Scott M. Sporer, MD is an orthopaedic total joint replacement surgeon in Chicago and holds an academic appointment at the rank of Assistant Professor at RUSH University Medical Center. He attended medical school at The University of Iowa before completing his orthopaedic residency training at Dartmouth Hitchcock Medical Center. He has completed a fellowship in adult reconstruction at RUSH Medical Center and currently has a clinical practice focusing on hip and knee arthroplasty. Dr. Sporer has a strong interest in clinical outcomes research and has completed a master’s program at Dartmouth College in the evaluative clinical sciences.

"The editors have done a remarkable job of selecting a variety of challenges that make the read interesting and valuable. This is a valuable book in the series. I have always been honored by the time mentors and professors have spent with me in sharing their approaches to challenging problems. This format mimics that experience and makes the book fun, efficient, easy to read, and a valuable addition to your clinical repertoire." -Mark R. Hutchinson, MD, University of Illinois at Chicago College of Medicine, Doody Enterprises, Inc.

• Dedication About the Editor Contributing Authors Preface Introduction Section I: Preoperative General Questions Question 1 I Have a 43-Year-Old Male Who Needs a Total Hip Arthroplasty. Should I Use Highly Cross-Linked Polyethylene, Ceramic, or a Metal-on-Metal Bearing Surface? Scott M. Sporer, MD Question 2 I Have a Patient With Both Back and Hip Arthritis. How Do I Determine Which Is Most Problematic and Causing the Patient's Symptoms? Matthew W. Squire, MD, MS and Richard Illgen II, MD Question 3 I Have a Patient With Severe Bilateral Hip Degenerative Arthritis. Do I Perform Bilateral Total Hip Replacement, or Do I Stage the Surgery? If I Do Stage the Surgery, How Long Should I Wait? Keith R. Berend, MD and Jorge Aziz-Jacobo, MD Question 4 How Do You Decide When a Patient Is Ready for a Total Hip Replacement? Is There a Downside to Waiting Until He or She Has More Severe Disease? Vivek Sood, MD Question 5 I Have a 58-Year-Old Female Alcoholic Patient Who Fell and Has a Femoral Neck Fracture. What Surgical Approach Should I Use to Treat This Fracture, and What Component Should I Use? James A. Ryan, MD and Paul E. Di Cesare, MD Question 6 A 65-Year-Old Patient Fell and Has a Displaced Femoral Neck Fracture. Should I Do a Hemiarthroplasty or a Total Hip Arthroplasty? Thomas E. Brown, MD; Khaled Saleh, MD, FRCSC; Quan Jun Cui, MD; and William Mihalko, MD, PhD Question 7 I Have a 63-Year-Old Patient Who Is 6 Years Postoperative From a Total Hip Replacement. He Was Doing Very Well Until Last Week When He Began Experiencing Increasing Hip Pain Following a Dental Appointment. I Think His Hip Is Infected. What Should I Do? Carl Deirmengian, MD Question 8 Should All of My Patients Donate Blood Prior to Total Joint Replacement? Jeffrey L. Pierson, MD and R. Michael Meneghini, MD Question 9 A 20-Year-Old Patient Suffered a Hip Dislocation in a Motor Vehicle Accident. He Has Developed Avascular Necrosis and Now Has Severe Degenerative Arthritis. How Do You Treat His Pain? Scott M. Sporer, MD Section II: Preoperative Acetabulum Questions Question 10 I Have a 34-Year-Old Female With Pain in Her Hip and Groin. Her X-Rays and MRI Are Unremarkable. Is Her Pain From Her Hip, and How Do I Know? Michael J. Taunton, MD and Robert T. Trousdale, MD Question 11 I Have a Patient With a Loose Acetabular Component and a Moderate Amount of Bone Loss. How Can You Determine the Degree of Acetabular Bone Loss You Will Encounter Intraoperatively With Preoperative Radiographs? Allan E. Gross, MD, FRCSC, OOnt Question 12 I Have a 72-Year-Old Patient Who Has Severe Hip Arthritis. He Had Undergone Prior Pelvic Radiation Due to Prostate Cancer. What Type of Hip Replacement Should I Perform? Saul