Revision total hip replacement without trochanteric osteotomy

Arthroscopically-assisted removal of distal centraliser of an MS-30 femoral stem using a cannulated reamer in revision hip arthroplasty

BACKGROUND

Revision hip arthroplasty can be challenging especially when difficulties to remove distal centralisers arise.

CASE

We report a case where we removed a well-fixed 1st-generation solid MS-30 distal centraliser combining standard cannulated trauma reamers and arthroscopical guidance. Such case has not been reported in the past and this technical tip can be useful in revision procedures of the specific implant.

Fixation of Chevron trochanteric osteotomy with two wire loops in isolated acetabular component revision

The use of two wire loops for fixation of the trochanteric fragment after Chevron osteotomy in revision THA achieves stable fixation with minimal hardware.

Revision of total hip arthroplasty using an anterior cortical window, extensive strut allografts, and an impaction graft: follow-up study

PURPOSE

To report the outcome of revised total hip arthroplasty procedures involving an anterior cortical window, extensive strut allografts, and an Exeter impaction graft.

METHOD

Eight patients (9 hips) with a mean age of 58 years underwent revision of total hip arthroplasty using the Exeter hip impaction graft system and strut allografts between 1995 and 1998. An extensile anterior approach was used, and an anterior cortical window was created in the femur, to remove the old implant. External strut allografts were attached by wires to provide cortical support. The mean follow-up duration was 74 months. Indications for surgery were aseptic loosening of previous implants in 8 hips and infection of one hip that had previously undergone total arthroplasty.

RESULTS

19 Dall Miles cables, 4 ordinary cerclage wires, and 8 cerclage wires tightened with the clincher knot technique were used to secure the allograft to the host bone. The strut grafts were found to be incorporated in all cases. No wires became loose. One patient developed 20 degrees of angulation at the allograft-host bone junction. Using the method of Fowler and Gie, we found that one femoral implant had subsided 2 mm within the cement mantle. Two other implants had 1 mm of subsidence at the cement bone interface, and one patient had a major subsidence of 15 mm that required revision.

CONCLUSION

Using an anterior cortical window in the femur to remove the old implant does not predispose to failure of the allograft to incorporate into the host bone.

The outcome of trochanteric reattachment in revision total hip arthroplasty with a Cable Grip System: mean 6-year follow-up

We have reviewed 251 hips that were revised by the senior authors with subsequent reattachment using the Dall-Miles Cable Grip System. Of these patients, 223 were available for follow-up. A trochanteric slide osteotomy was used for most cases (n = 170), and the remainder had conventional trochanteric osteotomy to facilitate surgical exposure. Follow-up period was 1 to 8 years. Forty-eight percent (n = 108) of the hips had a previous trochanteric osteotomy. Thirteen percent (n = 30) had a prior trochanteric nonunion. Of the 223 hips, 91% (n = 204) of the trochanters remained attached to the trochanteric bed when reapproximated by the cable grip system. The 2 multifilament cables were passed medially through drill holes in the lesser trochanter in 67% (n = 149) of cases. Of the hips, 16% (n = 35) had 2 cables passed through bone lateral to the prosthesis, and 17% (n = 39) had cables passed 1 medial and 1 lateral to the prosthesis. Cable breakage was noted in 10% (n = 23) of cases. Of those 23, 70% (n = 16) were stainless steel. Unraveling of the cable occurred in 18% (n = 41) of cases. There were 19 nonunions (9%). Of the 19 nonunions, 74% (n = 14) were stainless steel. The trochanter was reattached to bone in 9 hips, to cement in 4 hips, and to a proximal femoral allograft in 6 hips (P = .0001). Eight of the 19 hips (42%) had the cables placed lateral to the prosthesis (P = .0002). When bone-to-bone apposition was achieved at surgery, the nonunion rate was 4%. In this difficult group of revision procedures, the Dall-Miles Cable Grip has provided reliable trochanteric fixation. Factors associated with successful trochanteric healing include use of vitallium cables, use of a trochanteric slide osteotomy, cables passed medially through the lesser trochanter, cerclage rather than intramedullary placement, and bone-to-bone apposition.

Seven specialized exposures for revision hip and knee replacement

With the increasing rates and complexity of revision hip and knee arthroplasty, it has become more important than ever to approach the joint in a safe and rational manner. The development of extensile approaches have significantly simplified the removal of solidly fixed components without compromising bone stock. The extended trochanteric osteotomy enables controlled access to the femoral component and is a useful technique for revision of solidly-fixed femoral components. The trochanteric slide allows comprehensive exposure of the acetabulum and femur comparable to trochanteric osteotomy with a diminished risk of trochanteric escape. The vastus slide allows wide exposure of the femoral shaft when using an anterolateral approach. In revision total knee arthroplasty, the extensor mechanism is often at risk of disruption or avulsion, and in most cases, maneuvers that allow wide exposure of the femur and tibia while preserving the extensor mechanism are essential. Such exposures include one of the extensor mechanism reflecting techniques either proximally by rectus snip or patellar turndown, or distally by tibial tubercle osteotomy. Occasionally a femoral peel or epicondylar osteotomy is required. There should be a low threshold to consider one of these specialized approaches during revision hip and knee arthroplasty.

Early outcome of total hip arthroplasty using the direct lateral vs the posterior surgical approach

A consecutive series of 49 patients who had a primary total hip arthroplasty (THA) for osteoarthritis is reviewed to determine the difference in clinical outcome between the direct lateral and the posterior surgical approaches to the hip. Group 1 comprised 28 patients off had THA by the same surgeon using a posterolateral approach. Group 2 comprised 21 patients who had THA using the direct lateral approach, modified from Hardinge. The improvement in the limp, abductor strength, Trendelenburg test, and range of motion over time was similar in the two groups. The average Harris hip score at 1 year was 90 for Group 1 (posterior approach) and Group 2 (lateral approach). At 2-year minimum follow up, the Harris hip score was 94 for both groups. Radiographic review showed that the incidence and severity of heterotopic bone was also similar for both groups. The authors conclude that the clinical and radiographic outcome for THA using the posterior and the lateral approaches to the hip yield similar clinical results.

Combined anterior and posterior approach to the hip joint in reconstructive and complex arthroplasty

The combined anterior and posterior approach permits access to the front and back of the hip joint for reconstruction and complex arthroplasty, usually without osteotomy of the greater trochanter, with minimal muscle release. There is ease of access to the anterior and posterior capsule, which can be resected under direct vision, thus permitting accurate hemostasis. The entire acetabular rim is exposed for bone grafting as required. The authors review the useful standard approaches and illustrate the combination of the anterior and posterior approaches through a straight lateral incision. Concomitant exploration of the sciatic nerve is demonstrated, as is the osteotomy of the trochanter performed when the ilium superior to the acetabulum must be reconstructed. The utility and limitations of the operation is illustrated by representative cases. This extensive procedure usually can prevent neurologic and vascular compromise and allows excellent observation of the skeletal structures for accurate component alignment.