Abstract
Consider revision of total hip arthroplasty (THA) when patient has pain or functional disability due to: Implant loosening Implant fracture Advanced bearing surface wear Periprosthetic fracture Infection Recurrent dislocation - Implant mal-positioned Do not proceed to revision unless you have a clear idea about patient’s cause of symptoms
Keywords
- Acetabular Component
- Periprosthetic Fracture
- Limb Length Discrepancy
- Trabecular Metal
- Impaction Grafting
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Indications
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Consider revision of total hip arthroplasty (THA) when patient has pain or functional disability due to:
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Implant loosening
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Implant fracture
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Advanced bearing surface wear
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Periprosthetic fracture
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Infection
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Recurrent dislocation – Implant mal-positioned
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Do not proceed to revision unless you have a clear idea about patient’s cause of symptoms!
Preoperative Planning
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Especially for revision, THA adequate preoperative planning is of paramount importance.
Clinical Assessment
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A detailed history should be obtained. Ensure that patient is fit for surgery. Consult medicine, cardiology, urology, vascular surgery as appropriate.
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Observe patient’s gait. Marked trendelenburg gait indicates abductors damage or insufficiency.
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Assess limb length discrepancy (LLD).
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Ensure that you know the mechanism of THA failure.
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Learn as much as you can regarding the previous installed implants (company, size, and extraction tools).
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Exclude infection! Check ESR, CRP, and WBC. Perform hip aspiration in case of clinical suspicion. Prepare laboratories for intraoperative gram stain, frozen section and cultures.
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Check previous incision and assess the skin condition. Decide the length and shape of new incision accordingly. Avoid parallel or anterior incisions.
Radiological Assessment
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Ensure that adequate anteroposterior (AP) and lateral radiographs are available.
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Low AP radiograph of the pelvis is useful for determining relative limb length by comparing the inter-ischial line with a fixed point on the lesser trochanter.
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A cross-table lateral radiograph of the acetabulum is useful for evaluating acetabular version.
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Long films of the femur should be obtained.
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Special Judet views and CT scan can be useful to assess acetabular and femoral bone stock.
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MRI of the hip, using metal artifact reduction sequences (MARS) can be used to reveal occult causes of THA failure (Fig. 9.1).
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Preoperative templating is important to achieve leg length equality and to determine the appropriate size of the femoral and acetabular components to use. Pay attention to the magnification of the X-rays. Use the special markers to adjust measurements (Fig. 9.2).
Available Resources and Instrumentation
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Make sure that all equipments needed for previous implants removal are available (Stem extraction tools, head disassembly instruments, cement removal sets, flexible intramedullary reamers, trephine reamers, flexible osteotomes, reconstruction plates, and cages, cerclage wires, high speed burrs etc.) (Fig. 9.3).
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Consider all different sizes and types of femoral and acetabular implants that you may need. Always have alternative solutions available.
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Plan carefully all the different types of grafts that might be needed (bulk grafts, strut grafts, morcelized bone (Fig. 9.4), etc.).
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Have C-arm and X-ray technician ready if needed.
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Have blood available for transfusion, and inform anaesthesia for possible prolonged operation. Consider having ICU/HDU bed booked.
Operative Procedure
Anesthesia
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Regional (spinal/epidural) or general anesthesia.
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At induction, administer prophylactic antibiotic as per local hospital protocol (e.g., second generation cephalosporin). Consider a second dose if procedure is significantly prolonged. If infection is suspected, hold antibiotics until fluid and tissue cultures have been obtained.
Patient Positioning
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Patient supine or lateral decubitus position (according to surgeon’s experience and the desired approach) on a standard, preferably radiolucent, table.
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Patient prepped and draped in the usual fashion. Allow enough space to allow caudad or cephaland extension of the incision.
Surgical Approach
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Surgical approach should: secure adequate exposure to remove previous implants, facilitate reconstruction of the bony defects of acetabulum or femur and allow new implant positioning.
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If possible, a previous incision should be followed. Skin problems are not as common as in revision total knee arthroplasties, however parallel or anterior incisions should be avoided.
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Usually direct lateral (Hardinge) or posterolateral approach is used for revision THA (Fig. 9.5). Each approach has strengths and weaknesses. Surgeon’s experience, previous operations, and patient’s anatomy, influence the choice of surgical approach.
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The trochanteric osteotomy can provide excellent exposure to both acetabulum and femur but carries the risk of trochanteric non-union and/or escape (Fig. 9.6).
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Trochanteric slide, as an alternative, reduces the risk of trochanteric non-union. Can be performed using lateral or posterolateral approach and it allows wide exposure to the acetabulum but also the femur.
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Extended trochanteric osteotomy (ETO) is used for more difficult revisions. In that case, the throchanter is removed along with a segment of the lateral femoral cortex. The length of the osteotomy is determined by the preoperative templating. ETO is useful to remove well-fixed uncemented femoral implants as well as cemented implants and remaining in the canal cement. Also, in cases of varus remodeling of the femur, ETO is mandatory in order to allow new straight stem positioning (Figs. 9.7 and 9.8).
