Revision Total Hip Arthroplasty

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Revision Total Hip Arthroplasty

• Requires a clear preoperative plan.
• Plan - 1) Revision Dx. 2) Surgical approach
  3)Instruments 4) Bone Grafts 5) Implants
• Preparation to handle unexpected problems that
  may require a greater exposure .

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Surgical Approach

• Revisions performed with posterior approach
• May be extended proximally or distally
• Proximal extension exposes entire ilium and
  anterior column

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Trochanteric Osteotomy

• Most common extensile measure
• 4 types 1)Extended trochanteric slide 2)Simple
  trochanteric slide 3)Conventional trochanteric
  osteotomy 4)Extended conventional osteotomy

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Factors for Choice of Osteotomy

• Bone quality
• What needs to be exposed

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Indications for Extending Length

• Greater trochanter compromised by osteopenia or
  osteolysis - osteotomy lengthening ensures
  adequate amount of lateral bone for fixation
• Proximal medial bone loss - osteotomy extended
  into diaphysis so adequate medial bone is
  available for wire or cable fixation of the
  osteotomy

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Need for Increased Exposure

• Osteotomy choice is based on the required
  exposure
• Anterior trochanteric slide - exposes metaphysis
  of femur to the level of the lesser trochanter
• Conventional trochanteric - metaphysis of femur
  with improved acetabular, anterior wall, and
  ilium exposure

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Cont.

• Extended trochanteric slide - acetabular exposure
  of simple anterior trochanteric slide with better
  femoral exposure
• Extended conventional osteotomy - maximizes
  exposure of femur and acetabulum

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Revision Surgical Approach

• Posterolateral
• Previous incision is posterolateral or direct
  lateral - use the same incision
• New incision - landmarks are halfway b/w anterior
  and posterior borders of greater trochanter to
  allow more anterior exposure

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New Incision (cont.)

• Upper half - parallel to fiber of gluteus maximus
• Lower half - longitudinal extension toward the
  knee
• Gluteus Maximus insertion to femur is released to
  expose sciatic nerve - failure to do so increases
  the risk of constriction of the nerve by
  retraction

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Revision Surgical Approach (cont.)

• Retained femoral component - anterior capsule is
  divided to effect anterior displacement of the
  femur.
• Iliopsoas tendon sheath is entered to define
  plane and the capsule is divided from the inside
  out, starting distally at the lesser trochanter gt
  retractor placed over acetabulum to displace
  femur anteriorly

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Anterior Trochanteric Slide

• Indications
• Femoral - 1) removal of well-fixed proximal
  porous coated prosthesis 2) removal of failed
  endoprosthesis with bone fenestrations. Anterior
  and posterior femoral components can be reached
  with a osteotome

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Anterior Trochanteric Slide (cont)

• Acetabular - 1) acetabular protusio without easy
  dislocation 2)acetabular revision cases with
  femoral component retention.
• Small size of trochanteric fragment limits
  indications 1) If acetabular revision results in
  leg lengthening, fragment may not reach femoral
  bone for attachment. 2) Absence of medial bone
  for securing wires of cables.

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Technique for Anterior Trochanteric Slide

• 1) Posteriolateral approach extended 2 inches
  distally
• 2) elevate posterior border of vastus lateralis
  to the greater trochanter
• 3) expose gluteus medius by external rotation
• 4) Develop plane between gluteus medius and
  gluteus minimus

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Technique (cont.)

• 5) Osteotomy performed in internal rotation with
  distal margin below insertion of the v.
  lateralis, and the superior margin lateral to the
  piriformis fossa b/w the medius and minimus
  insertions.
• 6) Reattach the tochanteric fragment with 18
  gauge wires or cables through or below the lesser
  trochanter and through the greater trochanter

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Extended Conventional Trochanteric Osteotomy

• Indications - Extensive acetabular bone stock
  damage and difficult acetabular revisions where
  excessive leg lengthening can occur.
• Contraindications - Retention of a well fixed
  femoral component

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Technique

• 1) Distal margin - 5 cm. Distal to the greater
  trochanter on the lateral femoral shaft
• 2) Proximal margin - exits the greater trochanter
  between the gluteus medius and superior hip
  capsule
• 3) Vastus lateralis is stripped
• 4) Internal rotation - isolate posterior margin
  of gluteus medius

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Technique (cont.)

