Complex Revision Hip Replacement

Introduction

Most elderly patients who undergo hip replacement can expect the prosthesis to last 15 to 20 years, and sometimes even for life. However, some patients may require one or more revisions of their hip replacement, especially if the initial surgery was performed at a young age the patient leads an active physical lifestyle, the implant or bone anchoring had failed, or a deep infection developed.

A hip revision may involve the partial or complete replacement of your previous hip prosthesis, and thus the operation varies from minor adjustments to a more significant operation. The surgery can range from a simple liner exchange to changing one or all components of the previous hip replacement. Extra bone, such as cadaver bone, may be needed to compensate for any bone loss, and additional metal implants for stabilisation.

A revision total hip replacement is a more complex operation than a primary total hip replacement and typically requires more time.

Indications and Contraindications​

Indications for Complex Revision Hip Replacement Surgery:

  • Implant Failure: When the primary hip replacement components have worn out, loosened, or failed, leading to pain and joint instability.
  • Infection: In cases of deep or chronic infection in the hip joint, revision surgery may be necessary to remove infected components and address the infection.
  • Fracture: Hip replacement may be revised in cases of periprosthetic fractures, which are fractures occurring around the implant.
  • Dislocation: Recurrent hip joint dislocations that cannot be managed conservatively may require revision surgery.
  • Severe Bone Loss: Extensive bone loss due to osteolysis (bone resorption) or other factors, affecting the stability of the implant, may necessitate revision.
  • Instability or Malalignment: If the hip replacement components are improperly aligned or result in recurrent hip instability, revision surgery may be indicated.

Contraindications for Complex Revision Hip Replacement Surgery:

  • High Surgical Risk: Patients with significant underlying medical conditions that make surgery extremely high-risk, such as severe heart or lung disease, may not be suitable candidates.
  • Active Infection: May require additional surgeries to control the infection, prior to final implant reinsertion.
  • Inadequate Bone Stock: Severe bone loss and insufficient bone quality may limit the feasibility of revision surgery, as the new components may not have adequate support.
  • Poor Overall Health: Patients in poor overall health or with limited life expectancy may not be ideal candidates for revision surgery.
  • Unrealistic Expectations: Patients with unrealistic expectations regarding the outcomes of the revision surgery may not be good candidates if their expectations cannot be managed or met.

The decision to proceed with complex revision hip replacement surgery should be made after a thorough evaluation by a healthcare professional, taking into account the individual patient’s specific medical history, condition, and overall health

Indications and Contraindications​

Benefits of Complex Revision Hip Replacement Surgery:

  • Restoration of Function: The surgery can restore mobility and function to the hip joint, alleviating pain and allowing for improved quality of life.
  • Improved Implant Longevity: Revision surgery aims to address issues that led to the failure of the primary implant, potentially prolonging the lifespan of the new components.
  • Infection Resolution: In cases of infection, revision surgery can remove infected components, clear the infection, and install new components to re-establish joint function.
  • Correction of Malalignment: Revision surgery can correct issues like implant malalignment, improving joint stability and reducing the risk of dislocations.
  • Bone Preservation: Whenever possible, revision surgery aims to preserve as much healthy bone as possible to support the new implant.

Risks of Complex Revision Hip Replacement Surgery:

  • Infection: There is a risk of post-operative infection, which may necessitate further surgery or prolonged antibiotic treatment.
  • Implant Wear and Loosening: The new implant components may also wear out or become loose over time, requiring further revisions.
  • Nerve or Blood Vessel Damage: Injury to nearby nerves or blood vessels during surgery is a potential risk, although it is relatively rare.
  • Bone Loss: In some cases, bone loss can be so severe that it limits the ability to anchor new components securely.
  • Dislocation: The hip joint can dislocate, particularly in the early post-operative period, necessitating closed or open reduction.
  • Complexity: Revision surgeries are typically more complex and challenging, which may lead to longer operative times and increased surgical risks.
  • Scar Tissue Formation: The presence of existing scar tissue from previous surgeries may make the procedure more challenging and increase the risk of complications.
  • Functional Limitations: Some patients may experience residual functional limitations or require more extensive post-operative rehabilitation due to the complexity of the surgery.

Surgical Approach

Complex Revision Hip Replacement is a difficult procedure that requires careful planning and precise execution.

The surgical approach will be based on the patient’s general and orthopaedic condition, the need for accessory reconstruction of the bones and the soft tissues around the hip joint, available implants and the surgeon’s expertise.

