Revision Total Hip Replacement | Revision Total Hip Arthroplasty

What is revision total hip replacement?

Total hip replacement is one of the most common and successful procedures in all of medicine. Patients often return to daily activities quickly and go on to live a pain-free life. In certain instances, sometimes these implants must be revised. Any subsequent operation to an initial total hip replacement is termed a revision total hip replacement or revision hip arthroplasty. It is absolutely critical you consider a surgeon like Dr. Ramkumar who is fellowship-trained and well-versed in revision arthroplasty.

When is a revision total hip replacement recommended?

Unfortunately, revision may sometimes be necessary for a multitude of reasons. People typically think that revision is most commonly performed for implant wear.  Historically, this used to be the case when the plastic component between the metal implants would wear quickly. However, since the advent of modern plastic (referred to as highly crosslinked polyethylene), these implants can now last 20 or more years – if not longer! This is related to how active the patient is and the type of implant being used. We do not yet know how long today’s modern implants can last. Since this development, wear is actually one of the least common reasons for revision arthroplasty. Suspicion for wear should be considered in the setting of recent hip pain 15 or more years after a hip replacement that has otherwise served excellently. Wear can be detected with careful scrutiny of imaging by a revision hip arthroplasty surgeon like Dr. Ramkumar well versed in complications after total hip replacement.

The two most common causes of revision hip arthroplasty are infection and instability (dislocation). In these cases, and for many revision hip arthroplasty cases, the procedure is much longer and more complex, requiring extensive planning. It is often very important to know the make and model of the prior arthroplasty hardware, which requires having previous operative reports. This can involve removing one, two, or all four components of a total hip replacement. Every time a component is removed, supportive bone is removed and there can also be a risk of fracture. Additionally, more soft tissues are released for exposure, and this can make the recovery more challenging and painful. The residual bony structure is then rebuilt with metal and plastic. As a result, the recovery and outcomes after revision hip arthroplasty are less predictable than the first hip replacement.

Instability is a problematic issue that can be a result of many different factors, from postoperative protocol adherence to component positioning to changes in spinal alignment to preexisting risk factors. Treatment for instability may involve altering well fixed components or increasing the constraint of modular components to decrease the chance of dislocation. Revision for instability is unpredictable and recurrence can occur. Following the weight bearing and range of motion restrictions will be critical in the early phase of recovery. With each recurrent dislocation episode, the risk of infection increases.

Infection is a life-altering complication that similarly can be the result of preexisting risk factors, dietary habits, adherence to postoperative protocol, intraoperative sterility, dental health, cardiac health, and even a recent skin scrape. The mortality of a periprosthetic joint infection at 5 years is 26%. This carries a higher mortality than breast cancer, melanoma, bladder cancer, and melanoma. The treatment for a periprosthetic joint infection involves removing the implants, performing a thorough debridement, placing a temporary spacer, undergoing a minimum of 6 weeks of IV antibiotics, and replantation of new implants. Even after undergoing two operations and a period of antibiotics, the success rate is still only 60-70%. Periprosthetic joint infection rarely, if ever, causes sepsis and death when there are no other contributory sources of infection (endocarditis, inflammatory bowel disease, blood infection). However, this does cause persistent pain, swelling, and may lead to drainage – even years after a well healed incision.

Another cause of revision hip arthroplasty is fracture. This can be fixed with plates and screws, cables, and/or revision of components. After surgery, there will be restrictions and limitation in weight bearing and motion to promote fracture healing.

Dr. Prem Ramkumar, revision total hip replacement surgeon, is located in Long Beach and serves patients in Los Angeles, Orange County, and surrounding Southern California areas who are in need of a hip revision or replacement.

How are incisions made for a revision total hip replacement?

Dr. Ramkumar will approach your revision total hip replacement in one of three ways, but most commonly he will use your prior incision to avoid additional scars.

• Direct anterior – An incision is made in the front of the hip
• Superior – An incision is made over the buttock of the hip
• Transgluteal – An incision is made on the side of the hip.

Immediately after surgery, you may have a wound vacuum on your incision to decrease the rate of complications. The wound vacuum should not be suctioning fluid out of your body, and the cannister should be empty. It is meant to decrease the tension on your wound to decrease the likelihood of wound breakdown. This vacuum will be removed at your first postoperative visit.

What is the recovery like after a revision total hip replacement?

Recovery from a revision total hip replacement is often slower and more challenging than the first surgery. You will most likely stay in the hospital for several days before being sent home. Once home, you will follow Dr. Ramkumar’s post-operative protocol. You will always be encouraged to get up and moving, typically with the use of crutches or a walker. Depending on your condition, you should typically be off all assist devices by 4 weeks postoperatively.