Revision Hip Replacement Surgery Research Articles

Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry

Introduction: This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one-year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates. Methods: The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, body mass index (BMI) and American Society of Anesthesiologist (ASA) grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. Results: There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21-year period. There has been a statistically significant increase in both femoral fracture (4.1 - 14.9%, p<0.001) and pain (8.1 - 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection. Conclusions: The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces.

Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry

Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry

Epidemiology of revision hip replacement surgery in the UK over the past 15 years—an analysis from the National Joint Registry

ObjectivesTo investigate trends in the incidence rate and main indication for revision hip replacement (rHR) over the past 15 years in the UK.DesignRepeated national cross-sectional study from 2006 to 2020.Setting/participantsrHR...

Comparison of patients undergoing revision total hip arthroplasty and patients undergoing re-revision.

The aim of this study is to compare the demographic, clinical, and surgical characteristics of patients who underwent revision hip replacement surgery and those who underwent re-revision surgery. The secondary outcome is the investigation of the factors that play a role in estimating the time between primary arthroplasty surgery and revision surgery.The patients who underwent revision hip arthroplasty in our clinic between 2010- 2020, patients with at least 2 years of follow-up, and who underwent re-revision surgery if needed were included. Demographic and clinical data were investigated.Of the 153 patients who met the study criteria, 120 (78.5%) underwent revision (Group 1) and 33 (21.5%) underwent re-revision (Group 2). The mean age of Group 1 was 53.5 (32-85), and of Group 2 was 67 (38-81) (p=0.003). In both groups, patients who underwent hip replacement due to fracture had more revisions and re-revisions (p=0.794). While 53.3 of the patients in Group 1 did not need additional implants, 72.7% of the patients in Group 2 needed additional implants (p=0.010). Fracture-dislocation, fistula, and the need for debridement after the revision were statistically significantly higher in patients who underwent re-revision. Harris hip scores (HHS) were statistically lower in patients who went for re-revision.The need for reoperation in patients who have undergone revision total hip arthroplasty (THA) surgery is due to the fact that the patient's age is advanced and the indication for surgery is a fracture. While the rate of fistula, fracture, dislocation, and debridement increases after re-revision surgeries, the HHS values that indicate clinical success also decrease. We believe that studies with larger participation and longer follow-up periods are needed to explain this issue better.

Arthroplasty Registries Are Leading the Way in Orthopaedic Documentation: Commentary on an article by Ilana N. Ackerman, BPhysio(Hons), PhD, et al.: "Lifetime Risk of Revision Hip Replacement Surgery in Australia Remains Low. A Population-Level Analysis Using National Registry Data".

Arthroplasty Registries Are Leading the Way in Orthopaedic Documentation: Commentary on an article by Ilana N. Ackerman, BPhysio(Hons), PhD, et al.: "Lifetime Risk of Revision Hip Replacement Surgery in Australia Remains Low. A Population-Level Analysis Using National Registry Data".

Lifetime Risk of Revision Hip Replacement Surgery in Australia Remains Low: A Population-Level Analysis Using National Registry Data.

Well-validated data from arthroplasty registries provide an opportunity to understand contemporary use of revision hip replacement at a national level. Such information can underpin health-care resource allocation and surgical workforce planning. The purposes of the present study were to describe the demographic characteristics of patients managed with revision hip replacement surgery in Australia and to examine changes in the lifetime risk of revision hip replacement over a decade. Deidentified individual-level data on all revision hip replacement procedures performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Life tables and population data were sourced from the Australian Bureau of Statistics. The lifetime risk of revision surgery each year was estimated with use of a standardized approach, with separate calculations for males and females. A total of 46,086 revision hip replacement procedures were performed from 2007 to 2017. The median age at the time of surgery was 72 years (interquartile range, 63 to 80 years). While loosening or lysis became less frequent reasons for revision over time (from 51% in 2007 to 28% in 2017), revision hip replacement for infection became increasingly common (from 14% in 2007 to 25% in 2017). Revisions for metal-related pathology peaked in 2011. Utilization rates were highest for males ≥80 years of age (127.9 procedures per 100,000 population in 2017). Although a small rise was evident in 2011 and 2012 (to 2.39% and 2.22%, respectively), the lifetime risk of revision hip replacement in females decreased from 1.90% (95% confidence interval [CI], 1.82% to 1.99%) in 2007 to 1.74% (95% CI, 1.66% to 1.82%) in 2017. A similar pattern was evident for males; the lifetime risk was 1.78% (95% CI, 1.69% to 1.86%) in 2007 and 1.57% (95% CI, 1.49% to 1.65%) in 2017. These data enable us to understand the epidemiology of revision hip replacement in Australia, including the shifting clinical indications for this procedure. At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. These methods can be utilized for population-level surveillance of revision burden and to enable between-country benchmarking. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Utility of rotational thromboelastometry in total hip replacement revision surgery (case-control study).

