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  • What is revision total joint arthroplasty?
  • Why or when is it needed?
  • Special Issues for this surgical procedure
    • Hospital Stay
    • Blood Loss
    • Bone Graft
    • Postoperative Care
    • Revisions for Infection

1. What is revision joint arthroplasty?

Revision total joint replacement involves the replacement of an existing prosthesis with a new prosthesis.  In total joint replacement, an original total hip replacement has two components and an original total knee replacement includes three components. A revision procedure may replace any or all of the components.  The new prosthesis can be another of the original type of prosthesis (called a primary), or a prosthesis especially made for revision surgery, or a prosthesis especially made for your case (called a custom).

2. Why or when is it needed?

There are several different reasons which may have contributed to your physician’s decision to offer a revision total joint replacement.  These include prosthesis failure, infection, loosening, and osteolysis (bone loss). Each of these will be discussed in the following paragraphs. However, it should be understood that these reasons for reoperation are inter-related. That is, prosthesis failure or infection may cause bone loss and bone loss may cause loosening.

    Prosthesis Failure

    Recently, a common cause of prosthesis failure is the wearing out of the “plastic” part of the prosthesis (part of the cup in hip replacement and part of the tibia – shin bone – in knee replacement).  Techniques have been developed and prostheses modified so that the metal parts of the prosthesis can be left in place and only the worn plastic part replaced. Plastic in use today have been developed to be stronger, wear at a much slower rate, and ultimately last longer. For total hip replacement, another type of prosthesis failure occurs when the stem inside the femur (thigh bone) breaks or fractures.  With our new technology, this happens very rarely.  In these cases, the “broken” component must be removed and replaced with a similar component.

    Infection

    Once the primary cause for reoperation, deep infection still occurs in a small percentage of patients (less than 1%). One of the most significant adverse effects of an infection is the loss of bone surrounding the prosthesis. If this bone loss is permitted to progress, this bone loss can lead to the loosening of the implant.

    Osteolysis/Bone Loss

    One of the primary reasons for revision total joint replacement today is for osteolysis. Osteolysis is the loss of bone in the area surrounding the prosthesis.  Bone loss can occur when a prosthesis is loose, infected, or put in incorrectly (not positioned correctly in the bone).  Over the past decade, the scientific community has become aware that the development of osteolysis is associated with the accumulation of wear particles from the prosthesis.  One solution to this problem is to remove the area containing the wear particles, reconstruct the bone with bone graft, and replace the prosthesis. It is important to understand that not all prostheses with worn plastic have osteolysis and not all cases of osteolysis have worn plastic. As each case is unique to the individual, you should discuss your situation with your orthopaedic surgeon.

    Loosening

    As we have discussed, loosening may occur when there is loss of the bone support surrounding the prosthesis. Other reasons for loosening include both patient-related and physician-related factors. For example, improper placement of the prosthesis within the bone (called malpositioning) can cause the prosthesis to function improperly and become loose. With respect to the patient, excessive activity may lead to loosening. Any of these situations requires reoperation.

3. Special Issues for this surgical procedure

Much of the information concerning the original (or primary) joint replacement concerning preoperative, intraoperative, and postoperative care is also true for the revision procedure.  However, there are some differences of which you should be aware.

    Hospital Stay

    The hospital stay for a patient undergoing a revision total joint surgery may be slightly longer than for the original surgery.  Hospital stays for the original (primary) total joint replacement average around three days. This compares to 5 for a revision total joint replacement patient.

    Blood Loss

    As with the original joint replacement, revision total joint replacement is associated with some loss of blood during and immediately following the surgical procedure.  The lost blood can be replaced with either: 1) blood that you have donated before the surgery or 2) blood that is donated at an authorized blood bank.  In general, we prefer that patients do not donate their own blood prior to revision surgery. The blood available through the blood bank is tested with sophisticated and sensitive tests that assume it to be disease free. You will be in better physical health if you have not donated blood prior to surgery.

    Bone Graft

    In revision total joint replacement, a bone graft procedure involves the reconstruction of the bone surrounding the implant with new bone.  The new bone can either be taken from another location in your own body or from a donor patient. The decision to use your own bone (called autograft) versus donor bone (called allograft) is usually based upon how much bone is needed.  If only a small amount of bone is needed, bone can be obtained from either bone removed during the surgical procedure itself or bone taken from another site (such as the pelvis).  For many revision total joint replacement cases, more bone is needed than can be obtained from another site from your own body. When this is the case, donor bone is used.

    Similar to blood bank blood, we obtain our donor bone from a tissue bank that is certified by the American Association of Tissue Banks.  This association holds its members to the highest standards and is recognized by the federal government as the leader in this field.  These standards include screening of all donor samples for infectious agents (hepatitis, HIV, e.g.) and the assurance of proper processing.

    Postoperative Care

    Are there differences in PT? Because revision total hip replacement is associated with more extensive surgery than primary replacement and because the risk of dislocation is greater, we ask our patients to use a light weight removable plastic “hip spica” brace for 6 weeks after surgery. The use of walking aids [cane, walker, crutches] is highly variable and should be discussed with your surgeon.

    Revisions for Infection

    Depending on the type and extent of infection, you may be told that you need to undergo a “delayed exchange”. This involves two surgeries: 1) the removal of the prosthesis and the treatment of the bone to get rid of the infection, and 2) inserting a new prosthesis several weeks later.

     

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