904-739-0050

Bahri Orthopaedics

Revision Joint Replacement Surgery

Joint replacement surgery is one of the most successful orthopaedic procedures available. For approximately 40 years, hip and knee replacements have been resulting in improved quality of life for individuals with end stage arthritis. Approximately 400,000 hip and knee replacements are performed in the United States annually. Despite the success of these procedures, about ten percent of implants will stop working resulting in a second procedure, namely a revision surgery to remove the current implants and replace them with new components.

Joint revision surgery is a complex procedure that requires in depth preoperative preparation, use of specialized tools, and proficiency with difficult surgical techniques to obtain a good result. Drs. Georges Bahri possesses the required experience and skills to perform these advanced procedures for the hip, knee, and shoulder. As more young patients (less than 55-60 years of age) have these procedures, and as senior citizens continue to live longer, a greater number of joint replacement patients will outlive their implants.

The decision to perform a revision joint replacement is based on several factors. The joint may become painful or swollen, due to implant loosening, material wear, or infection. Function of the implant may deteriorate over time in conjunction with the previously mentioned issues.

It is critical that you have a realistic expectation of the results regarding your revision joint replacement surgery. Not all individuals achieve the same level of function after revision surgery. Depending on the reason for revision, you may require more than one operation to achieve a positive result.

Reasons for implant failure

Implants may fail for any of several reasons: infection, aseptic (non-infectious) loosening, dislocation, and/or patient specific issues.

Infection

Infection is one cause of implant failure. The implant components can serve as a surface for bacteria to latch onto and grow. The surrounding soft tissues also have blood supply that may have been adversely affected which may affect the ability of the body to fight infection. Even if the implants are well-fixed and stable, pain, swelling, and drainage often make revision surgery necessary. Chronic infections can weaken the person and endanger their life. Realistic risk of infection with current surgical techniques and antibiotic regimens is approximately 1 to 3 percent depending on the person’s overall health status.

Implant loosening

The metallic and plastic joint surfaces generate particles when they rub against each other over time. These particles accumulate and are digested by the body’s immune cells which over time (years) results in aseptic loosening. As the prosthesis becomes loose, the person may experience pain and instability. This digestive process also weakens normal bone. In some situations, there are bone defects that require treatment during the revision procedure. Aseptic loosening is the most common mode of failure of hip and knee joint replacements.

Dislocation

Dislocation is another way that joint replacements fail. It is more commonly a problem of hip replacements than knees. The rate of dislocation after hip replacement ranges from zero to 10%. Some patients will experience multiple dislocations and ultimately require revision. The dislocation may be caused by implant loosening, poor soft tissues tension, tissue impingement, component mal-position, neurologic problems (such as diabetic neuropathy or Parkinson’s disease), and patient noncompliance.

Patient-specific issues

Younger, active patients have a higher rate of revision surgery. Obese patients have a higher risk of wear and implant loosening. Patients whose primary surgery was performed for rheumatoid arthritis, avascular necrosis (dead bone), and previous hip fracture are at higher risk for loosening.

Diagnosis

Failed joint replacements will usually result in increased pain, implant position, and decreased function. Patients who demonstrate these problems may require revision joint surgery. A thorough history and physical examination is performed in conjunction with X-rays, lab tests, and possible joint aspiration. Occasionally, bone scans are performed when the cause for pain and dysfunction is unclear.

Physical Examination

Joint pain, change in activity level and increased use of assistive devices, such as crutches or a cane may indicate implant failure. Joint swelling (i.e. knee, shoulder) and skin changes (redness and warmth) may indicate a problem.

X-Rays

X-rays are important as a screening tool to evaluate the stability of the implant. The implant may have migrated in comparison to the previous X-rays, or there may be a clear line between the component and the cement or bone. Areas of bone loss can also be identified. Routine follow-up X-rays are recommended to catch joint failure at an early stage.

Laboratory Tests

The most common laboratory tests ordered are complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein test (CRP). These studies are most helpful in the evaluation of infected joint replacements. The white blood cell count is the least helpful of these lab tests.

