Total Hip and Hip Resurfacing Replacements will with time unfortunately fail, as they become worn out, be it to varying degrees and at different rates for the different types used. This failure and the need for revision surgery may present in a number of ways. The commonest cause for revision surgery of a hip replacement, or indeed any joint replacement, is aseptic loosening with osteolysis ie the artificial hip becoming loose with destruction of the surrounding bone. Also other causes for potential revision surgery are wear of the joint, instability / dislocation from the wear process, leg length changes, increasing bone destruction and the dreaded problem of infection.
What is a revision hip replacement?
Revision hip replacement surgery is a procedure to replace a worn out hip replacement implant. Hip replacements are among the most common procedures performed by orthopedic surgeons. This surgery is incredibly successful, and have excellent results in the vast majority of patients. The problem, unfortunately, is that over time hip replacements wear out.
Hip replacements wear out very slowly, but the problem does progress over the years. 10 years after a hip replacement, there is a 90% chance the implant will be functioning well. 20 years after surgery, the chance is about 80%. By 25-30 years after surgery, about 50% of hip replacements are still working well. Patients who wear out their prosthesis will require a revision hip replacement surgery.
Why do hip replacements wear out ?
Hip replacements can wear out for a variety of reasons. By far the most common cause of a hip replacement wearing out is called 'aseptic loosening.' Aseptic loosening occurs when the hip implants become loose within the bone. A loose hip implant tends to be painful, and usually requires revision hip replacement. Other causes of a hip replacement wearing out include infection, breaking of the prosthesis, breaking of the bone around the prosthesis, and other complications. Depending on the cause of the implant failing, treatment other than revision hip replacement may be needed. For example, in the case of infection, the hip replacement may need to be removed to treat the infection, followed by the revision hip replacement months later.
The problem of revision hip replacement
Revision hip replacements are more complicated surgeries and the outcomes are not as good as the first hip replacement. Technical problems include the quality of the bone and the ability to adequately secure the revision hip replacements into position. Furthermore, removing the old hip replacement can necessitate more extensive surgery. Together, these problems often require the revision hip replacement to be much more complex. Careful planning by your orthopedic surgeon is needed to ensure he or she will be able to construct a hip that will allow you to adequately recover.
Another problem with revision hip replacement is that the surgery itself can be more complicated. Patients tend to be older, and less tolerant of long surgical procedures. The procedure is technically more difficult that primary hip replacements, and the effects on the patient are more significant (longer surgery, more blood loss). Because of this, revision hip replacement must be carefully considered and planned. Involvement of general medical doctors, anesthesiologists, and the orthopedic surgeon are all important.
How do I know when I need revision hip replacement?
Only you and your orthopedic surgeon can decide when the time is right for revision hip replacement. Sometimes few symptoms are felt by the patients, but the x-rays will show a reason to consider a revision hip replacement. Other times, despite significant symptoms, your orthopedic surgeon may recommend against revision hip replacement.
Surgical Procedure for Hip Revision Surgery?
Surgery to repair or replace a loosened prosthetic hip joint is usually more difficult than the initial hip replacement. There may be less bone for the surgeon to work with, or more bone grafting may be needed to secure the second implant. The recovery period for revision surgery is usually longer as well, in part because the patient is older and often in weaker general health.
In preoperative evaluations, the surgeon tries to determine the exact surgical method to be used, taking into account the particulars of your individual case. He or she decides on the type and size of the new prosthesis. An effort is made to determine whether you will need additional bone grafts or other procedures to improve the quality of bone and tissue in the joint. If the joint has been damaged by infection, the surgeon will explain the need for multiple surgeries.
Surgery is performed by means of open incision. Commonly, these difficult operations take several hours. The old prosthesis is removed and, if possible during the first surgical procedure, replaced with a new one.
Rehabilitation After Hip Revision Surgery?
A physiotherapist will help you begin walking, first with a frame and then independently.
Major surgery like hip joint revision requires a period of adjustment. Take it easy during this time, trying to focus on the healing process and in gradual, practical improvements to your general condition. It is important to exercise your legs, as this reduces swelling. Elevate your legs above your heart whenever you are at rest.
After hip revision surgery, a patient will only get around with a walker. Normal everyday things like getting into a car or walking up steps will be difficult. It won't be long before a patient can put weight on the injured leg.
Having already taken part in physical therapy after the initial hip replacement surgery, a patient will be familiar with the physical therapy.
After about a month, a physician will take x-rays of the leg to monitor its healing. After about six months, patients with hip revision surgery will be able to walk without a limp, and the hip should no longer cause pain.
