The transfemoral approach for controlled removal of well-fixed femoral stems in hip revision surgery

Background: For the removal of well fixed femoral stems, various standard and extended approaches are possible, all of which have their advantages and disadvantages. They should allow good visualization and avoid uncontrolled damage to the bone (especially devascularization and fractures) and to the musculature (especially the gluteus medius). As an extended approach we prefer the transfemoral approach in a modified Wagner technique. It is indicated for the controlled removal of broken endoprosthetic stems, a significantly thinned bone at risk of fracture, a stable cement mantle, a partially fixed cementless prosthetic stem with a coarse, rough surface, and infected, fixed total hip endoprostheses. In this review article we describe our experience with our technique of the transfemoral approach.

Material and results: In 68 patients with hip revisions using the modified transfemoral approach, the Harris Hip Score increased continuously from 41.4 points preoperatively to 85.9 points 24 months postoperatively. The bony flap showed bone consolidation in 98.5% of cases. In 76 patients with transfemoral two-stage septic hip revisions, with closure of the flap around the interim prosthesis with cerclage wires and reopening of the flap during second stage revision, the Harris Hip Score was 62.2 ± 12.6 points before the replacement of the spacer and 86.6 ± 15.5 points two years after reimplantation. The healing rate of the bony flap after reimplantation was 98.7%, the absence of infection 93.4%, the rate of stem subsidence 6.6%, and the dislocation rate 6.6%; there was no aseptic loosening of the implants.

Conclusion: The transfemoral approach allows a reliable protection of the gluteus medius and the vastogluteal sling, and enables reproducibly good clinical outcomes.