Magitsky, MD Question 13 I Have a Patient With Start-Up Groin Pain 5 Years After Surgery, and I Think the Acetabular Component Is Loose. How Can I Tell for Sure? Amanda D. Marshall, MD Question 14 I Have a Patient With a Crowe Type III Hip Dysplasia. Where Do I Place the Acetabular Component? Duncan Jacks, MD; Alexander Siegmeth, MD, FRCS; and Bassam A. Masri, MD, FRCSC Question 15 I Have a Patient With a Pelvic Discontinuity. What Can I Expect to Find Intraoperatively, and How Should I Plan on Reconstructing This Defect? Scott M. Sporer, MD Question 16 I Have a Patient Who Is 10 Years Postoperative From a Hip Replacement With Severe Polyethylene Wear and Retroacetabular Osteolysis. When Do I Intervene With a Polyethylene Liner Exchange? Raju S. Ghate, MD Question 17 I Have a Patient Who Is 10 Years Postoperative From a Loose Acetabular Component. When Do I Need to Use More Than a Hemispherical Component? Brian P. Murphy, MD, MS Section III: Preoperative Femur Questions Question 18 I Have a Patient With a Crowe Type IV Hip Dysplasia. What Femoral Component Do I Use and When Do I Need to Do a Femoral Shortening Osteotomy? James Slover, MD, MS Question 19 I Have a Patient With Start-Up Thigh Pain 5 Years After Surgery, and I Think the Femoral Component Is Loose. How Can I Tell for Sure? Calin S. Moucha, MD Question 20 I Have a Patient With a Large Amount of Femoral Offset. How Do I Address This Intraoperatively? Matthew Beal, MD; Kirstina Olson, MD; and David Manning, MD Question 21 I Have A Patient With an Infected Well-Fixed Femoral Component. How Do I Remove This Without Destroying the Femoral Bone? Brett Levine, MD, MS Question 22 I Have a Patient With a Loose Femoral Component and Varus Remodeling of the Proximal Femur. What Surgical Approach and Implant Should I Use? Stephen M. Walsh, MD, FRCSC Question 23 I Have a Patient With Distal Osteolysis and a Loose Stem. What Type of Implant Should I Use and What Bone Stock Can I Anticipate Finding at the Time of Surgery? Mark F. Schinsky, MD Question 24 An 84-Year-Old Male Who Had a Previous Cemented Total Hip Replacement With Severe Proximal Osteolysis Fell and Has a Periprosthetic Femur Fracture. He Has Very Little Proximal Bone. Should I Reconstruct This With Allograft Bone or Use a Tumor Prosthesis? John L. Masonis, MD and Thomas K. Fehring, MD Section IV: Intraoperative General Questions Question 25 I Was Placing Screws in the Acetabular Component When I Began to Experience Profuse Bleeding. What Should I Do? Scott M. Sporer, MD Question 26 A 45-Year-Old Patient With Hip Fusion Is Now Complaining of Increasing Back Pain. What Should I Do? Steve Mussett, MD, FRCSC and Paul E. Beaulé, MD, FRCSC Question 27 I Am Doing a Routine Total Hip Arthroplasty and I Am Unable to Obtain Hip Stability. What Should I Do? Hari Parvataneni, MD and Harry E. Rubash, MD Section V: Intraoperative Acetabulum Questions Question 28 I Have a Portion of the Acetabular Component Uncovered During Acetabular Revision. Is This Is Okay, and How Much Uncoverage of the Component Is Acceptable to Use a Hemispherical Component Alone? Michael O'Rourke, MD Question 29 I Have a Patient With Severe Segmental Bone Loss in the Superior Dome of the Acetabulum. What Should I Do to Reconstruct This Defect? Steven H. Weeden, MD and Steven Ogden, MD Question 30 I Am Doing an Acetabular Revision While Retaining the Femoral Component and Cannot Get the Proximal Femur Out of the Way. What Should I Do? Andrew H. Glassman, MD, MS Question 31 I See a Fracture While Inserting an Acetabular Component With a 2-mm Press-Fit. The Component Is No Longer Stable. Now What Should I Do? Todd Sekundiak, MD, FRCS Question 32 While Reaming the Acetabulum, I Inadvertently Reamed Through the Medial Wall. What Should I Do? William A. Lighthart, MD Section VI: Intraoperative Femur Questions Question 33 I Was Impacting a Tapered Femoral