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Revision Hip Arthroplasty

Background

  • Increasing numbers of revision hip replacements are being performed

  • Much more difficult than primary surgery

  • Results definitely not as satisfactory as primary surgery

Infection rate

32% out of 140 hips revised for aseptic loosening, Hunter et al

Failure rates

29% failure rate at 8 years, Pellici et al

Failure rate with longer stems

12% at 6 yrs, but complications in  23% of patients, Turner et al

  •  Many failed primary arthroplasties can be traced to a technical problem at the time of the primary surgery. This is often the case when the pain has been present since immediately post op

  • A well done primary procedure clearly provides the patient with the best chance of long term success

Indications

  1. Painful aseptic loosening of one or both components (most common)

  2. Progressive loss of bone

  3. Fracture or mechanical failure of the implant

  4. Recurrent or irreducible dislocation

  5. Infected total hip arthroplasty as a one or two stage procedure

  6. Treatment of a periprosthetic fracture

Contraindications

  • Pain referred from elsewhere

  • Very debilitated patients where reconstruction would be complex, Girdlestone would probably be better

  • Rarely indicated for painless loss of motion

  • Not indicated for painless limb length discrepancy

  • Be wary of operating for limp unless an obvious cause such as a displacement of the trochanter exists

  • Be wary of operating for pain when you can find no cause for the pain, get the opinion of other hip surgeons

  • When the pain that was present prior to hip replacement persists the pain was probably not from the hip originally

Preoperative planning

  • Good quality hip and pelvic films, lateral view of the femur to determine any mismatch between the bow of the femur and the curve of a long femoral prosthesis

  • If intrapelvic cement present or markedly protruding acetabulum may require IVP and angiography

  • Acetabular defects can be accurately assessed with CT scan even in the presence of a metal backed acetabular component

  • Ensure access to the original op note if possible and information about the prosthesis to be removed, eg head size etc

  • Ensure adequate equipment is present

  • If allograft bone required order it in advance

  • Large prosthetic inventory

Equipment to consider using:

  1. ? image intensifier and radioluscent op table

  2. Stem extraction instrument

  3. Hand and or motorised cement removal instrumentation

  4. Flexible medullary reamers

  5. Flexible thin osteotomes for cementless stem removal

  6. Fibreopic lighting

  7. Screws and pelvic reconstruction plates

  8. Trochanteric fixation device and cerclage wires

  9. Allograft bone

Surgical approach

  • Previous skin incision should be used if possible

  • Any approach used for primary surgery can be used for revision, but for most complex procedures the transtrochanteric approach is best

  • The posterolateral approach is good for posterior aspect of the acetabulum and the femur but not good if the anterior aspect of the acetabulum needs to be reconstructed without removing the femoral component

  • A reasonable approach mentioned in Campbells is to begin with a posterolateral approach and a trochanteric osteotomy can be performed at any stage if necessary (standard or trochanteric slide or extensive trochanteric osteotomy (see femoral revision technique)

 Stem Removal

  • Loose does not always equate with easily removed

  • Use the designated extraction device

  • If no designated extraction device, use the collar as a platform to punch stem out

  • If curved proximal stem remove lateral proximal cement first

  • If after removal of proximal cement the prosthesis will not come out, perform an extended trochanteric osteotomy to expose more of the cement prosthesis interval

  • Or make a window anteriorly not at the tip of the prosthesis but just distal to the level to which cement has been removed

Removal of cement from femur

  • Usually performed after revision of acetabulum because bleeding from the femoral canal can cause obstruction of the view of the acetabulum

  • Oscar (high frequency ultrasound probes)

  • Osteotomes, radial splits followed by wedging between bone and cement pushing fragments of cement into the canal (if not # is likely to occur)

  • Pituitary rangeurs

  • Fibreoptic lighting

  • If difficult, extended trochanteric osteotomy

  • All cement should be removed in the presence of infection

  • Consider using a high speed burr but only with image intensifier, and consider making controlled perforations in the femoral cortex

 Removal of cup and cement from acetabulum



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