Revision Total Hip Arthroplasty

Author: Mark Karadsheh

Topic updated on 04/27/13 6:26pm

Introduction

Indications
- osteolysis
- loosening
- instability
- infection
- mal-alignment
- polyethylene wear
Options include
- acetabular component revision
  - most common reason for revision in the Charnley "low-friction" total hip arthroplasty
- femoral head and polyethylene exchange
- femoral component revisions
- conversion from a hip arthrodesis
Complications
- significantly higher than primary hip reconstruction
- include
  - dislocation (even in simple procedures)
  - infection
  - nerve palsy
  - cortical perforation
  - fractures
  - DVT
  - limb length inequalities

Classification of Bone Loss

Acetabulum

AAOS Classification of Acetabular Bone Loss
Type I (segmental)	Loss of part of the acetabular rim or medial wall
Type II (cavitary)	Volumetric loss in the bony substance of the acetabular cavity
Type III (combined deficiency)	Combination of segmental bone loss and cavitary deficiency
Type IV (pelvic discontinuity)	Complete separation between the superior and inferior acetabulum
Type V (arthodesis)	Arthrodesis

Paprosky Classification of Acetabular Bone Loss
Type I	Minimal deformity, intact rim
Type IIA	Superior bone lysis with intact superior rim
Type IIB	Absent superior rim, superolateral migration
Type IIC	Localized destruction of medial wall
Type IIIA	Bone loss from 10am-2pm around rim, superolateral cup migration
Type IIIB	Bone loss from 9am-5pm around rim, superomedial cup migration

Femur

AAOS Classification of Femoral Bone Loss
Type I (segmental)	Loss of bone of the supporting shell of femur
Type II (cavitary)	Loss of endosteal bone with intact cortical shell
Type III (combined)	Combination of segmental bone loss and cavitary deficiency
Type IV (malalignment)	Loss of normal femoral geometry due to prior surgery, trauma, or disease
Type V (stenosis)	Obliteration of the canal due to trauma, fixation devices, or bony hypertrophy
Type VI (femoral discontinuity)	Loss of femoral integrity from fracture or nonunion

Paprosky Classification of Femoral Bone Loss
Type I	Minimal metaphyseal bone loss
Type II	Extensive metaphyseal bone loss with intact diaphysis
Type IIIa	Extensive metadiaphyseal bone loss, minimum of 4 cm of intact cortical bone in the diaphysis
Type IIIb	Extensive metadiaphyseal bone loss, less than 4 cm of intact cortical bone in the diaphysis
Type IV	Extensive metadiaphyseal bone loss and a nonsupportive diaphysis

Presentation

Symptoms
- groin pain --> acetabulum
- thigh pain --> femoral stem
- start-up pain --> component loosening
- night pain --> infection

Imaging

Radiographs
- required views
  - AP pelvis
  - orthogonal views of involved hip
  - full-length femur radiographs
- additional views
  - pre-operative radiographs
  - immediate post-operative radiographs
  - Judet views
    - useful for assessment of columns
CT scan
- useful for determining extent of osteolysis
  - radiographs frequently underestimate extent of osteolysis
- assessment of component position

Evaluation

Laboratory analysis
- infectious laboratories
  - ESR
  - CRP
  - CBC
Aspiration
- recommended if infectious laboratories are suggestive of infection

