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The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Review article
The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery Bernd Fink* €die, Orthopa €dische Klinik Markgro €ningen gGmbH, Kurt-Lindemann-Weg 10, 71706, Klinik für Endoprothetik, Allgemeine und Rheumaorthopa €ningen, Germany Markgro Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2019 Received in revised form 2 November 2019 Accepted 4 November 2019 Available online xxx
Background: For the removal of well fixed femoral stems, various standard and extended approaches are possible, all of which have their advantages and disadvantages. They should allow good visualization and avoid uncontrolled damage to the bone (especially devascularization and fractures) and to the musculature (especially the gluteus medius). As an extended approach we prefer the transfemoral approach in a modified Wagner technique. It is indicated for the controlled removal of broken endoprosthetic stems, a significantly thinned bone at risk of fracture, a stable cement mantle, a partially fixed cementless prosthetic stem with a coarse, rough surface, and infected, fixed total hip endoprostheses. In this review article we describe our experience with our technique of the transfemoral approach. Material and results: In 68 patients with hip revisions using the modified transfemoral approach, the Harris Hip Score increased continuously from 41.4 points preoperatively to 85.9 points 24 months postoperatively. The bony flap showed bone consolidation in 98.5% of cases. In 76 patients with transfemoral two-stage septic hip revisions, with closure of the flap around the interim prosthesis with cerclage wires and reopening of the flap during second stage revision, the Harris Hip Score was 62.2 ± 12.6 points before the replacement of the spacer and 86.6 ± 15.5 points two years after reimplantation. The healing rate of the bony flap after reimplantation was 98.7%, the absence of infection 93.4%, the rate of stem subsidence 6.6%, and the dislocation rate 6.6%; there was no aseptic loosening of the implants. Conclusion: The transfemoral approach allows a reliable protection of the gluteus medius and the vastogluteal sling, and enables reproducibly good clinical outcomes. © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Transfemoral approach Extended trochanteric approach Revision arthroplasty
1. Introduction For the revision of hip endoprostheses, various standard and extended approaches are possible for controlled removal of the prosthesis and reimplantation of a new prosthesis, all of which have their advantages and disadvantages. Overall, they should allow good visualization and avoid uncontrolled damage to the bone (especially devascularization and fractures) and to the musculature. The gluteus medius and minimus muscle in particular should be spared, as they play a decisive role in the function and stability of the hip joint. A disruption of the vastogluteal sling as the
€dische * Klinik für Endoprothetik, Allgemeine und Rheumaorthop€ adie, Orthopa €ningen GGmbH, Kurt-Lindemann-Weg 10, 71706, Markgro €ningen, Klinik Markgro Germany E-mail address: bernd.fi[email protected].
connection between the gluteus medius muscle and the vastus lateralis muscle should also be avoided, since in the event of a trochanteric fracture, the disruption of the vastogluteal sling means the counterpart of the gluteus medius no longer exists and a dislocation of the trochanter major is unavoidable. Therefore, all approaches with weakening of the gluteal muscles and disruption of the vastogluteal sling are disadvantageous for maintaining the important function of the gluteal muscles.1 In this review article we describe our technique of the transfemoral approach and our results and discuss these with the results of the literature. 2. Operative technique Our published technique of the transfemoral approach is carried out using a modified Wagner technique.2e5 After an extended
https://doi.org/10.1016/j.jcot.2019.11.001 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
2
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
posterolateral approach in the lateral position, the posterior lateral edge of the femur ventral to the aspera line is visualized in the intermuscular lateral septum under ligation of the perforating vessels. The lateral circumference of the femur is displayed at the level of the planned end of the flap and 3.2 mm holes are drilled in the dorsal and ventral ends of the flap under cooling spanning the half circumference of the femur. The ventromedial trochanter region is then osteotomized with a chisel at the vastogluteal border and then the dorsolateral osteotomy, the connecting osteotomy between the two drill holes, and the distal ventromedial osteotomy of approx. 