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K-Wire Technique for the Removal of Uncemented Femoral Stem in Revision THA

Hafez, Mahmoud A. FRCS

doi: 10.1097/BTO.0000000000000202
Tips and Pearls

In this work, K wires were used for 5 patients undergoing revision total hip arthroplasty to remove well-fixed, uncemented femoral stem without osteotomy. The technique was successful and considered to be safer and more economic than osteotomy with shorter operative time and easier surgical set up.

The Orthopaedic Department, October 6 University, Cairo, Egypt

The author declares that there is nothing to disclose.

For reprint requests, or additional information and guidance on the techniques described in the article, please contact Mahmoud A. Hafez, FRCS, at or by mail at The Orthopaedic Department, Faculty of Medicine, October 6 University, 3rd Floor, October 6 University Hospital, Central axis, October 6 City, Giza, Egypt. You may inquire whether the author(s) will agree to phone conferences and/or visits regarding these techniques.

Total hip arthroplasty (THA) is the end-stage surgical intervention for hip fractures and hip joint arthritis that poorly respond to conventional medical treatment. Since its introduction, improvements have been continuously suggested to make successful operations with optimal outcomes in terms of functionality of the joint as well as survivorship of the patient and prosthesis.1,2 Cemented and uncemented hip implants are successful; however, there is an increase in using uncemented implants including the femoral component (stem). Consequentially, the number of revision surgeries for uncemented stems is increasing. An uncemented stem is difficult to remove and an osteotomy may be required to remove the stem.3,4

Kirschner wires (K-wires) have been introduced in orthopedics to fix bone fragments and support skeletal traction. They were originally indicated for temporary or definitive fixation of fractures by means of its anchorage and ability for intramedullary penetration. It is used more commonly for the fixation of the upper extremity and shoulder fractures.5

The aim of this study was to present a new technique based on our experience of using K-wires to remove a well-fixed uncemented femoral stem in revision THA without massive bone cutting or loss.

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PATIENTS AND METHODS

A new technique was applied on 5 patients who had revision THA. The patients underwent revision THA by the K-wire technique to remove a well-fixed uncemented femur stem without osteotomy. Reasons for revision THA among the patients in this series were different (Table 1). All cases were managed by the first author.

FIGURE 1

FIGURE 1

TABLE 1

TABLE 1

Routine digital templating was performed preoperatively using anteroposterior and lateral radiographs. All patients had a lateral approach and were positioned on their sides.

We used different sizes of K-wires (1 to 1.8 mm) to be inserted in the metal bone interface circumferentially. The wires were inserted nearly along the whole length of the femoral stem with a “to and from” manner to create a space and loosen the femoral stem (Figs. 2, 3). Small wires were used first to create a gap and to allow bigger wires to be used. Then, the stem was hammered back through direct knocking in the line of the femoral anatomic axis.

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

We direct the K-wire against the metal implant. We use standard full-length K-wires (9 inch) with a cumulated drive. We do not insert the entire depth of the K-wire first. Rather, we advance it slowly in 1 space, and then go right next to it, to the same depth, and so forth until we get around the circumference. We made a single use of the K-wires to avoid stress fractures of the wirers and to avoid losing it inside.

The procedure took an average of 30 minutes. All femoral components were well fixed, but the fixation method (distal or proximal) was not known.

Patients were followed up for 1 year to check for any postoperative adverse effects of the surgical procedure.

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RESULTS

All uncemented stems were successfully removed using the K-wire technique without converting to any type of femoral osteotomies. The assessment showed no evidence of bone loss or fracture, with a follow-up period of one and half years to 4 years.

In 1 incidence, the K-wire broke off below the entry point, but it was left alone without further problems, and in another case, the K-wire perforated the femoral cortex without any complications.

In another patient (patient number 5), the femoral stem had to be revised for aseptic acetabular loosening due to incompatibility of the taper and head size (Fig. 4).

FIGURE 4

FIGURE 4

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DISCUSSION

THA has proven to be a highly successful operation, but with its increased use in patients of different age groups and high physical demands, an increasing number of revision surgeries have been performed.

Failure of primary reconstruction in THA may be due to loosening, infection, soft tissue irritation, joint instability, and/or fracture. Revision surgery is needed to alleviate associated pain and restore function of the hip joint. Difficulty in implant or cement removal has been reported in the literature and this may complicate revision THA and worsen the case further.6

One of the primary steps in revision THA is the extraction of the retained implant before surgical reconstruction. In revision THA, the removal of well-fixed components and cement is reported to be a critical and time-consuming procedure. During removal of well-fixed components, there is a potential risk for massive bone loss or fracture of the femur or acetabulum.7,8 However, one of the drawbacks of cemented hip prostheses is the necessity of some osteotomy to assure full extraction of the implant and the surrounding cement to provide clear bony surfaces.

