Revision Hip Replacement
Why does a hip need to be revised?
A revision hip surgery varies from a minor adjustment of a small part of the original hip replacement to a massive operation replacing significant amounts of bone, and hence is difficult to generalize without discussing the particular details of your condition. Pain is typically the reason for revision, but in some cases the recommendation is made for revision in the absence of pain if, for instance, the old prosthesis is wearing out and causing bone loss.
Common causes of revision include:
- Polyethylene wear – this is one of the easier revisions where only the plastic insert is changed. Although modern plastic liners should last for a minimum of 25-30 years in most patients, older versions were frequently worn out by 10-15 years.
- Dislocation (instability) – means the hip is popping out of place. Hip surgeons usually recommend revision for instability after two or three dislocations.
- Loosening – of either the femoral or acetabular component. This is where one or both of the major components of the hip replacement is no longer solidly fixed to the bone. This usually presents as pain but may be asymptomatic.
- Infection – usually presents as pain, but may present as an acute fever or a general feeling of unwell. Most revisions for infection are best accomplished with two staged surgeries, approximately 2-3 months apart, known as a two-stage exchange. The first surgery removes the infected prosthesis and cleans the surrounding bone and tissue, while placing a temporary prosthetic device made of antibiotics. The second surgery occurs when the infection has completely resolved, and replaces the temporary antibiotic parts with a new, permanent device.
- Osteolysis (bone loss) - this can occur due to particles being released into the hip joint that result in bone being destroyed
- Painful hardware – e.g.. cables or wires causing irritation
- Periprosthetic fracture – the bone surrounding the pelvis (usually in the femur, or thigh bone) breaks, causing pain. This occurs rarely in the initial period following surgery, but more commonly occurs in the setting of a fall or significant trauma.
- Metal reaction – this is a rare complication, but certain devices may release metal particles in and around the hip joint, causing pain and a destructive reaction in the surrounding bone and soft tissues.
- X-rays are essential, as many of the reasons for failure can be readily made from an x-ray alone. Appropriate x-rays also help Dr. Cooper to plan the revision surgery with the necessary level of detail.
- Dr. Cooper may send you for routine blood tests to rule out infection or metal reaction, an MRI or CT scan to look closer at the anatomy, or bone scans to help to determine if a component is loose
- Aspiration of the joint is occasionally done to diagnose or rule out infection
- You will be asked to undertake a general medical check-up with a physician
- You should have any other medical, surgical or dental problems attended to prior to your surgery
- Make arrangements for help around the house prior to surgery
- Make arrangements to attend the pre-operative joint replacement education class. Details will be given to you by Dr. Cooper’s surgical coordinator. Please note, this class is mandatory, and helps further reduce your risk of acquiring an infection.
- Cease aspirin or anti-inflammatory medications 5 days prior to surgery as they can cause bleeding
- Cease any naturopathic or herbal medications 10 days before surgery
- Stop smoking as long as possible prior to surgery. Smoking is a significant risk factor for a multitude of complications following joint replacement surgery, and it is not advisable to undertake elective surgery in those who are actively smoking.
Day of your surgery
- You will be admitted to hospital on the day of your surgery
- Further tests may be required on admission
- You will be given hospital clothes to change into and have a shower prior to surgery
- You will meet the nurses and answer some questions for the hospital records
- You will meet your anesthesiologist, who will ask you a few questions
- Approximately 45 minutes prior to surgery, you will be transferred to the operating room
Hip revision will be explained to you prior to surgery including what is likely to be done. In revision surgery, the unexpected can happen and good planning is necessary to deal with these contingencies. Dr. Cooper has extensive training and experience in complex revision surgery, and coordinates thorough contingency plans in advance of every revision surgery.
The surgery is often but not always more extensive than your previous surgery and the complications similar but more frequent than the first operation. The surgery varies from a simple liner exchange to changing one or all of the components. Extra bone (cadaver bone) or tissue (cadaver tissue) may need to be used to make up for any bone loss.
You will wake up in the recovery room with a number of monitors to record your vitals. (blood pressure, pulse, oxygen saturation, temperature). You will have a dressing on your hip and you may have drains coming out of your wound or protecting your incision.
