R e m o v a l of B o n e C e m e n t F r o m t h e F e m o r a l Shaft Using a F e m o r a l W i n d o w i n g Device
Carl L. N e l s o n , M D , a n d C. L o w r y B a r n e s , M D
Abstract: The authors previously described a method of windowing the femur that allowed good exposure for femoral cement removal and provided for reconstruction of the defect. Since that report, they have developed instrumentation to facilitate windowing of the femoral shaft. They describe its use in this report. Key words: revision surgery, cement removal, femur perforation.
Since our first report, we have developed instrumentation to facilitate this technique. The template is used to assure an accurate cut and accurate fitting of the removed w i n d o w as well as for use as a temporary plug if cement is used for fixation of the new implant. It is then removed and the w i n d o w accurately fitted in place. In this report we describe the use of this technique for accessing the femoral canal for revision surgery.
The removal of firmly fixed cement from the femoral shaft is often a difficult task, demanding of both technical skill and operative time. The difficulty of removing cement from the proximal femur during revisions of total hip anhroplasty is well recognized (2, 4, 7, 10). Perforation or fracture of the femur during removal of cement has been reported (3, 6, 8, 9), and Mallory has suggested that perforation should be expected (5). W h e n trochanteric osteotomy and the use of special instruments are inadequate, or if the surgeon decides to visualize the femur directly and make an aperture for cement removal, the ability to fashion a w i n d o w quickly is desirable. We have addressed this problem by windowing the proximal femur, using a previously reported procedure (7). Our technique is essentially a controlled perforation as described by Dennis et al. (1), but it is larger and provides bony reconstruction of the defect. We have used a 45 ° beveled wedge-shaped wind o w large enough to admit high-velocity drills and special instruments; this type of w i n d o w has been satisfactory if properly fashioned.
Technique If the anterolateraI approach is used, the distal portion of the exposure is extended subperiostally to the tip of the original prosthetic cement complex. The lateral aspect of the femoral shaft is exposed by incising the fascia lata and the myofascia of the vastus lateralis. The muscle is divided to bone by blunt dissection and the cortex of the shaft stripped of soft tissue. The distal limits of the intended w i n d o w are preferably viewed radiographically. The site for the w i n d o w is chosen based on the needs of the patient and the individual characteristics of the cement distribution. It is prudent to remember, however, that once the w i n d o w is made the prosthesis to be inserted should have a tip that extends beyond the dis-
From the Department of Orthopaedic Surgery, Universityof Arkansas for Medical Sciences, Little Rock, Arkansas.
Reprint requests: Carl L. Nelson, MD, Department of Orthopaedic Surgery,Universityof Arkansas for Medical Sciences,4301 West Markham, Slot 531, Little Rock, AK 72205.
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Fig. 1. Femoral windowing template.
Fig. 3. Femoral window removed during surgery.
tal end of the w i n d o w by 2 - 3 diameters of the bone. The template (Figs. 1, 2) is placed against the bone where the osteotomy is to be made, usually on the anterior or anterolateral aspect of the femur, and held in place. The drill is inserted through the holes on the dorsal surface of the template, and a hole is made into the femur. The screws are then applied. These are short screws that only traverse the femoral cortex. The handle is then unscrewed and the metal template left in place. The saw is placed against the edge of the template and held carefully to assure that it parallels the template surface; the cuts are made. While making the cuts the areas are thoroughly irrigated to prevent necrosis of the bone. It is important not to overcut the corners, and this can be facilitated by using a smaller blade on both the proximal and distal cuts. Once the cuts are completed, the handle is reinserted and the cut tested, then the template and bone fragment are lifted from the femur (Fig. 3). It is important to test the cuts by gently wiggling the handle of the template, to be certain not to fracture the area. The cement is removed; if necessary, further
windows are made. If cement is used to place the revision prosthesis, a plastic cover is placed over the template and into and over the aperture. It can be held or wired into place. W h e n the cement has hardened, the template covering is removed, excess cement is excised, and the femoral w i n d o w is replaced. The femoral w i n d o w may need to be shaped and held into place, with either a plain suture or wires. Usually some adjustment is necessary on the inferior surface of the bone so that it fits against the implant, w h e t h e r it is porous coated or fits to the surface of the cement. We r e c o m m e n d packing b o n e graft slurry into the saw-cut area. In conclusion, we find this a valuable method for controlled perforation of the femoral shaft in revision total hip arthroplasty.
