Revision Total Hip Arthroplasty

David Mayman, MD

Dr. Mayman or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to Smith & Nephew; has stock or stock options held in OrthAlign; and serves as a board member, owner, officer, or committee member of the Knee Society.

Introduction

Revision total hip arthroplasty (THA) can mean many different things, thus rehabilitation protocols will be different depending on the type of revision. It is critically important to work directly with the surgeon on a specific rehabilitation protocol for each patient following revision THA. While primary THA is a successful surgery, revision THA is more complex and often challenging. The most common reason for failure after primary THA is instability, with mechanical loosening as the second most reported complication. Loosening can develop early or late after a primary THA that causes pain and poor clinical outcomes. Infection is another reason for revision arthroplasty. Patients requiring a revision THA can present for a variety of reasons, as described with each case assessed individually based on symptoms, clinical examination, and radiographs.

General categories of revision THA are:

Femoral head and acetabular liner exchange
Isolated acetabular revision
Isolated femoral revision
Both-component revision

Questions that need to be answered before developing a rehabilitation protocol include:

Weight-bearing status
Status of the abductors and greater trochanter
Precautions necessary

A case example of a chronically infected primary total hip replacement requiring a two-stage revision is seen in Figure 39.1.

Surgical Approaches

Hip replacement can be done through a number of surgical approaches. The approach used for surgery will affect the limitations or precautions in the early postoperative period.

Direct Anterior Approach

The direct anterior approach utilizes the intramuscular plane between the tensor fascia lata and the rectus femorus muscle. Exposure to the acetabulum is relatively simple, but exposure of the femur is more difficult. Posterior structures are left intact. The risk of posterior instability is low, but the risk of anterior instability is higher. The direct anterior approach can be used for acetabular revisions, but is rarely used for femoral revision.

Anterolateral Approach

The anterolateral approach has a low risk of dislocation, but the anterior portion of the gluteus minimus and gluteus medius are taken off of the trochanter for the procedure and have to heal back to the trochanter after surgery. This approach can be used for revisions but is not commonly used for femoral revisions.

Direct Lateral Approach

The direct lateral approach incorporates an osteotomy of the greater trochanter. This approach is commonly used if a well-fixed, uncemented femoral implant needs to be removed. If this approach is used, then the trochanteric fragment must be protected during rehabilitation until bony healing has occurred.

Posterolateral Approach

The posterolateral approach is the most common approach used for revision THA in the United States today. The abductors are left intact, but the posterior capsule, piriformis tendon, and conjoined tendon are released from the posterior aspect of the femur, necessitating posterior hip precautions during the healing period.

Early Postoperative Rehabilitation

Early postoperative rehabilitation is highly dependent on the surgical approach and weight bearing status. Early ambulation

is encouraged to minimize postoperative medical risks, such as deep vein thrombosis (DVT), pulmonary embolism, and pneumonia.

Figure 39.1 Radiographs of a case example of a chronically infected primary total hip replacement requiring a two-stage revision. A, Preoperative radiograph shows a total hip replacement with implants in good position, but the right hip is 10 mm shorter than the left. Bone quality is good around the acetabular and femoral implants. B, The implant is removed and an antibiotic-impregnated cement spacer is inserted. This spacer resembles a hip replacement but is not solidly fixed to the femur or acetabulum. The implants were removed through a posterior approach; thus, posterior hip precautions (no internal rotation, no flexion >90°, no internal rotation) were required and the patient was kept partial weight bearing because the implant is not fixed into the bone. C, The patient fell at home 3 weeks later, sustaining a greater trochanteric fracture, and the implant subsided approximately 6 mm. Abductor precautions and toe-touch weight bearing were instituted. Ambulation required a walker, but all other lower extremity exercises continued. D, At 10 weeks following completion of antibiotics with repeat hip aspiration negative, revision surgery was performed. The greater trochanteric fracture was healed. Revision was done through a posterior approach and, although the trochanter appeared healed, the healing was not robust at that time. The patient began standard postoperative early rehabilitation exercises, but followed trochanteric or abduction precautions and posterior hip precautions for 6 weeks. At 6 weeks, the patient progressed to weight bearing as tolerated and hip precautions were lifted. Leg length was restored and the infection cleared.

Figure 39.2 Illustration of standard posterior hip precautions. (Reproduced with permission from Sculco TP: Hospital for Special Surgery Orthopaedic Manual. Philadelphia, PA, Wolters Kluwer/Lippincott Williams & Wilkins, 2013.)

Direct Anterior Approach

Avoid hyperextension and external rotation (ER). These precautions decrease the risk of anterior dislocation.

Anterolateral Approach

Avoid hyperextension and ER. These precautions decrease the risk of anterior dislocation.

The abductor repair is protected for the first 6 weeks.

Direct Lateral Approach

Avoid flexion, adduction, and internal rotation (IR). Limitations to abduction will depend on the quality of the greater trochanteric fragment and the quality of the repair. The bony fragment can be a very solid piece of bone requiring minimal precautions or a very tenuous piece of bone requiring strict abductor precautions until healing is complete. This must be reviewed with the surgeon on a case-by-case basis.

Posterolateral Approach

Avoid flexion, adduction, and internal rotation. Take the following posterior hip precautions: Hip replacement done through a posterior approach leaves the abductors fully intact, but releases the piriformis tendon and the conjoined tendon from the back of the femur. The posterior capsule is then released. The hip is dislocated by a combination of hip flexion, adduction, and IR. Posterior hip precautions are designed to avoid harming the repair of the posterior structures or dislocation of the hip joint.

Standard Posterior Hip Precautions Are: