- 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