- Rule Out Infection:
- probably every revision joint procedure should have
frozen sections sent prior to insertion of the components
inorder 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 BR Hamlin 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.
Brian R. Hamlin, MD
JBJS (Am) 83:1700-1705 (2001)
- Bone Grafting:
- w/
stress shielding or
osteolysis consider need for
bone grafting;
- Selection of Implants:
