Tips and Tricks from the Experts for Revision THA
Dr. David Nazarian, Dr. William Hozack, and Dr. David Lewallen share their top 5 “moves” in the OR when performing a revision total hip arthroplasty.
Revision total hip arthroplasty (THA) is a technically demanding procedure. The trick, according to David G. Nazarian, MD, is to reduce the difficulties inherent in the procedure so that it is nearly as easy as a primary THA.
Dr. Nazarian, a joint replacement surgeon from the University of Pennsylvania in Philadelphia who is experienced in revision hip and knee procedures, shared his top tips for performing a revision THA during a session at ICJR’s recent 7th Annual Winter Hip & Knee Course.
Attendees heard from 2 other experienced surgeons – William J. Hozack, MD, from The Rothman Institute in Philadelphia, and David G. Lewellen, MD, from Mayo Clinic in Rochester, Minnesota – who also provided expert guidance for surgeons interested in performing revision procedures.
Dr. Nazarian named these as his top 5 “moves” in the OR:
- Preop preparation. As he talks with his patient on the first office visit, Dr. Nazarian fills out a simple form that provides him with all the information he needs about the nuances of the patient’s case. He can then use that information to order the equipment and tools he will need for the procedure well ahead of time. He also reviews the notes with his team in a preoperative conference, and then goes over them again the day before surgery to remind himself of the details.
- Extensile exposure. Dr. Nazarian uses the direct lateral approach for revision procedures. He has a low threshold for performing a trochanteric slide, which keeps the musculature intact distally and proximally and keeps the trochanter in place. It also allows him good access to the femur. He will do an extended trochanteric osteotomy (ETO) if need needs greater exposure to access a well-fixed stem, or a Wagner osteotomy to access the distal aspect of the prosthesis.
- Extraction tools. He has 3 “workhorse” extraction tools – taps, an ultrasonic cement remover, and explant osteotomes – that he has available for every revision THA.
- Acetabular reconstruction. The tools for acetabular reconstruction have improved tremendously in the past decade, Dr. Nazarian said. He generally uses an ultra-porous modular prosthesis, adding porous-coated augments as necessary to reconstruct the acetabulum.
- Femoral reconstruction. His preferred femoral components are a proximal cone and a single tapered stem. These have made revision THA a much easier procedure, in Dr. Nazarian’s opinion.
Click on the image below to watch Dr. Nazarian’s presentation.
Dr. Hozack is a proponent of the direct anterior approach for THA, and in his presentation, he reviewed the process for revision through this approach.
- Obtain additional exposure. The first thing Dr. Hozack does if he needs to improve proximal exposure is to hyperextend the table at the hip. This will bring the proximal femur into view. If more exposure is needed, he will do a controlled proximal release of the tensor fascia lata.
- Remove a well-fixed stem. Dr. Hozack gives a detailed description of his process in a surgical video that’s part of his presentation One of the key tips is to remove scar tissue to access the bone overhanging the component. It’s necessary to remove the superior bone so that the component can be removed without breaking the trochanter.
- Increase distal exposure. The incision can be extended down the lateral femur, going as far as the knee if necessary.
- Episiotomy. If increasing the distal exposure is not enough to remove the stem, Dr. Hozack will do an episiotomy on the anterior surface of the femur and then use osteotomes to open up the bone. This is often all that is needed to remove a difficult stem.
- Extended trochanteric osteotomy. However, if the episiotomy does not work, Dr. Hozack will perform an ETO. He will make every attempt to leave the vastus lateralis intact proximally on the trochanter.
Click on the image below to watch Dr. Hozack’s presentation.
Dr. Lewallen’s tips were based on the principles of a successful revision THA:
- Excellent exposure and visualization. Dr. Lewallen favors the anterolateral approach to THA. For greater exposure, he will use an anterior trochanteric wafer or, if he needs more exposure, a Wagner osteotomy of the femur.
- Minimize bone damage during implant removal. Dr. Lewallen was adamant that trephines should not be used to remove the implant, as they will destroy the anterior cortex of the femur. Instead, with modular tapered stems, he uses a long twist drill that he passes proximal to distal down the valleys of the implant. The component should come right out with that. Note that the drill needs to be matched to the implant and size of the valleys.
- Cancellous bone grafting of contained bone defects. Dr. Lewallen admitted this is easier said than done. He recommends creating a transacetular portal through the acetabular cup, bone grafting through the portal, and then cementing the liner in over the top. This allows him to safely graft without destroying the lateral strut of the bone.
- Maximize cementless implant contact on host bone, as this is where ingrowth occurs. Acetabular augments can be used with irregular shaped defects to customize the reconstruction and maximize support for the implant on what remains of the host bone.
- Rigid fixation of the uncemented cup. The surgeon should use multiple screws in an array from the dome to the base of the ischium. This creates a “locking screw” effect with a cemented liner.
Click on the image below to watch Dr. Lewallen’s presentation.