Revision Hip ReplacementRichard BodenConsultant Trauma and Lower Limb Orthopaedic Surgeon (locum) Lancashire Teaching Hospitals NHS Foundation TrustOverview Background of THR THR Failure Aims of Revision Basic Technique Complications Cases QuestionsBackground 86,488 hips in 2012 7.5% increase Revision hips 12% 11% 2011TJA Volume EstimatesAge at THRAge at THRAv Age 68.7 yrsBMIBMIBMIFailure MethodFailure MethodMethodPercentage1Aseptic Loosening40%2Pain23%3Dislocation/Subluxation13%LysisSoft Tissue Reaction6Infection12%Acetabular Component Wear8Periprosthetic Fracture8%9Malalignment5%10Implant Failure3%Failure MethodMethodPercentage1Aseptic Loosening40%2Pain23%3Dislocation/Subluxation13%LysisSoft Tissue Reaction6Infection12%Acetabular Component Wear8Periprosthetic Fracture8%9Malalignment5%10Implant Failure3%Failure MethodMethodPercentage1Aseptic Loosening40%2Pain23%3Dislocation/Subluxation13%Lysis13%Soft Tissue Reaction13%6Infection12%Acetabular Component Wear12%8Periprosthetic Fracture8%9Malalignment5%83%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)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 MetalTiming 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 MetalTiming of THR Failure 1.8% failure 9 yearsAseptic/Mechanical Loosening Most common indication for revision Regular radiological follow- up Observe zones Observe progression Note symptoms Early to avoid depleted bone stockAseptic/Mechanical LooseningGruenDeLee-CharnleyWear of Articular Bearing Surface Bearing Traditional Poly UHMWPE Ceramic Metal Ceramic Fractures? SQUEAKSOsteolysis Tissue response to wear debris Debris Phagocytosis Macrophage activation OSTEOLYSIS Most common with TRADITIONAL polyethylene bearingsDislocation/Instability Dislocation 1-2% Component position Acetabulum Femoral Soft tissue Tension (offset) Function Components used Head size ConstrainedMetal on Metal HipsMetal on Metal HipsMetal on Metal HipsMetal on Metal HipsPeri-Prosthetic Fracture Stress risers Osteoporotic bone Implant fixation Vancouver: A- trochanteric B- prosthesis 1- Implant stable 2- Implant loose 3- plus poor bone C- distalInfection Clean air theatre Elective wards Skin prep Surgical technique Time Tissue handling Patient factors Abx v Surgery?Infection 90% Gram Positives Staph Aureus CNS But Gram Negatives increasing! Only 12% have systemic symptomsInfection Early 3 weeks Cure with DAIR 1 week up to 90% 1 2 weeks 50/50 3 weeks plus 10%InfectionSingle Stage Stage 1 Stage 2 Hip Excision 24% 37% 36% 3% Up to 90% cureRadical Debridement Essential to the procedure Treat like a tumourCost of RevisionActivityCost per case Total Income10,097Total Costs11,998 (-1,901)Theatre 3,181Nursing 1,610Corporate Costs 1,217Prosthetics 1,132Consultant 746Site costs 688Drugs 438Radiology 96Pathology 94Pharmacy 88Cost of RevisionProcedureLOS (days) Total Cost Periprosthetic Fracture1618,400 1st Stage/Pseudarthrosis1714,240Exchange Resurfacing68,980 Direct Exchange79,230Revision 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 implantPre-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 prosthesisSurgery - 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 stemSurgery - 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?Summary Monitor new pains Startup pain Groin pain Suspect wear and loosening Suspect infection Check XR Early referralThank You