PreOp Planning for THR

- Surgical Considerations for Specific Diseases and Conditions:

- Medical Assesment:
- see Anesthesia, Medical Consderations, and Timing for Femoral Neck Frx
- preop cardiology, dental, GI, and urological considerations;
- with history of prostatic hypertrophy or surgery be prepared to have urologist available
for foley placement;
- anesthesia consult and posting
- vitamin D:
- Vitamin D deficiency in patients with osteoarthritis undergoing total hip replacement: a
cause for concern?
- transfusion considerations:
- preoperative hemoglobin is main indicator for need of postoperative transfusion;
- Hgb less than 11 g/dl is a strong indicator for need for transfusion;
- autologous blood: (see pRBC transfusion)
- 2 units for primary hips) or cell saver;
- disadvantages: time consuming, expense, significant decrease in preop Hbg level
(which actually increases likelihood of transfusion), possibility of clerical
error, possibility of transfusion reaction;
- in the study by Sculco TP and Gallina J (1999), 82% of these patients (autologous
or PAD patients) required transfusion of their own blood (vs 50% in patients that
did not donate autologous blood), but only 8% of PAD patients required
allogenic transfusion;
- 34 to 45% of autologous blood was discarded;
- w/ preop Hgb level of less than 11 g/dl about 93-96% of pts required a
transfusion vs. only 52-59% of pts w/ preop Hgb of greater than 14 g/dl;
- w/ THR, expected transfusion requirements are 0.8 units when the Hgb level
is more than 14 g/dl vs 1.6 units when Hgb level is less than 11 g/dl;
- erythropoitin
- references:
- Blood management experience: relationship between autologous blood donatoin
and transfusion in orthopaedic surgery.
- Efficacy of Intraoperative Blood Collection and Reinfusion in Revision Total Hip
Arthroplasty.
- urinary tract
- Are Antibiotics Necessary in Hip Arthroplasty With Asymptomatic Bacteriuria? Seeding
Risk With/Without Treatment

- Exam:
- previous incisions:
- limb length: most common cause of apparent limb length inequality is hip flexion
contracture;
- vascular status;
- delay surgery if any "minor" infections are present (such as infected ingrown toenail,
prostatitis, ect);
- flexion contracture:

- not caused by the weakness of the hip extensors;

- result of contractures of the flexor muscles and the joint capsule
- to compensate for reduced hip extension in terminal stance phase & to obtain step
length, there is development of increased anterior pelvic tilt in sagittal plane;
- obesity:
- Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty
- Factors associated with prolonged wound drainage after primary total hip and knee
arthroplasty
- Periprosthetic joint infection: the incidence, timing, and predisposing factors.
- Radiology of the Hip:
- preop acetabular evaluation: (postop eval)
- usually the acetabulum must be templated first, in order to determine the center of
rotation and the center of the femoral head;

- preop femur evaluation:

- standing AP of hip, knee, & ankle;
- consider: standing AP of hip, knee, & ankle to see whether any varus or valgus
deformity requires correction before THR;
- femoral offset - neck shaft angle:
- it is important to maintain the patient's original offset;
- acceptance of less femoral asset may result in abductor laxity and weakness,
increased joint reactive
forces, and hip instability;
- always know ahead of time whether the implant you are using has the option of an
increased offset femoral stem
in addition to knowing the modularity lengthening options of the femoral head;
- radiographic pitfalls:
- note that external rotation of the femur (as shown by a promient lesser trochanter)
will give the appearance that
there is a relative coxa valga, which will give a false impression of offset;
- in femoral neck frx, the neck shaft angle cannot be judged (use opposite hip for
templating);
- note that coxa vara, may lead to unexpected postoperative leg lengthening (w/
possible nerve palsy) as well as unexpected hip instability;
- consider use of a femoral stem w/ increased offset;
- references:
- The offset problem in total hip arthroplasty. Steinberg B and Harris WH. Contemp
Orthop. 1992(24):556-562.
- Arthroplasty of the hip. Leg length is not important.
- limb length:
- draw a line at level of, & parallel to, ischial tuberosities and intersecting the lesser

trochanter on each side;

- compare 2 points of intersection & measure difference to determine the amount of limb
shortening;
- draw horizontal at level of proposed neck cut which may be used as a reference point
during surgery;
- draw a horizontal line at the level of the greater trochanter & see where it intersects on
head of femoral component;
- during surgery postion of the greater trochanter can be compared to center of the
femoral prosthetic head, which gives an indication of relative leg lengthening;
- significant leg length descrepancies can partially be adressed w/ changing prosthetic
offset and partially w/ femoral neck cut;
- ref: Preoperative Radiographic Assessment of Limb-length Discrepancy in Total Hip
Arthroplasty
- template femoral neck cut
- note that the femoral neck cut should place the center of the femoral head component
at the approximate level of the tip of the greater trochanter;
- size of component:
- place femoral templates on film & select size that matches the contour of the proximal
canal and fills it most completely
- note thickness of cortex & width & shape of medullary canal;
- note amount of trochanteric back cut needed during surgery so that the stem is not
placed in varus;
- w/ longer stem implants, be sure that the anterior bow to the femur will not interfere w/
insertion;
- Surgical Alternatives:
- hip arthrodesis:
- girdlestone resection arthroplasty
- references:
- Osteoarthritis of the hip treated by
intertrochanteric osteotomy. A long-term follow-up.
- Medial-displacement intertrochanteric
osteotomy in the treatment of osteoarthritis of the hip.
A long-term follow-up study.
- Osteotomy for osteoarthritis of the hip. A
survivorship analysis.

Post Operative Radiographic Evaulation of

THR
- Discussion:
- evaluation of the painful hip replacement and exam for THR loosening:
- heterotopic ossification:
- post op AP & lateral x-rays should include entire length of stem & cement mass;
- femur and cement column are inspected carefully and compared w/ previous films for

changes indicating component loosening, stem failure, trochanteric

problems, or infection;
- Radiographic Views: (bone scans for THR)
- frog leg lateral: gives best lateral of prox portion of femoral component;
- cross table lateral:
- for evaluation of position of acetabular component (anteversion) & status of post bone
stock in posterior column & neck of ilium;
- weight bearing and non wt bearing views:
- may detect implant loosening;
- push pull views: to evaluate for loosening of components;
- same as AP view of hip w/ examiner providing distraction and compression to the hip
through the femur;
- references:
- A Systematic Approach to the Plain Radiographic Evaluation of the Young Adult Hip
- Leg Length and Offset:
- leg length descrepancy:
- measured by noting the realative positions of the lesser trochanters from a line drawn
tangential to the ischium;
- as noted by Ranawat (1999), 87% of patients had leg lengths within 5 mm of each other;
- note that with an increased offset femoral component, the gluteus medius may be tight
which causes a pelvic tilt, and gives an
apparent leg length inequality;
- as the gluteus medius stretches out over several months, the apparent leg length
inquality decreases toward normal;
- reference:
- Hip arthroplasty: postoperative management problems. The pants too short, the
leg too long.
- Clinical significance of leg-length inequality after total hip arthroplasty.
- Functional leg-length inequality following total hip arthroplasty.
- Surgical Treatment of Limb-Length Discrepancy Following Total Hip Arthroplasty.
- Leg-length Inequalities Following THA Based on Surgical Technique
- radiology of offset:
- horizontal and vertical offset depends on the the amount of acetabular reaming, femoral
neck cut, inaddition to the modular components in
both the acetabular cup and femoral stem;
- the easiest way to judge offset is to compare Shenton's line of the opposite (normal hip)
to the operative hip;
- a break in Shenton's line along with decreased area under the curve indicate decreased
offset;
- Radiology of Acetabular Component:
- note that plain radiographs may be more accurate for identifying femoral component
loosening than for acetabular loosening;
- radiographic evaluation of cup position:
- Judet views:
- cross table lateral:
- for evaluation of position of acetabular component (anteversion) & status of post

bone stock in posterior column & neck of ilium;

- Lowenstein lateral radiograph:
- provides a lateral view of the acetabular subchondral bone and the cup after
implantation
- modified Lowenstein lateral radiograph is similar to an oblique radiograph of the
pelvis;
- patient is turned onto the affected hip at least 45 and as much as necessary to
allow the lower limb to be in abduction and
external rotation and to be flat on the x-ray table;
- polyethylene wear (need to rule out osteolysis w/ annual radiographs);
- acetabular component loosening
- where as patients w/ loose femoral components will often complain of pain, in contrast,
patients w/ loose acetabular components may be asymptomatic;
- asymptomatic patients w/ radiographic evidence of loosening need to be followed for
implant migration and loss of bone stock;
- some surgeons will recommend revision for radiographic loosening even if patients have
no symptoms;
- Radiology of Femoroal Component: (post op x-rays for thr)
- post op ap & lateral x-rays should include entire length of stem & cement mass;
- yearly radiographs need to be taken to look for progressive osteolysis;
- radiographic views:
- frog leg lateral: gives best lateral of prox portion of femoral component;
- stress views:
- may detect implant loosening;
- weight bearing and non wt bearing views:
- push pull views: to evaluate for loosening of components;
- same as ap view of hip w/ examiner providing distraction and compression to the hip
through the femur;
- implant migration (indicates loosening);
- pistoning / subsidence:
- medial midstem pivot
- calcar pivot: (distal toggle)
- bending cantilever (distal pivot)
- cemented femoral component:
- femur and cement column are inspected carefully and compared w/ previous films for
changes indicating component loosening, stem
failure, trochanteric problems, or infection;
- press fit femoral component:
- end of stem pain is usually present from time of surgery, tends to improve during 1st
year, but may remain constant thereafter;
- although bone scans may help, many noncemented THR, esp long stems, may show
some increase in activity;
- divergent radiolucent lines in area of ingrowth indicate loosening;
- varus / valgus positioning:
- traditionally, varus positioning has been thought to lead to premature loosening;
- in the report by Sochart and Porter (1997), however, neither varus or valgus stem
position appeared to be associated w/ premature
stem loosening (w/ average of 20 years follow up)

The histology of the radiolucent line.

The long term results of Charnley Low Friction Arthroplasty in Young Patients who have
Congenital Dislocation, Degenerative Osteoarthritis, or Rheumatoid Arthritis.
Pelvic Rotation and Tilt Can Cause Misinterpretation of the Acetabular Index Measured on
Radiographs
Quality assessment of early versus late post-operative radiographs in joint replacement surgery.
The Internet Journal of Orthopedic Surgery. 2008 Volume 10 Number 2. Z.A. Jibri, S.R.
Fernando, S.B. Mirza, M.M. Glasgow.
We assessed the post-operative radiographs of 87 patients who had total hip (46 patients) or
total knee arthroplasty (41 patients).

This study has also demonstrated that the late post-operative radiographs following THR are of
better quality than the early ones. These early radiographs were of poor quality and we question
their role as a baseline for further examinations.
..... If the first postoperative radiographs were taken in the follow up clinic, this would result in a
better quality radiograph, in a more comfortable patient easily positioned by the radiographer. It
will reduce the pressure on the radiology services as the patient would not need to have the Xray during the hospital stay. It will also help in the logistics with in the hospitals as the patient
would normally walk to the radiology department in the late postoperative period and would not
need transport.
In conclusion, this study has demonstrated that there is a significant difference in the quality of
post-operative radiographs in favour of the late films.
TOTAL HIP REPLACEMENT ARE CHECK RADIOGRAPHS REQUIRED?
J Bone Joint Surg Br 2006 vol. 88-B no. SUPP II 249. JR Crawford, I Syed, M Babatope and GS
Keene
We included 50 consecutive patients that underwent a primary total hip replacement in our
study. During the post-operative period A-P and lateral check radiographs of the hip were
performed. We conclude that initial post-operative radiographs are of inferior quality and do not
alter the management of the patient. Consideration should be given to performing check
radiographs at the first out-patient clinic follow-up as an alternative.
Recovery room radiographs after total hip arthroplasty: tradition vs utility?
J Arthroplasty. 2012 Jun;27(6):1051-6. doi: 10.1016/j.arth.2011.12.020. Epub 2012 Feb 2.
Ndu A, Jegede K, Bohl DD, Keggi K, Grauer JN.
In a review of 632 consecutive recovery room series, Findings suggest that the single routine
inpatient series should be taken in the radiology suite, rather than in the recovery room.
Routine recovery room radiographs after total hip arthroplasty: ineffective for screening and
unsuitable as baseline for longitudinal follow-up evaluation.
J Arthroplasty. 2004 Apr;19(3):313-7. Mulhall KJ, Masterson E, Burke TE.
retrospectively analysed 2,065 consecutive hip arthroplasty patients... found a 0.1% rate of
radiologic diagnosis of dislocation in the population screened. In 100 patients randomly selected
for comparison, the image quality in the recovery room radiographs was significantly inferior to
standardized departmental radiographs (P<.001), with further significant differences between
cup version (P<.001), and stem alignment assessments (P=.002). With such poor information
and diagnostic yield for follow-up and screening, these investigations should only be performed
when clinically indicated.
Postoperative radiographs following hip fracture surgery. Do they influence patient
management?
Int J Clin Pract. 2007 Mar;61(3):421-4. Chakravarthy J, Mangat K, Qureshi A, Porter K.
conduct a national audit on current UK practice regarding the use of check radiographs
following hip fracture surgery. Retrospective case note review of all patients
undergoing hip fracture surgery at our hospital, from 2002 to 2004, was performed. Patients
undergoing revision surgery in the same admission were identified to determine
whether check radiograph influenced the decision. Subsequently a postal performa was sent to
450 randomly chosen UK Orthopaedic Consultants. The performa was designed to determine
practice relating to postoperative radiographs. It also attempted to determine whether

postoperative radiographs (when requested) influenced the subsequent clinical management of

the patient. A total of 1265 hip fractures treated surgically were reviewed locally. .....The study
highlights the lack of national consensus on the use of postoperative radiographs. We
recommend that following DHS/DCS fixation and CS fixation, the use of postoperative
radiographs should only be undertaken when clinically indicated. Postoperative radiographs
following hip hemiarthroplasty should only be undertaken if there are operative concerns or
postoperative complications.
Check radiography after fixation of hip fractures: is it necessary?
J R Coll Surg Edinb. 2000 Dec;45(6):398-9. Mohanty K, Gupta SK, Evans RM.
requesting routine post-operative check radiographs for these fractures are still a common
practice...
We suggest that routine post-operative radiographs after femoral neck fracture fixation are
unnecessary unless there is some clinical indication. This has significant implications in relation
to patient discomfort, radiation exposure and cost-effectiveness.

