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Surgical Technique for Distal Femur Prosthesis for Supracondylar Fracture Femur by Dr. Anoop Jhurani
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Surgical Technique for Distal Femur Prosthesis for Supracondylar Fracture Femur by Dr. Anoop Jhurani
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T00H12M56S
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https://cadmoreoriginalmedia.blob.core.windows.net/0f9260c9-9795-47bb-831d-e81cff04f66b/Surgical technique for distal femur prosthesis for supracond.mp4?sv=2019-02-02&sr=c&sig=ytefzb9MNoDl8jY4ep3vFh8x3BqCFeOvnyWFv3c18mg%3D&st=2024-11-21T14%3A21%3A06Z&se=2024-11-21T16%3A26%3A06Z&sp=r
Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about the principles, techniques and pearls for mega prosthetic replacement of distal femur, for a supracondylar fracture femur. So this lady 75 years presented with a neglected fracture, as you can see in the supracondylar area of the femur, and she had this fracture about four months back with advanced wear of the knee.
ANOOP JHURANI: So you can see there is supracondylar fracture, very low type, oblique, neglected for four months, advanced osteoarthrosis and also a stress fracture of the tibia. So the only way you can manage this case is by doing a megaprosthetic replacement. Now, one might argue, why not fix this fracture because it is so low and neglected for four months. And if you go for fixation, the lower piece is very osteoporotic and very small.
ANOOP JHURANI: One may not achieve success and the patient can't walk with such severe arthritis. So the only way to get this patient quickly rehabilitated is to do a megaprosthetic replacement of the distal femur. Now there are three types of megaprostheses, dystrophy or type available in our country, and we don't want to promote anything. But I would like to share with you the principles of all those three.
ANOOP JHURANI: The first is diffuse alveolar system, which is a very good system. It's got both cemented and uncemented rods. It's got a etched collar for the bone to ungrow, the part from where you attach the stem. It's a rotating platform and comes in various sizes and that's what we'll be using and we'll share with you in the surgical video that will follow this presentation. The second one is Stryker's GMRS, which is very similar.
ANOOP JHURANI: It has got both cemented and uncemented stems, and a etched collar at the end. The third is the Indian {INAUDIBLE} type of a prosthesis. It has got only cemented prostheses and the longevity is not as good as the DAS or the Stryker GMRS. system. Now, having said that, for our Indian patients with low affordability, you can use a social one. But scientifically speaking, it's either the {INAUDIBLE} or the GMRS which are best, which will give the best long term results.
ANOOP JHURANI: So let's go on to the surgical part now. And there we will discuss in detail all the principles of doing a distal femur mega prosthetic replacement. So let's now go to the surgical technique and the important principles of distal femur megaprosthetic replacement. So as we saw in the X ray, this is a very low supracondylar fracture of the left femur with a stress fracture of the device as well, very advanced osteoporosis.
ANOOP JHURANI: 75-year-old patient, and the only way to get her up and about is to do a distal femur tumour type replacement. Now you can see that the fracture is mobile. The range of movement of the knee is very poor, only 0 to 30, obviously because of very advanced OA of the knee. So we'll expose the distal femur. There is no tourniquet here because the incision is slightly bigger.
ANOOP JHURANI: So we don't use a tourniquet whenever we are doing a distal femur replacement. We generally don't use a tourniquet any which way in any of the knee replacements now. So that is the gradual clearance of the periosteum of the distal femur, starting medial. It's a very, very tight knee, very difficult exposure, and it's all stuck up because of four-month-old neglected fracture.
ANOOP JHURANI: So you can see I'm going very gently, this is the medial side, first removing the periosteum, the collateral attachments, all the soft tissues, and then leveraging the whole fragment from the periosteum with the help of a curved 20 millimetre osteotome. This is going inside the joint. So now we are in the tibiofemoral articulation, gradually removing the fibrous tissue with cautery and removing the stuck femur and tibia with osteophytes, where by the osteotome, removing the fibrous tissue from the tibiofemoral articulation.