3 cm is performed with a water-cooled oscillating saw (using a thin saw blade of 0.7 mm). The completion of the ventromedial osteotomy is performed using a small osteotome-chisel driven blindly under the vastus lateralis muscle to the proximal end of the osteotomy from the already prepared proximal, ventral osteotomy. After chiseling a few centimeters from distal to proximal the bony flap automatically breaks until the already performed proximal, ventral osteotomy.4,5 This transfemoral approach technique represents a modification of the original Wagner technique2,3,6 in which the osteotomy was performed dorsolaterally and ventromedially through the vastus lateralis muscle using chisel techniques. After the osteotomy, the flap is folded up medially with the vastus lateralis muscle attached. The prosthesis stem to be replaced is removed and the bony flaps cleaned; if necessary the acetabular cup is replaced, otherwise an inlay exchange is carried out and the fixation bed of the cementless revision stem is prepared. A double cerclage is applied to prevent a fissure in the area of the fixation bed in the isthmus of the femur. After implantation of a distally fixated cementless revision stem, the bony flap is closed by means of two double cerclage fixations with 1.5 mm cerclage wire or cable systems (Figs. 2 and 3). In the event of proximalization of the lid due to muscle tension, the resulting gap to the distal femur is filled with autologous cancellous bone or milled bone obtained during surgery. In the original technique according to Wagner,2,3 both the exact flap repositioning and fixation were dispensed with and the flap was merely sewn on using sutures. 3. Material and Results In a separate study, 68 hip prosthesis revisions were performed with Revitan Curved prostheses (ZimmerBiomet GmbH, Winterthur, Switzerland), which were implanted via this modified transfemoral approach, and prospectively followed clinically and radiologically over a period of 32.3 ± 10.2 months.4 The Harris Hip Score increased continuously from 41.4 ± 14.5 points preoperatively to 85.9 ± 14.6 points 24 months postoperatively. Two stems showed a temporary subsidence of more than 5 mm and two stems were loosened. In all four cases it was only possible to achieve a fixation region with a length of less than 3 cm in the isthmus of the femur. The bony flap showed bony consolidation in 98.5% of cases one year after surgery. Two postoperative trochanteric detachments healed without further action. The intraoperative blood loss averaged 970 ± 560 mL (from 420 to 2100 mL).4 For the analysis of the results of the transfemoral approach in the two-stage septic revision with closure of the flap around the interim prosthesis with cerclage wires and reopening of the bony flap during reimplantation, 76 patients were followed for an average of 51.2 ± 23.2 (24e118) months.7 The healing rate of the bony flap after reimplantation was 98.7%, the absence of infection 93.4%, the rate of stem subsidence 6.6%, and the dislocation rate 6.6%; there was no aseptic loosening of the implants. The Harris Hip Score was 62.2 ± 12.6 points with the spacer before prosthesis replacement and 86.6 ± 15.5 points two years after reimplantation. Four fractures of the flap (5.3%) occurred due to osteolysis or osteoporotic bone thinning, but all healed over time.
4. Discussion For the revision of hip endoprostheses, various standard and extended approaches are possible for controlled removal of the prosthesis and reimplantation of a new prosthesis, all of which have their advantages and disadvantages. Svennson et al.8 reported that after primary implantation of 97 total hip endoprostheses via the transgluteal approach, a separation of x-ray markers applied to each side of the muscle that had been cut during the approach occurred in 56% of cases. The repeated reinsertion of separated parts of the gluteus medius during prosthesis revision surgeries would further weaken the gluteal muscles and complicate functional rehabilitation. Therefore, the transgluteal approach for revision surgery seems to have considerable disadvantages for functionality. Furthermore, the risk of trochanteric fractures is increased, especially with this approach and the anterior approaches to revision.1 The standard posterolateral approach allows a good view of the acetabulum as well as a direct access to the shaft with very effective protection of the gluteal muscles. However, dislocation rates of 4e20% have been reported for revision surgery.9 This risk can be reduced to 2% by posterior capsule soft tissue repair at the reinsertion point of the external rotators.9 The trans-trochanteric approach has been largely abandoned, despite the equally suitable visualization of the acetabulum, due to the high non-union rates of 10e20%.10,11 The extended transgluteal approach, the so-called vastus slide, has the disadvantage of an alteration to the vastogluteal sling with an accompanying risk of uncontrolled dislocation of the trochanter in the event of a fracture during revision, since the counterpart of the gluteal muscle (the vastus lateralis muscle) has been separated from it during the surgical approach. If a vastus slide is adopted, the medial gluteus muscle should not be divided more than 4 cm above the original acetabular margin or more than 5 cm cranially of the trochanter tip in order to avoid iatrogenic damage to the superior gluteal nerve and the superior gluteal artery.10 Therefore, as an extended approach for femoral revision we prefer the transfemoral approach in a modified Wagner technique.2,3,6,12 In our opinion, it is indicated for hip prosthesis replacement with broken endoprosthesis stems, axial deviation of the femur due to loosening, a significantly thinned bone at risk of fracture, a stable cement mantle, a partially fixed cementless stem (especially for stems with rough surfaces (Fig. 1)) and for
Fig. 1. Radiograph of a 75-year old man with a loosened cementless stem and cup with rough surface 12 years after implantation on the left side. Osteolyses at the greater trochanter due to wear are visible.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Fig. 2. Radiograph after exchange of the endoprosthesis via the transfemoral approach. Due to the thin bone a fracture of the bony flap of the transfemoral approach occurred.
