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Modular Stem Reconstruction For Femoral Deficiency In Revision Hip Replacement by Dr. Anoop Jhurani
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Modular Stem Reconstruction For Femoral Deficiency In Revision Hip Replacement by Dr. Anoop Jhurani
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T00H12M28S
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https://cadmoreoriginalmedia.blob.core.windows.net/ba2722b3-0cae-4bd3-89fd-67bab018a046/Modular stem reconstruction for femoral deficiency in revisi.mp4?sv=2019-02-02&sr=c&sig=rfy3kfmhATcMkTpEZjoiXUDFW%2F9YzHs0GqY2txtX3mA%3D&st=2024-12-04T19%3A47%3A18Z&se=2024-12-04T21%3A52%3A18Z&sp=r
Upload Date:
2024-03-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision total hip, especially on the principles of preparation and reconstruction with the modular femoral stem. So this is a failed intra trochanter fracture which was infected. We had removed the nail and put a spacer and the spacer is also dislocated, obviously because of greater trochanter traction and abductor deficiency.
ANOOP JHURANI: So these cases are really challenging because the trochanter fragment is separate and you can see that there is a sub trochantric part of the fracture also so you need a modular stem for this kind of reconstruction so that the proximal part and the distal parts can be prepared independently and the modular sleeve when it is inserted helps in fixation of the fracture also. Now, the whole indication of doing a modular stem here is a sub trochantric fracture with different metaphysis and diaphyseal diameters
ANOOP JHURANI: and that's an indication of doing a modular stem. Now, this particular case, the spacer is also dislocating so we have decided to do a dual mobility on the socket side because there is abductor deficiency and it's likely that the total hip may also dislocate. So we'll do a dual mobility on the acetabular side and a modular stem on the femoral side and that will be the optimal reconstruction for this patient.
ANOOP JHURANI: Other challenges are bone quality because this is an elderly patient. So we have a cemented backup on the socket side, on the femoral side, we'll have obviously do a modular stem. There we have a cemented dual mobility backup, but mostly it'll be uncemented dual mobility and an uncemented modular system on the femur side with reconstruction of the trochanter, with the classical wire getting onto the lesser trochanter and tightening of the GT. The additional benefit of a sleeve is that everything gets fibrous union and the trochanter also sticks nicely to the modular sleeve.
ANOOP JHURANI: We'll see that. Now we are removing the spacer. This is a classical posterial lateral approach. The spacer comes out. The ESR/CIP in this patient are normal. We had identified the bug in the initial nail removal and spacer stage, giving her six weeks of antibiotic, given her six weeks holiday monitored, the CIP is at its normal. Now after three months, we are coming back and you see that is a socket exposure and there is a contained defect in which will impact allograft.
ANOOP JHURANI: We have allograft from Tata Memorial Bone Bank and we'll put some allograft pieces impacted into that contained defect because of the earlier PFM screw and as a socket reconstruction. And we are just debriding everything, we have again sent cultures and we generally wait for the cells per high power field and the total cell count. The cells per high power field should be less than 10 for every sitting sample per high power field.
ANOOP JHURANI: That's for further debridement and we'll send all this tissue back to the lab to see that the cell count, total cell count per cesis is also less than 3,000. So those are the three things, three important things that allograft from Tata Memorial Hospital and shape it as for the cavity and then impact it nicely/ It's important to fill up this cavity. It's a contained defect, but the acetabulum is otherwise OK for preparation of an uncemented cup.
ANOOP JHURANI: There's impaction of bone graft into the contained defect. And there you can see the allograft is nicely impacted into the contained defect and now we can prepare for an uncemented cup. We've already done some reaming. For the reaming for a breast fit Stryker uncemented cup in a revision situation, we'll be using a modular stem of Smith and Nephew on the femur side and a dual mobility cup on the socket side from Stryker.
ANOOP JHURANI: So in the revision situation you can mix and match. We are not going to promote any company, but on the socket side only Stryker has uncemented dual mobility so we'll put that. That's fitting of the socket in 40 degree inclination, 20 degree anteversion, always put a couple of screws in the thick iliac bone between 11 and 1 o'clock position and always check under c-arm. You can see that the screws, screws are nicely positioned into the thick iliac buttress, usually 140 and 125 over 30 screw in the right position impacting of an elevated liner.
ANOOP JHURANI: Once we checked under c-arm the position of the screw. That's critical. Now we come back to the femur and the main aim of this video is to discuss the preparation and the tips and pearls for the modular stem reconstruction. Now, we always pass one prophylactic wire distal to the fracture, always, because when we are impacting the stem or perforation, sometimes the crack can propagate.
