Revision hip replacement: why it is needed, risks and recovery

NHS inform describes a hip replacement as surgery in which a damaged hip joint is replaced with an artificial one, known as a prosthesis, and notes that a modern artificial hip is designed to last at least 15 years. It also says there is always the risk that the joint can wear out or go wrong before this, so that further surgery is required to repair or replace it, which is known as revision surgery.

The Wrightington Hospital leaflet explains that a revision total hip replacement involves removing the existing implants and replacing them with new components. Sometimes only the socket or only the stem needs replacing, and at other times both do. It describes this as complex surgery that is required in certain situations.

Some people only need a smaller procedure, for example for a dislocated hip that can be put back in place under anaesthetic. Revision is the term for the larger operation in which the implant itself is changed.

The Wrightington leaflet describes several reasons. A hip may become painful because it has been in place for many years and the components have begun to wear and loosen, moving a little in the bone. This usually causes some bone loss and damage, which has to be dealt with at the time of surgery. A hip can dislocate, and if it does so repeatedly, revision surgery is needed to prevent this. A deep infection may develop, and revision surgery will frequently be required to eradicate the infection and implant new components.

A Royal Bournemouth Hospital booklet also lists fracture around the implant as a reason, alongside loosening, infection and dislocation. NHS inform notes that some metal-on-metal replacements have worn more quickly than expected, damaging bone and tissue around the hip, and that there are concerns about metal being released into the bloodstream.

• Wear and loosening of the components, often causing pain.

• Repeated dislocation of the ball from the socket.

• Deep infection around the artificial joint.

• Fracture of the bone around the implant.

• Problems with a particular implant type, such as some metal-on-metal designs.

New or worsening pain in a previously comfortable hip replacement, a feeling that the hip is giving way, a change in how the leg lies, increasing stiffness, or heat, redness, swelling or discharge around the scar should be checked. The Wrightington leaflet says that if you think you have an infection you should always let the team know immediately.

A hip that has suddenly become very painful with inability to bear weight, or a leg that looks shortened or turned, needs emergency assessment at A&E. Fever with a painful joint also needs urgent attention. Contact your GP or the orthopaedic team that looked after you for anything less urgent.

The decision to revise is made by an orthopaedic surgeon after examination, X-rays and sometimes blood tests, scans or a joint aspiration to look for infection. The Wrightington leaflet describes a pre-operative assessment with checks on the heart and lungs, blood tests, skin swabs to test for MRSA carriage, and an X-ray and ECG if needed. It also advises that weight loss if necessary and stopping smoking have been proven to lower complications.

Alternatives depend on how severe the symptoms are. The leaflet says pain-relieving medication can be given, and if there is infection, antibiotics may be prescribed to try to improve symptoms, but these do not replace revision where the implant has failed.

The Wrightington leaflet says most people are recommended a spinal anaesthetic with a light general anaesthetic. The Royal Bournemouth booklet describes the surgeon making a cut on the outside of the hip, removing the original replacement and inserting the new parts, and says that if there is an infection the joint may be washed out and antibiotics placed into it, which prolongs the hospital stay. Revision is described as usually done in one or two stages depending on the presence of infection.

In a two-stage approach the infected implant is removed in the first operation and a course of antibiotics follows before the new joint is placed. The Wrightington leaflet notes that during revision surgery it may be necessary to make a cut in the thigh bone to allow the removal of existing implants, and that this can be treated with plates or wires. Your surgeon will explain which approach is planned and why.

The Wrightington leaflet states that the risks of revision are higher than in a first total hip replacement. It lists blood clots in the leg or lung, with a risk of death from a pulmonary embolism it quotes as rare, at 1 in 1000, joint infection with an increased chance of the infection returning when revision is for infection, dislocation, loosening in the future, unequal leg length, fracture, nerve injury, urinary problems, persistent pain and medical problems such as heart attack, stroke and pneumonia.

Prevention steps in that leaflet include early mobilisation, elasticated stockings for 6 weeks, and an injected blood thinner for around 35 days. It also says revision hip replacements have a limited lifespan, and that the younger and more active you are, the more likely you are to need a further revision.

The leaflet says length of stay can vary from 3 to 8 days after surgery, with longer if antibiotic treatment is needed. It describes hip precautions for the first 12 weeks: not crossing the legs, not bending the hip beyond 90 degrees, not twisting, and lying on the back in bed for the first 6 weeks, although your own surgeon's instructions take priority. Physiotherapy begins early and walking aids are used at first.

NHS inform says that after a hip replacement most people can resume normal activities within 2 to 3 months, but it can take up to a year to feel the full benefits. Revision recovery is often slower and more variable, and the final result depends on how much bone was lost and why the revision was needed.

Implant outcomes in England, Wales and Northern Ireland are monitored by the National Joint Registry, which the Wrightington leaflet recommends as an information resource.

Revision hip surgery is performed in NHS orthopaedic units and in private hospitals, though more complex revisions with major bone loss or infection are often concentrated in specialist centres. Ask which surgeon and team will carry out the operation, how many revisions they perform each year, and what the follow-up plan is.