO is the need for uncemented revision stems for reconstruction of the femur, because penetration of bone– cement into the osteotomy is to be avoided for proper bone healing. Due to the disadvantages of ETO, authors presented the endofemoral approach as an alternative treatment choice for the removal of solid femoral cemented and uncemented stems. As reported, using this technique, we could achieve a successful removal in 99% of all cases without the need for osteotomy. Relatively rare, the necessity for osteotomy was required. In general, we prefer to create a cortical window of the anterior part of the femur to expose the cement mantle and mobilize the stem, since a biomechanical study by Tóth et al. [10] have analyzed the differences in the resistance to fracture for the transfemoral approach (TFA), the distal fenestration (DF), and the endofemoral technique. The authors found that femora in the TFA group required significantly less force to fracture than specimens in the DF group. Analogously, the DF group required
significantly less force to create a fracture compared to the endofemoral approach [10]. In summary, the endofemoral technique is an excellent alternative for the removal of solid implants. For a successful and efficient implant removal, it is of enormous importance to have proper instruments available on the operating table. The proper instrument can make a difficult removal easy and can reduce the surgical time and may decrease the frustration level of the surgeon.
re fe r en ces
[1] Wagner H. Revision prosthesis for the hip joint in severe bone loss. Der Orthopade 1987;16:295–300. [2] Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. The Journal of Arthroplasty 1995;10:329–38. [3] Charity J, Tsiridis E, Gusmao D, Bauze A, Timperley J, Gie G. Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty. The Journal of Arthroplasty 2013;28:154–60. [4] Amstutz HC, Maki S. Complications of trochanteric osteotomy in total hip replacement. The Journal of Bone and Joint Surgery American Volume 1978;60:214–6. [5] Frankel A, Booth RE Jr., Balderston RA, Cohn J, Rothman RH. Complications of trochanteric osteotomy. Long-term implications. Clinical Orthopaedics and Related Research 1993:209–13. [6] Kolstad K, Adalberth G, Mallmin H, Milbrink J, Sahlstedt B. The Wagner revision stem for severe osteolysis. 31 hips followed for 1.5-5 years. Acta Orthopaedica Scandinavica 1996;67:541–4. [7] Kuruvalli RR, Landsmeer R, Debnath UK, Suresh SP, Thomas TL. A new technique to reattach an extended trochanteric osteotomy in revision THA using suture cord. Clinical Orthopaedics and Related Research 2008;466:1444–8. [8] MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, McCalden RW. Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Clinical Orthopaedics and Related Research 2003:210–6. [9] Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. The Journal of Arthroplasty 2005;20:79–83. [10] Toth K, Sisak K, Wellinger K, Mano S, Horvath G, Szendroi M, et al. Biomechanical comparison of three cemented stem removal techniques in revision hip surgery. Archives of Orthopaedic and Trauma Surgery 2011;131:1007–12.
M I N A R S I N
A
R T H R O P L A S T Y
] (2017) ]]]–]]]
Available online at www.sciencedirect.com
www.elsevier.com/locate/sart
Avoiding your next extended trochanteric osteotomy: An alternative for femoral component removal Mustafa Citak, MD, PhDn, Akos Zahar, MD, and Thorsten Gehrke, MD Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
article info
abstra ct
Keywords:
The removal of well-fixed implants can be challenging for every orthopedic surgeon. The
Solid implant
most commonly used methods for the removal of solid implants are the transfemoral
Total hip arthroplasty
osteotomy and the extended trochanteric osteotomy (ETO). However, those techniques are
Trochanteric osteotomy
often associated with various complications such as non-unions or migration of the
Complication
osteotomy fragment and persistent abductor weakness. Therefore, the authors present the endofemoral technique for the removal of well-fixed cemented and uncemented femoral stems. For a successful and efficient implant removal, it is of enormous importance to have proper instruments available. & 2017 Elsevier Inc. All rights reserved.
1.