THR: Acetabular Component

- See: Total Hip Replacement Menu / acetabular component revision:
- Surgical Technique:
- preoperative planning:
- acetabular biomechanics:
- operative considerations for hip dyplasia
- protrusio
- types of components:
- press fit components:

- cemented acetabular component:

- acetabular component revision
- clinical exam:
- note the amount of standing lordosis and the amount of hip abduction;
- adduction contracture may cause the pelvis to tilt downward which might overestimate the amount of hip abduction;
- acetabular exposure:
- if exposure is not optimal, then consider trochanteric osteotomy;
- re-establish anatomy of the acetabular floor:
- reaming technique:
- component insertion: (press fit components)
- component position: (anteversion and inclination)
- screw placement:
- bone grafting for acetabular defects:
- complications:
- acetabular fracture:
- acetabuli should not be underreamed by more than 1 mm, especially in
osteoporotic bone;
- underreaming of the acetabulum by two milimeters may result in frx in 20-25% of
cases;
- when intra-operative fracture is recognized intra-operatively, then augment the
component with as many acetabular screws as possible;
- references:
- Periprosthetic fracture of the acetabulum during and following total hip
arthroplasty.
- Fracture of the acetabulum during insertion of an oversized hemispherical
component.
- Intraoperative Fractures of the Acetabulum During Primary Total Hip
Arthroplasty
- acetabular component loosening:
- screw insertion injuries;
- osteolysis
- protrusio:
- dislocation
- references:
- The elevated-rim acetabular liner in total hip arthroplasty: relationship to
postoperative dislocation.
- Radiographic Evaluation:
- preop acetabular x-ray evaluation:
- protrusio vs DDH
- reference:
- Radiographic measurements in protrusio acetabuli.
- bone grafting for acetabular defects:
- references:
- The acetabular teardrop and its relevance to acetabular migration.
- Bone-grafting in total hip replacement for acetabular protrusion.
- postop radiographic evaluation:
- acetabular component loosening:
- component position;
- polyethylene wear:

- osteolysis:
- references:
- Severe Osteolysis of the Pelvis in Association with Acetabular Replacement
without Cement.
- The relationship between design, position, and wear of acetabular components
inserted without cement and development of pelvic osteolysis.
- Are cementless acetabular components the cause of excess wear and
osteolysis in total hip arthroplasty?
- acetabular component revision

Planning for THR: Considerations for

Acetabular Fracture
- See:
- Acetabular Fractures:
- Total Hip Arthroplasty:
- Discussion:
- in the report by Bellabarba C, et al, the authors compared the results of arthroplasty in
patients who had had prior operative treatment
of their acetabular fracture with those in patients who had had prior closed treatment of
their acetabular fracture;
- 30 THR were performed with use of a cementless hemispheric, fiber-metal-mesh-coated
acetabular component for the treatment of
posttraumatic osteoarthritis after acetabular fracture;
- median interval between the fracture and the arthroplasty was 37 months (range, eight
to 444 months);
- average age at the time of the arthroplasty was fifty-one years, and the average duration
of follow-up was 63 months;
- 15 patients had had prior open reduction and internal fixation of their acetabular fracture
(open-reduction group), and 15 patients
had had closed treatment of the acetabular fracture (closed-treatment group);
- operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion
requirements (p < 0.001) were
greater in the patients with posttraumatic arthritis than they were in the patients with
nontraumatic arthritis;
- hardware was removed only as needed to allow an unimpeded press-fit of the
acetabular component;
- bone-grafting was performed as required to provide two-column support for the
acetabular component and to maintain the integrity of the dome and the medial wall;
- in the nine patients requiring bone-grafting of acetabular defects, morselized cancellous
graft was taken from the femoral head and from the
acetabular reamings and was impacted into the contained cavitary defect both
manually and by reverse reaming (no structural grafts were required);
- prophylaxis against HO consisted of a single dose of radiation (500 to 1000 cGy) in 7
patients (four who had had ORIF and three who had had

closed treatment) and indomethacin (50 mg orally, 3 times a day for 3 weeks) in 1
patient w/ a prior ORIF;
- of the patients with posttraumatic arthritis, those who had had ORIF of their acetabular
fracture had a significantly longer index procedure (p = 0.01),
greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than
those in whom the fracture had been treated by closed methods;
- 2 of the 15 patients with a previous ORIF required bone-grafting of acetabular defects
compared with seven of the fifteen patients treated by closed means (p = 0.04).
- Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end
point, was 97%;
- results were similar to those of the patients who underwent primary total hip arthroplasty
for nontraumatic arthritis;
- the only failure occurred in a patient with an unsupported acetabular discontinuity;
- authors recommend plate fixation is required in conjunction with acetabular
reconstruction in such patients;
- in the report by Mears DC and Velyvis JH (2002), the authors assessed the role of acute
THR in a selected group of patients with a
displaced acetabular fracture and complicating features that greatly diminished the
likelihood of a favorable outcome after open reduction and internal fixation.
- 57 patients underwent an acute total hip arthroplasty for a displaced acetabular
fracture;
- mean follow up was 8.1 years;
- mean time from the injury to the arthroplasty was six days (range, one to twenty days);
- mean age of the patients at the time of the arthroplasty was sixty-nine years;
- indications for the acute arthroplasty included intra-articular comminution as well as fullthickness abrasive loss of the articular cartilage,
impaction of the femoral head, and impaction of the acetabulum that involved >40%
of the joint surface and included the weight-bearing region;
- at the time of the latest follow-up, the mean Harris hip score was 89 points (range, 69 to
100 points);
- 45 patients (79%) had an excellent or good outcome;
- there were six cases of heterotopic bone formation, including one of symptomatic gradeIV ossification;
- during the initial six postoperative weeks, the acetabular cups subsided an average of 3
mm medially and 2 mm vertically;
- all of the cups then stabilized, and none were loose at the latest follow-up
evaluation.
- 6 patients had excessive medialization of the cup, but none had late loosening or
osteolysis.
- no cup or stem had late clinical or radiographic evidence of loosening;
- technical considerations:
- bone grafting for acetabular defects
- gap cup
- infra-tectal or juxatecal transverse fractures and comminuted anterior column fractures:
stabilized with two 2.0 mm braided cables
- Stabilization of an acetabular fracture with cables for acute total hip arthroplasty.

THR: Posterolateral Approach

- See: Total Hip Replacement Menu:

- PreOp:
- Theory and Background:
- Checklist for THR: and Radiographs:

- Initial Exposure:
- positioning, prepping and antibiotics:
- posterolateral skin incision:
- incise thru iliotibial band:
- split gluteus maximus:
- The course of the superior gluteal nerve in the lateral approach to
the hip;
- identify the sciatic nerve
- measure leg lengths:
- external rotators and the posterior capsule
- hip dislocation: technique:
- Femoral Preparation:
- femoral neck resection:
- entry into femoral medullary canal:
- femoral reaming:
- broaching:
- femoral broaching for press fit stems:
- Acetabulum:
- acetabular exposure and preparation for reaming:
- acetabular reaming:
- acetabular cup insertion:
- acetabular cup position:
- screw insertion:
- Femoral Stem Insertion:
- insertion of cementless femoral stem:
- insertion of cemented femoral stem: (cementing: preparation and technique):
- trial reduction:
- Wound Closure:
- Rush Betadine Lavage Protocol:
- preparation of solution:
- scrub nurse draws up 17.5cc of 10% povidone-iodine with a syringe and mixes it
with 500cc of sterile normal saline;
- this results in a dilution of 0.35% povidone-iodine for use prior to wound closure;
- following implantation of the prosthetic components, the wound is soaked with
500cc of the dilute betadine solution for three minutes,
followed by pulsatile lavage with 1L of normal saline without antibiotics;
- prior to final closure, betadine is applied to the skin surrounding the incision;

- references:
- Dilute betadine lavage a simple, less expensive way to reduce postoperative
TKA infection
- Dilute Betadine Lavage in the Prevention of Postoperative Infection
- Dilute Betadine Lavage Before Closure for the Prevention of Acute Postoperative
Deep Periprosthetic Joint Infection

- Post Operative Care:

- anesthesia
- Continuous Lumbar Plexus Block for Postoperative Pain Control After Total Hip
Arthroplasty. A randomized controlled trial.
- exam:
- evaluate vascular and neurological status of both legs;
- assess leg lengths (based on level of malleoli) to r/o dislocation;
- deep venous thrombosis
- ref: Hypoxemia After Total Joint Arthroplasty: A Problem on the Rise
- postop radiographs:
- following THR in RR, x-rays must include the entire stem in two planes;
- ap view: may reveal cement outside the cortex;
- lateral view: may show the stem penetration of the cortex;
- hip precautions:
- patients need to hip limit flexion to 90 deg;
- patients will require and elevated toilet seat, and instruments to help with putting on
shoes and socks;
- it is unclear whether patients need restricted wt bearing (see forces acting on hip joint);
- references:
- Hip revision with impacted morselized allografts: unrestricted weight-bearing and
restricted weight-bearing have similar effect on migration. A radiostereometry analysis.
- Implant migration after early weightbearing in cementless hip replacement.
- postoperative dressing:
- modified vaccum assisted closure:
- dramatic reduction of post op wound drainage can be obtained by applying gauzefenestrated drain-gauze dressing covered by tegaderm which
is then hooked up to wall suction;
- references:
- Simplified wound care and earlier wound recovery without closed suction
drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations
- Blood loss after total hip replacement: a prospective randomized study
between wound compression and drainage.
- Wound complications after hip surgery using a tapeless compressive
support
- Suction dressings: a new surgical dressing technique.
- Suction dressings in total knee arthroplasty--an alternative to deep suction
drainage.
- External suction drainage in primary total joint arthroplasties.
- Incisional Vacuum-Assisted Closure Therapy
- Continuous high vacuum and primary skin closure in sternotomy wound infection
- Role of Vacuum Assisted Closure (VAC) Device in Postoperative

Management of Pelvic and Acetabular Fractures

- Incisional Wound Vac in Obese Patients
- Wound oozing after total hip arthroplasty.
- Factors associated with prolonged wound drainage after primary total hip
and knee arthroplasty.
- Is a fat stitch required when closing a hip hemiarthroplasty wound without a
drain?
- Blood loss after total hip replacement: a prospective randomized study
between wound compression and drainage.
- Wound complications after hip surgery using a tapeless compressive
support.
- Post Op Fever:
- references:
- The Role of Blood Cultures in the Acute Evaluation of Postoperative Fever in
Arthroplasty Patients
- Urinary-Bladder Management After Total Joint-Replacement Surgery.
- Factors Associated with Prolonged Wound Drainage After Primary Total Hip and
Knee Arthroplasty.
- Postoperative Ileus After Total Joint Arthroplasty (see prevention with chewing
gum)
- Febrile response after knee and hip arthroplasty.
- Evaluation of Postoperative Fever and Leukocytosis in Patients After Total Hip and
Knee Arthroplasty

Total Joint Arthroplasty: When Do Fatal or Near-Fatal Complications Occur?.