Total hip replacement revision surgery is accompanied by significant blood loss. Using rotational thrombelastometry (ROTEM) perioperatively to diagnose coagulopathy may help to provide rapid aimed therapy and thus decrease blood loss and the consumption of transfusion products. The aim of this case-control study was to find out whether point of care using of ROTEM may reduce blood loss and the consumption of blood transfusion products in hip replacement revision surgery.Data were prospectively collected from patients who underwent hip replacement revision surgery in the period 2017 to 2018 when the management of bleeding and coagulopathy was based on the results of ROTEM. Data were compared with a group of historical controls for the period 2015 to 2016 when bleeding and coagulopathy management was not based on ROTEM results. The consumption of blood transfusion products and perioperative blood loss were compared between the groups.The total number of analyzed patients was 90. Forty five patients were analyzed in the ROTEM group and the same number of patients were analyzed in the non-ROTEM group. Significantly decreased perioperative consumption of fresh frozen plasma and packed red blood cells was found in the ROTEM, as well as decreased perioperative blood loss comparing to non-ROTEM group. All data were statistically different with P < .05.Perioperative management of bleeding and coagulopathy based on the results of ROTEM during hip replacement revision surgery seems to help to decrease perioperative blood loss and the consumption of blood transfusion products, especially fresh frozen plasma.

Pilot study: Is a long‐term follow‐up service beneficial for patients undergoing revision hip replacement surgery?

PurposeTotal hip arthroplasty (THA) is highly successful but some patients will require later revision surgery. This pilot study evaluates the effects of long‐term follow‐up for patients undergoing revision hip replacement.MethodsConsecutive patients undergoing aseptic revision of THA were recruited from a large orthopaedic unit to a single centre, observational study. Primary outcomes were changes in patient‐reported scores from pre‐revision to 12 months post‐surgery. Secondary outcomes were costs during hospital stay up to 6 months post‐revision. Participants were retrospectively allocated to two groups—those with regular orthopaedic review prior to revision (Planned revision) or those without (Unplanned revision).Results52 patients were recruited, 7 were unrevised, one incomplete baseline questionnaires. There were 25 planned and 19 unplanned revisions with no significant differences between groups at baseline. At 12 months, 34 complete data sets were available for analysis, 17 in each group. Change scores were analysed with Mann–Whitney U test; none reached statistical significance. There was a significant difference for length of stay: Planned group 5 days (2–22), Unplanned 11 days (3–86) (Mann–Whitney U test, p = 0.023). No significant differences found for theatre time or component costs. Resource costs post‐revision surgery are presented.ConclusionThis pilot study indicates that some change in methods would be required for future work. The results show that there may be some financial benefit from providing long‐term follow‐up of THA but a larger study is needed to explore these findings and to discuss the impact on recommended guidelines.

A Surgical Robotic System for Treatment of Pelvic Osteolysis Using an FBG-Equipped Continuum Manipulator and Flexible Instruments.