periprosthetic fractures. The advantages of exchanging the stem using a transfemoral access or the so-called extended trochanteric osteotomy are the direct access to the distal canal of the femur for the removal of distal cement and for the efficient preparation of the new prosthesis fixation bed, the avoidance of uncontrolled intraoperative fractures and femoral perforations, the more reliable healing of the osteotomy compared to transtrochanteric osteotomy, the shorter operation time for difficult implant removal, and the protection of the vastogluteal sling.13e21 Moreover, by callus formation a bone regeneration and bone on-growth on the new implant occurs because of this approach.1 The transfemoral approach makes it possible to remove firmly seated stems and cement sheaths in a controlled manner, for example in septic prosthesis revision of firmly osteointegrated
3
cementless prosthesis stems with a coarse surface structure or solid cemented prosthetic stems with osseous osteolysis.22 In addition to the safe removal of all foreign material, a radical debridement of the prosthesis bed and the osteolysis can be reliably performed. Lim et al.23 carried out this surgery in 23 cases of periprosthetic joint infection, De Man et al.24 in 27 cases and our team, in an initial study, in 15 cases5 and in a second study in 76 cases7 with a resulting healing of the bony flap between 96 and 100%. We closed the bony flap around the spacer in the first step using cerclage wires and saw a freedom of infection in 93.4%.7 Therefore, in two-stage septic revisions, the transfemoral approach is a reliable method for removing fixed cementless and cemented stems without increasing the risk of infection by using cerclage to close the flap when inserting the interim prosthesis in the first stage. Similarly, the reopening of the flap in the second stage of the transfemoral septic revision does not result in a poorer healing rate of the flap.7 The difference between the so called extended trochanteric osteotomy and the transfemoral approach lies in the width and length of the flap. In the extended trochanteric osteotomy, a flap of 1/3 of the shaft circumference is created with an average length of 12.6e14.2 cm, depending on the report, and a range between 7 cm and 19 cm.13e16,18e20 In the transfemoral approach, the flap is larger and its width is half the circumference of the shaft. The osteotomy is extended distally to immediately above the fixation bed of the new prosthesis or into the apex of deformity.2,3,6 The transfemoral approach serves not only to improve access, but also to correct proximal femoral axis deviations and, above all, to provide direct, straight access to the fixation bed of a distally anchored cementless revision stem. It is therefore preferred for cementless revision stems with a conical design and distal, diaphyseal fixation. In our opinion, the transfemoral approach should be preferred to femoral windows, since it is not possible to predict whether the size of the selected window will reach the desired goal, such as cement removal or implant loosening, and whether the risk of uncontrolled femoral fracture will increase with window extensions. Moreover, femoral windows often loose the muscular connection, which is important for the vascularity of the window and therefore bony healing and union is less predictable in our opinion. The results of our described technique of the transfemoral approach are comparable to, or tendentially better, than those published in the literature (Tables 1 and 2).
Table 1 Outcomes of the extended femoral osteotomy. Inf. ¼ infected. Author 13
Mardones Huffman16 Miner18 Chen19 Peters21 Lim23 Morshed26 Levine27
n
Follow-up [years]
Reunification of the osteotomy
Flap fracture
74 42 166 46 21 23 inf. 13 inf. 23 inf.
2.0 1.4 3.9
98.6% 100% 98.7% 97.8% 100% 100% 100% 96%
5.4% 12.0% 2.4%
3.7 5.3 3.3 4.1
4.4% 8.7% 23.1% 8.7%
Table 2 Outcomes of the traditional transfemoral approach of Wagner. Author
n
Follow-up [years]
Reunification of the osteotomy
Wilkes28 Hartwig29 Grünig30 Isacson31 € hm32 Bo € hm33 Bo Warren34
24 23 18 42 60 60 17
1.5 2.3 3.9 2.1 4.8 5.4 4e7
83.3% 95.8% 94.4% 97.6%
Flap fracture
60% 60% 70.6%
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
4
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
References
Fig. 3. Radiograph 18 months after surgery showing osteointegrated implants and a healed bony flap because of protected muscles on the bony flap for blood supply.
The transfemoral approach can also be performed using a lateral (transgluteal) approach, whereby the flap is then folded dorsally. The disadvantage of this technique is that the gluteal musculature and the muscular vasto-gluteal sling are altered and not protected, and the lid cannot be extended distally at will due to the course of the vasculature. MacDonald et al.25 confirm this in their study and also describe 9% trochanteric escape with this technique. In general, it is important for the transfemoral approach that the musculature on the flap is preserved for blood circulation, which in our opinion can only be achieved reproducibly via a posterolateral approach without a limitation on the length of the flap (Fig. 3). The disadvantage of transfemoral approach is certainly the technically greater effort, the greater size of the access with potentially greater blood loss, and the somewhat longer rehabilitation time until the Trendelenburg sign becomes negative.4,5 5. Conclusion Summerizing our results with a modified Wagner technique and these of the literature, the transfemoral approach using an extended posterolateral approach is a reliable procedure with reproducibly good results with respect to the bony integration of the flap, the stability of the revision stem, the avoidance of uncontrolled intraoperative fractures and perforations, and clinical outcomes. It allows the controlled removal of firmly seated endoprosthetic stems while avoiding uncontrolled fractures and damage to the vastogluteal sling and gluteal muscles. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interest None.