In selected cases (infection), the hip revision process may need more than one procedure, first, control the infection, insert a temporary implant, and later insert a final prosthesis.

In our preoperative clinics, we routinely use 3D reconstruction techniques that allow us for meticulous assessment, digital planning and virtual surgery before the real surgery. We also employ patient-specific techniques, and we design custom-made implants, in cases when the readily available implants can’t support the demands of the surgery. 

Complex Revision Hip Replacement Pre-Surgery

The following is what can be expected prior to surgery:

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.  
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
  6. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Complex Revision Hip Replacement Surgical Procedure

  • Initial Incision Assessment: The surgeon will begin by following the incision line from your initial hip replacement surgery, which may need to be extended to remove the original components. If it is insufficient, an alternative incision may be added.
  • Exposure of the hip joint: Once the hip joint is exposed, the surgeon will carefully examine the soft tissue to ensure there’s no infection or adverse reaction to the metal components of the implant. They will also inspect the implant for wear and tear, looseness, or movement.
  • Removal of the first Prosthesis: The first prosthesis will be delicately removed to preserve as much bone tissue as possible. If cement was used during the first total hip replacement, it will also be removed, which can be a time-consuming process, making the revision surgery more complex.
  • Potential thighbone fracture: In some cases, the surgeon may need to “fracture” the thighbone (femur) to remove an implanted stem. Once the new stem is set in place, the femur will be securely reconnected.
  • Adjustments to the bone structure: Once the original implants are extracted, the surgeon will readjust the bone structure in the pelvic area and femur to accommodate the revision implants. Unfortunately, there may be a significant lack of bone in these regions, requiring the use of metal implants or a bone graft to address the deficiency. The revision implants are specifically tailored based on 3D modelling conducted by the surgical team before the surgery.
  • Implant stabilisation: To stabilise the fresh cup until the bone fully grows, several screws may be necessary. The surgeon will then assess the joint motion to ensure the implants are securely placed and the ball is safe and stable in the socket.

Our approach relies heavily on technology, utilising CT scans and 3D technology to create the best prosthesis configuration for each patient. Through this method and building our prostheses, we aim to provide the highest quality implementation using 3D modelling and printing technology to guide us.

Complex Revision Hip Replacement Post Surgical Care

Post-surgery care is essential to ensure a successful recovery. Here are some key aspects:

  • Immobilisation and Weight-Bearing: Patients may initially use crutches or a walker to avoid putting excessive weight on the operated hip. The surgeon will provide specific weight-bearing guidelines that should be closely followed to protect the joint.

  • Pain Management: Medications are prescribed to manage post-operative pain. Patients should adhere to the prescribed regimen and communicate any concerns about pain control with their healthcare provider.

  • Physical Therapy: Physical therapy is a critical component of recovery. Therapists design a customized exercise program to improve strength, flexibility, and joint mobility. Patients should diligently participate in these exercises to aid their rehabilitation.

  • Wound Care: Proper wound care is essential. Keep the surgical site clean, dry, and inspect for signs of infection, such as redness or swelling.

  • Activity Restrictions: Patients should adhere to activity restrictions and avoid high-impact activities or movements that could stress the hip joint, especially in the early post-operative period.

  • Follow-Up Appointments: Regular follow-up appointments with the surgeon are crucial to monitor progress and address any concerns or complications that may arise.

    •  1 week postop: for wound check, 
    • 2 weeks postop: for sutures removal, 
    • 6 weeks postop: for x-ray assessment of healing progressing,
    • 3 months, 6 months, 12 months and later annually for x-ray assessment of healing progress

  • Medication Management: Patients may need to continue medications, such as blood thinners, to prevent blood clots as advised by their healthcare provider.

  • Assistive Devices: In some cases, patients may need assistive devices for an extended period, such as raised toilet seats or grab bars, to enhance safety and mobility at home.

  • Lifestyle Adjustments: Depending on individual circumstances, patients might need to make adjustments to their living space or daily routines to facilitate a smoother recovery.

Comprehensive post-surgery care is vital to a patient’s overall well-being and the long-term success of complex primary hip replacement surgery. Effective communication with the healthcare team and strict adherence to their recommendations are crucial for a smooth recovery process.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 300

Call on +61 2 8882 9011

X-ray facilities at all locations | Urgent appointments available if necessary.

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Professor Munjed Al Muderis
Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical lecturer at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.
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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.