Revision Hip Replacement

What Is Revision Hip Replacement?

Revision hip replacement is surgery to treat a significant problem involving a previous artificial hip.

It may involve:

• Replacing the socket
• Replacing the femoral stem
• Replacing both components
• Changing the bearing surfaces
• Treating instability
• Managing infection
• Reconstructing bone loss
• Treating fracture around the implant

The required procedure depends on the failure mechanism.

Why Does a Hip Replacement Fail?

Possible causes include:

• Infection
• Aseptic loosening
• Recurrent dislocation
• Polyethylene wear
• Osteolysis
• Fracture around the prosthesis
• Implant breakage
• Corrosion or bearing-related problems in selected implants
• Bone loss
• Other mechanical problems

Pain alone does not identify the cause.

How Is a Painful Hip Replacement Evaluated?

Assessment may include:

• Detailed history
• Physical examination
• X-rays
• Comparison with previous imaging
• Blood investigations
• Joint aspiration when clinically appropriate
• CT in selected cases
• Other imaging where appropriate

The hip, lower back and surrounding soft tissues may all need assessment because not all pain after hip replacement originates from the implant. Revision should not be planned from pain or one radiographic finding alone.

How Is Infection Evaluated?

Evaluation for periprosthetic joint infection may include ESR, CRP, hip aspiration when clinically appropriate, synovial white blood cell count and differential, microbiological cultures, and additional synovial or intraoperative tests where appropriate.

No single blood or synovial test should be interpreted in isolation when evaluating a possible periprosthetic joint infection.

Normal inflammatory markers do not absolutely exclude infection when clinical suspicion remains significant.

What Is Aseptic Loosening?

Aseptic loosening occurs when an implant loses fixation to bone without infection being the primary cause.

It can lead to:

• Pain
• Component migration
• Progressive bone loss
• Reduced function

Before revision for presumed aseptic loosening, infection should remain part of the differential diagnosis and be investigated according to the clinical situation.

Revision surgery aims to restore durable fixation.

What Is Osteolysis?

Osteolysis refers to bone loss that can develop around prosthetic components.

It may be related to biological reactions to wear particles.

Significant osteolysis can weaken bone and complicate later reconstruction even before the implant becomes grossly loose.

What Causes Hip Dislocation After Replacement?

Potential contributors include:

• Component position
• Soft-tissue insufficiency
• Abductor weakness
• Previous surgery
• Spinal stiffness or deformity
• Neuromuscular conditions
• Trauma

Recurrent instability requires evaluation of the mechanism before treatment.

How Can Recurrent Dislocation Be Treated?

Treatment depends on the cause and may involve:

• Component repositioning
• Changing head or liner configuration
• Dual-mobility components in selected cases
• Constrained components in selected cases
• Soft-tissue management
• Other revision strategies

There is no single solution appropriate for every unstable hip.

What Is a Periprosthetic Hip Fracture?

A periprosthetic fracture occurs around an existing hip implant.

Treatment depends on:

• Fracture location
• Implant stability
• Bone quality
• Fracture pattern
• Patient factors

Some fractures can be fixed while retaining the implant.

Others require revision of the femoral component.

What Is Bone Loss in Revision Hip Surgery?

Previous implants, wear, loosening, infection and fracture can all result in bone deficiency.

Reconstruction may require:

• Larger revision components
• Modular stems
• Specialized acetabular components
• Augments
• Bone graft
• Other reconstructive techniques

Preoperative assessment of remaining bone is essential.

What Happens During Revision Hip Replacement?

Depending on the problem, surgery may involve:

• Removal of previous components
• Removal of cement when present
• Management of scar tissue
• Reconstruction of bone defects
• Implantation of revision components
• Restoration of hip stability
• Restoration of appropriate biomechanics

Complex revisions may require extensile surgical exposure.

How Is an Infected Hip Replacement Treated?

Treatment depends on multiple factors.

Options can include:

• Debridement, antibiotics and implant retention (DAIR) in selected cases
• One-stage exchange in selected circumstances
• Two-stage revision
• Other individualized approaches

Selection depends on timing and clinical presentation, the organism when known, implant fixation, soft-tissue condition, bone loss, patient health and reconstructive requirements. No one-stage or two-stage strategy is universally superior.

What Is Two-Stage Revision Hip Replacement?

In selected infections, the prosthesis is removed and the infection treated before final reconstruction.

An antibiotic-loaded spacer may be used during the interval depending on the case.

Definitive reimplantation occurs after appropriate reassessment.

Can the Direct Anterior Approach Be Used for Revision Surgery?

Selected revision procedures can be performed through an anterior approach by surgeons experienced with the technique.

However, complex revision surgery should not be constrained by the desire to use one particular incision.

The approach should provide safe access to the reconstruction required.

What Is a Proximal Femoral Replacement?

In very complex cases with severe proximal femoral bone loss, a larger endoprosthetic reconstruction may occasionally be required.

This is substantially different from routine revision hip replacement and is reserved for selected situations.

How Long Is Recovery?

Recovery depends on:

• Complexity of revision
• Bone quality
• Fracture or infection
• Soft-tissue condition
• Number of previous surgeries
• General health
• Weight-bearing restrictions

Recovery may be considerably longer than after primary hip replacement.