1. Fink B. Extended approach in hip revision and preservation of the muscles. Is that possible? Z für Orthop Unfallchirurgie. 2013;151:243e247. 2. Wagner H. Revisionsprothese für das Hüftgelenk bei schwerem Knochenver€de. 1987;16:295e300. lust. Der Orthopa €de. 1989;18: 3. Wagner H. Revisionsprothese für das Hüftgelenk. Der Orthopa 438e453. 4. Fink B, Grossmann A, Schubring S, Schulz MS, Fuerst M. A modified transfemoral approach using modular cementless revision stems. Clin Orthop Relat Res. 2007;462:105e114. 5. Fink B, Grossmann A. Modified transfemoral approach to revision arthroplasty with uncemented modular revision stems. Oper Orthop Traumatol. 2007;19: 32e55. 6. Wagner H, Wagner M. Hüftprothesenwechsel mit der FemurRevisionsprothese. Erfahrungen von 10 Jahren. Med Orth Tech. 1997;117: 138e148. 7. Fink B, Oremek D. The transfemoral approach for removal of well-fixed femoral stems in two-stage septic hip revision. J Arthroplast. 2016;31: 1065e1071. € ld S, Blomberg G. Integrity of the gluteus medius after the 8. Svensson O, Sko transgluteal approach in total hip arthroplasty. J Arthroplast. 1990;5:57e60. 9. Suh KT, Roh HL, Moon KP, Shin JK, Lee JS. Posterior approach with posterior soft tissue repair in revision total hip arthroplasty. J Arthroplast. 2008;23: 1197e1203. 10. Masri BA, Campbell DG, Garbuz DS, Duncan CP. Seven specialized exposures for revision hip and knee replacement. Orthop Clin N Am. 1998;29:229e240. 11. Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric osteotomies in revision total hip arthroplasty: contemporary techniques and results. Instr Course Lect. 2005;54:143e155. 12. Wagner H, Wagner M. Femur-revisionsprothese. Z Orthop. 1993;131:574e577. 13. Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. J Arthoplasty. 2005;20:79e83. 14. Glassman AH. Exposure for revision: total hip replacement. Clin Orthop Relat Res. 2004;420:39e47. 15. Della Valle CJ, Berger RA, Rosenberg AG, Jacobs JJ, Sheinkop MB, Paprosky WG. Extended trochanteric osteotomy in complex primary total hip arthroplasty. A brief note. J Bone Jt. Surg. 2003;85-A:2385e2390. 16. Huffman GR, Ries MD. Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site. J Bone Jt. Surg. 2003;85-A:273e277. 17. Paprosky WG, Weeden SH, Bowling Jr JW. Component removal in revision total hip arthroplasty. Clin Orthop Relat Res. 2001;393:181e193. 18. Miner TM, Momberger NG, Chong D, Paprosky WL. The extended trochanteric osteotomy in revision hip arthroplasty: a critical review of 166 cases at mean 3-year, 9-month follow-up. J Arthroplast. 2001;16:188e194. 19. Chen WM, McAuley JP, Engh Jr CA, Hopper Jr RH, Engh CA. Extended slide trochanteric osteotomy for revision total hip arthroplasty. J Bone Jt. Surg. 2000;82-A:1215e1219. 20. Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplast. 1995;10:329e338. 21. Peters Jr PC, Head WC, Emerson Jr RH. An extended trochanteric osteotomy for revision total hip replacement. J Bone Jt. Surg. 1993;75-Br:158e159. €fer P, Frommelt L. Two-stage cementless 22. Fink B, Grossmann A, Fuerst M, Scha revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467: 1848e1858. 23. Lim SJ, Moon YW, Park YS. Is extended trochanteric osteotomy safe for use in 2stage revision of periprosthetic hip infection? J Arthroplast. 2011;26: 1067e1071. 24. De Man FH, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T. Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. 22 one-stage and 50 two-stage revisions with a mean follow-up time of 5 (2-217) years. Acta Orthop. 2011;82:27e34. 25. MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, McCalden RW. Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Clin Orthop Relat Res. 2003;417:210e216. 26. Morshed S, Huffman R, Ries MD. Extended trochanteric osteotomy for 2-stage revision of infected total hip arthroplasty. J Arthoplasty. 2005;20:294e301. 27. Levine BR, Della alle CJ, Hamming M, Sporer SM, Berger RA, Paprosky WG. Use of the extended trochanteric osteotomy in treating prosthetic hip infection. J Arthroplast. 2009;24:49e55. 28. Wilkes RA, Birch J, Pearse MF, Lee M, Atkins RM. The Wagner technique for revision arthroplasty of the hip: a review of 24 cases. J Orthop Rheumatol. 1994;7:196e198. € hm P, Czech U, Reize P, Küsswetter W. The Wagner 29. Hartwig C-H, Bo revision stem in alloarthroplasty of the hip. Arch Orthop Trauma Surg. 1996;115:5e9. 30. Grünig R, Morscher E, Ochsner PE. Three- to 7-year results with the uncemented SL femoral revision prosthesis. Arch Orthop Trauma Surg. 1997;116: 187e197. 31. Isacson J, Stark A, Wallensten R. The Wagner revision prosthesis consistently restores femoral bone structure. Int Orthop. 2000;24:139e142.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx €hm P, Bischel O. Femoral revision with the Wagner SL revision stem. Eval32. Bo uation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Jt. Surg. 2001;83-A:1023e1031. €hm P, Bischel O. The uncemented diaphyseal fixation of femoral revision 33. Bo stems in case of large bone defects e analysis of twelve years experience with
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the Wagner SL revision stem. Z Orthop. 2001;139:229e239. 34. Warren PJ, Thompson P, Flechter MDA. Transfemoral implantation of the Wagner SL stem. The abolition of subsidence and enhancement of osteotomy union rate using Dall-Miles cables. Arch Orthop Trauma Surg. 2002;122: 557e560.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Review article