People who have hip revision surgery must be particularly cautious about infection. After the procedure, it is wise to always tell your dentist or physician that you have an artificial joint.
Having a large metal implant in your hip may sometimes set off metal detectors in an airport or at a public event. Just as before the revision surgery, you should carry a card identifying you as a patient with an artificial implant. Possible Complications of Hip Revision Surgery? Hip revision surgery is usually an elective procedure. The original artificial joint should be replaced with one of the high-quality prostheses currently available.
There may occasionally be unforeseen complications associated with anesthesia, including respiratory or cardiac malfunction. The procedure may be complicated by infection, injury to nerves and blood vessels, fracture, weakness, stiffness or instability of the joint, pain, or the need for additional surgeries.
Patients who may be at increased risk for complications include those who are immunocompromised in some way, such as patients with severe rheumatoid arthritis or systemic lupus. Those with disease, drug, or radiation-induced immunosuppression are also at increased risk, as are patients with insulin-dependent (type 1) diabetes, malnourishment, hemophilia, or those who have had previous prosthetic joint infections.
Many variables affect the ultimate success of hip revision surgery, including the strength of the patient's bone and musculature, his or her general health (including mental and emotional health) and lifestyle. Commitment to rehabilitation is a key part of the process, as improvement to the hip joint is determined not only by surgery but also by rehabilitative effort.
Revision surgery comes with a few disadvantages:
- The original component needs to be removed and new components put in its place, making for a longer surgery.
- Longer incisions are often needed.
- There is greater blood loss and post-operative pain.
- Older patients' health and strength may compound problems.
Long-term results are typically excellent. However, complications are a little more frequent than with the original surgery. For patients who are young when they undergo a hip replacement, revision surgery is almost inevitable. However, the newer materials available seem to improve the overall life span of the artificial joint, lessening the number of necessary revisions.
There are four approaches to the hip and access takes advantage of the muscular planes surrounding the hip joint :
o Anterior (front) Approach : -
The anterior approach has been revitalised for minimally invasive surgery (MIS) — a procedure that We Care India partner surgeon specialises in that can significantly reduce recovery time — when performing a total hip replacement.
o Lateral (side) Approaches : -
The anterolateral approach is the most commonly used approach for total hip replacements. The direct lateral approach exposes the hip joint by detaching the upper end of the thigh bone (the greater trochanter).
o Posterior (rear) Approach : -
The posterior approach is the second most common approach when performing a total hip replacement.
Approaches for Revision Hip Surgery
The approaches are the same as when performing primary hip replacements but the surgical approach can be extended for increased exposure for what is a more complex procedure.
Advantages : -
- Relief of pain and restoration of hip function
- Return to a full and active life style
Disadvantages : -
- Failure of the hip implant over time
- Inherent risks of surgery
Indications : -
- Revision surgery is required for patients when the hip implant has failed
Contraindications : -
- Patients who are frail and have severe heart conditions
- The presence of active infection is a contraindication to hip surgery
Possible Complications : -
- Dislocation: This occurs when the ball of the femoral component is dislocated from the acetabular cup.
- Infection: A bacterial invasion of the hip joint.
- Thromboembolism: Blood clots and migration of the clot to the lungs.
- Leg length discrepancy: Limb length discrepancies.
- Fracture of femur: A crack or split/break of thigh bone.
- Nerve injuries: Stretching, cautery or incision of a nerve.
- Vascular injuries: Penetration or incision of an artery or vein.
- Non union of the greater trochanter: The upper end of the thigh fails to unite following an osteomy.
- Heterotopic ossification: New bone formation where bone is not normally present.
- Stem breakage: A crack or fracture of the femoral stem.
- Loosening Loosening of the hip joint prostheses.
- Wear: The erosion of the surface of two materials in contact with one another.
- Pseudomembranous colitis: A bowel problem related to antibiotic treatment.
- Anaesthetic complication (Rare.)
- Death (Rare.)
The first day most patients will have had their intravenous drip removed. The physiotherapist will see you after surgery and from then on begin with muscle strengthening and stretching exercises. You will be taught the safe way of getting in and out of bed.
You will learn how to use a support and you will be encouraged to take exercise on a regular basis. By the time of discharge from around 3 to 7 days you will be able to perform all activities unassisted.
You will be able to go home in a car and it may be best to have some help when you return home. Walking is good for your hip joint and excellent exercise. Non-impact sports are advisable and these include swimming, cycling and golf. Your functional ability will improve rapidly week by week until you are able to drive a car at 6 weeks.
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