Re-revision Total Hip Arthroplasty

Abstract

Total hip replacement (THR) is being performed worldwide with published data showing a success rate of 95% at 15–20 years of follow-up. It is predicted that the projected number of hip replacements are likely to increase by 137% over the next 25 years with a proportional increase in the number of revisions. Despite these advances, revision surgeries continue to have higher failure rates. The reported incidence of failure of index revision surgery is approximately 12–20% and re-revisions today are not uncommon. The major causes of failure of revisions are instability—dislocation, aseptic loosening, wear—osteolysis and infection. Each indication for revision of the index revision surgery presents its own unique challenges. Some common pitfalls that remain during the first revision leading to failures should be identified to avoid further failures. Identification and quantification of the primary cause in terms of bone loss (acetabular bone loss), bone quality and soft tissue integrity (abductor power) are important. Ruling out infection, either occult or frank is essential. The selection of surgical technique and implants (porous coated, grit blasted cups, dual mobility cups, metal wedges and augments) also decides the success of re-revision. Various treatment strategies have been utilised with varying degrees of success such as isolated poly exchange, total revision of the cup, augmented stability with modular constrained liners or dual mobility cups, soft tissue repair like trochanteric advancement, gluteus repair/reconstruction used alone or in combination. Use of highly porous surface cups is the preferred material of choice in bone deficient situations. Femoral side challenges causing instability are non-integration of the stem to the endosteum. Subsidence leading to instability and version issues in socket alignment resulting in less than desired combined anteversion. The dictum in defining the length of the revision stem is “As long as necessary and as short as possible”. Routine preoperative workup protocols for identifying infection if any using automated BACTEC and routine culture methods plays a major role in the success after septic re-revision. Appropriate antibiotics in the antibiotic-loaded cement spacer (ALCS) and implants like trabecular metal shell, augments and highly integrating distal fitting stems along with other recent strategies in detection, materials and drugs should be considered for a successful outcome.