ANOOP JHURANI: So we always pass one or two prophylactic wires, as you can see that with the AO tensioner and then start preparation. Now the whole sub trochantric fragment and the trochantric fragment is separate and the femur is right and no one in front of us. And as the initial preparation for our modular system, as I said, of Smith Nephew. You can use any modular stem.
ANOOP JHURANI: Even Stryker has got a restoration stem, but that was not available on that particular day and these things happen in implant inventory. So one should use, one should be well-versed with a couple of implants and their preparation and reconstruction. So mono-block stem like a Wagner or a Smith Nephew can be used when their distal dia is uncompromised and the proximal bone is not compromised. Here,
ANOOP JHURANI: proximal metaphyseal bone is compromised and there is a meta-diaphyseal diameter mismatch and that is why we are using a modular stem. So this is the modular stem preparation. You can see that the modular stem conical remotes are separate and they prepare separately the diaphysis and metaphysis and this is the trial stem. And then we take the trial with the dual mobility articulation to ensure that there is no dislocation because there is a bit of abductor deficiency in these kind of complex cases.
ANOOP JHURANI: Dual mobility is our go to articulation for any revision situation with compromised abductors. Now there is the distal foot you can see under C-arm. Even if you see a millimeter of distance between the inner cortex and the trial stem, then that means you have to go one stem up and the commonest mistake in revision situations is to under size the femoral stem. There's the commonest mistake.
ANOOP JHURANI: Hence we should all always check under C-arm to see that we have sized it correctly and this stem was 18 millimeter. We generally like really press fit fixation of 5 to 7 centimeters in the diaphyseal bone, that's the stem, a modular stem on which we will also put a sleeve. So this is a sleeve that goes on to it for which we have reamed. So 18 is the dia distally and 23 is the dia proximally.
ANOOP JHURANI: And this is the advantage of a modular stem that this etched coated sleeve helps in union of the fracture and is sticking of the trochanter and converting that whole area to nice fibrous tissue. The trochanter may not attain bony union, but it will always have fibrous fixation to the sleeve and the sleeve and insert inserted impacts the fragment and helps in bony union. So this is the advantage of using a modular stem in these kind of cases where there is difference in the dia of the proximal bone and the distal bone and monoblock stem actually sink in because proximally it has more support.
ANOOP JHURANI: So this is the insertion of the modular stem. You can see how it was assembled on the table, how it was inserted, and the advantage of using a sleeve for impaction of the fracture and to aid in the fibrous attachment of the greater trochanter ultimately, all that area will attain bony or fibrous union. There's the dual mobility and you can see the dual mobility articulation, they combine anteversion is 40, 45.
ANOOP JHURANI: You can see that there is a trochantric fragment, which is separate, which will now be wired back on the sleeve and there's the modular stem. You can see that there's the combined anteversion, the, the whole articulation is very stable and the trochanter fragment, including the sub trochanter fragment, you can see the very big fragments will be attached back with two wires passed around the abductor so that all abductors are also tensioned.
ANOOP JHURANI: And there are good chances that this whole trochanter fragment will have some kind of fibrous attachment to the sleeve. So this is the way we reconstruct these complex cases with a modular stem. And two wires can be passed via the lesser trochanter by drilling a hole into it and through the greater trochanter.
ANOOP JHURANI: So again, just to summarize the indications of modular stem are wherever there is a metaphyseal, diaphyseal mismatch in the diameter and one can use a modular stem separately preparing the diaphysis. And then on that, the conical reamers go and prepare the metaphasis in a separate diameter. So essentially you are using a thicker diameter for the meta physis to have better fixation
ANOOP JHURANI: and because it is etched coated sleeve, it helps in union of the fracture when it is impacted and also union of the greater trochanter, at least there is some fibrous union over a period of weeks. So that's the final fixation of the trochanter and the dual mobility articulation in these cases helps prevent dislocation and its go to articulation for these kind of complex cases where there is abductor deficiency.
ANOOP JHURANI: One needs to follow these patients very carefully for subsidence of the stem. Subsidence of the stem is common in revision situations, both in monoblock and in modular. There are some reports of tendonosis at the modular taper junction, but they are becoming less and far. So this is the final reconstruction, a BB x-ray.
ANOOP JHURANI: There is some pelvic tilt, so there is apparent lengthening, but there is no true lengthening. The wires are holding the trochanter, but ultimately we'll see how it unites the dual mobility articulation. Most important to observe is that the stem is well fixed. It's really has a cortical purchase and that's the most important thing to prevent subsidence and late failure.
