Anterior Distal Femoral Osteotomy For Removal Of Long Femoral Stems In Revision Knee Arthroplasty Michael K. Merz MD, Yasser R. Farid MD, PhD PII: DOI: Reference:
S0883-5403(14)00060-6 doi: 10.1016/j.arth.2014.01.018 YARTH 53828
To appear in:
Journal of Arthroplasty
Received date: Accepted date:
6 September 2013 20 January 2014
Please cite this article as: Merz Michael K., Farid Yasser R., Anterior Distal Femoral Osteotomy For Removal Of Long Femoral Stems In Revision Knee Arthroplasty, Journal of Arthroplasty (2014), doi: 10.1016/j.arth.2014.01.018
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
32 33 34 35 36 37 38 39 40
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Anterior Distal Femoral Osteotomy For Removal Of Long Femoral Stems In Revision Knee Arthroplasty
SC
Michael K. Merz, MD* Yasser R. Farid, MD, PhD*
CE
PT
ED
MA
NU
*Department of Orthopaedic Surgery University of Illinois at Chicago Chicago, IL
AC
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Please address all correspondence to: Michael K. Merz, MD Department of Orthopaedic Surgery University of Illinois at Chicago 835 S. Wolcott Avenue, M/C 844 Chicago, IL, 60612, USA Phone: (312) 996-7161 Fax: (312) 996-9025 Email: [email protected]
ACCEPTED MANUSCRIPT 2 41
Anterior Distal Femoral Osteotomy For Removal Of Long
42
Femoral Stems In Revision Knee Arthroplasty
RI P
T
43 Abstract: Osteotomies of the proximal femur and proximal tibia in revision arthroplasty are well
45
described while guidelines for distal femoral osteotomy are limited. Femoral stems are used with
46
increasing frequency for fixation of revision components in knee arthroplasty and their removal
47
is technically challenging particularly in the setting of infection. We describe a technique of
48
anterior distal femoral osteotomy for revision knee arthroplasty to assist with removal of well-
49
fixed long stemmed cemented or porous femoral components, as well as debridement of
50
infection while preserving bone stock and soft tissue attachments.
ED
MA
NU
SC
44
51
55 56 57 58 59 60
CE
54
AC
53
PT
52
ACCEPTED MANUSCRIPT 3 61 62
Introduction: Proximal femoral osteotomies for revision of hip arthroplasty1,2 and tibial tubercle osteotomy2-5 for revision of knee arthroplasty have been extensively discussed in the literature.
64
Conversely, distal anterior femoral osteotomy for revision knee arthroplasty is only briefly
65
mentioned2-4. The largest report on this technique included only 4 patients by Massin, et al in
66
2012 and the technique was not clearly outlined5.
RI P
SC
NU
67
T
63
We describe our method of anterior distal femoral osteotomy to address revision of wellfixed, fully cemented or porous long stems on femoral components of knee arthroplasty. The
69
technique permits complete visualization of the femoral canal and is particularly valuable in the
70
setting of explantation for infection, in which complete removal of implants, cement mantle, and
71
canal restrictors along with thorough debridement are required. It permits the preservation of soft
72
tissue attachments to maintain the viability of the anterior cortical bone fragment.