Antibiotic Prophylaxis
- See:
- Antibiotic Menu
- Osteomyelitis
- Perioperative Prophylactic Antibiotics:
- the main question we need to ask is what are we trying to accomplish?
- obviously we want a strategy that prevents the infection of MRSA, MSSA, staph epi, and
anaerobic infections;
- giving ancef alone, would not prevent MRSA, staph epi, and anaerobic infections;
- hence there must be a strategy such as MRSA screening prior to surgery to prevent
infection (unless Vancomycin is routinely given - which it should not);
- it is essential that antibiotics be given prior to incision;
- in most cases, patients should receive 1-2 gm of IV Ancef 30 min prior to the incision;
- management of "penicillin allergy" (see anaphylaxsis)
- need to distinguish between nonimmune-mediated drug reactions and immunemediated reactions;
- need to distinguish an immediate IgE-mediated rxn (anaphylaxis) from delayed rxn that

is mediated by T cells, immune complexes, and/or antibodies;

- if patient has non-systemic signs of penicillin allergy, then ancef can usually be given
safely;
- if there is a history of a severe penicillin allergy (ie, hypotension, difficulty breathing)
then alternative medication such as clindamycin should be used;
- remember that it is unfair to label a patient as "penicillin allergic" when the history is
equivocal;
- furthermore, theoretically the OR is the safest place to manage an anaphylactic
reaction should one occur;
- references:
- Antibiotic Allergy
- Cephalosporin Allergy
- Reduction of vancomycin use in orthopedic patients with a history of antibiotic
allergy.
- need to redose intraoperative antibiotics:
- proper dosing and redosing is essential to maintain a serum level to MIC (mean
inhibitory concentration) of 8 to 1

Femoral Bone Grafting in THR

- See:
- Total Hip Replacement Menu:
- Acetabular Bone Grafting:
- Allografts
- Discussion:
- indicated for pts w/ severe osteolysis or for femoral shaft fractures;
- in younger pts, structural allografting may eventually allow some degree of revascularization
of dead bone, which restores patients bone stock;
- napkin ring calcar replacement:
- involves placement of a circumferential portion of allograft over top of the patients
deficient calcar;
- femoral component is then inserted in the usual way (usually w/ cement);
- main complications include graft resorption and subsidence;
- femoral strut allografts:
- in the report by Barden B, et al. (2001), large femoral cortical strut allografts were used
to provide structural
support of the femur in 20 patients in whom uncemented, extensively porous-coated,
press-fit revision femoral stems;
- mean followup was 4.7 years;
- radiographic analysis of the patients who had revision surgery revealed that in all 20

patients, cortical femoral strut allografts showed incorporation;

- small areas of graft resorption were observed in only two patients;
- 17 of the uncemented femoral revision stems radiographically showed bone
ingrowth;
- 3 of the revision femoral stems were interpreted as being fixed only by fibrous
ingrowth after early subsidence after surgery;
- before surgery, all patients were unable to walk and had severe pain;
- at followup, all patients were ambulatory and had considerable improvement in pain
relief and in their ability to walk;
- ref: Supportive strut grafts for diaphyseal bone defects in revision hip arthroplasty.
- Technical Pearls:
- in many cases, surgeons will elect to bridge a femoral shaft defect (or fracture) with a
cortical strut allograft and cables;
- realize that with time, the allograft may undergo partial resorption which can lead to wire
loosening;
- hence, cortical strut allografts and wires should not be relied upon to provided long term
support

Cementing Technique for THR

- See: Total Hip Replacement Menu:
- Addition of Antibiotics to Cement:
- Cemented Femoral Component Loosening:
- Insertion of Cemented Femoral Stems:
- Discussion:
- first generation technique:
- finger packing technique, w/o use of pressurization (no cement gun and no medullary
plug), and no reduction of porosity (centerfuge);
- aseptic loosening may be as high as 30% at 10 years (Stauffer RN. (1982));
- references:
- Ten-year follow-up study of total hip replacement
- modern cementing techniques:

- medullary brush;
- cement restrictor (either plastic or cement plug);
- meduallary pusaltile lavage
- insertion of adrenaline-soaked sponges
- reduction of cement porosity (centerfuge)
- precoating of the stem w/ cement (controversial)
- note that methods to increased bonding between the stem and the cement may
actually lead to early loosening in some cases;
- cement centralizers (applied to femoral stem tip)
- cement gun for retrograde insertion and pressurization
- pressurization: may be performed with surgeon's gloved finger or may be performed w/
a wedge shaped pressurization device which is pushed into the medullary canal;
- hazards:
- cement disease:
- insufficient cement:
- when using a new implant, always check w/ the manufacturing representative to
ensure two 40 gm bags of cement are sufficient;
- bone-cement radiolucencies:
- etiology may stem from thermal necrosis from large volumes of cement and 2%
shrinkage which occurs w/ cement hardening;
- PreCementing Checklist:
- optimize the exposure:
- it is important to realize that total hip arthroplasty can be performed thru a fairly small
incision, but in contrast, careful insertion of a cemented femoral stem requires a
larger exposure inorder to avoid varus/valgus and anteversion/retroversion
abnormalities;
- w/ an excessively small exposure, the femoral component will torque on the soft
tissues (which creates cement voids) as the component is driven downward;
- check the adequacey of the exposure by hand inserting an under-sized broach
component down the canal to ensure that the
surgeon's fingers (or the insertion jig) do not get in the way of a smooth femoral
stem insertion;
- calcar planning:
- this step is necessary to maximize contact w/ the femoral collar;
- countersink final broach size approx 2 mm below femoral neck cut;
- for prosthesis w/ collar, use calcar planer to make final adjustments of collar against
medial aspect of femoral neck cortex;
- check anteversion:
- prior to cementing, recheck femoral neck anteversion, by testing where component
touches calcar (also ensure that component will
not be placed in varus);
- once cement is injected, its illegal to rotate femoral component w/ in canal because this
will create voids w/in cement;
- trochanteric osteotomy wires:
- if trochanter has been removed wires are introduced before cement is inserted and a
further trial reduction then carried out;
- canal plugging: (cement restrictor)
- silastic plug is placed 1 to 1.5 cm distal to femoral stem tip (use a pen to mark the
insertion rod at the proper distance as measured

either off of the trial broach or stem);

- some authors (Russotti, et al (1988)) argue that at least 2 cm of distal cement is
necessary to prevent progressive radiolucency;
- other authors agrue that only 1-1.5 cm of distal cement is needed since the bigger
stems used today achieve fit by wedging
(not end bearing);
- in addition, w/ revision surgery, there is nothing worse than have to remove more
than 2 cm of cement;
- use largest silastic plug possible, becuase a small plug may be forced distally by the
pressurized cement;
- plug is inserted by hammering, which prevents sudden plunging, which might otherwise
occur w/ hand insertion;
- after restrictor is in place, reinsert femoral stem to ensure that there is adequate room;
- w/ plug in place, no further bleeding will come from the canal;
- references:
- Loosening of the femoral component after use of the medullary-plug cementing
technique. Follow-up note with a minimum five-year follow-up.
- Cemented total hip arthroplasty with contemporary techniques. A five-year
minimum follow-up study.
- removal of debris from femur:
- may begin cement mixing while preparing bone bed for cement;
- loose cancellous bone debris, blood, and tissue are removed w/ water pick & brush are
helpful, & routine mechanical drying of both
acetabular & femoral surfaces is important (continue water pick until returning fluid is
clear);
- apply dilute solution of Epi w/ moist sponge (prevents blood interposition)
- use hypotensive anesthesia to reduce bleeding during cementing;
- references:
- Medullary lavage reduces embolic phenomena and cardiopulmonary changes
during cemented hemiarthroplasty.
- An in vitro study of femoral intramedullary pressures during hip replacement using
modern cement technique.
- High-volume, high-pressure pulsatile lavage during cemented arthroplasty.
- The role of lavage in preventing hemodynamic and blood gas changes during
cemented arthroplasty.
- clean field:
- before inserting cement, keep field as dry as possible to optimize cement bonding;
- an "illegal sponge" can be placed in the acetabulum and over the abductors;
- suction:
- sucker tip should be changed, since contamination rate exceeds 50% after 100
min;
- in fact, it is often most useful to have a backup suction apparatus ready since the
primary suction tubing often becomes partially
clogged w/ debris during the lateral part of the case;
- components on the field:
- ensure that all components are on the field, and all insertion instruments are ready;
- minimize risk of DVT:
- consider use of intraoperative IV heparin to reduce the risk of DVT in THR;

- Cement Mixing:
- see vaccum mixing:
- in some situations, the addition of antibiotics may be appropriate;
- total joint replacement following renal or liver transplantation carries a risk of joint infection
of appoximately 19%;
- these patients will have a high relative mortality rate;
- references:
- The effect of centrifuging bone cement.
- Do we need to vacuum mix or centrifuge cement?
- Cement Delivery;
- insert cement into cement gun at 2 minutes, and insert into medullary canal at 3-4 minutes;
- insertion of cement w/ decreased viscosity results in greater strength;
- low viscosity prevents laminations which significantly weaken the polymerized cement
mass;
- delivering cement w/ syringe to allow retrograde filling;
- the syringe in which the cement is loaded must have a nozzle long enough to reach
cement restrict plug;
- Cement Pressurization:
- often the surgeon will wait until the cement is slightly doughy (4-6 minutes) before
pressurization, realizing that it is difficult to pressurize when the cement is watery;
- cement that extrudes around side should not be folded back on top because it is usually
contaminated w/ blood (add fresh cement);
- after cement is filled, the cement is pressurized w/ a mechanical device or with pressure
from a finger over a rubber dam;
- hazards: if pressurizing devices are used, then be sure to check the cement in the canal (as
opposed to the cement on the field) every 30
to 60 seconds to ensure that it is not "maturing" too quickly;
- it is important to check the canal cement rather than the residual cement on the field
because they may mature at different rates
(which means that the canal cement is hardening while the cement on the field is
still soft);
- references:
- Cement pressurisation during hip replacement.
- Pressurized cement fixation in total hip arthroplasty.
- Femoral Stem Insertion:
- cement is allowed to reach doughy state before components are inserted;
- if cement is not doughy at insertion, there will not be maximum pressurization as the
stem is inserted;
- usually the component should be inserted at 5-6 minutes;
- insert stem straight into canal w/ proper anteversion;
- any twisting of stem once in canal will change anteversion;
- component is held rigidly in place for 12-15 min while methacrylate hardens (polymerizes),
fixing the implant to the bone

Cemented Femoral Stems

- See: Total Hip Replacement Menu:
- Cemented Femoral Component: Loosening:
- Collar: in THR
- Optimal Cementing Technique
- Removal of Cemented Femoral Stems:
- Indications:
- cemented femoral stems probably remain gold standard for total hip arthroplasty;
- most indicated in older patients (more than 65 yrs), but are also used in younger patients
since there is some indications that cemented stems
are less prone to develop osteolysis;
- useful for patients w/ "stove pipe" type femur, previous fracture, or previous osteotomy since
these patients would not be expected to achieve
a tight fit which is necessary for ingrowth;
- may be indicated poor bone quality such as RA, osteoporosis, or Paget's disease;
- Harrington MA, et al, the authors determined that in a stair-climbing test model, the peak
proximal cement strains were increased more by changes in
body wt than they were by changes in neck length. Even during stair-climbing, calcarcollar contact reduced peak cement strains;
- peak strain magnitudes in proximal cement mantle were increased more by changes in
body wt than by changes in length of neck of stem;
- strong effect of stem size on the cement strains suggests that cemented femoral stems
should not be used in heavy
patients with small medullary canals that require a small cemented stem;
- references
- Cemented femoral fixation: a historical footnote.
- Effects of femoral neck length, stem size, and body weight on strains in the
proximal cement mantle.
- outcomes:
- in the study by Callaghan JJ, et al (2000) the authors followed Charnley Total Hip
Arthroplasty
patients (with cement) with a minimum 25 year follow up;
- of the 327 hips for which the outcome was known after a minimum of 25 years, 295
(90 %) had retained the original implants until
the patient died or until the most recent follow-up examination;
- of the 62 hips in patients who lived for at least 25 years after the surgery, 48 (77 %)
had retained the original prosthesis;
- Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up.
- Cemented Component Design:
- prosthesis should have relatively smooth surfaces, w/ no sharp edges, so that sites of stress
concentration are eliminated from both prosthesis and cement;
- a prosthesis that is broader laterally than medially may help to diffuse the compressive
stress medially;
- tapered shape from proximal to distal allows controlled subsidence within the cement
column;
- cobalt-chromium alloy stems are used in most stems, since they generate less particulate
debris than titanium implants;

- triple taper concept: femoral component tapers to a point in both the AP and lateral planes
and in addition, the stem is more narrow medially and widens laterally;
- references:
- Survivorship analysis of cemented high modulus total hip arthroplasty.
- Effects of Femoral Neck Length, Stem Size, and Body Weight on Strains in the
Proximal Cement Mantle
- The design features of cemented femoral hip implants.
- Analysis of 16 retrieved proximally cemented femoral stems.
- Component Surface:
- there is controversy about how much bonding should occur between the cement and the
femoral stem;
- excessive bonding between the cement and stem may transfer wt bearing stress to the
bone-cement interface, leading to loosening;
- in contrast, excessive motion between the cement-metal interface, may lead to
excessive osteolysis and rapid loosening;
- definitions:
- polished: (Ra less than 1 micrometer) polished stems create little abrasion;
- matte: (Ra less than 2 micrometer) matte finnish will not create excessive abrasion
unless stem allows large micomotion;
- rough: (Ra greater than 2 micrometer) expected to cause excessive abrasion;
- some are proponents of smooth surface, which may allow subsidence and thereby keeps
the cement in compressive loading;
- many components have a matt finish, which allows some mechanical interlock with the
cement;
- in the study by Howie DW, et al (1998), 4/20 matt coated stems had been revised for
aseptic loosening whereas
0/20 polished stems had been revised (9 year minimum follow up);
- in the study by Collis and Mohler, the authors evaulated loosening in grit blasted versus
polished stems;
- study included 244 consecutive total hip arthroplasties with a cemented femoral
component performed by one surgeon;
- 4 hips treated with the grit-blasted stem had aseptic loosening with substantial
surrounding lysis and required revision;
- an additional two hips in this group had radiographic evidence of substantial lysis and
were judged to have an impending need for revision;
- no hip treated with the polished stem required revision, and only one had minimal lysis;
- this difference regarding failures and impending failures was significant (p = 0.05);
- references:
- Loosening of matt and polished cemented femoral stems.
- Comparison of Clinical Outcomes in Total Hip Arthroplasty Using Rough and Polished
Cemented Stems with Essentially the Same Geometry
- The skeletal response to matt and polished cemented femoral stems.
- Effects of design changes on cemented tapered femoral stem fixation.
- Early loosening of the femoral component at the cement-prosthesis interface after total
hip replacement.
- A Rough Surface Finish Adversely Affects the Survivorship of a Cemented Femoral
Stem.
- Long-term results of use of a collared matte-finished femoral component fixed with

second-generation cementing techniques. A fifteen-year-median follow-up study.