ANOOP JHURANI: And the proximal dia is a wider dia which has the sleeve and it's holding the proximal bone close together. So friends, this is the modular stem reconstruction. Principles, pearls and points to remember. Thank you very much. [VIDEO ENDS]
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about revision total hip, especially on the principles of preparation and reconstruction with the modular femoral stem. So this is a failed intra trochanter fracture which was infected. We had removed the nail and put a spacer and the spacer is also dislocated, obviously because of greater trochanter traction and abductor deficiency.
ANOOP JHURANI: So these cases are really challenging because the trochanter fragment is separate and you can see that there is a sub trochantric part of the fracture also so you need a modular stem for this kind of reconstruction so that the proximal part and the distal parts can be prepared independently and the modular sleeve when it is inserted helps in fixation of the fracture also. Now, the whole indication of doing a modular stem here is a sub trochantric fracture with different metaphysis and diaphyseal diameters
ANOOP JHURANI: and that's an indication of doing a modular stem. Now, this particular case, the spacer is also dislocating so we have decided to do a dual mobility on the socket side because there is abductor deficiency and it's likely that the total hip may also dislocate. So we'll do a dual mobility on the acetabular side and a modular stem on the femoral side and that will be the optimal reconstruction for this patient.
ANOOP JHURANI: Other challenges are bone quality because this is an elderly patient. So we have a cemented backup on the socket side, on the femoral side, we'll have obviously do a modular stem. There we have a cemented dual mobility backup, but mostly it'll be uncemented dual mobility and an uncemented modular system on the femur side with reconstruction of the trochanter, with the classical wire getting onto the lesser trochanter and tightening of the GT. The additional benefit of a sleeve is that everything gets fibrous union and the trochanter also sticks nicely to the modular sleeve.
ANOOP JHURANI: We'll see that. Now we are removing the spacer. This is a classical posterial lateral approach. The spacer comes out. The ESR/CIP in this patient are normal. We had identified the bug in the initial nail removal and spacer stage, giving her six weeks of antibiotic, given her six weeks holiday monitored, the CIP is at its normal. Now after three months, we are coming back and you see that is a socket exposure and there is a contained defect in which will impact allograft.
ANOOP JHURANI: We have allograft from Tata Memorial Bone Bank and we'll put some allograft pieces impacted into that contained defect because of the earlier PFM screw and as a socket reconstruction. And we are just debriding everything, we have again sent cultures and we generally wait for the cells per high power field and the total cell count. The cells per high power field should be less than 10 for every sitting sample per high power field.
ANOOP JHURANI: That's for further debridement and we'll send all this tissue back to the lab to see that the cell count, total cell count per cesis is also less than 3,000. So those are the three things, three important things that allograft from Tata Memorial Hospital and shape it as for the cavity and then impact it nicely/ It's important to fill up this cavity. It's a contained defect, but the acetabulum is otherwise OK for preparation of an uncemented cup.
ANOOP JHURANI: There's impaction of bone graft into the contained defect. And there you can see the allograft is nicely impacted into the contained defect and now we can prepare for an uncemented cup. We've already done some reaming. For the reaming for a breast fit Stryker uncemented cup in a revision situation, we'll be using a modular stem of Smith and Nephew on the femur side and a dual mobility cup on the socket side from Stryker.
ANOOP JHURANI: So in the revision situation you can mix and match. We are not going to promote any company, but on the socket side only Stryker has uncemented dual mobility so we'll put that. That's fitting of the socket in 40 degree inclination, 20 degree anteversion, always put a couple of screws in the thick iliac bone between 11 and 1 o'clock position and always check under c-arm. You can see that the screws, screws are nicely positioned into the thick iliac buttress, usually 140 and 125 over 30 screw in the right position impacting of an elevated liner.
ANOOP JHURANI: Once we checked under c-arm the position of the screw. That's critical. Now we come back to the femur and the main aim of this video is to discuss the preparation and the tips and pearls for the modular stem reconstruction. Now, we always pass one prophylactic wire distal to the fracture, always, because when we are impacting the stem or perforation, sometimes the crack can propagate.
ANOOP JHURANI: So we always pass one or two prophylactic wires, as you can see that with the AO tensioner and then start preparation. Now the whole sub trochantric fragment and the trochantric fragment is separate and the femur is right and no one in front of us. And as the initial preparation for our modular system, as I said, of Smith Nephew. You can use any modular stem.
