Removal of a long cement mantle that is well fixed distally during total hip revision can be a technically demanding procedure with many potential complications.

The extended femoral slot offers a technique that allows direct visualisation during cement removal while maintaining an intact femoral tube.

The proximal end of the femur is exposed taking care to remove all soft tissue that might prevent removal of the loose femoral component. The loose femoral component is removed using thin osteotomes and a femoral extraction device as needed. The proximal cement mantle is removed under direct vision to the level of the flare of the greater trochanter. The outside of the femoral shaft below the flare of the greater trochanter is exposed by splitting the vastus lateralis. Pre-operative measurements are imperative to determine the distal level of the cement mantle. An extended rectangular slot approximately 1.5cm wide is made in the anterolateral aspect of the femur starting just below the flare of the greater trochanter and continuing to the level of the distal aspect of the cement mantle. This can be done using a pencil-tipped burr on the Midas Rex or an oscillating saw. The rectangular strip of bone is removed and saved to be replaced and secured with cerclage technique during closure.

The entire cement mantle is removed under direct vision using osteotomes and other cement removing instruments as needed. The opened femoral canal is then reamed to accept a new revision femoral component.

The extended femoral slot is a safe and effective technique for cement removal during revision hip arthroplasty in selected cases. It is not used when there is varus deformity of the proximal femur but in selected cases is an alternative to the extended greater trochanteric osteotomy and preserves the circumference of the femoral tube.

To properly care for femoral neck fractures, the surgeon must decide which fractures are to be fixed and which fractures will require a prosthesis. In addition, the type of prosthesis, hemiarthroplasty versus total hip arthroplasty must be selected. Total hip arthroplasty is an option in the active elderly.

The literature supports internal fixation in non-displaced fractures. Current literature supports the fact that ORIF of displaced femoral neck fractures results in failure and re-operation of 20% to 30%. By considering arthroplasty when the patient has multiple co-morbidities including renal disease, diabetes, rheumatoid arthritis and severe osteoporosis the re-operation rate can be reduced significantly. The single most important factor in preventing failure with fixation is an anatomic reduction. A femoral neck fracture left in varus is doomed to failure and re-operation.

A prosthesis should be used in most displaced femoral neck fractures in patients physiologically older than 65. In active elderly patients total hip replacement should be considered. In elderly patients with multiple co-morbidities who are relatively inactive in a nursing home or lower level community ambulators, a hemi-prosthesis should be considered. The decision-making process is always shared with the patient.

When a prosthetic replacement is performed, the low level nursing home or community ambulator who is not expected to live longer than six to seven years is a candidate for a cemented hemi-arthroplasty. Studies report a 25% – 30% re-operation rate in hemi-arthroplasty if the patient survives greater than six to seven years. In the active elderly with little co-morbidity, a total hip replacement should be used. This is not only cost effective but provides the best pain relief of any of the options for treatment of displaced femoral neck fractures. Treatment of femoral neck fractures remains a challenge but the surgeon must select the proper treatment based on fracture displacement, physiologic age of the patient as well as co-morbidities of the patient.