REVISION HIP ARTHROPLASTY An easy procedure ? Panayot Tanchev Gorna Bania University Hospital of Orthopaedics Sofia, Bulgaria

THE CHALLENGE REVISION IS NOT DIFFICULT ! T. Gehrke In: The Well-Cemented Total Hip Arthroplasty, eds. S.J. Breusch and H. Malchau, Springer, 2005 Really ? I strongly question this statement on the basis of a 30-year experience with over 3000 THA !!! No problem, Doggy ! It’s just a balloon

SWEDISH HIP ARTHOPLASTY REGISTER (Annual report 2007) RELATIVE DISTRIBUTION OF REASONS FOR REVISION 1979 - 2007 ASEPTIC LOOSENING - 74.3% DEEP INFECTION - 7.4% FRACTURE - 6.1% DISLOCATION - 8.0% TECHNICAL ERROR - 2.1% OTHERS - 2.2%

SWEDISH HIP ARTHOPLASTY REGISTER (Annual report 2007) Cumulative frequency of revisions (1- 27 postoperative years) Aseptic loosening 0 → 20% Deep infection 0.5 → 1.3% Dislocation 0.2 → 1.0%

REVISION RISK PER NUMBER OF THA/YEAR < 10 cases – 12% - < 30 cases – 8% - > 80 cases – 5% % of hips revised drops with experience C.R. Howie, Revision. The size of the problem, 2007 Espehaug et al. Acta Orthop. Scand., 1999 Coyte P.C. JBJS Am. , 1999

OUR DATA (01. 2006 - 12. 2008) Second Orthop OUR DATA (01.2006 - 12.2008) Second Orthop. Clinic, Gorna Bania Uni-Hospital ANTERO-LATERAL APPROACH (Watson-Jones) 80% CEMENTED THA 20% HYBRID THA (Etropal screw cup or Expansys cemetless cup, femoral stem – cemented) ANTIBIOTIC AND ANTITHROMBOTIC PROPHYLAXIS – MANDATORY ! EARLY AMBULATION ON 2 CRUTCHES FULL WEGHT BEARING AFTER 3RD P.O. MONTH

OUR DATA (01. 2006 - 12. 2008) Second Orthop OUR DATA (01.2006 - 12.2008) Second Orthop. Clinic, Gorna Bania Uni-Hospital 2006 2007 2008 Total Primary THA 187 155 152 494 Revisions 17 14 10 41 204 169 162 535 Crude Revision Rate 7.6%

OUR DATA (01. 2006 - 12. 2008) Second Orthop OUR DATA (01.2006 - 12.2008) Second Orthop. Clinic, Gorna Bania Uni-Hospital DISTRIBUTION OF REASONS FOR REVISION 2006 2007 2008 Aseptic loosening (%) 82 93 92 Infection (%) 12 7 10 Dislocation (%) 6

OUR DATA (01. 2006 - 12. 2008) Second Orthop OUR DATA (01.2006 - 12.2008) Second Orthop. Clinic, Gorna Bania Uni-Hospital CUMULATIVE FREQUENCY OF REVISIONS TOTAL PRIMARY THA 535 TOTAL REVISIONS 41 (7.6%) ASEPTIC LOOSENING / FRACTURES 36 (6.75%) DEEP INFECTION 4 (0.75%) DISLOCATION 1 (0.19%)

ASEPTIC LOOSENING In our series (6.75%) Most frequent reason for 2009 2009 D.I. ♀ 50 y. 2002 Most frequent reason for revisions (up to 75%) Prevalence also differs widely in the different publications, increasing with the number of postoperative years ( 0 → 20% according to the Swedish Hip Register, 1 → 27 years p.o. ) A large variety of technical solutions and treatment approach D.I. ♀ 57 y. D. I. ♀ 50 y. Coxarthrosis dyspl. sin. Cemented THA (2002) 7 years later – severe osteolysis and aseptic loosening of both implants Cemented reimplantation of a big size stem because of significant bone loss, transtrochanteric approach 2009 In our series (6.75%) D.I. ♀ 57 y.

