What’s Involved in a Revision Joint Replacement Surgery?

woman runningJoint replacement surgeries for hips and knees are usually very successful, lasting for decades without complications. Many of my patients who have undergone a primary joint replacement surgery enjoy increased mobility and relief from pain. In some cases, however, an implant develops a problem that necessitates re-operation or revision joint replacement surgery.

What is revision joint replacement surgery?

Revision total joint replacement is also known as “redo” surgery. In these procedures part or all of the prior artificial joint (called an implant or prosthesis) that was placed in a previous surgery is removed and exchanged for new parts.

There are many different problems for which revision surgery is performed, making each of these surgeries unique to each patient and his/her clinical presentation. Thus, revision surgeries represent a heterogeneous collection of diagnoses and implant problems that frequently require individualized treatments and solutions.

What makes revision joint replacement surgery necessary?

A replacement joint can wear out, loosen, develop excessive scar tissue, have components that break, or develop instability. An implant may also become infected, or the bone can fracture around the implant. We often make a distinction between those problems occurring early after joint replacement and those happening many years later. Those happening early after joint replacement sometimes have to do with problems directly related to the original surgery. Those happening years later most often have to do with issues related to wear and fatigue of the components.

Deep infection is by far the most catastrophic outcome for a total joint replacement. Prevention of infection is key. It is important to choose a surgeon and a hospital with a low early (acute) infection rate, like Hospital for Special Surgery. Our infection rate is approximately 0.3% for primary joint replacement -- the lowest in New York State and one of the lowest in the country. Late infections are more challenging to prevent. They occur in 1-2% of total joint patients. Often, an infection elsewhere in the body travels to the joint replacement and the prosthesis becomes an unfortunate, infected bystander. Early treatment of infections elsewhere in your body is critical to preventing this from happening. Additionally, taking prophylactic antibiotics prior to invasive dental work or other invasive procedures is essential.

For total hip replacement, dislocation, or the ball coming out of the socket, occurs in approximately 2-4% of all patients nationwide over the lifetime of the implant. Approximately 50% of these patients will suffer more than one dislocation. When this occurs, a revision total hip replacement may be recommended.

Common reasons for total hip replacement revision:

  1. Recurrent dislocation (ball popping out of the socket multiple times)
  2. Infection (bacterial infection of the components)
  3. Periprosthetic fracture (fracture of the thighbone or pelvis around the implants)
  4. Bearing surface wear (usually the plastic liner of the socket wearing out)
  5. Osteolysis (bone destruction around the implants because of bearing surface wear, particularly in the setting of older style plastic/polyethylene liners)
  6. Aseptic loosening (failure of fixation between the implant and bone, the implant and cement, or the cement and bone)

Common reasons for total knee replacement revision:

  1. Aseptic loosening (failure of fixation between the implant and bone, the implant and cement, or the cement and bone)
  2. Infection (bacterial infection of the components)
  3. Instability (subjective feeling of the knee giving way, often accompanied by recurrent swelling in the knee)
  4. Malalignment (the knee not being straight or the components rotated improperly)
  5. Periprosthetic fracture (fracture of the thighbone, shinbone, or kneecap around the implants)
  6. Arthrofibrosis (robust scar response around the knee leading to severe stiffness and very poor range of motion)

When complications arise following a primary joint replacement surgery, I may recommend a revision joint replacement surgery to correct the failed replacement. The surgery involves removing one or more of the parts of your original implant and replacing them with new ones, restoring your joint’s function and enabling you to move it without pain.

Revision surgeries tend to be longer, more complex procedures, and the risk for complications can be greater. Before any surgery is considered, I’ll make sure you understand the potential risks and benefits of the procedure in your particular case, and I’ll develop an individualized plan of care for you to ensure the best possible results.

What steps are involved in a revision joint replacement surgery?

If a revision joint replacement surgery is your best option, I’ll generally do the following:

  • Perform any necessary tests to determine the cause of your implant’s failure and determine the best surgical approach for revising it
  • Surgically remove one or more of the parts of your original implant
  • Use bone grafts, bone cement, and metallic hardware to help strengthen the remaining bone and secure new components around the joint
  • Make sure you understand the recovery steps you’ll need to take to maximize the benefit of your revision joint replacement

If a severe infection is present, I may need to complete the revision in two stages – one to remove the joint and give the infection time to heal, and one to replace the joint. This is called a “two-stage exchange arthroplasty”. A single stage exchange for infection, during which the infected implant is removed and the final revision is placed during the same surgery, is a possibility. We are currently investigating which approach is superior in terms of (1) eradicating infection and (2) providing the most clinical benefit to patients. If you have an infection and are interested in participating in this trial, please review the trial information on ClinicalTrials.gov.

If you’ve had a prior joint replacement surgery and are experiencing pain, instability, or other symptoms that may indicate that it has failed or is deteriorating, make an appointment today for a consultation at my New York City or Stamford office. I’ll conduct a thorough evaluation as well as perform any necessary tests and will discuss possible treatment options with you. 

Thank you for your submission. We will get back to you as soon as possible!