Introduction
Revision total hip arthroplasty (THA) is a challenging procedure and the removal of well-fixed femoral stems can be compounded by several pitfalls. In such cases, several removal techniques have been presented in the current literature. The most commonly used techniques are the transfemoral osteotomy presented by Wagner [1] and the extended trochanteric osteotomy (ETO) described by Younger et al. [2]. Those techniques provide an increased exposure of the fixation surfaces and were originally developed for the removal of well-fixed prosthesis stems. Despite the advantage of better intraoperative exposure, the complication rates are not unremarkable [3]. Therefore, it is always a good decision to avoid an extended trochanteric osteotomy if alternative techiques exist. In this context, the current authors present the endofemoral technique for the removal of well-fixed cemented and uncemented femoral stems and illustrate the advantages of endofemoral removal. n
Corresponding author. E-mail address: [email protected] (M. Citak).
http://dx.doi.org/10.1053/j.sart.2017.03.015 1045-4527/& 2017 Elsevier Inc. All rights reserved.
2.
Methods
The authors perform routinely the endofemoral removal of cemented and/or uncemented cases. In 2015, a total of 6832 arthroplasty procedures have been performed at the authors’ institution (Helios ENDO Klinik, Hamburg, Germany). From those, revision THA was done in 1190 cases and a total number of 487 cases had received one-stage septic exchange procedure. Using the endofemoral technique, 99% of stems could be removed successfully without the need for osteotomy. In the remaining cases, the authors created a cortical window of the anterior part of the femur or made a splitting osteotomy to remove the implant.
2.1.
Preoperative planning and surgical approach
Preoperatively, we use a digital image analysis system (mediCADs Classic Version 4.0.0.7; Hectec, Niederviehbach, Germany) to determine the appropriate stem length and cup position. Prior revision THA, we perform an aspiration of synovial fluid to
2
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
femur and enables easy endomedullary and periosteal preparation. The vastogluteal muscular flap is kept in place as a unit, but submuscular preparation along the intermuscular septum is often needed in order to expose the diaphysis of the femur. Cautious preparation allows for controlled ligation of the perforans vessels from the femoris profunda artery. Nevertheless, the removal of well-fixed femoral components can be very tricky also for high-level arthroplasty surgeons.
2.3. Figure 1 – An overview of required instruments. Forceps, long forceps, curetting instruments, and long drills are not presented. exclude a periprosthetic joint infection (PJI) in all patients according to the modified MSIS criteria. The patients are positioned on the operating table in the lateral position and the exposures are performed through a posterolateral approach. First, preparation and detachment of the gluteus maximus muscle, which allows for a better exposure to the posterior aspect of the joint and reduces rotational forces and prevents from periprosthetic femoral fracture. Then, the joint capsule is opened and all capsule and/or synovia are excised.
2.2.
Surgical procedure
In general, the posterolateral approach delivers excellent exposure to all parts of the acetabulum and to the whole
Figure 2 – The technique to disrupt the bone ingrowth between implant and bone in the proximal part of the femoral stem.
Removal of solid femoral implants
For a successful removal of well-fixed implants, it is crucial to have a wide range of diverse special instruments on the operating table. For removal of long and cemented stems special instruments such as curved chisels, long forceps, curetting instruments, long drills or burs, and cement taps are needed. Figure 1 gives an overview of required instruments. In general, different types of uncemented stems are available on the market. There is a difference in design between proximally coated and fully coated uncemented stems. Usually, proximally coated stems are not designed for diaphyseal ingrowth. Nevertheless, the removal of proximally coated stems should not be underestimated since the bone fixation in the distal portion of stem can also be very solid. First, all osteophytes around the collar have to be removed. The proximal part of the femur is chiseled using different sizes and types of osteotomes and chisels (Fig. 2). It is very crucial to go in the interface very carefully to avoid fractures of the femur. Cancellous bone is removed and the cortex is prevented from lever forces. Thin flexible osteotomes are useful to break the bony bond between the coated cementless stem and bone. In uncemented cases, it is of tremendous importance to disrupt the bone ingrowth between implant and bone. Then, a special explantation device (Waldemar Link GmbH & Co. KG, Hamburg, Germany) is attached by drill holes using 5 mm widia drill bit and small sharp screws to the taper of the solid implant (Fig. 3). The removal can be performed usually by sliding mallet taps. In some cases, the interface has to be further mobilized using K-wires before final explantation (Fig. 4). In the vast majority of cases, the stems can be removed using the special explantation device without the need for osteotomy (Fig. 5). The leg must be held carefully, because in the case of combination of poor bone quality in the distal femur and well-fixed uncemented stem
Figure 3 – The attachment process of the specific explantation device. (A) Creating drill holes in the taper of the implant. (B) Fixation of the explantation device using screws.