This paper presents the development and experimental evaluation of a redundant robotic system for the less-invasive treatment of osteolysis (bone degradation) behind the acetabular implant during total hip replacement revision surgery. The system comprises a rigid-link positioning robot and a Continuum Dexterous Manipulator (CDM) equipped with highly flexible debriding tools and a Fiber Bragg Grating (FBG)-based sensor. The robot and the continuum manipulator are controlled concurrently via an optimization-based framework using the Tip Position Estimation (TPE) from the FBG sensor as feedback. Performance of the system is evaluated on a setup that consists of an acetabular cup and saw-bone phantom simulating the bone behind the cup. Experiments consist of performing the surgical procedure on the simulated phantom setup. CDM TPE using FBGs, target location placement, cutting performance, and the concurrent control algorithm capability in achieving the desired tasks are evaluated. Mean and standard deviation of the CDM TPE from the FBG sensor and the robotic system are 0.50 mm, and 0.18 mm, respectively. Using the developed surgical system, accurate positioning and successful cutting of desired straight-line and curvilinear paths on saw-bone phantoms behind the cup with different densities are demonstrated. Compared to the conventional rigid tools, the workspace reach behind the acetabular cup is 2.47 times greater when using the developed robotic system.

Cure a Head-Ache: Cement Gun Technique

Assembly of dual mobility heads in revision hip replacement surgery can be fraught with anxiety. Conventional manufacturer jigs are fiddly to use, and often only one is present in the hospital at any time. Slips or drops or problems with sterility can pose significant problems intra-operatively. Often the only solution in some instances being to delay the surgery and wait for new kit to arrive from nearby hospitals or loans from the manufacturer.

Antibiotic-Loaded Hydrogel Coating to Reduce Early Postsurgical Infections in Aseptic Hip Revision Surgery: A Retrospective, Matched Case-Control Study.

Periprosthetic joint infections (PJIs) are a cause of frequent implant failure in revision hip replacement surgery. The purpose of this study is to evaluate the onset of early postoperative infections in patients who underwent hip surgery with cementless prostheses treated with an antibiotic loaded hydrogel on their surface, in addition to systemic prophylaxis, and compare them to a control group. The secondary objective was to evaluate the onset of any local and systemic adverse effects and interference with bone ingrowth processes and functional recovery. A retrospective observational study was conducted on patients who underwent revision hip surgery by performing a 1:1 match between patients treated with an antibiotic hydrogel (ALH) and the control patients. The incidence of PJIs was assessed with a minimum of six months follow-up. Seventeen patients treated with the ALH were compared with 17 patients from the control group. No PJIs were reported in the ALH group versus the six cases encountered in the control group (p < 0.0001). No significant differences were reported with regard to prosthetic osseointegration and functional results, nor were there side effects in the ALH group. Despite the low sample size, the use of on-site prophylaxis with ALH has proven effective and safe in reducing the risk of PJIs in patients with a high risk for infections. Further studies are needed to validate these results in other implant-related surgeries.

Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis

ObjectiveTo determine the impact of each cause of revision surgery in total hip arthroplasty during the period 2009–2013. To analyse the relationship between these causes with different variables. Materials and methodsA study was conducted on 127 patients who had hip replacement revision surgery in our hospital during this period. Parameters, such as age, sex, date of primary arthroplasty, prosthetic replacement date, and main cause of the revision were recorded. Those revisions performed within 5 years after the primary arthroplasty were considered as early rescue. ResultsThe most common cause of rescue was aseptic loosening in 38 (30%) followed by instability in 30 (24%).In terms of age at the time of rescue, statistically significant differences were found, with it being significantly higher in patients re-operated for a fracture.Differences in age at first surgery were found to be 7 years younger than those with late rescue (63.40) with respect to early (70.21). DiscussionSimilar results to ours have been observed in other published series, except for the higher incidence of instability in early rescue. ConclusionsThis study demonstrates aseptic loosening and instability as the most frequent causes of revision surgery in our hospital. Age is a very influential factor in relation to longevity of primary arthroplasty. Complications were higher in when the primary hip replacement is implanted in older patients.

Causas de cirugía de revisión en artroplastia total de cadera. Análisis epidemiológico retrospectivo

ObjectiveTo determine the impact of each cause of revision surgery in total hip arthroplasty during the period 2009-2013. To analyse the relationship between these causes with different variables. Materials and methodsA study was conducted on 127 patients who had hip replacement revision surgery in our hospital during this period. Parameters, such as age, sex, date of primary arthroplasty, prosthetic replacement date, and main cause of the revision were recorded. Those revisions performed within 5 years after the primary arthroplasty were considered as early rescue. ResultsThe most common cause of rescue was aseptic loosening in 38 (30%) followed by instability in 30 (24%).In terms of age at the time of rescue, statistically significant differences were found, with it being significantly higher in patients re-operated for a fracture.Differences in age at first surgery were found to be 7 years younger than those with late rescue (63.40) with respect to early (70.21). DiscussionSimilar results to ours have been observed in other published series, except for the higher incidence of instability in early rescue. ConclusionsThis study demonstrates aseptic loosening and instability as the most frequent causes of revision surgery in our hospital. Age is a very influential factor in relation to longevity of primary arthroplasty. Complications were higher in when the primary hip replacement is implanted in older patients.