ANOOP JHURANI: As you can see here, there is a distal femur, then holding it gradually when it is ready to be grasped by a pointed towel clip, again going from medial to lateral, lateral to medial many times just to tease it out gently out of all this stuck soft tissue and fibrous tissue. So we have to go medial, remove all the collateral attachments, then go posterior, remove all the capsular attachments, then come lateral, remove all the periosteum, the collateral attachments.
ANOOP JHURANI: And then only and only then will the distal fragment be delivered, as you can see here. So now we're removing the final periosteum, the soft tissue at the back. And there you can see the distal fragment is delivered, very small fragment, not amenable to fixation. Fixation would not succeed in this osteoporotic lady in such a low fracture, very hollow from inside, hardly any cancellous bone.
ANOOP JHURANI: There you can see it's a big hollow there. So better to do a distal femur replacement. Now, the first step is to measure what is the size in terms of the length of the fragment. So this is 5 cm and the length of the tumour replacement prosthesis minimum is 7 cm. So we need to resect about 1 and half, 2 centimetres from the distal femur. That is the most important thing, that is the first step of the operation.
ANOOP JHURANI: So you can see we are comparing the length and the width. Now, this width of this tumour post is smaller, so we'll choose the bigger one in terms of the width. And the length is 7 cm, the resected here is about 5 and a half. So we'll resect about 1 and 1/2. You can see there there is a shaft and we are dissecting 1 and 1/2 cm more of bone to make the total resection then 7 cm, which will be equal to the length of the distal femur tumour prosthesis.
ANOOP JHURANI: Then we are reaming the femoral canal. It's a board canal, so we have to be very careful that we don't perforate. We will ream till 12 millimetres and to three times and then putting in a 12 stem, the minimum of stem diam is 11 and the maximum is 14. So here you can see it's not going any further because of the bow as well. So we just take a trial stem and see that it should go easily and nicely along with 2 millimetres of cement metal all around.
ANOOP JHURANI: Then we prepare the femur for the distal femur prosthesis and once that is done, then we take onto the TBR, tibia are also full of fibrous tissue. We release it medial, lateral and posterior. You can see that it's all fibrous tissue, a lot of scarring because of old neglected fracture and years of osteoarthrosis process.
ANOOP JHURANI: So release all the periosteum and remove the menisci, and go behind the tibia so that we can put a Hohmann, so that our saw does not damage any vital structure. We put our TBR jig and remove only a very thin sliver just to make a flat surface for the tibial component. So we just remove four or 5 millimetres of bone to create a flat surface and then we can prepare it for the tibia. There you can see the tibial preparation for the rotating platform because all distal femur prostheses because of higher constraint to mitigate the constraint and loosening all the poly is rotating platform in most revision systems and hinge systems and tumour prostheses like this. Coming to the tibia, the stress fracture, there is a lot of sclerosis there.
ANOOP JHURANI: So we first use the interlocking guidewire and then ream over it because if we start reaming directly, we might perforate the cortex. So better to use interlock reamers, put a guidewire, then prepare it. We remove the extra bone medially, which is sclerotic on osteoarthrosis, just like a classical varus deformity. Drill holes in the tibia and the femur to have better preparation and penetration of the cement.
ANOOP JHURANI: This calcar reamer is working on the distal femur, make it a smooth surface, and there is a trial. Then there's a distal femur trial. There's a tibial trial. And we put it and put the locking mechanism so that we can trial that we are achieving full extension. And we not lengthening the limb. So it's very important to check the length of the limb at this point in time to ensure there is no lengthening, {INAUDIBLE} there will be stress on the femoral vessels.
ANOOP JHURANI: One shot under C-arm is very important to see that we are not too undersized or oversized on the stem, our joint line is maintained. So all those things are very important to see. The tibial stem is right in the centre, it's crossed the stress fracture, which is kind of united now, and then we'll see the lateral view. So here again, the tibial stem is in the centre. It's not hitting any cortex.
