Updated: 10/4/2016

Endoprosthetic Reconstruction of Proximal Femur Malignant Lesion

Preoperative Patient Care


Outpatient Evaluation and Management


Obtain focused history and performs focused exam

  • history
  • past history of cancer or radiation
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules


Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic


Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • check radiographs
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • hardware failure
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit

Advanced Evaluation and Management


Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • used to evaluate the extent and level of bony destruction
  • MRI
  • evaluates the medullary and extraosseous components of the tumor
  • intracapsular extension
  • presence of skip metastasis within the femoral canal
  • angiography of the illiofemoral vessels
  • lab studies
  • PSA
  • other tumor markers


Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty


Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)


Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling

Preoperative H & P


Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness
  • screen medical studies to identify and contraindications for surgery


Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion


Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention


Perform operative consent

  • describe complications of surgery including
  • Infection
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
  • Dislocation
  • Abductor insufficiency and trendelenburg gait
  • Prosthetic loosening

Operative Techniques


Preoperative Plan


Radiographic templating

  • determine the extent of the resection
  • determine the dimensions of the required prosthesis


Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • endoprosthesis system


Room setup and equipment

  • standard OR table
  • sterile hoods with circulating fans for surgical team
  • hip positioners or bean bag
  • check back table to make sure correct equipment available


Patient positioning

  • lateral decubitus with operative extremity facing up
  • axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, foley in place
  • in obese patients place towel or pad between positioners and skin
  • arms stacked on top of each other with blankets underneath and in between, taped down to arm boards
  • prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area
  • bovie pad on contralateral thigh or abdomen
  • foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep

Lateral Approach


Perform skin incision

  • make incision that starts 3 to 4 cm proximal to the greater trochanter
  • extend the incision to the distal 2/3 of the thigh


Expose the gluteus medius and maximus


Detach the gluteus medius and maximus

  • open the iliotibial band longitudinally
  • detach the femoral insertion of the gluteus maximus
  • retract the gluteus maximus posteriorly
  • this allows visualization to the retrogluteal area, external rotators, sciatic nerve, abductors and the posterior capsule
  • identify and mobilize the sciatic nerve
  • identify the abductors
  • transect the abductors through there tendinous attachments when there is no tumor involvement


Reflect the vastus lateralis

  • transect the vastus lateralis from its origin at the vastus ridge and reflect distally
  • ligate the posterior perforating vessels
  • identify the femoral nerve below the fascia
  • identify the superficial and profundus femoral artery and vein in the sartorial canal
  • if they have been invaded by tumor then they can be ligated just distal to there takeoff from there common femoral vessel

Detachment of the Posterior Hip Musculature and Capsule


Detach the posterior hip musculature and capsule

  • detach the rotator muscles en bloc 1 cm from their insertion on the proximal femur


Open the the hip capsule

  • if there is no tumor involvement the hip capsule should remain intact because of its role in stability of the prosthesis
  • open the capsule longitudinally along its anterolateral aspect and detach it circumferentially from the femoral neck


Dislocate the femur anterolaterally


Distal Femoral Osteotomy and Release of Medial Structures


Determine the level of the osteotomy

  • typically this is 3-4 cm distal to the farthest point for primary sarcomas and 1-2 cm distal for metastatic lesions


Perform resection

  • place a malleable retractor medial to the femoral shaft to protect the soft tissues
  • use an oscillating saw to make a right angle cut to the shaft of the femur


Remove the femur

  • remove the femur laterally
  • do not distract the femur because of the possibility of placing tension on the sciatic nerve


Identify the medial structures

  • identify and tag the psoas and the adductors

Reaming and Trial Articulation


Ream the intramedullary canal

  • use serial reaming to ream 2 mm above the chosen stem diameter
  • a 1 mm cement mantle is required around the stem


Perform trial articulation

  • match the length of the resected specimen to the length of the trial component
  • check pulses
  • if the pulses are diminished, they prosthesis should be shortened
  • pull the joint capsule over the femoral component


Check stability

  • test the prosthesis in flexion, adduction and internal rotation

Prosthetic Assembly and Implantation


Assemble the modular prosthesis


Cement the prosthesis into the medullary canal

  • use pulsatile lavage to irrigate the canal
  • use 2 bags of cement
  • place an intramedullary cement restrictor
  • reduce the cement by centrifugation
  • pressurize the cement then use a cement gun
  • precoat the proximal portion of the femoral stem with bone cement


Check the orientation of the prosthesis

  • use the linea aspera as a guideline
  • place the femoral neck 5 to 10 degrees anteverted with respect to the imaginary perpendicular line from the prosthesis and a line is drawn from the linea aspera through the body of the prosthesis


Cover tip of stem with extra cement


Soft Tissue Reconstruction


Secure the hip capsule

  • tightly suture the remaining hip capsule with a 3 mm dacron tape around the neck of the prosthesis


Reattach the external rotators

  • rotate the external rotators proximally and suture them to the posterolateral aspect of the capsule


Reattach the psoas

  • rotate the psoas anteriorly and tenodese to the anterior capsule


Reattach the abductor tendon to the prosthesis

  • use Dacron tape to attach the abductor tendon to the the lateral aspect of the prosthesis through a metal loop
  • use the vastus lateralis and tenodese to overlie the abductor muscle fixation
  • suture the remaining muscles to the vastus lateralis anteriorly and the hamstrings posteriorly

Wound Closure


Irrigation, hemostasis, and drain

  • close wound over a 28 gauge chest tube under continuous suction
  • cauterize peripheral bleeding vessels


Deep closure

  • use 0-vicryl for deep fascia


Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin


Dressing and immediate immobilization

  • place in balanced suspension with the hip elelvated and flexed 20 degrees

Postoperative Patient Care


Perioperative Inpatient Management


Write comprehensive admission orders

  • IV fluids
  • IV antibiotics
  • continue until all drainage tubes are removed
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • continuous suction of drain for 3 to 5 days
  • appropriately orders and interprets basic imaging studies
  • post-op xrays of hip to evaluate implant position
  • appropriate medical management and medical consultation
  • inpatient physical therapy
  • keep extremity in balanced extension for 5 days
  • order a customized abduction brace
  • mobilize in abduction brace for 6 weeks
  • weight bear as tolerated
  • active hip abduction is required before the abduction brace can be removed


Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
  • wound care

Complex Patient Care


Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy


Develops unique, complex post-operative management plans


Discusses prognosis and end of life care with patient and family


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