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Revision hip replacement

78 citationsUpdated Sep 2026

Overview

At a population level, the lifetime risk of revision hip replacement remains low, affecting fewer than 1 in 50 people [1]. The primary indications for revision have shifted as implant fixation has improved, rendering aseptic loosening much less common after revision total hip arthroplasty [3]. Consequently, instability now accounts for more than half of re-revisions in contemporary cases [3]. While survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years [9], specific implant types carry distinct risks. Revision of a primary hip resurfacing arthroplasty is associated with a high risk of rerevision [8], and five-year revision rates were significantly increased for all primary metal-on-metal total hip arthroplasties undertaken from 2007 onwards [4]. Despite survival that is substantially greater than that of large-head metal-on-metal total hip arthroplasties, there has been a marked decrease in the use of small-head metal-on-metal designs in the registry [26].

Patient-specific factors and material choices significantly influence long-term outcomes. The risk of revision in patients younger than 55 years depends on surgical approach, head size, and bearing type [11]. The use of cross-linked polyethylene for total hip arthroplasty markedly reduces revision surgery at 16 years [17], improving longevity and potentially enabling younger patients to undergo surgery with a reduced need for long-term revision [17]. Cemented total hip arthroplasty demonstrates excellent survivorship out to 15 years based on Australian Orthopaedic Association National Joint Replacement Registry data [30]. Additionally, prior bariatric surgery may decrease the rate of re-operation and revision following total hip arthroplasty [59]; patients who underwent total hip arthroplasty after bariatric surgery had fewer re-operations, revisions, and deep infections in the short-term than a matched group of patients who did not undergo bariatric surgery [59].

Complications following revision surgery carry significant morbidity. Revision for prosthetic joint infection within 1 year after primary total hip arthroplasty induces an increased mortality risk during the first year after the revision surgery [7]. Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary total hip arthroplasty or aseptic revision [18]. The choice of surgical approach in revision hip replacement should be based on the indication for revision, the particular implant to be removed, the presence of acetabular or femoral bone loss, previous surgical approaches used, and the preferences and training of the surgeon [28]. The choice of prosthesis should be determined by the rate of revision, local costs, and the preferences of the surgeon and patient [52].

Anatomy & Pathophysiology

Bony Anatomy

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [69]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [69]. The acetabulum consists of an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [69]. Inferiorly, the acetabulum is incomplete, forming a notch through which vital blood vessels and nerves pass to supply the joint [69]. This inferior surface contains the acetabular (cotyloid) notch, which is bound by the transverse acetabular ligament [75]. The posterosuperior articular surface of the acetabulum is thickened to accommodate weight bearing [75].

The femoral head forms two-thirds of a sphere, with a small depression at its center from which the ligamentum teres extends to connect to the acetabular notch [69]. The neck-shaft angle of the femur averages 125° [69], with a mean adult value of 130° ± 7° [79]. This angle averages 127 degrees, beginning at 141 degrees in the fetus [75]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [69]. The mean anteversion of the femoral neck is 10° ± 7° [79], while the femoral neck is normally anteverted approximately 14 degrees in relation to femoral condyles, with a range of 1–40 degrees [75]. The acetabulum is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally [75].

The proximal femur contains two prime trabecular groups: the principal tensile group and the principal compressive group [79]. Secondary compressive and tensile trabecular groups also exist in the proximal femur [79]. The weakest area in the femoral neck is located in the Ward triangle [79]. The calcar femorale is a medial area of dense trabecular bone that transfers stress from the femoral shaft to the inferior portion of the femoral neck [79].

Soft Tissue Anatomy

The acetabular labrum is a fibrocartilaginous ring that extends the articulating surface area and increases femoral head coverage [69]. Triangular in cross section, the labrum contributes to its ability to create a pressurized seal of the central compartment of the hip during loading [69]. Only the external one-third of the labrum contains blood vessels, leaving the majority of the structure avascular and limiting its healing ability following injury [69]. The labrum is highly innervated, with the presence of both mechanoreceptors and nociceptors [69]. The labrum is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as the continuation of the labrum [69].

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [69]. The capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [69]. The hip capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [70]. Inferiorly, the hip capsule is attached to the acetabular labrum [70]. The capsule is attached to the femur anteriorly along the intertrochanteric crest [70]. On the posterior side, the capsule attaches only partially, such that the basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [70].

Three main ligaments support the hip: Iliofemoral ligament: Y-shaped and the thickest and strongest of the three main ligaments, it functions to limit external rotation, while its lateral arm limits extension of the joint [69]. It becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [70]. The iliofemoral ligament may become very contracted in severe hip arthritis and may require release at surgery to relieve an internal and flexion contracture of the hip [70]. Ischiofemoral ligament: Extends from the ischial margin of the acetabulum to the greater trochanter of the femur and restricts internal rotation motion [69]. It reinforces the posterior capsule and provides a check to internal rotation of the hip [70]. Pubofemoral ligament: Extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [69]. It attaches to the inferior and medial part of the capsule and may cause a hip adduction contracture [70].

Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [69]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [70]. The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [70].

The sacrospinous and sacrotuberous ligaments create the boundaries of the greater and lesser sciatic foramina [70]. The sacrospinous ligament creates the upper border of the lesser sciatic foramen and the lower border of the greater sciatic foramen [70]. The sacrotuberous ligament creates the inferior border of the lesser sciatic foramen [70]. The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen [70]. The short external rotator muscles exit from the lesser sciatic foramen [70].

Vascular Anatomy

From birth to approximately 4 years of age, the major blood supply to the femoral head comes from the medial and lateral femoral circumflex arteries, with major contributions from the artery of the ligamentum teres [82]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries from the medial circumflex artery are the major blood supply to the femoral head [82]. In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [82].

The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament [82]. It passes anterior and medial to the hip capsule [82]. The common femoral vessels are the most commonly reported extrapelvic vascular structures that are injured during total hip arthroplasty [82]. The most common mechanism of injury to the common femoral vessels during total hip arthroplasty is errant retractor placement anterior to the acetabulum [82]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [82]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [82]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery [82].

The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [82]. Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [82]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery and exit the pelvis between the piriformis and coccygeus muscles [82]. The inferior gluteal vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [82].

The medial femoral circumflex artery is the main blood supply to the femoral head and terminates in the posterior aspect of the extracapsular arterial ring [79]. The lateral femoral circumflex artery gives rise to the anterior aspect of the extracapsular arterial ring [79]. The superior and inferior gluteal arteries contribute branches to the extracapsular arterial ring [79]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into lateral, medial, posterior, and anterior groups based on their anatomic relationship to the femoral neck [79]. The lateral group of ascending branches is the main blood supply to the femoral head [79]. The ascending branches give off multiple perforator vessels to the femoral neck and terminate in the subsynovial arterial ring located at the margin of the articular surface of the femoral head [79]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the femoral head from this system [79]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [79]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [79].

Muscular Anatomy

The average range of motion of a normal hip is approximately 120° of flexion, 30° of extension, 45° of abduction, 20° to 30° of adduction, 35° of internal rotation, and 45° of external rotation [77]. Normal gait function requires hip flexion of 30°, hyperextension of 10°, abduction and adduction of 5°, and internal and external rotation of 5° [77].

Primary hip flexors: The iliopsoas, rectus femoris, and sartorius muscles [77]. The iliopsoas muscle has a large origin along the iliac crest, iliac fossa, sacra ala, iliolumbar ligaments, and sacroiliac ligaments [77]. The rectus femoris crosses the hip joint and the knee joint, with the straight head originating from the AIIS and the reflected head originating from the supra-acetabular tubercle [77]. The sartorius muscle originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and the pes anserine complex [77]. The tensor fasciae latae muscle originates laterally on the anterolateral edge of the iliac crest and acts to flex, abduct, and rotate the hip [77].

Hip extensors: The gluteus maximus and hamstring muscles are the most important hip joint extensors [77]. The gluteus maximus originates from the sacrum, coccyx, and sacrotuberous ligaments [77]. Excessive internal rotation of the hip for prolonged periods during hip surgery can cause injury to the sciatic nerve underneath the gluteus maximus tendon, resulting in sciatic nerve palsy [77]. The hamstring muscles originate on the ischial tuberosity [77].

Hip abductors: The gluteus medius and minimus muscles are the predominant abductors [77]. The gluteus medius has three different components: anterior, middle, and posterior [77]. The gluteus medius and minimus muscles function together to maintain and abduct the femur during the stance phase of gait [77]. A Trendelenburg lurch is an attempt by the body to compensate for abductor weakness by bringing the center of gravity closer to the hip center [77]. Damage and/or weakness to the abductor muscles can occur during surgical approaches to the hip, affecting hip stability and potentially necessitating the use of constrained hip implants [77].

Hip adductors: The adductor muscles of the hip include the adductor brevis, adductor longus, adductors magnus, pectineus, and gracilis [77].

External rotators: The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [77]. The piriformis forms the reference structure for the posterior part of the hip [77]. The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [77]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris exit the pelvis below the piriformis [77]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [77]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [77].

Internal rotators: The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [77].

Pathophysiology

Femoroacetabular impingement (FAI) is recognized as a common cause of hip dysfunction and secondary osteoarthritis [46]. In FAI, distinct structural abnormalities produce repetitive impingement between the acetabulum and the femoral head-neck junction [46]. Three types of FAI are recognized: Cam impingement: Involves femoral-based abnormalities such as aspherical femoral head and reduced head-neck offset, resulting in repetitive abutment of the acetabular rim and femoral head-neck junction [46]. Pincer impingement: Involves acetabular-based disorders such as acetabular retroversion, global overcoverage, and acetabular protrusio, creating abnormal abutment of the acetabular rim and femoral head-neck junction [46]. Combined cam/pincer: A combination of the above structural abnormalities [46].

