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Wagner approach for hip revision is an alternative to extended osteotomy
Surgeons should be aware of neurovascular problems, ensure soft tissue attachments are maintained for optimal healing.
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David G. Lewallen, MD, recently presented information about why the Wagner approach is a safe and effective alternative to extended osteotomy for revision total hip arthroplasty.
“[The Wagner approach] is a safe and effective way to operate on the femoral side [of the hip],” Lewallen said at Orthopedics Today Hawaii 2017. “It is an extended osteotomy alternative for those of you who are accustomed to doing a Hardinge or anterolateral sort of exposure.”
Lewallen noted the Wagner approach is technically a bony extension of transgluteal approaches that have been used in total hip arthroplasty (THA) for a while.
“[The Wagner approach] is a surgical exposure that is worthwhile having in your armamentarium either for occasional use or routine use for revision surgery,” he said.
For primary surgery, Lewallen said to remove the anterior portion of the gluteus medius while maintaining its vertical fibers for the abductor portion of the procedure. He noted use of the Hardinge approach and a trochanteric wafer provides optimal reattachment, maintaining “the bulk of the abductor portion of the medius without detachment, without damage.”
To obtain extended exposure on the femoral side, “a split is made in the bone from lateral to medial and the anterior portion of the femur is elevated” to open the femur, which Lewallen said differs from the standard posterior/anterior extended trochanteric osteotomy.
Lewallen noted the saw-cut pencil tip burr is used distally. It is helpful to make perforations on the other side of the femur to create a hinge that helps expose the femur. This facilitates access on the acetabular side, Lewallen said.
“It avoids the problem of distal perforation of the anterior cortex,” he said.
According to Lewallen, the curve of the femur can be accommodated and the fluted-tapered stem can be potted distally by removing the anterior femur.
“It is something easily adapted to periprosthetic fractures,” he said. “You can connect the dots, if you will, between existing fracture lines, unroof the anterior part of the femur, get the implant out and then use the revision implant as a scaffold; pot it distally, rebuilding the proximal femur around it with cerclage,” he said. “You are just bringing the bone back around it. It does not have to be perfect.” – by Casey Tingle
- Reference:
- Lewallen DG. The Wagner femoral osteotomy in revision total hip arthroplasty. Presented at: Orthopedics Today Hawaii 2017. Jan. 8-12, 2017; Lahaina, Hawaii.
- For more information:
- David G. Lewallen, MD, can be reached at the Mayo Clinic, 200 1st St. SW, Rochester, MN 55905; email: lewallen.david@mayo.edu.
Disclosure: Lewallen reports he receives royalties from Pipeline/Mako/Stryker and Zimmer Biomet; receives consulting fees from Accuitive, Link and Zimmer Biomet; and has ownership interest with Accuitive and Ketai Medical Devices.