Revision Total Hip Arthroplasty

Vancouver classification guides treatment. B2-B3 require stem revision. Acetabular fractures with loose component require revision.

Severe liner wear causing osteolysis. Isolated liner exchange if components well-fixed and no bone loss. Otherwise, cup revision indicated.

Metal-on-metal tribocorrosion. Elevated cobalt/chromium ions, pseudotumor formation. Revision to ceramic or polyethylene bearing.

Ceramic liner fracture, modular neck fracture, dissociation. Rare but catastrophic. Requires complete revision.

100-point scale: pain (44), function (47), ROM (5), deformity (4). Score under 70 = poor, 70-79 = fair, 80-89 = good, 90-100 = excellent.

Western Ontario and McMaster Universities Osteoarthritis Index. 24 items covering pain, stiffness, function. Sensitive to change in revision.

12-item patient questionnaire. Score 0-48 (48 = best). Quick, validated for revision populations.

AP pelvis and lateral hip. Assess Paprosky classification, measure migration, evaluate bone loss. Full-length femur (AP) including knee to assess femoral canal and plan stem length.

45-degree obturator and iliac obliques. Assess posterior and anterior column integrity. Essential for detecting pelvic discontinuity. Iliac oblique shows anterior column, obturator shows posterior column.

3D reconstruction of pelvis and femur. Measure precise bone loss volumes. Plan custom implants (triflange). Gold standard for pelvic discontinuity detection. Essential for preoperative planning in Paprosky IIIB.

Metal artifact reduction sequences (MARS) for pseudotumor in metal-on-metal bearings. Assess soft tissue (abductor tears). Not routinely needed for standard aseptic loosening.

Bone loss: Minimal, rim intact, hemisphere preserved. Treatment: Standard hemispherical uncemented cup. Ream to bleeding bone, under-ream 1-2mm for press-fit. Supplemental screws optional. Expected outcome: 85-90% survival at 10 years.

Bone loss: Superior or medial deficiency, distorted hemisphere, rim partially supportive. Treatment: Hemispherical cup (may be oversized) with medial bone graft (Type IIA) or superior support (Type IIB). Screws for supplemental fixation. Expected outcome: 80-85% survival at 10 years.

Bone loss: Superior migration under 3cm, teardrop obscured, over 50% rim supportive. Treatment: Jumbo cup (62-66mm) with superior metal augments or structural allograft. Multiple screws. Restore anatomic hip center. Expected outcome: 75-85% survival at 10 years.

Bone loss: Superior migration over 3cm, medial wall deficient, under 50% rim supportive. Treatment: Cup-cage construct (uncemented cup + Burch-Schneider cage) OR custom triflange (3D-planned flanges to ilium/ischium/pubis). If pelvic discontinuity: Column plating first. Expected outcome: 70-80% survival at 10 years.

Bone loss: Minimal metaphyseal loss, diaphysis intact. Treatment: Standard length cementless stem with proximal fixation. Metaphyseal fit and fill. Expected outcome: 90-95% survival at 10 years.

Bone loss: Extensive metaphyseal damage, diaphysis over 4cm intact. Treatment: Extensively porous-coated diaphyseal-fitting stem. Bypass metaphysis, achieve distal fixation. Length 180-220mm typical. Expected outcome: 90-95% survival at 10 years.

Bone loss: Metaphysis nonsupportive, diaphysis over 4cm intact, isthmus preserved. Treatment: Modular tapered stem with proximal body for offset adjustment and distal fluted taper for diaphyseal fixation. Often requires ETO for well-fixed stem removal. Length 220-300mm. Expected outcome: 85-90% survival at 10 years.

Bone loss: Extensive diaphyseal damage, isthmus widened (IIIB) or severe cortical thinning (IV). Treatment: Modular tapered long stem with cortical strut allografts OR impaction bone grafting OR allograft-prosthetic composite. Reserved for extreme bone loss. Expected outcome: 70-80% survival at 10 years (salvage scenarios).

Remove liner first if modular. Use liner extraction tool. Identify locking mechanism. Protects metal shell during extraction attempts.

Determine if cup well-fixed or loose. Insert curved osteotomes at cup-bone interface. If loose, cup will mobilize easily. If well-fixed, proceed cautiously.

Remove all screws if accessible. Use screw extractor if heads stripped. Cut screws flush if inaccessible. Screw retention may aid new cup fixation (leave if not interfering).

Sequential osteotomes around entire periphery. Work from superior to inferior. Gigli saw if rigidly fixed. Avoid excessive force causing bone loss. Explant tool with slap hammer for final removal.

Closed suction drain for 24-48 hours. Remove when output under 30ml per 8 hours. Reduce hematoma risk.

Posterior capsule repair if using posterior approach. Enhances stability. External rotators reattached to greater trochanter.

Deep fascia closed in layers with absorbable suture. Avoid tension. Ensure hemostasis.

Subcuticular closure or staples. Sterile dressing. Abduction pillow if instability concern.

DVT prophylaxis: Chemical (LMWH or rivaroxaban) + mechanical (sequential compression). Continue for 35 days. Pain management: Multimodal analgesia - paracetamol, NSAIDs if no contraindication, opioids as needed. Drain removal: When output under 30ml per 8 hours, typically 24-48 hours.

Weight-bearing status: Depends on fixation and bone quality.

• Standard revision (good fixation): Touch weight-bearing to partial weight-bearing
• Structural graft or cage: Touch weight-bearing for 6-12 weeks
• ETO: Partial weight-bearing for 6-12 weeks until union Mobilize with physiotherapy: Walker or crutches. Hip precautions if posterior approach.

Wound check: Monitor for drainage, erythema, dehiscence. Functional goals: Independent transfers, toilet, short distances with walking aid. Discharge criteria: Pain controlled, mobilizing safely, home supports arranged.

Radiographs: AP pelvis, lateral hip. Assess component position, bone healing, no loosening. Weight-bearing advancement: If good fixation and no pain, progress to full weight-bearing. Continue protected if structural graft or ETO. Remove hip precautions: If stable construct and posterior repair intact.

Abductor strengthening: Critical for Trendelenburg gait prevention. Side-lying hip abduction, resistance band exercises. Hip flexor and extensor strengthening: Improve gait mechanics. Progress weight-bearing: Transition from two crutches to one cane to no aid as tolerated.

Expected function: Walking unlimited distances with or without cane. Stairs manageable. Return to sedentary work. Radiographs: Confirm stable implants, bone healing, no osteolysis.

Peak function: Most patients reach maximal improvement by 12 months. Return to low-impact activities. Surveillance: Annual radiographs first 2 years, then every 2 years. Monitor for loosening, wear, osteolysis.

Activity modification: Avoid high-impact sports (running, jumping). Low-impact activities encouraged (swimming, cycling, golf). Registry follow-up: Participate in AOANJRR if in Australia. Monitor symptoms and seek review if new pain or instability.

Symptomatic loosening typically triaged as Category 2 (target treatment within 90 days). Severe pain or bone loss threatening viability may warrant Category 1 (urgent, within 30 days).

Mandatory: CRP, ESR, radiographs (AP pelvis, lateral hip, full femur), hip aspiration if inflammatory markers elevated. CT scan if complex bone loss. Cardiac and anesthesia clearance.

Length of stay: Average 5-7 days vs 2-3 for primary. Blood cross-match 2-4 units. DVT prophylaxis 35 days. Physiotherapy daily. Occupational therapy for home modifications.

Supports: Arrange home modifications, community physiotherapy, walking aids. Follow-up at 6 weeks, 3 months, 12 months, then annually. Registry reporting.