Revision Roundtable BONUS - Stem Extraction

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Find the video version here: https://youtu.be/JejtfUfpULE

Meet our guest surgeons:
Dr. Kris Alden - https://www.krisalden.com/
Dr. John Horberg - https://www.premierboneandjoint.com/meet-dr-horberg
Dr. Aldo Riesgo - https://my.clevelandclinic.org/staff/22587-aldo-riesgo
Dr. Jonathan Yerasimides - https://www.louisvillehip.com/
Dr. Charles Lawrie - https://baptisthealth.net/doctors/charles-m-lawrie/1888379

Register now for AHF 2025 in Nashville, TN! https://anteriorhipfoundation.com/ahf2025-nashville/

Check out Dr. Yerasimides Anterior Approach Masterclass (including episodes on Acetabular and Femoral Revision) on YouTube! Find the playlist at https://www.youtube.com/playlist?list=PLDzGqZUR760dlZ8i9H78ZQuKRfBW5pXe7

Advanced Techniques in Femoral Stem Extraction: AHF Revision Round Table Bonus Episode

In this bonus episode of the AHF podcast, hosted by Joe Schwab, experts discuss advanced techniques in femoral stem extraction. The episode covers detailed procedural steps, including the use of specialized burrs and osteotomes for effective removal of recessed shoulder implants and stems. Emphasis is placed on proper surgical positioning, incision strategies, and the use of force during extraction to minimize bone loss. Listeners are also encouraged to check out the accompanying video content on YouTube for a comprehensive understanding of these advanced procedures.

00:00 Introduction and Bonus Episodes Announcement
00:41 Surgical Techniques and Tools for Stem Removal
02:15 Positioning and Exposure Tips
04:34 Incision and Orientation Strategies
05:40 Advanced Techniques and Personal Experiences

Episode Transcript

Joseph M. Schwab (00:00):
This is Joe Schwab host of the AHF podcast.

(00:03):
The response to our revisionround table series has been
tremendously positive.
So this week, and next week wehave two bonus episodes with
content that just couldn't makeit into the previous episodes.
While these two bonus episodeshave great content to listen, to
both have significant videoaspects that you may want to
check out as well.

(00:23):
We will put links to the videoversions on YouTube.
YouTube and you.
You can check us out there.
Now let's get on with more ofthe AHF.
Revision round table.

John Horberg (00:41):
head mounted camera.
So I apologize for any blood ordebris on the screen.
But basically I remove stems theexact way that I learned in my
training.
And then the guys like Jonathantaught me over the years from
teaching and attending courses.
I start with a burr and Icircumferentially go around the
prosthesis, anterior, posterior,lateral and medial.

(01:02):
And I think the key is, on theserecessed shoulder implants,
making sure you get around thelateral side as deeply as you
can.
And then I take a burr and Icompletely remove the calcar
bone all the way down to thelesser trochanter.
when I started practice, I wasusing flexible osteotomes and
occasionally K I've I found alot of benefit in using these,
purpose built, extractionosteotomes.

(01:24):
This is the exodus where take acurved osteotome, follow around
the lateral shoulder of theimplant, like I'm doing here,
and bit by bit, break up anyremaining bone around that
recessed lateral shoulderimplant.
And then they have differentattachments.
This one here is designed to goaround the collar on a cow car,
or go around the trunnion, atthe cow car.

(01:46):
So you can come medial side.
You've taken the deep as you cango on the medial side.
I like to use a three or fourcentimeter router tip burr to
get as deep as I can.
And this breaks up any remainingbone on the medial side, which
seems to be the trickiest to getoff on a tapered wedge stem.
And then some straightosteotomes on the anterior and
posterior cortices, which isjust what I'm doing here, trying

(02:10):
to break up any remaining bonethat might be adherent to the on
growth or in growth

Joseph M. Schwab (02:15):
I'm just going to pause it here for a second,
John, because I, just for, toorient people, who might not be
seeing, revisions like thisfrom, from the anterior
approach, you've got the legright now in an extended
position, all dropped all theway down to the floor, a
deducted, and the hookunderneath the femur, right?

(02:36):
Any other.
Any other special positioningthat you've got going on here or
anything different that you'redoing to get, cause that's an
absolutely beautiful view of theproximal femur in this case, in
what appears to be a relatively,fixed stem.
Anything else you're doing toget that type of exposure?

John Horberg (03:00):
I think the key at the beginning of the case for
getting your exposure is a lottimes we're, not focused as much
on the pubofemoral ligamentearly.
That's, that seems thing that wethink a lot about on primaries.
And I make sure that pubofemoralligament is released all the way
down to the lesser.
lot of times it's pretty denselyscarred in there and that
prevents the femur fromsubluxing laterally.