Component and I See a Small Crack of the Calcar. What Should I Do? Michael E. Berend, MD Question 34 I Have a Patient With Severe Osteolysis Surrounding Her Greater Trochanter During a Routine Polyethylene Liner Exchange. Do I Need to Do Anything to This Area of Bone Loss at the Time of Surgery? William G. Hamilton, MD Question 35 I Have a Patient With Severe Proximal Bone Loss That I Was Treating With an Extensively Coated Implant. During Insertion I Heard a Crack. What Should I Do? R. Michael Meneghini, MD and Jeffrey L. Pierson, MD Section VII: Postoperative Questions Question 36 When and How Do I Perform an Extended Trochanteric Osteotomy? Michael Archibeck, MD Question 37 I Have a Patient Who Is Complaining of a Leg Length Inequality Following Surgery. What Should I Tell Her? Charles R. Clark, MD Question 38 I Have a Patient Who Is 2 Weeks Postoperative From a Primary Total Hip Arthroplasty and the Wound Is Draining. What Should I Do? Craig J. Della Valle, MD Question 39 My Patient Has a Foot-Drop After Surgery. What Should I Do? Marc M. DeHart, MD Question 40 How Do You Manage the Patient With an Unexpectedly Positive Culture at the Time of a Revision Total Hip Arthroplasty? Scott M. Sporer, MD Section VIII: Failed General Questions Question 41 I Performed a Hip Revision Using a 20-mm Extensively Coated Stem. At Her 5-Year Follow-Up Appointment She Is Asymptomatic but I See Severe Proximal Bone Loss. Do I Need to Do Anything? Kevin B. Fricka, MD Question 42 A 74-Year-Old Patient Has Failed Two Attempted Two-Stage Exchanges for Infection and Continues to Have Purulent Drainage From the Wound. When Do You Use Antibiotic Suppression and When Do You Perform a Re Section Arthroplasty? W. Randall Schultz, MD, MS and J. Todd Bagwell, MD Question 43 I Have a Patient With Recurrent Hip Dislocation and I Think There Is Not Enough Anteversion in the Acetabular Component. How Can I Determine the Amount of Femoral and Acetabular Anteversion? R. Stephen J. Burnett, MD, FRCS(C) and Robert L. Barrack, MD Question 44 How Do You Evaluate a Patient With a Painful Total Hip Arthroplasty? Alexander Siegmeth, MD, FRCS and Donald S. Garbuz, MD, FRCS Section IX: Failed Acetabulum Questions Question 45 I Have a Patient Who Requires a Polyethylene Liner Revision and Has Minimal Anteversion in His Component. What Surgical Approach Do You Use When Performing an Isolated Polyethylene Liner Exchange? William V. Arnold, MD, PhD and William J. Hozack, MD Question 46 I Have a Patient Who Has Recurrent Hip Instability and the Components Appear Well Fixed and in Appropriate Position. What Should I Do? Devon D. Goetz, MD Section X: Failed Femur Questions Question 47 I Have a Patient With a Well-Fixed Extensively Porous-Coated Implant That Needs to Be Removed. How Do I Remove a Well-Fixed Extensively Coated Femoral Component Without Extensive Bone Loss? Kenneth D. Kleist, MD Question 48 A Patient Fell and Now Has a Periprosthetic Femur Fracture With a Loose Femoral Component. How Should I Approach This Surgery? Tad L. Gerlinger, MD Question 49 A Patient Fell and Now Has a Periprosthetic Femur Fracture With a Well- Fixed Femoral Component. How Should I Approach This Surgery? Mark Dumonski, MD and Walter W. Virkus, MD Index

Scott M. Sporer, MD is an orthopaedic total joint replacement surgeon in Chicago and holds an academic appointment at the rank of Assistant Professor at RUSH University Medical Center. He attended medical school at The University of Iowa before completing his orthopaedic residency training at Dartmouth Hitchcock Medical Center. He has completed a fellowship in adult reconstruction at RUSH Medical Center and currently has a clinical practice focusing on hip and knee arthroplasty. Dr. Sporer has a strong interest in clinical outcomes research and has completed a master’s program at Dartmouth College in the evaluative clinical sciences.