Removal of an uncemented well-fixed stem can be achieved by various methods, such as the standard trochanteric osteotomy, the trochanteric slide, and the extended trochanteric osteotomy as described by Jando and colleagues.9–12

Trochanteric osteotomy and extended trochanteric osteotomy offer an advantage related to excellent surgical exposure. The complications related to these techniques are high risk of bone trauma and blood loss, the need for secure fixation, and the possibility of osteotomy nonunion.13 In our series, no complications such as bone loss or fracture were reported.

In revision hip arthroplasty, the safe removal of well-fixed uncemented femoral components remains a challenging prospect as it is very essential and there is a potential risk to the remaining host bone. Therefore, an alternative technique to trachanteric osteotomy has been described using flexible osteotomes of various dimensions and shapes to develop a plane between the metal and the bone, aiming to free the implant.14

The K-wire technique could serve as an alternative for osteotomy because it is less invasive, with less blood and bone loss, requiring less experience, less instrumentation, and less expenses (osteotomy requires expensive cable plate fixation). In this series, patients are under 48 years old; however, patients with primary osteoarthritis are not common in our region. In our community arthroplasty register, the mean age for hip osteoarthritis is 51 years. Most of the cases of THA are performed for secondary OA (pediatric cases, hip diseases, failed ORIF of fracture neck of femur, AVN, and trauma).15

There are limitations in this study: for example, the author did not compare different types of stems in terms of their material, coating, and geometry. The ideal use of this technique is for proximally porous-coated stems where the surgeon has circumferential access to the proximal stem and for the removal of tapered conical stems. However, fully coated cylindrical stems and curved/bowed stems would be difficult to remove with this technique. The technique should vary according to the stem type and geometry (tapered wedge, fit-and-fill, anatomic, cylindrical, etc.) as well as the fixation approach (proximal, mid-coat, and distal). However, although this work focuses on the applicability of K-wires in removing uncemented hip implants, types and geometry of stems are outside the scope of this work, but it is worth considering them in future studies. The applicability of this technique for older patients or patients with an osteoporotic bone, stem-type wedge, proximal or diaphyseal engaging or shape is still beyond our experience and further studies are needed for these aspects.

Our technique offers a simple and safe method to extract a well-fixed uncemented femoral stem. Compared with other different femoral osteotomies, it has the advantage of being bone conserving. Furthermore, it is a significantly less expensive technique because subsequent osteotomy fixation is not needed.9 Finally, this technique provides the option of using a standard femoral stem and obviates the need for long revision femoral component in cases of femoral osteotomy.

One limitation of this work is that diverging of the wires could happen. This may lead to bone perforation, which will be felt by the surgeon. It is worth mentioning that patients included in this work were relatively young with good bone quality; the technique could be contraindicated for patients with established osteoporosis.

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CONCLUSIONS

The K-wire technique is a simple, safe, and more economic procedure for the revision of an uncemented femoral stem. This simple technique would offer a shortened operative time and easier surgical set up.

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REFERENCES

1. Rothman RH, Cohn JC. Cemented versus cementless total hip arthroplasty. A critical review. Clin Orthop Relat Res. 1990;254:153–169.
2. Charnley J. Surgery of the hip-joint: present and future developments. Br Med J. 1960;1:821–826.
3. Berry DJ, Harmsen WS, Cabanela ME, et al. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002;84A:171–177.
4. Abdulkarim A, Ellanti P, Motterlini N, et al. Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials. Orthop Rev (Pavia). 2013;5:e8.
5. Li WC, Xu RJ, et al. Comparison of Kirschner wires and AO cannulated screw internal fixation for displaced lateral humeral condyle fracture in children. Int Orthop. 2012;36:1261–1266.
6. Taylor JW, Rorabeck CH. Hip revision arthroplasty. Approach to the femoral side. Clin Orthop Relat Res. 1999;369:208–222.
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10. Boardman KP, Bocco F, Charnley J. An evaluation of a method of trochanteric fixation using three wires in the Charnley low friction arthroplasty. Clin Orthop Relat Res. 1978;132:31–38.
11. Mardones R, Gonzalez C, Cabanela ME, et al. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. J Arthroplasty. 2005;20:79–83.
12. Meek RM, Greidanus NV, Garbuz DS, et al. Extended trochanteric osteotomy: Planning, surgical technique, and pitfalls. Instr Course Lect. 2004;53:119–130.
13. Akrawi H, Magra M, Shetty A, et al. A modified technique to extract fractured femoral stem in revision total hip arthroplasty: a report of two cases. Int J Surg Case Rep. 2014;5:361–364.
14. Bal SHozack W. Femoral component removal. Surgical Treatment of Hip Arthritis, 1st ed. Saunders; 2010:299. Available at: http://plasticsurgerykey.com/femoral-component-removal/.
15. Hafez M, Mounir A. A community arthroplasty register. Bone & Joint Surgery, Orthopaedic Proceedings. 2013. Available at: http://www.bjjprocs.boneandjoint.org.uk/content/95-B/SUPP_15/188.
Keywords:

revision THA; uncemented femoral component; K-wires

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