Direct Anterior Approach to Revision Total Hip Arthroplasty

A 69-year-old woman underwent primary total hip arthroplasty (THA) using a direct anterior approach without apparent complications ( Fig. 51.1 ). She presented to a local emergency department complaining of increased right hip pain and an inability to bear weight on the affected limb. She denied any preceding trauma or injury. Radiographs revealed significant subsidence of the stem without an obvious fracture ( Fig. 51.2 ), and after a discussion with the primary surgeon, she was discharged to her home with instructions not to bear weight on the leg. She presented to the emergency department 1 week later with severe pain, an inability to ambulate, and drainage from the incision. Radiographs ( Fig. 51.3 ) revealed a periprosthetic fracture with subsidence. The patient was treated conservatively with protected weight bearing for 6 weeks.

She presented to my office approximately 1 year after the initial surgery complaining of an inability to ambulate because of pain and significant shortening of the limb. She could perform transfers with difficulty and could ambulate minimally with a 1-inch external shoe lift placed by the operating surgeon. On physical examination, she appeared to be nontoxic, and using a walker, she ambulated with an obvious Trendelenburg lurch. Her incision was well healed with no signs of infection, but she described hip, groin, and thigh pain with hip range of motion and weight-bearing activities. Radiographs revealed obvious subsidence of the stem, a healed malunion of the proximal metaphysis of the femur, and significant shortening of the limb ( Fig. 51.4 ). Results of the laboratory workup for infection were negative.

After discussing the treatment options with the patient, she underwent revision THA through her previous direct anterior incision. The femoral component was revised with a modular, tapered, distal-fitting stem (Reclaim Modular Revision Hip System, DePuy, Warsaw, Ind.) ( Fig. 51.5 ). Exposure was augmented with an iliac wing osteotomy ( Fig. 51.6 ) to improve femoral access. Postoperatively, no hip precautions were instituted, and no abduction wedge or knee immobilizer was used. Weight bearing was protected by 50% solely for the iliac wing osteotomy for 2 weeks, and the patient was able to ambulate with the use of a cane at 3 weeks. Follow-up radiographs at 3 months ( Fig. 51.7 ) revealed complete healing of the osteotomy and incorporation of the stem, which resolved the patient’s pain and leg length discrepancy and restored a near-normal gait and unrestricted activity.