What is revision total joint arthroplasty?
Why or when is it needed?
Special Issues for this surgical procedure
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.
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.
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.
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.
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.
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
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
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
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.