Tips & Tricks for Removing Components from an Infected Hip
Dr. Thomas Fehring and Dr. Gwo-Chin Lee provide insights on removing femoral and acetabular components in a revision total hip arthroplasty.
Despite the precautions orthopaedic surgeons take before, during, and after total hip arthroplasty, a certain percentage of hips will become infected and a revision procedure will be needed.
At ICJR’s annual Winter Hip & Knee Course in Vail, Colorado, Thomas K. Fehring, MD, and Gwo-Chin Lee, MD, offered their tips and tricks for safely removing the femoral and acetabular components.
Femoral Component Removal
Dr. Fehring, from OrthoCarolina, Charlotte, North Carolinia, discussed 3 key areas:
- Soft tissue management. Adequate exposure and then adequate debridement of the sinus tract and soft tissue are essential. Dr. Fehring said that if another surgeon were to walk into the OR at the end of the case, he or she should not be able to tell the joint was infected.
- Extraction planning. Understand the design and fixation features of the patient’s implant, as the design – such as length and geometry of the stem, type of metal, and extent of grit blast and porous coating – will dictate the removal strategy. With this knowledge, the surgeon can ensure he or she has the right tools to remove the component.
- Extraction. If an extended trochanteric osteotomy (ETO) is needed, don’t go all the way to the bottom of the stem. Dr. Fehring leaves 4 to 5 cm of bone to allow for adequate diaphyseal contact distally during the second stage of the revision.
Click the image below to watch Dr. Fehring’s presentation and hear more of his tips and tricks for femoral component removal.
Acetabular Component Removal
Dr. Lee, from the University of Pennsylvania in Philadelphia, noted that there’s no template for acetabular component removal, as each case requires individualized planning. However, surgeons can generally follow a systematic approach that includes the exposure, the component removal, and reconstruction.
Dr. Lee prefers the posterior approach, regardless of the approach used in the primary procedure. Whichever approach a surgeon uses, it needs to be extensile. He agrees with Dr. Fehring that there’s no role for minimally invasive techniques in revision of an infected hip. The exposure, Dr. Lee said, should allow a 360° view of the acetabular cup to facilitate removal.
Dr. Lee described 3 general principles for acetabular component removal:
- Don’t try to remove implants until the ingrown interfaces are divided.
- Cut bone ingrown interfaces with thin, high-speed cutting tools.
- Be careful with conventional osteotomes: They tend to fracture cortical bone rather than cut it.
To ensure reproducible reconstruction, Dr. Lee recommends that surgeons:
- Be prepared. Have the right tools on hand to make the component removal easier.
- Be systematic. Have a plan for the procedure that’s tailored to the patient’s anatomy and implant.
- Be calm, even if the cup doesn’t come out in the first couple of tries.
Click the image below to watch Dr. Lee’s presentation and hear more of his tips and tricks for acetabular component removal.