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Outcomes of revision total hip arthroplasty using a vascularised anterior femoral window

Authors:
Rajpreet Sahemey at University Hospitals Coventry and Warwickshire NHS Trust
Rajpreet Sahemey
Kanai Garala
Kanai Garala
Kanai Garala
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Gurdip Chahal at South Warwickshire NHS Foundation Trust
Gurdip Chahal
Trevor Lawrence
Trevor Lawrence
Trevor Lawrence
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Abstract and Figures

PurposeExtraction of the distal femoral cement mantle and restrictor during revision total hip arthroplasty (rTHA) is challenging and can compromise host bone stock. The aim of this study is to report outcomes of our femoral windowing technique for cement removal.Methods We report on a cohort of 36 patients with an average age of 68.7 years who underwent 40 cemented rTHA between 2011 and 2017 using a vascularised anterior femoral window. Clinical and radiological outcomes were retrospectively reviewed with a mean follow-up of 6.6 years (range, 3.8–10).ResultsLatest mean WOMAC score was 25.4 and all windows achieved radiographic union by a mean of 7.9 weeks. Femoral component survivorship was 100% and 38 out of 40 rTHAs showed no evidence of radiological loosening.Conclusion The vascularised anterior window to remove the distal femoral cement mantle under direct vision is safe and reproducible with excellent clinical and radiographic results.
Access for the anterior femoral window. a The outline of a 10 cm elliptical window is centred over the distal tip of the original implant (which has been superimposed on this image) on the anterior aspect of the femur. Once the stem has been removed, it can be placed against the femur to confirm the correct tip position. b A small amount of soft tissue is elevated along the anterior and posterior aspects of the planned osteotomy, clearing a path to allow multiple cortical drill hole perforations to be made along the edge of the elliptical window. c With the soft tissues still adherent, the rounded proximal and distal apices are cut with an oscillating saw, which is then run along the drill holes to complete the osteotomy (lateral profile of the osteotomy fragment pictured alongside). d The oval bone flap, which is attached to vastus lateralis, is retracted anteromedially providing full access to underlying cement and restrictor. e After canal preparation the cortical flap is reduced and secured with one or more cerclage cables
Access for the anterior femoral window. a The outline of a 10 cm elliptical window is centred over the distal tip of the original implant (which has been superimposed on this image) on the anterior aspect of the femur. Once the stem has been removed, it can be placed against the femur to confirm the correct tip position. b A small amount of soft tissue is elevated along the anterior and posterior aspects of the planned osteotomy, clearing a path to allow multiple cortical drill hole perforations to be made along the edge of the elliptical window. c With the soft tissues still adherent, the rounded proximal and distal apices are cut with an oscillating saw, which is then run along the drill holes to complete the osteotomy (lateral profile of the osteotomy fragment pictured alongside). d The oval bone flap, which is attached to vastus lateralis, is retracted anteromedially providing full access to underlying cement and restrictor. e After canal preparation the cortical flap is reduced and secured with one or more cerclage cables
… 
a A cemented THA in a 54-year-old male presenting with aseptic loosening of the acetabular component A single-stage revision was performed b Six-week post-operative radiograph showing union of the femoral window secured with two cerclage cables. The revision stem and cement mantle extend well below the window (drill holes are faintly visible). c The seven-year post-operative radiograph shows a stable cement mantle and a WOMAC score of 3.9 at last assessment
a A cemented THA in a 54-year-old male presenting with aseptic loosening of the acetabular component A single-stage revision was performed b Six-week post-operative radiograph showing union of the femoral window secured with two cerclage cables. The revision stem and cement mantle extend well below the window (drill holes are faintly visible). c The seven-year post-operative radiograph shows a stable cement mantle and a WOMAC score of 3.9 at last assessment
… 