• 5) External rotation - isolate anterior margin of
  gluteus medius
• 6) Osteotomy cuts are made through lateral half
  of periosteal surface and lateral third of
  endosteal surface
• 7) Reflect osteotomy with care to protect
  inferior gluteal nerve
• Repair with 2 wires or cables

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Post-Operative Rehabilitation

• Based on the stability of trochanteric attachment
• ROM limitations determined intraoperatively
• Fixation strength of trochanter is determined by
  stressing the trochanter with adduction and ROM
• FWB _at_ 3 months

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Rehab (cont.)

• PROM without adduction within the recorded limits
  of hip stability recorded intraoperatively
• No hip flexion or adduction for 6 weeks

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Vascular Schaphoid Window for Access to Femoral
Canal In Revision THA

• Jeff Easom, D.O.
• Garden City Hospital

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Introduction

• Removal of distal cement from femoral canal
  involves substantial risks of canal perforation
• Cement removal that extends beyond apex of
  anterior femoral bow may not be possible
• cortical perforation increases the risk of later
  femoral fracture

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• Measures taken are controlled windows and
  extended osteotomies.

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Femoral Windows

• Muller - 1cm X 20cm anterior gutter
• Nelson and Weber - Lateral rectangular window 2cm
  wide x 6cm long
• Sydney and Mallory - Serial 9 mm perforations to
  guide instruments and afford access for punches
  to remove broken stems - 9 post-op frxs. Of 219
  cases

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Femoral Windows (cont.)

• Shepherd and Turnbull - 1 cm by 2 cm window on
  the anterior surface of femur b/w 3.2mm drill
  holes without replacement fixation - early
  healing and good results
• Klein and Rubash - Shepherd window creations with
  size of 2 cm by 5 cm - complete detachment from
  soft tissue with fixation by cerclage wires -
  mean healing 17 weeks and no post-op fractures.

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Extended Femoral Osteotomy

• Extension of a trochanteric osteotomy distally
  along femoral shaft
• Peters and Assoc. - good results
• Younger and Assoc. - 20 cases with extended
  osteotomy of greater trochanter with 1/3 of
  cortical diameter of the femur hinged anteriorly
  with preservation of blood supply by soft-tissue
  attachments-healing _at_ 3 months

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Advantages

• Ease of component and cement extraction
• Superior visualization of the distal femoral
  canal, which allows mor accurate preparation of
  distal femur and eliminates varus placement of
  revision implant.

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Advantages (cont.)

• Anterolateral, posterior, or combined approaches
  to hip joint itself may be implemented

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Vascularized Schaphoid Window Technique

• Lateral incision 30 degrees posteriorly proximal
  to the greater trochanter
• Extend incision to beyond distal extent of
  proposed osteotomy
• elevate vastus lateralis width of 1cm to expose
  lateral femur - maintains blood supply by
  muscular attaachments

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Technique (cont.)

• Scaphoid osteotomy - Through both cortices of
  femur lateral to medial with incorporation of
  smooth rounded edges.
• Avoid muscle stripping
• Replace with 1 or more cerclage wires
• Reimplantation devices should bypass the window
  by _at_ least 2 cortical diameters with protected
  weightbearing for 12 weeks.

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Conclusion

• Combines the advantages and avoids the
  disadvantages of other osteotomies.
• Afford an approach that give excellent exposure
  of the femoral canal over whatever length is
  require for safe implant and cement removal
• Permits all reconstructive possibilities and
  minimizes risk of complicaitons (nonunion of
  window and fracture).

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