Impingement abnormalities can cause labral tears, degeneration, or ossification [46]. Impingement abnormalities can cause acetabular cartilage delamination [46]. Impingement abnormalities can cause secondary osteoarthritis [46].

Developmental dysplasia of the hip (DDH) is a gradually progressive disorder associated with distinct anatomic changes, many of which are initially reversible [74]. DDH is a malformation of anatomic structures that have developed normally during the embryologic period [74]. Relatively gentle forces, persistently applied, are probably the cause of deformations in DDH [74]. In unstable hips at birth, the posterosuperior rim of the acetabulum loses its sharp margin and becomes flattened and thickened in the area over which the femoral head slides [74]. A ridge of thickened articular cartilage called the neolimbus arises along the posterosuperior acetabular wall as the femoral head rides in and out of the socket [74]. In hips that remain dislocated, secondary barriers to reduction develop, including thickening of the pulvinar, elongation and thickening of the ligamentum teres, and hypertrophy of the transverse acetabular ligament [74]. The inferior capsule of the hip assumes an hourglass shape in dislocated hips, eventually presenting an opening smaller in diameter than the femoral head [74]. The iliopsoas tendon is pulled tight across the capsular isthmus in dislocated hips, contributing to narrowing and acting as a barrier to closed reduction [74]. The capsule narrows through a "Chinese finger-trap" mechanism in dislocated hips [74]. Femoral changes in DDH include an increase in anteversion and some flattening of the femoral head as it lies against the ilium [74].

Excessive pressure on the cartilaginous upper femur can cause a loss of vascular perfusion, resulting in necrosis of chondrocytes [72]. Various portions of the femoral head and growth plate can be injured by excessive pressure, with resulting patterns of deformity corresponding with the areas of injury [72]. The greater trochanteric area is usually unaffected by excessive pressure on the cartilaginous upper femur and continues to grow normally, gradually becoming more proximal than the femoral head [72]. Muscle imbalance can significantly affect the growth and morphology of the upper femur [72]. Excessive adductor pull or inadequate abductor muscle function results in a valgus deformity of the upper femur [72].

At birth, the neonatal acetabulum is completely composed of cartilage, with a thin rim of fibrocartilage called the labrum [72]. The hyaline cartilage of the acetabulum is continuous with the triradiate cartilages, which divide and interconnect the three osseous components of the pelvis [72]. The surface of the acetabular cartilage abutting the bone of the pelvis is made up of epiphyseal cartilage in the shape of a hemisphere and functions as a major growth plate [72].

Classification

Instability: Instability has come to account for more than half of re-revisions in contemporary revision total hip arthroplasty [3].

Bearing Surface and Head Diameter: In head diameter, bearing type, and surgical approach, clear trends were visible, indicating that characteristics of total hip arthroplasty in young patients were subject to changing perspectives [22]. Adverse reactions to metal debris occur with all types of hip replacement not just metal-on-metal hips [36]. Over 1 million metal-on-metal hip prostheses were implanted worldwide with enormous excess failure [33]. All large-diameter head metal-on-metal total hip arthroplasties should be followed up in strict protocols based on recommendations by national bodies [21]. Although greater than 95% of hips performed well at 5-12 years, results for metal-on-metal bearings were inferior compared to metal-on-polyethylene bearings using the same acetabular component [23]. Revision risk was significantly higher with standard polyethylene liners compared to metal-on-highly-cross-linked polyethylene [55]. Excellent clinical and radiological outcomes were obtained for both metal-on-highly cross-linked polyethylene and ceramic on ceramic bearings in cementless total hip arthroplasty [61].

Acetabular Liner Design: The use of lipped polyethylene liners is associated with a lower midterm risk of revision for all causes and for dislocation [60]. The use of lipped polyethylene liners does not compromise the associated risk for revision for aseptic loosening [60].

Fixation Method: Solid shells performed significantly better in younger patients compared to other fixation methods [55]. Cementless hip replacements had worse survival than cemented and hybrid hip replacements in octogenarians [27]. Ten years postoperatively, 6.1% of cementless total hip arthroplasties were revised compared with 2.6% and 1.9% of cemented and hybrid total hip arthroplasties in octogenarians [27]. Cementless hip replacements were especially associated with a high risk of early failure with a hazard ratio of 2.9 compared with cemented hip replacements [27]. Cementless femoral stems had a 1.7-fold risk of early revision compared with their cemented counterparts [27]. Cementless acetabular cups had a 1.4-fold risk of early revision compared with their cemented counterparts [27]. Reverse hybrid total hip arthroplasty confirms successful outcomes irrespective of age, gender, head size and surgeon grade [29]. The authors do not recommend the use of a non-porous-coated acetabular component inserted without cement in primary total hip arthroplasty [6].