a A cemented THA in an 81-year-old female presenting with prosthetic joint infection b Patient underwent first-stage revision utilising the anterior femoral window to extract the cement restrictor and fixation of the cortical window with cerclage cable. c One-year post-operative radiograph following the second stage with cementation of definitive implants. The cortical window has healed but a lucent line is appreciated at Gruen zones 1 and 6. d Six-year post-operative radiograph does not show further progression of lucency and a WOMAC score of 15.6
a A cemented THA in an 81-year-old female presenting with prosthetic joint infection b Patient underwent first-stage revision utilising the anterior femoral window to extract the cement restrictor and fixation of the cortical window with cerclage cable. c One-year post-operative radiograph following the second stage with cementation of definitive implants. The cortical window has healed but a lucent line is appreciated at Gruen zones 1 and 6. d Six-year post-operative radiograph does not show further progression of lucency and a WOMAC score of 15.6
… 
of responses to patient-reported satisfaction survey pie charts to demonstrate responses to (left) overall satisfaction with surgery and (right) if the patient would recommend the revision surgery to others
of responses to patient-reported satisfaction survey pie charts to demonstrate responses to (left) overall satisfaction with surgery and (right) if the patient would recommend the revision surgery to others
… 
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European Journal of Orthopaedic Surgery & Traumatology (2022) 32:1325–1332
https://doi.org/10.1007/s00590-021-03106-w
ORIGINAL ARTICLE
Outcomes ofrevision total hip arthroplasty using avascularised
anterior femoral window
RajpreetSahemey1 · KanaiGarala1· GurdipChahal2· TrevorLawrence3
Received: 25 April 2021 / Accepted: 25 August 2021 / Published online: 5 September 2021
© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2021
Abstract
Purpose Extraction of the distal femoral cement mantle and restrictor during revision total hip arthroplasty (rTHA) is
challenging and can compromise host bone stock. The aim of this study is to report outcomes of our femoral windowing
technique for cement removal.
Methods We report on a cohort of 36 patients with an average age of 68.7years who underwent 40 cemented rTHA between
2011 and 2017 using a vascularised anterior femoral window. Clinical and radiological outcomes were retrospectively
reviewed with a mean follow-up of 6.6years (range, 3.8–10).
Results Latest mean WOMAC score was 25.4 and all windows achieved radiographic union by a mean of 7.9weeks. Femoral
component survivorship was 100% and 38 out of 40 rTHAs showed no evidence of radiological loosening.
Conclusion The vascularised anterior window to remove the distal femoral cement mantle under direct vision is safe and
reproducible with excellent clinical and radiographic results.
Keywords Revision total hip arthroplasty· Hip· Cemented· Window· Femur
Introduction
The incidence of revision total hip arthroplasty (rTHA) has
been rising over the past two decades in parallel with the
increasing demand and use of total hip arthroplasty [1].
Despite the successes of cement-in-cement femoral com-
ponent revision, thorough removal of the femoral cement
mantle is often necessary in cases of aseptic loosening,
periprosthetic joint infection (PJI) and implant failure. In
such cases, meticulous removal of the distal cement mantle
and cement restrictor can be technically demanding. The use
of osteotomes, high-speed burrs and ultrasonic instruments
can be associated with femoral fracture, cortical perfora-
tion and can cause significant loss of cancellous bone from
metaphyseal and diaphyseal regions [2]. Various techniques
have been developed to facilitate the removal of the restrictor
and cement from around the distal stem under direct vision,
including the extended trochanteric osteotomy (ETO), stand-
ard and slide trochanteric osteotomies and cortical window-
ing of the femoral diaphysis [3].
Popularised by Younger etal. [4], the ETO involves the
development of an anterolateral bone flap incorporating the
greater trochanter. Though commonly utilised, the overall
complication rate has been reported as high as 24%, which
includes trochanteric fracture, fragment migration, wire
breakage and non-union [5, 6]. Revisions using a proximal
osteotomy also risk jeopardising metaphyseal bone stock,
warranting the need for uncemented revision stems with
predominantly distal fixation [7].
