Revision Total Hip Arthroplasty
synonyms:
Revision THA CPT
- 27134 (revision of both components)
- 27137 (revision of acetabular component only)
- 27138 (revision of femoral component only)
Revision THA Indications
- Aseptic loosening
- Recurrent dislocation
- Sepsis (periprosthetic infection)
Revision THA Clinical Evaluation
- Pain (initially at night/rest), fever, chills, draining sinus tracts. Symptoms may be mild and difficult to differentiate between asceptic loosening, instability, etc.
Revision THA Xray / Diagnositc Tests
- Xrays: evaluate for periosteal reaction, scattered foci of osteolysis, bone resoprtion, implant wear, progressive radiolucencies, osteopenia, .
- Bone Scan: sensitivity = 33%, specificity = 86%, positive predictive value = 30%, negative predictive value = 88% for infection. (Levitsky KA, J Arthroplasty. 1991;6:237)
- ESR (Westergen erthrocyte sedimentation rate): rises normally after total joint surgery. Returns to normal 6 weeks after surgery. Infection suggested if elevated 3 months after surgery.
- CRP (C-reactive protein): Rises normally after total joint surgery. Returns to normal @3weeks after surgery. Infection suggested if elevated 3 months after surgery.
- Interleukin-6 (IL-6): Rises normally after total joint surgery. Returns to normal within 48 hours after surgery. Elevated (>10 pg/mL [>10 ng/L]) in patients with periprosthetic infection.
- Aspiration of Joint fluid: send for aerobic culture anaerobic culture, sensitivities, Gram stain, acid-fast staining, CBC with differential. Leukocyte count > 1.7x109/L indicates infection.
Revision THA Classification / Treatment
- Femoral Bone Loss - Paprosky Classification
-Type 1: minimla metaphyseal involvement and adequate cancellous bone. RX: 6in long primary fully porous-coated stem.
-Type 2: metaphyseal damage with a minimally involved diaphysis. RX: 6in long primary fully porous-coated stem.
-Type 3A: metadiaphyseal damage with 4cm of reliable cortex proximal to the isthmus. RX: 7-10in long revision fully porous-coated stem.
-Type 3B: metadiaphyseal damage with 4cm of reliable cortex distal to the isthmus. RX: 7-10in long revision fully porous-coated stem.
-Type 4: extensive metadiaphyseal and thin ballooned cortices with widened canals precluding reliable fixation. RX: impaction grafting, modular tapered stems, allorgraft prosthetic composites, megaprosthesis.
- Impaction bone grafting (Schreurs BW, JBJS 2006;88A:259)
- Acetabular Bone Loss - Paprosky Classification
-Type 1: rim and columns intact with more than 50% of the cup in contact with host bone. RX: allograft filling of contained defects with press-fit cup supplemented with screws.
-Type 2A: anterior and posterior columns intact, partial loss of the superomedial wall. RX: allograft filling of contained defects with press-fit cup supplemented with screws.
-Type 2A: anterior and posterior columns intact, partial loss of the superolateral wall. RX: allograft filling of contained defects with press-fit cup supplemented with screws.
-Type 2A: anterior and posterior columns intact, partial loss of the medial wall. RX: allograft filling of contained defects with press-fit cup supplemented with screws.
-Type 3A: severe bone loss involving the acetabular walls and pelvic columns. Rx: bulk allograft with antiprotrusio cages or porous tantalum metal augmentations. (Sporer SM, J Arthroplasty 2006;21S:83).
-Type 3B: severe bone loss involving the acetabular walls and pelvic columns with pelvic discontinuity. Rx: bulk allograft with antiprotrusio cages or porous tantalum metal augmentations. (Sporer SM, J Arthroplasty 2006;21S:87).
Revision THA Associated Injuries / Differential Diagnosis
- Periprosthetic infection
- Mechanical failure
- Dislocation
- Death (cardiac / pulmonary)
- Nerve palsy (peroneal, sciatic, femoral)
- Vascular injury (femoral, iliac, obturator
- DVT/PE
- Leg-length discrepancy
Revision THA Complications
Revision THA Follow-up Care
Revision THA Review References
- Sporer SM, CORR 2003;417:203
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