KEY CHOICES AND TECHNIQUES IN REVISION THA AND TKA Step-by-Step Decisions
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1 KEY CHOICES AND TECHNIQUES IN REVISION THA AND TKA Step-by-Step Decisions Moderator: Panelists: Daniel J Berry, Mayo Clinic John J Callaghan William L Griffin Thomas P Vail Michael P Bolognesi
2 Presenter Disclosure Information The author has received royalties from DePuy related to certain hip and knee products The author s institution receives research support from: DePuy, Zimmer, Stryker, Biomet, Smith- Nephew Board of Governors, Mayo Clinic; Board of Directors, AJRR; Presidential line, Hip Society
3 REVISION THA
4 EXPOSURE
5 THAR: Exposure Old Skin Incisions: Which ones do you use?
6 THAR: Exposure In revision THA, how often do you perform an extended greater trochanteric osteotomy? Under what circumstances?
7 THAR: Exposure What type of ETO do you prefer? - lateral 1/3 of femur (Paprosky) - anterior 1/3 of femur (Wagner) Laterally based ETO Anteriorly based ETO
8 IMPLANT REMOVAL Infected
9 THAR: Implant Removal Well-fixed uncemented cup removal Technical Tips
10 THAR: Implant Removal Well fixed uncemented stem removal?
11 THAR: Implant Removal Well fixed broken stem removal?
12 Implant Removal Well-fixed fluted tapered stem removal? Infected
13 BONE LOSS
14 THAR: Acetabular Bone Loss Mild-Moderate Bone Loss: What is your go to technique? Loose cup
15 THAR: Acetabular Bone Loss Do you always use an enhanced ingrowth surface in revisions? Failed impaction grafting
16 Acetabular Bone Loss When you have major medial segmental loss, what is your preferred reconstruction method? - cancellous graft - bulk graft - metal augments
17 THAR: Acetabular Bone Loss When you have major lateral segmental acetabular bone loss, what are your indications for: - highly porous metal augments? - bulk bone allograft?
18 Acetabular Bone Loss When do you need more than a hemisphere? Any indications for custom triflange cup? Failed impaction grafting
19 THAR: Acetabular Bone Loss Pelvic Discontinuity: Go to method?
20 THAR: Femoral Bone Loss Mild-Moderate Bone Loss: What is your go to method in mild femoral bone loss? Loose subsided stem
21 Femoral Bone Loss What is your go to category of stem when there is notable femoral bone loss? - fluted tapered modular - extensively coated - cemented long stem - impaction grafting
22 Femoral Bone Loss Is there a role for impacting grafting? For bulk proximal femoral allograft? Impaction grafting Femoral allograft
23 HIP STABILITY
24 Joint Stability In revisions, when do you use: - large fixed head? - dual mobility? - constrained?
25 Joint Stability Revision for recurrent dislocation: - large head? - dual mobility? - constraint?
26 HISTORY OF INFECTION
27 Infection Question: Do you typically use a one stage or a two stage protocol for infected THA? Infected
28 Infection Question: During two stage treatment, do you prefer articulated or non articulated spacers? Articulated Non articulated
29 Infection Question: During two stage treatment, what is your typical resection interval?
30 Question: TOUGH REVISION THA AND TKA Infection Femoral fixation at reimplantation? - cemented? - uncemented?
31 POSTOP MANAGEMENT
32 Postop Postop: Hip guide brace? Weight bearing - cup revision with bone loss - femoral revision with bone loss
33 REVISION TKA
34 EXPOSURE
35 TKAR: Exposure Your go to exposure when things are tight? Quad snip Tibial tubercle osteotomy
36 IMPLANT REMOVAL
37 TKAR: Implant Removal Implant Removal in Revision TKA: Multiply Revised Knee: - technical tips to: - speed removal - avoid complications
38 TKAR: Implant Removal Do you ever need to do something exotic like osteotomy to get out well-fixed stemmed implants? Infected
39 IMPLANT FIXATION BONE LOSS
40 TKAR: Bone Loss/Fixation Options to Improve Fixation/Manage Bone Loss: Cemented stems Uncemented stems Metaphyseal cones/sleeves Bone graft
41 TKAR: Bone Loss - Fixation Cemented Versus Uncemented Stems? Balance of fixation versus Removability Vs.
42 TKAR: Bone Loss - Fixation How do you get fixation in sclerotic canal damaged by previous stem? Loose Loose
43 TKAR: Bone Loss - Fixation One Good Method: Metaphyseal cone Impacting grafting
44 TKAR: Bone Loss - Fixation When do you use metaphyseal sleeves or porous metal cones?
45 TKAR: Bone Loss - Fixation When do you use particulate bone graft? Particulate graft
46 TKAR: Bone Loss - Fixation When do you use smallmedium size bulk bone allograft? Femoral Head Graft
47 TKAR: Bone Loss - Fixation When do you use massive bulk bone allograft? Distal Femoral Allograft
48 TKAR: Bone Loss - Fixation When do you go to distal femoral replacement?
49 STABILITY/CONSTRAINT
50 TKAR: Implant Constraint What % of implants for multiply revised knees? PS Constrained condylar Hinge
51 TKAR: Implant Constraint Indications for hinge?
52 TKAR: Implant Constraint Role of ligament augmentation/ ligament allograft? No MCL
53 EXTENSOR MECHANISM
54 TKAR: Extensor Mechanism What do you do with the very deficient patella? Leave unresurfaced? Bone graft with pouch? Gull wing osteotomy?
55 TKAR: Extensor Mechanism Extensor Mechanism Deficiency: Role of allograft? Role of marlex mesh reconstruction?
56 Hope You Have Enjoyed the Course Thank You
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