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
3
Figure 4 – The break-down process of the bony bond between the coated cementless stem and bone using K-wires.
Figure 6 – The successful removal of cement using a threaded device (“cork-screw”).
the axial mallet taps may result in supracondylar femur fracture (Vancouver type C).
in the distal part of the femur should be addressed by reversed cutting hooks.
2.5. 2.4.
Osteotomy techniques
Removal of cemented femoral stems and decementing
First, excess cement between the prosthesis and greater trochanteric region must be removed using different sizes and types of chisels and/or osteotomes. Then, the implant– cement interface should be debonded by thin osteotomes. The implant–cement interface loosening can be also done using an oscillating saw. The mobilized femoral stem can be removed using an extraction device or with direct blows using a punch .The stem can also be extracted using the specific explantation device as described above (Fig. 5). Afterwards, the residual cement is then removed step by step using different chisels, osteotomes, rongeurs, taps, and drills. Again, it is essential to go very carefully in the bone–cement interface to avoid fractures or perforations of the femur. First, cement removal of the proximal part can be addressed using different types of chisels and osteotomes. The break-down of cement lamellae should be done with specific curved chisels by twisting in its longitudinal axis. The cement in the distal part of the femur can be shipped away by longer chisels and the cement in the cortical zone can be removed using different sizes of taps by grasping the plug and tapping out in a retrograde manner (Fig. 6). This technique is to be avoided if the cement mantle is wider in the distal portion than the diameter of the femoral canal beyond the isthmic part of the femur, because extracting to proximal may result in a fracture when passing the isthmus. Alternatively, the cement can be milled using a high-speed bur. The remaining cement
In a limited number of cases, the final possibility in case of the femoral stem cannot be removed from proximal, requiring a femoral osteotomy to expose the cement mantle. The current authors institution perform either a splitting osteotomy or create a cortical window to have a better access to the femoral stem (Fig. 7). The cortical window is done in the anterior part of the femur to mobilize the stem (Fig. 7B). In such cases, a revision stem must be available that extends beyond the uppermost extension of the cortical window by at least two cortical diameters of the femur. The splitting osteotomy is made by a longitudinal osteotomy of the entire distance of the shaft with the oscillating saw without opening the medullary canal. Then, the osteotomy is spread with two Lambotte chisels taking advantage of the elasticity of the bone. Afterwards, the stem is mobilized and removed using the explantation device. The osteotomy zone is then fixed with cerclage using the Cable-Readys system (Zimmer Biomet, Warsaw, IN) or any other wire device.
3.
Discussion
The most commonly reported and used techniques in the literature for removal of well-fixed implants are the transfemoral osteotomy and the extended trochanteric osteotomy [1,2]. The main advantage of ETO is the direct access to the distal canal for easier removal, which also results in a lower rate of
Figure 5 – Successful removal of the femoral stem with the explantation device: (A) During removal and (B) after removal.
