Functional femoral slit technique for removal of well fixed cement mantle in the femoral diaphysis. A case report of one-stage revision for aseptic loosening of a cemented total hip replacement

A well fixed cement mantle in the femoral diaphysis demands a longer Extended Trochanteric Osteotomy (ETO) than usual during a Revision Total Hip Replacement (THR). But it is mandatory to have 4–6 cm of good diaphyseal bone for adequate fixation if an Uncemented diaphyseal fitting Revision Stem is planned for reconstruction. With our technique of Functional Femoral Slit, getting access to the femoral canal distal to the osteotomy level is possible without compromising the diaphyseal bone stock and there by the fixation of the Revision stem. A 49 year old female presented with complaints of persistent right hip pain and difficulty in walking for 4 months. Past history of fully treated Tuberculosis (TB) hip in 2007 and she underwent Right Cemented Total Hip Replacement in 2008. Her x-rays and CT scan showed loosening of Femoral stem and Prosthesis Protrusio with Paprosky Type III B Acetabular defect. There were no clinical signs or laboratory findings suggestive of infection. Left lateral decubitus position and conventional Posterior approach was used for exposure. Femoral stem was found to be very loose and removed easily. The cement was adhered to the diaphyseal femur. Extended trochanteric osteotomy 4 cm short of the cement mantle was performed giving adequate exposure of acetabulum too. 3cm long and 3mm wide Functional Femoral Slit was made distal to and in continuity with ETO to facilitate exposure of bone cement interface without compromising the functional structure of that segment to support a diaphyseal fitting implant. It allowed us to work with a Pencil tip High speed Burr through it to dislodge and remove the cement mantle. A Revision Uncemented stem was inserted with adequate axial and rotational stability and the ETO fragment was secured with multiple Stainless Steel wires. Revision with Fluted Tapered Titanium (FTT) stem cannot have adequate fixation in distal 1/3rd of diaphysis where the endosteal canal begins to flare. Therefore shortening the size of ETO and retaining the cylindrical mid 1/3rd segment is critical. This can be successfully achieved with functional femoral slit technique without any specialized instrumentation.