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Revision tha

This document provides information on revision total hip arthroplasty (THA). It discusses indications such as painful loosening or fracture of implant components. Preoperative planning involves high-quality imaging to identify implant type and deficiencies. Complex revisions require additional equipment for tasks like cement and implant removal. The posterolateral surgical approach provides best exposure. Deficiencies of the acetabulum and femur are reconstructed using bone grafts, augments, and special implants to restore joint mechanics and implant fixation. Massive defects may require proximal femoral allografts or modular replacements.

Health & Medicine◦
Revision THA Dr Asish Rajak Fellow Sports Medicine and Arthroplasty Grande International Hospital
INDICATIONS (1) Painful , aseptic loosening of one or both components; (2) Progressive loss of bone; (3) fracture or mechanical failure of the implant; (4) recurrent or irreducible dislocation; (5) infected total hip arthroplasty as a one- stage or two-stage procedure; and (6) treatment of a periprosthetic fracture.
CONTRAINDICATIONS •Functional problems, such as painless loss of motion in the hip or painless limb lengthening •Shortening of the operated limb •absence of substantial heterotopic bone formation
PREOPERATIVE PLANNING • More time • Anticipation of potential complications and the formulation of numerous contingency plans to deal with them influence the requirements for additional equipment and expedite their management during surgery. • High-quality radiographs of the pelvis and entire femur must be obtained. • Lateral views of the femur -- several different degrees of rotation • Intrapelvic cement or a markedly protruded acetabular component - intravenous pyelography or vascular studies • Acetabular deficiencies -- CT
•Radiographic identification of the type of prosthesis •a review of the operative notes •Unique extraction tools, screwdrivers, and head disassembly instruments •large prosthetic inventory
• Additional equipment and materials often needed during revision surgery include the following: ■ Image intensifier and radiolucent operating table ■ Stem extraction instruments ■ Hand instruments for cement removal ■ Motorized cement removal instruments ■ Motorized metal-cutting instruments ■ Flexible intramedullary reamers ■ Flexible thin osteotomes for cementless stem removal ■ Trephine reamers ■ Curved osteotomes or modular blades for cementless socket removal ■ Fiberoptic lighting ■ Pelvic reconstruction plates, screws, and instruments ■ Trochanteric fixation device and cerclage wires or cables ■ Allograft bone (femoral head, struts, and segmental allograft) ■ Intraoperative blood salvage device
SURGICAL APPROACH •If possible, a previous incision should be used. •Anterior approach - Bone grafting of the posterior column of the acetabulum is difficult, as is extensile exposure of the femur •Posterolateral approach - excellent exposure of the posterior column of the acetabulum and of the femoral shaft, risk of dislocation is higher •The transtrochanteric approach provides the best exposure of the femur and the acetabulum and is the approach of choice for most complex revision procedures
Standard trochanteric osteotomy (1), Trochanteric slide osteotomy (2), and Extended trochanteric osteotomy (3).
REMOVAL OF CEMENTED FEMORAL COMPONENT •Extraction device •If no extraction device is available, use the collar as a driving platform.
Femoral component extractors
Moreland V osteotome for removal of lateral cement over shoulder of implant for stems with proximal curvature.
REMOVAL OF A CEMENTLESS FEMORAL COMPONENT •depending on the extent of the porous coating, amount of bone ingrowth versus fibrous encapsulation, and the degree to which the stem fills the medullary canal. •disrupt the areas of bone ingrowth using specialized thin, flexible osteotomes
Moreland specialized, thin, flexible osteotome for disrupting bone ingrowth at proximal end of porous-coated stem.
REMOVAL OF IMPLANTS WITH EXTENSIVE DISTAL BONE INGROWTH
Removal of implants with extensive distal bone ingrowth (Glassman and Engh). A, Prosthesis is transected with carbide-tipped, metal-cutting burr. B, Distal cylindrical portion of stem is removed by reaming over it with trephine reamer
Extended trochanteric osteotomy for difficult stem removal. A, Longitudinal portion of osteotomy follows lateral border of stem and extends distally to predetermined level. B, Anterior cortex is divided, and entire lateral cortical segment, with trochanter, is retracted anteriorly, exposing lateral surface of stem. C, Bone ingrowth is disrupted with Gigli saw passed down medial side of stem.
REMOVAL OF A BROKEN FEMORAL COMPONENT •fiberoptic light •Creation of a femoral cortical window to give direct access to the stem.