ANOOP JHURANI: Those are very important things to see. Otherwise, later on there is a regret that we made a mistake and did not see it. It's always better to see it while the surgery is on. Patella preparation, we always do the patella because otherwise it hurts later on, and there is a tibial perforation. Medial effect will be two screws and will bypass the stress fracture with the stem.
ANOOP JHURANI: The cement restrictor goes in the femoral canal so that the cement does not go right up to the hip. It stops where just proximal to the tip of the stem that's marking the linea aspera and the external rotation. Mark you can see that there is the external rotation mark and we will keep our stem 10 degrees external, rotate it to the vertical, which essentially means we'll be rotating it externally. Those are the implants, the distal femur, the proximal tibia, the polyethylene, and the locking pin and the patella.
ANOOP JHURANI: It's very important to be well-versed with these implants because more and more people are going to need ream in these special situations. Then we lavage thoroughly the femur and the tibia, and after lavage we put the cement in by hand. We can use a cement gun. But in elderly patients, we avoid to prevent cement thromboembolism and patient mortality.
ANOOP JHURANI: So we pressurize with the thumb and you can see there is etched collar on the stem, which will invite bone to ungrow to it and prevent loosening because of the long term stresses on the stem. So these etched collars are very important to prevent early loosenings. Then the tibia is cement in a very similar manner. Pressurize the cement, the tibial stem is crossing the stress fracture.
ANOOP JHURANI: And then we put the final poly, lock it in and then extend it till it sets firmly. There you can see a gradual extension, the limb is not in flexion, not in hyperextension. There is a hinge joint, it reflects to neutral. There you can see the patellar tracking very nice.
ANOOP JHURANI: There's the final alignment. You can see nice and straight. Getting 90 to 100 degrees of range of movement. Patella tracking is very good. We have maintained the joint line. There is no extra residual cement and there is a distal femur prosthesis. To critically analyze the post-op x-ray, we see that the joint line is maintained.
ANOOP JHURANI: The tibial and femoral stems are nicely centered. They are not oversized, they are not undersized. Slope is well maintained and the stems have got good cement. The femoral stem has got good cement all around it to prevent any early loosening. So those are the important things to be observed in the post-op X-ray. So friends, I hope you have found this video useful. It was to share with you the idea, the principle, the technique and the pearls for distal femur tumour replacement with advanced OA, which presents very often to us these days in various forms, various ways.
ANOOP JHURANI: So thank you very much.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about the principles, techniques and pearls for mega prosthetic replacement of distal femur, for a supracondylar fracture femur. So this lady 75 years presented with a neglected fracture, as you can see in the supracondylar area of the femur, and she had this fracture about four months back with advanced wear of the knee.
ANOOP JHURANI: So you can see there is supracondylar fracture, very low type, oblique, neglected for four months, advanced osteoarthrosis and also a stress fracture of the tibia. So the only way you can manage this case is by doing a megaprosthetic replacement. Now, one might argue, why not fix this fracture because it is so low and neglected for four months. And if you go for fixation, the lower piece is very osteoporotic and very small.
ANOOP JHURANI: One may not achieve success and the patient can't walk with such severe arthritis. So the only way to get this patient quickly rehabilitated is to do a megaprosthetic replacement of the distal femur. Now there are three types of megaprostheses, dystrophy or type available in our country, and we don't want to promote anything. But I would like to share with you the principles of all those three.
ANOOP JHURANI: The first is diffuse alveolar system, which is a very good system. It's got both cemented and uncemented rods. It's got a etched collar for the bone to ungrow, the part from where you attach the stem. It's a rotating platform and comes in various sizes and that's what we'll be using and we'll share with you in the surgical video that will follow this presentation. The second one is Stryker's GMRS, which is very similar.
ANOOP JHURANI: It has got both cemented and uncemented stems, and a etched collar at the end. The third is the Indian {INAUDIBLE} type of a prosthesis. It has got only cemented prostheses and the longevity is not as good as the DAS or the Stryker GMRS. system. Now, having said that, for our Indian patients with low affordability, you can use a social one. But scientifically speaking, it's either the {INAUDIBLE} or the GMRS which are best, which will give the best long term results.
