Revision Total Hip and Knee Replacement

William T. Long, M.D.

Definition of revision surgery:

Revision total hip replacement and revision total knee replacement are defined as a reoperation to replace one or more components of a hip or knee replacement.   These operations have evolved into a subspecialty of joint replacement surgery. The complexity of these operations can vary from replacing one of the parts to replacing all of the parts.    These operations are usually performed by surgeons with special interest training and experience in hip and knee replacement surgery.  As a rule, general orthopedic surgeons who performed many types of orthopedic operations usually refer these cases to a joint replacement specialist.   There are exceptions to the rule and at times a general orthopedist will perform revision operations. Many of these operations require special instruments and implants, therefore the hospitals where these operations are performed must be prepared and have a consistent volume of these operations.  

Patients that have a failed joint replacement have a different perspective than patients who are undergoing their first operation.   Many patients who have had an unsuccessful joint replacement will research the surgeons and the institutions as they seek help for their failed joint replacement.   Even if a patient is referred from one doctor to another doctor, the patients often come with knowledge and experience regarding joint replacement surgery that they didn’t have before their first joint replacement.   These patients are often willing to travel long distances or even to a different country in order to find an experienced team to address their particular problem.

Making the correct diagnosis:

Proper treatment of a failed hip or knee replacement requires a correct diagnosis in order to define the underlying cause of the failed operation. The variety and complexity of problems that lead to a failed operation can vary to very simple and obvious to very complicated and mysterious.  For example, a common cause of dissatisfaction with hip replacement is that the operated limb was fixed so that it is too long or too short.  In this circumstance, the problem is usually obvious. Another example is a hip or a knee that is unstable and dislocates or comes out of socket.   The cause of dislocation is not always obvious because parts can dislocate for a variety of reasons including weak muscles, improper positioning of the hip or knee components, or broken or worn out parts.   The appropriate solution is based on defining the cause of the problem.   An infection can be obvious due to high fever, pain, and draining pus, or it may be difficult to detect in a patient who has no drainage or redness, but complains of constant pain and night pain.  Joint replacements that were put in 10 or 20 years ago will sometimes fail because the parts have worn out.  In particular, old plastic bearing surfaces can wear and the debris that is generated by the worn plastic can make the bone weak or even destroy the bone. Old plastic can also fail because loss of material will eventually make a hip or knee unstable to the point where it will not move properly and it may dislocate. Most of the time, the correct diagnosis can be made by carefully interviewing and examining the patient and correlating these findings with x-rays.  In cases where the diagnosis is not obvious, then special diagnostic tests may be necessary.  In other cases, consultants from specialties outside of orthopedics are called upon to assist making the proper diagnosis.   The combination of a careful history and physical examination, proper use of diagnostic tests, and contributions from specialists will usually lead to the correct diagnosis.  

Preoperative education and preparation:

Preparation for revision hip and knee replacement is different than preparation for primary joint replacement surgery.   As with all Arthritis Institute patients, each patient must be evaluated by an internist to make sure that they are in good physical condition to undergo an operation.  If special diagnostic tests are required this may add time to the preparation for surgery.   At times a period of observation is required prior to performing the operation.  The treating surgeon may want to examine the patient’s response to nonoperative treatment prior to committing to revision surgery.  Most patients will want to avoid any unnecessary blood transfusion, and this can be accomplished by donating ones own blood or having ones loved ones donate blood. The blood count can also be built up using special medications that are given prior to surgery. The bloodless surgery program helps determine which method is best for an individual patient.   Revision surgery may require special education that is not required for patients undergoing primary surgery. After surgery the chance of needing a brace, a cast, or assistive devices, such as crutches or a walker, is increased.  Special modifications to the home may be required to assist patients in living independently during the recovery phase of revision hip or knee replacement. 

The surgical plan:

Preoperative planning by the surgical team is more complicated with revision surgery than with primary surgery.   It is necessary to identify the make and model of the old implants. Many revisions do not require removing all of the implants.   If it is possible to fix the problem by removing one part then matching parts must be made available.  In addition to a plan that includes removing only one part, it is also necessary for the operative team to have a back-up plan.  If the initial plan calls for removal of one part, but in surgery it is determined that all parts must be removed, then the new replacement parts must be available at the time of the revision surgery.   This increased inventory requires space and the use of less familiar implant systems and requires special training and preparation by the operating room team.   The physician assistants, surgical technicians, and nurses must prepare for revision surgery by becoming familiar with the systems that will be used on that day, as well as the back up system.  Special machines to visualize the bone during surgery or remove old parts must be ordered and checked so that they are in excellent working condition.   Bone grafts, reinforced metal parts, and special machines to remove or replace implants are all included as part of the plan for revision surgery.   Revision surgery provides an opportunity to improve the prosthetic components by providing new materials that were unavailable at the time of the primary surgery.  An unsightly scar can be revised to a new better looking incision.  

Hospital stay and recovery:

Recovery from revision surgery is often longer and more challenging than recovery from primary surgery.  A major determining factor on recovery is whether implants must be removed from the bone.   At times implants do not have to be removed from the bone and at other times, they must.  Operations that require removal of implants from the bone require a longer recovery period, longer incisions a longer time on the operating room table, and more extensive dissection usually correlates to a longer hospital stay.  The longer hospital stay expands the relationship with  nurses, physical therapists, occupational therapists, and the discharge planner.   Services that a patient receives in the hospital must be balanced with the services that can be provided to the patient at home. If a patient is to go home sooner, then modifications to the home are sometimes required in order to allow the patient to become independent after revision joint replacement surgery.   In contrast, some revisions only require snapping a new liner into well fixed joint replacement parts.  The attachment of the components to the bone is not disturbed.   In these cases the recovery is much easier than the original operation.

Revision hip and knee replacement surgery is a special type of joint replacement surgery.   The patient is usually more knowledgeable regarding joint replacement and the patient brings with them their previous experience whether it is good or bad.  The operation may be less extensive than the primary surgery, but in most cases it is more extensive.   The operation allows the opportunity to correct unequal leg lengths or upgrade parts to newer and better parts.  The Arthritis Institute is one of the most experienced revision joint replacement centers.  We offer an experienced team, and modern technology to address the challenging problem of failed joint replacement surgery.  Patients who face the possibility of revision surgery are welcome to come into our office for an opinion and discuss the options that are available to help restore healthy joint function.