Revision Surgery in Total Hip Arthroplasty

230 Pages·1990·12.39 MB·English

by  B. M. Wroblewski MB, ChB, FRCS (auth.)

B. M. Wroblewski
Revision Surgery in
Total Hip Arthroplasty ..
With 179 figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
B. M. Wroblewski, MB, ChB, FRCS
Consultant Orthopaedic Surgeon, The Centre for Hip Surgery,
Wrightington Hospital, near Wigan, Lanes WN6 9EP, UK.
ISBN-13: 978-1-4471-1790-2 e-ISBN-13: 978-1-4471-1788-9
001: 10.1007/978-1-4471-1788-9
Cover
Fig 18.4b. A sinogram showing extensive sinus. The line drawing is adapted from the graph illustrated in
Fig. 10.4.
British Library Cataloguing in Publication Data
Wroblewski, B. M. (Boguslaw Michael) 1934-
Revision surgery in total hip arthroplasty.
1. Man. Hips. Arthroplasty
I. Title
617.581059
ISBn-13: 978-1-4471-1790-2
Library of Congress Cataloging-in-Publication Data
Wroblewski, B. M., 19~
Revision surgery in total hip arthroplastyfB.M. Wroblewski.
p. cm. Includes bibliographical references.
ISBN-13: 978-1-4471-1790-2
1. Total hip replacement-Reoperation. I. Title. [DNLM: 1. Arthroplasty. 2. Hip Joint-surgery. .
3. Hip Prosthesis. 4. Surgery, Operative. WE 860 W957r) RD549.W76 1990 617.5'810592-dc20
DNLMlDLC 90-9747
for Library of Congress CIP
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© Springer-Verlag London Limited 1990
Softcover reprint ofthe hardcover 1s t edition 1990
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For Peggy, Michael, Paul, Ania and John
in appreciation of their patience, understanding and support
Mike/Tatus
Preface
Revision surgery defines secondary operative intervention in cases of total hip arthro
plasty for whatever reason this has to be undertaken. Thus it includes a broad spectrum
of operative procedures from minor ones to a full-scale exchange. The very rapid
development of this field brings with it new demands and necessitates the continuous
availability of the operative and design skills of the surgeon who remains under
obligation to provide indefinite follow-up and revision facilities for the patient.
The increase in the number of revisions is in some measure the result of longer follow
up and improved identification of problems and provision of solutions for individual
patients. It is the success of revision surgery for the individual patient that has made this
type of work worthwhile. Success cannot be readily quantified and is often a very
personal aspect of clinical practice.
The use of total hip arthroplasty as a method of choice for the treatment of the arthritic
hip is so extensive that certain suggestions must be given serious consideration. The
complexity of this type of treatment is such that revision surgery must be concentrated in
the hands of surgeons devoted to this type of work. This must be recognized at the
professional and administrative level as being of long-term benefit to the patient, the
surgeon and the system which provides such care.
The purpose of this book is to present to the surgeons involved in total hip arthroplasty
ideas and methods for the management of problems in revision surgery. It is based on 20
years of practical experience with the Charnley low-friction arthroplasty and over 5000
operations including over 1200 revisions performed personally. It is not intended to be a
collection of all the references on the subject; the reader must study these personally. Nor
is it a vade mecum for a "do-it-yourself" enthusiast containing the latest diagnostic
procedures and practical solutions in this rapidly developing and changing field. It is
primarily a practical approach to revision surgery, evolved over a number of years. The
lessons learned from revisions are used for the benefit of patients undergoing primary
operations. It is for this reason that the two types of operation must continue to evolve
simultaneously and not be separated for administrative or other reasons.
The author offers no apology for expressing personal views which at times may be in
disagreement with the views of others. As with so many studies of this nature it is bound
to be changed and modified with time. A certain degree of repetition in the text is
inevitable and even deliberate. Some of it is to avoid the nuisance of repeated interruption
by frequent referral to other parts of the book, some to maintain the continuity of
argument, or line of evolution, but most of it is to stress the importance of the topic under
discussion.
viii Preface
Having accepted the benefits of the operation, the patient and the surgeon must realize
and accept that there are certain responsibilities inherent to the procedure. The operation
marks the beginning and not the end of the treatment. No patient can be formally
discharged from follow-up. Regular follow-up by serial radiographs is essential, the time
interval depending on the age and life style of the patient and on radiographic
appearances. Revision surgery may have to be undertaken on the basis of radiographic
changes alone, each operation bringing with it the risks associated with major surgery
and an ever diminishing bone stock. This responsibility must be understood and shared
by the patient and surgeon alike, before the primary operation.