ANOOP JHURANI: So let's go on to the surgical part now. And there we will discuss in detail all the principles of doing a distal femur mega prosthetic replacement. So let's now go to the surgical technique and the important principles of distal femur megaprosthetic replacement. So as we saw in the X ray, this is a very low supracondylar fracture of the left femur with a stress fracture of the device as well, very advanced osteoporosis.
ANOOP JHURANI: 75-year-old patient, and the only way to get her up and about is to do a distal femur tumour type replacement. Now you can see that the fracture is mobile. The range of movement of the knee is very poor, only 0 to 30, obviously because of very advanced OA of the knee. So we'll expose the distal femur. There is no tourniquet here because the incision is slightly bigger.
ANOOP JHURANI: So we don't use a tourniquet whenever we are doing a distal femur replacement. We generally don't use a tourniquet any which way in any of the knee replacements now. So that is the gradual clearance of the periosteum of the distal femur, starting medial. It's a very, very tight knee, very difficult exposure, and it's all stuck up because of four-month-old neglected fracture.
ANOOP JHURANI: So you can see I'm going very gently, this is the medial side, first removing the periosteum, the collateral attachments, all the soft tissues, and then leveraging the whole fragment from the periosteum with the help of a curved 20 millimetre osteotome. This is going inside the joint. So now we are in the tibiofemoral articulation, gradually removing the fibrous tissue with cautery and removing the stuck femur and tibia with osteophytes, where by the osteotome, removing the fibrous tissue from the tibiofemoral articulation.
ANOOP JHURANI: As you can see here, there is a distal femur, then holding it gradually when it is ready to be grasped by a pointed towel clip, again going from medial to lateral, lateral to medial many times just to tease it out gently out of all this stuck soft tissue and fibrous tissue. So we have to go medial, remove all the collateral attachments, then go posterior, remove all the capsular attachments, then come lateral, remove all the periosteum, the collateral attachments.
ANOOP JHURANI: And then only and only then will the distal fragment be delivered, as you can see here. So now we're removing the final periosteum, the soft tissue at the back. And there you can see the distal fragment is delivered, very small fragment, not amenable to fixation. Fixation would not succeed in this osteoporotic lady in such a low fracture, very hollow from inside, hardly any cancellous bone.
ANOOP JHURANI: There you can see it's a big hollow there. So better to do a distal femur replacement. Now, the first step is to measure what is the size in terms of the length of the fragment. So this is 5 cm and the length of the tumour replacement prosthesis minimum is 7 cm. So we need to resect about 1 and half, 2 centimetres from the distal femur. That is the most important thing, that is the first step of the operation.
ANOOP JHURANI: So you can see we are comparing the length and the width. Now, this width of this tumour post is smaller, so we'll choose the bigger one in terms of the width. And the length is 7 cm, the resected here is about 5 and a half. So we'll resect about 1 and 1/2. You can see there there is a shaft and we are dissecting 1 and 1/2 cm more of bone to make the total resection then 7 cm, which will be equal to the length of the distal femur tumour prosthesis.
ANOOP JHURANI: Then we are reaming the femoral canal. It's a board canal, so we have to be very careful that we don't perforate. We will ream till 12 millimetres and to three times and then putting in a 12 stem, the minimum of stem diam is 11 and the maximum is 14. So here you can see it's not going any further because of the bow as well. So we just take a trial stem and see that it should go easily and nicely along with 2 millimetres of cement metal all around.
ANOOP JHURANI: Then we prepare the femur for the distal femur prosthesis and once that is done, then we take onto the TBR, tibia are also full of fibrous tissue. We release it medial, lateral and posterior. You can see that it's all fibrous tissue, a lot of scarring because of old neglected fracture and years of osteoarthrosis process.
