- Total Femoral Replacement:
- indications: reconstruction following tumor resection
- technique:
- lateral position on a bean bag
- begin proximally with a posterior approach to the hip
- divide fascia laterally over femur and continue proximally to divide the fascia over the gluteus maximus in line with fibers of the muscle;
- separate the maximus in line with its fibers to expose the trochanter;
- palpate nerve and place Charnley.
- remove short external rotators from the posterior aspect of the trochanter;
- identify anterior/posterior borders of medius;
- perform an oblique trochanteric osteotomy or sharply lift abductors from greater trochanter;
- lift abductors proximally to expose underlying capsule
- divide hip capsule sharply and tag for later repair;
- dislocate femoral head
- extend incision down lateral aspect femur to lateral condyle
- divide fascia
- approach the femur posterior to vastus lateralis;
- release gluteus maximus from femur proximally and lift proximal femur out of wound;
- careful with sciatic nerve proximally;
- tag the iliopsoas for later repair;
- release the femur medially from adductor mass;
- in order to do this safely, one must identify the femoral artery and vein;
- perforating vessels will require vessel clips;
- one should extend the incision distally and medially to the tibial tubercle and perform a lateral parapatellar approach to the knee;
- distally, proceed with femoral extraction with care not to injure the femoral vessels anteromedially and the tibial/peroneal nerves just medial to the biceps femoris;
- divide the collaterals, cruciates and extract femur;
- keep in mind that the aforementioned apporach varies with the location of the tumor and the desired margin;
- prepare the proximal tibia according to the protocol of the particular hinged knee system;
- resurface patella if needed;
- be gentle in patellar and tibial preparation as tibial or peroneal neuropraxia could result;
- measure the length of the resected femur and create a modular femur of similar length on the back table;
- perform a trial reduction
- vary femoral neck length or tibial polyethylene spacer width as needed to gain desired soft tissue tension;
- usually 5-10mm of pistoning is appropriate.
- cement tibial component and allow to harden
- place femur
- repair hip capsule
- sew iliopsoas to inferior capsule
- bring medius or greater trochanter to prosthesis using nonabsorbable suture or tape;
- wire is discouraged secondary to fretting;
- repair gluteus maximus to fascia lata;
- incorporate gluteus medius into fascia lata repair to decrease lurch;
- close wound in layers over drain;
- knee immobilizer post -op, WBAT;
- Results (Nerubay, et al (1988))
- excellent 5/19, good 9/19, fair 3/19, poor 2/19
- no evidence of mechanical failure or aseptic loosening though 14 prosthesis were followed for >2 years;
- Complications:
- most are the result of tumor spread. Many patients die disallowing long term follow-up;
- wound healing problems occur 50% of the time due to necrosis at wound edges;
- 4/19 required intra-operatice wound revision;
- 1/19 require hip disarticulation due to sepsis 4 months post-op;
- hematoma formation due to erosion of the popliteal vein by a big tibial platform occurred in 1/19;
- 1/19 tibial components fractured between thetibial stem and the platform
- indications: reconstruction following tumor resection
- technique:
- lateral position on a bean bag
- begin proximally with a posterior approach to the hip
- divide fascia laterally over femur and continue proximally to divide the fascia over the gluteus maximus in line with fibers of the muscle;
- separate the maximus in line with its fibers to expose the trochanter;
- palpate nerve and place Charnley.
- remove short external rotators from the posterior aspect of the trochanter;
- identify anterior/posterior borders of medius;
- perform an oblique trochanteric osteotomy or sharply lift abductors from greater trochanter;
- lift abductors proximally to expose underlying capsule
- divide hip capsule sharply and tag for later repair;
- dislocate femoral head
- extend incision down lateral aspect femur to lateral condyle
- divide fascia
- approach the femur posterior to vastus lateralis;
- release gluteus maximus from femur proximally and lift proximal femur out of wound;
- careful with sciatic nerve proximally;
- tag the iliopsoas for later repair;
- release the femur medially from adductor mass;
- in order to do this safely, one must identify the femoral artery and vein;
- perforating vessels will require vessel clips;
- one should extend the incision distally and medially to the tibial tubercle and perform a lateral parapatellar approach to the knee;
- distally, proceed with femoral extraction with care not to injure the femoral vessels anteromedially and the tibial/peroneal nerves just medial to the biceps femoris;
- divide the collaterals, cruciates and extract femur;
- keep in mind that the aforementioned apporach varies with the location of the tumor and the desired margin;
- prepare the proximal tibia according to the protocol of the particular hinged knee system;
- resurface patella if needed;
- be gentle in patellar and tibial preparation as tibial or peroneal neuropraxia could result;
- measure the length of the resected femur and create a modular femur of similar length on the back table;
- perform a trial reduction
- vary femoral neck length or tibial polyethylene spacer width as needed to gain desired soft tissue tension;
- usually 5-10mm of pistoning is appropriate.
- cement tibial component and allow to harden
- place femur
- repair hip capsule
- sew iliopsoas to inferior capsule
- bring medius or greater trochanter to prosthesis using nonabsorbable suture or tape;
- wire is discouraged secondary to fretting;
- repair gluteus maximus to fascia lata;
- incorporate gluteus medius into fascia lata repair to decrease lurch;
- close wound in layers over drain;
- knee immobilizer post -op, WBAT;
- Results (Nerubay, et al (1988))
- excellent 5/19, good 9/19, fair 3/19, poor 2/19
- no evidence of mechanical failure or aseptic loosening though 14 prosthesis were followed for >2 years;
- Complications:
- most are the result of tumor spread. Many patients die disallowing long term follow-up;
- wound healing problems occur 50% of the time due to necrosis at wound edges;
- 4/19 required intra-operatice wound revision;
- 1/19 require hip disarticulation due to sepsis 4 months post-op;
- hematoma formation due to erosion of the popliteal vein by a big tibial platform occurred in 1/19;
- 1/19 tibial components fractured between thetibial stem and the platform