Revision Total Hip Arthroplasty - PowerPoint PPT Presentation

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Revision Total Hip Arthroplasty

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Revision Total Hip Arthroplasty Requires a clear preoperative plan. Plan - 1) Revision Dx. 2) Surgical approach 3)Instruments 4) Bone Grafts 5) Implants – PowerPoint PPT presentation

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Title: Revision Total Hip Arthroplasty


1
Revision Total Hip Arthroplasty
  • Requires a clear preoperative plan.
  • Plan - 1) Revision Dx. 2) Surgical approach
    3)Instruments 4) Bone Grafts 5) Implants
  • Preparation to handle unexpected problems that
    may require a greater exposure .

2
Surgical Approach
  • Revisions performed with posterior approach
  • May be extended proximally or distally
  • Proximal extension exposes entire ilium and
    anterior column

3
Trochanteric Osteotomy
  • Most common extensile measure
  • 4 types 1)Extended trochanteric slide 2)Simple
    trochanteric slide 3)Conventional trochanteric
    osteotomy 4)Extended conventional osteotomy

4
Factors for Choice of Osteotomy
  • Bone quality
  • What needs to be exposed

5
Indications for Extending Length
  • Greater trochanter compromised by osteopenia or
    osteolysis - osteotomy lengthening ensures
    adequate amount of lateral bone for fixation
  • Proximal medial bone loss - osteotomy extended
    into diaphysis so adequate medial bone is
    available for wire or cable fixation of the
    osteotomy

6
Need for Increased Exposure
  • Osteotomy choice is based on the required
    exposure
  • Anterior trochanteric slide - exposes metaphysis
    of femur to the level of the lesser trochanter
  • Conventional trochanteric - metaphysis of femur
    with improved acetabular, anterior wall, and
    ilium exposure

7
Cont.
  • Extended trochanteric slide - acetabular exposure
    of simple anterior trochanteric slide with better
    femoral exposure
  • Extended conventional osteotomy - maximizes
    exposure of femur and acetabulum

8
Revision Surgical Approach
  • Posterolateral
  • Previous incision is posterolateral or direct
    lateral - use the same incision
  • New incision - landmarks are halfway b/w anterior
    and posterior borders of greater trochanter to
    allow more anterior exposure

9
New Incision (cont.)
  • Upper half - parallel to fiber of gluteus maximus
  • Lower half - longitudinal extension toward the
    knee
  • Gluteus Maximus insertion to femur is released to
    expose sciatic nerve - failure to do so increases
    the risk of constriction of the nerve by
    retraction

10
Revision Surgical Approach (cont.)
  • Retained femoral component - anterior capsule is
    divided to effect anterior displacement of the
    femur.
  • Iliopsoas tendon sheath is entered to define
    plane and the capsule is divided from the inside
    out, starting distally at the lesser trochanter gt
    retractor placed over acetabulum to displace
    femur anteriorly

11
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12
Anterior Trochanteric Slide
  • Indications
  • Femoral - 1) removal of well-fixed proximal
    porous coated prosthesis 2) removal of failed
    endoprosthesis with bone fenestrations. Anterior
    and posterior femoral components can be reached
    with a osteotome

13
Anterior Trochanteric Slide (cont)
  • Acetabular - 1) acetabular protusio without easy
    dislocation 2)acetabular revision cases with
    femoral component retention.
  • Small size of trochanteric fragment limits
    indications 1) If acetabular revision results in
    leg lengthening, fragment may not reach femoral
    bone for attachment. 2) Absence of medial bone
    for securing wires of cables.

14
Technique for Anterior Trochanteric Slide
  • 1) Posteriolateral approach extended 2 inches
    distally
  • 2) elevate posterior border of vastus lateralis
    to the greater trochanter
  • 3) expose gluteus medius by external rotation
  • 4) Develop plane between gluteus medius and
    gluteus minimus

15
Technique (cont.)
  • 5) Osteotomy performed in internal rotation with
    distal margin below insertion of the v.
    lateralis, and the superior margin lateral to the
    piriformis fossa b/w the medius and minimus
    insertions.
  • 6) Reattach the tochanteric fragment with 18
    gauge wires or cables through or below the lesser
    trochanter and through the greater trochanter

