MEDULLOSCOPY ASSISTED CANAL PREPARATION IN SEPTIC AND ASEPTIC REVISION THA
One of the primary steps in revision hip arthroplasty is the extraction of retained components and cement before surgical reconstruction. In revision hip arthroplasty, the removal of well fixed cement can be extremely demanding, time consuming and damaging to the remaining host bone. A number of studies report on the usefulness of endoscopy of the medullary canal (medulloscopy) to facilitate cement removal from top. Different endoscopy systems have been designed to visualise the endosteal surface of the bone. We hereby report a multicenter prospective study on cement removal in both infected and non-infected hip arthroplasty using standard available endoscopy equipment. The aim of our study was:
· To define the usefulness and quality of view using standard available laparoscopic equipment · To report on intra-operative complications during medulloscopy assisted cement removal · To define the risk factors of femoral perforation and intra-operative fracture · Define the indications and limitations of medulloscopy for cement removal · Make a critical analysis of completeness of cement removal, especially in septic revisions.
Click here to view the AAOS 2006 poster regarding this Introduction.
2. MATERIAL AND METHODS
This study includes 107 revision hip arthroplasties and its population consists of 67 aseptic cemented revisions (revised because of loosening) and 34 septic cases. All aseptic revisions were performed as a one stage procedure. All septic cases were operated in two stages with the first stage essentially consisting of a Girdlestone procedure with removal of both acetabular and cemented femoral components. Pre-operative radiological evaluation consisted of Barrack’s classification to evaluate the quality of the existing cement mantle . Endo-clinic and AAOS classification were chosen to examine the femoral bone deficiencies. Bone defects were localised on the pre-operative X-rays using Gruen-zone classification. Total operating time, endoscopy time and endoscopy time relative to operating time were noted, as well as blood loss and transfusion need. Based on the operating notes and per-(??? Pre) operative video recordings fractures of the trochanteric region, femoral fractures and perforations were recorded. The need for extended trochanteric osteotomy and for windows and completeness of cement plug removal were also recorded. Post operative X-rays were reviewed by an independent reviewer blinded for (unaware of???) the operative details. Especially in the infected cases a detailed radiological analysis was made of the femoral X-rays after the first stage of the revision. Fractures, unnoticed perforations and the existence and localisation of remaining cement were recorded. In the infected cases a comparison was made between the pre- and post-operative femoral deficiencies using AAOS and endo-clinic classification. Retained cement was localised according to Gruen-zone classification. A comparison was also made between pre-operative quality of cement mantle, bone quality and risk of perforation. In this multicenter study two different video endoscopy equipment tools were used. At the Pellenberg University Hospital where the septic cases were operated on, a Dyonics 5mm 0° laparoscope was used. The non-septic cases at Sint Blasius Hospital were operated on with a 5 and 10mm Storz laparoscope .Endoscopy equipment consisted of a Trinitron monitor (model PVM20M2MDE, SONY), a Storz camera (TELECAM 20212030, Karl STORZ) and control unit (TELECAM SL Pal 20212020, Karl STORZ), a cold light fountain (XENON NOVA 20131520, Karl STORZ), a fibre glass light conducting cable (495NCS, Karl STORZ) and several Hopkins telescopes. The following Karl STORZ telescopes were used: two 0-deg forward view 5 and 10 mm in diameter (Models 26006AA and 26003AA res.) and one 30-deg forward oblique view 5 mm in diameter (Model 28031BA). The most recent 5 aseptic cases were operated on using a chip on the tip 5mm laparoscopy system. Cement splitting chisels ( set Smith & Nephew ) were used to remove the proximal cement. Plug perforation and distal cement removal was facilitated by ultrasound driven disposable 6.0 mm plug puller and 7.0 mm Helix tip ( Ultradrive model 50 , Biomet ,Warsaw ) . Diaphyseal cement was reamed out with Sentinel low pressure cannulated reamers ( Zimmer Warsaw ) .
Click here to view the AAOS 2006 poster regarding Material and Methods. 3. SURGICAL TECHNIQUE
A similar cement removal technique was used for both infected and aseptic revisions. Patients were positioned in the lateral decubitus. Anterolateral, transgluteal (Hardinge) approach was used for both septic and aseptic revisions. Multiple cultures were taken after the incision of the fascia and arthrotomy of the hip and also from removed membrane and the intramedullary canal. Following sequential operative steps were used for implant and cement removal. Removal of cement between the trochanter and the shoulder of the prosthesis to allow stem extraction. Extraction of implant stem using cement-extraction instruments. Endoscopic evaluation of existing cement mantle (fig). Removal of all accessible proximal cement using narrow osteotomes and chisels of various sizes and thickness. Radial and longitudinal splitting of metaphyseal cement and removal using a variety of grasping instruments.
