Indications for Revision Total Hip Arthroplasty

CHAPTER 31 Indications for Revision Total Hip Arthroplasty

Slif D. Ulrich, Frank R. Kolisek, Ronald E. Delanois, Michael A. Mont

CHAPTER OUTLINE

Indications for Revision Total Hip Arthroplasty 242

Aseptic Loosening 242

Recurrent Dislocation 243

Infection 243

Periprosthetic Fractures 243

Osteolysis 244

Summary 246

Primary total hip arthroplasty is often described as one of the greatest advances in healthcare of the twentieth century.^1,² Presently, success rates for total hip arthroplasty at 10 years or longer exceed 95% survivorship in patients older than 75 years of age.²^–⁴ With the increasing life expectancy of our population, more patients are undergoing total hip arthroplasty, and they are generally expected to maintain a higher level of activity.^5,⁶ Because of the increasing number of procedures performed, the number of revision total hip arthroplasties is expected to increase in the near future.⁷ It is estimated that more than 20% of all hip arthroplasties will need to be revised, which translates into 30,000 to 50,000 hip arthroplasty revisions yearly.

Revision total hip arthroplasty, constituting close to one quarter of all total hip arthroplasties performed in the United States, places immense financial burdens on the health care system and has less favorable outcomes than primary total hip arthroplasty.⁸ Potential reasons for hip revisions can be stratified into three groups: patient related, implant related, and reasons related to inadequate surgical technique.^9,¹⁰ Osteolysis and aseptic loosening, resulting from failure of bearing surfaces, constitute a common reason for revision total hip arthroplasty.³ These are failures that typically occur relatively long after the primary implantation. Other causes of failure that occur at an earlier time point include implant-related problems such as delamination of the porous coating⁹ or other manufacturing problems. Patient-related factors leading to the failure of total hip arthroplasty include comorbidities such as sickle cell anemia,¹⁰ poor bone quality, or other patient factors that predispose the patient to infections or dislocation. Surgical technique may affect the outcome of total hip arthroplasty. The influence of surgical technique is likely to be greater than previously believed, as many revisions are required because of recurrent dislocation, malposition of the components, or other technical problems.^11,¹² Deep infection after total hip arthroplasty is also a common reason for patients to undergo an eventual revision procedure after the infection has been eradicated.

Surgeons spend a tremendous amount of time deciding on the technique for the procedure and on prosthesis selection when contemplating a revision. However, the entire decision-making process regarding when to revise a hip arthroplasty needs to be clearly understood and evaluated in individual circumstances. Not every patient with a painful total hip arthroplasty needs a revision. There are many situations in which patients are better off not undergoing a complex procedure. This might be quite obvious in a 92-year-old patient who has had three heart attacks and has only occasional pain when ambulating. In other situations this decision might not be as obvious. Straightforward situations that necessitate a revision include patients with severe painful aseptically loose stems or cups, patients with recurrent dislocation that cannot be managed nonoperatively, situations in which massive osteolysis and bone loss are present, and patients with various periprosthetic fractures that lead to component loosening. Another common indication for revision is patients who have had a deep infection, when they are able to have a reimplantation of the prosthesis. This chapter discusses these various obvious reasons for revision, as well as subtle situations that may or may not warrant a revision procedure.

There are many situations in which a hip revision procedure would never be indicated. These include patients who have enigmatic thigh pain with no specific cause, such as loosening or infection. Trochanteric bursitis or heterotopic ossification would only rarely warrant an exploratory procedure and would not be an indication for revision. These problems can be typically differentiated by a thorough history, physical examination, and complete radiographic evaluation to rule out obvious reasons that would necessitate a revision hip arthroplasty. Patients should also undergo workup to rule out other sources for their pain, such as back problems from disk disease, spinal stenosis, arthritis, or previous back procedures. Other problems that might lead to pain but do not necessitate a revision include metastatic disease, intra-abdominal processes, and prior pelvic fractures. In conclusion, the surgeon should differentiate disorders that are not related to the hip from processes that are specifically originating from the hip arthroplasty itself. This is usually fairly obvious from examination and radiographic evaluation, but sometimes special laboratory tests, hip aspirations and/or injections, and specialized scans may be necessary.

Even though there may be a direct indication for revision, such as loosening, based on radiographic analysis, it is important for the surgeon to understand the concept of a risk-to-benefit ratio. This concept for analysis may be relatively straightforward in some cases. For example, a 42-year-old patient with a loose stem who needs two crutches to ambulate more than a block would clearly need a revision total hip procedure. A 90-year-old patient with minimal pain and a loose stem who has multiple medical problems would probably not benefit from a hip revision, and therefore this would not be an appropriate indication. The surgeon should always try to help the patient and primum non nocere. If there is a high likelihood of increasing ambulation, relieving pain, and increasing the patient’s quality of life, then hip revision may be indicated. Patients with less likelihood of benefit should not undergo a revision procedure. These may include patients who have extensive medical comorbidities that increase the risk of a procedure or conditions that would limit the ability to ambulate. In addition, some patients may have tremendously unreasonable expectations, and surgery would not be indicated in such situations.¹²

A recent study by Lachiewicz and colleagues compared reasons for revisions in two groups of 100 patients who were operated on 10 years apart. In the initial group the indications for revision included loosening of both components, infection, periprosthetic fracture, recurrent dislocation, and polyethylene wear. In the second group of patients there were similar reasons for revision,¹³ but the most important indications changed. There were statistically significant increases for dislocation, wear, and loosening of the femoral components 10 years later (Table 31-1).

TABLE 31-1 CHANGING INDICATIONS FOR TOTAL HIP ARTHROPLASTY

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