A number of diaphyseal cortical windowing techniques
have been described to facilitate the removal of the cement
restrictor yet leaving the trochanteric region relatively pre-
served [8–10]. These methods describe the fashioning of
a devascularised cortical lid, or window, from the ante-
rior or anterolateral femoral diaphysis, with the resultant
defect either being filled by the cortical lid or allogenic
strut bone graft and fixed with cerclage wire. Nonetheless,
these modifications of the revision technique still report a
* Rajpreet Sahemey
rajpreet.s@gmail.com
1 Orthopaedic Department, University Hospitals Coventry
andWarwickshire, Coventry, UK
2 Orthopaedic Department, Warwick Hospital, Warwick, UK
3 Orthopaedic Department, University Hospitals Birmingham,
Birmingham, UK
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... [27,39]. Nach vollständiger Entfernung der Zementreste und Fremdmaterialien wird der Knochendeckel mittels Cerclagen refixiert [41][42][43]. ...
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Background The anterior femoral cortical window is an attractive alternative to the extended trochanteric osteotomy when removing femoral cement in revision hip arthroplasty. CT-based additive manufacturing technology has now permitted the creation of patient-specific instrumented (PSI) jigs to facilitate this. The jig simplifies creation of the window, potentiating medullary exposure through an optimally-sized window and therefore cement removal. Between 2006 and 2021 this technique was used in 22 cases at a regional hospital in New Zealand (mean age 74; range 44 to 89 years). 16 cases were for aseptic loosening and 6 for infection. We describe the technique and our case series. Bone incorporation for the cortical window was assessed in all cases using CT imaging. Oxford scores were obtained at a minimum of 6 months after revision surgery. Of the 6 septic cases 5 went onto successful stage-2 procedures, the other to a Girdlestone procedure. Results The mean rectangular shaped window size was 8 × 1.5 cm and in each case, this provided adequate intramedullary access. On average at minimum 5 months post-surgery, 84% bone incorporation of the cortical window occurred on CT (40–100%). The functional outcome Oxford hip score was 37 (range 22–48) for 10 cases. There were 2 cases with femoral component subsidence which then stabilised. Conclusions This technique description and retrospective case series has shown the effectiveness of removing a distal femoral cement mantle in revision hip arthroplasty using an anterior femoral cortical window, recently optimised using a PSI jig. This technique is a straightforward alternative to a trochanteric osteotomy. Reliable bony integration of the cortical window occurred and functional outcomes were comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry.
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To assess the failure rate of cemented, uncemented, hybrid, and reverse hybrid total hip replacements in patients aged 55 years or older. Register study. Nordic Arthroplasty Register Association database (combined data from Sweden, Norway, Denmark, and Finland). 347 899 total hip replacements performed during 1995-2011. Probability of implant survival (Kaplan-Meier analysis) along with implant survival with revision for any reason as endpoint (Cox multiple regression) adjusted for age, sex, and diagnosis in age groups 55-64, 65-74, and 75 years or older. The proportion of total hip replacements using uncemented implants increased rapidly towards the end of the study period. The 10 year survival of cemented implants in patients aged 65 to 74 and 75 or older (93.8%, 95% confidence interval 93.6% to 94.0% and 95.9%, 95.8% to 96.1%, respectively) was higher than that of uncemented (92.9%, 92.3% to 93.4% and 93.0%, 91.8% to 94.0%), hybrid (91.6%, 90.9% to 92.2% and 93.9%, 93.1% to 94.5%), and reverse hybrid (90.7%, 87.3% to 93.2% and 93.2%, 90.7% to 95.1%) implants. The survival of cemented (92.2%, 91.8% to 92.5%) and uncemented (91.8%, 91.3% to 92.2%) implants in patients aged 55 to 64 was similar. During the first six months the risk of revision with cemented implants was lower than with all other types of fixation in all age groups. The survival of cemented implants for total hip replacement was higher than that of uncemented implants in patients aged 65 years or older. The increased use of uncemented implants in this age group is not supported by these data. However, because our dataset includes only basic information common to all national registers there is potential for residual confounding.
