Name:
Total Hip Replacement for AVN with Fibular Graft and Stuck Screws by Dr. Anoop Jhurani
Description:
Total Hip Replacement for AVN with Fibular Graft and Stuck Screws by Dr. Anoop Jhurani
Thumbnail URL:
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Duration:
T00H07M08S
Embed URL:
https://stream.cadmore.media/player/bd1172b7-7c98-4cb0-835a-8671917e78c9
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/bd1172b7-7c98-4cb0-835a-8671917e78c9/Total Hip Replacement for AVN with fibular graft and stuck.mp4?sv=2019-02-02&sr=c&sig=NBM4dkKdGLE%2BsDWirkJa4ZFIAu08Zee5ZtQYLuN82PM%3D&st=2024-11-21T14%3A43%3A57Z&se=2024-11-21T16%3A48%3A57Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ANOOP JHURANI: Hello, friends. This video is about an apparently simple case. This is a case who had a fractured neck femur AVN and then it was dealt with a quad femurus graft, avascular pedicle graft. And so there are some screws there and there is the old fibula tract and obviously there is AVN.
ANOOP JHURANI: So this is a young patient of about 40 years of age with a sequiliio fracture, neck femur, who had avascular radical graft with fibula about 12 years back. So obviously, we are expecting a lot of sclerosis. The main challenge here is that the two screws in the neck are from anterior to posterior. So whatever approach we choose, these screws put about 12 years back are going to be extremely, extremely difficult to remove.
ANOOP JHURANI: We take the posterior approach and you can see the screws are from anterior to posterior and if you are approaching the hip from posterior side it will be extremely difficult to remove these screws on which there will be a lot of bone formation because after a vascular pedicle graft, it becomes very difficult to remove these screws as there is a lot of sclerosis. The first screw can be removed after the head removal, as you can see here, but the two neck screws are going to be extremely difficult to remove because of the direction anterior to posterior and because of a lot of sclerotic bone formation.
ANOOP JHURANI: The best way to remove them is with a high speed bar called Midas, and we use this Midas tool routinely for revisions. You can see dense, sclerotic bone. It's not possible to remove these screws, they are embedded in, and you need a Midas tool or a high speed bar to take out all the sclerotic bone around these screws, to remove the screws, and they can all be removed with a screwdriver.
ANOOP JHURANI: You have to really take them out with an osteotome. Once you're boarded out, removed all the sclerotic bone, gently take it out without disrupting the calcar or the neck part of the bone, which will take the cord of the stem. So it's important not to destroy the proximal part of the femur because this young patient will be using a primary type of a stem or a little longer stem, but the cord is in the proximal wedge of the bone.
ANOOP JHURANI: Hence it's important to remove the implants safely without causing much loss of bone. But still, you can see we have to remove all this sclerotic bone with a Midas high speed. But otherwise, you can just cannot remove these two screws and then you just pull it down from the cavity because you cannot screw them either from the anterior to posterior and/or otherwise. So when I suggest gently use a plier to take it out, unscrew it, remove all the bone from the calcar to the neck.
ANOOP JHURANI: You can see it's dense, sclerotic bone in the whole calcar after 12 years of avascular pedicle graft, which causes a lot of reaction, a lot of vascular fibrous type of reaction and new bone formation. The second is screws further deep and we have to, again with acid, find it out under CR and with us just there with ICE to the bone. And you can see the second screw there. Now, again, removing the bone, very gently, chiseling it out without destroying the proximal part of the femur.
ANOOP JHURANI: It's important to shape the proximal part of the femur with Midas, only because you cannot broach this femur, which is so sclerotic and there is dense reactive bone there. So whereas tumor does the proximal part not only to remove the screw but also to shape the femur for the wedge of the primary stem so that it's still working on the screw. You can see they're very difficult to remove, the X-ray may look very simple, but this one has to differentiate between chalk and cheese.
ANOOP JHURANI: So you know, the surgeon has to be wise enough, experienced enough to differentiate what is a difficult case which may apparently not be so on an X-ray. So you have to differentiate between a snake and a rope, differentiate between chalk and cheese to find out what can be a difficult case but doesn't look like on X-ray. Further, Midas on the medial part to give it shape of the proximal stem because brooch cannot be passed in the initial broach of the uncemented stem.
ANOOP JHURANI: So one has to Midas quite laterally also to remove all that sclerotic bone to make it, make the initial shape for the uncemented stem. Once you've done all of that, then you prepare. We have chosen a longer stem because there is some disruption of bone for a primary small stem, so we have to use a small stem proximally. Actually, we have used a synergy type of a stem which also takes distal hold.
ANOOP JHURANI: But the growth part, the cord is proximal only, but the fixation is distal as well so it's a long stem. So to prepare for the cylinder distally and a wedge proximally. These stems should be used where there is some proximal disruption of the shape. You still want to use a primary stem because the patient is young.
ANOOP JHURANI: You don't want the fully coated stem because the patient may need a second revision. So the choice of the stem can be a small anthological type of stem where the native femur, the wedge shaped proximal femur is normal, but where there is some disruption in the proximal, that shape of the bone, where the head shape cord comes, then one can choose a synergy type of a stem which takes purchase in the diaphysis also, but does not have any growth in the distal part.
ANOOP JHURANI: One can check the position of the cup and the stem to ensure there is proper lateralization of the stem and then use a synergy type of stem. As you can see here in the post op X-Ray. The cup looks good, the bone quality was good. It's a primary uncemented cup, hip screws were not required because the fixation was solid and it's a 36 ceramic head. More important, the message here is how to remove these incarcerated screws under dense, sclerotic bone with a Midas bar and how to use a longer synergy type of a stem in these cases where there is some disruption in the proximal metaphyseal area.
ANOOP JHURANI: Thank you very much.