Defining clinical success of the operation for an individual patient is of very personal or
anecdotal value only and yet is the essence of clinical practice. The aim of total hip
arthroplasty for most, if not all, patients is the long-term success of the method. Failing
that, the least that should be offered is the predictability of the outcome of the operation
for an individual patient, accepting that statistical probabilities derived from large
numbers do not apply to the individual patient.
The Centre for Hip Surgery, B. M. Wroblewski
Wrightington Hospital
Near Wigan, Lancs
June 1989
Acknowledgements
Any study involving clinical, experimental and research aspects cannot be satisfactorily
carried out by an individual working alone. In this the author has been very fortunate to
be associated with a number of helpful and co-operative people. It is not possible to
mention them all individually for fear of omitting some.
However, I would like to acknowledge the late Professor Sir John Charnley, who was
the prime mover in encouraging the study and management of revision surgery, and a
number of anaesthetists - Drs. George Brittain, Dec Ryan, John Crook, Maurice Girgis
and the late Rasheed Sobhy - who have made surgery safe for the patient and enjoyable
for the surgeon.
I would also like to thank Theatre and Anaesthetic Department staff, including Staff
Nurse, now Sister Maureen Abraham and Sister Cathy Platt, who patiently put up with
long operating sessions; Geoff Halliwell, the late Mr. David Jones, Brian Blundell, Brian
Spencer and Andrew Burrows ("the leg holders") who could "winkle out" any hip
without trouble; the residents and the nursing staff caring for the patients on the wards
and for out-patients; physiotherapists, radiographers and all hospital staff; and Biomec
hanical Research Laboratory staff including the late Mr. Ken Marsh, Mr. Frank Brown
and, more recently, Drs. Phillip Shelley and Graham Isaac, who were ready to put new
ideas into workable form but who always tempered the enthusiasm with constructive
criticism and the knowledge of practical possibilities. Dr. Shelley'S role as Research
Fellow and his extensive knowledge of mechanics and computers as well as their practical
application to clinical practice has been invaluable.
I thank Dr. Randolph White who by his encouragement and critical analysis often
added statistical respectability to the finished product, and Chas. F. Thackray Ltd. of
Leeds who were always ready with practicaLpelp and patiently awaited the completion of
this study. Lack of commercialism and pressure was greatly appreciated.
My thanks also go to Mr. Peter Kilshaw and the Department of Medical Illustration for
their help with photography and graphics; to my secretary Mrs. Brenda Lowersop who so
sympathetically dealt with patients, retyped numerous manuscripts and acquired the
new skills of dealing with computers and authors' hieroglyphics; and to the publishers,
Springer-Verlag, who patiently waited during the long gestation (and transverse arrest)
of this work.
Thanks must be given to my colleagues who showed their confidence by referring their
patients for revision surgery, who offered constructive comments when visiting the Unit
and who gave the author the privilege of addresssing them at various meetings both
nationally and internationally.
x Acknowledgements
My special thanks go to the patients themselves who were prepared to undergo
surgery and who kept in touch and attended follow-up clinics, often travelling long
distances. It is true to say that without their involvement all this would not have been
possible.
