Background
Extended trochanteric osteotomy is a commonly used technique for retrieving a previously implanted femoral stem. While it is safe and provides good access, there are associated complications including subsidence1 and non-union.2 An intact greater trochanter and circular rim in which to implant a revision stem would potentially lead to better outcomes. It has been suggested that trochanteric sparing osteotomies may be desirable.3 We describe a technique that reliably provides access to an implanted stem, aiding removal while avoiding osteotomy of the greater trochanter, maintaining bone stock and an intact circular rim.
Technique
The femur is exposed and the osteotomy site marked (Fig 1). A window with a rectangular base is created using a drill and saw. It is important to maintain soft tissue attachments to the osteotomised fragment to facilitate subsequent fusion. The fragment can be turned like a door on a hinge. Flexible osteotomes are passed antegrade from the neck and retrograde through this window (Fig 2). The stem is removed. The osteotomised fragment may be reimplanted with the aid of cables. This technique provides good access to the tip, avoids violation of the abductor mechanism and the need for trochanteric plates or tension band wiring, saves time and allows early weight bearing. Only simple instruments are required. Figure 3 shows x-rays of a trochanteric sparing osteotomy in practice.
Figure 1.
The femur is exposed and the osteotomy site marked
Figure 2.
A flexible osteotome can be passed through the window created to release the implant
Figure 3.
Radiography of a trochanteric sparing osteotomy in practice
Discussion
Where possible, the stem should be removed without resorting to the osteotomy described. Furthermore, cemented implants can be simply removed using an in-cement technique. However, this technique can also be useful for well integrated cementless implants or to remove a cement mantle and a cement restrictor.
References
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