73
Technique:
ED
PT
CE
In the supine position, a midline incision and medial parapatellar arthrotomy are
AC
74
MA
68
75
performed as extensile as necessary. Osteotomes are utilized to divide the surface fixation
76
interface of the femoral component along the anterior, posterior, and chamfer cuts and removal
77
of the component is attempted first. The osteotomy is indicated if the stem is well fixed. To
78
perform the osteotomy, sharp dissection on the anterior aspect of the femur is done in a
79
longitudinal line along the medial femoral border extending as proximal as necessary then
80
transversely across the femur to demarcate the length of the osteotomy fragment (Fig 1A). The
81
length of the osteotomy is determined according to preoperative planning and intraoperative
82
measurements and depends on the length and fixation of the stem. The layered quadriceps
ACCEPTED MANUSCRIPT 4 muscle deep to the arthrotomy allows preservation of muscular attachments on the anterior
84
femoral surface proximal to the femoral component and lateral to the longitudinal cut. A high-
85
speed pencil-tipped burr is utilized to divide the full thickness of the cortex along the distal,
86
medial, and proximal boundaries of the osteotomy fragment (Fig 1B). Flexible, sharp osteotomes
87
are driven through the medial cut parallel to the anterior surface to divide the lateral cortex deep
88
to the remaining muscular attachments of the vastus intermedius (Fig 1C). Wide osteotomes are
89
utilized to elevate the fragment laterally (Fig 1D) and retractors are placed inside the fragment to
90
maintain exposure of the femoral canal and its contents (Fig 2A). High-speed burr and
91
osteotomes are utilized to dissociate the stem (Fig 2B) and the femoral component is driven out
92
(Fig 2C). Further removal of infected cement, canal restrictors, and bone debridement can be
93
performed under direct vision. Porous stems could be removed similarly and longer stems could
94
be cut with metal-cutting carbide burr and the remaining proximal part, which was not be fully
95
exposed by the osteotomy is removed with trephine reamers. A long osteotomy may facilitate
96
explantation but leaves less isthmus for press fit fixation of a revision stem. On the other
97
hand, a short osteotomy paradoxically facilitates revision but explanation and debridement
98
of infection become more challenging. For revision, we prefer to press fit long stems (either
99
porous or grit-blasted) extending at least two cortical diameters beyond the osteotomy and
AC
CE
PT
ED
MA
NU
SC
RI P
T
83
100
engaging the isthmus. We coat the distal part of the stem, the taper junction, and the non-
101
articular condylar portion of the component with cement, and then impact the stem. This is
102
followed by fixation of the osteotomy with previously passed cables while cement is still
103
soft and removal of excess cement. We keep cable passers strictly subperiosteal in order to
104
avoid vascular entrapment. (Fig 2D). A similar technique is utilized for insertion of a static
105
cement and rod knee spacer in the setting of infection. Protection of soft tissue attachments is
ACCEPTED MANUSCRIPT 5 important during osteotomy, debridement, and osteotomy fixation. Postoperatively,
107
immobilization of the knee or modification of postoperative rehabilitation protocol is
108
unnecessary.
109
Discussion:
Penteado and colleagues showed significant vascularization of the distal third of the
SC
110
RI P
T
106
femoral periosteum particularly through the femoral and lateral metaphyseal arteries 6. Another
112
cadaveric study showed that percutaneous cerclage wires of the femur minimally affect femoral
113
blood supply due to significant anastomoses of the vasculature7. This allows healing of the
114
osteotomy assuming maintenance of soft tissue attachments throughout the procedure (Figure 3).
115
The described technique was utilized in six complex revision knee arthroplasties by the senior
116
author (Y.R.F.) without surgical complications related to the osteotomy. It significantly
117
facilitated removal of well-fixed cemented and porous stems particularly in the setting of deep
118
periprosthetic infection.
119
References:
120
1. Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric Osteotomies in
121
Revision Total Hip Arthroplasty: Contemporary Techniques and Results. Instr Course
122
Lect 2005;54:143-55.
123 124 125 126
AC
CE
PT
ED
MA
NU
111
2. Masri BA, Mitchell PA, Duncan CP. Removal of Solidly Fixed Implants During Revision Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2005;13:18-27. 3. Dennis DA, Berry DJ, Engh G, Fehring T, MacDonald SJ, Rosenberg AG, Scuderi G. Revision Total Knee Arthroplasty. J Am Acad Orthop Surg 2008;16:442-454.