Treatment

Femoral revision
- primary total hip arthroplasty components
  - indications
    - minimal methaphyseal bone loss
- uncemented extensively porous-coated long stem prosthesis (or porous-coated/grit blasted combination)
  - indications
    - most Paprosky II and IIIa defects
  - outcomes
    - 95% survival rate at 10-years
- impaction bone grafting
  - indications
    - large ectactic canal and thin cortices
    - Paprosky IIIb and IV defects
  - outcomes
    - most common complication is stem subsidence
- allograft prosthetic composite
  - indications
    - Paprosky IV defects
- modular oncology components
  - indications
    - massive bone loss with a non-supportive diaphysis
- cemented stems
  - indications
    - irradiated bone
    - elderly
    - low-demand patients
  - outcomes
    - high failure rate
Acetabular revision
- porous-coated hemisphere cup secured with screws
  - indications
    - rim is competent (> 2/3 of rim remaining)
- reconstruction cage with structural bone allograft
  - indications
    - rim is incompetent (<2/3 of rim remaining)
  - outcomes
    - allograft failure is the most common complication
    - high failure rate (40-60%) without reconstruction cage due to component migration after graft resorption
Combined revision
- femoral head and polyethylene exchange
  - indications
    - eccentric wear of the polyethylene with stable acetabular and femoral components
  - outcomes
    - hip instability is the most common complication of isolated liner exchange
- conversion from a hip arthrodesis
  - indications
    - low back and knee pain as a result of arthrodesis
  - outcomes
    - implant survival greater than 95% at 10 years
    - competence of gluteal musculature is predictive of ambulatory success

Surgical Techniques

Femoral revision with uncemented extensively porous-coated long stem prosthesis
- technique
  - femoral stem must bypass most distal defect by 2 cortical diameters
    - prevents bending moment through cortical hole
  - cavitary lesions are grafted with particulate graft
  - allograft cortical struts may be used to reinforce cortical defects
Femoral impaction bone grafting
- technique
  - morselized fresh frozen allograft packed into canal
  - smooth tapered stem cemented into allograft
Acetabular revision with porous-coated hemisphere cup with screws
- technique
  - cavitary lesions are filled with particulate graft
  - cup placement should be inferior and medial
    - lowers joint reactive forces
  - metallic wedge augmentation may be used if cup in good position and rigid internal fixation is achieved
  - jumbo cups may be used when larger reamer is needed to make cortical contact
  - structural allografts may be used to provide stability while bone grows into cementless cup
Acetabular revision with reconstruction cage and structural bone allograft
- technique
  - polyethylene cup is cemented into reconstruction cage
  - bone graft placed behind cage
Femoral head and polyethylene exchange
- technique
  - exchange both head and liner
  - osteolytic defects may be bone grafted through screw holes to fill bony defects

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Qbank (8 Questions)

TAG

(OBQ10.7) A 72-year-old female returns to clinic for 15 year follow up of left total hip arthroplasty. She ambulates without any assistive devices, has no pain, and denies any recent fevers or systemic illness. A radiograph is provided in figure A. Which of the following is the best treatment option? Topic

Review Topic

FIGURES: A

1. Follow up radiographs in 1 year
2. Follow up radiographs in 5 years
3. Revision surgery with femoral head and polyethylene exchange and retroacetabular bone grafting
4. Revision of acetabular component with jumbo cup and femoral head exchange
5. Revision of acetabular component with jumbo cup and femoral stem revision

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates osteolytic lesions behind the acetabular cup and eccentric wear of the polyethylene with superior migration of the femoral head within the cup. Options 1 and 2 are poor choices because the osteolysis must be addressed to prevent further bone loss and eventual loosening of the implant. The acetabular cup remains in acceptable position and does not need to be revised unless found to be grossly loose intraoperatively. The osteolytic lesions need to be addressed with bone grafting to prevent cavitary bone loss. The femoral stem shows no indication of loosening or osteolysis around the stem and can be retained.

Maloney et al reported a case series of 35 patients who underwent femoral head and polyethylene exchange with retroacetabular bone grafting of osteolytic lesions. All 35 cups remained stable and had not been revised at 2 years.

Maloney et al discusses the treatment of osteolytic defects following hip and knee arthroplasty at the 2007 Implant Wear Symposium.