Removal of Cemented Acetabular Components
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Exposing the rim of the acetabulum circumferential is crucial. When this is done, the cement – bone interface and the cement – cup interface is identified. Using curved thin osteotomes the cement- implant interface is disrupted. The implant is carefully removed. The remaining cement at the acetabulum is meticulously removed using thin osteotomes and cement splitters (Fig. 9.9).
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Start “breaking” the cement mantle from the “tear drop” area and proceed medially and superiorly.
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Alternatively, reaming of the cemented liner has been proposed up to the polyethylene cement interface and then removal of the cement as described above.
Removal of Uncemented Acetabular Components
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Use the same approaches as described above.
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Expose meticulously the acetabular rim.
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Check the stability of the component. Consider liner exchange only, if possible, to avoid devastating bone loss.
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If screws are present the polyethylene liner has to be removed first. Use special liner extraction devises or osteotomes as appropriate to remove the liner. Alternatively, a screw can be used against the metal shell to pull out the polyethylene liner. Remove the screws carefully from the shell. If screws are broken, prefer to leave the broken parts in situ, rather than causing more bone loss.
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Use a high-speed burr to initiate exposure of the bone–implant interface. Then curved osteotomes can be used circumferential to disrupt the bone–implant interface. Alternatively, the Explant (Zimmer) instrument set can be used for easier and better results (Fig. 9.9).
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When cup is removed asses the degree of bone loss and plan the appropriate reconstruction technique.
Removal of Cemented Femoral Stem
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If implant is grossly loose, removal is relatively easy. Before removing the implant, it is very important to remove any bone from the implant’s “shoulder,” in order to avoid trochanteric fracture (Fig. 9.10).
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Sometimes, the implant can be easily separated from the well fixed cement mantle. Consider cement on cement technique if possible.
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If the implant is well fixed, then consider techniques that facilitate exposure, such as ETO (Fig. 9.11).
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Removal of well-fixed cement from the femur can be challenging. Proximal cement can be relatively easily removed using thin and flexible osteotomes and cement splitters. Be very careful to avoid fractures as proximal bone can be compromised due to osteolysis.
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Distal cement and cement plug can be very challenging to remove. Special instrumentation is usually needed, including fiberoptic light source, suction catheter, special long osteotomes, long pituitary rongeurs, hooked instruments, and different sized reamers. Ultrasound devices can also be very useful.
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Always consider ETO if reaching the distal cement is challenging. Controlled osteotomy is always better than devastating perforations and fractures. Always take in consideration varus remodeling, especially when you are trying to reach the distal cement plug or distal cement fragments, using straight tools.
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The cement plug is usually removed using the drill and tap technique. A long drill is centered in the distal plug, and a drill hole is made to it. C-arm can be used to confirm that there is no distal cortex penetration. Then a long tap is used to remove the plug. If removal of plug is very difficult and there is no sign of infection, then pushing the cement plug down to the distal femur is an acceptable option.
Removal of Uncemented Stem
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Removal of loose uncemented stem can be very easy. Pay attention to release implant’s “shoulder” before trying to remove it, as described above, to avoid trochanteric fractures.
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Be sure that you know as much as possible regarding the implant’s type and geometry. Have available implant-specific removal tools.
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Proximal coated uncemented stems can be removed using high-speed burrs and flexible thin osteotomes. Patiently detach the proximal part of the implant from the surrounding bone, making sure that no fracture is caused. If removal is difficult, then consider a short ETO.
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More distal porous coated, or fully porous coated stems can be very challenging to remove. Usually, ETO is required at least up to the beginning of the cylindrical part of the distal stem. The proximal part is then released from the bone using high-speed burr, flexible thin osteotomes, or a Gigli saw. An attempt can be made at that point to remove the stem using the extraction tools. If not successful, then a high-speed cutting burr is used to cut the metal stem at the junction of the cylindrical part. Appropriate-size trephines are then used to remove the distal part of the stem. This procedure can be hard and time consuming (Figs. 9.12 and 9.13). Be prepared and make sure that all instruments and at least five trephines are available.
Reconstruction of the Femur and Acetabulum
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Implant removal in revision THA can be challenging, but it only represents the 50% of the whole procedure. The final goal in successful revision THA is to achieve stable fixation of the femoral and acetabular components resulting in pain free, functional total hip arthroplasty.
Reconstruction of the Acetabulum
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Even though preoperative radiographic examination can give an estimation of the bone loss at the acetabular side, the remaining bone stock and the corresponding classification can be done only after removal of the acetabular component. Often, unpleasant surprises await the surgeon who has to be prepared.
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There are at least three classifications for assessment of acetabular bone loss: the AAOS Classification of Acetabular Deficiencies, the system described by Alan Gross, and the system described by Paprosky.