Other Considerations: Thirty years postoperatively, 29% of hips undergoing periacetabular osteotomy for hip dysplasia can be preserved [16]. More than 70% of hips undergoing periacetabular osteotomy for hip dysplasia will develop progressive osteoarthritis, pain, and/or undergo total hip arthroplasty within 30 years [16]. There is a stark increase in progression to total hip arthroplasty within 10 years of periacetabular osteotomy for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis [20].

Clinical Presentation

Instability is the dominant mode of failure in this population, accounting for more than half of re-revisions following revision total hip arthroplasty [3]. When evaluating patients with a history of acetabular fracture, clinicians must recognize that these individuals present with markedly inferior 10-year survivorship and a higher frequency of serious complications compared to patients undergoing total hip arthroplasty for primary osteoarthritis or avascular necrosis [24].

Age and fixation method significantly alter the risk profile for early failure. In octogenarians, cementless hip replacements are associated with a high risk of early failure, demonstrating a hazard ratio of 2.9 compared with cemented hip replacements [27]. This elevated risk is driven by specific component types: cementless femoral stems carry a 1.7-fold risk of early revision compared with their cemented counterparts [27], while cementless acetabular cups present a 1.4-fold risk of early revision relative to cemented cups in the same age group [27].

Investigations

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip [45]. A complete hip series usually consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [45]. The Dunn 45° view may be more accurate for determining the alpha angle measurement than CT or MRI [45]. For a neutral pelvic tilt on an AP pelvis radiograph, the sacrococcygeal joint should be between 3 and 5 cm above the superior border of the symphysis pubis [45].

Radiographic Parameters and Classification: Osteoarthritis of the hip can be categorized using the Kellgren-Lawrence or Tönnis classifications [45]. The Kellgren-Lawrence classification is a 4-point grading system classified into doubtful, mild, moderate, and severe [45]. The Tönnis classification is a 3-point grading system categorized into mild, moderate, and severe [45]. The femoral head extrusion index is defined by the length of the femoral head that lies beyond the acetabulum as a percentage of the total horizontal width of the femoral head [45]. Femoral head extrusion index values greater than 25% are considered abnormal [45]. The Tönnis angle is defined by the angle of the acetabular sourcil and a line parallel to the transverse pelvis axis [45]. Tönnis angles between 0° and 10° are considered normal [45]. The lateral center-edge angle of Wiberg is the angle between a line from the center of the femoral head perpendicular to the transverse pelvis axis and a second line from the center of the femoral head to the superolateral most point of the acetabulum [45]. Center-edge angles of 20°–40° are considered normal, while angles from 20° to 25° are considered borderline [45]. The "crossover" sign on AP pelvis radiographs indicates acetabular retroversion related to lateralization of the anterior acetabular wall relative to the posterior acetabular wall [45].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology due to its superior sensitivity and specificity [86]. Magnetic resonance arthrography (MRA) is more appropriate than conventional MRI for determining injuries to labrochondral structures, the ligamentum teres, and identifying loose bodies and synovial chondromatosis [86]. However, the utility of MRA in the accurate detection and staging of articular cartilage lesions is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [86]. Recent advances in MRI imaging techniques, such as delayed gadolinium-enhanced MR imaging and T2* mapping, allow for a more in-depth analysis of the structure of articular cartilage [86]. These techniques were effective at detecting early changes to the articular cartilage surfaces of patients with hip dysplasia and femoroacetabular impingement [86]. Noncontrast MRI at 3T is generally adequate for diagnosing intra-articular pathology [89]. If 3T imaging is unavailable, MRA can be considered at 1.5T for increased diagnostic accuracy [89]. MRI is helpful in assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [89]. Major MRI findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [89]. MRI or magnetic resonance arthrography provides information regarding the integrity of the acetabular labrum and articular cartilage [46]. The sensitivity of MRI to acetabular rim chondral lesions is limited [46].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for surgical planning [86]. Low-dose CT with three-dimensional reformats is particularly useful in surgical planning of complex or borderline deformities [46]. CT arthrography can evaluate chondrolabral abnormalities in patients with contraindications to MRI [71].

Ultrasonography: Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [71]. It can be used to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions such as bursitis [86]. Ultrasonography cannot image inside bone because bone cortex reflects almost all sound waves [90].

Clinical Examination: A thorough history is essential to differentiating between common causes of hip pain [44]. Clinical examination tests and imaging findings should be used to confirm a suspected clinical diagnosis [44]. Patients with symptomatic femoroacetabular impingement (FAI) frequently present with activity-related groin pain that is exacerbated by hip flexion activities [46]. Patients with FAI will exhibit restricted hip internal rotation in 90° of flexion [46]. The impingement test (flexion, adduction, internal rotation) will elicit pain in patients with FAI, but the test is not specific for FAI [46].