REFERENCES:

1. Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997 Nov;79(11):1628-34. PMID:9384421 (Link to Abstract)

2. Maloney W, Rosenberg A; Implant Wear Symposium 2007 Clinical Work Group. What is the outcome of treatment for osteolysis? J Am Acad Orthop Surg. 2008;16 Suppl 1:S26-32. PMID:18612010 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Ben Taylor MD,

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TAG

(OBQ10.187) Which of the following is true regarding the conversion of hip arthrodesis to total hip arthroplasty? Topic

Review Topic

1. Implant survivorship is greater than 95% at 20 years following conversion to arthroplasty
2. Conversion to arthroplasty should not be performed if arthrodesis is more than 15 years old
3. Pre-operative status of gluteus medius is predictive of ambulatory status
4. Rate of complication is equivalent to primary total hip arthroplasty
5. Incidence of nerve palsy is comparable to primary total hip arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: Hip arthrodesis is a viable solution for the very young laborer with debilitating hip disease. Conversion to total hip arthroplasty once the patient has become less active has been clinically successful in relieving adjacent knee and low back pain although complications are more frequent than primary hip arthroplasty. There is no time limit for conversion as successful revision arthroplasty has been documented 30 years following arthrodesis. A radiographic example is provided in illustration A (Morsi. Journal of Arthroplasty Sept. 2007). Joshi et al reviewed 208 hip fusions converted to total hip arthroplasties. 79% reported minimal pain and good to excellent range of motion. Arthroplasty survival was 96% at 10 years, 93% at 15 years, and 73% at twenty years. Complications included nerve palsy in 7% of hips and heterotopic ossification in 14% of hips. Hamadouche et al reports on 45 hip fusions converted to arthroplasty. Satisfactory outcome was reported in 91%. Implant survival was 97% at 8 years. Other studies have demonstrated much poorer clinical outcomes including survivorships of less than 70% at 10 years. Incompetence of the gluteal muscle groups was predictive of poor ambulatory outcome. Preoperative EMG studies can be useful to evaluate the competence of the gluteal musculature prior to surgery.

Illustrations: A

REFERENCES:

1. Joshi AB, Markovic L, Hardinge K, Murphy JC. Conversion of a fused hip tototal hip arthroplasty. J Bone Joint Surg Am. 2002 Aug;84-A(8):1335-41. PMID:12177262 (Link to Abstract)

2. Hamadouche M, Kerboull L, Meunier A, Courpied JP, Kerboull M. Total hiparthroplasty for the treatment of ankylosed hips : a five to twenty-one-yearfollow-up study. J Bone Joint Surg Am. 2001 Jul;83-A(7):992-8. PMID:11451967 (Link to Abstract)

Question Authors:

John Badylak MD,

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TAG

(OBQ08.148) A 75-year-old man who underwent total hip arthroplasty 20 years ago now complains of thigh pain for the past four months. Laboratory studies show a normal white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An aspiration of the hip is performed and is negative for infection. A radiograph is shown in Figure A. Which of the following is the best management option for the femoral implant? Topic

Review Topic

FIGURES: A

1. Bone scan to look for loosening
2. Touch down weight bearing and physical therapy
3. Revision with a tumor prosthesis
4. Revision of femoral component with metaphyseal cement fixation of the stem
5. Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph shows lucency around the femoral stem cement mantle consistent with osteolysis. There is significant bone loss in the proximal femur. Diaphyseal fixation is required. Revision to a cementless femoral stem is the most appropriate management.

Paprosky et al described their results of cementless revision of femoral components and report 95% surviorship with a minimum of 10 years follow up.

Haydon et al showed that despite historical literature discouraging the use of cemented femurs for revision, in their experience cemented femoral revision had 91% survivorship when the cause was aseptic loosening. They found early generation cementing techniques, poor cement mantle, poor bone quality, age of less than 60, and male gender to be risk factors for failure in cemented revisions.

