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Extended proximal femoral osteotomy for severe acetabular protrusion following total hip arthroplasty
The Journal of Arthroplasty Vol. 12 No. 3 1997
Brief Communication
Extended Proximal Femoral Osteotomy for Severe Acetabular Protrusion Following Total Hip Arthroplasty A Technical Note Theodore P. Firestone, MD, and Anthony K. Hedley, MD
A b s t r a c t Exposing and removing the femoral and acetabular components after severe intrapelvic protrusion has occurred can be difficult and dangerous. An extended proximal femoral osteotomy carried distally to the level of the stem tip allows for atraumatic removal of the femoral stem without the need for preliminary dislocation. The exposure afforded by the osteotomy also facilitates acetabular component removal. K e y w o r d s : extended femoral osteotomy, acetabular protrusion, total hip arthroplasty.
SurgicalTechnique
Intrapelvic migration of an acetabular compon e n t after total hip arthroplasty (THA) represents a challenging revision situation. Dislocating the protrused prosthetic femoral head from the p o l y e t h y l e n e liner can be extremely difficult. Forceful distraction and rotation m a y result in fracture of the already deficient bone stock. In addition, an abrupt shear of the fibrous m e m brane attached to the undersurface of the acetabular c o m p o n e n t a n d / o r c e m e n t m a y result in injury to intrapelvic structures. For this reason, a two-stage approach that includes a retroperitoneal dissection has been advocated [1]. We describe our use of the e x t e n d e d proximal femoral o s t e o t o m y w h e r e b y the femoral c o m p o n e n t is r e m o v e d atraumatically w i t h o u t the need for preliminary dislocation.
Preoperative planning includes a preoperative vascular imaging study and the availability of an on-call vascular surgeon. The surgical preparation and draping is e x t e n d e d proximally, allowing for easy access to the retroperitoneum. The patient is placed in the lateral decubitus position. A standard posterolateral approach is used and extended distally. The proximal f e m u r is exposed by elevating the vastus lateralis off the intermuscular septum. An oscillating saw is used to create a trochanteric osteotomy, which maintains continuity with the proximal femur. The lateral femoral cortex is osteotomized just lateral to the linea aspera. The osteotomy is e x t e n d e d to a point that corresponds to the tip of the femoral stem as d e t e r m i n e d by preoperative templating. The osteotomy fragment measures approximately 12-15 cm long and 2.5-3.5 cm wide, corresponding to one third of the shaft circumference. After the e x t e n d e d trochanteric fragment is retracted anteriorly, the stem tip is freed from its cement
From the Institute for Bone and Joint Disorders, Phoenix, Arizona.
Reprint requset: Theodore P. Firestone, MD, Institute for Bone and Joint Disorders, 3320 N. 2nd Street, Phoenix, AZ 85012.
344
Osteotomy for Acetabular Profusion AfterTHA
•
Firestone and Hedley
345
Discussion
Fig. 1. The osteotomy fragment is retracted anteriorly (arrow) and the tip of the stem is elevated from the femoral canal.
m a n t l e and lifted f r o m the f e m u r (Fig. 1). Excision of capsular scar tissue is necessary to allow for easy disarticulation of the prosthetic joint. The wide exposure offered by the approach allows for the introduction of periosteal elevators and curved Moreland osteotomes for careful dissection around the c o m p o n e n t and/or cement mantle. The subseq u e n t acetabular reconstruction is accomplished with a bulk structural allograft. On the femoral side, a porous coated stem of sufficient length is used to bypass the osteotomy site. The extended osteotomy fragment is a p p r o x i m a t e d with cerclage wires or cables (Fig. 2).
The use of an extended o s t e o t o m y has b e e n advocated by Younger et al. [2] as a m e a n s of r e m o v i n g well-fixed c e m e n t e d and cementless femoral c o m p o n e n t s during revision THA. We h a v e used an extended o s t e o t o m y for the surgical m a n a g e m e n t of six hips in five patients with severe acetabular protrusion following THA. In each of these cases, the c e m e n t e d stem was a standard length and the trochanter was in continuity with the lateral femur. There w e r e no complications as a result of the a p p r o a c h or c o m p o n e n t removal. Fortunately, severe protrusio following THA is rare. More often, medial wall compromise is accompanied by s y m p t o m s and findings serious e n o u g h to w a r r a n t revision prior to advanced collapse and intrapelvic migration. W h e n this does occur, h o w ever, the extended o s t e o t o m y a p p r o a c h allows for a t r a u m a t i c r e m o v a l of the femoral stem and ample access to the acetabular c o m p o n e n t .
References 1. Eftekhar NS: Intrapelvic migration of total hip prostheses: operative treatment. J Bone Joint Surg 71A: 1480, i989 2. Younger TI, Bradford MS, Paprosky WG: Removal of a well-fixed cementless fen]oral component with an extended proximal femoral osteotomy. Contemp Orthop 30:375, 1995
A B Fig. 2. (A) Preoperative and (B) postoperative radiographs demonstrating restoration of the medial wall, healed osteotomy, and well-positioned revision components.
