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Total Femoral Replacement

- Total Femoral Replacement:
    - indications: reconstruction following tumor resection
    - technique:
        - lateral position on a bean bag
        - begin proximally with a posterior approach to the hip
        - divide fascia laterally over femur and continue proximally to divide the fascia over the gluteus maximus in line with fibers of the muscle;
        - separate the maximus in line with its fibers to expose the trochanter;
        - palpate nerve and place Charnley.
        - remove short external rotators from the posterior aspect of the trochanter;
        - identify anterior/posterior borders of medius;
        - perform an oblique trochanteric osteotomy or sharply lift abductors from greater trochanter;
        - lift abductors proximally to expose underlying capsule
        - divide hip capsule sharply and tag for later repair;
        - dislocate femoral head
        - extend incision down lateral aspect femur to lateral condyle
        - divide fascia
        - approach the femur posterior to vastus lateralis;
        - release gluteus maximus from femur proximally and lift proximal femur out of wound;
        - careful with sciatic nerve proximally;
        - tag the iliopsoas for later repair;
        - release the femur medially from adductor mass;
               - in order to do this safely, one must identify the femoral artery and vein;
        - perforating vessels will require vessel clips;
        - one should extend the incision distally and medially to the tibial tubercle and perform a lateral parapatellar approach to the knee;
        - distally, proceed with femoral extraction with care not to injure the femoral vessels anteromedially and the tibial/peroneal nerves just medial to the biceps femoris;
        - divide the collaterals, cruciates and extract femur;
        - keep in mind that the aforementioned apporach varies with the location of the tumor and the desired margin;
        - prepare the proximal tibia according to the protocol of the particular hinged knee system;
        - resurface patella if needed;
        - be gentle in patellar and tibial preparation as tibial or peroneal neuropraxia could result;
        - measure the length of the resected femur and create a modular femur of similar length on the back table;
        - perform a trial reduction
        - vary femoral neck length or tibial polyethylene spacer width as needed to gain desired soft tissue tension;
        - usually 5-10mm of pistoning is appropriate.
        - cement tibial component and allow to harden
        - place femur
        - repair hip capsule
        - sew iliopsoas to inferior capsule
        - bring medius or greater trochanter to prosthesis using nonabsorbable suture or tape;
        - wire is discouraged secondary to fretting;
        - repair gluteus maximus to fascia lata;
        - incorporate gluteus medius into fascia lata repair to decrease lurch;
        - close wound in layers over drain;
        - knee immobilizer post -op, WBAT;
    - Results (Nerubay, et al (1988))
        - excellent 5/19, good 9/19, fair 3/19, poor 2/19
        - no evidence of mechanical failure or aseptic loosening though 14 prosthesis were followed for >2 years;
    - Complications:
        - most are the result of tumor spread.  Many patients die disallowing long term follow-up;
        - wound healing problems occur 50% of the time due to necrosis at wound edges;
              - 4/19 required intra-operatice wound revision;
              - 1/19 require hip disarticulation due to sepsis 4 months post-op;
        - hematoma formation due to erosion of the popliteal vein by a big tibial platform occurred in 1/19;
        - 1/19 tibial components fractured between thetibial stem and the platform


Total femoral replacement.