(03:21):
And then carrying my releasearound all the way to the, the
conjoint tendon into theobturator externus.
I like to use bed as anassistant.
You can see there's a long bentretractor behind the greater
trochanter there that I'mholding in place with a coker.
and then I have a one or twogood medial retractors subluxing
the femur laterally so I getgood view and that's what my

Kris Alden (03:42):
is exactly the kind of exposure you'd want to see.
it's just John, congratulations.
sometimes you don't alwaysachieve that.
It's Sometimes it's not thateasy, but basically you can see
once you get that stem out, youcould really put any stem in
there.
So the approach shouldn'tdictate what, stem to use.

(04:04):
It would be the bone loss, the,competency of the proximal
femur.
So all those factors play arole.
It shouldn't, how some peoplesay, this is anterior approach
friendly as far as the stem isconcerned, but I feel like you
should, that's a fallacy in myopinion.

Joseph M. Schwab (04:22):
incision at all?
Either the length or thedirection of the incision, based
on it being a femoral revision?

John Horberg (04:34):
I, I usually start off with a very similar
incision, but incision lengthdoesn't dictate what surgery is,
quote unquote, minimallyinvasive or not.
So I'll take incision as I needbased on the patient as I, carry
on my exposure.
I think, edis teaches fairly,consistently that we need to
angle and orient based on thewe're doing.

(04:57):
And in this case, I start myincision, right at the lateral
edge of the A SIS and angle it.
to the tensor fasciae lataecoming down lateral and when is
dropped, if you're going to putin a linear, revision modular
implant, you need to have thatcorrect incisional or you're
going to be beating up the skinas you ream and broach and put
in your implant.

(05:17):
Whereas if you're off table,that classic two centimeters
lateral, two centimeters distalmight be more appropriate.
So I think understanding theorientation that your long
straight stem is going to go isimportant in understanding

Joseph M. Schwab (05:28):
can also be important so you're not,
broaching or reaming away atthat proximal portion of the
skin.
That's what I've seen before inrevision scenarios like this.

Kris Alden (05:37):
To

John Horberg (05:40):
is, just carrying on with the osteotome and then
I'm transitioning to a punch.
This trick that Jonathan taughtme that's made a huge
improvement in my practice.

Kris Alden (05:49):
do

John Horberg (05:52):
the bones burr in your osteotomes, you're
Oftentimes you hit that stemdown, it'll break free any final
adhesions actually knock it outwithout having to go any
further.
in this case, that was the case.
I was able to punch it down,break it loose, pull the stem
minimal bone loss.
the next step, if I'm unable tobreak it up from here, would be
using an extraction and I'veactually started using, a stem

(06:16):
extractor that Kris designedoriented very well anterior
approach.
It grabs the trunnion verysecurely.
And that's, my next step if Ican't break it up by punching
down.
I know the common argument is ifyou hit the stem down, what
happens if you break the femurwith a tapered wedge stem, you
can mitigate this with a,surplus wire before you do it.

(06:36):
But also my next step, if Ican't the stem out after hitting
it down is to osteotomize thefemur, which I'm going to repair
with surplus wires, or I canpotentially crack the femur

Jonathan Yerasimides (06:46):
Yeah, I think it's amazing the amount of
force that you can deliver downon a stem before the femur
actually fractures.
I've this, this trick, I didn'tinvent this.
And I want to claim that itactually a DePuy rep who's since
passed, unfortunately greatolder guy.

(07:08):
but hell, he taught me thismaybe.
Somewhere 13, 15 years ago, Iwas taking out an old tri lock
with, with a one piece tri lockwith a fixed head that I had to
take out.
And he told me to hit down onit.
I said, you're crazy hittingdown on it.
That's going to explode thefemur.
Jesus.
and I did it that one time andshit, if it doesn't work and

(07:32):
femurs do not explode.
They just don't.
And I've taken my three poundmallet and swung literally as
hard as I possibly can down onstems, to free up that,
interface.
I've taken out well fixed, oldCorail stems, large Corail
stems.

(07:53):
He's hunting the bigger sizesthat get to 155, 160 millimeters
taken, fixed top to bottomCorails out hitting down on the
damn implant.
It is.
Unbelievable.
it's nerve wracking.
It takes, take some getting usedto most people that come back to
me and say, Oh, that, thattechnique doesn't work.

(08:14):
I say, you're not hitting hardenough because, you just gotta,
you gotta hit it hard.