Proximal Femoral Replacement With Tumor Prosthesis; Total Femur Replacement
Kevin I. Perry
Massive bone loss of the femur after total hip arthroplasty (THA) can occur secondary to osteolysis, stress shielding, mechanical loosening, infection (Figure 34.1A-D), periprosthetic fracture, tumor resection, and multiple previous reconstructive procedures.
Salvage of the abductors and reattachment to the prosthesis whenever possible can help with patient function in this difficult cohort of patients.
Complications following these procedures can be high. Dislocation and infection are two of the most common complications.
Constrained or dual-mobility acetabular implants should be considered to mitigate the risk of dislocation.
Patients often ambulate with a significant limp and require some form of gait aid after proximal or total femoral replacement.
Sterile Instruments and Implants
Routine hip and knee (for total femur) retractors, including a Charnley retractor, and assortment of blunt and sharp Hohman retractors
2.5- or 3.2-mm drill
Blunt or sharp bone hook
Proximal femoral replacement and/or total femoral replacement systems
Lateral decubitus position for proximal femoral replacement or a sloppy lateral decubitus position on a bean bag for total femoral replacement
Two hip bolsters
Operative leg draped free for ease of acetabular and femoral exposure for the hip and for adequate femoral and tibial exposure for the knee
Removal of the hip implants can be accomplished from either an anterolateral or posterolateral approach depending on surgeon preference.
For total femoral replacement, often a combination of a laterally based approach to the hip and an anterior-based approach to the knee is needed. Alternatively, total femoral replacement can be accomplished from an extensive lateral approach to the leg.
Previous operative reports containing implant information is vital so that the appropriate instrumentation can be available for implant removal.
Preoperative inflammatory markers (erythrocyte sedimentation rate and C-reactive protein) should be obtained, and the hip should be aspirated preoperatively to rule out infection prior to surgery.
Preoperative radiographs should be obtained, such as an anteroposterior (AP) of pelvis and an AP and lateral of the femur, which are critical to preoperative planning (Figures 34.2A,B and 34.3A-D). These help determine the level of bone resection (in the setting of a proximal femoral replacement), the diameter of the planned prosthesis, and if there will be any remaining bone stock left in the distal femur. AP and lateral radiographs of the knee should be included if a total femoral prosthesis is planned.
Consideration of surgical approach, necessity of osteotomy (if removing implants), and understanding the implants in place is imperative to a successful operation
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