JAAOS Monograph series (Paprowsky).
1. Trochanteric slide
This is a modification of the direct lateral approach (Hardinge).
The anterior portion of the GT is osteotomised with the insertion of gluteus medius, and origin of vastus lateralis attached to it. This is then reflected anteriorly to expose the femoral metaphysis and acetabulum.
It is reattached by circlage wires passed around the LT.
The opposing forces of the gluteus medius (pulling it superior), and vastus lateralis (pulling it distal), results in inherent stability.
2. Vastus slide
Essentially this is a subperiosteal peel of the origin of the vastus lateralis, and anterior insertion of gluteus medius.
The incision is in the shape of a question mark.
3. Extended proximal femoral osteotomy
An osteotomy of the anterolateral 1/3 of the proximal femur, including the entire GT.
The abductors and VL remain attached to fragment.
It is carried as distal as necessary to facilitate removal of the implant.
Pre-op templating will show how far this is – the revision stem must be longer than the end of the osteotomy site by at least 4cm or 2 cortical diameters.
1. Poly exchange
Always be prepared with equipment for entire acetabular revision in-case the locking mechanism is damaged.
Implant specific tools.
Drill into the polyethylene.
Split the polyethylene.
2. Cemented acetabular removal
In order to disrupt the bone-cement interface, you usually need to disrupt the implant-cement interface first.
Start superio-lateral edge of the cup.
Pass curved gouges and osteotomes to disrupt the implant-cement interface.
In removing cement be wary of possibility if intrapelvic content adhesion to cement fragments.
3. Cemented cup removal
The aim is to remove the cup with minimal bone loss.
4. Cemented femoral stem removal
Obtain circumferential exposure of shoulder of prosthesis. This is crucial.
May require trimming of any over-hanging trochanter.
Disrupt the implant-cement interface first.
Attach an extraction device and extract the stem.
Piece-meal extraction of all cement.
Remove in a proximal to distal fashion.
Variety of tools:
5. Cementing back into a cement mantle
It is essential in this situation where the cement mantle is not compromised. (For example, Revision for limb length, acetabular revision.)
6. Cementless femoral stem removal