Updated: 1/22/2019

THA Revision

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https://upload.orthobullets.com/topic/5009/images/13a_moved.jpg
https://upload.orthobullets.com/topic/5009/images/aaos acetabulum.jpg
https://upload.orthobullets.com/topic/5009/images/aaos type 2 acetabular.jpg
https://upload.orthobullets.com/topic/5009/images/aaos type iii acetabular..jpg
https://upload.orthobullets.com/topic/5009/images/aaos pelvic discontinuity.jpg
https://upload.orthobullets.com/topic/5009/images/paprosky acetabulum.jpg
 Introduction
  • Indications
    • osteolysis
    • loosening
    • instability 
    • infection
    • mal-alignment
    • polyethylene wear
    • fracture or implant failure
  • 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
      • abductor deficiency 
      • 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 metaphyseal bone loss, Paprosky I
    • uncemented extensively porous-coated long stem prosthesis (or porous-coated/grit blasted combination) or modular tapered stems   
      • indications
        • most Paprosky II and IIIa defects; Paprosky IIIb (modular fluted tapered stem)
      • 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 IIIb and IV defects
    • modular oncology components
      • indications
        • massive bone loss with a non-supportive diaphysis
        • Paprosky IIIB and IV defects
    • 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 
  • Gluteus maximus transfer in setting of irreparable abductor deficiency 
    • technique
      • along with the tensor fascia lata, the anterior aspect of the gluteus maximus is freed and transferred to the greater trochanter so that the fibers are similarly oriented to the native abductor musculature

 

 

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Questions (30)
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(OBQ08.148) A 85-year-old man who underwent hemiarthroplasty 5 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? Review Topic

QID: 534
FIGURES:
1

Bone scan to look for loosening

16%

(207/1300)

2

Touch down weight bearing and physical therapy

1%

(16/1300)

3

Revision with a tumor prosthesis

3%

(41/1300)

4

Revision of femoral component with metaphyseal cement fixation of the stem

13%

(168/1300)

5

Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem

66%

(862/1300)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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(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? Review Topic

QID: 360
FIGURES:
1

Morselized allograft and/or autograft bone, combined with a cemented acetabular component

4%

(90/2507)

2

Acetabular revision with use of a bilobed cementless component and morselized allograft

7%

(172/2507)

3

Morselized allograft and/or autograft bone, combined with a cementless acetabular component

7%

(165/2507)

4

Revision using an ilioischial reconstruction ring acetabular component and structural corticocancellous graft

71%

(1779/2507)

5

Revision using a roof ring acetabular component and structural corticocancellous graft

12%

(291/2507)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 3280
1

Implant survivorship is greater than 95% at 20 years following conversion to arthroplasty

5%

(129/2814)

2

Conversion to arthroplasty should not be performed if arthrodesis is more than 15 years old

6%

(166/2814)

3

Function of gluteus medius is predictive of ambulatory status

86%

(2413/2814)

4

Rate of complication is equivalent to primary total hip arthroplasty

2%

(51/2814)

5

Incidence of nerve palsy is comparable to primary total hip arthroplasty

1%

(40/2814)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(OBQ12.17) A 71 year old gentleman underwent left total hip arthroplasty 10 years ago. Eighteen months ago he began having hip and thigh pain. Over the past 6 weeks, the pain has become excruciating and he has been unable to ambulate, even with the aid of a walker. He has mild pain with passive internal and external rotation of the hip. He is unable to ambulate in the office. Laboratory values are notable for a WBC of 10,300, CRP of 0.2, and ESR of 13. A radiograph is provided in figure A. Which of the following is the best treatment option? Review Topic

QID: 4377
FIGURES:
1

Radionuclide bone scan and MRI

3%

(142/5129)

2

Open reduction internal fixation with a cable plate and allograft strut

5%

(245/5129)

3

Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft

63%

(3254/5129)

4

Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation

21%

(1072/5129)

