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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.

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Presentation on theme: "Femoral Deformity and Deficiency in Complex Primary & Revision THA David A. Mattingly, MD Chief, Joint Reconstruction Director, Otto E. Aufranc Fellowship."— Presentation transcript:

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 1.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.

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

15 THA In Femoral Deformity Metaphyseal CAUTION!!!! –Osteotomy Small fragment Fixation difficult –Monoblock Metaphyseal Filling Implants Fracture Poor fit

16 THA In Femoral Deformity Metaphyseal - Diaphyseal Mismatch Large canals Small canals Deformity

17 Enlarged Femoral Canal  Cement  Cementless modular  Extensively coated (stress shielding?)  Reduction osteotomy Difficult 1° THA

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

19 Stenotic Femur  Avoid cement (stem too small)  Cementless modular  Expansion osteotomy Difficult 1° THA

20 THA In Femoral Deformity Diaphyseal Distal to implant –Ignore deformity –Treat independent of THA

21 THA In Femoral Deformity Diaphyseal Short implant or resurfacing Long implant / osteotomy Two stage (correct deformity, heal, THA)

22 THA In Femoral Deformity Individualize Management –Level of deformity –Type of deformity –Bone quality –Patient factors –Surgeon preferences

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

24 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)

25 AAOS Classification Femoral Deficiencies I. Segmental II. Cavitary III. Combined Segmental & Cavitary IV. Malalignment V. Stenosis VI. Discontinuity

26 Paprosky Classification

27 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

28 Extensile Lateral Limitations: Post-column, retained trochanter, limp, H.O., lengtheningLimitations: Post-column, retained trochanter, limp, H.O., lengthening retained trochanter, limp, H.O., lengtheningretained trochanter, limp, H.O., lengthening Improved femoral exposureImproved femoral exposure Reduces need for femoral fluoroscopyReduces need for femoral fluoroscopy Perforations further weaken compromised femoral canalPerforations further weaken compromised femoral canalIndications Most complex THA’sMost complex THA’s Less instabilityLess instability SepsisSepsis Postop irradiationPostop irradiation

29 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

30 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

31 Extended Trochanteric Osteotomy Indications Well fixed implants (cement; porous) Well fixed cement Extensive Trochanteric Lysis Trochanteric Overhang/Varus Remodeling Malalignment Proximal Femur

32 Extended Trochanteric Osteotomy Advantages Excellent exposure femur/acetabulum Atraumatic implant/cement removal Decreased perforations, fractures Deformity correction Protection of compromised trochanter Predictable healing

33 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 )

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


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