Abstract
Indications for removal of well-fixed cementless femoral components include infection, improper femoral height/offset/anteversion, and fracture. More recently, removal of well-fixed but recalled femoral components that are associated with adverse local tissue reaction (ALTR) has created a new indication for this procedure. The goal in all cases is to preserve bone stock and soft-tissue attachments to the greatest extent possible during implant removal. The strategy for implant removal depends to a large extent on the type of implant to be removed. Implants with limited proximal fixation can often be removed from the top using narrow osteotomes. Implants with more extensive fixation typically require more extensive exposure. When performing an extended trochanteric osteotomy, plan for the bone flap length based on measurement from the tip of the greater trochanter. Instead of devascularising the lateral bone flap, be sure to preserve the quadriceps attachment to the bone flap, exposing the lateral femur only where the transverse and posterior osteotomies are planned. The anterior osteotomy can be performed using a dotted line of osteotomes trans-muscularly as described by Heinz Wagner. Placement of a prophylactic cerclage below the osteotomy is prudent. Most importantly, if the need for a transfemoral exposure is likely, it should be performed primarily so that the posterior capsule and short rotators can be preserved. There is no need to perform a full posterior exposure and then to secondarily perform a transfemoral exposure since the former is unnecessary if the latter is performed. Discrete, limited fixation of the lateral bone flap proximally and distally should be performed to prevent strangulation of the living bone flap during the refixation process. The transfemoral technique can be applied not only to removal of well-fixed devices but also for conversion from hip fusion and for Z-shortening of the femur during Crowe 4 reconstruction instead of using a transverse osteotomy and intercalary shortening.
