Anesthesia by epidural catheter is routinely used for revisions and is often supplemented by a general anesthetic. Patients are placed in the lateral position, and anterior and posterior pelvic clamps are used to stabilize the pelvis. The pelvis is perpendicular to the operating table with the back parallel and the opposite hip flexed. A foam pad is placed between the knees and taped in place to allow knees and ankles to be palpated for leg-length determination. Small foam pads are used to cushion the underlying fibula head and lateral malleolus.

Preparation and draping is along standard lines with alcoholic chlorhexidine paint used to prepare the whole leg from the malleoli to nipple-line and across the midline, the groin being painted last. A large drape is placed over the contralateral leg to the groin, and another over the trunk above iliac crest. A U-drape is used to cutoff perineum but permitting maximal posterior access and leaving the iliac crest exposed. The leg is bagged with crepe bandage to just above the knee. Large paper or plastic disposable hip drapes are placed over the leg. An iodized Steri-Drape is folded double under the thigh and a large iodized drape over. Access should be available from the iliac crest and include the proximal two-thirds of the femur. The outer gloves are changed at this stage before starting incision. With the heels together, the positions of the flexed knees are compared as a guide to leg length.

Expose the hip joint using your approach of choice. More extensive exposure is generally required for revision surgery. An extensive exposure is recommended, especially in difficult revision cases. We would strongly recommend using a posterior approach. We do not usually use an extended trochanteric osteotomy but it can be used and if done, the osteotomy is reduced and wired prior to cementing. A straight distal skin incision centered over the greater trochanter and curving slightly posterior proximally toward the posterior one-third of the iliac crest is used with the hip flexed 20 degrees and adducted across the contralateral thigh.

There are key points during the exposure to which we pay particular attention. Firstly, as successful revision surgery is reliant on maintaining good abductor function, take time to clearly identify the gluteus medius muscle and tendon. The simplest way to do this is by performing the fasciotomy along the anterior margin of the gluteus maximus (Fig. 124.3A), identifying the anterior margin of maximus and developing the plane between the gluteus medius and gluteus maximus from anterior to posterior (Fig. 124.3B), eventually identifying clearly the plane between the main tendon posteriorly and the piriformis tendon (Fig. 124.3C,D). In this way the abductors will always be protected whereas, simply dividing gluteus maximus in the line of its fibers can cause devastating and irreparable damage to the medius in the common revision scenario where medius is adherent to maximus with scar tissue. We would always advise dividing the tendinous insertion of gluteus maximus from the femur during revision surgery to facilitate exposure and while doing this and while dividing the short external rotators, we place the foot on a padded, draped Mayo table so that the femur drops into some internal rotation allowing the sciatic nerve to fall away from the area of dissection. The sciatic nerve is identified in almost all cases, and having been visualized, its course is checked to make sure it is clear of the dissection. This does not require full exposure but at least palpation of the nerve course. In general, stay on bone during dissection. To control bleeding, use cutting diathermy frequently throughout the procedure.