The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery Bernd Fink* €die, Orthopa €dische Klinik Markgro €ningen gGmbH, Kurt-Lindemann-Weg 10, 71706, Klinik für Endoprothetik, Allgemeine und Rheumaorthopa €ningen, Germany Markgro Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2019 Received in revised form 2 November 2019 Accepted 4 November 2019 Available online xxx
Background: For the removal of well fixed femoral stems, various standard and extended approaches are possible, all of which have their advantages and disadvantages. They should allow good visualization and avoid uncontrolled damage to the bone (especially devascularization and fractures) and to the musculature (especially the gluteus medius). As an extended approach we prefer the transfemoral approach in a modified Wagner technique. It is indicated for the controlled removal of broken endoprosthetic stems, a significantly thinned bone at risk of fracture, a stable cement mantle, a partially fixed cementless prosthetic stem with a coarse, rough surface, and infected, fixed total hip endoprostheses. In this review article we describe our experience with our technique of the transfemoral approach. Material and results: In 68 patients with hip revisions using the modified transfemoral approach, the Harris Hip Score increased continuously from 41.4 points preoperatively to 85.9 points 24 months postoperatively. The bony flap showed bone consolidation in 98.5% of cases. In 76 patients with transfemoral two-stage septic hip revisions, with closure of the flap around the interim prosthesis with cerclage wires and reopening of the flap during second stage revision, the Harris Hip Score was 62.2 ± 12.6 points before the replacement of the spacer and 86.6 ± 15.5 points two years after reimplantation. The healing rate of the bony flap after reimplantation was 98.7%, the absence of infection 93.4%, the rate of stem subsidence 6.6%, and the dislocation rate 6.6%; there was no aseptic loosening of the implants. Conclusion: The transfemoral approach allows a reliable protection of the gluteus medius and the vastogluteal sling, and enables reproducibly good clinical outcomes. © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Transfemoral approach Extended trochanteric approach Revision arthroplasty
1. Introduction For the revision of hip endoprostheses, various standard and extended approaches are possible for controlled removal of the prosthesis and reimplantation of a new prosthesis, all of which have their advantages and disadvantages. Overall, they should allow good visualization and avoid uncontrolled damage to the bone (especially devascularization and fractures) and to the musculature. The gluteus medius and minimus muscle in particular should be spared, as they play a decisive role in the function and stability of the hip joint. A disruption of the vastogluteal sling as the
€dische * Klinik für Endoprothetik, Allgemeine und Rheumaorthop€ adie, Orthopa €ningen GGmbH, Kurt-Lindemann-Weg 10, 71706, Markgro €ningen, Klinik Markgro Germany E-mail address: bernd.fi[email protected].
connection between the gluteus medius muscle and the vastus lateralis muscle should also be avoided, since in the event of a trochanteric fracture, the disruption of the vastogluteal sling means the counterpart of the gluteus medius no longer exists and a dislocation of the trochanter major is unavoidable. Therefore, all approaches with weakening of the gluteal muscles and disruption of the vastogluteal sling are disadvantageous for maintaining the important function of the gluteal muscles.1 In this review article we describe our technique of the transfemoral approach and our results and discuss these with the results of the literature. 2. Operative technique Our published technique of the transfemoral approach is carried out using a modified Wagner technique.2e5 After an extended
https://doi.org/10.1016/j.jcot.2019.11.001 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
2
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
posterolateral approach in the lateral position, the posterior lateral edge of the femur ventral to the aspera line is visualized in the intermuscular lateral septum under ligation of the perforating vessels. The lateral circumference of the femur is displayed at the level of the planned end of the flap and 3.2 mm holes are drilled in the dorsal and ventral ends of the flap under cooling spanning the half circumference of the femur. The ventromedial trochanter region is then osteotomized with a chisel at the vastogluteal border and then the dorsolateral osteotomy, the connecting osteotomy between the two drill holes, and the distal ventromedial osteotomy of approx. 3 cm is performed with a water-cooled oscillating saw (using a thin saw blade of 0.7 mm). The completion of the ventromedial osteotomy is performed using a small osteotome-chisel driven blindly under the vastus lateralis muscle to the proximal end of the osteotomy from the already prepared proximal, ventral osteotomy. After chiseling a few centimeters from distal to proximal the bony flap automatically breaks until the already performed proximal, ventral osteotomy.4,5 This transfemoral approach technique represents a modification of the original Wagner technique2,3,6 in which the osteotomy was performed dorsolaterally and ventromedially through the vastus lateralis muscle using chisel techniques. After the osteotomy, the flap is folded up medially with the vastus lateralis muscle attached. The prosthesis stem to be replaced is removed and the bony flaps cleaned; if necessary the acetabular cup is replaced, otherwise an inlay exchange is carried out and the fixation bed of the cementless revision stem is prepared. A double cerclage is applied to prevent a fissure in the area of the fixation bed in the isthmus of the femur. After implantation of a distally fixated cementless revision stem, the bony flap is closed by means of two double cerclage fixations with 1.5 mm cerclage wire or cable systems (Figs. 2 and 3). In the event of proximalization of the lid due to muscle tension, the resulting gap to the distal femur is filled with autologous cancellous bone or milled bone obtained during surgery. In the original technique according to Wagner,2,3 both the exact flap repositioning and fixation were dispensed with and the flap was merely sewn on using sutures. 