1. Revision Hip Replacement Richard Boden Consultant Trauma and Lower Limb Orthopaedic Surgeon (locum) Lancashire Teaching Hospitals NHS Foundation Trust

2. Overview • Background of THR • THR Failure • Aims of Revision • Basic Technique • Complications • Cases • Questions

3. Background • 86,488 hips in 2012 • 7.5% increase • Revision hips 12% • 11% 2011

4. TJA Volume Estimates

5. Age at THR

6. Age at THR Av Age 68.7 yrs

7. BMI

8. BMI

9. BMI

10. Failure Method

11. Failure Method

12. Failure Method

13. Failure Method

14. Aims of Revision Hip • Removal loose components • Limit destruction of host bone/soft tissue • Reconstruction bone defects • Metal • Bone Graft • Stable revision implants • Restore normal hip COR (biomechanics)

15. Timing of THR Failure • Early • Recurrent dislocation • Infection • Implant failure • Intra-operative fracture • Later • Wear of bearing surface • Osteolysis • Mechanical loosening • Infection • Peri-prosthetic fracture • Metal on Metal

16. Timing of THR Failure • Early • Recurrent dislocation • Infection • Implant failure • Intra-operative fracture • Late • Wear of bearing surface • Osteolysis • Mechanical loosening • Infection • Peri-prosthetic fracture • Metal on Metal

17. Timing of THR Failure • 1.8% failure 9 years

18. Aseptic/Mechanical Loosening • Most common indication for revision • Regular radiological follow-up • Observe zones • Observe progression • Note symptoms • Early to avoid depleted bone stock

19. Aseptic/Mechanical Loosening Gruen DeLee-Charnley

20. Wear of Articular Bearing Surface • Bearing • Traditional Poly • UHMWPE • Ceramic • Metal • Ceramic • Fractures? • SQUEAKS

21. Osteolysis • Tissue response to wear debris • Debris  Phagocytosis  Macrophage activation  OSTEOLYSIS • Most common with TRADITIONAL polyethylene bearings

22. Dislocation/Instability • Dislocation 1-2% • Component position • Acetabulum • Femoral • Soft tissue • Tension (offset) • Function • Components used • Head size • Constrained

23. Metal on Metal Hips

24. Metal on Metal Hips

25. Metal on Metal Hips

26. Metal on Metal Hips

27. Peri-Prosthetic Fracture • Stress risers • Osteoporotic bone • Implant fixation • Vancouver: • A- trochanteric • B- prosthesis • 1- Implant stable • 2- Implant loose • 3- plus poor bone • C- distal

28. Infection • Clean air theatre • Elective wards • Skin prep • Surgical technique • Time • Tissue handling • Patient factors • Abx v Surgery?

29. Infection • 90% Gram Positives • Staph Aureus • CNS • But Gram Negatives increasing! • Only 12% have systemic symptoms

30. Infection • Early < 3 weeks • Late > 3 weeks • Cure with DAIR • < 1 week up to 90% • 1 – 2 weeks 50/50 • 3 weeks plus <10%

31. Infection Single Stage Stage 1 Stage 2 Hip Excision 24% 37% 36% 3% Up to 90% cure

32. Radical Debridement • Essential to the procedure • Treat like a tumour

33. Cost of Revision

34. Cost of Revision

35. Revision • Much more difficult than primary • Poor results (comparatively) • Up to 20% infection rate • 29% failure at 8 years • 5% dislocation risk • Require excellent pre-op planning with good choice of implant

36. Pre-op • Good films, long leg AP and Lat. • CT for acetabulum? • Get original op note for component size and make • Get equipment to remove • Order bone struts etc. • Have a good choice of prosthesis

37. Surgery - Femur • Use previous skin incision if possible • In-cement revision • Cement out from top? • Extended trochanteric osteotomy • Radical debridement in infection • Bypass stress-riser with long stem

38. Surgery - Acetabulum • Consider uncemented with screws if rim is intact (or at least 2/3) • Bone graft defects (controversial in infection) • Structural allograft in large defect • High failure rate (40%) if resorbed • Mesh? Cage? Trabecular metal? • Constrained liner??

39. Summary • Monitor new pains • Startup pain • Groin pain • Suspect wear and loosening • Suspect infection • Check XR • Early referral

40. Thank You