- Radiographic Failure Patterns of Polished Cemented Stems.
- Cement Technique:
- in the report by Shepard MF, et al, the authors performed an experimental study on cement
technique;
- they determined that when using a roughened or precoated cemented femoral
component, the surgeon should consider
cementing earlier with wetter cement to maximize the cement-prosthesis bond;
- when implanting a polished femoral component, it is preferable that the cement is
doughy, because the cement-prosthesis bond is not influenced
by the wetness of the cement and it is easier to maintain the orientation of the
femoral component.
- references:
- Influence of Cement Technique on the Interface Strength of Femoral Components.
- Loosening of the femoral component after use of the medullary-plug cementing
technique. Follow-up note with a minimum five-year follow-up.
- Pressurized cement fixation in total hip arthroplasty.
- Do we need to vacuum mix or centrifuge cement?
- Patterns of osteolysis around total hip components inserted with and without cement.
- The prevalence of femoral osteolysis associated with components inserted with or
without cement in total hip replacements. A retrospective matched-pair series.
- The results of improved cementing techniques for total hip arthroplasty in patients less
than fifty years old. A ten-year follow-up study.
- Radiolucency at the bone-cement interface in total knee replacement. The effects of
bone-surface preparation and cement technique.
- The femoral component in total hip arthroplasty. Six to eight-year follow-up of one
hundred consecutive patients after use of a third-generation cementing technique.
- Total hip arthroplasty with use of so-called second-generation cementing techniques. A
fifteen-year-average follow-up study.
- Cement Mantle:
- current recommendations are to have at least 2 mm of a uniform cement mantle around the
femoral component;
- in the study by Joshi RP, et al (1999), the authors found that a 3 mm cement mantle around
the femoral component, and a
6 mm mantle around the acetabular component were associated with the lowest
incidence of osteotlysis;
- references:
- Changes in the calcar femoris in relation to cement technology in total hip
replacement.
- The cement mantle in total hip arthroplasty. Analysis of long-term radiographic results.
- Osteolysis after Charnely primary low friction arthroplasty. A comparison of two
matched paired groups.
- Should the cement mantle around the femoral component be thick or thin?
- Cement microcracks in thin-mantle regions after in vitro fatigue loading.
- Importance of a thin cement mantle. Autopsy studies of eight hips.

- Grading of Cement Technique: (Barrack, et al. (1992) and Mulroy, et al. (1995))
- grade A: meduallary canal completely filled w/ cement (white out).
- grade B: a slight radiolucency exists at the bone cement interface.
- grade C: a radiolucency of more than 50% at the bone cement interface.
- grade D: a radiolucency involving more than 100% of the interface between bone and
cement in any projection, including absence of cement distal to the stem tip;
- note: this grading system has been criticized since it is somewhat influenced by the amount
of cancellous bone removed during reaming and broaching;
- when the entire cancellous bed is removed, there will often be "white out" (indicating
good cementing technique), and yet
there will be no cancellous foothold for the cement;
- cement mantle:
- as noted by Mulroy, et al. (1995), a femoral cement mantle less than 1 mm and defects
in the cement mantle are associated with early loosening;
- Jasty, et al (1990), noted that cement voids and stem abutment against the femur
(indicating an inadequate cement mantel) were associated w/ loosening;
- similarly, Maloney, et al (1990), note that circumferential cement mantles with
component centralization prevents loosening;
- references:
- Improved cementing techniques and femoral component loosening in young
patients with hip arthroplasty. A 12-year radiographic review.
- Total hip arthroplasty with use of so-called second-generation cementing
techniques. A fifteen-year-average follow-up study.
- Histomorphological studies of the long-term skeletal responses to well fixed
cemented femoral components.
- Bone lysis in well fixed cemented femoral components.
- Radiographic comparison of cementing techniques in total hip arthroplasty.

- Cement Disease:
- references:
- Cement disease.
- Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report
of seven cases.
- Bone lysis in well-fixed cemented femoral components

- Charnely:

- Charnely-Muller:

Collar: in THR
- See: Total Hip Replacement Menu:
- Discussion:
- stress transfer to femur is desirable because it provides physiologic stimulus for maintaining
bone mass & preventing disuse osteoporosis;
- if prosthesis has a collar that is seated on the cut surface of the neck or if there is a layer of
cement in contact with the bone and
undersurface of the collar, there will be axial loading of the bone;
- although the role of a collar in preventing loosening of a cemented femoral component has
not clearly established, any loading of
proximal medial neck is likely to decrease bone resorption and thereby reduce
stresses in the proximal cement;
- collar also serves as a simple means of determining depth of insertion of femoral
component, since vision is temporarily obscured by
extrusion of the cement;
- Collar in Austin Moore Prosthesis:
- Calcar Pivot: (distal toggle) is frequent complication of a non cemented collared prosthesis;
- only true calcar support prosthesis is the old Moore implant, whose stem was too small to
provide canal fill in most cases;
- designed for patients w/ 1/2 to 3/4 inches of remaining femoral neck above the lesser
trochanter;
- collar of Austin Moore prosthesis is more transverse than that of the Thompson prosthesis,

a fact that increases ability of neck to receive

the compression stresses inserted on to it;
- Moore initially desinged his prosthesis with fenestrations in the stem in an effort to
induce "self locking" and bony ingrowth

Dislocation of THA
- See: Total Hip Replacement Menu:
- acetabular components
- acetabular component position:
- Discussion:
- occurs in 1-4% of primary THA and upto 16% in
revision cases;
- about 74% of THR dislocations are posterior, 16% anterior, and 8%
lateral; (from Cobb TK, et al. (1996));
- most commonly caused by looseness of hip (improper neck length), and component
malposition (see acetabular component position);
- revision arthroplasty:
- dislocation is much more common in revision THA;
- careful testing w/ trial components w/ correction of neck lengths w/ correction of neck
length, impingement, & repair of trochanter may avoid this complication;
- ref: The elevated-rim acetabular liner in total hip arthroplasty: relationship to postoperative
dislocation.
- Differential Dx:
- patient risk factors:
- excessive alcohol intake (dislocation of up to 20%);
- in patients w/ DDH, risk of dislocation may be as high as 8%;
- positional dislocations:
- components are positioned correctly & soft tissues are balanced;
- patient puts the hip into a position that is beyond the range possible w/ prosthetic
components;
- soft tisse laxity:
- shortening in either verticle or horizontal direction causes soft tissue imbalance,
possibly resulting in dislocation;
- radiographs should be evaluated for limb length inequaility;
- late dislocation may be related to gradual stretching of pseudocapsule;
- laxity of soft tissue is most frequent cause of instability of THR when radiographs
reveal good position of components;
- trochanteric non union is another risk factor for dislocation because
of soft tissue tension;
- component malposition: (acetabular component position)
- safe position: 35 +/- 10 deg anteversion 40 +/- 10 deg abduction
- acetabular abduction angle
- horizontal cup placement (less than 40 deg) may lead to early
impingement in flexion;
- in this case there is impingement between neck and poly

liner;
- result can cause osteolysis, liner dislodgement, and component loosening;
- version of acetabulum (true lateral view) (see radiographic evaluation)
- anteversion is determination directly by measuring angle between line drawn
thru axis of metal shell or wire marker & verticle
on cross table lateral view of acetabulum;
- unnoticed forward rotation of pelvis when surgical procedure is done in lateral
postion is one cause of malalignment of
component that can result in an unnoticed retroversion position of cup;
- version of femoral component;
- references:
- Factors predisposing to dislocation after primary total hip arthroplasty: a
multivariate analysis.
- The Effect of the Orientation of Acetabular and Femoral Components on the
Range of Motion of the Hip at Different Head-Neck Ratios.
- Joint motion and surface contact area related to component position in total hip
arthroplasty.
- Computed tomographic evaluation of component position on dislocation after
total hip arthroplasty.
- Position, orientation and component interaction in dislocation of the total hip
prosthesis.
- componenet impingement:
- posterior dislocation may be caused by anterior osteophytes which protrude beyond
the edge of the acetabular cup;
- anterior dislocation may be partially due to the presence of a high wall liner placed
posteriorly;
- overmedialization of the cup:
- more common in protrusio
- overmedialization causes impingement of the femoral neck on the pelvis
- management of this situation may involve use of a lateralized liner (high wall
liner will not help this);
- horizontal cup placement (less than 40 deg) may lead to early impingement in
flexion;
- in this case there is impingement between neck and poly liner;
- result can cause osteolysis, liner dislodgement, and component loosening;
- acetabular occupancy:
- cause of dislocation in RR, & once hip is rereduced, hip is stable;
- femoral head size:
- smaller diameter head (22-28 mm) allow less stress/torque but may result in
increased central acetabular wear and dislocation;
- larger head sizes (32-36 mm) allow increased ROM and reduced dislocation, but
have less net wall thickness for long term wear;
- references:
- Independent contribution of elevated-rim acetabular liner and femoral head size
to the stability of total hip implants.
- Relationship of femoral head and acetabular size to the prevalence of
dislocation.
- component subsidence:
- limb length shortening is a known cause of dislocation;
- lateral / medial offset:
- lateralized femoral stem may be used to restore stability, but this may increase

component micromotion;
- ref: Micromotion measurements with hip center and modular neck length alterations.
- Assessment:
- need to review operative note for specific details about hip stability;
- flouroscopy to determine range of hip stability and to determine whether any of
components are loose (femoral component, acetabular cup, and acetabular liner);
- exam: neurovascular exam before and after the reduction;
- posterior dislocation
- caused by flexion, adduction, and internal rotation;
- anterior dislocation
- caused by extension, adduction, and external rotation;
- in the example below, the patient sustained an anterior
dislocation in the RR;
- it was felt that the dislocation occurred as a result of performing a partial anterior
capsulotomy in addition
to the lingering effects of the spinal anesthetic;
- he was placed in a bledsoe brace, which held the hip in 30 deg flexion;

- Reduction Maneuver:
- typically the patient will be placed on a flouro bed (if one is available);
- an assistant stands near the patients head, and provides downward traction on the pelvis;
- the surgeon should step up onto the bed, standing over the patient;
- grasp the patient's leg between the surgeon's arm and armpit, leaving both hands free to
grasps the knee;
- surgeon uses his/her legs to effect an appropriate amount of traction, while the surgeon
uses his hands to internally and externally rotate hip (as directed
by the flouroscopic picture) inorder to guide the hip into a reduced position;
- difficult reduction:
- ensure that the patient is paralyzed;
- if the femoral head is brought down to the level of the acetabulum and the reduction
does not occur, then the femoral head is most likely posterior,
which means that the hip needs to be flexed allowing traction to be directed
anteriorly;
- consider placing the patient in the lateral position, allowing flexion, internal rotation
and traction in the usual manner;

