When Does a Hip Replacement Need to Be Revised?
Total hip replacement has outstanding long-term outcomes — but a proportion of implants will eventually fail, whether through a well-defined mechanical process or, less commonly, through infection or instability. When failure occurs and non-operative measures are insufficient, revision surgery may be required.
Revision hip replacement involves the removal of one or more components of the original hip replacement and their replacement with new implants designed specifically for the revision setting. It is a significantly more demanding operation than the original primary procedure — typically longer, associated with greater blood loss, and requiring more complex implants to address bone deficiency and restore a stable, functional reconstruction.
With increasing numbers of primary hip replacements being performed — and in younger patients who may outlive their implants — the demand for revision hip surgery is rising. Large registry studies show that approximately 10–15% of patients who receive a hip replacement in their fifties will require at least one revision procedure within 20 years.
Mr. Lodge has a specialist interest and considerable experience in revision hip replacement, including complex cases referred from other centres. Every revision is approached within a structured, multidisciplinary framework — involving specialist microbiologists, radiologists and anaesthetists — to ensure the cause of failure is fully characterised before surgery is planned.
The fundamental principle of revision hip surgery is the same as for revision knee surgery: establish the cause of failure before operating. Revision surgery undertaken without a clear understanding of why the original replacement has failed is unlikely to address the underlying problem — and may leave the patient no better off, or worse.
Why Do Hip Replacements Fail?
Several well-recognised failure modes can necessitate revision hip surgery. The timing of failure after primary surgery provides an important clue — infection and instability tend to occur early, within the first two years; aseptic loosening and osteolysis are characteristically late, often a decade or more after primary surgery. Understanding the mechanism is essential, since each failure mode requires a different surgical response.
Aseptic Loosening
The most common cause of hip replacement revision, accounting for approximately two thirds of all revision procedures. Over time, the bond between the implant and bone — whether cemented or biological — can fail in the absence of infection. Wear particles from the bearing surface trigger a chronic inflammatory response, leading to progressive osteolysis and bone resorption around the implant, eventually causing it to subside, migrate or fracture. Patients typically describe a progressive deep ache in the groin or thigh, often with a "start-up" pain on rising from a chair or after periods of rest. Standing X-rays show progressive radiolucent lines, migration or subsidence of components. CT and nuclear medicine bone scanning are used to characterise the extent of bone loss and confirm the diagnosis before revision is planned.
Most common indication — clear mechanical causePeriprosthetic Joint Infection (PJI)
Infection of a hip replacement accounts for approximately 11% of revision procedures and is one of the most serious and surgically demanding complications in orthopaedics. PJI may present acutely — with fever, wound breakdown, severe pain and systemic illness — or in an indolent, chronic form with persistent low-grade discomfort, elevated inflammatory markers and subtle radiographic changes. Diagnosis requires a combination of blood tests (CRP, ESR, D-dimer, serum interleukin-6), joint aspiration with microbiological culture and white cell count, and in equivocal cases, nuclear medicine imaging and the alpha-defensin synovial fluid biomarker. Treatment almost always involves surgical revision — in most cases a two-stage exchange, with an antibiotic-loaded spacer in the interval — guided by the specific organism identified and the chronicity of infection. Infection must be definitively excluded or confirmed before any revision is planned.
Clear indication — requires specialist pathwayInstability & Recurrent Dislocation
Dislocation — where the femoral head comes out of the acetabular socket — is one of the most distressing early complications of hip replacement and accounts for a significant proportion of revision procedures. Recurrent dislocation that cannot be managed non-operatively is a clear indication for revision. The cause may be component malposition (the cup or stem at an incorrect angle), impingement between the neck of the implant and the rim of the cup, abductor muscle deficiency, or patient-related factors including adverse spinopelvic mobility. Identifying the precise cause is essential — revision to correct a malpositioned cup, upgrade to a dual mobility bearing, or augment the abductor mechanism will each be appropriate in different circumstances. Performing revision for dislocation without identifying and addressing the underlying mechanism risks recurrence.