ANOOP JHURANI: Even Stryker has got a restoration stem, but that was not available on that particular day and these things happen in implant inventory. So one should use, one should be well-versed with a couple of implants and their preparation and reconstruction. So mono-block stem like a Wagner or a Smith Nephew can be used when their distal dia is uncompromised and the proximal bone is not compromised. Here,
ANOOP JHURANI: proximal metaphyseal bone is compromised and there is a meta-diaphyseal diameter mismatch and that is why we are using a modular stem. So this is the modular stem preparation. You can see that the modular stem conical remotes are separate and they prepare separately the diaphysis and metaphysis and this is the trial stem. And then we take the trial with the dual mobility articulation to ensure that there is no dislocation because there is a bit of abductor deficiency in these kind of complex cases.
ANOOP JHURANI: Dual mobility is our go to articulation for any revision situation with compromised abductors. Now there is the distal foot you can see under C-arm. Even if you see a millimeter of distance between the inner cortex and the trial stem, then that means you have to go one stem up and the commonest mistake in revision situations is to under size the femoral stem. There's the commonest mistake.
ANOOP JHURANI: Hence we should all always check under C-arm to see that we have sized it correctly and this stem was 18 millimeter. We generally like really press fit fixation of 5 to 7 centimeters in the diaphyseal bone, that's the stem, a modular stem on which we will also put a sleeve. So this is a sleeve that goes on to it for which we have reamed. So 18 is the dia distally and 23 is the dia proximally.
ANOOP JHURANI: And this is the advantage of a modular stem that this etched coated sleeve helps in union of the fracture and is sticking of the trochanter and converting that whole area to nice fibrous tissue. The trochanter may not attain bony union, but it will always have fibrous fixation to the sleeve and the sleeve and insert inserted impacts the fragment and helps in bony union. So this is the advantage of using a modular stem in these kind of cases where there is difference in the dia of the proximal bone and the distal bone and monoblock stem actually sink in because proximally it has more support.
ANOOP JHURANI: So this is the insertion of the modular stem. You can see how it was assembled on the table, how it was inserted, and the advantage of using a sleeve for impaction of the fracture and to aid in the fibrous attachment of the greater trochanter ultimately, all that area will attain bony or fibrous union. There's the dual mobility and you can see the dual mobility articulation, they combine anteversion is 40, 45.
ANOOP JHURANI: You can see that there is a trochantric fragment, which is separate, which will now be wired back on the sleeve and there's the modular stem. You can see that there's the combined anteversion, the, the whole articulation is very stable and the trochanter fragment, including the sub trochanter fragment, you can see the very big fragments will be attached back with two wires passed around the abductor so that all abductors are also tensioned.
ANOOP JHURANI: And there are good chances that this whole trochanter fragment will have some kind of fibrous attachment to the sleeve. So this is the way we reconstruct these complex cases with a modular stem. And two wires can be passed via the lesser trochanter by drilling a hole into it and through the greater trochanter.
ANOOP JHURANI: So again, just to summarize the indications of modular stem are wherever there is a metaphyseal, diaphyseal mismatch in the diameter and one can use a modular stem separately preparing the diaphysis. And then on that, the conical reamers go and prepare the metaphasis in a separate diameter. So essentially you are using a thicker diameter for the meta physis to have better fixation
ANOOP JHURANI: and because it is etched coated sleeve, it helps in union of the fracture when it is impacted and also union of the greater trochanter, at least there is some fibrous union over a period of weeks. So that's the final fixation of the trochanter and the dual mobility articulation in these cases helps prevent dislocation and its go to articulation for these kind of complex cases where there is abductor deficiency.
ANOOP JHURANI: One needs to follow these patients very carefully for subsidence of the stem. Subsidence of the stem is common in revision situations, both in monoblock and in modular. There are some reports of tendonosis at the modular taper junction, but they are becoming less and far. So this is the final reconstruction, a BB x-ray.
ANOOP JHURANI: There is some pelvic tilt, so there is apparent lengthening, but there is no true lengthening. The wires are holding the trochanter, but ultimately we'll see how it unites the dual mobility articulation. Most important to observe is that the stem is well fixed. It's really has a cortical purchase and that's the most important thing to prevent subsidence and late failure.
ANOOP JHURANI: And the proximal dia is a wider dia which has the sleeve and it's holding the proximal bone close together. So friends, this is the modular stem reconstruction. Principles, pearls and points to remember. Thank you very much. [VIDEO ENDS]
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