most patient: union uneventfully
Becautious
1. Pathological fx
2. Unstable or comminuted
3. Medical comorbidity
4. Severe osteopenia
5. Previous implant failure
must r/o infection nonunion in previous operation failure
1. ESR & CRP
2. Intra-OP culture or smear
Approach
1. W/O greater trochanter fracture: AL or PL approach
2. W/ greater trochanter fracutre: Trochanter osteotomy aproach
Issue 1: When to remove prosthesis
1. after surgical dislocation
- femoral shaft w/o implant is weak. and his/her hip joint is stiff. iatrogenic shaft may be occured during surgical dislocation if implant was removed
- 先切掉head? eliminate femoral shaft fracture?
Issue 2: choice of Cup
- cementless with screw sugmentation
- press-fit w/o screw fixation is not recommended
Issue 3: choice of stem
calcar replacing prosthesis
- restore length
- reduce lesser or greater tuberosity
- fixation with Wire or cable
Issue 4: preparation of femoral canal
- scleroting tract, callus, deformity: deflecting reamer or broacher → iatrogenic fracture or femora canal peforation
- high speed burr to open femoral canal, then prepare femoral canal with reamer and broacher
Issue 5: stem length in femur with previous implant fixation
- 6 cm distal to previous screw hole ( 2 fold diaphysis diameter)
- avoid stress riser from screw hole
Issue 6: cemented stem
- good choice for severe osteopenic patient
- large cement leakage: cause of late periprosthetic fracture
- Clean and curette extravasation of cement
Issue 7: greater trochanter fracture
- cable or multiple wires
- stable enough for early mobilization
- autogenous bone grafting is recommended (harvested from femoral head)
- avoid abductor muscle strengthening in first 6 weeks
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