1. Revision Hip Replacement Richard Boden Consultant Trauma and Lower Limb Orthopaedic Surgeon (locum) Lancashire Teaching Hospitals NHS Foundation Trust

2. Overview Background of THR THR Failure Aims of Revision Basic Technique Complications Cases Questions

3. Background 86,488 hips in 2012 – 7.5% increase Revision hips 12% – 11% 2011

4. TJA Volume Estimates

5. Age at THR

6. Av Age 68.7 yrs

7. BMI

10. Failure Method

11. MethodPercentage 1Aseptic Loosening40% 2Pain23% 3Dislocation/Subluxation13% Lysis Soft Tissue Reaction 6Infection12% Acetabular Component Wear 8Periprosthetic Fracture8% 9Malalignment5% 10Implant Failure3%

12. Failure Method MethodPercentage 1Aseptic Loosening40% 2Pain23% 3Dislocation/Subluxation13% Lysis Soft Tissue Reaction 6Infection12% Acetabular Component Wear 8Periprosthetic Fracture8% 9Malalignment5% 10Implant Failure3%

13. Failure Method MethodPercentage 1Aseptic Loosening40% 2Pain23% 3Dislocation/Subluxation13% Lysis13% Soft Tissue Reaction13% 6Infection12% Acetabular Component Wear12% 8Periprosthetic Fracture8% 9Malalignment5% 83%

14. 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)

15. 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 Metal

16. Timing 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 Metal

17. Timing of THR Failure 1.8% failure 9 years

18. Aseptic/Mechanical Loosening Most common indication for revision Regular radiological follow- up Observe zones Observe progression Note symptoms Early to avoid depleted bone stock

19. Aseptic/Mechanical Loosening GruenDeLee-Charnley

20. Wear of Articular Bearing Surface Bearing – Traditional Poly – UHMWPE – Ceramic – Metal Ceramic – Fractures? – SQUEAKS

21. Osteolysis Tissue response to wear debris Debris  Phagocytosis  Macrophage activation  OSTEOLYSIS Most common with TRADITIONAL polyethylene bearings

22. Dislocation/Instability Dislocation 1-2% Component position – Acetabulum – Femoral Soft tissue – Tension (offset) – Function Components used – Head size – Constrained

23. Metal on Metal Hips

27. Peri-Prosthetic Fracture Stress risers Osteoporotic bone Implant fixation Vancouver: – A- trochanteric – B- prosthesis 1- Implant stable 2- Implant loose 3- plus poor bone – C- distal

28. Infection Clean air theatre Elective wards Skin prep Surgical technique – Time – Tissue handling Patient factors Abx v Surgery?

29. Infection 90% Gram Positives – Staph Aureus – CNS But Gram Negatives increasing! Only 12% have systemic symptoms

30. Infection Early < 3 weeks Late > 3 weeks Cure with DAIR – < 1 week up to 90% – 1 – 2 weeks 50/50 – 3 weeks plus <10%

31. Infection Single Stage Stage 1 Stage 2 Hip Excision 24% 37% 36% 3% Up to 90% cure

32. Radical Debridement Essential to the procedure Treat like a tumour

33. Cost of Revision ActivityCost per case Total Income£10,097 Total Costs£11,998 (-£1,901) Theatre £3,181 Nursing £1,610 Corporate Costs £1,217 Prosthetics £1,132 Consultant £746 Site costs £688 Drugs £438 Radiology £96 Pathology £94 Pharmacy £88

34. Cost of Revision ProcedureLOS (days)Total Cost Periprosthetic Fracture16£18,400 1 st Stage/Pseudarthrosis17£14,240 Exchange Resurfacing6£8,980 Direct Exchange7£9,230

35. Revision 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 implant

36. Pre-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 prosthesis

37. Surgery - 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 stem

38. Surgery - 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??

39. Summary Monitor new pains – Startup pain – Groin pain Suspect wear and loosening Suspect infection Check XR Early referral

40. Thank You