Stage 4: flattening of femoral head

 E: Limited Femoral Head Resurfacing

Femoral head preserving / pre-collapse


Technique
- femoral head allograft reconstruction (no 7 shape)
- fix with 6.5 mm screws
- tap first to prevent fracture
- ream into bone

- 80% developed femoral head collapse in both groups

- must have sufficient intact femoral head to weight bear upon

Bipolar hip arthroplasty using tight fitting cup for AVN hip has a low incidence of groin pain, acetabular erosion, and revision in midterm followup. This procedure can be used for treatment in young adults with Ficat Stages 3 and 4 AVN of the femoral head to defer a definitive THA. Further large series with long term followups, multicentric randomized studies and reproducibility of results will be needed to establish this method.

Restores spericity to femoral head

5 postoperative complications such as acute myocardial.
Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in patients with displaced femoral neck fractures.

- ensure no femoral head fractures or loose fragments


- force required to distract femoral head varies considerably

Note that the neck of the femoral stem passes into acetabular component and that there.
Is there a Significant Difference in Surgery and Outcomes between Unipolar and Bipolar Hip Hemiarthroplasty?

- allows access to anterior aspect femoral head


In 2009, a 60-year-old Asian woman presented with a displaced fracture of the neck of femur after a mechanical fall. She is a non-smoker and her co-morbidities include hypertension, non insulin-dependent diabetes mellitus, ischaemic heart disease and peripheral vascular disease. A right hip bipolar hemi-arthroplasty was performed and she recovered well post-operatively. She was later lost to follow-up after one year post-operatively. She was community ambulant with a walking frame 3 years post-operatively with intermittent right hip pain. 5 years later, she presented with right hip pain following a low velocity mechanical fall. Pelvic AP X-ray and right hip AP/lateral X-ray demonstrated grade III (Sotelo-Garza and Charnley 1978) severe acetabular prosthetic protrusion with peri-prosthetic fracture,causing loosening over the femoral stem implant, ( Fig. 1(a), (b) and (c)). Her C-reactive protein (CRP) was 21.7 milligram/litre and erythrocyte sedimentation rate (ESR)was 87mm/hour. CT angiogram showed a patent abdominal aorta and iliac arteries. The right common femoral artery travelling closest to the implant (within 8 mm at the 12 o’clock position) with no evidence of aneurysm or dissection noted. Aspiration of her right hip under fluoroscopic guidance was performed with negative culture and unremarkable histological findings with no malignant cells or significant acute inflammation. However, in view of the elevated inflammatory markers, there was significant concern for peri-prosthetic joint infection and the patient was counseled for a 2-stage revision arthroplasty.
The first stage revision surgery was performed under general anaesthesia in a left lateral position. The old surgical incision via posterior approach was used. Intra-operatively, there was a large amount of fibrotic scar tissue and heterotropic ossification around the proximal femur, with no frank pus or purulent fluid collection. A thick pseudomembrane was present at the base of the protruded bipolar cup. The wires were removed and a proximal, extended trochanteric osteotomy was performed to expose the femoral stem and gain access to the acetabulum. Tissues were sent for cultures and histology. The femoral stem was removed and the superior, anterior edge of the acetabulum was osteotomised to remove the bipolar head. Methylene blue and tobramycin Simplex cement was moulded over a humeral nail and inserted into the femur as a spacer and the femoral fracture was stabilized with cable wires. The pseudomembrane at the acetabulum was covered with chronos chips and cement was moulded into a ball and inserted into the acetabulum. The greater trochanter was then stabilized to the femur and spacer with wires. Post-operative images are shown in Fig. 2(a) and (b).
Intra-operative tissue cultures yielded pan-sensitive Citrobacter koseri. Under the advice of infectious disease specialist, the patient was started on long-term intravenous antibiotics (Aztreonam 2 grams Q8 Hourly) for 8 weeks and subsequently oral ciprofloxacin 500mg BD with trending of inflammatory markers. Before the second stage surgery, a CT-guided core biopsy of the right hip was performed to rule out residual inflammation which showed a negative culture. The patient then underwent a second stage revision arthroplasty 4 months after the first stage of revision arthroplasty. Intra-operatively, frozen section of peri-prosthetic tissues revealed no significant acute inflammatory cell infiltrate. The humeral nail and cement puck was removed. The acetabulum was reamed and fitted with Trabecular Metal™ Modular Acetabular System cup (Zimmer, Inc) with rim fit and press fit in 45 degrees inclination and 20 degrees anteversion and secured with two screws. The femur was reamed with tapered reamers and a press fit femoral stem implant was used, which is further stabilized with cerclage wires. Post-operatively the patient underwent physiotherapy and was able to ambulate on post-operative day 4 and was discharged well after one week. At six months post surgery, the patient is, ambulating well, able to do activities of daily living with minimal right hip pain, her follow-up images are shown in Fig. 3(a) and (b).

- dislocate femoral head anteriorly / surgical dislocation

femoral stem prosthesis, bipolar arthroplasty) replacement (total hip arthroplasty) with or without.
Bipolar cemented hip hemiarthroplasty in patients with femoral neck We determined the outcome of bipolar hemiarthroplasty for hip fracture Hip Prosthesis.
A Patient's Guide to Hemiarthroplasty of the Hip Introduction.