Revision Total Hip Arthroplasty - Wheeless' Textbook of Orthopaedics

- See: Total Hip Replacement Menu:

- Discussion:
- evaluation of the painful THR
- indications for revision:
- evaluation for loosening:

- 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:
- 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
    - extraction instruments:
    - selection of implants:
- components for acetabular revision:
- femoral cementless revision:
- cemented femoral revision:

- Surgical Approach:
    - give prophylactic antibiotics in normal fashion;
    - 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;
- partial release of the psoas tendon;
- partial release of gluteus maximus insertion;
- release of reflected head of the rectus femorus;
          - ref:  Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic Infection.

    - 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;
- femoral component revision;
- 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;
- 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.
          - removal of acetabular components:
- grafting of acetabular defects:
- acetabular component revision (technique):
- references:
- A new approach to the hip for revision surgery.
- A technique of extensile exposure for total hip arthroplasty. Glassman A.H., Engh C.A., and Bobyn J.D. J. Arthroplasty 2:11, 1987.
- Extensile exposure of the hip for revision arthroplasty. WC Head et al. J. Arthroplasty. Vol 2. 1987. p 265-273.

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.

Revision total hip arthroplasty with osseous allograft reconstruction. A clinical and roentgenographic analysis.

Freeze-dried proximal femur allografts in revision total hip arthroplasty. A preliminary report.

Preparation of the proximal femur in cementless total hip revision.

The Fate of Well Fixed Cemented Femoral Components Left in Place at the Time of Revision of the Acetabular Component. C.L. Peters MD, L. Kulll, J.J. Jacobs MD, A.G. Rosenberg MD, and J.O

Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up.

Component removal in revision total hip arthroplasty.

The Diagnostic and Predictive Value of Hip Anesthetic Arthrograms in Selected Patients Before Total Hip Arthroplasty.

Fixation of revision implants is improved by a surgical technique to crack the sclerotic bone rim.