- Treatment Options:
- treatment depends on the etiology of the dislocation;
- if alcoholism was related to the dislocation then education and bracing are necessary;
- if component mal-positioning or gluteus medius laxity are present, then these may need to
be managed operatively;
- simple closed reduction:
- in general, if more than 2 dislocations have occurred, revision surgery should be
considered;
- if a dislocation occurs late after surgery, then consider surgery as recurrent
dislocations can be expected;
- references: Late Dislocation After Total Hip Arthroplasty.
- in the report by Li E, et al. (2000), the authors followed a total of 1,036 consecutive
total hip replacements between 1989 and 1992;
- 40 (3.9%) were known to have dislocated posteriorly (24 of these dislocations
occurred after primary replacements, and 16 after revision);
- 85 % of the dislocations occurred within 2 months and were reduced closed;
- 23 of the 40 dislocated hips (57.5%) redislocated
- 16 of the 40 hips (40%) required reoperation for recurrent dislocation;
- references:
- The Natural History of a Posteriorly Dislocated Total Hip Replacement
- Outcome of treatment for dislocation after primary total hip replacement
- trochanteric advancement:
- may be indicated if options for increased neck length are not present;
- revision total hip replacement:
- femoral component revision: increased lateral offset can be achieved by increasing
neck length;
- ref: Modular revision for recurrent dislocation of primary or revision total hip
arthroplasty.
- acetabular liner:
- as noted by Cobb et al 1996, the presence of a high wall liner can
reduce incidence of dislocation in primary THR from about 3.8% to 2.2%
- the beneficial effect is probably higher w/ revision surgery;
- paradoxically, high wall liner may actually increase incidence of anterior dislocation
(due to impingement between femoral neck and elevated lip of liner);
- liners may also contribute to increased polyethylene wear;
- reference:
- The Elevated Rim Acetabular Liner in Total Hip Arthoplasty: Relationship to
Postoperative Dislocation.
- acetabular component revision
- increased anteversion (if posterior dislocation is present);
- increased lateral offset (using lateralized liner);
- constrained acetabular liner component
- bipolar hip arthroplasty as a Salvage Treatment for Instability of the Hip
- in the report by Parvizi J and Morrey BF (2000), reviewed the records of 27 patients who
had
undergone bipolar hip arthroplasty as a salvage procedure for the treatment of
recurrent instability of the hip after total hip replacement;
- all patients had undergone at least two, and a mean of three, stabilizing operative
procedures on the hip prior to the bipolar arthroplasty.

- the mean duration of follow-up was five years (range, two to twelve years), with no
patient lost to follow-up;
- bipolar arthroplasty prevented redislocation in twenty-two hips (81%);
- 25 patients (93%) had a stable hip at the time of last followup;
- complications: revision because of disassembly of the cup in one hip, revision bipolar
arthroplasty because of continuing instability in two, resection
arthroplasty because of deep infection in two, revision arthroplasty because of
recalcitrant groin pain in one, and revision arthroplasty
because of deep infection and superior migration of the implant in one;
- 12 patients in our study had hip pain, and two had severe groin pain;
- refs:
- Bipolar hip arthroplasty as a salvage treatment for instability of the hip.
- Bipolar hip arthroplasty for recurrent dislocation after total hip arthroplasty. A report
of three cases.

DVT/PE Prophylaxis in THR

- See Total Hip Replacement Menu:
- Discussion: (general discussion of DVT)
- 40-60% of THR patients who do not receive prophylaxis will get a DVT (dependment on
imaging method);
- ref: Significance of deep venous thrombosis in the lower extremity after total joint
arthroplasty.
- in contrast, the study by Fender, et al (1997) showed that the incidence of fatal PE (as
diagnosed by postmortem examination) was 4 / 2111 patients (0.19%);
- in this study, use of chemical prophylactic agents had no impact on the occurance of a
fatal PE (3 patients that died had been on
chemical prophylactic agents and one patient died that had no prophylaxis);
- these authors feel that the issue can only be solved by a large scale prospective
randomized trial (tens of thousands of patients);
- supporting this data, is the study by Warwick, et al which showed one fatal PE out of 1162
consecutive total hip replacements (death rate from PE was 0.34% );
- Mortality and fatal pulmonary embolism after primary total hip replacement. Results
from a regional hip register.
- Death and thromboembolic disease after total hip replacement. A series of 1162 cases
with no routine chemical prophylaxis.
- risks of rehospitalization:
- in the study by White, et al (2000) identified 297 patients 65 years of age or older who
were
rehospitalized for thromboembolism within 3 months after THR;
- total of 89.6% with thromboembolism and 93.8 % of controls were treated w/ SCDs,
warfarin, enoxaparin, or unfractionated heparin, alone or in combination;
- 22.2 % and 29.7 %, respectively, received warfarin after discharge;
- body-mass index (wt in kg divided by square of ht in meters) of 25 or greater was
associated w/ rehospitalization for thromboembolism, w/ odds ratio of 2.5;
- Predictors of Rehospitalization for Symptomatic Venous Thromboembolism after
Total Hip Arthroplasty.

- Thromboembolic Disease after Total Hip Arthroplasty: Who is at Risk?

- when is prophylaxis to be initiated?
- in the review article by Salvati, et al, the authors point out that timing of heparin
administration may be critcal for DVT prophylaxis;
- they point out that thrombogenesis begins during the preparation of the femur and is
most pronounced with implantation of femoral components
with cement rather than without cement;
- in this phase, thrombotic mediators are released which leads to femoral venous
occlusion occurs;
- the authors recommend giving a bolus of IV heparin (approx 3000 units) just before
cement preparation of the femur;
- because the half life of IV heparin is short (approx 30-40 min), risk of significant
bleeding is minimal;
- Recent Advances in Venous Thromboembolic Prophylaxis During and After Total Hip
Replacement.
- how long should prophylaxis be given?
- in the report by Comp PC, et al, the authors evaluated the efficacy and safety of a
prolonged post-hospital regimen of enoxaparin;
- following elective THR or TKR, 968 patients received subcutaneous enoxaparin (30
mg twice daily) for 7-10 days, and 873 were then randomized to receive
three weeks of double-blind outpatient treatment with either enoxaparin (40 mg
once daily) or a placebo;
- enoxaparin was superior to the placebo in reducing the prevalence of venous
thromboembolism in patients treated with THR;
- 8.0% of patients treated with enoxaparin had DVT compared with 23.2% of patients
treated with the placebo;
- enoxaparin had no significant benefit in the patients treated with knee replacement;
- 17.5% of the patients treated with enoxaparin had DVT compared with 46 20.8% of
patients treated with the placebo;
- symptomatic PE developed in three patients, one with a hip replacement and two
with a knee replacement, all had received the placebo;
- there was no significant difference in the prevalence of hemorrhagic episodes or
other types of toxicity between the enoxaparin and placebo-treated groups;
- references:
- Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip
or knee replacement. Enoxaparin Clinical Trial Group.
- The Cost-Effectiveness of Extended-Duration Antithrombotic Prophylaxis After Total
Hip Arthroplasty.
- Diagnostic Methods:
- references:
- B-mode ultrasound scanning in the detection of proximal venous thrombosis after total
hip replacement.
- Duplex scanning versus venography as a screening examination in total hip arthroplasty
patients.
- Prophylactic Agents:
- aspirin:

- references:
- Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein
thrombosis in total hip arthroplasty.
- Thromboembolic Disease Prophylaxis in Total Hip Arthroplasty.
- heparin and low molecular wt agents:
- in THR, relative risk reduction for DVT using LMWHs is about 70%;
- even with use of low molecular wt heparins, the risk of DVT following THR may be as
high as 15%;
- ref: Finding the right fit: Effective thrombosis risk stratification in orthopaedic
patients.
- in a total hip arthroplasty study by Colwell, et al (1999), the overall rate of throboembolic
disease was 3.6% for patients receiving
lovenox versus 3.7 % for patients receiving adjusted dose coumadin;
- lovenox (or coumadin) was continued only for the length of the primary
hospitalization (which averaged 7 days;
- references:
- Comparison of enoxaparin and warfarin for the prevention of venous
thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three
months after discharge.
- Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip
replacement. A controlled, prospective, randomized multicenter trial
- The effect of intravenous fixed-dose heparin during total hip arthroplasty on the
incidence of deep-vein thrombosis. A randomized, double-blind trial in patients operated on with
epidural anesthesia and controlled hypotension.
- Prevention of venous thrombosis after total hip arthroplasty. Antithrombin III and
low-dose heparin compared with dextran 40.
- Complications of heparin therapy after total joint arthroplasty.
- Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty.
A prospective, randomized, controlled, clinical trial.
- Prevention of deep-vein thrombosis and pulmonary embolism after total hip
replacement. Comparison of low-molecular-weight heparin and unfractionated heparin.
- Intraoperative adjusted-dose heparin thromboembolic prophylaxis in primary total
hip arthroplasty.
- Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty.
A prospective, randomized, controlled, clinical trial.
- Efficacy and safety of enoxaparin to prevent deep vein thrombosis after hip
arthroplasty.
- Recent Advances in Venous Thromboembolic Prophylaxis During and After Total
Hip Replacement.
- Prolonged enoxaparin therapy to prevent venous thromboembolism after primary
hip or knee replacement. Enoxaparin Clinical Trial Group.
- pentasaccharides:
- in the report by Turpie AG, et al., the authors studied the effects of the pentasaccharide
Org31540/SR90107A,
a highly selective, indirect inhibitor of activated factor X, is the first of a new class of
synthetic antithrombotic agents;
- double-blind study, patients had doses of one of five daily doses of
Org31540/SR90107A, given qd, or to 30 mg of enoxaparin, given q 12 hours;
- treatment was continued for 10 days or until bilateral venography was performed
after a minimum of 5 days;
- of 933 patients treated, 593 were eligible for the efficacy analysis;

- with Org31540/SR90107A a dose effect was observed (P=0.002), with rates of

venous thromboembolism of 11.8 %, 6.7 %, 1.7 %, 4.4 %,
and 0 % for groups assigned to 0.75 mg, 1.5 mg, 3.0 mg, 6.0 mg, and 8.0 mg
of drug, as compared with a rate of 9.4 % in enoxaparin group;
- reduction in risk of venous thromboembolism was 82 % for 3.0-mg
Org31540/SR90107A group (P=0.01) and 29 % for 1.5-mg group (P=0.51);
- enrollment in the 6.0-mg and 8.0-mg Org31540/SR90107A groups was
discontinued because of bleeding complications;
- major bleeding occurred 3.5 percent less frequently in the 0.75-mg group (P=0.01)
and 3.0 percent less frequently
in the 1.5-mg group (P=0.05) than in the enoxaparin group (in which the rate was
similar to that in the 3.0-mg group);
- the authors concluded that Org31540/SR90107A, a synthetic pentasaccharide, has
the potential to improve significantly the risk-benefit
ratio for the prevention of venous thromboembolism, as compared with lowmolecular-weight heparin.
- ref: A Synthetic Pentasaccharide for the Prevention of Deep-Vein Thrombosis after
Total Hip Replacement
- warfarin:
- references:
- Routine use of adjusted low-dose warfarin to prevent venous thromboembolism
after total hip replacement.
- Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip
replacement.
- Intermittent pneumatic compression versus coumadin. Prevention of deep vein
thrombosis in lower-extremity total joint arthroplasty.
- Prevention of deep venous thrombosis after total hip arthroplasty. Comparison of
warfarin and dalteparin.
- Pulmonary embolism in total hip and knee arthroplasty. Risk factors in patients on
warfarin prophylaxis and analysis of the prothrombin time as an indicator of warfarin's
prophylactic effect.
- compressive devices:
- references:
- Intermittent pneumatic compression to prevent proximal deep venous thrombosis
during and after total hip replacement. A prospective, randomized study of compression alone,
compression and aspirin, and compression and low-dose warfarin.
- Intermittent pneumatic compression versus coumadin. Prevention of deep vein
thrombosis in lower-extremity total joint arthroplasty.
- Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial
comparing a mobile compression device with low-molecular-weight heparin.
- vena cava filter:
- reference:
- Use of the Greenfield filter to prevent fatal pulmonary embolism associated with
total hip and knee arthroplasty.
- Treatment:
- standard treatment algorithm (confirmation of DVT/PE, followed by IV heparin or SQ low
molecular wt heparin, followed by PO warfarin;
- consider applying a hip spica compression dressing (from toes to waist) to reduce swelling
and risk of hematoma;

- in the report by Lawton RL and Morrey BF (1999), the authors advise that patients who
demonstrate clinical signs of a PE
should have the diagnosis confirmed before starting empiric IV heparin;
- they noted at 47% complication rate in their patients (versus 20% in patients that did
not receive heparin);
- they found no benefit to starting IV heparin prior to confirmation of the diagnosis;
- The use of heparin in patients in whom a pulmonary embolism is suspected after total
hip arthroplasty.