REFERENCES:

1. Haydon CM, Mehin R, Burnett S, Rorabeck CH, Bourne RB, McCalden RW, MacDonald SJ. Revision THA with cemented femoral component: 10yr results. JBJS (Am) 2004;86:1179-1185 PMID:15173290 (Link to Abstract)

2. Paprosky WG, Greidanus NV, Antoniou J. Minimum 10yr results of extensively porous-coated stems in revision THA. CORR 1999;369:230-242 PMID:10611878 (Link to Abstract)

Question Authors:

John Badylak MD, Dave Marcu MD, Michael Hughes MD,

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TAG

(OBQ08.217) A 67-year-old female with history rheumatoid arthritis presents with acute onset severe left hip pain eight years status-post total hip arthroplasty. She is unable to weight bear on the left leg, but denies any other pain or systemic symptoms. A current radiograph of the pelvis is shown in Figure A. What is the most likely cause of the patient's current hip pain symptoms? Topic

Review Topic

FIGURES: A

1. Poor surgical technique
2. Rheumatoid arthritis flare
3. Catastrophic implant failure
4. Development of pelvic discontinuity
5. Acute sepsis

PREFERRED RESPONSE ▶

DISCUSSION: Figure A demonstrates pelvic discontinuity. The radiographic findings associated with this diagnosis include a visible fracture line through the anterior and posterior columns, and medial translation and rotation of the inferior aspect of the hemipelvis relative to the superior aspect on an AP pelvic radiograph.

Berry et al defined patients at risk for pelvic discontinuity, the typical radiographic findings, and success with revision surgical treatment. They found that patients with rheumatoid arthritis were at greatest risk for developing this condition. Also, those with minimal bone loss in which a socket can be satisfactorily supported by native bone without cement, a posterior column plate to stabilize the pelvis and a porous-coated socket is the preferred revision contsruct.

Della Valle et al describe a comprehensive classification of periprosthetic fractures associated with THA a a guide for management in their ICL.

Illustration A shows an example of a posterior column plate and a porous-coated socket.

Illustrations: A

REFERENCES:

1. Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME. Pelvic discontinuity in revision total hip arthroplasty. J Bone Joint Surg Am. 1999 Dec;81(12):1692-702. PMID:10608380 (Link to Abstract)

2. Della Valle CJ, Momberger NG, Paprosky WG. Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course Lect. 2003;52:281-90. PMID:12690856 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Michael Hughes MD,

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TAG

(OBQ06.174) Figure A shows an AP hip radiograph of a 72-year-old woman who had had a right total hip arthroplasty fifteen years previously. CT imaging of the affected hip shows non-contained defects in both the anterior and posterior columns of the peri-acetabular region affecting greater than 50% of the weight bearing surface. Which of the following revision procedures would restore the most acetabular bone stock and be most appropriate for this patient? Topic

Review Topic

FIGURES: A

1. Morselized allograft and/or autograft bone, combined with a cemented acetabular component
2. Acetabular revision with use of a bilobed cementless component and morselized allograft
3. Morselized allograft and/or autograft bone, combined with a cementless acetabular component
4. Revision using an ilioischial reconstruction ring acetabular component and structural corticocancellous graft
5. Revision using a roof ring acetabular component and structural corticocancellous graft

PREFERRED RESPONSE ▶

DISCUSSION: In cases of minor, contained, acetabular defects, morcellized allograft and/or autograft bone, combined with a cemented or cementless acetabular component can lead to successful reconstruction. However, these constructs do not confer enough stability when the loss of bone stock is more extensive and encroaches on the acetabular columns, or compromises >50% of the weight-bearing surface. A bilobed implant is a viable option in these scenarios, however these components replace lost bone with artificial materials rather than restoring acetabular bone stock making revision very difficult. Roof ring acetabular components have been largely replaced by cementless cups fixed with multiple screws, and do not offer the same degree of fixation stability found with reconstruction rings for large bone defects. Goodman et al review the complications, management, and outcome of a consecutive series of 61 ilioischial reconstruction rings performed by 1 surgeon over a 15-year period. On the acetabular side, allograft failure was the most common complication. Illustration A shows an example of an ilioischial reconstruction ring, and Illustration B shows this reconstruction ring in situ.