At this stage we used a 10 mm laparoscope as an additional light source. Positioning of …. Ultrasound tool under endoscopic control. (fig). Perforation of distal cement plug using ultrasound. Inspection of plug perforation with a 5mm laparoscope after cleaning and wash out of the canal using pulsed lavage. Advancement of ball-tipped guide wire into the distal part of the femur. Positioning of guide wire checked with image intensifier With a standard flexible cannulated low pressure intramedullary reamer the well-fixed cement mantle is gradually reamed out with 0;5 mm increments(fig).. After every reamer passage the canal is washed out and inspected using the 5mm laparoscope. Care is taken to avoid eccentric femoral canal reaming as the surrounding bone might be softer than the cement mantle. Ultrasonic driven curettes are used to remove remaining cement from side-walls. After the cement has been completely removed, the membrane lining the medullary canal is meticulously curetted out under endoscopic control.
Before placement of cementless revision stems with distal fixation, reaming and sizing of the distal femur is performed under endoscopic control.
Click here to view the AAOS 2006 poster regarding Surgical Technique. 4. RESULTS The average age of our patients was 7O years and the time between primary and revision procedure 69 months. Total blood loss was 2.5 units on average. A comparison was made of the complications between the aseptic and the septic cases. There was 13.44% risk of intra-operative complication in the aseptic cases and a much higher (38%) risk in the septic cases. The risk for perforation was however not predictable by 3 operative X-ray using the AAOS or Endo-Clinic classification. A detailed analysis was made of the residual cement after the primary procedure in septic revisions. There was statistically more cement distal to the cement plug and in the distal part of the medullary canal at Gruen zones for and 11. There was one broken instrument and three broken ultrasound tips during endoscopically assisted cement removal.
Click here to view the AAOS 2006 poster regarding pictures of the results.
Click here to view the AAOS 2006 poster regarding figures of the results. 5. TIPS AND TRICS
5 and 10 mm laparoscopes with a 0° lens angle are the best choice when standard equipment is used for medulloscopy Arthroscopes with angled lenses and insufficient light source cause incorrect orientation of instruments. Different measures can be taken to reduce the intramedullary bleeding and improve visualisation of : – spinal epidural anaesthesia with controlled hypotension – wash-out of the medullary canal using pulsed lavage with freezing saline – application of methylated spirit solution prevents fogging of lens tip Avoid eccentric reaming of medullary canal as the cortical bone can be softer than the cement. Use of ultrasound driven reverse curette to remove cement from side-walls. Even after extended trochanteric osteotomy, medulloscopy is usefull to inspect the distal femur for completeness of cement removal and sizing of the final implant. Set operating room clock at 45 minutes when cement removal is started to avoid excessive increase of operating time.
Click here to view the AAOS 2006 poster regarding Material and Methods.
6. DISCUSSION AND PUBLISHINGS
Today arthroscopy and endoscopic techniques are part of the everyday work of the orthopaedic surgeon. The ideas for minimal invasive and endoscopically assisted surgery seem to be unlimited. Orthopaedic surgeons have always been attracted to endoscopic inspection of the inside of the bone and the medullary canal (ref. Bojkow). Intramedullary bone endoscopy (IBE, Oberst), bone endoscopy (Köster) and medulloscopy (Roberts) are synonyms for describing visual inspection of the intramedullary canal. Most of the clinical experience so far focuses on endoscopically assisted cement removal in revision hip arthroplasty. Endoscopy of the bone has also been used to assist pedicle screw placement, core decompression, autogenous bone grafting, canal preparation in primary THA and inspection of the medullary canal in septic fracture non-unions. Removal of well-fixed or loose cement (polymethylmethacrylate) present many challenges for orthopaedic surgeons. In cases of very loose femoral components with extensive bone-cement radiolucencies, extraction of cement may not prove to be too difficult, because a well-defined soft tissue plane, that has been biologically placed, facilitates removal of hard cement from hard bone. In other cases where well fixed cemented components and cement have to be extracted, due to infection, catastrophic wear, revision implant mismatch or malposition with chronic dislocations, this cement removal can become technically very demanding. It may lead to an increased operative time with severe blood loss, bone perforation or even femoral fracture.(Di-cesare). Medulloscopy for cement removal has been published by many surgeons (table).
AUTHOR | N° PATIENTS | CLINICAL | SCOPE USED | SURGICAL FINDINGS | O.R. TIME | Bassett | 13 | Slipped capital femoral epiphysis | ? | 2 articular penetrations | | Bojkow WP, Karalin AN. | 350 | Endoscopically assisted fracture reduction | ? | | | Campbell | 2 | Cemented revision hip arthroplasty | arthroscope | | | Drake C. | ? | Cement removal in revision hip arthroplasty | Ortho scope | Use of pneumatically -powered ballistic chisels | | Gerber SD. | 1 | Femoral Rod removal | | | | Govaers K. | 90 | Canal preparation in primary total hip arthroplasty | 10mm laparoscope | Arterial bleeding, eccentric reaming | 3.49 hours | Govaers K. | 25 | Cement removal in revision hip arthroplasty | 5 and 10mm laparoscope | Reduced need for trochanteric osteotomies | | Govaers K. | 12 | Core decompression in osteonecrosis | 5mm laparoscope | Improved accuracy , one accidental perforation | | Johnson LL. | 9 | 5 tibial non-unions, 4 humeral non-unions | | | | Kim SJ | 8 | Endoscopic bone graft of 4 humeral shaft and 4 femoral shaft non-unions | ? | Refreshment of fracture + endoscopic bone grafting under direct vision | | Köster | 28 | | | | | Lavernia C.J. | 1 | Pelvic osteolitic lesion | ? | Arthroscopic debridement of pelvic osteolyses | | Lu | 1 | Replacement DHS | ? | Endoscopy of new portal of screw canal | | Morgan-Jones RL. | 6 | Arthroscopic pin track debridement. | | | | Oberst (2) IBE,Erste Klin. Anwendung | 2 | Cement removal lost of reamer | | Salvage of lost reamer | | Porsch | 28 | | | 1 cortical fissuring | 13-75 min | Roberts | 7 | Septic non union femur & tibia | | 86 % visualization nonunion | | Ruch D.S. | ? | Core decompression of the hip | Hip arthroscopy | Placement of guidewire within the centre of the infarct | | Stricker S.J. | 3 | Femoral head chondroblastoma | | | | Toms A.D. | | Revision hip arthroplasty | cystoscope | | |
Most studies report a small number of patients with little emphasis on the risks and possible complications inherent to medulloscopy assisted cement removal.