Clear indication — cause must be identified firstOsteolysis & Bearing Surface Wear
Osteolysis — progressive periprosthetic bone loss driven by the biological response to wear debris — may develop silently over many years, detectable on X-ray before the patient develops significant symptoms. If identified early, while the underlying components remain well-fixed, limited revision of the bearing surface alone — exchanging a worn polyethylene liner without disturbing a well-integrated cup or stem — can address the problem with a relatively straightforward procedure and preserve critical bone stock for any future revision. Left unaddressed, progressive osteolysis will eventually cause structural failure of the surrounding bone, transforming what would have been a manageable liner exchange into a complex reconstruction requiring structural bone graft or custom implants. Regular long-term follow-up with plain X-ray review is essential precisely to identify this window of intervention.
Early identification improves surgical optionsPeriprosthetic Fracture
Fracture of the bone around a hip replacement — most commonly around the femoral stem — may occur following a fall or, in the context of osteolysis, with minimal trauma. The Vancouver classification system categorises periprosthetic femoral fractures by their location relative to the stem and whether the implant remains well-fixed. Where the stem is stable, fracture fixation with plates and cables may be all that is required. Where the stem is loose or the fracture pattern compromises its stability, revision to a longer revision stem that bypasses the fracture and achieves fixation in undamaged diaphyseal bone is required. Acetabular fractures around a well-fixed cup are less common but pose considerable reconstructive challenges, often requiring pelvic reconstruction techniques or custom implants.
Requires urgent assessment and careful planningAdverse Reaction to Metal Debris (ARMD)
A specific and serious failure mode associated predominantly with metal-on-metal hip replacements — a bearing surface no longer used in Mr. Lodge's practice. In susceptible patients, cobalt-chromium wear particles and ions released from the articulation trigger a destructive soft tissue reaction — producing fluid collections (pseudotumours), destruction of the surrounding muscles and tendons, and in severe cases, bone loss and nerve injury. Elevated metal ion levels in the blood (cobalt and chromium) and characteristic appearances on MRI are the key diagnostic features. Revision must address the damaged soft tissues as well as the implant, and the degree of tissue destruction encountered at surgery significantly influences the outcome and reconstruction required.
Requires specialist MoM pathway assessmentThe Timing of Failure Matters
When a hip replacement fails matters as much as how it fails. Infection and instability/dislocation tend to occur early — within the first two years after primary surgery — while aseptic loosening and osteolysis are characteristically late phenomena, often presenting a decade or more after implantation. Periprosthetic fracture can occur at any stage, though risk is higher in the context of pre-existing osteolysis or osteoporosis. Understanding this temporal pattern helps to focus the diagnostic workup and avoid overlooking a less obvious cause — for example, ensuring infection is adequately excluded even when a patient presents late with apparent loosening.
Revision for Unexplained Pain — Why a Clear Cause Is Essential
Unlike knee replacement — where a significant minority of patients experience unexplained pain after technically successful surgery — hip replacement carries a somewhat lower rate of persistent unexplained symptoms. Nevertheless, the same fundamental principle applies: revision surgery for pain alone, in the absence of a clearly identifiable and correctable mechanical cause, carries a high risk of a poor outcome.
The hip is surrounded by many structures — the lumbar spine, the sacroiliac joint, the gluteal tendons, the femoral nerve and its branches, and the abductor musculature — all of which can generate pain perceived in or around the hip region. Before concluding that pain arises from the hip replacement itself, it is essential to exclude these adjacent sources. This is precisely the context in which a diagnostic intra-articular steroid injection — discussed in more detail on the Management Options page — can be invaluable: a clear response to injection confirms the joint as the primary pain generator and supports further surgical planning; a minimal response redirects attention to extra-articular causes.
