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Cemented Femoral Revision in Total Hip Arthroplasty: A View in the 21st Century

Key Points Cement-bone interface strength is reduced in revisions owing to loss of cancellous bone and less cement interdigitation with bone. The historical rate of cemented femoral component failure was high when cemented revisions were used in all cases owing to mechanical failure of the cement-bone interface. Cemented femoral revision now is used mostly in first-time revisions of older, low-demand patients in whom good cancellous bone…

Femoral Revision: Classification of Bone Defects and Treatment Options

Key Points Failure of a primary total hip arthroplasty (THA) typically occurs with varying degrees of femoral bone loss. Classifying femoral bone defects is a critical part of the preoperative planning required for a successful revision THA. Paprosky, the American Academy of Orthopaedic Surgeons, Endo-Klink, Mallory, Saleh et al., Engh and Glassman, Gustillo and Pasternak, and Chandler and Penenberg have all published classification systems that differ in…

Acetabular Revision With Metal Cup Augments or Cage Construct

Key Points Several key steps are required to maximize the chance of a successful reconstruction and durable long-term fixation: Obtain excellent acetabular exposure and visualization. Minimize bone damage during prior implant removal. Cancellous bone grafting of contained bone defects. Maximize implant contact on host bone. Gain rigid initial fixation of the implant to allow subsequent bone ingrowth (with adjunctive fixation or support as needed). Major bone…

Acetabular Revision With Custom Implants

Key Points A thorough preoperative radiographic examination, including thin-slice computed tomography, is necessary to evaluate osseous defects and help identify a pelvic discontinuity. Extensive planning is necessary in the design of custom triflanged acetabular components (CTACs), which is a dynamic process often requiring multiple iterations. Obtaining an adequate buttress between the implant and remaining ilium is vital to reducing shear stresses on the flange screws. Failure…

Acetabular Revision: Impaction Bone Grafting

Key Points Acetabular impaction grafting allows restoration of bone stock and normal hip biomechanics. Acetabular impaction grafting is particularly successful as a technique for the reconstruction of cavitary defects. It is a technically exacting procedure; attention to surgical detail is required for successful results. The creation of a stable, contained acetabular defect is essential to its success. Secure fixation of mesh using appropriately placed screws is…

Acetabular Revision: Uncemented Hemispheric Components

Key Points A cementless hemispheric acetabular component has become the preferred system to employ for most acetabular revisions. Radiographic evidence of polyethylene wear with significant osteolysis warrants acetabular revision even in the absence of clinical or functional symptoms. The most critical feature of preoperative planning is careful evaluation of anteroposterior (AP) and lateral radiographs. A computed tomography (CT) scan with 3-dimensional (3D) reconstructions can be extremely…

Acetabular Reconstruction: Classification of Bone Defects and Treatment Options

Key Points Successful reconstruction of the acetabulum during revision total hip arthroplasty requires a thorough understanding of host bone defects. In an attempt to better define these defects, classification systems are used. The most commonly used systems are the American Academy of Orthopaedic Surgeons (AAOS) and Paprosky classifications of acetabular defects. The Paprosky classification is based on the anteroposterior pelvis radiograph. It uses radiographic criteria to…

Osteolysis Around Well-Fixed Total Hip Arthroplasty

Key Points Osteolytic lesions of the pelvis that progress over a 3- to 6-month period in patients with osseointegrated cementless sockets are an indication for operative treatment. Severe polyethylene wear may justify a lower threshold for treatment because it is optimal to intervene before the time when the head wears through the liner and engages the shell. Key factors in determining whether the well-fixed shell can…

Implant Removal in Revision Hip Arthroplasty

Key Points Ensuring maximum possible intact host bone following implant removal provides an optimum platform on which to build a successful hip reconstruction. Successful implant removal depends on careful preoperative planning, which cannot be separated from planning for subsequent hip reconstruction. Choice of surgical approach is determined by the design of the implant to be removed, implant fixation, the appreciated cause of implant failure, and surgical…

Preoperative Planning and Templating for Revision Hip Arthroplasty

Key Points Preoperative planning begins with a thorough history and physical examination to determine the cause and location of hip pain, the general medical condition of the patient, and the functional goals of the patient. Radiographic evaluation is helpful in determining the cause of hip arthroplasty failure and in assessing component type, component alignment, bone stock, and infectious or osteolytic processes. Infection is a source of…

