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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