Additional Tests

Joint fluid may be removed for microbiologic analysis. The knee joint can usually be reached with a needle in the physician's office, but the hip and shoulder joints require X-ray guidance. In addition, bone scan studies that use short-acting radioactive isotopes may be used. One study, the Technetium-99 bone scan, can detect abnormal bone activity in situations such as infection, fracture, or irritation from prosthetic motion. The Indium111 scan may be used in addition to detect infection versus aseptic loosening.

Treatment options

Revision joint surgery has a higher complication rate than primary surgery. Some patients are too infirm to undergo repeat surgery. Patients who are treated non-surgically must realize that they will have significant limits on their function and activity. Pain that is caused by a failed joint replacement may be initially treated with pain medication. Assistive devices, such as a cane, crutches, or a walker, may be used to postpone revision surgery. Similarly an abduction brace may decrease episodes of hip instability or dislocation. Restriction of activity may be used to decrease symptoms. Some infected joint replacements are treated with lifetime suppressive antibiotics to control the infection, but this approach has a poor success rate and will not eliminate the infection. This option is generally reserved for patients who cannot tolerate surgical intervention and/or anesthesia.

Alternatives to revision implant surgery

There are surgical alternatives to revision joint surgery, but the options of resection arthroplasty and fusion are not commonly used due to the functional limitations of each procedure. Resection arthroplasty involves removal of the entire joint. This may give the person give pain relief, but will lead to decreased function as compared to a joint replacement. A fusion, also known as an arthrodesis may be used as an alternative to revision surgery. This procedure is generally used in situations where an infection cannot be eradicated.

Revision implant surgery

In hip revision surgery, both sides of the joint are usually addressed (femoral and acetabular components). The femur and acetabulum may have bone loss due to lysis with implant loosening. All or a portion of the existing components are removed. There are specific techniques that are used to remove well fixed implants such as ultrasonic cement removal systems and bendable bone wedge instruments (osteotomes). The reconstruction may involve placement of larger and longer implants, bone grafts to fill defects, cement and metal cages. The revision femoral and acetabular components must be firmly fixed to the bone with cement or through implant surfaces.

With revision knee surgery, the femur (thigh bone), tibia (shin bone), and patellar (knee-cap) components are usually removed. Bone loss due to lysis may require use of metallic augments and extensions. Much like revision hip implant surgery, the failed components are removed with specialized instruments and surgical techniques. Instability may be addressed with “hinged” implants.

With revision shoulder replacement surgery, the humeral stem and/or the socket (glenoid) components are removed. When infection is a concern, a two step process is generally performed to eliminate the infection first. This usually involves placement of an antibiotic spacer and use of IV antibiotics which is monitored by an Infectious Disease specialist. The second step involves reconstructing the shoulder with new humeral and glenoid components if possible.

Possible complications associated with revision surgery

Any surgery has the potential to have complications. Due to the increased complexity of revision joint surgery, the risk of complications also increases. Infection, bleeding, and trauma to nerves or blood vessels are possible. These are addressed and minimized by using antibiotics before and after surgery, strict observation of sterile technique, use of blood-conserving techniques, and pre-planned surgical exposures. Revision implants may move due to poor bone quality or fixation to the bone. Deep venous thrombosis and pulmonary embolism can occur with a revision procedure. Hip dislocation occurs more often with revision hip surgery. This is primarily due to the poorer quality of the soft tissues (muscle and tendon attachments) after multiple procedures. Pre-existing medical problems may be aggravated by the revision procedure. Heart, lung, and kidney complications may occur.

Rehabilitation

Physical therapy generally begins within 24 hours of the procedure and may continue for several months following the surgery. Weight-bearing may be restricted initially. A protective brace or sling may also be utilized. Assistive devices, such as a walker or crutches, will be used early in the initial post-op period. As with primary surgery, precautions may be placed regarding sitting, bending, and sleeping positions. There may also be restrictions regarding the use of arm for daily activities such as lifting. The duration of restrictions generally remains in place for six to 12 weeks. Some patients will continue their rehabilitation as an inpatient in a rehabilitation hospital, while others go home with outpatient therapy. Functional improvement may take one to two years.