Revision Hip Arthroplasty

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.