Preoperative Evaluation, Planning, and Templating for Revision Total Hip Arthroplasty

Stephen M. Petis

Daniel J. Berry

Preoperative Evaluation

Create a differential diagnosis for possible etiologies that explain the cause of total hip arthroplasty (THA) failure, and use patient history, physical examination, and investigations to determine the most likely diagnosis.
Anticipate challenges related to exposure, implant removal, bone reconstruction, and hip instability.
The goal is to treat the cause of failure, while minimizing further complications. A successful revision THA will have well-fixed implants in good position, bone deficiencies have been addressed, and a hip can move through a functional range of motion without subluxating or dislocating, while avoiding complications of the revision operation.
Use templating to determine which implants provide the best reconstruction options and also to determine anticipated implant sizes. Use templating to predict intraoperative challenges and solutions to problems such as bone deficiencies and bone deformities.

History

Understand the indication for the initial surgery (i.e., primary osteoarthritis, posttraumatic arthritis), as this may help predict reasons for failure.
- Was there a period of time when the hip was functioning well and pain-free? If not, rule out periprosthetic joint infection as a cause for ongoing pain.
- Elicit any history of hip instability and any previous treatment attempts (i.e., closed or open reductions).
- The location of the patient’s pain may help delineate which implant has failed—groin and buttock pain most commonly is associated with a failed acetabular component or synovitis, whereas thigh pain most commonly is associated with a failed femoral component.
Obtain and review previous operative reports.
Obtain “stickers” to confirm brand and size of implants in place.

Physical Examination

Inspect the patient’s gait—look for signs of antalgia or a Trendelenburg or Duchenne gait suggestive of abductor insufficiency. Evaluate abductor strength to help detect insufficiencies.
Inspect old surgical incisions: are there any signs of infection? If there are multiple incisions, choose the one that will allow treatment of as many problems as possible and provide the most intraoperative flexibility.
Evaluate and document hip range of motion.
A painful resisted straight leg raise often is associated with hip pathology.
Evaluate and document neurovascular status, particularly the sciatic nerve.
Rule out any preexisting lumbar spondylosis or radiculopathy, as well as pelvic or intra-abdominal pathology that may cause referred pain to the hip.

Radiographs

Obtain anteroposterior pelvis views and anteroposterior with shoot-through lateral views of the involved hip. Make sure radiographs are of sufficient scope to show the entire hip prosthesis and any bone likely to be instrumented during the revision surgery.
Judet views are useful in assessing acetabular bone loss and to assess for pelvic discontinuity (Figure 21.1).
A computed tomography scan with metal suppression can be a helpful adjunct to assessing bone deficiencies.
Magnetic resonance imaging with metal suppression is useful to evaluate adverse local soft tissue reactions related to wear of metal-metal bearings on taper corrosion.
Full-length femur views should be obtained when long revision stems will be used to ensure there is no aberrant distal femur morphology or other implants distally in the femur.