Definition

Hip joint replacement is surgery to replace all or part of the hip joint with a man-made joint. The artificial joint is called a prosthesis. Over time some or all parts of a prosthesis may wear out due to several reasons. The prosthesis may also loosen up with trauma or infection. When this happens, another surgery is needed to replace or repair the artificial hip joint. This is called total hip joint replacement revision.

Alternative Names

Hip revision surgery; Revision total hip replacement; Revision hip arthroplasty

Description

The results of hip replacement surgery are often excellent. Most artificial hip joints last 15 to 20 years before they loosen and need to be replaced again. Revision of hip joint replacement may either require replacement of the whole prosthesis or some of its parts.

You will not feel any pain during the surgery. You will have one of the following types of anesthesia:

• General anesthesia -- This means you will be asleep and unable to feel pain.
• Regional (spinal or epidural) anesthesia -- Medicine is put into your back to make you numb below your waist. You will also get medicine to make you sleepy. And you may get medicine that will make you forget about the procedure, even though you will not be fully asleep.

After you receive anesthesia, your surgeon will:

• Make an incision following the same line used for the primary (initial) hip replacement surgery.
• Assess the soft tissues for any infection.
• Examine all the parts of the prosthesis to check if any part is worn, loose, or dislocated.
• Remove the existing implant, if required.
• Remove cement, if it was used in the primary surgery.
• Remove the metal stem from the thigh bone (femur), if required.
• Prepare the bone surfaces in the pelvis and femur for the revision implant.
• Use metal parts (augments) or a bone graft for bone reconstruction, if there is significant bone loss.
• Fix specialized implants, specially designed to make up for the damage to the soft tissue and bone.
• Place a temporary drain to collect extra blood or fluid.

Total hip replacement revision surgery takes longer to perform than primary total hip joint replacement. It usually lasts for several hours. In complex cases, it may take even longer.

Why the Procedure Is Performed

Disabling pain is the most common reason for revision surgery. Depending upon the part of the prosthesis that is affected, pain may occur in the hip region, groin, thigh, or knee.

Pain may occur due to:

• Implant wear
• Infection
• Mechanical or septic implant loosening
• Implant failure or breakage
• Repetitive hip dislocation
• Bone degeneration (osteolysis)
• Bone fracture around the artificial hip joint (periprosthetic fracture)

Even if you don't have disabling pain, you still may need revision surgery if your surgeon thinks that the joint will continue to wear out and loosen and make the surgery difficult at a later time.

Revision surgery is not recommended for certain functional problems, such as limb lengthening or painless loss of motion.

These problems are unlikely to get resolved with revision and may even cause greater problems such as recurrent dislocation.

Risks

People at a higher risk of needing revision surgery include:

• Younger, more active people. They may put extra stress on the artificial hip, causing it to wear out earlier and not last as long. Part of or the whole prosthesis may need to be replaced again if that happens.
• People who have had an artificial hip joint for 15 years or longer. Most artificial hip joints last 15 to 20 years. After that, the joint may loosen and need to be replaced again.

Before the Procedure

You will have a complete physical examination several weeks before the revision surgery. This is to check if you are healthy enough for the surgery. If you have diabetes, heart disease, or other medical conditions, your surgeon may ask you to see your health care provider who treats you for these conditions to see if it is safe for you to have the surgery.

You will have imaging tests to check the condition of your hip and the extent of bone loss around the implant:

• X-rays
• CT scan
• MRI

Imaging tests help to determine if there is loosening or other mechanical problems of the prosthesis or its parts.

Your surgeon may order blood tests to determine if you have an infection. Aspiration of hip joint fluid may need to be done to check for infection.

You may need to make some changes before the surgery.

Tell your surgeon or nurse if:

• You are taking any medicines, including drugs, supplements, or herbs you bought without a prescription.
• You have been drinking a lot of alcohol, more than 1 or 2 drinks per day.

If you smoke you need to stop. Ask your providers for help. Smoking will slow down wound and bone healing. Your recovery may not be as good if you keep smoking.

During the 2 weeks before your surgery:

• Prepare your home ahead of time.
• You may be asked to temporarily stop taking medicines that keep your blood from clotting. These medicines are called blood thinners. This includes over-the-counter medicines and supplements such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and vitamin E. Many prescription medicines are also blood thinners.
• You may also need to stop taking medicines that can make your body more likely to get an infection. These include methotrexate, etanercept (Enbrel), or other medicines that suppress your immune system. Make sure you ask your surgeon when it is safe to resume taking these medicines.
• Ask your surgeon which medicines you should still take on the day of your surgery.
• Always let your surgeon know about any cold, flu, fever, herpes breakout, or other illness you have before your surgery.
• You may want to visit a physical therapist to learn some exercises to do before surgery and to practice using a walker or crutches.
• Ask your provider whether you need to go to a nursing home or rehabilitation facility after surgery. If you do, you should check out these places ahead of time and note your preference.

Practice using a cane, walker, crutches, or a wheelchair correctly to:

• Get in and out of the shower
• Go up and down stairs
• Sit down to use the toilet and stand up after using the toilet
• Use the shower chair

On the day of your surgery:

• Follow instructions about when to stop eating and drinking.
• Take the medicines your surgeon told you to take with a small sip of water.
• Arrive at the hospital on time.

After the Procedure

After the revision surgery, you will stay in the hospital for several days. The type of care you will receive can be similar to the care you received after primary hip replacement surgery. However, it is important to check with your surgeon as you may need to follow more precautions after a revision surgery.

Physical therapy will be started as soon as the first day after surgery and will continue for up to 3 months. You will require a walker, cane, or crutches during the recovery phase. As your condition improves, you may use a cane or walk without any aid.

Recovery after revision surgery takes longer than recovery after primary hip replacement surgery. Complete recovery will take 6 months to a year.

Some people need a short stay in a rehabilitation center after they leave the hospital and before they go home. At a rehab center, you will learn how to safely do your daily activities on your own. Home health services are also available.

Outlook (Prognosis)

Total hip joint replacement revision is a complex surgery. Certain complications are more common after revision surgery than the primary surgery, such as:

• Infection
• Dislocation
• Thromboembolism
• Nerve injury (nerve palsy)
• Thigh (femur) bone fracture
• Leg-length inequality
• Blood clots

Revision surgery will help relieve your pain and improve your hip stability and function. However, because it is the second replacement, you may still have some pain or instability following revision surgery.

References

Harkess JW, Crockarell JR. Arthroplasty of the hip. In: Azar FM, Beaty JH, eds. Campbell's Operative Orthopaedics. 14th ed. Philadelphia, PA: Elsevier; 2021:chap 3.

Rizzo TD. Total hip replacement. In: Frontera WR, Silve JK, Rizzo TD, eds. Essentials of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 61.