Treatment

Non-Operative

The provided evidence base does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions for revision hip replacement.

Operative

Indications: Surgical planning must account for patient-specific risk factors that influence outcomes. Patients with a prior acetabular fracture demonstrate markedly inferior 10-year survivorship and more frequent serious complications compared with those undergoing THA for primary osteoarthritis or AVN [24]. Additionally, lumbar spinal surgery prior to THA is associated with less reduction of pain, worse health-related quality of life, and less satisfaction one year after the procedure [131].

Surgical Approach / Technique: The choice of surgical approach should be based on the indication for revision, the particular implant to be removed, the presence of acetabular or femoral bone loss, previous surgical approaches used, and the preferences and training of the surgeon [28]. For proximal femoral replacement with a structural allograft, careful planning is necessary, including detailed templating, procurement of a suitable allograft, determination of the availability of an appropriate implant and familiarity with its use, and ensuring that a wide range of equipment is readily available [113]. Ideally, cement should be used for fixation of the implant to the allograft but not for fixation of the graft to the host [113]. A stable graft-host junction should be achieved either through press-fit fixation of the composite to the remaining femur or through step-cut or oblique preparation of the allograft-host junction [113]. Preservation of the bivalved proximal part of the host femur as a vascularized autogenous graft wrapped around the allograft and the graft-host junction is suggested [113]. The trochanteric slide is probably a better approach than a transtrochanteric approach for proximal femoral replacement as it decreases the risk of trochanteric escape [113]. A transverse osteotomy may be indicated when more than six centimeters of lengthening is needed, in which cases the tension in the sciatic nerve must be carefully observed both during and at the end of the procedure [113].

Implant Selection: Femoral component selection offers multiple viable techniques. The results support the continued use of femoral impaction grafting in revision total hip arthroplasty [10]. In a series of Exeter V40 cemented femoral components, no stem was revised for aseptic loosening at a minimum 10-year follow-up [19]. A cementless hydroxyapatite proximally-coated modular femoral stem has shown excellent long-term survivorship and good clinical outcome [34]. The use of a proximal femoral allograft for the treatment of a Vancouver type-B3 periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years [109]. Indications for cement-in-cement revision of the femoral stem include allowing improved access to the acetabular component, revision for dislocation/instability, leg length discrepancy, selected periprosthetic fractures, conversion of a well cemented hemi-arthroplasty to a total hip arthroplasty, revision of a cemented monoblock stem, exchange of a modular stem with a damaged trunnion, fracture of a cemented stem, and in some patients with an infection [42]. Cement-in-cement revision may reduce intraoperative complications and is less time consuming than traditional revision techniques [42].

For acetabular components, cementing a polyethylene liner into an acetabular cup with a deficient locking mechanism remains a valuable option in revision THA for appropriately selected patients, such as older, less active individuals with a well-positioned shell and limited osteolysis [14]. Cementation of a highly cross-linked PE liner into a well-fixed metal shell could provide good midterm durability and be an acceptable alternative during acetabular revision surgery [54]. Cemented liner exchange surgery can halt the progression of osteolysis and bone grafting has the potential to restore bone [108].

Fixation Method Considerations: In octogenarians, cementless hip replacements had worse survival than cemented and hybrid hip replacements, with 6.1% of cementless THAs revised at 10 years compared with 2.6% and 1.9% of cemented and hybrid THAs [27]. Cementless hip replacements were especially associated with a high risk of early failure (HR, 2.9; 95% CI, 1.7-5.1; p < 0.001) compared with cemented hip replacements in this age group [27]. Specifically, cementless femoral stems had a 1.7-fold risk (95% CI, 1.3-2.2; p < 0.001) of early revision compared with their cemented counterparts [27], and cementless acetabular cups had a 1.4-fold risk (95% CI, 1.1-1.8; p = 0.007) of early revision compared with their cemented counterparts [27]. Revision risk was significantly higher with standard polyethylene liners compared to metal-on-highly-cross-linked polyethylene, and solid shells performed significantly better in younger patients [55].

Alignment / Balancing Strategy: Biomechanical data suggest that a threshold of acceptable anteversion during revision total hip arthroplasty is less than 20 degrees, as fixation strength significantly decreases at 20 degrees and higher [53].

Other Considerations: As implant fixation has improved, aseptic loosening has become much less common after revision THA, and instability has come to account for more than half of re-revisions [3]. All large-diameter head metal-on-metal THAs should thus be followed up in strict protocols based on recommendations by national bodies [21]. MoMHRs revised for ARMD have approximately half the risk of rerevision compared with non-ARMD revisions [63].

Regarding infection and mortality, revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery [7]. Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision [18].