3. Material and Results In a separate study, 68 hip prosthesis revisions were performed with Revitan Curved prostheses (ZimmerBiomet GmbH, Winterthur, Switzerland), which were implanted via this modified transfemoral approach, and prospectively followed clinically and radiologically over a period of 32.3 ± 10.2 months.4 The Harris Hip Score increased continuously from 41.4 ± 14.5 points preoperatively to 85.9 ± 14.6 points 24 months postoperatively. Two stems showed a temporary subsidence of more than 5 mm and two stems were loosened. In all four cases it was only possible to achieve a fixation region with a length of less than 3 cm in the isthmus of the femur. The bony flap showed bony consolidation in 98.5% of cases one year after surgery. Two postoperative trochanteric detachments healed without further action. The intraoperative blood loss averaged 970 ± 560 mL (from 420 to 2100 mL).4 For the analysis of the results of the transfemoral approach in the two-stage septic revision with closure of the flap around the interim prosthesis with cerclage wires and reopening of the bony flap during reimplantation, 76 patients were followed for an average of 51.2 ± 23.2 (24e118) months.7 The healing rate of the bony flap after reimplantation was 98.7%, the absence of infection 93.4%, the rate of stem subsidence 6.6%, and the dislocation rate 6.6%; there was no aseptic loosening of the implants. The Harris Hip Score was 62.2 ± 12.6 points with the spacer before prosthesis replacement and 86.6 ± 15.5 points two years after reimplantation. Four fractures of the flap (5.3%) occurred due to osteolysis or osteoporotic bone thinning, but all healed over time.
4. Discussion For the revision of hip endoprostheses, various standard and extended approaches are possible for controlled removal of the prosthesis and reimplantation of a new prosthesis, all of which have their advantages and disadvantages. Svennson et al.8 reported that after primary implantation of 97 total hip endoprostheses via the transgluteal approach, a separation of x-ray markers applied to each side of the muscle that had been cut during the approach occurred in 56% of cases. The repeated reinsertion of separated parts of the gluteus medius during prosthesis revision surgeries would further weaken the gluteal muscles and complicate functional rehabilitation. Therefore, the transgluteal approach for revision surgery seems to have considerable disadvantages for functionality. Furthermore, the risk of trochanteric fractures is increased, especially with this approach and the anterior approaches to revision.1 The standard posterolateral approach allows a good view of the acetabulum as well as a direct access to the shaft with very effective protection of the gluteal muscles. However, dislocation rates of 4e20% have been reported for revision surgery.9 This risk can be reduced to 2% by posterior capsule soft tissue repair at the reinsertion point of the external rotators.9 The trans-trochanteric approach has been largely abandoned, despite the equally suitable visualization of the acetabulum, due to the high non-union rates of 10e20%.10,11 The extended transgluteal approach, the so-called vastus slide, has the disadvantage of an alteration to the vastogluteal sling with an accompanying risk of uncontrolled dislocation of the trochanter in the event of a fracture during revision, since the counterpart of the gluteal muscle (the vastus lateralis muscle) has been separated from it during the surgical approach. If a vastus slide is adopted, the medial gluteus muscle should not be divided more than 4 cm above the original acetabular margin or more than 5 cm cranially of the trochanter tip in order to avoid iatrogenic damage to the superior gluteal nerve and the superior gluteal artery.10 Therefore, as an extended approach for femoral revision we prefer the transfemoral approach in a modified Wagner technique.2,3,6,12 In our opinion, it is indicated for hip prosthesis replacement with broken endoprosthesis stems, axial deviation of the femur due to loosening, a significantly thinned bone at risk of fracture, a stable cement mantle, a partially fixed cementless stem (especially for stems with rough surfaces (Fig. 1)) and for
Fig. 1. Radiograph of a 75-year old man with a loosened cementless stem and cup with rough surface 12 years after implantation on the left side. Osteolyses at the greater trochanter due to wear are visible.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
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Fig. 2. Radiograph after exchange of the endoprosthesis via the transfemoral approach. Due to the thin bone a fracture of the bony flap of the transfemoral approach occurred.
