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Hip revision surgery, which is also known as revision total hip arthroplasty, is a procedure in which the surgeon removes a previously implanted artificial hip joint, or prosthesis, and replaces it with a new prosthesis. Hip revision surgery may also involve the use of bone grafts. The bone graft may be an autograft, which means that the bone is taken from another site in the patient’s own body; or an allograft, which means that the bone tissue comes from another donor.
Unlike standard THR, however, hip revision surgery is a much longer and more complicated procedure. It is not unusual for a hip revision operation to take five to eight hours.
The most critical factor affecting the length of the operation and some of the specific steps in hip revision surgery is the condition of the bone tissue in the femur. As of 2003, defects in the bone are classified in four stages as follows:
• Type I. Minimal bone defects.
• Type II. Most of the damage lies at the metaphysis (the flared end of the femur), with minimal damage to the shaft of the bone.
• Type III. All of the damage lies at the metaphysis.
• Type IV. There is extensive bone loss in the femoral shaft as well as at the metaphysis.
The first stage in all hip revision surgery is the removal of the old prosthesis. The part attached to the acetabulum is removed first. The hip socket is cleaned and filled with morselized bone, which is bone in particle form. The new shell and liner are then pressed into the acetabulum.
Revision of the femoral component is the most complicated part of hip revision surgery. If the first prosthesis was held in place by pressure rather than cement, the surgeon usually cuts the top of the femur into several pieces to remove the implant. This cutting apart of the bone is known as osteotomy. The segments of bone are cleaned and the new femoral implant is pressed or cemented in place. If the patient’s bone has been classified as Type IV, bone grafts may be added to strengthen the femur. These grafts consist of morselized bone from a donor (allograft bone) that is packed into the empty canal inside the femur. This technique is called impaction grafting. The segments of the femur are then reassembled around the new implant and bone grafts, and held in place with surgical wire.
A newer technique that was originally designed to help surgeons remove old cement from prostheses that were cemented in place can sometimes be used instead of osteotomy. This method involves the use of a ballistic chisel powered by controlled bursts of pressurized nitrogen. The ballistic chisel is used most often to break up pieces of cement from a cemented prosthesis, but it can also be used to loosen a prosthesis that was held in place only by tightness of fit. In addition to avoiding the need for an osteotomy, the ballistic chisel takes much less time. The surgeon uses an arthroscope in order to view the progress of the chisel while he or she is working inside the femur itself.
After all the cement has been removed from the inner canal of the femur, the surgeon washes out the canal with saline solution, inserts morselized bone if necessary, and implants the new femoral component of the prosthesis. After both parts of the prosthesis have been checked for correct positioning, the head of the femoral component is fitted into the new acetabular component and the incision is closed.
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