Porsch introduces a miniaturized chiselling system (Swiss OrthoClast) that allows endoscopically controlled cement removal even from deep within the femur in hip revision arthroplasty. Their device consists of a control unit, a hand piece, a set of chisels of different lengths and shapes, a set of plug extraction tools and a specially designed intrafemoral endoscope. It uses simple ballistic principles to fracture the bone cement. Inside the hand piece is a projectile accelerated that strikes the chisel head. The tip moves at high speed and with a small excursion towards the cement, which is fragmented mechanically by the movement of the chisel tip without generating heat. According to their reported devices validated in a prospective, international, multicenter study they publish on their first 28 clinical procedures. The average duration of cement removal is 32 min (13 to 75 min). In all but one case, the cement was completely removed and they had only one case of cortical fissuring. The same pneumatically-powered ballistic chisels under endoscopic control have been reported on by Drake C. and Ezzet K (ref. 6). They report on the use of this system in 15 complex femoral revision cases where normally an extended trochanteric osteotomy was anticipated. 14 cases had well-fixed distal cement and 1 case a well-fixed cementless component. In all 15 cases (100%), the femoral component was successfully revised without a trochanteric osteotomy. 3 cases required a small single femoral window less than 1 cm. 80 % of the cases that would ordinarily require an osteotomy were successfully managed without an osteotomy, window or perforation. The endoscope allowed direct visualisation within the distal femur and the pneumatic chisels were small enough to fit alongside the endoscope inside the femur. As far as we know, only one study compares cement removal from top with trochanteric osteotomy. In 1987 Arnold Berman (ref. 3) was the first orthopaedic surgeon to describe the use of an arthroscope to assist cement removal in revision hip surgery. He used the fibre-optic head lamp and the light source of an arthroscope to enhance visualisation during cement removal. 63 total hip revisions were divided into two groups comparing 21 trochanteric osteotomised revisions to 44 with trochanteric sparing techniques. In the non osteotomised group there was a 21% decreased blood loss, a 14% decrease in persistent abductant weakness and a 14% decrease in subluxation and dislocation. Furthermore there was a 30% decrease in operating time and a 50% reduction in intraoperative femoral perforation. Although there is no statistical evidence to prove this claim, we feel that the quality of view obtained with different endoscopy systems has a great influence on the quality of surgical performance. Classic 5mm laparoscopes provided insufficient light deep down in the femoral canal and near the cement plug. This was greatly improved by the use of modern chip on the tip laparoscopes. It has yet to be proven in a prospective trial that the use of modern video equipment can reduce the amount of retained cement near the tip and deep down in the femoral canal, which is of paramount importance in septic revisions[d3] . Medulloscopy assisted cement removal requires a great amount of extra equipment in the operating room .High quality video equipment , ultrasound , flexible reamers , pulsatile lavage pistols and image intensifier are essential instruments in making this a successful procedure . Prospective randomised trials are mandatory to compare cement exposure by extended trochanteric osetotomy to medulloscopy assisted removal .Intraoperative complications ,blood loss , hospital stay , .patient recovery and cost have to be compared . 7. REFERENCES | | | 1. | Bassett GS Bone endoscopy: direct visual confirmation of cannulated screw placement in slipped capital femoral epiphysis. J Pediatr Orthop. 1993 Mar-Apr;13(2):159-63 | 2. | Beck A, Strecker W, Gebhard F, et al Influence of prosthesis design on intramedullary femoral pressure during the implantation of femoral stem prostheses. Unfallchirurg 2001;104:1140-1144. | 3. | Berman AT, Salter FL, Koenig T. Revision Total Hip Replacement without Trochanteric Osteotomy Orthopedics.1987 May;Vol.10/N°5 | 4. | Bojkow WP, Karalin AN. Bone marrow endoscopy. Orthop Travmatol Protez. 1989;3:68-69 | 5. | Campbell DG, Rietveld JA Technique for arthroscopic assisted revision hip arthroplasty. Int Orthop. 2001;25(‘):236-8 |
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