Where a painful hip replacement has been thoroughly investigated and no clear mechanical, infective or structural cause is identified, revision surgery is unlikely to be of benefit and Mr. Lodge will say so directly. Undertaking revision in this context exposes the patient to all the risks and complexity of a major operation without addressing an identifiable problem — a risk-benefit calculation that cannot be justified.
Before any revision hip surgery is undertaken, a clear, specific and correctable cause must be identified. Revision directed at a proven mechanical failure — loosening, malalignment, instability or infection — can produce excellent outcomes. Revision undertaken on the hope that changing components will resolve unexplained pain is not supported by the evidence and should be avoided.
Investigating the Failing Hip Replacement
A systematic and unhurried work-up is the cornerstone of revision hip surgery planning. The investigation aims to confirm the mechanism of failure, exclude or confirm infection, quantify bone loss, and plan the reconstruction before the patient enters theatre. This process may take several weeks.
Clinical & Radiographic Assessment
First-line evaluation
- Detailed history — onset and character of pain, any wound healing problems or antibiotic courses around the time of primary surgery, previous dislocations and any precipitating factors
- Clinical examination — gait, leg length, impingement testing, abductor strength, signs of trochanteric bursitis, any skin or wound changes suggesting infection
- Weight-bearing plain X-rays — component position, radiolucent lines, subsidence, migration, periprosthetic fracture, heterotopic ossification
- CT scan — detailed assessment of component orientation (cup version and inclination, stem alignment), bone stock and the extent of osteolytic defects
- MRI with metal artefact reduction sequences (MARS MRI) — essential where ARMD or soft tissue pathology is suspected
Laboratory & Microbiological Tests
Excluding or confirming infection
- Blood tests: CRP, ESR, serum interleukin-6, white cell count, fibrinogen and D-dimer — elevated in PJI but also in other inflammatory states; interpretation requires clinical context
- Metal ion levels (serum cobalt and chromium) — essential in patients with any metal-on-metal bearing history
- Hip joint aspiration under image guidance — synovial fluid white cell count, differential and culture; the most informative single investigation for ruling in or out PJI
- Extended microbiological culture — samples held for a minimum of two weeks to detect slow-growing organisms including Propionibacterium acnes, which is notoriously difficult to culture
- Alpha-defensin synovial fluid assay — high sensitivity and specificity for PJI; particularly valuable where standard tests are equivocal
- Nuclear medicine imaging — white cell-labelled scintigraphy or SPECT/CT where aspiration is equivocal or impractical
Infection must be excluded before any aseptic revision is undertaken. Revising a hip for apparent loosening or instability in a joint that is in fact infected will result in early failure of the revision and greatly complicates subsequent management. Where any doubt exists, aspiration is mandatory before operating.
What Does Revision Surgery Involve?
Revision hip replacement is tailored entirely to the individual patient's failure mode, the extent of bone loss, the soft tissue status and the components that need to be addressed. No two revision hip procedures are the same — it is this variability that makes revision surgery one of the most technically demanding fields in orthopaedics.
Scope of Revision
In some patients, only one component requires revision. Isolated acetabular cup revision — for malposition, liner wear or aseptic loosening of the socket alone — is a more limited procedure with a faster recovery than full revision. Similarly, isolated femoral stem revision may be undertaken where the cup remains well-fixed. Where the bearing surface alone has failed — for example, wear through of a polyethylene liner with a well-fixed metal shell — liner exchange is a relatively straightforward procedure that avoids disturbing well-integrated components and preserves bone stock.
Full revision of both components is required where both are loose, where infection mandates complete implant removal, or where the overall reconstruction needs to be rebuilt from the ground up. This is a substantially larger operation — typically two to four hours — and requires a well-planned and carefully executed strategy for bone defect management, implant selection and soft tissue reconstruction.
