Iris Publishers - Current Trends in Clinical & Medical Sciences (CTCMS)

 External Cortical Femoral Implant in A THP A Long Term Follow Up of a Clinical Case


Authored by Yves Cirotteau



Everyone, in his practice, had patients with more or less severe brain dysfunction, one is hemiplegia [1]. What could happen for the patient from an orthopedic point of view, on the lower limb when such a disease happens? The reduced use of the limb reduces the pressure on the bearing bone and, from a physiological point of view, a reduction of the mineralization. The bone becomes osteoporotic [2]. The physical phenomenon is reversible when the pressure conditions are restored. Here are two examples. This patient had a right haemorrhagic stroke few years ago. He had a left hemiplegia and spent a long time in physiotherapy due to the difficulty to walk. Note the thin both femoral cortical due to the bad utilization of the left lower limb (Figure a). Few years later, he recovered a best walk. Note the very good thickening due to the best support of his body weight by the limb (Figure b). Adversingly, despite the severe coxarthrosis note the good thickness of the femoral cortex before surgery (Figure a, b). Few years later the patient had a hemiplegia. Note the increasing diameter of the femoral medullary canal (Figure c). What would have happened if an intramedullary implant was settle in it?

Scientific Reasons of this New Concept

The choice of this implant’s design was done in the aim of a more physiological respect of the bone structures [3-5].

a) The joint elasticity is mainly due to the cancellous bone of a joint. Most of the intra-medullary canal implants destroy it. In this case the cancellous bone is in the upper femoral metaphyseal neck, more or less in totality (Figure a, b).

b) The bone marrow has one of the most important roles in bone physiology: vascularization, cells of bone remodeling, blood cells, proteins and minerals are the major actors of the normal bone life.

c) The periosteum is acting all lifelong (even after 100 years) and covers all foreign bodies which are fixed on the shaft, keeping a fixation stronger and stronger by time (Figure c, d).

d) The pressure on the calcar is necessary to increase and maintain it thickness. A large crown on the upper part of the implant rests firmly there so that there is no resorption [8-9].

Technical procedure

A cemented Charnley’s cup in polyethylene was cemented in the acetabulum. An external stem implant in titanium was fixed on the lateral cortex of the femoral shaft, below the periosteum. A 22,2 mm diameter of the head was used on the right side. Four years later, a non-cemented metal back acetabulum with a 22,2 diameter of the head was placed on the left side. Insert in polyethylene. A lateral femoral Implant in titanium was screwed. Screws of 5 mm of diameter for the femoral shaft, 6 mm of diameter to fix the greater trochanter.

Clinical story and examination

Me T… Françoise is Born the 04 12 1938 - Her Height is 1.59m, her Weight is 59kg. This 80-year-old patient had a bilateral coxarthrosis. When she was 51 years old, in 1989, she was operated on the left side. Four years later, a THP as placed on the right side in 1993. She was seen in clinic office in May 2019. Follow up: 30 years on the right side Follow up: 26 years on the left side She has no pain. She can climb stairs up and down without difficulty. Over three floors, she uses the ramp stairs. She walks without help as long as she wants. One hour without stop She walks without limping.

Functional scores

Postel-Merle d’Aubigné (PMA) Pain, Mobility, Walk 4 grades: 18 excellent. Harris hip score: Douleur, function, mobilité, absence de déformation Score jusquà 100: 90-100: excellent. Oxford hip score: Activities of the daily Life. Auto-administrated survey with12 items giving a score: 42-48: excellent.

Discussion

The first planning was to start with a well-considered definition of the goal expected. It was to secure the femoral implant on its support so that it would stay all day long, as long as patient’s life, without physical activity limitation. The second question was followed by the development of an effective strategy. Once establishing the goal and the strategy, do we have worked backwards to identify the next steps? Have we reach the goal expected? Can we be sure that the fémoral implant will be aware of complications in 100%.

In fact, the purpose is to answer to three questions:

a. Does bone physiology have been respected? The answer is yes concerning the cancellous bone, the femoral cortices, the role of the periosteum. There was no calcar resorption.

b. Do we have had any mechanical complications such as: broken screws or broken plates. Yes, in a very small cases, some screws fixing the greater trochanter broke. If the osteotomy of this apophysis is consolidated, nothing will happen. In some case the lateral part of the broken screws must be removed when painful. Since we have changed the design of the screws, (6 mm of diameter) no one broke. Have we reach the goal? In this experience, the answer is yes [4]. Not any femoral plate was removed. All patients are either too old now or are in a very high place in the sky where nobody can reach them or are still living with their implants.

Conclusion

The lateral femoral implant is, according to this cohorte, one of the good solutions for a long implant’s life, as long as the patient’s life, whatever his age [5-7]. But we should stress the difficulty of its fixation on the upper femoral metaphysis. The greater trochanteric osteotomy must be perfect. The screws must be of a good size and length. The consolidation delay of this bone section must be respected. The patient must walk with two crutches during this time with only a contact support. Surgeon must keep in mind that he is not at all a simple machine to operate. He must practice with his heart and must explain to his patient what he will do and why he will do for it in order to reach the target [9]. In this way, the surgeon does not destroy the intra-medullary bone marrow. He keeps as much as possible the cervical cancellous bone (Figure a, b). The implant applies a constant pressure on the femoral calcar [8], and the periosteum osteogenic power covers by time the implant plate, connecting strongly mechanically both bone and metal. This patient is

in good health, has a normal activity for her age. Both femoral implants remain stable and will stay so until the end of the story.

To read more about this article: https://irispublishers.com/ctcms/fulltext/external-cortical-femoral-implant-in-a-thp-a-long-term-follow-up-of-a-clinical-case.ID.000510.php

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