Revision Hip Arthroplasty

Revision Hip Arthroplasty

Prepared by Dr. Kayahan KARAYTUG

Revision Total Hip Arthroplasty (rTHA) addresses failure or complications of primary hip arthroplasty, including aseptic loosening, periprosthetic fracture, infection, and instability. As primary THA volumes increase globally, rTHA has become more common. Outcomes depend on etiology, implant selection, and restoration of biomechanics rather than mere component replacements.

Revision Hip Arthroplasty 

Causes of Failure

• Aseptic loosening – most frequent long-term failure cause
• Periprosthetic fracture – increasing with aging populations
• Infection – early or late, mandates staged revision
• Instability/dislocation – often multifactorial: soft-tissue, malposition, or impingement
• Wear/osteolysis – related to polyethylene or metal debris
• Stem or cup mechanical failure – fatigue or undersized components

Cemented vs. Uncemented Revision

• Uncemented stems are preferred for younger, active patients and in cases with adequate diaphyseal bone. They allow press-fit or modular diaphyseal fixation.
• Cemented stems remain reliable in older or osteoporotic patients, providing immediate fixation and lower intraoperative fracture risk.
  .In a 2025 multicentre study of 183 patients, 5-year survival was 98.1%, and 12-year survival 83.9%, with mean Harris Hip Score = 81.3s00264-025-06526-z
  Common failure modes: infection (57%), aseptic loosening (28%), and stem breakage (15%).

Dual-Mobility Dislocations (Intraprosthetic)

• DM constructs feature an inner femoral head (22–28 mm) that articulates within a larger polyethylene outer head.
• During reduction attempts, the “bottle-opener mechanism” may cause the polyethylene to dissociate from the femoral head — producing an IPD.
• Radiographic clues:
  Eccentric femoral head position within cup
  “Bubble sign” (radiolucent halo from displaced liner)
• Management:
  Avoid reduction under conscious sedation — perform in the OR under anesthesia and fluoroscopic control.
  All confirmed IPDs → mandatory open revision to replace the DM liner.

Articulating Spacer Dislocations

• Seen in staged revision for infection using semi-constrained PROSTALAC® spacers.
• The locking polyethylene cup may allow partial engagement after closed reduction.
• Indicators of incomplete reduction:
  Femoral head not fully seated or >5 mm distance from cup base
  Lack of audible “clunk” during reduction
• Safe technique:
  Lateral decubitus position, 30° abduction, medial pressure on greater trochanter → verify fluoroscopically for full seating.

Complex and Nonconcentric Dislocations in Modern THA

with the following structure:

• Overview: Rise of dual-mobility and articulating spacers → new instability patterns.
• Radiographic Clues: Eccentric head, “bubble sign,” partial seating, increased head–cup gap.
• Management Tips: Reduction under anesthesia + fluoroscopy; confirm true reduction before discharge.
• Complications: IPD → mandatory revision; partial reduction → redislocation or liner damage.

Instability and Constraining Devices

• Instability is the most common reason for re-revision, particularly after multiple surgeries.
• Constraining options include:
  Dual-mobility (nonconstrained tripolar) cups — low dislocation rates with larger effective head size.
  Constrained liners — last resort for severe abductor deficiency or neuromuscular compromise.

Surgical Principles

• Preoperative work-up: Infection rule-out, imaging (CT, EOS), bone stock classification (Paprosky).
• Approach: Posterior or extended trochanteric depending on exposure needs.
• Goals: Restore centre of rotation, leg length, and offset; achieve stable fixation in viable bone.
• Soft-tissue management: Repair capsule and abductors whenever possible to reduce instability risk.
• Intraoperative adaptability: Be prepared to escalate from liner exchange to full component revision if instability or bone loss encountered intraoperatively.

Complications

• Recurrent instability
• Periprosthetic joint infection (PJI)
• Nerve injury (sciatic > femoral)
• Dislocation after constrained or dual-mobility revision
• Fracture propagation during extraction
• Leg length discrepancy

Outcomes

• Long-term survival >80% at 10 years achievable with appropriate technique.
• Functional results approach those of primary THA when biomechanics are restored.
• Dual-mobility and modular cemented stems provide excellent mid-term survivorship in elderly patients with poor bone stock.

Clinical Pearls

💡 Always identify and correct the primary cause of failure — revising components without addressing malposition or soft-tissue insufficiency leads to recurrent failure.
💡 Use Paprosky and AAOS bone loss classifications to guide fixation strategy.
💡 Constrained liners should never compensate for poor component alignment.
💡 Infection work-up (ESR/CRP, aspiration, frozen section) is mandatory before any revision.

References:

1. .Tomáš T, Apostolopoulos V, et al. Long-term implant survival, functional, and radiological assessment of cemented stem in revision hip arthroplasty. Int Orthop. 2025;49:1615–1624s00264-025-06526-z
2. .Van der Merwe JM. Comprehensive review of current constraining devices in total hip arthroplasty. J Am Acad Orthop Surg. 2018;26:479–488Comprehensive Review of Current…
3. Paprosky WG, et al. Reconstruction of femoral bone loss in revision total hip arthroplasty. Clin Orthop Relat Res. 1999;369:231–243.
4. Bozic KJ, et al. Causes of revision total hip arthroplasty: a review. Clin Orthop Relat Res. 2009;467:638–644.