Managing Bone Loss
Bone loss — either from osteolysis around the primary implant or from the process of removing it — is one of the greatest challenges in revision hip surgery. Classification systems such as the Paprosky classification for both acetabular and femoral bone defects guide the choice of reconstruction. Options for addressing bone deficiency include:
- Modular metal augments — titanium or tantalum wedges and blocks that fill cavitary or segmental defects and provide a stable platform for the revision cup or stem.
- Impaction bone grafting — where cancellous bone graft is firmly impacted into the defect to restore biological bone stock before cementing the revision component.
- Structural allograft — bulk bone graft from a bone bank, used to reconstruct major structural deficiencies — most commonly large segmental acetabular defects.
- Trabecular metal (tantalum) constructs — highly porous metal components with excellent biological fixation properties, used for complex acetabular reconstruction where standard press-fit fixation is insufficient.
- Custom-made triflange or monoflange implants — patient-specific 3D-printed implants designed from CT data for the most severe pelvic bone defects, where no standard implant can provide adequate fixation.
Femoral Revision
Revision femoral stems typically use longer, distally fixing designs that bypass areas of bone loss or cortical deficiency and achieve fixation in intact diaphyseal bone. Fully hydroxyapatite-coated, fluted and tapered stems — which rely on rotational stability and axial load transfer — are widely used in the revision setting with excellent medium- and long-term results. In cases with significant proximal femoral bone loss, modular revision stems allow independent adjustment of length, offset and version to restore the optimal hip biomechanics.
Two-Stage Revision for Infection
The standard of care for confirmed periprosthetic joint infection in the UK remains a two-stage revision in the majority of cases. In the first stage, all implants and cement are removed, the hip is thoroughly debrided, and an antibiotic-loaded cement spacer — either a static or articulating design — is inserted to maintain the joint space and deliver high local antibiotic concentrations. A targeted course of intravenous antibiotics, guided by the organism identified and the advice of a specialist microbiologist, follows.
Once infection eradication is confirmed — through clinical assessment, normalisation of inflammatory markers and, where indicated, repeat aspiration — the second stage reimplantation is performed using the definitive revision reconstruction. The interval between stages is typically six weeks to three months. The two-stage approach delivers the highest rates of infection eradication, though it requires substantial patient commitment and carries its own risks at each stage.
One-stage revision for infection — where implants are replaced at the same sitting after thorough debridement — may be appropriate in carefully selected patients where the organism is known, sensitive to antibiotics, and the soft tissue status is favourable. The evidence base for single-stage exchange is growing, and Mr. Lodge will discuss which approach is most appropriate in your specific circumstances at consultation.
What Can You Expect from Revision Hip Surgery?
The outcomes of revision hip replacement are generally less predictable than those of primary surgery, and vary considerably depending on the indication, the degree of bone loss encountered, the complexity of reconstruction required and whether a clear cause of failure was identified and specifically addressed.
When revision is undertaken for a well-characterised mechanical failure — loosening, malalignment or a correctable instability — with good residual bone stock and healthy soft tissues, outcomes can be very good, with meaningful improvement in pain and function. Revision for isolated liner exchange in a well-fixed cup, or isolated socket revision for malposition, carries outcomes approaching those of primary surgery in selected patients.
More complex reconstructions — involving significant bone loss, massive augmentation or infection — carry a higher burden of complications, longer recovery and less predictable functional results. Patients undergoing complex revision hip surgery should approach the procedure with realistic expectations and understand that recovery will be slower and more demanding than the primary operation.
Infection (Re-infection or New Infection)
Higher than primary surgeryThe risk of infection is substantially higher following revision surgery than after a primary hip replacement — estimated at two to three times the primary rate. In patients undergoing revision specifically for infection, reinfection rates of 10–15% are reported even after thorough two-stage exchange. Larger surgical exposure, longer operative time, compromised host tissue and altered local biology all contribute. Meticulous surgical technique, extended antibiotic prophylaxis and careful post-operative wound management are essential. Patients should remain vigilant for the lifetime of their revision implant and seek prompt treatment for infections anywhere in the body.
