Revision Hip Replacement FAQs

What is the revision hip replacement? What does revision surgery mean?

There are numerous reasons why a total hip replacement may need to be revised. It may be because the hip has worn out, or it may be because it is infected, or the reason may be because there is a break in the bone adjacent to the hip replacement, and the break has also caused loosening of the artificial hip replacement.

What are the common reasons for revision of a hip?

There are four main reasons why hip replacements are revised. One is infection, second is dislocation, the third one is loosening, and the fourth one is fracture.

What are the results of a total revision hip replacement?

The results of a revision total hip replacement depend upon the reason for getting a total hip replacement done, as well as the manner the hip was revised. If significant stripping of the soft tissues was needed to achieve fixation, patients, especially elderly patients, have difficulty rehabbing the muscles, and most of them walk with a cane in the opposite hand for a long time.

If adequate fixation was not achieved surgically, or if the bone deteriorates after the procedure, there may be loosening at the interface between the implant and the bone, or between the cement and the bone, and there may be failure of the revision total hip replacement. If the patient dislocates the revision total hip replacement, that may need surgery to decrease the risk of subsequent dislocations.

This surgery for dislocation could be in the form of a constrained liner, or could be changing the orientation of the components to decrease the risk of infection. If a dislocation happens, there are additional options available- there are larger heads available, and different types of heads that articulate into better cups to decrease the risk of dislocation after revision total hip arthroplasty.

Am I too old to have revision total hip replacement surgery?

Revision hip replacement surgery is performed when there are no other options. If revision is performed for a fracture next to the artificial joint, then the surgery is done to achieve ambulation. It is impossible to ambulate with a displaced fracture next to an artificial joint that could have given rise to loosening of that joint. To conclude, revision hip surgery is performed only when absolutely necessary. When the surgery is performed thorough medical testing is done before the surgery to ensure that the patient is optimized to undergo the surgery. In addition, most orthopedic surgeons have a medical doctor follow the patient closely in the postoperative period. Preoperatively, in addition to the routine medical clearances, patients who are elderly with cardiac issues will need a cardiac clearance and may need additional tests prior to the revision hip replacement surgery.

How long does the surgery take?

The time taken for the hip replacement surgery depends on what is being performed. If it is a minor surgery, like exchange of the head and the plastic, the surgery is done within less than an hour. If it’s a major reconstruction, it may take several hours. The time for the surgery is always less than the time the patients go in and are next seen by their relatives. I always tell the relatives that there is a lot of time that goes by before the actual surgery starts- time for anesthesia, for prepping and draping the patients etc. After the surgery in the postoperative care unit it is important to ensure that the patient has settled down in the postoperative care area before the nurse calls for relatives to see the patient.

How long does it take to recover from a revision hip replacement surgery?

Recovery from revision hip replacement surgery depends on the amount of the work that was done to revise the joint. If only the head and the plastic are exchanged, which means that the parts not attached to the bones were exchanged, recovery from the revision hip replacement can be very fast. Sometimes even faster than a regular hip replacement surgery because the components that are attached to the bone are not removed.

When only the head and the plastic are exchanged, only the replaceable part of the artificial hip replacement are removed. It’s like taking a cap off a pen and then reinserting a new one. This type of surgery is perhaps the least invasive of all types of revision hip surgeries.

Depending upon whether the artificial part attached to the thigh bone or to the pelvis is removed, the surgery becomes additionally complex. If both part of the components are removed, the surgery recovery is more than only replacing one part of the hip.

Additionally, if there is bone erosion (bone being eaten up by debris) that needs replacement of the bone with metallic augments or with structural allograft (bones from donors), significant stripping of the soft tissues is done intraoperatively and the recovery is significantly longer.

The most common long-term problem with the stripping of soft tissues to replace the lost bone with artificial bone with bone augments or with structural bone graft from donors, is a limp. A limp is accommodated by the patient by the use of a cane or by the use of a walker

Can you sleep on your side after revision hip replacement?

It’s extremely important to follow hip dislocation precautions after revision hip replacement surgery. The risk of a hip dislocating after the revision hip replacement surgery is significantly higher than after a primary hip replacement surgery. When patients sleep, they should ensure that their knees are separated and they do not bend their hips beyond 90 degrees. If they sleep on the side of the hip replacement, they might get pain on the outside of the hip joint, because typically the incision is sore after the surgery. If they decide to sleep on the opposite side, they should be extremely careful not to cross over their knee to the other side and touch the bed, because this is exactly the position in which the hip dislocates especially if the hip is flexed. If they keep their knees separated with the cushion/apparatus given to them after the surgery, they are allowed to sleep on the opposite side.

How long will I be incapacitated after revision hip replacement surgery?