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According to Paprosky classification of acetabular bone defects (Table 9.1):
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Type I and II defects can be usually treated with cemented or hemispheric uncemented cups, with or without screws, and with use of morcelized allograft where needed (Figs. 9.14–9.16).
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Type III defects can be challenging even for the experienced arthroplasty surgeon.
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For IIIA defects, large cups with screws can be used. Alternatively, superior figure of 7 distal femoral allograft with hemispherical cup, trabecular metal shell with superior augments, or high-hip center with hemispherical cup can be considered (Fig. 9.17).
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For IIIB defects cage with cancellous allografts, custom triflange implants or trabecular metal implants with augments can be used (Fig. 9.18).
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For pelvic discontinuity, reconstruction acetabular plate can be used. Alternatively, acetabular transplants or custom triflange implants have been proposed with good results. Lately, the “cup and cage” construct has been used with good midterm results.
Reconstruction of the Femur
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Similar with the acetabular bone loss, many classifications have been proposed for the femoral bone loss as well, that influence the decisions for femoral reconstruction techniques (Chandler and Penenberg, Endo-Klinik, Engh and Glassman, Paprosky et al.).
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The Paprosky classification system evaluates the femoral diaphysis for its ability to support an uncemented fully porous coated prosthesis (Table 9.2).
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For type I defects, femoral revision is straightforward and no additional bone graft is usually required. Defects are managed as a primary arthroplasty (Cemented or uncemented).
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In type II defects, there is more extensive metaphyseal bone loss. For these defects a fully coated stem is preferred. Calcar replacement stems are often required to restore limb length (Fig. 9.19).
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Type IIIA defects are characterized by extensive metaphyseal cancellous bone loss with some diaphyseal bone loss as well. There is adequate diaphyseal bone to support distal fixation. In these cases, fully coated bowed stem or, less commonly, a straight stem can be used.
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Type IIIB <4 cm of intact diaphysis is remaining with extensive metaphyseal and diaphyseal bone loss. These defects are treated with modular tapered fluted stems or impaction grafting.
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Type IV femurs have a widened femoral canal and no diaphyseal bone of sufficient quality for cementless fixation. These femurs are treated with impaction grafting, allograft prosthetic composite, modular revision stems or modular tumor megaprosthesis (Fig. 9.20).
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Wound Closure
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Irrigate the wound thoroughly.
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Use drain as per protocol.
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Identify and close fascia lata (PDS or Vicryl 2/0). Close subcutaneous fat with absorbable sutures.
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Skin closure with stainless steel surgical staples or non-absorbable sutures.
Post-operative Care
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Position an abduction triangular pillow to maintain abduction of hip while patient is recovering from anesthesia.
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Continue antibiotics for 24 h post-op or according to culture results in case of infection.
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Start mechanical VTE prophylaxis at admission and continue until the patient no longer has significantly reduced mobility. Start pharmacological VTE prophylaxis after surgery and continue for 28–35 days.
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Routine bloods. Radiographs of pelvis (long films) on post-op day #2.
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Remove drain in 24 h.
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Begin physiotherapy on post-op day #1. Adjust program according the surgical exposure and the stability of the hip (Posterior, lateral precautions).
Complications
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Infection.
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Intraoperative fractures.
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Non-unions of the osteotomies and also of the implanted bulk allografts.
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Dislocation (up to 20%). LLD, muscle atrophies and damage (especially abductors insufficiency), wrong implant positioning and implant fixation failure, all are some of the reasons leading to early or late dislocations.
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Nerve injuries. Extensive soft tissue strip and entrapment of nerves (especially sciatic nerve) to the scar tissue of previous operations can lead to reversible or not nerve injuries with devastating some times consequences for the patient.
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Heterotopic ossification.
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Vascular injuries.
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Deep venous thrombosis.
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Periprosthetic fractures.
Outpatients Follow-Up
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Patients are assessed clinically and radiographically at 1, 3, 6, and 12 months, and every 5 years thereafter, unless GP’s request.
Further Reading
Gross AE, Goodman S. The current role of structural grafts and cages in revision arthroplasty of the hip. Clin Orthop Relat Res. 2004;429:193.
Paprosky WG, Magnus RE. Principles of bone grafting in revision total hip arthroplasty: acetabular technique. Clin Orthop Relat Res. 1994;298:147.
Younger TI, Bradford MS, Magnus RE, et al. Extended proximal femoral osteotomy: a new technique for femoral revision arthroplasty. J Arthroplasty. 1995;10:329.
Lieberman JR, Berry DJ, editors. Advanced reconstruction: hip. Rosemont: American Academy of Orthopaedic Surgeons; 2005.
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Nikolaou, V.S., Antoniou, J. (2011). Revision Total Hip Arthroplasty. In: Giannoudis, P. (eds) Practical Procedures in Elective Orthopaedic Surgery. Springer, London. https://doi.org/10.1007/978-0-85729-814-0_9
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