Collis and Dubrul method for removal of broken stem. A, Trephine is used to cut circumferentially around fractured prosthesis; stem acts as drill guide for trephine. B, Stem is removed from medullary canal with slide hammer and collet instrumentation.
Method of removal of broken stem described by Moreland, Marder, and Anspach. Small window is made in anterior femoral cortex just distal to break in stem. Carbide punch is used to push prosthesis proximally.
REMOVAL OF FEMORAL CEMENT •Most time-consuming and hazardous part •delayed until after the acetabular component has been revised •fiberoptic light source; a long, straight suction catheter; cement removal osteotomes with various configurations; a long pituitary rongeur for removal of loose cement fragments; long, hooked instruments for retrograde cement removal; a high-speed burr with long attachments; and reamers of graduated diameters.
Removal of cement from femoral canal. A and B, After removal of varus stem, channel in cement is such that drill or osteotome tends to follow channel and penetrate cortex. C, Cement must be removed from medial wall to prevent penetration; fiberoptic light is helpful in this procedure
Removal of cement from femoral canal. Longitudinal radial splits are made in proximal cement column
Fragmentation of proximal cement. After longitudinal radial splits have been made in cement column, curved osteotome is inserted into bone-cement interface and cement fragment is fractured into central vacancy.
Removal of solid cement below tip of prosthesis. A, Thin, curved hook is inserted between cortex and cement plug. B, Hook is turned 90 degrees and used to pull up cement Centering sleeve is used as drill guide to position drill bit precisely in center of cement plug
Segmental extraction of cement. Well-intruded cement was removed because of infection. After stem had been removed, new cement was injected around thread-forming rod. Extraction rods were screwed into threaded hole. Entire mantle was removed successfully in short segments.
REMOVAL OF A CEMENTED ACETABULAR COMPONENT •The trochanter should be osteotomized if needed •Drive a thin, curved osteotome between the cup and cement
Removal of polyethylene cup. A, Curved, thin osteotome or gouge is used to disrupt interface between implant and cement. B, Cup is removed by prying it gently from cement with extraction device.
Acetabular reamer reams cup until cement is visible through transparent polyethylene. Remaining polyethylene and cement are removed with curved osteotomes or gouges.
REMOVAL OF A CEMENTLESS ACETABULAR COMPONENT • Removal of a well-fixed, porous, cementless acetabular component is difficult and may result in removal of additional bone stock with the need for a larger implant for reconstruction.
1 Explant System (Zimmer Orthopaedics, Warsaw, IN) used to remove well-fixed, acetabular, cementless components. 2 Two blades used by Explant System. Short blade (left) and full-radius blade (right).
RECONSTRUCTION OF ACETABULAR DEFICIENCIES Causes of deficiencies: (1) osteolysis caused by wear, loosening, or infection; (2) excessive bone resection at the time of previous surgery, especially if the patient has had a resurfacing procedure or previous acetabular revision; (3) preexisting bone deficit from acetabular fracture or dysplasia that was not corrected at the time of previous surgery; and (4) inadvertent destruction of bone during removal of a previous component or cement.
•A segmental deficiency is a complete loss of bone in the supporting rim of the acetabulum, including the medial wall. •A cavitary deficiency is a volumetric loss in the bony substance of the acetabular cavity.
A, Type I defect has minimal bone loss and negligible component migration. B, Type 2A defect with less than 2 cm superomedial migration. C, Type 2B defect with less than 2 cm superolateral migration. D, Type 2C defect with medial migration only. E, Type 3A defect with more than 2 cm component migration and bone loss from 10-o’clock to 2-o’clock position. F, Type 3B defect with more than 2 cm migration and bone loss from 9-o’clock to 5-o’clock position.
MANAGEMENT objectives of acetabular reconstruction are to (1) Restore the center of rotation of the hip to its anatomical location, (2) establish normal joint mechanics, (3) reestablish the structural integrity of the acetabulum, and (4) obtain initial rigid fixation of bone graft, adequate containment of the new prosthesis, and rigid fixation of the revision prosthesis to host bone.
A, Large cavitary deficiencies in 85-year-old woman with acetabular loosening 18 years after primary cemented arthroplasty. Large superior and medial cavitary deficiencies combined with poor bone stock. Fixation is unlikely with conventional porous-coated implants. B, Extensive bone grafting with cancellous allograft combined with antiprotrusio cage. Implant is stable at 2 years, and bone graft is incorporated.
Anterior segmental deficiency in young woman. A, Polyethylene wear produced this segmental deficiency (between arrows) in anterior column of acetabulum. Posterior column is intact. B, Revision accomplished with large-diameter porous implant and cancellous bone grafting. No structural graft was required.
