Revision Total Hip Replacement

DR. (PROF.) ANIL ARORAMS (Ortho) DNB (Ortho) Dip SIROT (USA)

FAPOA (Korea), FIGOF (Germany), FJOA (Japan)Commonwealth Fellow Joint Replacement

(Royal National Orthopaedic Hospital, London, UK)

Senior knee and Hip Joint Replacement SurgeonAssociate Director

Department of Orthopaedics and Joint ReplacementMax Superspeciality Hospital, Patparganj, Delhi (India)

Email: anilarora@delhiorthojournal.com

Difficult Journey…..Revision THR

• Planning

• Preparedness

• Prayer

……. previous operative notes

Planning

Why did earlier one “failed” ??

What implants are in.

How to remove them.

What bone stock will be left. Use classification

system for preparedness

What all Implants are needed

Need for allograft.

Postop Rehabilitation

Why the earlier one “failed”………?

Aseptic loosening / Particle disease

Infection

Instability

Implant failure

Periprosthetic fracture

Any other cause

Plain radiograph

AP

Orthogonal

Full Length Femur

Judet Views

Judet’s Views

4 parameters…..ACETABULAR EVALUATION

– Amount of superior migration of hip centre.

– Ischial osteolysis…superior border of obturator foramen (Loss of bone from inferior aspect of posterior column)

– Teardrop Osteolysis (Loss of bone from inferior aspect of anterior column, lateral aspect of pubis and medial wall)

– Medial Migration relative to Kohler’s line

• Outline your bone loss!

A Crucial Identification : Pelvic Discontinuity

4 key elements:

Visible transverse fracture line

Medial shift of hemi-pelvis

Rotation of hemipelvis (superior relative to inferior)

Obturator foramen asymmetry

Bone Scan : NPV

The sensitivity and negative predictive value of the indium leukocyte scan for infection are both very high, approaching 95% and 100%, respectively,

Useful >>>

Try to rule out Infection..Reasonably

ESR Eeak 5-7 days operation, pre-operative levels in 3 months.

CRP Early peak 2-3 days after surgery,normal first 3 wks after operation.

IL-6 Peak - first 6 to 12 hours baseline- 3 Days

A combination of CRP and IL-6 has recently been shown to provide excellent sensitivity in the assessment of infection after THR.

Bottner F, Erren M, Wegner A, Winkelmann K, et al. Interleukin-6, procalcitonin and TNF alpha: markers of peri-prosthetic infection following total joint replacement. J Bone Joint Surg [Br] 2007;89-B:94-9.

Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty.Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG.J Bone Joint Surg Am. 2008 Sep;90(9):1869-75. 201 Revision THR

● Preop ESR < 30mm/hr & CRP < 10 mg/dL–NONE infected !!!!!!!!!!!!!!!!!

● ESR > 30mm/hr & CRP>10mg/dL & Synovial fluid WBC count > 3000 wbc/ml Strongly correlated with periprosthetic infection

Implants

All possible head sizes

Metal rings and cages

Cables

Pelvic reconstruction Plates

Constrained liners

Allogenic bone grafts

Keep set of implants with you for surgery

Cups / Ring /Cage /

Keep set of implants with you for surgery

Allogenic bone grafts

Cables

Plates

Exposure

Multiple Incision

• Try and Re-establish planes

• Identify and Isolate Sciatic Nerve

Exposure : Wide Exposure

Generous Release (Fibrous tissue

may be stronger than thin Papery

Bone)

Excise Pseudocapsule and metal

laiden tissue if any

Careful Dislocation

Exposure

Sequence of Removal

• Femoral Stem (Head in

Uncemented)

• Acetabulam

• Cement

• Debridement

Cemented Acetabular Removal

Uncemented Acetabular Removal

……..

Femoral Implant Removal

Don’t Hesitate to PerformETO

ETO Advantages

• Enhancement of cemented and cementlessfemoral component removal.

• Exposure of the femoral diaphysis for bone grafting femoral deficiencies.

• Increased exposure of the acetabulum

• Correction of femoral deformities such as varusremolding.

• Improved soft-tissue tensioning of the trochanter and abductor mechanism.

• Increased trochanteric union rate.

• Decreased operative time.

Cement Removal Set

Equipment

• Flexible thin osteotomes for

cementless stem removal

• Image Intensifier

• Flexible Medullary Reamers

• Fiberoptic lighting

High Speed Pneumatic Drills and Burr

Orthosonics System for Cemented Arthroplasty Revision (OSCAR)

Acetabular Reconstruction

Paprosky Classification of Acetabular Bone Loss

“Severity of Bone Loss”

and

“Ability of remaining host bone

To provide INITIAL STABILITY to

Cementless Acetabular Cup

till bony ingrowth occurs”.