Evaluation of the Failed Total Hip Arthroplasty

Key Points A thorough history and physical must be performed when evaluating a patient with a symptomatic total hip arthroplasty (THA) to establish an accurate diagnosis. The clinician needs to differentiate between intraarticular and extraarticular causes of pain. Ruling out infection should be part of every workup of a failed THA. A complete series of radiographs and previous reports need to be obtained to make the…

Acute Femoral Neck Fracture

Key Points Bipolar/monopolar hemiarthroplasty treatment for displaced femoral neck fractures is best in the elderly population with comorbidities. Total hip arthroplasty for displaced femoral neck fractures is best in healthier, more active, and younger patients for management of displaced femoral neck fractures. Modern treatment protocols for displaced femoral neck fractures decrease complications. Cemented femoral stem fixation for displaced femoral neck fractures improves outcomes by decreasing some…

High Body Mass Index

Key Points Careful preoperative planning, along with pharmacologic consultation, is essential for optimal results in obese patients undergoing total hip arthroplasty (THA). Early postoperative mobilization, although possibly more difficult for obese patients, is critical to avoid decline in function as well as thromboembolic and respiratory complications. Intraoperative radiographic evaluation is important in obese THA patients to assist the surgeon in attaining proper acetabular cup placement and…

Sickle Cell Disease

Key Points Sickle cell disease is a systemic disorder that requires a thorough preoperative evaluation in close coordination with multiple comanaging services. Preoperative blood transfusion according to a standardized protocol managed by an experienced hematologist may reduce the risk of postoperative vaso-occlusive crisis and acute chest syndrome. Cortical thinning and medullary sclerosis of the proximal femur increases the risk of intraoperative fracture and cortical perforation; modified…

Protrusio Acetabuli

Key Points The clinical signs of protrusio acetabuli are groin pain, limited hip abduction and, often, a hip flexion contracture. Deepening of the acetabulum leads to painful limitation of abduction as the femoral neck impinges on the superior acetabular margin. Further progression may lead to adductor spasm, and fixed flexion deformities develop. There is often hyperlordosis of the lumbar spine, which compensates for the fixed flexion…

Previous Hip Arthrodesis

Key Points Conversion of a previously arthrodesed hip to total hip replacement is indicated for pain relief in surrounding joints (low back, ipsilateral knee, contralateral hip). However, patients may also seek conversion because of the disability related to an immobile hip or before undergoing ipsilateral total knee replacement. Surgical exposure is dependent on the type of arthrodesis and presence and location of hardware but typically requires…

The Neuromuscular Hip

Key Points Neuromuscular hip disorders can be classified as intrinsic or extrinsic. Both types may be spastic or flaccid. Patients with intrinsic neuromuscular disorders (e.g., cerebral palsy and myelomeningocele), or in whom a neuromuscular affliction occurs while the hip is still in early development (e.g., poliomyelitis, encephalitis, cerebrovascular accident, childhood spinal cord injury, and brain trauma), are at increased risk for hip subluxation-dislocation. Treatment options for…

Osteonecrosis of the Hip

Key Points Characteristics common among patients with avascular necrosis (AVN) of the hip: Present at a younger age than patients with osteoarthritis (OA) of the hip Systemic disease or condition associated with the osteonecrosis Abnormal bone quality of the hip and femur Total hip arthroplasty (THA) poses a unique set of challenges in patients with AVN: Poor bone quality of the hip and femur Previous surgical…

Metabolic Bone Disease

Key Points Patients with metabolic bone disease have a heterogeneous variety of disorders with very different pathophysiologies and associated decision-making and technical challenges related to hip surgery. The most common metabolic bone problems leading to total hip arthroplasty (THA) are Paget disease and severe renal disease, which are the focus of this chapter. Patients with Paget disease scheduled for THA should undergo a complete preoperative medical…

Proximal Femoral Deformity

Key Points Proximal femoral deformity may be iatrogenic or develop as a consequence of a pathologic process. Treatment of proximal femoral deformity with total hip arthroplasty (THA) is challenging and requires careful preoperative planning. The surgeon considering THA for proximal femoral deformity with previous surgery should have a high index of suspicion for infection. Correction of the deformity is not always necessary. Corrective osteotomy may need…