ASEPTIC LOOSENING (cont’d) A.I.♂ 65 y. Alexandar J.♂ 65 y. Bilateral coxarthrosis, THA bilaterally (2005) 4 years later → osteolysis of the femoral canal and loosening of right stem Reimplantation of a cemented stem, titanium mesh funnel and autologous bone grafts 2005 A.I.♂ 65y. 2009 A.I.♂ 69 y. 2009 A.I.♂ 69 y.

ASEPTIC LOOSENING (cont’d) Nedelka K. ♀ 61 y. Dysplastic coxarthrosis with concommitant AVN; Hybrid THA(1995) 14 years later (75 y.) → Acetabular cup wear and loosening Reimplantation of a new acetabular cup, femoral stem was stable and was not exchanged, transtrochanteric approach N.K.♀ 1995 N.K.♀ 1995 N.K.♀ 2009 Reendo N.K.♀ 2009

ASEPTIC LOOSENING (cont’d) Rilka G. ♀ 45 y. Dysplastic coxarthrosis dex.; Hybrid THA(1983) 24 years later – complaints and x-ray data for loosening of both implants; rejected revision THA; one year later → in the age of 70 worsening of complaints, and breakage of stem Reimplantation with short stem prostheis, distal part of stem left in situ R.G. ♀ 45 y. 1983 R R R 2008 R 2007

ASEPTIC LOOSENING (cont’d) Anka I. ♀ 48 y. Coxarthrosis dex.; cemetless THA(1988) 9 years later – complaints and x-ray data for loosening of both implants; cemented revision THA; 10 years later → in the age of 67 - severe osteolysis of the femoral canal and loosening of the stem Exchange of the stem – cemented stem, titanium mesh funnel, autologous grafts; acetabular cup was stable A.I A.I 1988 1997 2007 2007

ASEPTIC LOOSENING (cont’d) Veneta Ch. ♀ 47 y. Dysplastic coxarthrosis sin. Cemented THA(1991) 17 years later (64 y.) → Loosening of both implants with extreme osteolysis and acetabular protrusion Reimplantation of a cemented THA and reconstruction of the acetabulum and femoral canal with titanium mesh basket and mesh funnel, demineralized bone allografts V.Ch. 47 y. V.Ch. 64 y. 1991 2008 V.Ch. 64 y. V.Ch 2008

ASEPTIC LOOSENING (cont’d) Lida Z. ♀ 50 y. Dysplastic coxarthrosis sin. Hybrid THA, intraoperative femoral fracture, late weight bearing, successful consolidation (1997) 6 years later (56 y.)– loosening of the stem → exchange with long (220 mm) cemented stem 5 years later (61 y.) – loosening of the acetabular cup with protrusion, stem stable → exchange of acetabular cup, demineralized bone allografts L.Z. 50 y. 1997 1997 2003 L.Z. 61 y. 03. 2009 Last follow-up 2003 2008

TECHNICAL ERROR TECHNICAL ERROR 2.1% (1979-2007)  1% (2005-2007) N.G ♀. 57 y. TECHNICAL ERROR (SWEDISH HIP ARTHOPLASTY REGISTER -Annual report 2007) - 2.1% (1979-2007)  1% (2005-2007) CLOSELY CONNECTED TO EXPERIENCE AND LEARNING CURVE POOR POSITIONING AND POOR CEMENTATION BILATERALLY  DISLOCATION AND LOOSENING N.G ♀. 57 y. BILATERAL REVISIONS WITH REIMPLANTATION IN CORRECT POSITIONING

DISLOCATION OF IMPLANTS Important issue Rate ranging 0.017 – 1.7% (Meek RM et al. Clin. Orthop, 2006) Learning curve important ! Strong correlation with positioning of implants at primary surgery Postoperative care and kinesitherapy – important from operating table to bed and ambulation training !!! In our series (0.19%)