Most revision hip replacement surgeries are able to weight bear as tolerated immediately after the procedure. When anesthesia has worn away, I encourage my patients to stand up and weight bear as tolerated. Walking is a very important step for the patient to develop confidence. In addition, weight bearing is extremely important to prevent the risk of blood clots after the surgery. Walking is also important so that the patients can gain muscle bulk after hip replacement surgery that may have been deteriorating for a long time, which necessitated the surgery in the first place.

Will I need blood after the hip revision?

Depending upon the reason why the revision hip replacement surgery was performed, patients may need blood transfusions during the surgery, or immediately in the postoperative period. If revision hip surgery is done in its most minor form, in which only the head and the plastic are replaced, the possibility of needing blood is very low. On the other hand, if there is a major blood loss that need augmentation of bone with metallic implants, the possibility of needing a blood transfusion is extremely high.

How long will I be in the hospital?

Most patients with revision hip replacement surgery are in the hospital for about two to five days. Patients who are able to weight bear as tolerated are able to leave the hospital after being cleared from a medical perspective, and once they do not need IV pain medications. Hip replacement surgery patients who have had a revision done for infection, or if infection is suspected after revision hip replacement surgery, then the hospital stay is about five days. The reason for the extended stay in the hospital is to ensure the patient leaves on the correct antibiotic if they have an infection. The results of the tissue from the joint sent to the lab takes about three to five days to return in its most accurate form. I typically use tissue cultures taken from five different places to ensure I get the most accurate results if infection is suspected, or if the revision is for infection. I do not send “swabs”, because they are not accurate for culture and sensitivity, and for antibiotic selection after the surgery.

What if I live alone and have had revision hip replacement surgery? Where do I go after surgery?

Patients are evaluated totally by the physical therapist and the case worker before discharge from the hospital. My preference is for patients to go home after the surgery, however if patients are not able to do whatever the patient typically does at home, then going to a rehab facility is an option.

Which hip implants have been recalled?

Unfortunately, there are numerous hip implants that have been recalled. I have always used implants that have had an excellent track record, and have never used an implant that has been recalled until the writing of this article. Implants tested in the lab can do extremely well, but have had bad results in patients in the postoperative period. It is best to refrain from implants that are new and improved.

Which rehabilitation facility shall I go to after having revision hip replacement surgery?

Rehabilitation facilities are not hospitals. There are always issues with rehab facilities that patients select, and I encourage them to do their own research, along with the case management at the hospital, to determine which facilities they should go to. It’s extremely important for the rehab facility to maintain correspondence with the surgeon to ensure that proper postop instructions are followed. There have been facilities which do not listen to the surgeons and I have had poor patient care with certain facilities. I always tell patients which facilities they should not go to.

Will the revision hip replacement surgery be painful?

Typically, the pain from a revision hip replacement surgery is different from the pain that was there from the reason to have hip replacement surgery in the first place. As an example, if the patient is having hip replacement surgery for a fracture which is around the artificial hip, the pain from the break is gone. The patient has only postoperative pain from the surgery which only gets better after the surgery.

How long and where will my scar be?

Most hip replacement surgeries are performed through the posterior approach and the scar is on the side and behind of the hip joint. I always tell my patients that the scar will be “as much as is necessary and as less as possible”. What is important is to have a good, long-term outcome and to ensure that there is excellent stability in the joint.

Will I need a private nurse after revision hip replacement surgery?

Most patients do not need a private nurse after hip replacement surgery. They hospitals where I operate out of have excellent nursing care, and the patient is very well taken care of.

Who will get me the equipment I need to ambulate after revision hip replacement surgery?

The hospital will provide the patient with walker, crutches in the postoperative period. If the patient is able to walk with a cane in the postoperative period, this will also be provided by the hospital.

After revision hip replacement surgery, where will I go after discharge from the hospital?

My strong preference is for patients to go home from the hospital after revision hip replacement surgery. However, if the patient is not able to do the activities of daily living at home, especially if they’re living alone, the case management at the hospital, along with the physical therapist carefully reviews the ambulatory status of the patient, and decisions are made to go home or to a rehab facility.

Will I need help at home after revision hip replacement surgery?

When patients have revision hip replacement surgery, I tell them they should be the center of the world and they should get all the help that they need. A visiting nurse, as well as a physical therapist, is allowed by most insurances in the postoperative period to help after revision hip replacement surgery.

Will I need physical therapy when I go home after revision hip replacement surgery?

Physical therapy is needed after hip revision surgery to strengthen the muscles, to help in gait, and to improve ambulation. Physical therapy is also needed for education to ensure that the patients follow hip dislocation precautions. The physical therapist visiting home will also advise on how the house can be altered (if needed), at least in the postoperative period, to accommodate for the patient having the revision hip replacement surgery. As an example, the physical therapist will advise on how to get in and out of bed. The physical therapist will also advise on how to use the high chair, or how to convert the existing chairs in the house into high chairs with the use of non-collapsible blankets or cushions.