Dislocation
9–25% after revision surgeryDislocation is one of the most common and serious complications of revision hip surgery — occurring at substantially higher rates than after primary surgery. Published series report dislocation rates of 9–25% in the revision setting, reflecting the compromised abductor musculature, altered bone anatomy, the frequent need for constrained or dual mobility bearings, and the inherent instability associated with large bone defects. Dual mobility constructs are routinely used by Mr. Lodge in the revision setting, where the increased dislocation risk makes their mechanical advantages particularly valuable.
Blood Loss & Transfusion
Greater than primary surgeryRevision hip surgery involves more extensive dissection, longer operative time and greater bone preparation than primary replacement, all contributing to increased blood loss. Cell salvage, tranexamic acid and careful haemostatic technique are used routinely, but the requirement for blood transfusion is meaningfully higher than in primary surgery. Pre-operative optimisation of haemoglobin — including iron supplementation where anaemia is identified — reduces this risk and improves post-operative recovery.
Nerve Injury
Higher than primary surgeryThe sciatic nerve — and particularly its common peroneal branch — is at increased risk during revision hip surgery due to scarring from previous procedures, altered tissue planes, the need for more extensive dissection and the potential for leg lengthening during reconstruction. Nerve monitoring is used in selected complex cases. The majority of nerve injuries are neuropraxic — temporary conduction block without axonal disruption — and resolve over weeks to months. Permanent nerve injury is uncommon but a recognised risk, particularly in cases requiring significant correction of leg length inequality or extensive acetabular reconstruction.
Intraoperative Fracture
More common than in primary surgeryFracture of the femur or pelvis during implant removal or reimplantation is more likely in revision surgery — particularly where cement requires removal or where bone is weakened by osteolysis. Intraoperative fractures are addressed at the time of surgery, typically with cables, plates or by extending the femoral stem beyond the fracture. Their occurrence prolongs operative time and may require modification of the planned reconstruction, but outcomes are generally good when managed promptly and appropriately.
Re-revision & Further Failure
Higher than primary; indication-dependentThe risk of requiring further revision after an initial revision is considerably higher than the risk of revising a well-functioning primary replacement. Published registry data show that approximately 19% of revision hip replacements fail within five years — with infection being the leading cause of early re-revision, followed by instability and aseptic loosening. Each subsequent revision is associated with greater bone loss, more complex reconstruction and progressively less predictable outcomes. This reinforces the absolute importance of thorough pre-operative planning, correct indication and appropriate surgical expertise at the time of the first revision.
Overall perspective: Revision hip replacement is a highly specialised undertaking with a complication profile substantially higher than primary surgery. When performed for a clearly identified cause, by a surgeon with specific revision experience, and with appropriate pre-operative planning, the results can be genuinely transformative. The decision to revise should never be taken lightly — but equally, when revision is truly indicated, delaying it allows progressive bone loss and soft tissue deterioration that will only increase the complexity and risk of the eventual procedure.
Concerned About Your Hip Replacement?
If you are experiencing problems with a hip replacement — whether recently performed or many years ago — the first step is a thorough specialist assessment to understand whether a problem has developed, what the cause might be, and what options are available.
Mr. Lodge sees patients from across North Yorkshire, West Yorkshire and East Yorkshire with problematic or failing hip replacements, including cases referred for a second opinion from other centres. Not every painful or underperforming hip replacement requires revision surgery — and in many cases, reassurance, physiotherapy, or a diagnostic injection may provide answers and relief without the need for further surgery.
Where revision is indicated, early assessment allows more surgical options to be preserved — particularly in the context of progressive osteolysis, where intervening before significant bone loss occurs can make the difference between a limited liner exchange and a complex reconstruction. If you have any concerns about your hip replacement, please contact us to arrange a consultation.