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Revision Hip Replacement

The hip is one of the largest joints in the human body and is a ball-and-socket joint. The ball is the femoral head, which is the upper end of the femur (thighbone). The socket is formed by the acetabulum, which is part of the large pelvis bone. The bone surfaces of the ball and socket are covered with articular cartilage, a smooth, white connective tissue that enables the bones of a joint to easily glide over one another with very little friction allowing easy movement. The remaining surfaces of the hip joint are covered by the synovial membrane, which is a thin tissue lining that releases fluid that lubricates the cartilage, reducing the friction within the hip joint. Large ligaments (tough bands of tissues) connect the ball and the socket in order to stabilize the joint by preventing excessive movement.

Overview

When an individual has arthritis of the hip, the underlying bone develops spurs and irregularities which can cause severe pain and loss of motion. A total hip replacement (also referred to as total hip arthroplasty) has the ability to relieve pain and restore normal function in patients whose hip joint has been significantly damaged by overuse or trauma. In this type of surgery, the damaged hip ball-and-socket of the femur is replaced by man-made, prosthetic implants. Total hip replacement surgery has been done routinely for the past 50+ years with the main objective being to restore the natural, pain-free movement of the hip joint and allowing patients to return to their desired level of activity. Of all the joints currently replaced in the human body, total hip replacement has had the most success, is the most durable (lasting upwards of 30 years), and has the quickest recovery period. While these implants are made to last a long time, when a total hip replacement no longer functions correctly, revision surgery is often required where the old prosthetics are replaced with new ones.

With wear and tear the original components of the original hip replacement break down and loosen from the surface of the bones they were previously attached to. This loosening can cause significant pain and instability in an individual's day-to-day activities, in which case a revision hip replacement surgery might be a viable option. Revision hip replacement involves replacement of some or all of the prosthetic implants, generally made of metal alloys, high-grade plastics and polymers, from the primary knee replacement. The complexity of this revision hip replacement surgery depends on the amount of loosening and any potential damage that may have occurred over time. In order to rebuild the hip joint, specialized components along with cement and bone grafts may be used.

Symptoms

Individuals who require a revision hip replacement surgery typically experience these symptoms:

  • Diminished stability and/or reduced function of the replaced hip joint
  • Severe pain or infection soon after the initial hip replacement surgery

Diagnosis

Arthritis of the hip can be diagnosed with a combination of physical examination as well as imaging studies. After gathering information about the individual's general health and the extent of his or her hip pain and how it affects their ability to perform day-to-day activities, the physician may examine the hip to assess the motion, stability, strength, and overall alignment of the hip joint. The physician may order X-rays to assess the extent of deformity or damage in the hip joint or an MRI scan to determine the condition of the tissues and bones of the hip and identify the type of arthritis. The physician will educate you on the benefits from this surgery as well as what to expect post-operatively.

Arthritis is the most common cause of chronic hip pain and disability. Although there are many types of arthritis that cause pain, the most common that often lead to a total hip replacement are the following:

  • Osteoarthritis - Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage on the ends of your bones wears down over time. It's often called a degenerative joint disease where the cartilage experiences a significant amount of wear and tear over a long period of time, generally occurring in individuals over the age of 50.
  • Rheumatoid Arthritis (RA) - Rheumatoid arthritis is quite possibly the most serious form of arthritis as it is a major crippling disorder. Unlike osteoarthritis, rheumatoid arthritis affects the synovial membrane (lining of the joints), causing a painful swelling, resulting in joint deformity and bone erosion. Rheumatoid arthritis is three to four times more likely to occur in women and may affect various systems of the body such as eyes, heart, lungs, skin, and the nervous system.
  • Post-Traumatic Arthritis - Traumatic arthritis is caused by repeated trauma to the articular cartilage. This is most common among individuals who were/are athletic or active. Injuries to joints such as a fracture or sprain can cause major damage to the articular cartilage, which leads to arthritic changes in the joint over time.
    • Avascular Necrosis - Avascular necrosis occurs when the blood supplied to the femoral head is limited due to an injury such as a dislocation or fracture to the hip. The lack of blood can cause the surface of the bone to breakdown, resulting in arthritis.

Treatment

A revision hip replacement procedure takes anywhere between one to two hours to complete and occurs in the following order:

  • Entering the Joint - Depending on the approach and the physician, an incision is made near the front, side, or back of the hip (the incision made during the first hip replacement is often used) and the muscles, tendons, and other tissues are moved away from the joint to expose the femoral head (ball) and acetabulum (socket). The hip is then positioned to expose or open up the joint.
  • Removal of Old Implants - During this step, the old femoral and acetabular components that are loose or worn from their original attachment are carefully removed to avoid loss of underlying supportive bone. The respective surfaces are cleaned out in preparation for the new replacement implants.
  • Femora Canal Preparation - Any cement used to enforce the previous femoral stem is cleaned out from the hollowed-out femur. A new acetabular metal shell component is carefully fit into the space along with a plastic liner to surround the prosthetic femoral head to allow or a smooth gliding surface.
  • Femoral Placement - The new femoral stem may be secured with the use of cement or be "press-fit" into the hollow center of the femur. A carefully fitted metal or ceramic ball is then secured to the top of the femoral stem.
  • Rejoining the Hip Joint - The hip joint is then rejoined and all the surrounding muscle and tissues are repaired back to position and the procedure is completed.

Recovery

Recovery after a revision hip replacement will depend heavily on how well the individual follows home care and precautions after the surgery. After a revision hip replacement surgery, there will be some pain, but the medical team will provide the proper medication to make the patient as comfortable as possible. Walking and hip movement will being soon after the surgery where a physical therapist will provide instructions on the specific exercises to strengthen the leg and restore hip movement to allow for walking and other activities post operatively. Major part of the recovery process will occur at home where proper care must be taken in terms of wound care, diet, and activity as prescribed by the physician and physical therapist. Patients who have undergone revision hip replacement surgery generally resume normal activities three to six weeks post operatively. The biggest risk to hip revision surgery is a higher rate of dislocation, and infection compared to a primary total hip replacement. This has been published in all series of hip revisions compared to primary total hip surgery. Each patient is unique, so the recovery period will vary depending on the level of activity the individual hopes to return to; this should be discussed with the physician as well as the physical therapist. Relative to the original procedure, some patients may experience restricted motion and activities following a revision hip replacement.

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