periprosthetic fractures. The advantages of exchanging the stem using a transfemoral access or the so-called extended trochanteric osteotomy are the direct access to the distal canal of the femur for the removal of distal cement and for the efficient preparation of the new prosthesis fixation bed, the avoidance of uncontrolled intraoperative fractures and femoral perforations, the more reliable healing of the osteotomy compared to transtrochanteric osteotomy, the shorter operation time for difficult implant removal, and the protection of the vastogluteal sling.13e21 Moreover, by callus formation a bone regeneration and bone on-growth on the new implant occurs because of this approach.1 The transfemoral approach makes it possible to remove firmly seated stems and cement sheaths in a controlled manner, for example in septic prosthesis revision of firmly osteointegrated
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cementless prosthesis stems with a coarse surface structure or solid cemented prosthetic stems with osseous osteolysis.22 In addition to the safe removal of all foreign material, a radical debridement of the prosthesis bed and the osteolysis can be reliably performed. Lim et al.23 carried out this surgery in 23 cases of periprosthetic joint infection, De Man et al.24 in 27 cases and our team, in an initial study, in 15 cases5 and in a second study in 76 cases7 with a resulting healing of the bony flap between 96 and 100%. We closed the bony flap around the spacer in the first step using cerclage wires and saw a freedom of infection in 93.4%.7 Therefore, in two-stage septic revisions, the transfemoral approach is a reliable method for removing fixed cementless and cemented stems without increasing the risk of infection by using cerclage to close the flap when inserting the interim prosthesis in the first stage. Similarly, the reopening of the flap in the second stage of the transfemoral septic revision does not result in a poorer healing rate of the flap.7 The difference between the so called extended trochanteric osteotomy and the transfemoral approach lies in the width and length of the flap. In the extended trochanteric osteotomy, a flap of 1/3 of the shaft circumference is created with an average length of 12.6e14.2 cm, depending on the report, and a range between 7 cm and 19 cm.13e16,18e20 In the transfemoral approach, the flap is larger and its width is half the circumference of the shaft. The osteotomy is extended distally to immediately above the fixation bed of the new prosthesis or into the apex of deformity.2,3,6 The transfemoral approach serves not only to improve access, but also to correct proximal femoral axis deviations and, above all, to provide direct, straight access to the fixation bed of a distally anchored cementless revision stem. It is therefore preferred for cementless revision stems with a conical design and distal, diaphyseal fixation. In our opinion, the transfemoral approach should be preferred to femoral windows, since it is not possible to predict whether the size of the selected window will reach the desired goal, such as cement removal or implant loosening, and whether the risk of uncontrolled femoral fracture will increase with window extensions. Moreover, femoral windows often loose the muscular connection, which is important for the vascularity of the window and therefore bony healing and union is less predictable in our opinion. The results of our described technique of the transfemoral approach are comparable to, or tendentially better, than those published in the literature (Tables 1 and 2).
Table 1 Outcomes of the extended femoral osteotomy. Inf. ¼ infected. Author 13
Mardones Huffman16 Miner18 Chen19 Peters21 Lim23 Morshed26 Levine27
n
Follow-up [years]
Reunification of the osteotomy
Flap fracture
74 42 166 46 21 23 inf. 13 inf. 23 inf.
2.0 1.4 3.9
98.6% 100% 98.7% 97.8% 100% 100% 100% 96%
5.4% 12.0% 2.4%
3.7 5.3 3.3 4.1
4.4% 8.7% 23.1% 8.7%
Table 2 Outcomes of the traditional transfemoral approach of Wagner. Author
n
Follow-up [years]
Reunification of the osteotomy
Wilkes28 Hartwig29 Grünig30 Isacson31 € hm32 Bo € hm33 Bo Warren34
24 23 18 42 60 60 17
1.5 2.3 3.9 2.1 4.8 5.4 4e7
83.3% 95.8% 94.4% 97.6%
Flap fracture
60% 60% 70.6%
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
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References
Fig. 3. Radiograph 18 months after surgery showing osteointegrated implants and a healed bony flap because of protected muscles on the bony flap for blood supply.
The transfemoral approach can also be performed using a lateral (transgluteal) approach, whereby the flap is then folded dorsally. The disadvantage of this technique is that the gluteal musculature and the muscular vasto-gluteal sling are altered and not protected, and the lid cannot be extended distally at will due to the course of the vasculature. MacDonald et al.25 confirm this in their study and also describe 9% trochanteric escape with this technique. In general, it is important for the transfemoral approach that the musculature on the flap is preserved for blood circulation, which in our opinion can only be achieved reproducibly via a posterolateral approach without a limitation on the length of the flap (Fig. 3). The disadvantage of transfemoral approach is certainly the technically greater effort, the greater size of the access with potentially greater blood loss, and the somewhat longer rehabilitation time until the Trendelenburg sign becomes negative.4,5 5. Conclusion Summerizing our results with a modified Wagner technique and these of the literature, the transfemoral approach using an extended posterolateral approach is a reliable procedure with reproducibly good results with respect to the bony integration of the flap, the stability of the revision stem, the avoidance of uncontrolled intraoperative fractures and perforations, and clinical outcomes. It allows the controlled removal of firmly seated endoprosthetic stems while avoiding uncontrolled fractures and damage to the vastogluteal sling and gluteal muscles. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interest None.