"The editors have done a remarkable job of selecting a variety of challenges that make the read interesting and valuable. This is a valuable book in the series. I have always been honored by the time mentors and professors have spent with me in sharing their approaches to challenging problems. This format mimics that experience and makes the book fun, efficient, easy to read, and a valuable addition to your clinical repertoire." -Mark R. Hutchinson, MD, University of Illinois at Chicago College of Medicine, Doody Enterprises, Inc.

• Dedication About the Editor Contributing Authors Preface Introduction Section I: Preoperative General Questions Question 1 I Have a 43-Year-Old Male Who Needs a Total Hip Arthroplasty. Should I Use Highly Cross-Linked Polyethylene, Ceramic, or a Metal-on-Metal Bearing Surface? Scott M. Sporer, MD Question 2 I Have a Patient With Both Back and Hip Arthritis. How Do I Determine Which Is Most Problematic and Causing the Patient's Symptoms? Matthew W. Squire, MD, MS and Richard Illgen II, MD Question 3 I Have a Patient With Severe Bilateral Hip Degenerative Arthritis. Do I Perform Bilateral Total Hip Replacement, or Do I Stage the Surgery? If I Do Stage the Surgery, How Long Should I Wait? Keith R. Berend, MD and Jorge Aziz-Jacobo, MD Question 4 How Do You Decide When a Patient Is Ready for a Total Hip Replacement? Is There a Downside to Waiting Until He or She Has More Severe Disease? Vivek Sood, MD Question 5 I Have a 58-Year-Old Female Alcoholic Patient Who Fell and Has a Femoral Neck Fracture. What Surgical Approach Should I Use to Treat This Fracture, and What Component Should I Use? James A. Ryan, MD and Paul E. Di Cesare, MD Question 6 A 65-Year-Old Patient Fell and Has a Displaced Femoral Neck Fracture. Should I Do a Hemiarthroplasty or a Total Hip Arthroplasty? Thomas E. Brown, MD; Khaled Saleh, MD, FRCSC; Quan Jun Cui, MD; and William Mihalko, MD, PhD Question 7 I Have a 63-Year-Old Patient Who Is 6 Years Postoperative From a Total Hip Replacement. He Was Doing Very Well Until Last Week When He Began Experiencing Increasing Hip Pain Following a Dental Appointment. I Think His Hip Is Infected. What Should I Do? Carl Deirmengian, MD Question 8 Should All of My Patients Donate Blood Prior to Total Joint Replacement? Jeffrey L. Pierson, MD and R. Michael Meneghini, MD Question 9 A 20-Year-Old Patient Suffered a Hip Dislocation in a Motor Vehicle Accident. He Has Developed Avascular Necrosis and Now Has Severe Degenerative Arthritis. How Do You Treat His Pain? Scott M. Sporer, MD Section II: Preoperative Acetabulum Questions Question 10 I Have a 34-Year-Old Female With Pain in Her Hip and Groin. Her X-Rays and MRI Are Unremarkable. Is Her Pain From Her Hip, and How Do I Know? Michael J. Taunton, MD and Robert T. Trousdale, MD Question 11 I Have a Patient With a Loose Acetabular Component and a Moderate Amount of Bone Loss. How Can You Determine the Degree of Acetabular Bone Loss You Will Encounter Intraoperatively With Preoperative Radiographs? Allan E. Gross, MD, FRCSC, OOnt Question 12 I Have a 72-Year-Old Patient Who Has Severe Hip Arthritis. He Had Undergone Prior Pelvic Radiation Due to Prostate Cancer. What Type of Hip Replacement Should I Perform? Saul Magitsky, MD Question 13 I Have a Patient With Start-Up Groin Pain 5 Years After Surgery, and I Think the Acetabular Component Is Loose. How Can I Tell for Sure? Amanda D. Marshall, MD Question 14 I Have a Patient