ANOOP JHURANI: So release all the periosteum and remove the menisci, and go behind the tibia so that we can put a Hohmann, so that our saw does not damage any vital structure. We put our TBR jig and remove only a very thin sliver just to make a flat surface for the tibial component. So we just remove four or 5 millimetres of bone to create a flat surface and then we can prepare it for the tibia. There you can see the tibial preparation for the rotating platform because all distal femur prostheses because of higher constraint to mitigate the constraint and loosening all the poly is rotating platform in most revision systems and hinge systems and tumour prostheses like this. Coming to the tibia, the stress fracture, there is a lot of sclerosis there.
ANOOP JHURANI: So we first use the interlocking guidewire and then ream over it because if we start reaming directly, we might perforate the cortex. So better to use interlock reamers, put a guidewire, then prepare it. We remove the extra bone medially, which is sclerotic on osteoarthrosis, just like a classical varus deformity. Drill holes in the tibia and the femur to have better preparation and penetration of the cement.
ANOOP JHURANI: This calcar reamer is working on the distal femur, make it a smooth surface, and there is a trial. Then there's a distal femur trial. There's a tibial trial. And we put it and put the locking mechanism so that we can trial that we are achieving full extension. And we not lengthening the limb. So it's very important to check the length of the limb at this point in time to ensure there is no lengthening, {INAUDIBLE} there will be stress on the femoral vessels.
ANOOP JHURANI: One shot under C-arm is very important to see that we are not too undersized or oversized on the stem, our joint line is maintained. So all those things are very important to see. The tibial stem is right in the centre, it's crossed the stress fracture, which is kind of united now, and then we'll see the lateral view. So here again, the tibial stem is in the centre. It's not hitting any cortex.
ANOOP JHURANI: Those are very important things to see. Otherwise, later on there is a regret that we made a mistake and did not see it. It's always better to see it while the surgery is on. Patella preparation, we always do the patella because otherwise it hurts later on, and there is a tibial perforation. Medial effect will be two screws and will bypass the stress fracture with the stem.
ANOOP JHURANI: The cement restrictor goes in the femoral canal so that the cement does not go right up to the hip. It stops where just proximal to the tip of the stem that's marking the linea aspera and the external rotation. Mark you can see that there is the external rotation mark and we will keep our stem 10 degrees external, rotate it to the vertical, which essentially means we'll be rotating it externally. Those are the implants, the distal femur, the proximal tibia, the polyethylene, and the locking pin and the patella.
ANOOP JHURANI: It's very important to be well-versed with these implants because more and more people are going to need ream in these special situations. Then we lavage thoroughly the femur and the tibia, and after lavage we put the cement in by hand. We can use a cement gun. But in elderly patients, we avoid to prevent cement thromboembolism and patient mortality.
ANOOP JHURANI: So we pressurize with the thumb and you can see there is etched collar on the stem, which will invite bone to ungrow to it and prevent loosening because of the long term stresses on the stem. So these etched collars are very important to prevent early loosenings. Then the tibia is cement in a very similar manner. Pressurize the cement, the tibial stem is crossing the stress fracture.
ANOOP JHURANI: And then we put the final poly, lock it in and then extend it till it sets firmly. There you can see a gradual extension, the limb is not in flexion, not in hyperextension. There is a hinge joint, it reflects to neutral. There you can see the patellar tracking very nice.
ANOOP JHURANI: There's the final alignment. You can see nice and straight. Getting 90 to 100 degrees of range of movement. Patella tracking is very good. We have maintained the joint line. There is no extra residual cement and there is a distal femur prosthesis. To critically analyze the post-op x-ray, we see that the joint line is maintained.
ANOOP JHURANI: The tibial and femoral stems are nicely centered. They are not oversized, they are not undersized. Slope is well maintained and the stems have got good cement. The femoral stem has got good cement all around it to prevent any early loosening. So those are the important things to be observed in the post-op X-ray. So friends, I hope you have found this video useful. It was to share with you the idea, the principle, the technique and the pearls for distal femur tumour replacement with advanced OA, which presents very often to us these days in various forms, various ways.
ANOOP JHURANI: So thank you very much.
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