Medium-term Outcomes of Cemented Prostheses and Cementless Modular Prostheses in Revision Total Hip Arthroplasty

There is an increasing trend towards cementless modular femoral prostheses for revision hip replacement surgery, especially in patients with severe proximal femoral bone defects. However, for minor femoral bone defects, the benefit of cementless modular is not clear. We designed a retrospective cross-sectional study to compare outcomes of the two femoral implant designs. There were no significant differences in terms of visual analog pain scores, Harris hip scores, femoral bone restoration, stem subsidence, leg length correction, or overall complication rate. Three femoral reoperations (11%) occurred in the cemented group, and two (9%) in the cementless modular group. One femoral stem re-revised (4%) in the cemented group due to recurrent deep infection. Five-year survival for femoral reoperation was 88.2% for patients with the cemented implant and 91.3% for cementless group. Both groups had good clinical and radiological outcomes for femoral revision in patients with minor femoral bone defects during medium-term follow-up.

Strontium doping of bone graft extender

Background and purpose Allografts are often used during revision hip replacement surgery for stabilization of the implant. Resorption of the allograft may exceed new bone formation, and instability of the prosthesis can develop. We investigated whether strontium could regulate the imbalance of fast resorption of allograft and slower formation of new bone, because it is both an anabolic and an anticatabolic agent.Method Strontium was added to the implant interface environment by doping a hydroxyapatite bone graft extender. 10 dogs each received 2 experimental titanium implants. The implants were inserted within a 2.7-mm concentric gap in cancellous bone. The gap was filled with 50% (v/v) allograft mixed with 50% bone graft extender. The extender either had 5% strontium doping (SrHA) or was undoped (HA). After 4 weeks, osseointegration and mechanical fixation were evaluated by histomorphometry and by push-out test.Results SrHA bone graft extender induced a 1.2-fold increase in volume of new bone, a 1.2-fold increase in allograft remaining in the gap, and a 1.4-fold increase in surface area of the bone graft extender material in contact with new bone compared to HA bone graft extender. All these increases were statistically significant.SrHA bone graft extender did not significantly improve ongrowth of bone onto the implants or improve any of the mechanical push-out parameters compared to HA bone graft extender.Interpretation Doping of the HA bone graft extender with 5% strontium increased gap healing, preserved more of the allograft in the gap, and increased the ongrowth of bone onto the bone graft extender material, but did not improve mechanical fixation.

Serum procalcitonin, interleukin-6, soluble intercellular adhesin molecule-1 and IgG to shortchain exocellular lipoteichoic acid as predictors of infection in total joint prosthesis revision

The diagnosis of prosthetic joint infection and its differentiation from aseptic loosening remains problematic. The definitive laboratory diagnostic test is the recovery of identical infectious agents from multiple intraoperative tissue samples; however, interpretation of positive cultures is often complex as infection is frequently associated with low numbers of commensal microorganisms, in particular the coagulase-negative staphylococci (CNS). In this investigation, the value of serum procalcitonin (PCT), interleukin-6 (IL-6) and soluble intercellular adhesion molecule-1 (sICAM-1) as predictors of infection in revision hip replacement surgery is assessed. Furthermore, the diagnostic value of serum IgG to short-chain exocellular lipoteichoic acid (sce-LTA) is assessed in patients with infection due to CNS. Presurgical levels of conventional serum markers of infection including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white blood cell count (WBC) is also established. Forty-six patients undergoing revision hip surgery were recruited with a presumptive clinical diagnosis of either septic (16 patients) or aseptic loosening (30 patients). The diagnosis was confirmed microbiologically and levels of serum markers were determined. Serum levels of IL-6 and sICAM-1 were significantly raised in patients with septic loosening (P=0.001 and P=0.0002, respectively). Serum IgG to sce-LTA was elevated in three out of four patients with infection due to CNS. In contrast, PCT was not found to be of value in differentiating septic and aseptic loosening. Furthermore, CRP, ESR and WBC were significantly higher (P=0.0001, P=0.0001 and P=0.003, respectively) in patients with septic loosening. Serum levels of IL-6, sICAM-1 and IgG to sce-LTA may provide additional information to facilitate the diagnosis of prosthetic joint infection.

