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Endoprosthetic Reconstruction of Proximal Femur Malignant Lesion

Preoperative Patient Care
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
Private Note

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