5

Revision arthroplasty with a total femur prosthesis

7%

(384/5129)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ12.16) Which of the following statements is true regarding the thirty-year follow-up data obtained from the Charnley "low-friction" total hip arthroplasty? Review Topic

QID: 4376
1

Acetabular component failure was the least common reason for revision surgery

5%

(224/4627)

2

The number of revisions required for periprosthetic fractures was higher than that for deep infections

5%

(231/4627)

3

Acetabular component failure was a more common reason for revision than deep infection

63%

(2913/4627)

4

Femoral component failure was a more common reason for revision than acetabular component failure

16%

(753/4627)

5

Deep infection was the most common reason for revision

10%

(458/4627)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 603
FIGURES:
1

Poor surgical technique

1%

(35/2461)

2

Rheumatoid arthritis flare

2%

(42/2461)

3

Catastrophic implant failure

16%

(387/2461)

4

Development of pelvic discontinuity

80%

(1971/2461)

5

Acute sepsis

1%

(20/2461)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ12.149) A 91-year-old male with a history of chronic leukemia and dementia falls and sustains the hip fracture shown in Figure A. He undergoes a hemiarthroplasty through a posterior approach. A post-operative radiograph is shown in Figure B. Three weeks later he dislocates the hip arising from the toilet seat. A radiograph is shown in Figure C. The patient undergoes a closed reduction and is placed in a hip abduction brace. Post reduction radiograph is shown in Figure D. One month later he returns to clinic complaining of pain and inability to bear weight through the leg. A radiograph of the hip is included in Figure E. Which of the following factors has MOST likely contributed to the instability of the hip hemiarthroplasty? Review Topic

QID: 4509
FIGURES:
1

Femoral stem subsidence

1%

(59/3966)

2

Increased offset

13%

(534/3966)

3

Inadequate femoral stem neck length

13%

(524/3966)

4

Patient's dementia status

70%

(2778/3966)

5

Patient's gender

1%

(36/3966)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ12.67) A 72-year old female who underwent an uncemented right total hip arthroplasty 2 years ago complains of right hip pain after a fall. Figure A shows her current radiograph. Which acetabular bone defect classification and treatment option best describes this scenario? Review Topic

QID: 4427
FIGURES:
1

AAOS Type III - anti-protrusio cage with augmentation and a posterior column plate

24%

(939/3904)

2

AAOS Type IV - anti-protrusio cage with screw fixation and a posterior column plate

62%

(2409/3904)

3

AAOS Type II - jumbo cup with augmentation and a posterior column plate

8%

(308/3904)

4

AAOS Type I - total acetabular allograft with a cemented cup

1%

(46/3904)

5

AAOS Type II - custom triflange acetabular component

4%

(168/3904)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.50) A 74-year-old man presents with start-up thigh pain following a total hip replacement 10 years ago. Immediate post-operative radiograph is shown in Figure A. A current radiograph is shown in Figure B. Aspiration of the hip yields 1,005 white blood cells/ml. ESR is 12 (normal <40) and CRP is 0.4 (normal <1.2). Which of the following is the most appropriate management at this time? Review Topic

QID: 4410
FIGURES:
1

Revision of the femoral component to an uncemented, long, fully porous-coated stem

78%

(3329/4254)

2

Revision of the femoral component to a cemented stem

16%

(689/4254)

3

Revision of the femoral component to an allograft prosthetic composite

2%

(73/4254)

4

Revision of the femoral component to a proximal femoral replacement

1%

(61/4254)

5

Removal of prosthesis with insertion of antibiotic spacer

2%

(74/4254)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 3095
FIGURES:
1

Follow up radiographs in 3 years

21%

(716/3372)

2

Follow up radiographs in 5 years

2%

(65/3372)

3

Revision surgery with femoral head and polyethylene exchange and retroacetabular bone grafting

64%

(2147/3372)

4

Revision of acetabular component with jumbo cup and femoral head exchange

10%

(336/3372)

5

Revision of acetabular component with jumbo cup and femoral stem revision

3%

(102/3372)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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