Exposure for revision: total hip replacement.
The author uses four basic approaches for the majority of revision total hip replacements (THRS). The posterior approach is used for most simple revisions of loose endoprostheses, short, loose, cemented stems, and straightforward cup revisions. The key technical maneuvers are the soft tissue releases necessary to adequately displace the proximal femur anteriorly. The sliding trochanteric osteotomy is used when greater exposure of the femoral shaft is necessary to remove implant materials, to treat deformities or fractures, when abductor tension must be adjusted, or when enhanced acetabular exposure is required. Proper orientation of the osteotomy and excision of anterior pseudocapsule are necessary to mobilize the muscular osseous sleeve created by this approach. The extended trochanteric osteotomy is recommended for the most difficult femoral revisions, including the removal of well-fixed cementless and cemented components. The lateral 1/3 of the femoral shaft is removed as far distally as necessary. Careful attention to the creation, elevation, mobilization, and fixation of the osteotomized fragment is important in avoiding fracture or nonunion. The combined AP extensile approach is used for the most difficult acetabular reconstructions, including total acetabular allografting. Cadaveric training and possibly general, vascular, or urologic surgical assistance is recommended for this difficult approach.