Revision Total Hip Arthroplasty

(See also: Total Hip Replacement Menu)

Discussion

• evaluation of the painful THR
• indications for revision
• evaluation for loosening
• outcomes:
  • references:
    • Why revision total hip arthroplasty fails.
    • Revision Hip Arthroplasty: Infection is the Most Common Cause of Failure

Examination

• examination for loosening:
• previoius incisions;
• contracture of the flexors and adductors (adds to complexity of the case);
• impingement: tenderness to forced internal rotation may indicate anterior impingement;
• leg-length inequality is noted;
  • ref: Surgical Treatment of Limb-Length Discrepancy Following Total Hip Arthroplasty.
• neurovascular status of the limbs is recorded (EMG can be ordered if necessary);
• trendelenburg gait:
  • power of the abductor muscles is noted;
  • marked Trendelenburg gait may indicate that abductors are non functional;
  • may be due to paralysis or loss of continuity;
  • if no trochanteric frx is present, then consider EMG to evaluate for paralysis;

PreOp Planning » (radiographs, equipment, implant selection);

• radiographs
• extraction instruments
• selection of implants:
  • components for acetabular revision
  • femoral cementless revision
  • cemented femoral revision
• rule out infection:
  • besides ruling out joint infection, consider culture of nares since preoperative staph aureus nasal carriage is associated w/ postop infection;
  • references:
    • Revision operations on infected total hip arthroplasties. Two- to nine-year follow-up study.
    • The value of aspiration of the hip joint before revision total hip arthroplasty.
    • Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic Infection. 
      • Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection

Surgical Approach »

• give prophylactic antibiotics in normal fashion;
  • ref:  Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic Infection. 
• sciatic nerve is identified:
  • Incidence of Sciatic Nerve Palsy After Revision Hip Arthroplasty Through a Posterior Approach
• soft tissue release is extensive so that manual force can be minimal during dislocation;
  • partial release of the psoas tendon;
  • partial release of gluteus maximus insertion;
  • release of reflected head of the rectus femorus;
  • references:
    • A new approach to the hip for revision surgery.
    • A technique of extensile exposure for total hip arthroplasty. 
    • Extensile exposure of the hip for revision arthroplasty.

surgical dislocation of hip

• because femur usually has been weakened owing to cortical defects or cavitation, great care is taken in dislocating hip and exposing femur to avoid fracture;
• greater trochanter osteotomy will facilatitate dislocation;
• the entire pseudocapsule is excised or released;

need for tissue biopsy cultures from the component membrane interface

• remember that in the case of biofilm, there may be minimal infection in joint fluid and capsule, and the main area of infection will be over the component /bone-membrane interface;
• consider adding tissue culture (or at least saline) to the tissue sample inorder to improve true positive results;
• references:
  • A comprehensive microbiological evaluation of fifty-four patients undergoing revision surgery due to prosthetic joint loosening.
  • The fate of the unexpected positive intraoperative cultures after revision total knee arthroplasty
  • The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?
  • Use of broth cultures peri-operatively to optimise the microbiological diagnosis of musculoskeletal implant infections.

femoral component revision »

• trochanteric osteotomy

acetabular component revision »

• exposure of acetabulum:
  • requires wide exposure of hip w/ removal of pseudocapsule, exposing entire proximal end of femur & entire circumference of acetabulum to permit careful implant removal;
  • references:
    • A new approach to the hip for revision surgery.
    • A technique of extensile exposure for total hip arthroplasty. 
    • Extensile exposure of the hip for revision arthroplasty.
• retention of acetabular shell
  • in some revision situations, the acetabular cup is noted to be stable and is left in place (ie only femoral revision is performed);
  • references:
    • Fate of Cementless Acetabular Components Retained During Revision Total Hip Arthroplasty.
    • Cementing a Liner into a Stable Cementless Acetabular Shell: The Double-Socket Technique.
    • Cementation of a Polyethylene Liner Into a Metal Shell
    • Cementation of a Metal-Inlay Polyethylene Liner Into a Stable Metal Shell in Revision Total Hip Arthroplasty.
    • Cementing Acetabular Liners Into Secure Cementless Shells for Polyethylene Wear Provides Durable Mid-term Fixation
    • Long-Term Outcomes of Liner Cementation into a Stable Retained Shell: A Concise Follow-up of a Previous Report.
• removal of acetabular components
• grafting of acetabular defects
• management of pelvic discontinuity

Post Op Anesthesia

• Local Analgesia Infiltration Techniques – Hip and Knee Arthroplasty

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• Revision total hip arthroplasty
• Long-term results of revision total hip replacement. A follow-up report.
• Multiple revisions for failed total hip arthroplasty not associated with infection.
• Component removal in revision total hip arthroplasty.
• The Fate of Well Fixed Cemented Femoral Components Left in Place at the Time of Revision of the Acetabular Component.
• Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up.
• The Diagnostic and Predictive Value of Hip Anesthetic Arthrograms in Selected Patients Before Total Hip Arthroplasty.
• Fixation of hydroxyapatite-coated revision implants is improved by the surgical technique of cracking the sclerotic bone rim.