Illustrations: A

REFERENCES:

1. Goodman S, Saastamoinen H, Shasha N, Gross A. Complications of ilioischial reconstruction rings in revision total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4):436-46. PMID:15188101 (Link to Abstract)

Question Authors:

Joshua Blomberg MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

Cases

	Aseptic loosening (C1026) Recon - - Revision Total Hip Arthroplasty HPI - 77 y/o male with right hip pain after THA Patient with predominately thigh pain... What is your preferred revision system? why? What is your preferred method...	2/12/2011 9 responses
	TBC (tuberculous coxitis) Infection of Hip (C1110) Recon - - Revision Total Hip Arthroplasty HPI - femoral head resection for tbc septic arhritis and head collapse. antitbc drug t... How would you treat this patient?	12/13/2011 57 responses

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Posts

Total Hip Arthroplasty for the Treatment of Ankylosed Hips: a Five to Twenty-one-year Follow-up Study. Includes Poll

Hamadouche M, Kerboull L, Meunier A, Courpied JP, Kerboull M
J Bone Joint Surg Am. 2001 Jul;83-A(7):992-8. PMID: 11451967 (Link to Pubmed)

Recon - Journal Club - Revision Total Hip Arthroplasty

3 weeks ago

15 responses

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Groups

ABOS II: Revision THA

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br. 1972 Feb;54(1):61-76. PMID:5011747 (Link to Abstract)
Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty: follow-up for 30 to 40 years. J Bone Joint Surg Br. 2009 Apr;91(4):447-50. PMID:19336802 (Link to Abstract)
Sporer SM, Paprosky WG. Revision total hip arthroplasty: the limits of fully coated stems. Clin Orthop Relat Res. 2003 Dec;(417):203-9 PMID:14646718 (Link to Abstract)
Moreland JR, Moreno MA. Cementless femoral revision arthroplasty of the hip: minimum 5 years followup. Clin Orthop Relat Res. 2001 Dec;(393):194-201. PMID:11764349 (Link to Abstract)

Level of Evidence 4 (Case Series)

Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997 Nov;79(11):1628-34. PMID:9384421 (Link to Abstract)
Joshi AB, Markovic L, Hardinge K, Murphy JC. Conversion of a fused hip tototal hip arthroplasty. J Bone Joint Surg Am. 2002 Aug;84-A(8):1335-41. PMID:12177262 (Link to Abstract)
Hamadouche M, Kerboull L, Meunier A, Courpied JP, Kerboull M. Total hiparthroplasty for the treatment of ankylosed hips : a five to twenty-one-yearfollow-up study. J Bone Joint Surg Am. 2001 Jul;83-A(7):992-8. PMID:11451967 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Maloney W, Rosenberg A; Implant Wear Symposium 2007 Clinical Work Group. What is the outcome of treatment for osteolysis? J Am Acad Orthop Surg. 2008;16 Suppl 1:S26-32. PMID:18612010 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Valle CJ, Paprosky WG. Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone Joint Surg Am. 2003;85-A Suppl 4:1-6 PMID:14652388 (Link to Abstract)
Sporer SM, Paprosky WG. Revision total hip arthroplasty: the limits of fully coated stems. Clin Orthop Relat Res. 2003 Dec;(417):203-9. PMID:14646718 (Link to Abstract)
Haydon CM, Mehin R, Burnett S, Rorabeck CH, Bourne RB, McCalden RW, MacDonald SJ. Revision THA with cemented femoral component: 10yr results. JBJS (Am) 2004;86:1179-1185 PMID:15173290 (Link to Abstract)
Paprosky WG, Greidanus NV, Antoniou J. Minimum 10yr results of extensively porous-coated stems in revision THA. CORR 1999;369:230-242 PMID:10611878 (Link to Abstract)
Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME. Pelvic discontinuity in revision total hip arthroplasty. J Bone Joint Surg Am. 1999 Dec;81(12):1692-702. PMID:10608380 (Link to Abstract)
Della Valle CJ, Momberger NG, Paprosky WG. Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course Lect. 2003;52:281-90. PMID:12690856 (Link to Abstract)
Goodman S, Saastamoinen H, Shasha N, Gross A. Complications of ilioischial reconstruction rings in revision total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4):436-46. PMID:15188101 (Link to Abstract)

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Revision Total Hip Arthroplasty

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