What are the consequences of not following through the recommended physical therapy program?

I strongly recommend that the patients follow the physical therapy program until they are independent. Most patients after revision hip replacement surgery are weight bearing as tolerated, and I encourage them to walk as much as needed. Contrary to patients after primary hip replacement surgery where physical therapy is hardly needed, patients having undergone revision hip replacement surgery need physical therapy for a significantly longer period depending upon the extent of the surgery that was done.

How often will I need to be seen by a doctor following the surgery?

Patients who go to a rehab facility after revision hip replacement surgery are seen on a daily basis by the attending physician at the rehab facilities. Patients who have hip revision surgery from an orthopedic surgeon typically go back to see the orthopedic surgeon in about three to six weeks, depending upon where (home or rehab) the patient has been discharged from the hospital. Patients who are discharged home see the orthopedic surgeon in about three weeks. Patients who have gone to rehab facility see the orthopedic surgeon back in about six weeks with an x-ray.

Will I notice anything different about my hip after revision hip replacement surgery?

After revision hip replacement surgery, the patient will notice that the pain in the hip is different than what was there before. If the hip revision surgery is done for a fracture, the patient will immediately realize that the hip is more stable, and the patient is able to ambulate after a revision hip replacement surgery. If the hip replacement surgery is done for an infection, the patients symptoms from an infection will be gone, the joint will no long be red and hot, and the systemic symptoms of infection, like high-grade fever, will be gone after the first revision done for an infected hip in which a spacer is placed into the joint.

How should you sit after revision hip replacement surgery?

After revision hip replacement surgery, I strongly advise the patient to follow hip dislocation precautions. The patient should be sitting on a high chair. I strongly advise patients to keep their knees separated. One easy way to remember and follow hip dislocation precautions, is to be looking at the “inside” of the knee joints and not at the “outside” of their knee joints.

Is hip revision surgery a disability?

Patients who have had revision hip replacement surgery may be disabled depending upon what was done during the hip replacement surgery. If the hip was entirely removed (as example for infection), the patients gait is significantly affected because the hip is not stable, their ambulation is unstable, and they may need a walker or a crutch to ambulate for the rest of their lives. If the hip replacement surgery involved a replacement of bone, then the muscles take several months to rehab and they will be disabled for a significant amount of time. If the patient has had hip replacement surgery for a workman’s comp case, then I follow the New York State Guidelines for Determining Permanent Impairment, and award disability according to state guidelines for loss of wage earning capacity.

How much does it cost to get revision hip replacement?

Revision hip replacement surgery is covered by all insurances. If the patient has Medicare with supplemental insurance, it is important to see whether the deductible for the Medicare has been met for the year, and if the patient has a deductible for their secondary insurance. If it’s a supplemental plan like AARP, typically there is no deductible, and the secondary or supplemental covers 20 percent of the cost of the revision hip replacement surgery. There may be additional costs with durable medical equipment that may be needed in the postoperative period, like a grasper to follow the hip dislocation precautions, an insert for placing the ankle into the shoe, etc., which are minor costs. There may be costs associated with medications depending upon the prescription plan that the patient has.

What exercises can you do after revision hip replacement surgery?

Exercises after revision hip replacement surgery include exercises to strengthen the muscles and the tissues around the effected hip, as well as the effected extremity, as well as exercises to strengthen the contralateral extremity. In addition, I also advise patients to do exercises for the back, and core strengthening of the abdominal muscles for better stability and improving gait. Additionally, there are gait training exercises taught by physical therapists after revision hip replacement surgery.

How long does a revision hip replacement surgery last?

Unfortunately, the data around revision hip replacement surgery is not accurate as that after primary hip replacement surgery, especially considering the various reasons why the surgery is performed. The lack of numbers of revision hip replacement compared to primary replacement, there is no strong data to tell the patients how long the hip revision will last.

Typically if the stability of the prosthesis is good with accompanying good bone stock, the thought is that the revision hip replacement surgery will last as much as primary hip replacement. However, if significant soft tissue stripping was performed during the surgery, the rehabilitation from revision hip replacement surgery may last from several months, to years, and patients may be walking with a can for the remainder of their life. The orthopedic surgeon can advise the patient and counsel them as to the life of the revision hip replacement surgery, as well as if they may need ambulatory tools for ambulation after the revision hip replacement surgery.

What are the signs and symptoms of metallosis?

Artificial hip replacement, as the word suggests, is made of artificial parts. They don’t have the ability to repair themselves. Eventually, with time, these artificial components can wear out. When the metal rubs on metal, it gives rise to corrosion and erosion of the components and that causes these metals from the artificial parts to go into the surrounding tissues, which is called as metallosis.

Metallosis is a large amount of wear of metallic debris into the joint, it can cause inflammation of the surrounding tissues and cause pain in the artificial joint, which may require revision surgery.

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Dr. Nakul Karkare

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