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

2. 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

3. SWEDISH HIP ARTHOPLASTY REGISTER (Annual report 2007)
RELATIVE DISTRIBUTION OF REASONS FOR REVISION
ASEPTIC LOOSENING %
DEEP INFECTION %
FRACTURE %
DISLOCATION %
TECHNICAL ERROR %
OTHERS %

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

5. 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

6. OUR DATA (01. 2006 - 12. 2008) Second Orthop
OUR DATA ( ) 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

7. OUR DATA (01. 2006 - 12. 2008) Second Orthop
OUR DATA ( ) 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%

8. OUR DATA (01. 2006 - 12. 2008) Second Orthop
OUR DATA ( ) 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

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

10. 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.

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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.
Last
follow-up
2003
2008

17. 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% ( )  1% ( )
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

18. DISLOCATION OF IMPLANTS
Important issue
Rate ranging – 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%)

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

20. 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 !

21. 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

22. 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.

23. 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.
Last follow-up

24. 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 ???

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

26. 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 !