- This retrospective study evaluated 252 consecutive patients who underwent revision of total hip arthroplasty because of adverse local tissue reactions
- The most common complications were dislocations
- Patients who had a metal rather than ceramic femoral head placed at the time of revision were significantly more likely to require re-revision (P = .01)
- Early recognition and diagnosis of the need for revision may prevent late local tissue damage and reduce the risk of post-revision complications
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Following total hip arthroplasty with a metal-on-metal (MoM) or metal-on-polyethylene (MoP) implant, revision is recommended for symptomatic patients who have elevated metal ion levels and adverse local tissue reactions (ALTRs) on MRI. Revision surgery is often challenging, though, because significant bone and soft tissue necrosis requires careful debridement.
In The Journal of Arthroplasty, Bryant Bonner, MD, chief orthopaedic surgery resident, Young-Min Kwon, MD, PhD, program director of the Adult Reconstructive Surgery Fellowship Program and director of the Bioengineering Laboratory in the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues report high rates of complications and multiple revisions in symptomatic THA patients with ALTRs.
The researchers retrospectively studied 252 consecutive THA patients who underwent revision surgery because of ALTRs. 147 patients had received a MoM implant during primary surgery and the others had received MoP. All procedures were performed by a single senior surgeon.
The average time between primary and revision surgery was 58.7 months (range, 2–259). The patients were evaluated at regular intervals for an average of 28 months from revision (range, 24–198).
Complications after initial revision occurred in 52 patients (21%), most commonly:
- Dislocation requiring closed reduction—22 patients
- ALTR recurrence—14
- Periprosthetic fracture—7
- Prosthetic joint infection—6
- Aseptic loosening—3
The occurrence of a complication after the initial revision was associated with the need for re-revision (P < .01).
40 of the 52 patients (77%, or 16% of all 252 patients) went on to require re-revision. The most common complication was dislocation. ALTR recurrence, fracture, infection and loosening were observed in about the same proportions as after the initial revision.
Patients who had a metal rather than a ceramic femoral head placed at the time of revision were more likely to require re-revision surgery (P = .01).
14 of the 40 patients (35%) developed complications after re-revision. 12 of them (28%, or 5% of all 252 patients) required a third revision. The most common indications were dislocation and infection.
Implications for Surgical Planning
Placing a ceramic femoral head with titanium sleeve during revision surgery may minimize the need for re-revision. In light of the frequency of dislocation, surgeons may consider surgical options such as dual mobility bearings or constrained liners when planning revision or re-revision surgery. The high occurrence of complications in revision THA patients associated with extensive intraoperative tissue necrosis suggests the importance of a systematic evaluation of all THA patients with at-risk implants in optimizing ALTR associated revision outcome, as early recognition and diagnosis may prevent late local tissue damage and reduce the risk of post-revision complications.
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