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Femoral Deformity and Deficiency in Complex Primary & Revision THA

Femoral Deformity and Deficiency in Complex Primary & Revision THA. David A. Mattingly, MD Chief, Joint Reconstruction Director, Otto E. Aufranc Fellowship New England Baptist Hospital Boston, MA. Femoral Deformity. Developmental Dysplasia (DDH) Prior Surgery ( THR, Osteotomy )

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Femoral Deformity and Deficiency in Complex Primary & Revision THA

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  1. Femoral Deformity and Deficiency in Complex Primary & Revision THA David A. Mattingly, MD Chief, Joint Reconstruction Director, Otto E. Aufranc Fellowship New England Baptist Hospital Boston, MA

  2. Femoral Deformity • Developmental Dysplasia (DDH) • Prior Surgery ( THR, Osteotomy ) • Post-traumatic • Secondary Osteoarthritis • LCP; SCFE; Sepsis • Coxa Vara & Coxa Valga

  3. Femoral Deformity • Small Femoral Canal • JRA; Dwarf; SED • Large Femoral Canal • RA, AS, ETOH • Paget’s Disease

  4. Preoperative Planning • Complete H&P • Leg lengths;N/V status • X-Ray Evaluation • AP Pelvis& Hip (Marker) • Lauenstein lateral • CT; scanogram *Identify equipment, prosthetic, osteotomy and bone graft requirements. Femoral Deformity in THA

  5. THA In Femoral Deformity • Individualize Management • Level of deformity • Type of deformity • Bone quality • Patient factors • Surgeon preferences

  6. THA In Femoral Deformity • Location of Deformity • Greater Trochanter • Femoral Neck • Metaphysis • Metaphyseal-Diaphyseal • Diaphysis • Distal to Diaphysis

  7. Surgeon Requirements • Proper Implant Selection • Exact Implant Positioning • Select Proper Surgical Approach • Specialized Techniques • Trochanteric osteotomy • Corrective osteotomy • Leg lengthening

  8. Treatment Options • Alter bone to fit prosthesis (osteotomy) 2. Select prosthesis to fit femur 3. Short implants or surface replacement to avoid more distal deformity

  9. THA In Femoral Deformity Greater Trochanteric Solutions • Trochanteric Osteotomy (exposure) • Trochanteric Advancement

  10. THA In Femoral Deformity Femoral Neck • Varus • Valgus • Abnormal Version

  11. THA In Femoral Deformity Abnormal Version • Cement small femoral implant in proper anteversion independent of anatomy • Modular cementless implants • Derotational osteotomy (subtrochanteric)

  12. Implantation Modular Advantages • Goal: Avoid hard bearing impingement while maximizing range of motion. • The ability to adjust femoral anteversion after cup placement has become increasingly important when using hard bearing implants where only neutral acetabular liners are available. • The ability to adjust femoral anteversion after cup placement has become increasingly important when using hard bearing implants where only neutral acetabular liners are available.

  13. THA In Femoral Deformity Metaphyseal • Cemented implants • Uncemented modular • Uncemented distal fixation • Resect deformity, replace with implant

  14. THA In Femoral DeformityMetaphyseal CAUTION!!!! • Osteotomy • Small fragment • Fixation difficult • Monoblock Metaphyseal Filling Implants • Fracture • Poor fit

  15. THA In Femoral DeformityMetaphyseal - Diaphyseal • Mismatch • Large canals • Small canals • Deformity

  16. Enlarged Femoral Canal • Cement • Cementless modular • Extensively coated (stress shielding?) • Reduction osteotomy Difficult 1° THA

  17. Small Patient • JRA, SED, dwarf • Acet. & femoral dysplasia • Templating critical • Modular, custom, mini components • Expansion osteotomy Difficult 1° THA

  18. Stenotic Femur • Avoid cement (stem too small) • Cementless modular • Expansion osteotomy Difficult 1° THA

  19. THA In Femoral DeformityDiaphyseal • Distal to implant • Ignore deformity • Treat independent of THA

  20. THA In Femoral DeformityDiaphyseal • Short implant or resurfacing • Long implant / osteotomy • Two stage (correct deformity, heal, THA)

  21. THA In Femoral Deformity • Individualize Management • Level of deformity • Type of deformity • Bone quality • Patient factors • Surgeon preferences

  22. Bone Defect Classification and Common Surgical Exposures David A. Mattingly,MD Chief, Joint Reconstruction Director, Otto Aufranc Fellowship New England Baptist Hospital Boston,MA

  23. Femoral Revision THA Principles • Rotational implant stability • Rigid implant fixation • Stability with range of motion • Restore Femoral Integrity & Continuity • Prevent and/or Augment Bone Loss • Restore Biomechanics (leg length; offset)

  24. AAOS ClassificationFemoral Deficiencies I. Segmental II. Cavitary III. Combined Segmental & Cavitary IV. Malalignment V. Stenosis VI. Discontinuity

  25. Paprosky Classification

  26. Adequate Exposure in Complex THA • Aids in Component Removal and Re-Insertion • Accuracy of Instrument and Component positioning • Reduces incidence of fractures and perforations • Bone grafting procedures easier, faster, more accurate

  27. Extensile Lateral • Limitations: Post-column, retained trochanter, limp, H.O., lengthening • retained trochanter, limp, H.O., lengthening • Improved femoral exposure • Reduces need for femoral fluoroscopy • Perforations further weaken compromised femoral canal • Indications • Most complex THA’s • Less instability • Sepsis • Postop irradiation

  28. Posterior • Excellent exposure, minimal muscle damage, fast rehab • Easy to make extensile (soft tissue releases; femoral or trochanteric osteotomies) • Retained trochanter limits distal canal access (>180 to 200 mm) • Increased risk posterior dislocation • Indications • Most acetabular/femoral revisions • Posterior column plating Complex THA

  29. Trochanteric Osteotomy Advantages • Allows extensile acetabular exposure (cages; posterior plating) • Improves distal femoral access • Decreases fractures, perforations, varus • Assists in limb lengthening (>1.5 cm) and shortening (5-10 mm) • Advancement improves M-F tension & stability

  30. Extended Trochanteric OsteotomyIndications • Well fixed implants (cement; porous) • Well fixed cement • Extensive Trochanteric Lysis • Trochanteric Overhang/Varus Remodeling • Malalignment Proximal Femur

  31. Extended Trochanteric OsteotomyAdvantages • Excellent exposure femur/acetabulum • Atraumatic implant/cement removal • Decreased perforations, fractures • Deformity correction • Protection of compromised trochanter • Predictable healing

  32. Distal Oblique Femoral Osteotomy • Facilitates distal cement removal (>200 mm) • Re-directional • 60o angle improves rotational stability, maximizes contact, allows cerclage wiring ( Miller, et.al )

  33. Retroperitoneal(Turner, Camer) • Stage III - IV Protrusio • Extruded medial cement • IVP, venogram • General, vascular surgeon

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