4
SE
M I N A R S I N
AR
T H R O P L A S T Y
] (2017) ]]]–]]]
Figure 7 – (A) The splitting osteotomy of the shaft. The hole is drilled with a 12 mm diameter at the tip of the stem to mobilize the stem with a mallet. (B) The technique of a cortical window made in the anterior part of the femur.
intraoperative fractures and/or femoral perforations. Another advantage is that those approaches preserve the hip abductors and the lateral vastus muscle in continuity [1,2]. Despite the reported advantages of ETO, we recommend the endofemoral way to remove a solid implant and bone–cement for following reasons. First, the complication rate of ETO should not to be underestimated. As reported by several authors, nonunion of the osteotomy, migration of the osteotomy fragment, wire breakage, trochanteric bursitis, and persistent hip abductor weakness are well-known complications following ETO [3–9]. For instance, the incidence of proximal migration of the ETO fragment is as high as 6.6% [7,9]. The reported non-union rate varies from 5% to 11% [7,8]. Another important consideration that must be taken into account, when using ETO, is the fact that after removing of long cemented and/or uncemented femoral stems, there are limitations regarding implant choice. With the ETO, the removal of solid implants can result in further loss of proximal bone stock in the distal part of the femur, which necessitated longer revision stems for more distal fixation. This can lead to a more challenging revision surgery in case of failure. Especially, the radical debridement in case of a possible periprosthetic infection after ETO is more challenging compared to the endofemoral approach. It must be also noted, that in ETO septic revision, the infected femoral canal could contaminate the uninfected soft tissue outside the femoral canal, which is contradictory to the standards of septic revision surgery. Another disadvantage of ETO is the need for uncemented revision stems for reconstruction of the femur, because penetration of bone– cement into the osteotomy is to be avoided for proper bone healing. Due to the disadvantages of ETO, authors presented the endofemoral approach as an alternative treatment choice for the removal of solid femoral cemented and uncemented stems. As reported, using this technique, we could achieve a successful removal in 99% of all cases without the need for osteotomy. Relatively rare, the necessity for osteotomy was required. In general, we prefer to create a cortical window of the anterior part of the femur to expose the cement mantle and mobilize the stem, since a biomechanical study by Tóth et al. [10] have analyzed the differences in the resistance to fracture for the transfemoral approach (TFA), the distal fenestration (DF), and the endofemoral technique. The authors found that femora in the TFA group required significantly less force to fracture than specimens in the DF group. Analogously, the DF group required
significantly less force to create a fracture compared to the endofemoral approach [10]. In summary, the endofemoral technique is an excellent alternative for the removal of solid implants. For a successful and efficient implant removal, it is of enormous importance to have proper instruments available on the operating table. The proper instrument can make a difficult removal easy and can reduce the surgical time and may decrease the frustration level of the surgeon.
re fe r en ces
[1] Wagner H. Revision prosthesis for the hip joint in severe bone loss. Der Orthopade 1987;16:295–300. [2] Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. The Journal of Arthroplasty 1995;10:329–38. [3] Charity J, Tsiridis E, Gusmao D, Bauze A, Timperley J, Gie G. Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty. The Journal of Arthroplasty 2013;28:154–60. [4] Amstutz HC, Maki S. Complications of trochanteric osteotomy in total hip replacement. The Journal of Bone and Joint Surgery American Volume 1978;60:214–6. [5] Frankel A, Booth RE Jr., Balderston RA, Cohn J, Rothman RH. Complications of trochanteric osteotomy. Long-term implications. Clinical Orthopaedics and Related Research 1993:209–13. [6] Kolstad K, Adalberth G, Mallmin H, Milbrink J, Sahlstedt B. The Wagner revision stem for severe osteolysis. 31 hips followed for 1.5-5 years. Acta Orthopaedica Scandinavica 1996;67:541–4. [7] Kuruvalli RR, Landsmeer R, Debnath UK, Suresh SP, Thomas TL. A new technique to reattach an extended trochanteric osteotomy in revision THA using suture cord. Clinical Orthopaedics and Related Research 2008;466:1444–8. [8] MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, McCalden RW. Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Clinical Orthopaedics and Related Research 2003:210–6. [9] Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. The Journal of Arthroplasty 2005;20:79–83. [10] Toth K, Sisak K, Wellinger K, Mano S, Horvath G, Szendroi M, et al. Biomechanical comparison of three cemented stem removal techniques in revision hip surgery. Archives of Orthopaedic and Trauma Surgery 2011;131:1007–12.