Acknowledgements for Illustrations
The author wishes to thank the following journals and publishers for permission to
reproduce previously published illustrations:
Acta Orthopaedica Scandinavica: Figs. 16.4, 16.5
Clinical Orthopaedics and Related Research G.B. Lippincott): Table 9.1
Engineering in Medicine (by permission of the Council of the Institution of Mechanical
Engineers): Fig. 9.6b
Journal of Bone and Joint Surgery: Figs. 3.5, 5.5, 5.6a and b, 10.5b and c, 10.6, 10.13b and c,
12.1b and c, 13.6a, 13.12, 13.13a
Orthopedic Clinics of North America (W.B. Saunders): Figs. 1O.la-d, ll.la
Springer-Verlag: 1.1, 3.1c and d, 3.6, 5.13, 8.2, 8.3, 9.5, 10.4, 14.7, 14.9a, band c, 14.10a
and b, 14.12a, 14.13a and b, 19.10
Wear (Elsevier Sequoia S.A.): Figs. 10.8a, c and d, 10.9a and b, 10.10a and b, l1.1a-e
Contents
Preface .................................................................................................... vii
Acknowledgements ................................................................................... ix
1 Introduction ........................................................................................ 1
SECTION I: COMPLICATIONS LEADING TO REVISION SURGERy................ 5
2 Haematoma ......................................................................................... 7
Introduction ......................................................................................... 7
The Role of Anaesthesia ......................................................................... 8
Classification of Haematoma ................................................................... 9
Superficial Haematoma ....................................................................... 9
Deep Haematoma .............................................................................. 10
Infected Haematoma .......................................................................... 10
3 Problems Arising from an Inadequate Exposure ........................................ 11
What is Required at the Time of the Exposure? .......................................... 11
Exposure of the Acetabulum ................................................................ 14
Exposure of the Medullary Canal .......................................................... 16
Preservation of the Integrity of the Ab~uctors ......................................... 18
4 Trochanteric Osteotomy and Problems Resulting from It ............................ 19
Introduction......................................................................................... 19
Trochanteric Osteotomy ......................................................................... 22
Problems Related to Trochanteric Osteotomy............................................. 24
Increased Blood Loss and Operating Time ............................................. 24
Trochanteric Bursitis (or Trochanteric Pain) ............................................ 26
Trochanteric Non-union...................................................................... 27
Pain ................................................................................................. 27
Limp ................................................................................................ 27
Dislocation ........................................................................................ 28
xii Contents
5 Dislocation .......................................................................................... 29
Introduction ......................................................................................... 29
The Mechanism of Dislocation ................................................................ 30
Impingement .................................................................................... 30
Distraction......... .... ..... .... ......... ...... ..... ....... ....... ........ ....... ........ ......... 31
Dislocation Following Primary Surgery ..................................................... 31
Loss of the Abductor Mechanism ......................................................... 32
Shortening of the Limb ....................................................................... 32
Malorientation of the Components........................................................ 35
Practical Approach to Dislocation: Non-operative Methods .......................... 41
Operative Procedures ............................................................................ 42
Recent Advances ............................................................................... 43
.6 · InJection ............................................................................................. 47
Introduction ......................................................................................... 47
Incidence of Deep Infection .................................................................... 48
The Size of the Sample Studied ............................................................ 48
The Length of the Follow-up ............................................................... 48
Deep Sepsis in Osteoarthritis .................................................................. 48
Deep Sepsis in Rheumatoid Arthritis ........................................................ 48
Deep Sepsis Following Previous Hip Surgery ............................................ 48
Patients at Risk for Deep Sepsis ............................................................... 49
Males with Post-operative Urinary Retention, Catheterization and
Prostatectomy ............................................................................. 49
Diabetics .......................................................................................... 49
Patients with Psoriasis ........................................................................ 49
Prevention of Deep Infection .................................................................. 49
Review of the Use of ALAC in Total Hip Arthroplasty ................................ 50
Leaching out from Acrylic Bone Cement ................................................ 50
Revisions for Deep Sepsis Using Plain Acrylic Cement ............................. 50
Revisions for Deep Sepsis Using ALAC (Palacos plus 0.5 g Gentamicin) ..... 50
Release of Gentamicin from Acrylic Cement: Ex Vivo Study ...................... 50
Comparison of Plain CMW Acrylic Cement and ALAC (Palacos plus 0.5 g
Gentamicin) ................................................................................ 51
Diagnosis of Deep Infection .................................................................... 51
Classification of Infection ....................................................................... 53
Late Infection... ....... ..... ..... .... ..... ...... .... ........ ......... ...... ....... ............... 53
Management of Deep Infection ............................................................... 55
Conservative ..................................................................................... 55
Operative - One- or Two-Stage Revision? .............................................. 56
The Principles of One-Stage Revision for Deep Infection .......................... 56
Results of Revisions for Deep Infection .................................................. 58
The Use of Antibiotic-Loaded Acrylic Beads .............................................. 61
The Concept ..................................................................................... 61
Clinical Use ...................................................................................... 61
7 Loosening of the Components ................................................................ 63
Introduction ......................................................................................... 63
What is Required for Component Fixation? ............................................... 65
Containment and Pressurization of Cement .............................................. 65
Socket Fixation ..................................................................................... 66
The Femur ........................................................................................... 67