ACCEPTED MANUSCRIPT 6
129
Relat Res 2006;446:76-82. 5. Massin P, Boyer P, Sabourin M, Jeanrot C. Removal of infected cemented hinge knee
T
128
4. Mason JB, Fehring TK. Removing Well-fixed Total Knee Arthroplasty Implants. Clin Orthop
RI P
127
prostheses suing extended femoral and tibial osteotomies: Six cases. Orthop Traumatol
131
Surg Res 2012;98:840-844.
135
NU
134
sites of elevation. Surg Radiol Anat 1990;12(1):3-7. 7. Apivatthakakul T, Phaliphot J. Leuvitoonvechkit S. Percutaneous cerclage wiring, does it
MA
133
6. Penteado CV, Masquelet AC, Romana MC, Chevrel JP. Periosteal flaps: anatomical bases of
disrupt femoral blood supply? A cadaveric injection study. Injury 2013;44(2):168-74.
ED
132
SC
130
136
AC
CE
PT
137
ACCEPTED MANUSCRIPT 7 138 139
Figure Legends: Fig 1. Osteotomy technique: A. Outline of osteotomy showing preservation of vastus intermedius attachment.
141
B. A high-speed pencil-tip burr is used to make the oseotomy.
142
C. Multiple wide osteotomes are used to elevate the fragment.
143
D. Osteotomy fragment retracted laterally.
SC
RI P
T
140
Fig 2. Removal of prosthesis and osteotomy fixation:
145
A. Exposure of stem fixation interface.
146
B. Division of cement fixation interface with high-speed pencil-tip burr.
147
C. Disimpaction of prosthesis and stem.
148
D. Cemented revision with a rotating-hinge prosthesis and cable fixation of the
151
MA
ED
PT
150
osteotomy.
Fig 3. X-rays preoperatively and 14 months following the osteotomy in a different
CE
149
NU
144
patient show medial periosteal reaction and undetectable osteotomy line. A. Preoperative knee anteroposterior radiograph
153
B. Preoperative knee lateral radiograph
154
C. Postoperative distal femur anteroposterior radiograph
155
D. Postoperative distal femur lateral radiograph
156 157
AC
152
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8
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S0883-5403(14)00060-6 doi: 10.1016/j.arth.2014.01.018 YARTH 53828
To appear in:
Journal of Arthroplasty
Received date: Accepted date:
6 September 2013 20 January 2014
Please cite this article as: Merz Michael K., Farid Yasser R., Anterior Distal Femoral Osteotomy For Removal Of Long Femoral Stems In Revision Knee Arthroplasty, Journal of Arthroplasty (2014), doi: 10.1016/j.arth.2014.01.018
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
32 33 34 35 36 37 38 39 40
RI P
T
Anterior Distal Femoral Osteotomy For Removal Of Long Femoral Stems In Revision Knee Arthroplasty
SC
Michael K. Merz, MD* Yasser R. Farid, MD, PhD*
CE
PT
ED
MA
NU
*Department of Orthopaedic Surgery University of Illinois at Chicago Chicago, IL
AC
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Please address all correspondence to: Michael K. Merz, MD Department of Orthopaedic Surgery University of Illinois at Chicago 835 S. Wolcott Avenue, M/C 844 Chicago, IL, 60612, USA Phone: (312) 996-7161 Fax: (312) 996-9025 Email: [email protected]
ACCEPTED MANUSCRIPT 2 41
Anterior Distal Femoral Osteotomy For Removal Of Long
42
Femoral Stems In Revision Knee Arthroplasty
RI P
T
43 Abstract: Osteotomies of the proximal femur and proximal tibia in revision arthroplasty are well
45
described while guidelines for distal femoral osteotomy are limited. Femoral stems are used with
46
increasing frequency for fixation of revision components in knee arthroplasty and their removal
47
is technically challenging particularly in the setting of infection. We describe a technique of
48
anterior distal femoral osteotomy for revision knee arthroplasty to assist with removal of well-
49
fixed long stemmed cemented or porous femoral components, as well as debridement of
50
infection while preserving bone stock and soft tissue attachments.