16
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17
Extended Conventional Trochanteric Osteotomy
  • Indications - Extensive acetabular bone stock
    damage and difficult acetabular revisions where
    excessive leg lengthening can occur.
  • Contraindications - Retention of a well fixed
    femoral component

18
Technique
  • 1) Distal margin - 5 cm. Distal to the greater
    trochanter on the lateral femoral shaft
  • 2) Proximal margin - exits the greater trochanter
    between the gluteus medius and superior hip
    capsule
  • 3) Vastus lateralis is stripped
  • 4) Internal rotation - isolate posterior margin
    of gluteus medius

19
Technique (cont.)
  • 5) External rotation - isolate anterior margin of
    gluteus medius
  • 6) Osteotomy cuts are made through lateral half
    of periosteal surface and lateral third of
    endosteal surface
  • 7) Reflect osteotomy with care to protect
    inferior gluteal nerve
  • Repair with 2 wires or cables

20
Post-Operative Rehabilitation
  • Based on the stability of trochanteric attachment
  • ROM limitations determined intraoperatively
  • Fixation strength of trochanter is determined by
    stressing the trochanter with adduction and ROM
  • FWB _at_ 3 months

21
Rehab (cont.)
  • PROM without adduction within the recorded limits
    of hip stability recorded intraoperatively
  • No hip flexion or adduction for 6 weeks

22
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23
Vascular Schaphoid Window for Access to Femoral
Canal In Revision THA
  • Jeff Easom, D.O.
  • Garden City Hospital

24
Introduction
  • Removal of distal cement from femoral canal
    involves substantial risks of canal perforation
  • Cement removal that extends beyond apex of
    anterior femoral bow may not be possible
  • cortical perforation increases the risk of later
    femoral fracture

25
  • Measures taken are controlled windows and
    extended osteotomies.

26
Femoral Windows
  • Muller - 1cm X 20cm anterior gutter
  • Nelson and Weber - Lateral rectangular window 2cm
    wide x 6cm long
  • Sydney and Mallory - Serial 9 mm perforations to
    guide instruments and afford access for punches
    to remove broken stems - 9 post-op frxs. Of 219
    cases

27
Femoral Windows (cont.)
  • Shepherd and Turnbull - 1 cm by 2 cm window on
    the anterior surface of femur b/w 3.2mm drill
    holes without replacement fixation - early
    healing and good results
  • Klein and Rubash - Shepherd window creations with
    size of 2 cm by 5 cm - complete detachment from
    soft tissue with fixation by cerclage wires -
    mean healing 17 weeks and no post-op fractures.

28
Extended Femoral Osteotomy
  • Extension of a trochanteric osteotomy distally
    along femoral shaft
  • Peters and Assoc. - good results
  • Younger and Assoc. - 20 cases with extended
    osteotomy of greater trochanter with 1/3 of
    cortical diameter of the femur hinged anteriorly
    with preservation of blood supply by soft-tissue
    attachments-healing _at_ 3 months

29
Advantages
  • Ease of component and cement extraction
  • Superior visualization of the distal femoral
    canal, which allows mor accurate preparation of
    distal femur and eliminates varus placement of
    revision implant.

30
Advantages (cont.)
  • Anterolateral, posterior, or combined approaches
    to hip joint itself may be implemented

31
Vascularized Schaphoid Window Technique
  • Lateral incision 30 degrees posteriorly proximal
    to the greater trochanter
  • Extend incision to beyond distal extent of
    proposed osteotomy
  • elevate vastus lateralis width of 1cm to expose
    lateral femur - maintains blood supply by
    muscular attaachments

32
Technique (cont.)
  • Scaphoid osteotomy - Through both cortices of
    femur lateral to medial with incorporation of
    smooth rounded edges.
  • Avoid muscle stripping
  • Replace with 1 or more cerclage wires
  • Reimplantation devices should bypass the window
    by _at_ least 2 cortical diameters with protected
    weightbearing for 12 weeks.

33
Conclusion
  • Combines the advantages and avoids the
    disadvantages of other osteotomies.
  • Afford an approach that give excellent exposure
    of the femoral canal over whatever length is
    require for safe implant and cement removal
  • Permits all reconstructive possibilities and
    minimizes risk of complicaitons (nonunion of
    window and fracture).

34
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