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Revision Roundtable BONUS - Stem Extraction · AHF Podcast

• 0:00
  Joseph M. Schwab: This is Joe Schwab host of the AHF podcast.
• 0:03
  Joseph M. Schwab: The response to our revision round table series has been tremendously positive.
• 0:07
  Joseph M. Schwab: So this week, and next week we have two bonus episodes with content that just couldn't make it into the previous episodes.
• 0:15
  Joseph M. Schwab: While these two bonus episodes have great content to listen, to both have significant video aspects that you may want to check out as well.
• 0:23
  Joseph M. Schwab: We will put links to the video versions on YouTube.
• 0:25
  Joseph M. Schwab: YouTube and you.
• 0:26
  Joseph M. Schwab: You can check us out there.
• 0:28
  Joseph M. Schwab: Now let's get on with more of the AHF.
• 0:31
  Joseph M. Schwab: Revision round table.
• 0:41
  John Horberg: head mounted camera.
• 0:41
  John Horberg: So I apologize for any blood or debris on the screen.
• 0:44
  John Horberg: But basically I remove stems the exact way that I learned in my training.
• 0:49
  John Horberg: And then the guys like Jonathan taught me over the years from teaching and attending courses.
• 0:55
  John Horberg: I start with a burr and I circumferentially go around the prosthesis, anterior, posterior, lateral and medial.
• 1:02
  John Horberg: And I think the key is, on these recessed shoulder implants, making sure you get around the lateral side as deeply as you can.
• 1:09
  John Horberg: And then I take a burr and I completely remove the calcar bone all the way down to the lesser trochanter.
• 1:14
  John Horberg: when I started practice, I was using flexible osteotomes and occasionally K I've I found a lot of benefit in using these, purpose built, extraction osteotomes.
• 1:24
  John Horberg: This is the exodus where take a curved osteotome, follow around the lateral shoulder of the implant, like I'm doing here, and bit by bit, break up any remaining bone around that recessed lateral shoulder implant.
• 1:38
  John Horberg: And then they have different attachments.
• 1:39
  John Horberg: This one here is designed to go around the collar on a cow car, or go around the trunnion, at the cow car.
• 1:46
  John Horberg: So you can come medial side.
• 1:48
  John Horberg: You've taken the deep as you can go on the medial side.
• 1:52
  John Horberg: I like to use a three or four centimeter router tip burr to get as deep as I can.
• 1:57
  John Horberg: And this breaks up any remaining bone on the medial side, which seems to be the trickiest to get off on a tapered wedge stem.
• 2:04
  John Horberg: And then some straight osteotomes on the anterior and posterior cortices, which is just what I'm doing here, trying to break up any remaining bone that might be adherent to the on growth or in growth
• 2:15
  Joseph M. Schwab: I'm just going to pause it here for a second, John, because I, just for, to orient people, who might not be seeing, revisions like this from, from the anterior approach, you've got the leg right now in an extended position, all dropped all the way down to the floor, a deducted, and the hook underneath the femur, right?
• 2:36
  Joseph M. Schwab: Any other.
• 2:37
  Joseph M. Schwab: Any other special positioning that you've got going on here or anything different that you're doing to get, cause that's an absolutely beautiful view of the proximal femur in this case, in what appears to be a relatively, fixed stem.
• 2:53
  Joseph M. Schwab: Anything else you're doing to get that type of exposure?
• 3:00
  John Horberg: I think the key at the beginning of the case for getting your exposure is a lot times we're, not focused as much on the pubofemoral ligament early.
• 3:08
  John Horberg: That's, that seems thing that we think a lot about on primaries.
• 3:11
  John Horberg: And I make sure that pubofemoral ligament is released all the way down to the lesser.
• 3:16
  John Horberg: lot of times it's pretty densely scarred in there and that prevents the femur from subluxing laterally.
• 3:21
  John Horberg: And then carrying my release around all the way to the, the conjoint tendon into the obturator externus.
• 3:27
  John Horberg: I like to use bed as an assistant.
• 3:29
  John Horberg: You can see there's a long bent retractor behind the greater trochanter there that I'm holding in place with a coker.
• 3:34
  John Horberg: and then I have a one or two good medial retractors subluxing the femur laterally so I get good view and that's what my
• 3:42
  Kris Alden: is exactly the kind of exposure you'd want to see.
• 3:47
  Kris Alden: it's just John, congratulations.
• 3:50
  Kris Alden: sometimes you don't always achieve that.
• 3:52
  Kris Alden: It's Sometimes it's not that easy, but basically you can see once you get that stem out, you could really put any stem in there.
• 3:59
  Kris Alden: So the approach shouldn't dictate what, stem to use.
• 4:04
  Kris Alden: It would be the bone loss, the, competency of the proximal femur.
• 4:08
  Kris Alden: So all those factors play a role.