ED
MA
NU
SC
44
51
55 56 57 58 59 60
CE
54
AC
53
PT
52
ACCEPTED MANUSCRIPT 3 61 62
Introduction: Proximal femoral osteotomies for revision of hip arthroplasty1,2 and tibial tubercle osteotomy2-5 for revision of knee arthroplasty have been extensively discussed in the literature.
64
Conversely, distal anterior femoral osteotomy for revision knee arthroplasty is only briefly
65
mentioned2-4. The largest report on this technique included only 4 patients by Massin, et al in
66
2012 and the technique was not clearly outlined5.
RI P
SC
NU
67
T
63
We describe our method of anterior distal femoral osteotomy to address revision of wellfixed, fully cemented or porous long stems on femoral components of knee arthroplasty. The
69
technique permits complete visualization of the femoral canal and is particularly valuable in the
70
setting of explantation for infection, in which complete removal of implants, cement mantle, and
71
canal restrictors along with thorough debridement are required. It permits the preservation of soft
72
tissue attachments to maintain the viability of the anterior cortical bone fragment.
73
Technique:
ED
PT
CE
In the supine position, a midline incision and medial parapatellar arthrotomy are
AC
74
MA
68
75
performed as extensile as necessary. Osteotomes are utilized to divide the surface fixation
76
interface of the femoral component along the anterior, posterior, and chamfer cuts and removal
77
of the component is attempted first. The osteotomy is indicated if the stem is well fixed. To
78
perform the osteotomy, sharp dissection on the anterior aspect of the femur is done in a
79
longitudinal line along the medial femoral border extending as proximal as necessary then
80
transversely across the femur to demarcate the length of the osteotomy fragment (Fig 1A). The
81
length of the osteotomy is determined according to preoperative planning and intraoperative
82
measurements and depends on the length and fixation of the stem. The layered quadriceps
ACCEPTED MANUSCRIPT 4 muscle deep to the arthrotomy allows preservation of muscular attachments on the anterior
84
femoral surface proximal to the femoral component and lateral to the longitudinal cut. A high-
85
speed pencil-tipped burr is utilized to divide the full thickness of the cortex along the distal,
86
medial, and proximal boundaries of the osteotomy fragment (Fig 1B). Flexible, sharp osteotomes
87
are driven through the medial cut parallel to the anterior surface to divide the lateral cortex deep
88
to the remaining muscular attachments of the vastus intermedius (Fig 1C). Wide osteotomes are
89
utilized to elevate the fragment laterally (Fig 1D) and retractors are placed inside the fragment to
90
maintain exposure of the femoral canal and its contents (Fig 2A). High-speed burr and
91
osteotomes are utilized to dissociate the stem (Fig 2B) and the femoral component is driven out
92
(Fig 2C). Further removal of infected cement, canal restrictors, and bone debridement can be
93
performed under direct vision. Porous stems could be removed similarly and longer stems could
94
be cut with metal-cutting carbide burr and the remaining proximal part, which was not be fully
95
exposed by the osteotomy is removed with trephine reamers. A long osteotomy may facilitate
96
explantation but leaves less isthmus for press fit fixation of a revision stem. On the other
97
hand, a short osteotomy paradoxically facilitates revision but explanation and debridement
98
of infection become more challenging. For revision, we prefer to press fit long stems (either
99
porous or grit-blasted) extending at least two cortical diameters beyond the osteotomy and
AC
CE
PT
ED
MA
NU
SC
RI P
T
83
100
engaging the isthmus. We coat the distal part of the stem, the taper junction, and the non-
101
articular condylar portion of the component with cement, and then impact the stem. This is
102
followed by fixation of the osteotomy with previously passed cables while cement is still
103
soft and removal of excess cement. We keep cable passers strictly subperiosteal in order to
104
avoid vascular entrapment. (Fig 2D). A similar technique is utilized for insertion of a static
105
cement and rod knee spacer in the setting of infection. Protection of soft tissue attachments is
ACCEPTED MANUSCRIPT 5 important during osteotomy, debridement, and osteotomy fixation. Postoperatively,
107
immobilization of the knee or modification of postoperative rehabilitation protocol is
108
unnecessary.