Femoral Component
- See: Total Hip Replacement Menu
- Discussion:
- design considerations
- femoral stem collar
- cemented femoral stems (radiology of cemented femoral stems)
- press fit femoral stems
- femoral component offset
- rotational position of femoral component:
- see: femoral component anteversion / adult femoral and acetabular anteversion:
- if component is placed in anteversion with respect to axis of knee, femur is placed
posteriorly with respect to pelvis;
- this is a stable situation, because excessive internal rotation is needed before the hip
dislocates posteriorly and the abductors do not allow
enough external rotation for hip to dislocate anteriorly;
- excessive anteversion of femoral component of THR does not lead to dislocation
problem, but it does limit external rotation;
- excessive retroversion tends to produce posterior dislocation;
- femoral components with inherent anteversion should be placed in neutral with respect
to the plane of flexion of the knee;
- ref: Patterns of stress distribution at the proximal femur after implantation of a modular
neck prosthesis. A biomechanical study.
- stiffness of femoral stem:
- high modulus (stiffer material such as cobalt chrome) will increase stresses in the stem
and decrease stresses in the cement;
- transfer of the stress into the distal stem might stress shield the proximal femur and
lead to disuse bone resorption;
- lower modulus (more flexible material such as titanium) can increase stress on the
proximal bone but might also increase stress on, and
thus fatigue, the proximal cement increasing incidence of loosening;
- femoral head size:
- metal on metal designs begin at 36 mm and go upto greater than 50 mm;
- the larger femoral head size allows for increased stability and less impingement;
- polyethylene liner: (traditional design)
- choice of femoral head size seems to have settled on 26 or 28 mm;
- less acetabular strain and lower revision rates are associated w/ use of a twentysix or 28 mm head;

- 32 mm head: 32 mm allow increased ROM before it impinges against the

acetabulum, and therefore theoretically has less dislocation;
- main disadvantage is that it has less net wall thickness, and produces too large a
volume of wear debris;
- 22 mm head
- produces too much linear wear or creep;
- smaller diameter head (22 mm) allow less stress/torque but may result in
increased central acetabular wear and dislocation;
- references:
- Effect of femoral head size on wear of the polyethylene acetabular component.
- Size of the femoral head and acetabular revision in total hip-replacement
arthroplasty.
- Range of Motion and Stability in Total Hip Arthroplasty With 28-, 32-, 38-, and 44mm Femoral Head Sizes.
- Effect of Femoral Head Diameter and Operative Approach on Risk of Dislocation
After Primary Total Hip Arthroplasty.

THR: Periprosthetic Femur Fractures

- See: Total Hip Replacement Menu:
- IntraOperative Frx:
- frx may occurr early while the attempt to dislocate hip is made;
- most postoperative femoral fractures can be prevented by avoiding injury to the bone during
the original THR procedure;
- bone lysis from secondary aseptic loosening may significantly compromise strength of the
femur and can lead to eventual frx;
- prevention of frx:
- osteotomy of the trochanter before dislocation may reduce the force necessary for
dislocation and thereby reduce the risk of frx;
- fragile bone of elderly pts and of pts with RA or disuse osteoporosis may be frxd by
moderate rotational force;
- when resistance is met in attempting dislocation in these pts, psoas tendon & more of
capsule must be released;
- to dislocate hip posteriorly, partial transverse section of fascia lata & maximus insertion
may be necessary as well as release of tight, fibrotic band
along posterior edge of medius;
- Frx Occurring in the Post Op Period:
- risk factors:
- inadequate calcar cancellous bone removal (w/ subsequent calcar resorption);
- varus positioning of the stem;
- lateral stem nicks produced by drilling for greater trochanteric wires;
- progressive osteolysis;
- vancouver classification:
- type B frx: fractures occurring at or near the distal tip of a hip prosthesis with a stable
femoral stem (Vancouver type-B fractures)

- type-B1 periprosthetic fractures:

- defined as a fractures occurring at or near the distal tip of a prosthesis with a
stable femoral stem;
- associated with the most complications of all of the fracture types because of the
inherently unstable fracture pattern;
- references:
- Fixation of periprosthetic femoral shaft fractures adjacent to a well-fixed
femoral stem with reversed distal femoral locking plate.
- Locking compression plate fixation of Vancouver type-B1 periprosthetic
femoral fractures.
- Locking plate osteosynthesis for Vancouver Type B1 and Type C
periprosthetic fractures of femur: a report on 12 patients.
- type-B2:
- fractures occur in the same region with a loose stem
- type-B3:
- fractures occur with a loose stem where the proximal bone is of poor quality
and/or severely comminuted
- references:
- Classification of the hip.
- Periprosthetic fractures of the femur. An analysis of 93 fractures
- Treatment protocol for proximal femoral periprosthetic fractures.
- managment:
- management depends on frx location, fixation of the prosthesis, and amount of
displacement;
- in general, if the prosthesis is well fixed and if the fracture is minimally displaced, a
trial of non operative treatment is indicated;
- femoral shaft perforations:
- need to bypass perforation by at least one and one half shaft diameters in order to
reduce risk of shaft frx through the perforation;
- clinical recommendations have been to use a femoral component that ends 2-3 shaft
diameters distal to the perforation;
- proximal femur frx;
- frx usually cannot occur unless there is loss of fixation of proximal femoral
component;
- frx may have produced disruption of the bone cement prosthesis interface or there
may have been preexisting loosening;
- requires revision of the femoral component;
- example of femur frx occuring distal to the stem tip, which healed with use of traction
and a cast brace;
- even though the fracture was angulated, the clinical result was good;

- long oblique frx at tip of prosthesis:

- more amenable to treatment in traction w/ subsequent cast bracing, if good alignment
can be maintained;
- the main complication of non operative treatment is mal-alignment;

- short oblique frx at stemp tip:

- arises due to a stress riser effect between prosthesis and bone;
- these frx are at high risk for displacement, shortening, & non union;
- not amenable to closed treatment;
- loose component:
- using large uncemented prosthesis & obtaining stability in
diaphyseal region is often successful treatment of
these fractures;
- well fixed component:
- if component appears to be well fixed, consider leaving the prosthesis in place,
and managing the fracture with a plate;
- proximal to the femoral component, the plate is secured w/ unicortical screws
or with cerclage wires;
- ref: Locking Compression Plate Fixation of Vancouver Type-B1 Periprosthetic
Femoral Fractures
- bone distruction:
- w/ extensive bone destruction is such that large allograft is needed;
- femoral cortical allograft may be applied to the medial femoral cortex and is
secured by a laterally applied plate;
- above the level of the prosthesis the allograft is secured w/ cerclage wires;
- medial cortical allograft is applied thru an extended medial approach;
- this treatment strategy often produces allograft healing by 5 months unless
the patient has had previous stripping the femoral periosteum in
which case non union is possible;
- Cerclage Fixation Techniques: (from Cheng, et al (1993))
- Hairpin Cerclage Knot
- is significantly stronger than other fixation techniques;
- technique:
- wire is bent into a "U" shape;
- "U" is then passed around one end of the bone;
- one of the free ends of the wire is passed thru the "U" of the loop, and then the free
ends of the wire are tension w/ a single throw of a square knot;
- Harris Wire Tightener:

- single throw of a square knot is thrown and is then tensioned w/ the Harris wire
tightener;
- wire is twisted 180 deg while under tension (more twisting may break wire);
- Harris tightener is released and final twisting is completed with pliers;
- references:
- A comparison of the strength and stability of six techniques of cerclage wire fixation for
fractures.

Infected / Septic THR

- See: Total Hip Replacement Menu: and see total knee replacement infections
- Diagnosis:
- diagnosis of septic loosening is initially based on history, x-ray findings, and elevated sed
rate;
- clincially patients may note increasing pain at both rest and with activity;
- despite the variety of tests available, it may be difficult to distinguish aseptic loosening
(acetabular and femoral) from an infected THR;
- risk factors:
- Methods to Prevent Infection
- references: Perioperative factors associated with septic arthritis after arthroplasty.
Prospective multicenter study of 362 knee and 2,651 hip operations.
- classification:
- type I: early postoperative
- type II: late chronic (two-stage revision arthroplasty)
- type III: acute hematogenous (such as from dental procedures)
- type IV: positive intraoperative cultures with clinically unapparent infection
- Prosthetic joint infection diagnosed postoperatively by intraoperative culture.
- Radiographs:
- classic findings include, irregular or scalloped border on the endosteal surface of the
cortex, marked periosteal reaction, or late dislocation;
- dx of THR infection that is difficult to appreciate grossly is often delayed, especially in a
patient w/o fever or severe pain;
- x-ray signs of loosening of prosthesis are seen in 2/3 of late infections, but in less
than 50 % of early infections;
- arthrography: (see: hip aspiration)
- may be helpful for determining loosening of cemented acetabular components by
showing penetration of dye between cement and bone;
- note that a fibrous membrane between cement and bone will impede penetration of
cement (false negative);
- bone scans in THR:
- references:
- Evaluation of musculoskeletal sepsis with indium-111 white blood cell
imaging.
- Asymptomatic total hip prosthesis: Natural history determined using Tc99MDP bone scans.
- Laboratory Evaluation and Aspiration:
- bacteriology:

- currently staph epidermidis has emerged as the most common infectious organism
followed closely by staph aureus;
- above two bacterial species along with pseudomonas are slime producers
(glycocalyx) which makes them particularly resistant to treatment w/ antibiotics;
- gram negative organisms which do not produce a glycocalyx may not be as virulent
as previously thought;
- consider need for Ziehl Nielsen stains, mycobacterial cultures, and fungal cultures;
- references:
- Methicillin-resistant Staphylococcus epidermidis in infection of hip arthroplasties.
- Deep infection of cemented total hip arthroplasties caused by coagulase
negative staphylococci.
- Total Hip Arthroplasty Infection With Chlamydia
Pneumoniae and Mycobacterium Chelonae

- Management: (see revision THR);

- debridement and retension of components: (Tsukayama (1996))
- Infection after total hip arthroplasty. A study of the treatment of one hundred and six
infections.
- one stage replantation:
- two stage replantation:
- antibiotic suppression:
- success rate of 20-30%;
- antibiotic treatment will not eliminate chronic deep infection about prosthesis;
- antibiotic management can be used as suppressive treatment for established infection.
- antibiotic suppression can be used if the following are met:
- prosthesis removal is not feasible (pt not candidate for anesthesia)
- microorganism is of low virulence & susceptible to antibiotics;
- patient can tolerate antibiotic w/o serious toxicity;
- prosthesis is not loose;
- ref: Conservative treatment of staphylococcal prosthetic joint infections in elderly
patients
- girdlestone arthroplasty

Evaluation for THR Loosening

- See: THR Main Menu:
- Discussion:
- evaluation of painful THR:
- when previously pain free hip becomes painful, suspect loosening;
- where as acetabular loosening tends to cause groin pain, femoral loosening tends to cause
thigh pain;
- increased limp and shortening are signs of subsidence;
- patient may need to use his hands to lift leg onto exam table;
- inability to perform straigt leg raises;
- patient may then complain that his leg has become increasingly externally rotated as the
component sinks into retroversion;

- in a cemented hip, thigh pain of implant origin indicates loosening, however, this is not
necessarily the case with uncemented stems;
- Types of Femoral Component Loosening:
- cemented femoral component: loosening:
- bending cantilever
- calcar pivot: (distal toggle)
- medial midstem pivot
- pistoning:
- Radiologic Findings:
- radiology of press fit stems
- radiology of cemented stems
- radiology of the acetabular component
- Differential Injections: (see painful THR)
- intra-articular injection of marcaine can be used in the diagnosis of component loosening;
- in the study by Crawford RW, et al (1997), 15 patients with a painful THR received a
marcaine injection;
- 14 patients received relief with the injection and 13 of them were found to have loose
components (either femoral and/or acetabular);
- it did not seem to matter whether components were cemented or press fit;
- hip was aspirated and any fluid obtained was sent for culture, and if fluid was not
obtained then inject 5 ml of Hartman's syndrome and re-aspirate;
- after aspiration, 10 cc of marcaine is injected

THR: Osteolysis
- See: Total Hip Replacement Menu
- Discussion:
- most common complication in total hip arthroplasty and most common cause of component
failure;
- osteolysis is a time dependent process which arises from inflammatory reaction
against polyethylene particulate debris;
- patho-biology:
- osteolysis is mediated primary by macrophages (fibroblasts and endothelial cells also
play a role);
- these cells are activated by wear debris (primarily polyethylene, but also metal and
polymethylmethacrylate debris);
- chemical mediators include: interleukin-1 (bone-resorbing cytokine) and tumor necrosis
factor;
- in the report by Bi Y, et al (2001), the authors present study showed that titanium
particles induced both murine marrow cells and human peripheral blood monocytes to produce
factors that stimulated osteoclast differentiation;
- mean increase in osteoclast differentiation was 29.3 9.4-fold.
- they showed that titanium particles stimulate in vitro bone resorption primarily by
inducing osteoclast differentiation;

- ref: Titanium Particles Stimulate Bone Resorption by Inducing Differentiation of Murine

Osteoclasts
- systemic effects:
- main concern involves dissemination of wear particles to the liver, spleen, and
abdominal lymph nodes of THR patients;
- debris can be demonstrated in the fixed macrophages and Kupffer cells lining the
hepatic sinusoids;
- role of ceramic bearing surfaces:
- ceramic bearing surfaces have offered hope in some series of decreasing osteolysis by
minimizing wear debri;
- it is noted that alumina ceramic provides an ultra smooth surface (compared to metal on
polyethylene);
- in the series by Yoon TR (1998), 103 hips had insertion of the ceramic head and
acetabular component;
- at mean duration of 92 months, femoral osteolysis occured in 23 hips and
acetabular osteolysis occured in 49 hips;
- in patients who underwent revision for osteolysis, abundant ceramic wear
particles;
- the authors cited caution with this type of component noting the high rate of failure;
- references:
- Osteolysis in association with a total hip arthroplasty with ceramic bearing
surfaces.
- Femoral Osteolysis:
- endosteal, intracortical, or non-linear cancellous bone destruction;
- in contrast, loosening will tend to demonstrate progressive linear
radiolucency;
- mechanism of osteolysis:
- wear debris migrates down medullary canal between bone-cement (or
press fit interface) following path of least resistance;
- intracapsular pressure may be a driving force;
- poorly fitting components may accentuate accumulation of wear debris
down the medullary canal;
- do cemented femoral stems show less osteolysis that press fit stems?
- some authors postulate that cement is a more reliable barrier to migration of wear
debris down the medullary canal as compared
to press fit components;
- depending on the data being examined, osteolysis may occur in up to 10-30% of
femoral stems inserted without cement as compared to a prevalence of 1-2% using modern
cementing techniques;
- w/ press fit designs some authors feel that circumferential press fit stems offer more
reliable protection against wear debris as compared to non circumferential designs;
- porous coating may provide a barrier to migration of wear debris;
- references:
- Polyethylene wear and calcar osteolysis.
- Patterns of osteolysis around total hip components inserted with and without cement.
- Studies of the mechanism by which the mechanical failure of polymethylmethacrylate
leads to bone resorption.
- Measurement of Polyethylene Wear in Acetabular Components Inserted with and without
Cement. A randomized trial.