• 4:11
  Kris Alden: It shouldn't, how some people say, this is anterior approach friendly as far as the stem is concerned, but I feel like you should, that's a fallacy in my opinion.
• 4:22
  Joseph M. Schwab: incision at all?
• 4:24
  Joseph M. Schwab: Either the length or the direction of the incision, based on it being a femoral revision?
• 4:34
  John Horberg: I, I usually start off with a very similar incision, but incision length doesn't dictate what surgery is, quote unquote, minimally invasive or not.
• 4:43
  John Horberg: So I'll take incision as I need based on the patient as I, carry on my exposure.
• 4:49
  John Horberg: I think, edis teaches fairly, consistently that we need to angle and orient based on the we're doing.
• 4:57
  John Horberg: And in this case, I start my incision, right at the lateral edge of the A SIS and angle it.
• 5:04
  John Horberg: to the tensor fasciae latae coming down lateral and when is dropped, if you're going to put in a linear, revision modular implant, you need to have that correct incisional or you're going to be beating up the skin as you ream and broach and put in your implant.
• 5:17
  John Horberg: Whereas if you're off table, that classic two centimeters lateral, two centimeters distal might be more appropriate.
• 5:22
  John Horberg: So I think understanding the orientation that your long straight stem is going to go is important in understanding
• 5:28
  Joseph M. Schwab: can also be important so you're not, broaching or reaming away at that proximal portion of the skin.
• 5:32
  Joseph M. Schwab: That's what I've seen before in revision scenarios like this.
• 5:37
  Kris Alden: To
• 5:40
  John Horberg: is, just carrying on with the osteotome and then I'm transitioning to a punch.
• 5:44
  John Horberg: This trick that Jonathan taught me that's made a huge improvement in my practice.
• 5:49
  Kris Alden: do
• 5:52
  John Horberg: the bones burr in your osteotomes, you're Oftentimes you hit that stem down, it'll break free any final adhesions actually knock it out without having to go any further.
• 6:03
  John Horberg: in this case, that was the case.
• 6:04
  John Horberg: I was able to punch it down, break it loose, pull the stem minimal bone loss.
• 6:09
  John Horberg: the next step, if I'm unable to break it up from here, would be using an extraction and I've actually started using, a stem extractor that Kris designed oriented very well anterior approach.
• 6:20
  John Horberg: It grabs the trunnion very securely.
• 6:22
  John Horberg: And that's, my next step if I can't break it up by punching down.
• 6:26
  John Horberg: I know the common argument is if you hit the stem down, what happens if you break the femur with a tapered wedge stem, you can mitigate this with a, surplus wire before you do it.
• 6:36
  John Horberg: But also my next step, if I can't the stem out after hitting it down is to osteotomize the femur, which I'm going to repair with surplus wires, or I can potentially crack the femur
• 6:46
  Jonathan Yerasimides: Yeah, I think it's amazing the amount of force that you can deliver down on a stem before the femur actually fractures.
• 6:55
  Jonathan Yerasimides: I've this, this trick, I didn't invent this.
• 6:59
  Jonathan Yerasimides: And I want to claim that it actually a DePuy rep who's since passed, unfortunately great older guy.
• 7:08
  Jonathan Yerasimides: but hell, he taught me this maybe.
• 7:11
  Jonathan Yerasimides: Somewhere 13, 15 years ago, I was taking out an old tri lock with, with a one piece tri lock with a fixed head that I had to take out.
• 7:21
  Jonathan Yerasimides: And he told me to hit down on it.
• 7:23
  Jonathan Yerasimides: I said, you're crazy hitting down on it.
• 7:25
  Jonathan Yerasimides: That's going to explode the femur.
• 7:26
  Jonathan Yerasimides: Jesus.
• 7:28
  Jonathan Yerasimides: and I did it that one time and shit, if it doesn't work and femurs do not explode.
• 7:34
  Jonathan Yerasimides: They just don't.
• 7:35
  Jonathan Yerasimides: And I've taken my three pound mallet and swung literally as hard as I possibly can down on stems, to free up that, interface.
• 7:47
  Jonathan Yerasimides: I've taken out well fixed, old Corail stems, large Corail stems.
• 7:53
  Jonathan Yerasimides: He's hunting the bigger sizes that get to 155, 160 millimeters taken, fixed top to bottom Corails out hitting down on the damn implant.
• 8:03
  Jonathan Yerasimides: It is.
• 8:04
  Jonathan Yerasimides: Unbelievable.
• 8:05
  Jonathan Yerasimides: it's nerve wracking.
• 8:07
  Jonathan Yerasimides: It takes, take some getting used to most people that come back to me and say, Oh, that, that technique doesn't work.
• 8:14
  Jonathan Yerasimides: I say, you're not hitting hard enough because, you just gotta, you gotta hit it hard.