Pre Op Planning for Revision Total Hip Arthroplasty

Rule Out Infection »

• probably every revision joint procedure should have frozen sections sent prior to insertion of the components  in order to determine whether acute inflammation is present (indicating infection);
• references:
  • Failed total hip replacement: assessment by plain radiographs, arthrograms, and aspiration of the hip joint.
  • The value of aspiration of the hip joint before revision total hip arthroplasty.

Radiographic Evaluation »

• role of arthrogram
• technical failures causing loosening:

Plan for Visualization

• Arthroscopic Lamp;
• Flouroscopy;
• Windowing of the Femur;
• Trochanteric Osteotomy
  • offers more complete access to proximal femur but comprimises stability provided greater trochanter to press fit system;

Management of Bleeding

• transfusion therapy
• aprotinin
• cell saver

Plan for Component Extraction

• see: surgical instruments:
• it is essential to know preoperatively whether the components are loose or are well fixed;
  • trochanteric osteotomy may be required if either the acetabular or the femoral components appear well fixed;
• uncemented femoral components
  • note the amount of component ingrowth material; (see: characteristics of uncemented femoral component loosening)
  • w/ titanium stems, ingrowth may occur outside of the coated region;
  • w/ extensive ingrowth into a press fit femoral stem consider need for extended trochanteric osteotomy;
  • removal of cementless stems:
• cemented femoral components
  • note length of distal cement plug;
  • note that w/ first generation stems, cement was radiolucent;
  • see: characteristics of cemented femoral component loosening:
  • removal of cemented femoral stems:
• removal of broken femoral stems:
• acetabular component
  • consider need for acetabular bone grafting;
  • in the study by Hamlin BR, et al (2001), the authors evaluated decision-making when a well-fixed cemented cup is encountered at the time of a revision of a femoral component of a total hip replacement;
    • all patients who had a revision of the femoral component and retention of an all-polyethylene acetabular component from 1971 to 1996 were identified;
    • 374 patients with a total of 395 cemented total hip replacements fit the inclusion criteria;
    • at the time of the latest follow-up, at an average of nine years after the femoral revision and 17.3 years after the primary arthroplasty, 342 (86.6%) of the 395 cups remained in situ;
    • 53 cups (13.4%) in fifty-two patients had been revised, at an average of 10.0 ± 5.7 years after the femoral revision and 16.7 ± 5.3 years after the primary arthroplasty;
    • rate of survival of the retained acetabular components was 96.9% at five years, 89.3% at ten years, and 78.7% at fifteen years after the femoral revision and was 95.1% at fifteen years and 87.1% at twenty years after the primary arthroplasty;
    • increased age (p < 0.0001) and a shorter time-interval (less than 7.5 years) between the primary arthroplasty and the femoral revision (p = 0.05) were significantly associated w/ increased likelihood of survival free of cup revision;
    • ref: Retention of All-Polyethylene Acetabular Components After Femoral Revision of a Cemented Total Hip Replacement. 

Bone Grafting »

• w/ stress shielding or osteolysis consider need for bone grafting;

Selection of Implants »