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THR Revision: Removal of Femoral Stem

- Discussion:
    - removal of broken femoral stems:
    - removal of cementless stems:
    - removal of cemented femoral stems:
    - as noted by Peters, et al. (1997), at the time of acetabular component revision, evidence supports leaving a well fixed cemented component in place;
           - in femoral components inserted w/ first generation cementing techniques, the rate of mechanical failure was 22% at 5 years following the acetabular component revision;

- Surgical Exposure:
    - it is essential that prior to attempted femoral component removal, that there is a clear retrograde path for stem removal;
           - this exposure is essential to clearly visualize the lateral bone-cement interface, which could otherwise risk trochanteric fracture;
           - this means that any trochanteric overhang is removed, either with a high speed bur or with an trochanteric osteotomy:
           - trochanteric frx, is especially indicated w/ press fit stems that have a collar;

- Extraction Instruments:

- Initial Attempt at Extraction:
    - after adequate exposure has been established, attempt to remove the femoral component w/ several slaps of the slap hammer (w/ universal extractor);
           - alterantively, clear away enough bone under the proximal collar to allow enough space to allow an impaction rod underneath the collar;
    - if the prosthesis does not move w/ several blows of the slap hammer, then the prosthesis is stable, and will require disruption of the
           bone-prosthesis or the bone-cement interface

- Removal of the Stable Prosthesis:
    - removal of cementless stems 
    - removal of cemented femoral stems

- References:

Femoral windows in revision total hip arthroplasty.

The Fate of Well Fixed Cemented Femoral Components Left in Place at the Time of Revision of the Acetabular Component

Preparation of the proximal femur in cementless total hip revision.

Modular Femoral Stem Removal During Total Hip Arthroplasty Using a Universal Modular Stem Extractor