Alternative procedures and adjunctive considerations include the following. Thirty years postoperatively, 29% of hips undergoing PAO for hip dysplasia can be preserved, but more than 70% will develop progressive osteoarthritis, pain, and/or undergo THA [16]. There is a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis [20]. When experienced surgeons use refined and proper surgical technique, women show promise as excellent candidates for hip resurfacing as an alternative treatment for their debilitating hip conditions [13]. After improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time [51].

Complications

Infection (PJI): Revision for prosthetic joint infection (PJI) within one year of primary total hip arthroplasty (THA) carries an increased mortality risk during the first year post-revision [7]. Patients revised for periprosthetic infection exhibit higher mortality rates than the general population and those undergoing primary THA or aseptic revision [18], with PJI associated with significantly higher mortality risk than major aseptic revisions [104]. A history of septic arthritis prior to THA confers a ten-fold increased risk of PJI compared with osteoarthritis, resulting in a ten-year cumulative incidence of 7% [135]. The use of antibiotic-loaded bone cement is associated with lower rates of revision due to PJI [134]. Conversely, trabecular metal acetabular components used for PJI revisions do not reduce the subsequent risk of all-cause rerevision or rerevision for infection compared with non-trabecular metal implants from the same manufacturer [132]. Patients who underwent THA after bariatric surgery experienced fewer deep infections in the short term than matched controls who did not undergo bariatric surgery [59].

Instability: Dislocation remains a primary driver of rerevision following isolated liner exchange for wear, accounting for 48.4% of cases [98]. Nonhooded liners are associated with a higher revision rate for dislocation at all times up to 15 years compared to hooded liners (HR, 1.31; 95% CI, 1.17–1.47; p < 0.001) [99]. The use of lipped polyethylene liners is associated with a lower midterm risk of revision for all causes and for dislocation, without compromising the associated risk for revision for aseptic loosening [60]. Increasing body mass index (BMI) is associated with an increasing risk of early dislocation, with effects becoming progressively more pronounced for higher BMIs [100].

Aseptic Loosening: As implant fixation has improved, aseptic loosening has become much less common after revision THA [3]. In octogenarians, cementless hip replacements demonstrate worse survival than cemented and hybrid designs, with a 10-year revision rate of 6.1% for cementless THAs compared with 2.6% for cemented and 1.9% for hybrid THAs [27]. Cementless femoral stems in this age group carry a 1.7-fold risk of early revision compared with cemented stems (95% CI, 1.3-2.2; p < 0.001) [27], while cementless acetabular cups carry a 1.4-fold risk compared with cemented cups (95% CI, 1.1-1.8; p = 0.007) [27]. The use of low-viscosity cement is associated with an increased rate of revision due to aseptic loosening of femoral components compared with high-viscosity cement [115]. Long-term data indicate that the Exeter Contemporary flanged cemented acetabular component achieved 100% survivorship at 12.5 years [57], and no femoral stem was revised for aseptic loosening in a series of Exeter V40 cemented femoral components at a minimum 10-year follow-up [19]. Acetabular impaction grafting without cage reinforcement showed 85.9% survival at 13.5 years [106]. Metal-on-metal (MoM) THA with a 28-mm head showed a relatively low rate of aseptic implant loosening at a mean follow-up of 20 years [118].

Other Considerations: Five-year revision rates were significantly increased for all primary metal-on-metal total hip arthroplasties undertaken from 2007 onwards [4]. Revisions of failed MoM THA present significant surgical challenges, especially in cases with soft tissue damage and pseudotumor [62]. However, MoM hip revisions performed for adverse reactions to metal debris (ARMD) have approximately half the risk of rerevision compared with non-ARMD revisions [63]. Close surveillance of MoM THA patients is recommended given higher failure and complication rates [38], and all large-diameter head MoM THAs should be followed up in strict protocols based on national body recommendations [21]. Despite survival substantially greater than that of large-head MoM THAs, there has been a marked decrease in the use of small-head MoM designs in the registry [26].

Increasing BMI is associated with increasing risk of reoperation, implant revision or removal, and infection [100]. The use of cross-linked polyethylene for THA markedly reduces revision surgery at 16 years [17], potentially reducing the "all-cause" revision rate by a conservative figure of 40% compared with conventional polyethylene [47]. Screw usage patterns in primary THA with modern cups and liners are associated with neither an advantage nor disadvantage regarding acetabular loosening revision risk [48]. The use of femoral stems with exchangeable necks in primary THA increases the rate of revision [56], whereas the use of unmatched components in THA has no adverse effect on outcomes [93].