Brief Communication
Extended Proximal Femoral Osteotomy for Severe Acetabular Protrusion Following Total Hip Arthroplasty A Technical Note Theodore P. Firestone, MD, and Anthony K. Hedley, MD
A b s t r a c t Exposing and removing the femoral and acetabular components after severe intrapelvic protrusion has occurred can be difficult and dangerous. An extended proximal femoral osteotomy carried distally to the level of the stem tip allows for atraumatic removal of the femoral stem without the need for preliminary dislocation. The exposure afforded by the osteotomy also facilitates acetabular component removal. K e y w o r d s : extended femoral osteotomy, acetabular protrusion, total hip arthroplasty.
SurgicalTechnique
Intrapelvic migration of an acetabular compon e n t after total hip arthroplasty (THA) represents a challenging revision situation. Dislocating the protrused prosthetic femoral head from the p o l y e t h y l e n e liner can be extremely difficult. Forceful distraction and rotation m a y result in fracture of the already deficient bone stock. In addition, an abrupt shear of the fibrous m e m brane attached to the undersurface of the acetabular c o m p o n e n t a n d / o r c e m e n t m a y result in injury to intrapelvic structures. For this reason, a two-stage approach that includes a retroperitoneal dissection has been advocated [1]. We describe our use of the e x t e n d e d proximal femoral o s t e o t o m y w h e r e b y the femoral c o m p o n e n t is r e m o v e d atraumatically w i t h o u t the need for preliminary dislocation.
Preoperative planning includes a preoperative vascular imaging study and the availability of an on-call vascular surgeon. The surgical preparation and draping is e x t e n d e d proximally, allowing for easy access to the retroperitoneum. The patient is placed in the lateral decubitus position. A standard posterolateral approach is used and extended distally. The proximal f e m u r is exposed by elevating the vastus lateralis off the intermuscular septum. An oscillating saw is used to create a trochanteric osteotomy, which maintains continuity with the proximal femur. The lateral femoral cortex is osteotomized just lateral to the linea aspera. The osteotomy is e x t e n d e d to a point that corresponds to the tip of the femoral stem as d e t e r m i n e d by preoperative templating. The osteotomy fragment measures approximately 12-15 cm long and 2.5-3.5 cm wide, corresponding to one third of the shaft circumference. After the e x t e n d e d trochanteric fragment is retracted anteriorly, the stem tip is freed from its cement
From the Institute for Bone and Joint Disorders, Phoenix, Arizona.
Reprint requset: Theodore P. Firestone, MD, Institute for Bone and Joint Disorders, 3320 N. 2nd Street, Phoenix, AZ 85012.
344
Osteotomy for Acetabular Profusion AfterTHA
•
Firestone and Hedley
345
Discussion
Fig. 1. The osteotomy fragment is retracted anteriorly (arrow) and the tip of the stem is elevated from the femoral canal.
m a n t l e and lifted f r o m the f e m u r (Fig. 1). Excision of capsular scar tissue is necessary to allow for easy disarticulation of the prosthetic joint. The wide exposure offered by the approach allows for the introduction of periosteal elevators and curved Moreland osteotomes for careful dissection around the c o m p o n e n t and/or cement mantle. The subseq u e n t acetabular reconstruction is accomplished with a bulk structural allograft. On the femoral side, a porous coated stem of sufficient length is used to bypass the osteotomy site. The extended osteotomy fragment is a p p r o x i m a t e d with cerclage wires or cables (Fig. 2).
The use of an extended o s t e o t o m y has b e e n advocated by Younger et al. [2] as a m e a n s of r e m o v i n g well-fixed c e m e n t e d and cementless femoral c o m p o n e n t s during revision THA. We h a v e used an extended o s t e o t o m y for the surgical m a n a g e m e n t of six hips in five patients with severe acetabular protrusion following THA. In each of these cases, the c e m e n t e d stem was a standard length and the trochanter was in continuity with the lateral femur. There w e r e no complications as a result of the a p p r o a c h or c o m p o n e n t removal. Fortunately, severe protrusio following THA is rare. More often, medial wall compromise is accompanied by s y m p t o m s and findings serious e n o u g h to w a r r a n t revision prior to advanced collapse and intrapelvic migration. W h e n this does occur, h o w ever, the extended o s t e o t o m y a p p r o a c h allows for a t r a u m a t i c r e m o v a l of the femoral stem and ample access to the acetabular c o m p o n e n t .
References 1. Eftekhar NS: Intrapelvic migration of total hip prostheses: operative treatment. J Bone Joint Surg 71A: 1480, i989 2. Younger TI, Bradford MS, Paprosky WG: Removal of a well-fixed cementless fen]oral component with an extended proximal femoral osteotomy. Contemp Orthop 30:375, 1995
A B Fig. 2. (A) Preoperative and (B) postoperative radiographs demonstrating restoration of the medial wall, healed osteotomy, and well-positioned revision components.