Revision Total Hip Arthroplasty - Acetabular Component
intermediate Level
Primary Indication
Aseptic loosening, instability, wear, osteolysis of acetabular component
Danger Structures
Superior gluteal nerve - exits greater sciatic notch 25-40mm proximal to tip of greater trochanter, supplies gluteus medius and minimus, injury causes irreversible abductor weakness and Trendelenburg gait - EXAM KEY: stay within 5cm distal to greater trochanter tip (safe zone), never extend split proximally beyond this
Inferior gluteal nerve - enters gluteus maximus 20-30mm inferior to piriformis, injury rare in lateral approach - EXAM KEY: protected by staying anterior to muscle belly
Femoral nerve - lies 40-60mm anterior/medial to surgical field, at risk with over-aggressive anterior retractor placement - EXAM KEY: anterior retractor should stay on bone (ilium/acetabular rim), never slide medially
Sciatic nerve - runs 30-40mm posterior to hip joint, less at risk than posterior approach but can be injured with posterior retractor - EXAM KEY: posterior retractor should stay on ischium/posterior wall, limit retraction time
Lateral femoral cutaneous nerve - runs 50-70mm anterior/superior to incision, generally safe in direct lateral approach - EXAM KEY: incision centered on GT, not extending too far anterior/superior
Profunda femoris artery with medial/lateral femoral circumflex branches - at risk during vastus lateralis mobilization 40-50mm distal to lesser trochanter - EXAM KEY: subperiosteal dissection along vastus ridge protects vessels
Visual Atlas
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Step-by-Step Technique
1
Extended posterior approach with trochanteric slide if needed
2
Careful exposure preserving abductors
3
Identify and protect sciatic nerve (may be scarred)
4
Remove polyethylene liner first
5
Curved osteotomes around cup-bone interface
6
Specialized extraction devices for well-fixed cups
7
Assess bone loss - Paprosky classification
8
Ream to bleeding bone
9
Structural allograft for cavitary defects
10
Augments or cups with flanges for segmental defects
11
Trial component - assess stability and coverage
12
Consider cup-cage construct for severe deficiency
13
Press-fit porous coated cup or cemented cup
14
Multiple screws in dome and posterior column
15
Highly cross-linked poly liner, consider constrained if instability