- Effect of Circumferential Plasma-Spray Porous Coating on the Rate of Femoral

Osteolysis After Total Hip Arthroplasty.
- Acetabular Osteolysis:
- acetabular osteolysis is generally asymptomatic and may occur regardless of whether the
component is well fixed;
- because osteolysis is asymptomatic, it is necessary to obtain periodic radiographs;
- note that acetabular osteolysis often will only be evident on oblique radiographs;
- as noted by Devane et al. (1997), osteolysis was associated with an increased rate
of polyethylene wear only in hips that were inserted w/o cement;
- as noted by Bohm and Bosche (1998), the 11 year survivorship of press fit Harris Galante
components was 97.7%;
- there was only one case of osteolysis in this study;
- holes in the acetabular component did not correlate with pelvic osteolysis;
- note that the majority of femoral heads in this study were made of ceramic;
- management: revising the component:
- main risks include probability that there will be major bone loss during implant removal;
- surgeon should be prepared to re-insert a much larger acetabular component following
component removal;
- ref:
- Measurement of Polyethylene Wear in Acetabular Components Inserted with and
without Cement. A randomized trial.
- Survival analysis of the Harris-Galante I acetabular cup.
- Noncemented acetabular component removal in the presence of osteolysis: the
affirmative.
- management: leaving the component in place:
- this avoids all of the complications of implant removal and re-insertion;
- main disadvantage is limitation of exposure (limitation of debridement and bone
grafting);
- if the area of osteolysis is central then consider curretage and bone grafting through the
component screw holes (if these are present);
- if the area of osteolysis is superior or peripheral, consider making an osseous window to
gain access to the lesion;
- in the study by Maloney et al (1997), 35 THR patients w/ porous acetabular components
demonstrated acetabular osteolysis;
- these patients were managemed by liner removal, debridement of the osteolytic
defect and bone grafting, followed by liner exchange;
- after an average of 3 years, the bone grafts had appeared to consolidated and no
progressive bone erosion was seen;
- as noted by Schmalzried, et al (1998), osteolysis was successfully managed by leaving
well fixed components in place and by working around the component (either thru the
component holes or around the perimeter) inorder to currett out the osteolytic lesion;
- maximum size of lesions was about 7 x 5 cm;
- defects were filled with autograft or allograft;
- non of the osteolytic lesions were noted to progress after an average of 40
months;
- controversies:
- fosfamax: some evidence that this can reverse the effects of osteolysis;
- references:
- Treatment of pelvic osteolysis associated with a stable acetabular component inserted

without cement as part of a total hip replacement.

- The fate of pelvic osteolysis after reoperation. No recurrence with lesional treatment.
- Survival analysis of the Harris Galante I acetabular cup.
- Improving the detection of acetabular osteolysis using oblique radiographs.

- Case Example:
- 50 year old patient w/ a well placed acetabular cup (against the tear drop) and well placed
femoral stem;
- after 7 years, the patient has developed extensive osteolysis;

- Cemented Acetabular Component:

- 60 year old patient w/ a Charnley Muller THR which has done well for over 15 years;
- note that there is no acetabular osteolysis;

- Case Example:
- note that a large cup was used on this patient's left side (no osteolysis) where as a smaller
cup was used on the right side (significant osteolysis is present at 7 years postop)

Evaluation of the Painful Total Hip

Replacement:
- See: THR Main Menu and Radiographic evaluation of THR
- Discussion:
- normal gait adaptions:
- trendelenburg limp after THR is a clinical sign of gluteal insufficiency;
- static trendelenburg sign: drop of the pelvis on the contralateral side while the
individual stands on the operative side;
- many patients will compensate for an isolated drop of the pelvis w/ Duchenne limp;
- Duchenne limp: bending of the trunk toward the stance side combined with an
additional lift of the pelvis on the side of the swinging limb;
- infection:
- stress fracture
- Pubic Ramus Insufficiency Fractures Following Total Hip Arthroplasty. A Report of Six
Cases.
- Acetabular fracture associated with cementless acetabular component insertion: a
report of 13 cases.
- aseptic loosening
- examination for loosening
- osteolysis:
- thigh pain from press fit stem: (press fit stems)
- trochanteric bursitis:
- Trochanteric Bursitis After Total Hip Arthroplasty: Incidence and Evaluation of
Response to Treatment
- hernia
- Evaluation of patients with pain following total hip replacement.
- Strangulated obturator hernia masquerading as pain from a total hip replacement.
- hematoma:
- Femoral nerve palsy due to iliacus hematoma occurred after primary
total hip arthroplasty.
- component malposition
- acetabular component malposition
- excessive acetabular anteversion
- can cause mechanical impingement of posteroinferior aspect of the neck of
the femoral component, with impingement

between the socket and the femoral neck during the maximum
extension of the hip
- increased posterior tilt of pelvis in the standing position can
make anteversion of the acetabular cup more significant, which
will enhanced the cup-neck impingement during the gait;
- references:
- Posterior femoral neck impingement secondary to excess
acetabular anteversion in hip resurfacing arthroplasty.
- Cup-neck Impingement Due to the Malposition of the Implant as a Possible
Mechanism for Metallosis in Metal-on-metal Total Hip Arthroplasty
- Notching of the femoral stem neck in metal-on-metal total hip replacement: a
case report
- psoas tendonitis: (see psoas tendon)
- regional sciatica
- Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma
- Sciatic nerve palsy--a complication of posterior approach using enhanced soft tissue
repair for total hip arthroplasty
- Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum
- Compression of the sciatic nerve by wear debris following total hip replacement: a
report of three cases.
- metal corrosion:
- metal on metal prosthesis
- references:
- Corrosion at the Head-Neck Taper as a Cause for Adverse Local Tissue Reactions
After Total Hip Arthroplasty
- A 68-year-old woman with hip pain 3 years after primary total hip arthroplasty
- Role of Differential Injections: (see hip aspiration)
- intra-articular injection of marcaine can be used in the diagnosis of component loosening;
- in the study by Crawford RW, et al (1997), 15 patients with a painful THR received a
marcaine injection;
- 14 patients received relief with the injection and 13 of them were found to have loose
components (either femoral and/or acetabular);
- it did not seem to matter whether components were cemented or press fit;
- hip was aspirated and any fluid obtained was sent for culture, and if fluid was not
obtained then inject 5 ml of Hartman's syndrome and re-aspirate;
- after aspiration, 10 cc of marcaine is injected;
- ref: Intra-articular local anesthesia for pain after hip arthroplasty.

Press Fit Femoral Stems

- See: Total Hip Replacement Menu:
- Insertion of Cementless Femoral Stem:
- Radiology of Press Fit Stems:
- Removal of Cementless Stems:

- Discussion:
- indications:
- younger patients (less than 65 years of age w good bone stock, and absence of
hemophilia, sickle cell, or renal diseases;
- relative contra-indications:
- not the stem of choice for patients w/ "stove pipe" type femur, previous fracture, or
previous osteotomy since these patients would
not be expected to achieve a tight fit which is necessary for ingrowth;
- poor quality bone stock is more likely to undergo plastic deformation and to allow
subsidence of the femoral component;
- design considerations:
- collar:
- Does a collar improve the immediate stability of uncemented femoral hip stems in
total hip arthroplasty? A bilateral comparative cadaver study.
- Subsidence of collarless uncemented femoral stems in total hips replacements
performed for trauma.
- Comparison of collared and collarless femoral components in primary
uncemented total hip arthroplasty.
- The effect of collar on aseptic loosening and proximal femoral bone resorption in
hybrid total hip arthroplasty.
- The biomechanical effect of the collar of a femoral stem on total hip arthroplasty.
- coating for bone ingrowth: (see bone ingrowth)
- extent of coating:
- proximal fixation stems:
- distal fixation stems;
- references:
- Porous surface replacement of the hip with chamfer cylinder design.
- The influence of stem size and extent of porous coating on femoral bone
resorption after primary cementless hip arthroplasty.
- The effect of stem fit on bone hypertrophy and pain relief in cementless total hip
arthroplasty.
- stiffness of femoral stem:
- prosthesis should be minimally stiff and maximally stable;
- prosthesis should prevent migration of particles from articular surface to stem of the
prosthesis;
- minimization of stiffness of prosthesis may result in less pain in thigh;
- methods to minimize stiffness: creating slots (clothespin design) as well as grooves
have been utilized;
- simply increasing the flexibility of the implant w/o considering the need for additional
fixation is as unwise as increasing fixation w/o
thought of its effect on load transfer;
- methods of maximizing stiffness:
- filling of the medullary canal;
- extensive porous coating;
- proximal filling;
- references:
- Radiographic analysis of a low-modulus titanium-alloy femoral total hip component.
Two to six-year follow-up.
- Total hip arthroplasty with a low-modulus porous-coated femoral component.
- stem motion:

- torsional loading (rather than axial) loading is more likely to result in micromotion;
- less than 50 microns of motion is optimal;
- stress levels and the quality of proximal and distal fixation must be balanced so that
both proximal and distal micromotions of the
stem can be reduced to an acceptable level;
- references: Interface Micromotion of Uncemented Femoral Components from
Postmortem Retrieved Total Hip Replacements

- Complications:
- aseptic loosening (see osteolysis):
- stress shielding;
- femoral fracture;
- thigh pain: (see eval of painful hip)
- upto 20% may have mild pain, 11% will have moderate pain (which limits some
activities), and about 2% will have severe pain;
- causes:
- motion at bone prosthesis interface (loosening);
- stem position:
- thigh pain may be more common with varus stem position (which is revealed by
distal lateral cortical hypertrophy);
- extent of porous coating;
- host bone morphology;
- excessive stress transfer from stem to host femur;
- stem material (titanium has a lower modulus of elasticity than cobalt chrome):
- stem size and stem size mismatch;
- management:
- patients should initially be managed with time, since thigh pain may resolve over
the first two years following surgery;
- in report by Domb B, et al (2000), the authors applied lateral cortical strut grafts w/
cerclage fixation,
centered over the femoral stem tip;
- motivation for this type of treatment is that the strut may increase the rigidity of
the host bone over the region of the femoral stem tip,
thereby increasing the modulus mismatch;
- 7 patients underwent this procedure, w/ 6 of these patients obtaining good or
excellent relief of symptoms;
- references:
- Cortical strut grafting for enigmatic thigh pain following total hip arthroplasty.
- The effect of stem fit on bone hypertrophy and pain relief in cementless total hip
arthroplasty.
- Pain in the thigh following total hip replacement with a porous-coated anatomic
prosthesis for osteoarthritis. A five-year follow-up study.

