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PreOp Planning for Removal of Cemented Stems

- Evaluate Proximal Stem:
    - decide whether trochanteric osteotomy is required;
    - it is essential to avoid a proximal femoral frx while extracting the stem;
    - direct extraction of a femoral stem can be blocked by excessive cement or proximal bony overgrowth medial to the greater trochanter;
    - this situation is worsened if the femoral stem is curved;
    - surgical options are to remove the impedeing bone or cement which overly the lateral aspect of the stem (using high speed burr or osteotomes) or
          to perform a trochanteric osteotomy;
    - in either case, the lateral aspect of the stem shold be visualized prior to stem removal;

- Evaluate Distal Stem:
     - note areas cement fragmentation;
     - note on lateral view, where the femur begins to curve anteriorly;
     - this will indicate how far distally cement chisels may pass;
     - note amount of distal cement plugging;
     - in the past 2 cm of distal plugging was recommended, often because the stems were end bearing;
     - w/ more than 1-2 cm of cement, the procedure becomes much more complex;

- Surgical Instruments:

- Visualization:
     - arthroscopic lamp;
     - windowing of the femur;
          - trochanteric osteotomy:
          - offers more complete access to proximal femur but comprimises stability provided greater trochanter to press fit system;
          - flouroscopy:
               - image intensification is extremely useful in avoiding bone damage, but it introduces increased risks of potential contamination of the surgical site