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Direct anterior approach for femoral component revision: Surgical technique for extended trochanteric osteotomy and anterior cortical window
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Objective Direct anterior approach (DAA) is becoming a popular option for both primary and revision total hip arthroplasty (THA). Adequate exposure is crucial in the setting of revision THA. The purpose of this article is to describe two different techniques for expanded femoral exposure through the DAA, the anterior extended trochanteric osteotomy and anterior cortical window. Methods Extensile exposure were carried out in cadavers, using the contralateral hip as a control. The exposure and technical viability were assessed. Results It was demonstrated that both extensile techniques can be carried out safely. Conclusions Extensile exposures including femoral osteotomies can be safely carried out for revision THA via DAA.
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Purpose To report the outcome of revised total hip arthroplasty procedures involving an anterior cortical window, extensive strut allografts, and an Exeter impaction graft. Method Eight patients (9 hips) with a mean age of 58 years underwent revision of total hip arthroplasty using the Exeter hip impaction graft system and strut allografts between 1995 and 1998. An extensile anterior approach was used, and an anterior cortical window was created in the femur, to remove the old implant. External strut allografts were attached by wires to provide cortical support. The mean follow-up duration was 74 months. Indications for surgery were aseptic loosening of previous implants in 8 hips and infection of one hip that had previously undergone total arthroplasty. Results 19 Dall Miles cables, 4 ordinary cerclage wires, and 8 cerclage wires tightened with the clincher knot technique were used to secure the allograft to the host bone. The strut grafts were found to be incorporated in all cases. No wires became loose. One patient developed 20° of angulation at the allograft-host bone junction. Using the method of Fowler and Gie, we found that one femoral implant had subsided 2 mm within the cement mantle. Two other implants had 1 mm of subsidence at the cement bone interface, and one patient had a major subsidence of 15 mm that required revision. Conclusion Using an anterior cortical window in the femur to remove the old implant does not predispose to failure of the allograft to incorporate into the host bone.
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Modular tapered titanium stems in revision arthroplasty of the hip: The Risk and Causes of Stem Fracture
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Tapered fluted titanium stems are increasingly used for femoral revision arthroplasty. They are available in modular and non-modular forms. Modularity has advantages when the bone loss is severe, the proximal femur is mis shapen or the surgeon is unfamiliar with the implant, but it introduces the risk of fracture of the stem at the junction between it and the proximal body segment. For that reason, and while awaiting intermediate-term results of more recently introduced designs of this junction, non-modularity has attracted attention, at least for straightforward revision cases. We review the risks and causes of fracture of tapered titanium modular revision stems and present an argument in favour of the more selective use of modular designs. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):50–3.
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Polymer Cable/Grip-Plate System with Locking Screws for Stable Fixation to Promote Healing of Trochanteric Osteotomies or Fractures in Revision Total Hip Arthroplasty.
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Multiple methods have been proposed to establish stable fixation to promote healing of trochanteric osteotomies or fractures in revision total hip arthroplasty (revTHA), from wiring techniques through cable-plate systems with or without supplemental locking screws. The purpose of this study is to report the clinical results of a single cable-plate system with locked screw fixation in revTHA. Between 2009 and 2012, 27 grip-plates (Supercable® System, Kinamed Inc., Camarillo, CA) were used in 26 patients in 27 revTHA procedures. Utilization was 12 1-hole (50 mm) grip-plates, 10 2-hole (135 mm) grip-plates, four 4-hole (190 mm) grip-plates, and one 6-hole (245 mm) grip-plate. There were 14 women and 12 men. Age averaged 63.2 years and BMI averaged 29.4 kg/m2. At average 2.5 year follow-up, grip-plate fixation was considered successful in 22 hips (81%) with five failures. Three failures consisted of 50 mm/short grip-plates used in one trochanteric slide, and two intraoperative trochanteric fractures during revTHA. The two additional failures were related to pre-revision trochanteric avulsion from bony necrosis of the proximal femur. An additional three grip-plates were removed electively for soft-tissue irritation and pain but with successful fixation and bony healing. Thus 70% of hips were free of reoperation related to the grip-plate. All other hips had successful fixation and the grip-plate was not symptomatic. In this study, the cable-grip system and isoelastic Supercables provided reliable fixation for adequate healing of difficult ETO and trochanteric fractures with an 81% rate of mechanical success with radiographic and clinical healing observed.
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