Cement-in-cement revision of the femoral stem is less time consuming than traditional revision techniques and gives equivalent or better outcomes [42]. Cementation of a highly cross-linked polyethylene liner into a well-fixed metal shell could provide good midterm durability and be an acceptable alternative during acetabular revision surgery [54]. Femoral impaction bone grafting is supported by the largest series of revision total hip arthroplasties using this technique [10]. Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data [30]. Following liner exchange revision for wear, survivorship was 93.4% in the first year, with a steady decline to 75.3% at 10 years [98]. Of 612 isolated liner exchanges for wear recorded in the NZJR, 91 (14.9%) had undergone a rerevision [98].

Patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary osteoarthritis or avascular necrosis [24]. In head diameter, bearing type, and surgical approach, clear trends were visible indicating that characteristics of THA in young patients were subject to changing perspectives [22]. The majority of complications in patients with developmental dysplasia of the hip undergoing THA with cement were related to wear of the polyethylene liner [133].

Recovery

Other Considerations: The provided evidence base does not contain specific data regarding recovery timelines, rehabilitation protocols, or functional milestones (e.g., weeks for light activity, months for full activity, or outcome plateau durations). Consequently, the standard recovery phase labels are omitted to avoid misrepresenting follow-up intervals as recovery periods. The available data pertains to long-term survivorship and registry trends. Although greater than 95% of hips performed well at 5-12 years, results were inferior compared to metal-on-polyethylene bearings using the same acetabular component [23]. Despite survival that is substantially greater than that of large-head MoM THAs, there has been a marked decrease in the use of small-head MoM designs in our registry [26]. This study highlights the consequences of widespread and poorly monitored adoption of a medical technology, noting that over 1 million metal-on-metal hip prostheses were implanted worldwide with enormous excess failure [33]. As revision of MOM THA becomes more common, it will be important to continue monitoring postrevision outcomes and providing treatment strategies to mitigate complications for these patients [15]. This evidence suggests that the longevity of THA is likely to be improved, which may enable younger patients to undergo surgery, confident of a reduced need for revision in the long term [17]. The investigation demonstrates a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis [20].