Superior segmental deficiency. A, Multiple previous revisions had been done for sequelae of congenital hip dysplasia. Socket previously was placed in false acetabulum with high hip center. Large superior segmental defect is above true acetabulum. B, Five years after revision with structural bone grafting of superior segmental deficit and cementless acetabular component, no migration is seen but bone ingrowth is unlikely.
COMBINED DEFICITS •Distal femoral allografts, •trabecular metal augments, •cancellous allograft combined with an antiprotrusio cage, •acetabular allografts, •custom triflanged acetabular components, and •hemispherical components placed at a high hip center.
Paprosky “7” graft for segmental acetabular deficiency. A, Distal femoral allograft is shaped to resemble numeral 7. B, Graft is shaped to fit acetabular deficiency and fixed as shown, with several screws placed above acetabulum through remaining cortical portion of graft. C, Graft is reamed, and revision component is implanted.
PELVIC DISCONTINUITY •Paprosky et al. 1. Healing potential exists, the discontinuity is treated in compression with plating of the posterior column and a structural allograft or with a tantalum revision socket used as a hemispherical plate. 2. If healing potential is insufficient, as in the setting of previous pelvic irradiation, the discontinuity is placed in distraction and the acetabulum is reconstructed with an acetabular allograft, a tantalum metal socket combined with an antiprotrusio cage (“cup-cage” construct), or a custom triflanged acetabular component.
Cup-cage construct. Pelvic discontinuity and large superior segmental defect required tantalum hemispherical acetabular component with superior augment, antiprotrusio cage, and cemented polyethylene liner.
Custom porous-coated triflanged acetabular prosthesis for pelvic discontinuity.
RECONSTRUCTION OF FEMORAL DEFICIENCIES result from (1)osteolysis caused by loosening, wear, or infection; (2)perforation or creation of windows during removal of the previous stem or other implant; (3)stress shielding from an excessively stiff or extensively porous-coated implant; or (4)preexisting osteoporosis and thin femoral cortices.
•A segmental deficit is defined as any loss of bone in the supporting cortical shell of the femur. •A cavitary deficit is a contained lesion representing an excavation of the cancellous or endosteal cortical bone without violation of the cortical shell of the femur. •Malalignment refers to a distortion of the femoral architectural geometry and can be either angular or rotational. •Stenosis describes a partial or complete occlusion of the femoral canal resulting from previous trauma, fixation devices, or bony hypertrophy. •Femoral discontinuity refers to a loss of femoral integrity, from either an acute fracture or an established nonunion.
MANAGEMENT Objectives of femoral revision surgery are to (1)Maintain femoral integrity and bone stock, (2)achieve rigid prosthetic fixation, (3)restore hip biomechanics to promote efficient abductor function, and (4) equalize leg lengths.
A, Patient was referred with failed long-stem cemented revision prosthesis. Large anterolateral cortical window had been created during previous surgery and was filled with cement (arrows). B, Window was used for cement removal. Femur was reconstructed with cementless long stem and allograft cortical strut to restore lateral cortex. Note restoration of bone stock at 3 years.
Restoration of femoral length with calcar replacement prosthesis. A, Severe stem subsidence produced this proximal segmental deficiency. Limb was 5 cm short. B, Length was easily restored, and stable fixation was achieved with calcar replacement stem.
Failed cemented femoral component with large cavitary deficiencies and ectasia
One year after impaction grafting and cemented revision with collarless, polished, tapered stem. Small degree of subsidence has occurred.
MASSIVE DEFICITS •have had multiple previous operations on the hip, and the femur may have been fractured or perforated. •The cortex in the proximal femur is thin and fragile and may be completely absent in several areas, requiring a massive proximal femoral allograft or modular proximal femoral replacement prosthesis.
Proximal femoral allograft. A and B, Extensive ectasia and osteolysis of proximal femoral cortex in 42-year-old woman with three previous failed revisions. Distal portion of stem remained well fixed and required slotting of femur for removal of cement and stem. C and D, Reconstruction with proximal femoral allograft. Long step-cut in graft covered cortical slot and improved rotational stability between graft and host bone. Stem was cemented to graft only and not distally.
Modular proximal femoral replacement stem. Massive osteolysis due to loose cemented stem with unreconstructable proximal femur required proximal femoral replacement. Remaining proximal femoral fragments were wrapped around prosthesis to enhance soft tissue attachment and leg control.
References Campbell’s Operative Orthopedics – 12th Edition
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