1. Fink B. Extended approach in hip revision and preservation of the muscles. Is that possible? Z für Orthop Unfallchirurgie. 2013;151:243e247. 2. Wagner H. Revisionsprothese für das Hüftgelenk bei schwerem Knochenver€de. 1987;16:295e300. lust. Der Orthopa €de. 1989;18: 3. Wagner H. Revisionsprothese für das Hüftgelenk. Der Orthopa 438e453. 4. Fink B, Grossmann A, Schubring S, Schulz MS, Fuerst M. A modified transfemoral approach using modular cementless revision stems. Clin Orthop Relat Res. 2007;462:105e114. 5. Fink B, Grossmann A. Modified transfemoral approach to revision arthroplasty with uncemented modular revision stems. Oper Orthop Traumatol. 2007;19: 32e55. 6. Wagner H, Wagner M. Hüftprothesenwechsel mit der FemurRevisionsprothese. Erfahrungen von 10 Jahren. Med Orth Tech. 1997;117: 138e148. 7. Fink B, Oremek D. The transfemoral approach for removal of well-fixed femoral stems in two-stage septic hip revision. J Arthroplast. 2016;31: 1065e1071. € ld S, Blomberg G. Integrity of the gluteus medius after the 8. Svensson O, Sko transgluteal approach in total hip arthroplasty. J Arthroplast. 1990;5:57e60. 9. Suh KT, Roh HL, Moon KP, Shin JK, Lee JS. Posterior approach with posterior soft tissue repair in revision total hip arthroplasty. J Arthroplast. 2008;23: 1197e1203. 10. Masri BA, Campbell DG, Garbuz DS, Duncan CP. Seven specialized exposures for revision hip and knee replacement. Orthop Clin N Am. 1998;29:229e240. 11. Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric osteotomies in revision total hip arthroplasty: contemporary techniques and results. Instr Course Lect. 2005;54:143e155. 12. Wagner H, Wagner M. Femur-revisionsprothese. Z Orthop. 1993;131:574e577. 13. Mardones R, Gonzalez C, Cabanela ME, Trousdale RT, Berry DJ. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. J Arthoplasty. 2005;20:79e83. 14. Glassman AH. Exposure for revision: total hip replacement. Clin Orthop Relat Res. 2004;420:39e47. 15. Della Valle CJ, Berger RA, Rosenberg AG, Jacobs JJ, Sheinkop MB, Paprosky WG. Extended trochanteric osteotomy in complex primary total hip arthroplasty. A brief note. J Bone Jt. Surg. 2003;85-A:2385e2390. 16. Huffman GR, Ries MD. Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site. J Bone Jt. Surg. 2003;85-A:273e277. 17. Paprosky WG, Weeden SH, Bowling Jr JW. Component removal in revision total hip arthroplasty. Clin Orthop Relat Res. 2001;393:181e193. 18. Miner TM, Momberger NG, Chong D, Paprosky WL. The extended trochanteric osteotomy in revision hip arthroplasty: a critical review of 166 cases at mean 3-year, 9-month follow-up. J Arthroplast. 2001;16:188e194. 19. Chen WM, McAuley JP, Engh Jr CA, Hopper Jr RH, Engh CA. Extended slide trochanteric osteotomy for revision total hip arthroplasty. J Bone Jt. Surg. 2000;82-A:1215e1219. 20. Younger TI, Bradford MS, Magnus RE, Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplast. 1995;10:329e338. 21. Peters Jr PC, Head WC, Emerson Jr RH. An extended trochanteric osteotomy for revision total hip replacement. J Bone Jt. Surg. 1993;75-Br:158e159. €fer P, Frommelt L. Two-stage cementless 22. Fink B, Grossmann A, Fuerst M, Scha revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467: 1848e1858. 23. Lim SJ, Moon YW, Park YS. Is extended trochanteric osteotomy safe for use in 2stage revision of periprosthetic hip infection? J Arthroplast. 2011;26: 1067e1071. 24. De Man FH, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T. Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. 22 one-stage and 50 two-stage revisions with a mean follow-up time of 5 (2-217) years. Acta Orthop. 2011;82:27e34. 25. MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, McCalden RW. Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty. Clin Orthop Relat Res. 2003;417:210e216. 26. Morshed S, Huffman R, Ries MD. Extended trochanteric osteotomy for 2-stage revision of infected total hip arthroplasty. J Arthoplasty. 2005;20:294e301. 27. Levine BR, Della alle CJ, Hamming M, Sporer SM, Berger RA, Paprosky WG. Use of the extended trochanteric osteotomy in treating prosthetic hip infection. J Arthroplast. 2009;24:49e55. 28. Wilkes RA, Birch J, Pearse MF, Lee M, Atkins RM. The Wagner technique for revision arthroplasty of the hip: a review of 24 cases. J Orthop Rheumatol. 1994;7:196e198. € hm P, Czech U, Reize P, Küsswetter W. The Wagner 29. Hartwig C-H, Bo revision stem in alloarthroplasty of the hip. Arch Orthop Trauma Surg. 1996;115:5e9. 30. Grünig R, Morscher E, Ochsner PE. Three- to 7-year results with the uncemented SL femoral revision prosthesis. Arch Orthop Trauma Surg. 1997;116: 187e197. 31. Isacson J, Stark A, Wallensten R. The Wagner revision prosthesis consistently restores femoral bone structure. Int Orthop. 2000;24:139e142.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001
B. Fink / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx €hm P, Bischel O. Femoral revision with the Wagner SL revision stem. Eval32. Bo uation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Jt. Surg. 2001;83-A:1023e1031. €hm P, Bischel O. The uncemented diaphyseal fixation of femoral revision 33. Bo stems in case of large bone defects e analysis of twelve years experience with
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the Wagner SL revision stem. Z Orthop. 2001;139:229e239. 34. Warren PJ, Thompson P, Flechter MDA. Transfemoral implantation of the Wagner SL stem. The abolition of subsidence and enhancement of osteotomy union rate using Dall-Miles cables. Arch Orthop Trauma Surg. 2002;122: 557e560.
Please cite this article as: Fink B, The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.11.001