- Post-operative X-rays will be performed in the operating room or the recovery room (also known as the “PACU” – post-anesthesia care unit).
- Once you are stable and awake you will be taken back to the orthopaedic floor. However, it is not unusual for the more complex revision surgeries to require monitoring in the intensive care unit postoperatively, particularly in patients who have multiple medical problems.
- You will have one or two IV’s in your arm for fluid and pain relief. This will be explained to you by your anesthesiologist.
- On the day following surgery, you will most likely be allowed to sit out of bed or walk depending on what was done.
- Discomfort is to be expected, but if you are in a lot of pain, inform your nurse and your medications can be adjusted, or a pain management specialist can attend to your individualized needs.
- You will likely be able to put all your weight on your hip and your physical therapist will help you with the post-op hip exercises.
- You will be discharged home or to a rehabilitation hospital approximately 2-7 days after surgery depending on a number of factors, including your pain, your help at home, your ability to mobilize, and the extent of the procedure.
- Dr. Cooper typically uses absorbable sutures, but some wounds are better closed with stitches or skin staples, which typically should be removed around 14 days after surgery.
- A post-operative visit will be arranged prior to your discharge; if you are unsure of plans, please call the office. This initial visit is usually around 2 weeks after surgery, and is important for Dr. Cooper to evaluate the incision and ensure you are healing appropriately.
Precautions following revision hip replacement are extremely variable depending on the reason for revision and the extent of the surgery. While Dr. Cooper should be able to give you a reasonable expectation of your limitations in advance of your procedure, please make sure you understand your specific precautions prior to leaving the hospital.
If you have increasing redness or swelling in the wound or temperatures over 100.5 degrees you should call your doctor.
Please delay all elective dental work and any other elective surgery for at least 3 months following hip replacement. After this time, if you are having these procedures, you should take antibiotics to prevent infection in your new prosthesis. Consult your surgeon for details.
Your hip replacement may go off in a metal detector at the airport.
Risks and Complications
As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to the hip.
Medical complications include those of the anesthetic and your general well-being. Almost any medical condition can occur, so this is not comprehensive. The most common medical complications include:
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission or adverse effects
- Heart attack, stroke, kidney failure, pneumonia, urinary tract infection
- Complication from nerve blocks such as infection or nerve damage
- Although most medical complications that arise are dealt with expeditiously and resolve, serious medical complications can lead to ongoing health concerns, prolonged hospitalization, or rarely death.
Complications Specific to the Hip
- Infection: Infections can occur superficially at the incision site or in the joint space of the hip, a more serious infection.
- Wound irritation: Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint
- Fractures: This is rare but can occur during or after surgery. This may prolong your recovery or require further surgery.
- Nerve damage: Trauma to nerves may be temporary or permanent and can cause numbness, tingling, pain, and weakness. Irritation of branches of the lateral femoral cutaneous nerve, which supplies feeling to the front and side of the thigh, occurs in approximately 15-20% of patients undergoing Anterior Hip Replacement.
- Hemarthrosis: A condition caused by excess bleeding into the joint after the surgery is completed. This may require additional surgery to irrigate the joint and evacuate the blood.
- Blood clots (Deep Venous Thrombosis or DVT): A DVT can form in the calf muscles and can travel to the lung, a life threatening condition called pulmonary embolism (PE). If you get calf pain or shortness of breath at any stage, you should notify your Dr. Cooper.
- Dislocation: A condition that occurs when the artificial ball and socket come apart after surgery. This risk is statistically much higher following revision hip replacement than it was after your original hip surgery.
- Leg length inequality: In the setting of bone loss and soft tissue deficiency commonly encountered in revision hip replacement, it can sometimes be difficult to match the lengths of the legs exactly. The vast majority of leg length inequalities can be treated by a simple shoe raise on the shorter side.
- Wear: All joints eventually wear out. The more active you are the quicker this will occur. In general 80-90% of hip replacements should still be functioning well 20 years after surgery.
- Limp: Due to muscle weakness or damage, which is often present prior to revision surgery and may not fully resolve afterward.
- Failure to completely relieve pain: This is rare but may occur especially if some pain is coming from other areas such as the spine.
Discuss your concerns thoroughly with Dr. Cooper prior to surgery.