With a Crowe Type III Hip Dysplasia. Where Do I Place the Acetabular Component? Duncan Jacks, MD; Alexander Siegmeth, MD, FRCS; and Bassam A. Masri, MD, FRCSC Question 15 I Have a Patient With a Pelvic Discontinuity. What Can I Expect to Find Intraoperatively, and How Should I Plan on Reconstructing This Defect? Scott M. Sporer, MD Question 16 I Have a Patient Who Is 10 Years Postoperative From a Hip Replacement With Severe Polyethylene Wear and Retroacetabular Osteolysis. When Do I Intervene With a Polyethylene Liner Exchange? Raju S. Ghate, MD Question 17 I Have a Patient Who Is 10 Years Postoperative From a Loose Acetabular Component. When Do I Need to Use More Than a Hemispherical Component? Brian P. Murphy, MD, MS Section III: Preoperative Femur Questions Question 18 I Have a Patient With a Crowe Type IV Hip Dysplasia. What Femoral Component Do I Use and When Do I Need to Do a Femoral Shortening Osteotomy? James Slover, MD, MS Question 19 I Have a Patient With Start-Up Thigh Pain 5 Years After Surgery, and I Think the Femoral Component Is Loose. How Can I Tell for Sure? Calin S. Moucha, MD Question 20 I Have a Patient With a Large Amount of Femoral Offset. How Do I Address This Intraoperatively? Matthew Beal, MD; Kirstina Olson, MD; and David Manning, MD Question 21 I Have A Patient With an Infected Well-Fixed Femoral Component. How Do I Remove This Without Destroying the Femoral Bone? Brett Levine, MD, MS Question 22 I Have a Patient With a Loose Femoral Component and Varus Remodeling of the Proximal Femur. What Surgical Approach and Implant Should I Use? Stephen M. Walsh, MD, FRCSC Question 23 I Have a Patient With Distal Osteolysis and a Loose Stem. What Type of Implant Should I Use and What Bone Stock Can I Anticipate Finding at the Time of Surgery? Mark F. Schinsky, MD Question 24 An 84-Year-Old Male Who Had a Previous Cemented Total Hip Replacement With Severe Proximal Osteolysis Fell and Has a Periprosthetic Femur Fracture. He Has Very Little Proximal Bone. Should I Reconstruct This With Allograft Bone or Use a Tumor Prosthesis? John L. Masonis, MD and Thomas K. Fehring, MD Section IV: Intraoperative General Questions Question 25 I Was Placing Screws in the Acetabular Component When I Began to Experience Profuse Bleeding. What Should I Do? Scott M. Sporer, MD Question 26 A 45-Year-Old Patient With Hip Fusion Is Now Complaining of Increasing Back Pain. What Should I Do? Steve Mussett, MD, FRCSC and Paul E. Beaulé, MD, FRCSC Question 27 I Am Doing a Routine Total Hip Arthroplasty and I Am Unable to Obtain Hip Stability. What Should I Do? Hari Parvataneni, MD and Harry E. Rubash, MD Section V: Intraoperative Acetabulum Questions Question 28 I Have a Portion of the Acetabular Component Uncovered During Acetabular Revision. Is This Is Okay, and How Much Uncoverage of the Component Is Acceptable to Use a Hemispherical Component Alone? Michael O'Rourke, MD Question 29 I Have a Patient With Severe Segmental Bone Loss in the Superior Dome of the Acetabulum. What Should I Do to Reconstruct This Defect? Steven H. Weeden, MD and Steven Ogden, MD Question 30 I Am Doing an Acetabular Revision While Retaining the Femoral Component and Cannot Get the Proximal Femur Out of the Way. What Should I Do? Andrew H. Glassman, MD, MS Question 31 I See a Fracture While Inserting an Acetabular Component With a 2-mm Press-Fit. The Component Is No Longer Stable. Now What Should I Do? Todd Sekundiak, MD, FRCS Question 