SOME SPECIAL TOOLS AND STRATEGY FOR STEM REVISION IN TOTAL HIP.

Abstract

Femoral revision is frequent, due to femoral loosening, thigh pain, recurrent dislocation, osteolysis or sepsis. Whatever the reason, with the exception of some difficult septic cases, our strategic approach is similar. Some of our expertise concern femoral stem retrieval. Our reconstruction strategy is different if we are revising total hip in active and young patient or if it is an old and inactive one.

First step is always an large “en bloc” tissue excision. For old and inactive, it is sometimes possible to retain the stem if not loosed and perform a “in cement” cementation; In this group we select usually metal or alumina on polyethylene couple and cemented implants; In young and active, we select alumina on alumina combination which resumed in cementless acetabular fixation, and cementless or cemented stem.

Stem retrieval of a well fixed cementless stem is performed via a large transtrochanteric approach associated with a transfemoral one. Repair is performed using cerclage and long cemented stem.

Cement retrieval is performed since 9 years using Ultra sound (Oscar*) material, which in our hand is very successful specially for cement retractor retrieval. Then medullary canal is reamed in order to get a bloody healthy bone receive either a cemented or sometimes a cementless stem, depending on the bone quality.

To compensate femoral bone destruction and enhance cemented stem fixation, we used a modified Ling technique replacing allogenic morcellised bone by hydroxyapatite granules. Granules of 5 mm in diameter are made of 70% HA and 30% of β TCP. Mechanical resistance is excellent and biological activity is high. Thus stem stability can be obtained easily. This can be done either with a cemented or a cementless stem (about 60 cases).

In case of very severe bone loss and osteolysis, we performed massive allogenic bone transplant associated with long cemented stem and distal HA granules with cement.(17 cases).

As we usually performed one stage revision for septic cases, strategy is not different; It is only in selected cases with many sepsis recurrence and specially aggressive bacteria that we performed a two stage procedure.