A strut graft substitute consisting of a metal core and a polymer surface

In revision hip replacement surgery cortical strut grafts made of allograft bone are used to augment femoral bone stock and to fix periprosthetic femoral fractures. These struts are made from femoral bone as hemi-cylinders and are fixed to host bone with cerclage wires. We developed an artificial bone substitute for such strut grafts in order to overcome availability restrictions and potential infectious hazards with allograft bone. The partially biodegradable implant consists of a functionally-graded combination of titanium, polylactide, hydroxyapatite, and calcium carbonate. It is made by manual dip-coating of the metal (after chemical surface treatment) into solutions of polylactide with suspended calcium salts. In this way the titanium core is surrounded by an inner layer of slowly biodegradable poly(L-lactide) with calcium carbonate. The part of the implant that is in contact with the bone consists of rapidly biodegradable poly(D,L-lactide), hydroxyapatite and calcium carbonate. This method leads to an implant which is easily adaptable before the implantation to the geometry of the patient's bone when moderately heated (70 degrees C), but has a sufficient mechanical strength to serve as support under physiologic temperatures. The implant is mechanically stable, biocompatible, partially biodegradable, and provides a scaffold for growing bone.

Cementing a liner into a stable cementless acetabular shell: the double-socket technique.

During revision hip replacement surgery, the cementless acetabular shell is often well fixed but the locking mechanism may be ineffective. Cementing a new liner into the existing acetabular shell (the double-socket technique) can provide a simple solution. The purposes of the present study were to review our initial clinical results and to define the potential limitations of this technique. Thirty-two hips with a preexisting well-fixed acetabular socket that had been in situ for an average of 8.6 years were treated with the insertion of a new polyethylene liner (seventeen hips) or a metal liner (fifteen hips) with use of cement. The indication for this technique was a deficient locking mechanism in twenty-two hips and the unavailability of a matching liner in ten hips. Anteroposterior radiographs of all hips were analyzed by a single independent reviewer. The mean duration of follow-up was 5.1 years. Six hips required a reoperation after a mean of 29.7 months; the reasons for the reoperations included aseptic failure of the acetabular construct (four hips), instability (one hip), and sepsis (one hip). The University of California at Los Angeles hip scores improved significantly (p < 0.001) compared with the preoperative values; specifically, the mean score improved from 6.2 to 9.1 for pain, from 6.3 to 8.3 for walking, from 6.2 to 7.8 for function, and from 4.7 to 5.8 for activity. The prevalence of dislocation was 22%. Kaplan-Meier analysis with revision as the end point revealed a five-year survival rate of 78% (95% confidence interval, 55% to 91%). The double-socket technique is a good alternative to acetabular socket removal for suitable candidates who have a well-fixed cementless socket with an inner diameter that is larger than the outer diameter of the cemented liner. This technique preserves acetabular bone stock and permits conversion to alternate bearing surfaces. We believe, however, that removal of a well-fixed acetabular shell or the use of a constrained liner should be strongly considered for patients with a history of hip instability.

Revision hip replacement surgery

Revision hip replacement surgery

Ten strategies to reduce blood loss in orthopedic surgery

In any operative procedure, careful surgical dissection with precise hemostasis is one of the most effective ways to minimize surgical blood loss and reduce the need for allogeneic red blood cell transfusion. Several other techniques contribute to reduce blood loss in major orthopedic procedures. These techniques are reviewed and include rehearsal of the procedure and positioning the patient to reduce venous engorgement. In addition, a case report is presented that demonstrates the feasibility of revision hip replacement surgery without the use of transfusion in a Jehovah's Witness patient.