109
Discussion:
Penteado and colleagues showed significant vascularization of the distal third of the
SC
110
RI P
T
106
femoral periosteum particularly through the femoral and lateral metaphyseal arteries 6. Another
112
cadaveric study showed that percutaneous cerclage wires of the femur minimally affect femoral
113
blood supply due to significant anastomoses of the vasculature7. This allows healing of the
114
osteotomy assuming maintenance of soft tissue attachments throughout the procedure (Figure 3).
115
The described technique was utilized in six complex revision knee arthroplasties by the senior
116
author (Y.R.F.) without surgical complications related to the osteotomy. It significantly
117
facilitated removal of well-fixed cemented and porous stems particularly in the setting of deep
118
periprosthetic infection.
119
References:
120
1. Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric Osteotomies in
121
Revision Total Hip Arthroplasty: Contemporary Techniques and Results. Instr Course
122
Lect 2005;54:143-55.
123 124 125 126
AC
CE
PT
ED
MA
NU
111
2. Masri BA, Mitchell PA, Duncan CP. Removal of Solidly Fixed Implants During Revision Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2005;13:18-27. 3. Dennis DA, Berry DJ, Engh G, Fehring T, MacDonald SJ, Rosenberg AG, Scuderi G. Revision Total Knee Arthroplasty. J Am Acad Orthop Surg 2008;16:442-454.
ACCEPTED MANUSCRIPT 6
129
Relat Res 2006;446:76-82. 5. Massin P, Boyer P, Sabourin M, Jeanrot C. Removal of infected cemented hinge knee
T
128
4. Mason JB, Fehring TK. Removing Well-fixed Total Knee Arthroplasty Implants. Clin Orthop
RI P
127
prostheses suing extended femoral and tibial osteotomies: Six cases. Orthop Traumatol
131
Surg Res 2012;98:840-844.
135
NU
134
sites of elevation. Surg Radiol Anat 1990;12(1):3-7. 7. Apivatthakakul T, Phaliphot J. Leuvitoonvechkit S. Percutaneous cerclage wiring, does it
MA
133
6. Penteado CV, Masquelet AC, Romana MC, Chevrel JP. Periosteal flaps: anatomical bases of
disrupt femoral blood supply? A cadaveric injection study. Injury 2013;44(2):168-74.
ED
132
SC
130
136
AC
CE
PT
137
ACCEPTED MANUSCRIPT 7 138 139
Figure Legends: Fig 1. Osteotomy technique: A. Outline of osteotomy showing preservation of vastus intermedius attachment.
141
B. A high-speed pencil-tip burr is used to make the oseotomy.
142
C. Multiple wide osteotomes are used to elevate the fragment.
143
D. Osteotomy fragment retracted laterally.
SC
RI P
T
140
Fig 2. Removal of prosthesis and osteotomy fixation:
145
A. Exposure of stem fixation interface.
146
B. Division of cement fixation interface with high-speed pencil-tip burr.
147
C. Disimpaction of prosthesis and stem.
148
D. Cemented revision with a rotating-hinge prosthesis and cable fixation of the
151
MA
ED
PT
150
osteotomy.
Fig 3. X-rays preoperatively and 14 months following the osteotomy in a different
CE
149
NU
144
patient show medial periosteal reaction and undetectable osteotomy line. A. Preoperative knee anteroposterior radiograph
153
B. Preoperative knee lateral radiograph
154
C. Postoperative distal femur anteroposterior radiograph
155
D. Postoperative distal femur lateral radiograph
156 157
AC
152
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