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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 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 ) • Post-traumatic • Secondary Osteoarthritis • LCP; SCFE; Sepsis • Coxa Vara & Coxa Valga
Femoral Deformity • Small Femoral Canal • JRA; Dwarf; SED • Large Femoral Canal • RA, AS, ETOH • Paget’s Disease
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
THA In Femoral Deformity • Individualize Management • Level of deformity • Type of deformity • Bone quality • Patient factors • Surgeon preferences
THA In Femoral Deformity • Location of Deformity • Greater Trochanter • Femoral Neck • Metaphysis • Metaphyseal-Diaphyseal • Diaphysis • Distal to Diaphysis
Surgeon Requirements • Proper Implant Selection • Exact Implant Positioning • Select Proper Surgical Approach • Specialized Techniques • Trochanteric osteotomy • Corrective osteotomy • Leg lengthening
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
THA In Femoral Deformity Greater Trochanteric Solutions • Trochanteric Osteotomy (exposure) • Trochanteric Advancement
THA In Femoral Deformity Femoral Neck • Varus • Valgus • Abnormal Version
THA In Femoral Deformity Abnormal Version • Cement small femoral implant in proper anteversion independent of anatomy • Modular cementless implants • Derotational osteotomy (subtrochanteric)
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.
THA In Femoral Deformity Metaphyseal • Cemented implants • Uncemented modular • Uncemented distal fixation • Resect deformity, replace with implant
THA In Femoral DeformityMetaphyseal CAUTION!!!! • Osteotomy • Small fragment • Fixation difficult • Monoblock Metaphyseal Filling Implants • Fracture • Poor fit
THA In Femoral DeformityMetaphyseal - Diaphyseal • Mismatch • Large canals • Small canals • Deformity
Enlarged Femoral Canal • Cement • Cementless modular • Extensively coated (stress shielding?) • Reduction osteotomy Difficult 1° THA
Small Patient • JRA, SED, dwarf • Acet. & femoral dysplasia • Templating critical • Modular, custom, mini components • Expansion osteotomy Difficult 1° THA
Stenotic Femur • Avoid cement (stem too small) • Cementless modular • Expansion osteotomy Difficult 1° THA
THA In Femoral DeformityDiaphyseal • Distal to implant • Ignore deformity • Treat independent of THA
THA In Femoral DeformityDiaphyseal • Short implant or resurfacing • Long implant / osteotomy • Two stage (correct deformity, heal, THA)
THA In Femoral Deformity • Individualize Management • Level of deformity • Type of deformity • Bone quality • Patient factors • Surgeon preferences
Bone Defect Classification and Common Surgical Exposures David A. Mattingly,MD Chief, Joint Reconstruction Director, Otto Aufranc Fellowship New England Baptist Hospital Boston,MA
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)
AAOS ClassificationFemoral Deficiencies I. Segmental II. Cavitary III. Combined Segmental & Cavitary IV. Malalignment V. Stenosis VI. Discontinuity
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
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
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
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
Extended Trochanteric OsteotomyIndications • Well fixed implants (cement; porous) • Well fixed cement • Extensive Trochanteric Lysis • Trochanteric Overhang/Varus Remodeling • Malalignment Proximal Femur
Extended Trochanteric OsteotomyAdvantages • Excellent exposure femur/acetabulum • Atraumatic implant/cement removal • Decreased perforations, fractures • Deformity correction • Protection of compromised trochanter • Predictable healing
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 )
Retroperitoneal(Turner, Camer) • Stage III - IV Protrusio • Extruded medial cement • IVP, venogram • General, vascular surgeon