What are the considerations and procedures for revision Total Hip Replacement (THR)?

Revision Total Hip Replacement: Key Considerations and Procedures

Revision THR should be performed when patients have refractory pain and disability despite a failed primary implant, with the primary goals being pain relief, functional restoration, and implant longevity, recognizing that revision surgery carries higher complication rates and lower survival rates than primary THR.

Indications for Revision THR

The most common indications for revision surgery include 1:

• Aseptic loosening (most favorable prognosis with 84% implant survival) 2
• Prosthesis loosening (most common cause of failure within first 7 years) 1
• Periprosthetic infection 3
• Recurrent dislocation 3
• Periprosthetic fracture 3
• Unexplained pain (worst prognosis with only 58% survival) 2

Expected Outcomes and Survival Rates

Revision THR demonstrates significantly lower survival rates compared to primary surgery, with 10-year survival of 82% and 20-year survival ranging from 54-65% 1, 2:

• Acetabular component survival: 71% at 10 years, 54% at 20 years 3
• Femoral component survival: 80% at 10 years, 62% at 20 years 3
• Most failures occur within the first 7 years post-revision 1

Functional Outcomes

Pain relief and functional improvement are substantial but less dramatic than primary THR 1:

• 83% of patients report good to excellent pain relief 1
• 52% report good to excellent functional improvement 1
• Mean Oxford Hip Score of 34 at long-term follow-up 2
• 92% patient satisfaction rate among those with unrevised hips 2

Positive Predictive Factors

Age greater than 70 years at time of revision surgery is a positive predictor of implant survival 2:

• Revision for aseptic loosening (versus other indications) predicts better outcomes 2
• Revision of both components or acetabular component alone shows better survival than isolated femoral revision 2

Surgical Approach Selection

The posterior approach should be used for most straightforward revision cases 4:

• Simple revisions of loose endoprostheses 4
• Short, loose cemented stems 4
• Straightforward cup revisions 4
• Key technical requirement: adequate soft tissue releases to displace proximal femur anteriorly 4

Advanced Exposure Techniques

For complex revisions requiring greater exposure 4:

• Sliding trochanteric osteotomy: When greater femoral shaft exposure needed, for implant removal, deformity/fracture treatment, or enhanced acetabular exposure 4
• Extended trochanteric osteotomy: For most difficult femoral revisions including removal of well-fixed cementless and cemented components; lateral 1/3 of femoral shaft removed as far distally as necessary 4
• Combined AP extensile approach: Reserved for most difficult acetabular reconstructions including total acetabular allografting; requires cadaveric training and possibly vascular/urologic surgical assistance 4

Complication Rates

Revision THR carries higher complication rates than primary surgery 3:

• Dislocation: 6.1% 3
• Periprosthetic fractures: 5.5% 3
• Sciatic nerve palsy: 2.2% (most resolve without intervention) 3
• Deep infection: 1.1% 3
• Vascular injury: 0.6% 3

Special Considerations for Timing

In patients with severe bone loss, deformity, or ligamentous instability, proceed to revision THR without delay 1:

• Delaying surgery increases instability and juxtaarticular bone loss 1
• Progressive deformity increases technical difficulty and risk of failure 1
• These patients already have increased revision risk that worsens with time 1

For neuropathic joints, proceed without delay when diagnosis is established 1:

• Early-stage disease may show severe destruction without major symptoms 1
• Disease progression worsens bone loss and necessitates more constrained implants 1
• Delaying surgery increases technical difficulty without improving outcomes 1

Bone Stock Restoration

Attempt to restore bone stock with allograft where indicated during revision surgery 3:

• This approach supports long-term implant fixation 3
• Particularly important in younger patients who may require future revisions 3

Critical Pitfall

Avoid using lateral surgical approaches for revision THR 5:

• Lateral approaches associated with higher revision rates (HR 1.12) 5
• Increased 90-day mortality risk (HR 1.15) 5
• More self-reported complications compared to posterior approach 5
• The posterior approach should be considered the current standard 5