Hip Revision Surgery

A failed hip is revised for a reason. Finding that reason comes before any new implant.

In national registry data on more than 215,000 hip replacements, 57.9 percent were still in place 25 years after surgery. When one fails, the cause sets the plan.

Why a hip replacement needs revising

Every artificial hip wears and every one can fail in time. A Lancet review in 2019 pooled national registry data on more than 215,000 hip replacements from Australia and Finland and found that 57.9 percent were still in place at 25 years, while published case series from specialist centers reported 77.6 percent. Failure is not only a matter of age, though, because some hips fail within the first two years from a dislocation, an infection or a fracture around the implant, and others fail after decades as the plastic liner wears, the debris it sheds inflames the tissues and the bone holding the implant thins away. An analysis of more than 51,000 revisions in the United States found the leading causes to be instability or dislocation in 22.5 percent, mechanical loosening in 19.7 percent and infection in 14.8 percent, with fractures around the implant, wear and implant breakage making up much of the rest. The cause decides the whole plan, so the first job is always to find it, and a revision done for the wrong reason, say a new implant put into a hip with an unrecognized low-grade infection, fails again.

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Finding the cause first

Infection has to be ruled out in every painful hip.

A low-grade infection can look exactly like simple loosening on an X-ray. Clues that raise the suspicion include the following.

• Pain at rest and at night.
• A wound that drained for weeks or needed antibiotics after the first surgery, even if it healed in the end and the hip felt good for a while.
• Early loosening.

Partial or full revision

Not every revision replaces everything.

Changing only the worn parts

When a hip dislocates or the liner wears while the cup and stem stay firmly fixed, the surgeon can exchange only the head and liner, a shorter operation with a faster recovery.

Changing a loose cup or stem

A loose cup or a loose stem has to come out, and removing a well-fixed stem sometimes needs a controlled cut along the thigh bone, an extended trochanteric osteotomy, which is wired shut at the end. Lost bone is replaced with bone graft or porous metal augments, and long stems that grip healthy bone further down the thigh carry the load when the upper femur has thinned. Dislocation remains one of the main reasons a revised hip needs another operation, and surgeons choose a larger head or a dual mobility cup, which has a second moving surface inside the cup, to make it harder for the ball to slip out, and the final choice is often made on the table once the surgeon has tested how stable the hip feels through its full range of movement. Data from the Australian national joint registry on 1,295 first revisions found no difference between dual mobility cups and large femoral heads, with a dislocation re-revision rate of 4.0 against 4.1 percent at five years.

One stage or two for an infected hip

Both approaches remove the infected implant and all infected tissue.

In a one stage exchange the new hip goes in during the same operation, while a two stage exchange removes the implant, places a temporary antibiotic cement spacer and puts in the new hip weeks later once the infection has settled. A 2015 meta-analysis of 98 studies with more than 5,800 patients found reinfection in 8.2 percent after one stage and 7.9 percent after two stage revision, and no randomized trial had yet settled the question at that point.

Getting ready for surgery

Risks and the chance of another revision

Revision is a bigger operation than a first hip replacement, and its results are less predictable.

The same Australian registry data showed that 17.6 to 17.8 percent of first revisions done for reasons other than infection had a second revision within five years.

The recovery

Weight bearing depends on the reconstruction.

Patients sit out of bed and stand with a physiotherapist on the first or second day, and walking with a frame or crutches begins on the ward, but how much weight the leg may take varies far more than after a first hip replacement, because a revision with a long stem gripping healthy bone allows full weight at once while a large bone graft, an osteotomy that has to unite or a fracture fixed with plates calls for touching the foot down only, for six weeks or more. Hip precautions, such as not bending past a right angle or crossing the legs, protect against dislocation in the first weeks. Most of the walking gain comes over three to six months, strength in the muscles around the hip can keep improving for a year, and patients who had several earlier operations should expect a longer road, perhaps with a stick for outdoor walking.

How long to stay in Istanbul

Plan for two weeks, and longer for an infected hip.

Published revision packages in Istanbul list five or six nights in hospital and recommend about fourteen days in Turkey, with the operation itself lasting three hours or more. A two stage exchange for infection means two trips or one long stay, since the second operation follows weeks after the first, and one Istanbul center describes one to two months for the full treatment.

Fitness to fly is checked before you leave Istanbul, with a dry wound, safe walking on crutches and a clot prevention plan for the journey.

What decides the cost

Five things set most of the figure.

1. Whether one part or every part is changed.
2. Augments, long stems or grafts for lost bone, which add both to the implants used and to the time in theater.
3. An osteotomy to remove a well-fixed stem.
4. The number of nights in hospital.
5. One operation or two for an infected hip.

What published hip revision packages in Istanbul cover varies from one center to the next.

• Listed in most of them are the operation, the implants, anesthesia, five or six hospital nights and transfers.
• Listed in some are a companion's stay, preoperative tests, medicines and translation.
• Left out of several are flights, hotel nights, extra tests and changes in the plan found during surgery.

Your quote should name the parts to be changed, any augments or long stems, the nights in hospital and the plan if infection is found during surgery. That figure comes only from a surgeon reading your X-rays, CT scan, blood results and the original operation note. The review costs nothing.

Arranging the trip

Your coordinator answers the first WhatsApp message, stays with you until discharge and keeps the same number afterward, and the team speaks English, Arabic, French, Russian, Serbian, Romanian and Spanish, with an interpreter for any other language. One person can stay in your room on a companion bed, and the international patients office books the hotel, sends the invitation letter for a medical visa ten days before travel and arranges transfers. Halal, vegetarian and diabetic meals come from the hospital kitchen, a prayer room sits on site, and a request for a female physician goes to the department with your first message.

Bring the original implant details.

The old operation note saves time.

Once you are back home

X-rays at six weeks, three months, one year and then every few years follow the new implant, and a local surgeon can take them while the coordinator passes them to the surgeon in Istanbul. Antibiotics after an infected revision continue exactly as written.

A hip that slips out, sudden pain after a fall, fever, a red or draining wound, or a swollen painful calf. Each needs a doctor the same day.

Hip revision surgery FAQ