Acetabular Protrusio
- See: Bone Grafting for Acetabular Defects:

- Discussion:
- it is probably the result of remodeling of weak, medial acetabular bone after multiple,
recurring stress fractures.
- intrapelvic protrussion of the acetabulum may be primary or secondary;
- protrusio acetabuli is not found only in inflammatory arthritides;
- most cases are in patients with osteoarthritis.
- primary protrusio: Otto Pelvis (Arthrokatadysis)
- primary protrusio acetabuli characterized by progressive protrusio in middle aged
women;
- is bilateral in 1/3 of pts & causally related to osteomalacia
- large cortical-cancellous bone grafting may be required using pt's femoral head in a
primary arthroplasty as well as a large acetabular component;
- primary form, Otto pelvis (arthrokatadysis), involves both hips, occurs most often in
females, & causes pain & limitation of motion at a relatively early age;
- varus deformity of femoral neck & arthritic changes are
common;
- secondary protrusio:
- secondary form may be caused by femoral head prosthesis, cup
arthroplasty, septic arthritis, central fracture dislocation, or
THR, & may be present bilaterally
in paget's, marfan's, RA, AS, & osteomalacia;
- deformity may progress until femoral neck impinges on side of pelvis;
- often, because of medial migration of the femur, the sciatic near is nearer the joint than
normally;
- Radiographic Diagnosis: (see preoperative radiographic evaluation)
- Kohler's line:
- relationship of femoral head to ilioishial line;
- if femoral head is medial to Kohler's line, then protrusio is present;
- may also use radiographic line from lateral border of the sciatic notch to the medial
border of the obturator foramen;
- Center Edge Angle of Wiberg;
- if CE angle is greater than 35 deg, protrusio is present;
- Considerations in THR:
- template preoperative leg length inequality;
- realize that adaptive soft tissue changes may not allow full restoration of leg length
inequality;
- in considering the best technique, it can be helpful to contrast this with the cotyloplasty
technique;
- component selection:
- acetabular component design
- the peripheral fit is the key element for fixation;
- ideally component should contain a "peripheral flare" rather than a true hemisphere
inorder to prevent progressive medialization of the component;
- peripherally placed screws may also prevent medialization;
- ref: Incomplete seating of press-fit porous-coated acetabular components: the fate of
zone 2 lucencies.

- Surgical Technique: (see THR surgical technique)

- dislocation of hip:
- in some pts such as those w/ protrusio, neck should be divided & head removed from
acetabulum in a retrograde fashion rather than risk fracture;
- note that the sciatic nerve may be closer in proximity to the femoral neck than is
usually seen;
- reaming technique:
- it is essential not to deepen the acetabulum while reaming;
- medial wall of the acetabulum is usually thin or may be partially membranous, and
should not be penetrated;
- surgeon should ream inorder to obtain good peripheral fit;
- peripheral reaming technique must be exact because all residual cartilage must be
removed for ingrowth, while the peripheral subchondral surface
must be preserved, since this will provide the structural support for the implant;
- need to establish proper offset:
- failure to restore normal lateral offset may cause the greater trochanter to inpinge off
of the anterior edge of the acetabulum (leading to posterior instability);
- the peripheral fit dictates the offset;
- cups with the option of acetabular screws allows the surgeon to check the depth of the
cup position, can allow for more graft placement through screw
holes, and scews may prevent medial cup migration;
- bone grafting: bone grafting for acetabular defects:
- w/ bone grafting a noncemented cup be placed in a more lateral and anatomic position
and secured with acetabular screws;
- femoral head autograft is one immediate option;
- in young pt w/ acetabular protrusion secondary to longstanding inflammatory arthritis,
most authorities advise strengthening thin and medially
displaced medial wall of the acetabulum w/ placement of a block cancellous
autograft taken from the femoral head of the patient;
- large cortical-cancellous bone grafting may be required using pt's femoral head in a
primary arthroplasty as well as large acetabular component;
- outcome studies:
- in the report by E. Garcia-Cimbrelo (2000):
- authors followed 148 primary THR with acetabular protrusion between 1972 and
1990;
- 62 with a mild protrusion were classified as group 1, 54 with moderate or severe
protrusion as group 2 and 32 with moderate and severe protrusion
which required bone grafts as group 3;
- mean follow-up was 18.3 years (3 to 24) for group 1, 17.4 years (8 to 22) for
group 2 and ten years (8 to 13) for group 3.
- there were 31 revisions of the cup, 12 in group 1 and 19 in group 2;
- according to the Kaplan-Meier analysis the overall rates at 20 years were 21
10.79% in group 1 and 37 11.90% in group 2;
- there were 43 radiological loosenings: 22 in group 1, 21 in group 2 and none so
far in group 3, at ten years;
- overall loosening rates at 20 years were 42 14.76% in group 1 and 49
19.50% in group 2;

- grafts were well incorporated in all group-3 hips, and the bone structure
appeared normal after one year;
- the distance between the centre of the head of the femoral prosthesis and the
approximate true centre of the femoral head was less
in group 3 than in groups 1 and 2 (p < 0.01);
- better results were obtained in moderate and severe protrusions reconstructed
with bone grafting than in hips with mild protrusion which were not grafted.
- weakness of this study is that the authors were including patients back from the
1970's and 1980's that had insertion of early press fit designs;
- authors did not specify how many cups contained a peripheral flare and
how many had screw augmentation;
- ref: Loosening of the cup after low-friction arthroplasty in patients with acetabular
protrusion. The Importance of the position of the cup.

Revision Total Hip Arthroplasty

- See: Total Hip Replacement Menu

- Discussion:
- evaluation of the painful THR
- indications for revision
- evaluation for loosening
- outcomes:
- references:
- Why revision total hip arthroplasty fails.
- Revision Hip Arthroplasty: Infection is the Most Common Cause of Failure
- Examination:
- examination for loosening:
- previoius incisions;
- contracture of the flexors and adductors (adds to complexity of the case);
- impingement: tenderness to forced internal rotation may indicate anterior
impingement;
- leg-length inequality is noted;
- ref: Surgical Treatment of Limb-Length Discrepancy Following Total
Hip Arthroplasty.
- neurovascular status of the limbs is recorded (EMG can be ordered if
necessary);
- trendelenburg gait:
- power of the abductor muscles is noted;
- marked Trendelenburg gait may indicate that abductors are non functional;
- may be due to paralysis or loss of continuity;
- if no trochanteric frx is present, then consider EMG to evaluate for paralysis;

- PreOp Planning: (radiographs, equipment, implant selection);

- radiographs
- rule out infection:
- besides ruling out joint infection, consider culture of nares since preoperative staph
aureus nasal carriage is associated w/ postop infection;
- references:
- Revision operations on infected total hip arthroplasties. Two- to nine-year follow-up
study.
- The value of aspiration of the hip joint before revision total hip arthroplasty.
- Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic
Infection.
- Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection
- The Chitranjan Ranawat Award: Should Prophylactic Antibiotics Be Withheld Before
Revision Surgery to Obtain Appropriate Cultures?
- extraction instruments
- selection of implants:
- components for acetabular revision
- femoral cementless revision
- cemented femoral revision
- Surgical Approach:
- give prophylactic antibiotics in normal fashion;
- sciatic nerve is identified:
- Incidence of Sciatic Nerve Palsy After Revision Hip Arthroplasty Through a Posterior
Approach
- soft tissue release is extensive so that manual force can be minimal during dislocation;
- partial release of the psoas tendon;
- partial release of gluteus maximus insertion;
- release of reflected head of the rectus femorus;
- ref: Perioperative Antibiotics Should Not Be Withheld in Proven Cases of Periprosthetic
Infection.
- surgical dislocation of hip;
- because femur usually has been weakened owing to cortical defects or cavitation, great
care is taken in dislocating hip and exposing femur to avoid fracture;
- greater trochanter osteotomy will facilatitate dislocation;
- the entire pseudocapsule is excised or released;
- need for tissue biopsy cultures from the component membrane interface
- remember that in the case of biofilm, there may be minimal infection in joint fluid and
capsule, and the main area of infection will be over the component /bone-membrane interface;
- ref: A comprehensive microbiological evaluation of fifty-four patients undergoing
revision surgery due to prosthetic joint loosening.
- femoral component revision;
- trochanteric osteotomy
- acetabular component revision:
- exposure of acetabulum:
- requires wide exposure of hip w/ removal of pseudocapsule, exposing entire
proximal end of femur & entire circumference of acetabulum to permit careful implant removal;
- retention of acetabular shell:

- in some revision situations, the acetabular cup is noted to be stable and is left in
place (ie only femoral revision is performed);
- references:
- Fate of Cementless Acetabular Components Retained During Revision Total
Hip Arthroplasty.
- Cementing a Liner into a Stable Cementless Acetabular Shell: The DoubleSocket Technique.
- Cementation of a Polyethylene Liner Into a Metal Shell
- Cementation of a Metal-Inlay Polyethylene Liner Into a Stable Metal Shell in
Revision Total Hip Arthroplasty.
- Cementing Acetabular Liners Into Secure Cementless Shells for Polyethylene
Wear Provides Durable Mid-term Fixation
- removal of acetabular components
- grafting of acetabular defects / management of pelvic discontinuity
- acetabular component revision (technique)
- references:
- A new approach to the hip for revision surgery.
- A technique of extensile exposure for total hip arthroplasty.
- Extensile exposure of the hip for revision arthroplasty.

Greater Trochanteric Osteotomy

- See: Total Hip Replacement Menu:
- Discussion:
- indications for osteotomy:
- considerations for wire re-attachment:
- wires can theoretically undergo gavanic corrosion if they are close to or touch the metal
implant;
- this is usually of little significance even if the wires break;
- use chrome-cobalt wires (Vitallium) rather than stainless steel;
- all wires in the greater trochanter tend to break in time even if trochanter is solidly
united;
- w/ soft bone (rheumatoid patients), then consider use of wire mesh or plate, which
prevents the wire from cutting throught the trochanteric fragment;
- Surgical Technique:
- release the origin of the vastus lateralis from vastus tubercle;
- osteotomy is performed 1 cm below vastus tubercle, w/ oscillating saw
aimed at the junction of the greater trochanter
w/ the femoral neck;
- greater trochanter is subjected to forces in mainly two directions;
- vertical pull of glutei, which tends to pull trochanter proximally
- anterior pull is more troublesome, and the trochanter is subject to
this pull every time the hip is flexed;
- vertical resistance:
- two drill holes are made through the peripheral edges of the lateral cortex, (one drill
hole is made anteriorly and the

other is made posteriorly);

- the 2 mm drill is directed toward the respective edges of the calcar;
- usually these drill holes are made 2 cm below level of the ostetomy, but in soft
bone or when a trochanteric advancement is to be performed,
then it is necessary to place the holes even more inferiorly;
- wires are threaded thru these holes and are then subsequently inserted thru the
Sharpy's fibers of the gluteus medius insertion;
- once, all wires have been inserted, a Harris wire tightener is then used to secure the
trochanteric fragments with square knots;
- transverse resistance:
- drill hole is made thru the lesser trochanter, and the wire is then brought upwards thru
two drill holes made in the trochanteric fragment;
- this wire will prevent transverse motion as well as preventing rotation;
- references:
- A New Technique to Reattach an Extended Trochanteric Osteotomy in Revision THA
Using Suture Cord
- Fixation of Chevron Trochanteric Osteotomy With Two Wire Loops In Isolated
Acetabular Component Revision
- Sliding Osteotomy Technique:
- Extended Trochanteric Osteotomy:
- Considerations for Cemented Components:
- if possible, reattach the trochanteric fragment (esp w/ extended osteotomy) prior to insertion
of the cemented component (otherwise the supero-lateral
portion of the component will not be covered by cement;
- before the osteotomy fragment is tightened, place dry gel foam strips along its edges,
inorder to prevent cement from leaking out;
- as suggested by McGory, et al., temporarily placed hose clamps will provide maximal
tension while cement hardens and later when cerclage wires are placed;
- Trochanteric Osteotomy for Total Hip Arthroplasty: Six Variations and Indications for their
use.
Complications
- Trochanteric Non-Union:
- references:
- Complications of trochanteric osteotomy. Long-term implications.
- Case Report: Superficial Femoral Artery Injury Resulting From Cerclage Wiring During
Revision THA

Radiology of the Hip

- AP view:
- patient is supine with the foot internally rotated 15 deg to obtain best
views of the femoral neck;
- central beam is directed toward the femoral head;

- X-ray tube should be positioned 100 cm from focal plane of film cassette to yield an image
at 20%
magnification, corresponding to the magnification incorporated in the templates;
- tape measure will allow accurate assessment of radiographic magnification;
- Lateral View:
- surgical lateral view:
- this view should be obtained on all patients suspected of having a hip fracture or
dislocation;
- do not order a frog leg lateral in any patient suspected of having a hip fracture or
dislocation)
- patient is supine; the opposite hip is flexed and abducted;
- cassette is placed against the lateral aspect of the affected hip;
- central beam is directed horizontally toward the groin with about
20 degree of cephalic tilt;
- frogleg lateral view:
- do not order a frog leg lateral in any patient suspected of having hip fracture or
dislocation);
- patient is supine w/ knees flexed, soles of feet together, and the thighs maximally
abducted;
- central beam is directed vertically or with a 10 to 15 deg cephalic tilt to a point slightly
above pubic symphysis;

- Radiographic Evaluation for Hip Arthroplasty:

- preop x-rays for THR:
- post op x-rays for THR:
- Radiographic Evaluation of Femoral Neck Fractures:
- Radiographic Evaluation for Acetabular Fractures
- judet views
- roof arc measurements:
- Radiographic Evaluation for Pelvic Frx