DEEP INFECTION Important issue ! The infected THA is a surgical disease ! Incidence < 1% of primary THA 2+% of revisions (Steckelberg et al., 2000) Prevention (prophylactic antibiotics, good surgical technique, antibiotic impregnated cement, etc) Risk factors (R.A., Psoriasis, Diabetes, prior surgeries, etc) In our series - (0.75%) L.S. Borden, SA, Snowmass, 2006

DEEP INFECTION Jordan. U.♂ 51 y. Necrosis aseptica cap. femoris dex. Status post core decompression – procedure, THA Early infection, 2 unsuccessful debridements, followed by implant extraction, lavage, drainage The patient is satisfied with the “Girdlestone hip”, rejects any reimplantation !

PERIPROSTHETIC FRACTURES A condition difficult to treat (frequency ranging 6-8%) Problems with the stability of the prosthesis (often loosened, exchange needed) osteosynthesis (prosthesis in situ, quality of bone, osteolysis) Problems with fracture healing (bone grafts adviced) 15 y. p.o. no complaints Lilia T. ♀ 63 y. Coxarthrosis dex. Femoral fracture Type 3 (Cook&Newman) after fall at home 2 weeks after THA, prosthesis stable, plating with screws → complete recovery

PERIPROSTHETIC FRACTURES (cont’d) Vera K. ♀ 50 y. Coxarthrosis dex. St.post proximal femoral fracture, RSOM, deep infection (1995) Cemented THA (1999 ) 4 years later – Breakage of femoral stem and femur; Reimplantation of a long femoral stem, cemented, titanium mesh funnel, demineralized bone grafts, acetabular cup was stable and was not exchanged Follow-up 5 years later (2008) – no complaints V.K. 1999 V.K. V.K. 2003 2008 Stress riser site V.K.

PERIPROSTHETIC FRACTURES (cont’d) 1995 2007 1995 PERIPROSTHETIC FRACTURES (cont’d) Zh.M. ♂ 41 y. s Zheko M. ♂ 41 y. M. Bechcet. Coxarthritis bil. THA sin. et dex. (1995) 12 years later (53 y.) – loosening of the left THA → Reimplantation of cemented THA, intraoperative femoral fracture, wiring (insufficient!) 10 mo. later – refracture → wiring and plating, bony allografts 9 mo. later – last follow-up, X-ray signs of consolidation, no complaints, walking on one cane allowed s s Zh.M. ♂ 54 y. Zh.M. ♂ 53 y. 10.07. 2007 17.05.2008 12.02.2009 Last follow-up

THE CATASTROPHIC CASE 2009 ??? Bisera Z. ♀ 78 y. LCC. Coxarthrosis dysplastica dex. Cemetless THA 1987 (56 y.) 10 years later (1997) – revison with hybrid THA 8 years later (2005) – rerevision with cemented THA 4 years later (2009) in the age of 78 – catastrophic situation → Loosening of both implants, cup wear and dislocation, protrusion, severe accompanying diseases; Operability strongly questioned ? Therapeutic options ? Girdlestone hip, reimplantation with acetabular reconstruction or partial extraction of the acetabular parts ? 1997 2009 ???

CONCLUSION 1 REVISION HIP ARTHROPLASTY IS A VERY DIFFICULT AND DEMANDING PROCEDURE EVERY NEXT REVISON IS MORE DIFFICULT AND LESS SUCCESFULL

CONCLUSION 2 THANK YOU FOR ATTENTION ! THE SURGEON SHOULD BE WELL PREPARED TO FACE THIS CHALLENGE BY COMPREHENSIVE TRAINING AND PRECISE PREOPERATIVE PLANNING FOR EVERY INDIVIDUAL CASE INTRAOPERATIVE CHANGE OF PROCEDURE COURSE IS NOT AN EXCEPTION На кой му е страв од мечки, во шума не оди ! THANK YOU FOR ATTENTION !