Paprosky Classification of Acetabular Bone Loss

Type 1 - Minimal deformity, Intact Rim

• Rim is intact and supportive without distortion

• Focal areas of contained bone loss

• Hemispherical cementlessimplant is almost completely supported by native bone and has full inherent stability

• No migration of the component

Type 2 (A,B,C)

• Acetabulum is distorted.• At least 50% host bone contacting the surface

area of the component.• Anterior and posterior columns remain intact• May elevate hip centre to 1.5 cm to achieve

stability.

Xray: • Superior migration of the hip center is <3 cm• No significant osteolysis, Ischium or Teardrop

Type 2 A- “Intact superior rim”with Superomedial bone Lysis

• Defect is contained

• Superior medial

Type 2 B – “Absent Superior Rim” Superolateral Migration

• Superior rim is deficient for <1/3 Circumference

• Columns are supportive for a hemispherical cementless implant

• Defect is lateral

• Segmental defect

Type 2 C- “Intact Rim”Localized destruction of medial wall

• Migration of the acetabularcomponent medial to Kohler line

• Medial wall defect

• Rim will support a hemispherical component

Type 3 : More than 1/3 rim missing !

Superior Migration >3 cm

The remaining acetabular rim will notprovide adequate initial stability for thecomponent to achieve reliable biologicfixation.

Structural allograft or highly porous metalaugments are required to restore the centerof rotation to the proper anatomic locationand provide mechanical stability to theimplant.

Type 3 A- Rim loss from 10-2.0’clock,

Supero-Lateral cup migration

• Defect involves >1/3 but not more than 1/2 the

circumference (10 .0’clock - 2.0’clock )

Up and Out !

• Migration >3 cm above theobturator line

• Ischial lysis <15 mm inferior to theobturator line

• Partial destruction of the teardrop.• Component will be at or lateral to

Kohler line and the ilioischial andiliopubic lines will be intact.

Type 3A

Type 3B - Bone loss from 9 - 5.0’clock around rim,

Supero-Medial cup migration

• Rim defect is >1/2 the circumference (9-5.0’clock)• High risk for occult pelvic discontinuity• < 40% host bone…. No inherent stability achievable

with a trial implant

Up and In!

• >3 cm of superior migration to the obturatorline

• Complete destruction of the teardrop• More extensive ischial osteolysis (>15 m

below the superior obturator line)• Migration medial to Kohler line

Cages

• Lateralize the hip center

• Often lie quite vertical.

• Often lie in a Retroverted position

….so cement the Cup

In Appropriate Position

Pelvic Discontinuity

Other Options

IMPACTION GRAFTING

Benefits Fills big defects Osteoconductive properties Moderate support features

Disadvantages Poor osseointegration Lysis of the bone graft High risk of infection

“The greater the extent of the coverage of the acetabular component by thegraft, the greater the rate of late failure”[Shinar AA, Harris WH. J Bone Joint Surg Am. 1997 Feb;79(2):159-68]

“…total survival rate of 87.5%, anti-protrusio cages and structural allografts…”[Regis D. et al. J Arthroplasty. 2008 Sep;23(6):826-32]

IMPACTION GRAFTING

INTRAOP PAP 3 AFTER CUP REMOVAL

INTRAOPLOOSE CUP

POSTOPXRAY AFTER 2YEARSIMPACTION

GRAFTING

Constrained AcetabularInsert

Primary and revision patients at high risk of hip dislocation due to

History of prior dislocation, Bone loss Joint or soft tissue laxityNeuromuscular disease Intraoperative instability

•Bone or musculature compromised by disease, infection or prior implantation, which cannot provide adequate support or fixation for the prosthesis.•Infection in or about the hip joint.• Skeletal immaturity.

YES

NO

Paprosky Classification

of

Femoral Bone Loss

Based on three variables

a) The location of bone loss (metaphyseal vs. diaphyseal)

b) The degree of remaining support of the proximal femur

(degree of cancellous bone loss)

a) The amount of isthmus remaining for diaphyseal fixation.

Type I- Minimal Metaphyseal bone loss

Type II- Extensive Metaphyseal bone loss

with Intact Diaphysis

● Extensive Meta-

Diaphyseal bone loss

Type III A

● Minimum of 4 cm of

intact cortical bone

in the diaphysis

● Extensive Meta-

Diaphyseal bone loss

Type III B

● Less than 4 cm of

intact cortical bone

in the diaphysis

Type IV

Extensive Meta-diaphyseal

bone loss NONSUPPORTIVE

diaphysis

Other Options

Cement in cement

77 Yr

72 YR

APC Femur

A reliable way to reconstruct in difficult scenario.

APC Acetabulum

INTRAOP

INTRAOP

APC

PREOP

8 YRS POSTOP

PreparednessBe ready for all sorts of possible complications

Massive bone defects

Fracture / Cortical perforation

Incomplete removal of implants/Hardware

Inability to achieve solid fixation

Neurovascular injury

Iatrogenic pelvic discontinuity

Message

Need to learn Tips and Tricks

Always keep “Bail out” implants and

adequate amount of allograft.

Shall have done about 100 hips

Assist as many revisions as you can

(at least twenty) before venturing.