Fig. 2. Template applied to femur.
References 1. Dennis DA, Dingman CA, Meglan DA et al: Femoral cemented removal in revision total hip arthroplasty. Clin Orthop 220:142, 1987 2. Effekhar NS: Rechannelizafion of cemented femur using a guide and drill system. Clin Orthop 123:29, 1977 3. Johannson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg 63A:1435, 1981 4. Kavanaugh BF: Revision total hip arthroplasty. J Bone Joint Surg 67A:517, 1985 5. Mallory TH: Preparation of the proximal femur in cementless total hip revision. Clin Orthop 235:47, 1988 6. McElffesh EC, Coventry MB: Femoral and pelvic fractures after total hip anhroplasty. J Bone Joint Surg 56A:483, 1974 7. Nelson CL, Weber MJ: Technique of windowing the
Femoral Windowing Device femoral shaft for removal of bone cement. Clin Orthop 154:336, 1981 8. Scott RD: Femoral fractures in conjunction with total hip replacement. J Bone Joint Surg 57A:494, 1974 9. Scott RD, Schilz JP: Femoral fracture and revision arthroplasty, p. 127. In Turner RD, Scheller AD (eds):
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Nelson and Barnes
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Revision total hip anhroplasty. Grune & Stratton, New York, 1982 10. Tumer RH, Emerson RH Jr: Femoral revision total hip arthroplasty, p. 75. In Turner RW, Scheller AD (eds): Revision total hip anhroplasty. Grune & Stratton, New York, I982
Carl L. N e l s o n , M D , a n d C. L o w r y B a r n e s , M D
Abstract: The authors previously described a method of windowing the femur that allowed good exposure for femoral cement removal and provided for reconstruction of the defect. Since that report, they have developed instrumentation to facilitate windowing of the femoral shaft. They describe its use in this report. Key words: revision surgery, cement removal, femur perforation.
Since our first report, we have developed instrumentation to facilitate this technique. The template is used to assure an accurate cut and accurate fitting of the removed w i n d o w as well as for use as a temporary plug if cement is used for fixation of the new implant. It is then removed and the w i n d o w accurately fitted in place. In this report we describe the use of this technique for accessing the femoral canal for revision surgery.
The removal of firmly fixed cement from the femoral shaft is often a difficult task, demanding of both technical skill and operative time. The difficulty of removing cement from the proximal femur during revisions of total hip anhroplasty is well recognized (2, 4, 7, 10). Perforation or fracture of the femur during removal of cement has been reported (3, 6, 8, 9), and Mallory has suggested that perforation should be expected (5). W h e n trochanteric osteotomy and the use of special instruments are inadequate, or if the surgeon decides to visualize the femur directly and make an aperture for cement removal, the ability to fashion a w i n d o w quickly is desirable. We have addressed this problem by windowing the proximal femur, using a previously reported procedure (7). Our technique is essentially a controlled perforation as described by Dennis et al. (1), but it is larger and provides bony reconstruction of the defect. We have used a 45 ° beveled wedge-shaped wind o w large enough to admit high-velocity drills and special instruments; this type of w i n d o w has been satisfactory if properly fashioned.
Technique If the anterolateraI approach is used, the distal portion of the exposure is extended subperiostally to the tip of the original prosthetic cement complex. The lateral aspect of the femoral shaft is exposed by incising the fascia lata and the myofascia of the vastus lateralis. The muscle is divided to bone by blunt dissection and the cortex of the shaft stripped of soft tissue. The distal limits of the intended w i n d o w are preferably viewed radiographically. The site for the w i n d o w is chosen based on the needs of the patient and the individual characteristics of the cement distribution. It is prudent to remember, however, that once the w i n d o w is made the prosthesis to be inserted should have a tip that extends beyond the dis-
From the Department of Orthopaedic Surgery, Universityof Arkansas for Medical Sciences, Little Rock, Arkansas.
Reprint requests: Carl L. Nelson, MD, Department of Orthopaedic Surgery,Universityof Arkansas for Medical Sciences,4301 West Markham, Slot 531, Little Rock, AK 72205.
67
68
The Journal of Arthroplasty Vol. 5 No. 1 March 1990
!
LJ
T
Fig. 1. Femoral windowing template.
Fig. 3. Femoral window removed during surgery.
tal end of the w i n d o w by 2 - 3 diameters of the bone. The template (Figs. 1, 2) is placed against the bone where the osteotomy is to be made, usually on the anterior or anterolateral aspect of the femur, and held in place. The drill is inserted through the holes on the dorsal surface of the template, and a hole is made into the femur. The screws are then applied. These are short screws that only traverse the femoral cortex. The handle is then unscrewed and the metal template left in place. The saw is placed against the edge of the template and held carefully to assure that it parallels the template surface; the cuts are made. While making the cuts the areas are thoroughly irrigated to prevent necrosis of the bone. It is important not to overcut the corners, and this can be facilitated by using a smaller blade on both the proximal and distal cuts. Once the cuts are completed, the handle is reinserted and the cut tested, then the template and bone fragment are lifted from the femur (Fig. 3). It is important to test the cuts by gently wiggling the handle of the template, to be certain not to fracture the area. The cement is removed; if necessary, further
windows are made. If cement is used to place the revision prosthesis, a plastic cover is placed over the template and into and over the aperture. It can be held or wired into place. W h e n the cement has hardened, the template covering is removed, excess cement is excised, and the femoral w i n d o w is replaced. The femoral w i n d o w may need to be shaped and held into place, with either a plain suture or wires. Usually some adjustment is necessary on the inferior surface of the bone so that it fits against the implant, w h e t h e r it is porous coated or fits to the surface of the cement. We r e c o m m e n d packing b o n e graft slurry into the saw-cut area. In conclusion, we find this a valuable method for controlled perforation of the femoral shaft in revision total hip arthroplasty.
Fig. 2. Template applied to femur.
References 1. Dennis DA, Dingman CA, Meglan DA et al: Femoral cemented removal in revision total hip arthroplasty. Clin Orthop 220:142, 1987 2. Effekhar NS: Rechannelizafion of cemented femur using a guide and drill system. Clin Orthop 123:29, 1977 3. Johannson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg 63A:1435, 1981 4. Kavanaugh BF: Revision total hip arthroplasty. J Bone Joint Surg 67A:517, 1985 5. Mallory TH: Preparation of the proximal femur in cementless total hip revision. Clin Orthop 235:47, 1988 6. McElffesh EC, Coventry MB: Femoral and pelvic fractures after total hip anhroplasty. J Bone Joint Surg 56A:483, 1974 7. Nelson CL, Weber MJ: Technique of windowing the
Femoral Windowing Device femoral shaft for removal of bone cement. Clin Orthop 154:336, 1981 8. Scott RD: Femoral fractures in conjunction with total hip replacement. J Bone Joint Surg 57A:494, 1974 9. Scott RD, Schilz JP: Femoral fracture and revision arthroplasty, p. 127. In Turner RD, Scheller AD (eds):
•
Nelson and Barnes
69
Revision total hip anhroplasty. Grune & Stratton, New York, 1982 10. Tumer RH, Emerson RH Jr: Femoral revision total hip arthroplasty, p. 75. In Turner RW, Scheller AD (eds): Revision total hip anhroplasty. Grune & Stratton, New York, I982