32 While Reaming the Acetabulum, I Inadvertently Reamed Through the Medial Wall. What Should I Do? William A. Lighthart, MD Section VI: Intraoperative Femur Questions Question 33 I Was Impacting a Tapered Femoral Component and I See a Small Crack of the Calcar. What Should I Do? Michael E. Berend, MD Question 34 I Have a Patient With Severe Osteolysis Surrounding Her Greater Trochanter During a Routine Polyethylene Liner Exchange. Do I Need to Do Anything to This Area of Bone Loss at the Time of Surgery? William G. Hamilton, MD Question 35 I Have a Patient With Severe Proximal Bone Loss That I Was Treating With an Extensively Coated Implant. During Insertion I Heard a Crack. What Should I Do? R. Michael Meneghini, MD and Jeffrey L. Pierson, MD Section VII: Postoperative Questions Question 36 When and How Do I Perform an Extended Trochanteric Osteotomy? Michael Archibeck, MD Question 37 I Have a Patient Who Is Complaining of a Leg Length Inequality Following Surgery. What Should I Tell Her? Charles R. Clark, MD Question 38 I Have a Patient Who Is 2 Weeks Postoperative From a Primary Total Hip Arthroplasty and the Wound Is Draining. What Should I Do? Craig J. Della Valle, MD Question 39 My Patient Has a Foot-Drop After Surgery. What Should I Do? Marc M. DeHart, MD Question 40 How Do You Manage the Patient With an Unexpectedly Positive Culture at the Time of a Revision Total Hip Arthroplasty? Scott M. Sporer, MD Section VIII: Failed General Questions Question 41 I Performed a Hip Revision Using a 20-mm Extensively Coated Stem. At Her 5-Year Follow-Up Appointment She Is Asymptomatic but I See Severe Proximal Bone Loss. Do I Need to Do Anything? Kevin B. Fricka, MD Question 42 A 74-Year-Old Patient Has Failed Two Attempted Two-Stage Exchanges for Infection and Continues to Have Purulent Drainage From the Wound. When Do You Use Antibiotic Suppression and When Do You Perform a Re Section Arthroplasty? W. Randall Schultz, MD, MS and J. Todd Bagwell, MD Question 43 I Have a Patient With Recurrent Hip Dislocation and I Think There Is Not Enough Anteversion in the Acetabular Component. How Can I Determine the Amount of Femoral and Acetabular Anteversion? R. Stephen J. Burnett, MD, FRCS(C) and Robert L. Barrack, MD Question 44 How Do You Evaluate a Patient With a Painful Total Hip Arthroplasty? Alexander Siegmeth, MD, FRCS and Donald S. Garbuz, MD, FRCS Section IX: Failed Acetabulum Questions Question 45 I Have a Patient Who Requires a Polyethylene Liner Revision and Has Minimal Anteversion in His Component. What Surgical Approach Do You Use When Performing an Isolated Polyethylene Liner Exchange? William V. Arnold, MD, PhD and William J. Hozack, MD Question 46 I Have a Patient Who Has Recurrent Hip Instability and the Components Appear Well Fixed and in Appropriate Position. What Should I Do? Devon D. Goetz, MD Section X: Failed Femur Questions Question 47 I Have a Patient With a Well-Fixed Extensively Porous-Coated Implant That Needs to Be Removed. How Do I Remove a Well-Fixed Extensively Coated Femoral Component Without Extensive Bone Loss? Kenneth D. Kleist, MD Question 48 A Patient Fell and Now Has a Periprosthetic Femur Fracture With a Loose Femoral Component. How Should I Approach This Surgery? Tad L. Gerlinger, MD Question 49 A Patient Fell and Now Has a Periprosthetic Femur Fracture With a Well- Fixed Femoral Component. How Should I Approach This Surgery? Mark Dumonski, MD and Walter W. Virkus, MD Index