Key Evidence

• [L4] At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. [1] (10.2106/jbjs.20.01235)
• [L4] Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. [2] (10.1302/0301-620x.99b2.bjj-2016-0076.r1)
• [L3] As implant fixation has improved, aseptic loosening has become much less common after revision THA, and instability has come to account for more than half of re-revisions. [3] (10.1016/j.arth.2019.01.031)
• [L2] The five-year revision rates were significantly increased for all primary metal-on-metal total hip arthroplasties undertaken from 2007 onwards. [4] (10.1302/0301-620x.100b1.bjj-2017-0625.r2)
• [L4] Revision total hip arthroplasty with retention of the acetabular component is associated with good outcomes in hips with an appropriately positioned, well-fixed acetabular component. [5] (10.2106/jbjs.l.01177)
• [L4] The authors do not recommend the use of this component inserted without cement in primary total hip arthroplasty. [6] (10.2106/00004623-199610000-00005)
• [L3] Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. [7] (10.1007/s11999-017-5289-6)
• [L3] Revision of a primary hip resurfacing arthroplasty is associated with a high risk of rerevision. [8] (10.1007/s11999-015-4215-z)
• [L4] Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years. [9] (10.1007/s11999-008-0566-z)
• [L4] This is the largest series of revision total hip arthroplasties with femoral impaction grafting, and the results support the continued use of this technique. [10] (10.1302/0301-620x.98b12.37414)
• [L3] The risk of revision in patients younger than 55 years depends on surgical approach, head size and bearing type. [11] (10.1186/s12891-019-2765-z)
• [L3] When experienced surgeons use refined and proper surgical technique, women show promise as excellent candidates for hip resurfacing as an alternative treatment for their debilitating hip conditions. [13] (10.1016/j.arth.2017.06.003)
• [L4] This technique remains a valuable option in revision THA for appropriately selected patients, such as older, less active individuals with a well-positioned shell and limited osteolysis. [14] (10.1097/corr.0000000000003996)
• [L4] As revision of MOM THA becomes more common, it will be important to continue monitoring postrevision outcomes and providing treatment strategies to mitigate complications for these patients. [15] (10.1007/s11999-013-3157-6)
• [L3] Thirty years postoperatively, 29% of hips undergoing PAO for hip dysplasia can be preserved, but more than 70% will develop progressive osteoarthritis, pain, and/or undergo THA. [16] (10.1007/s11999-016-5169-5)
• [L3] This evidence suggests that the longevity of THA is likely to be improved, which may enable younger patients to undergo surgery, confident of a reduced need for revision in the long term. [17] (10.2106/jbjs.17.01221)
• [L3] Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision. [18] (10.2106/jbjs.24.01629)
• [L4] No stem was revised for aseptic loosening in this series. [19] (10.1302/0301-620x.100b8.bjj-2017-1535.r1)
• [L4] The investigation demonstrates a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis. [20] (10.2106/jbjs.18.00983)
• [L3] All large-diameter head metal-on-metal THAs should thus be followed up in strict protocols based on recommendations by national bodies. [21] (10.1007/s11999.0000000000000159)
• [L3] In head diameter, bearing type, and surgical approach, clear trends were visible, indicating that characteristics of THA in young patients were subject to changing perspectives. [22] (10.1016/j.arth.2018.08.020)
• [L3] Although greater than 95% of hips performed well at 5-12 years, results were inferior compared to metal-on-polyethylene bearings using the same acetabular component. [23] (10.1016/j.arth.2016.01.058)
• [L3] Patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary osteoarthritis or AVN. [24] (10.1007/s11999-015-4509-1)
• [L3] Despite survival that is substantially greater than that of large-head MoM THAs, there has been a marked decrease in the use of small-head MoM designs in our registry. [26] (10.1007/s11999.0000000000000209)
• [L2] [27] (10.1007/s11999-014-3641-7)
• [L5] The choice of approach should be based on the indication for revision, the particular implant to be removed, the presence of acetabular or femoral bone loss, previous surgical approaches used, and the preferences and training of the surgeon. [28] (10.5435/00124635-199803000-00002)
• [L3] This is the largest reported study into reverse hybrid THA and it confirms successful outcomes, irrespective of age, gender, head size and surgeon grade. [29] (10.1302/0301-620x.100b8.bjj-2017-1297.r1)
• [L3] Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data. [30] (10.1016/j.arth.2019.03.061)
• [L3] This study highlights the consequences of widespread and poorly monitored adoption of a medical technology, noting that over 1 million metal-on-metal hip prostheses were implanted worldwide with enormous excess failure. [33] (10.2106/jbjs.17.00039)
• [L3] We have shown excellent long-term survivorship and good clinical outcome of a cementless hydroxyapatite proximally-coated modular femoral stem in revision hip surgery. [34] (10.1302/0301-620x.96b6.33381)
• [L3] [36] (10.1186/s12891-016-1329-8)
• [L2] Close surveillance of MoM THA patients is recommended considering the higher failure and complication rates reported in this cohort. [38] (10.1016/j.arth.2018.01.019)
• [L3] [42] (10.1302/0301-620x.99b4.bjj-2016-1222.r1)
• [L4] [47] (10.1016/j.arth.2019.02.038)
• [L3] In this study of survivorship following routine uncomplicated primary THA with modern cups and liners, screw usage patterns were associated with neither an advantage nor disadvantage; neither screw usage nor avoidance was associated with differences in acetabular loosening revision risk. [48] (10.1016/j.arth.2024.10.019)
• [L3] However, after improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time. [51] (10.1302/0301-620x.101b9.bjj-2018-1208.r1)
• [L2] We would recommend that the choice of prosthesis should be determined by the rate of revision, local costs and the preferences of the surgeon and patient. [52] (10.1302/0301-620x.97b4.34242)
• [L5] Biomechanical data suggest that a threshold of acceptable anteversion during revision total hip arthroplasty is less than 20 degrees, as fixation strength significantly decreases at 20 degrees and higher. [53] (10.1016/j.arth.2016.05.053)
• [L4] Cementation of a highly cross-linked PE liner into a well-fixed metal shell could provide good midterm durability and be an acceptable alternative during acetabular revision surgery. [54] (10.1016/j.arth.2013.07.042)
• [L3] Revision risk was significantly higher with standard polyethylene liners compared to metal-on-highly-cross-linked polyethylene, and solid shells performed significantly better in younger patients. [55] (10.1016/j.arth.2012.11.021)
• [L3] There appears to be little evidence to support the continued use of prostheses with an exchangeable neck in primary THA undertaken for OA. [56] (10.1302/0301-620x.99b6.38020)
• [L3] Kaplan–Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 12.5 years and for all causes was 97.8%. [57] (10.1302/0301-620x.98b3.35901)
• [L3] Patients who underwent THA after bariatric surgery had fewer re-operations, revisions, and deep infections in the short-term than a matched group of patients who did not undergo bariatric surgery. [59] (10.1302/0301-620x.98b9.37943)
• [L3] The use of lipped PE liners is associated with a lower midterm risk of revision for all causes and for dislocation, without compromising the associated risk for revision for aseptic loosening. [60] (10.1097/corr.0000000000001039)
• [L3] Excellent clinical and radiological outcomes were obtained for both types of bearings. [61] (10.1016/j.otsr.2018.04.016)
• [L4] Revisions of failed MoM THA showed improvements in clinical outcomes, but present significant surgical challenges and complications especially in cases with soft tissue damage and pseudotumor. [62] (10.1016/j.arth.2019.04.019)
• [L3] Contrary to previous observations, MoMHRs revised for ARMD have approximately half the risk of rerevision compared with non-ARMD revisions. [63] (10.1007/s11999.0000000000000029)
• [L3] Data from the NZJR confirm that the use of unmatched components in THA has no adverse effect on outcomes. [93] (10.1016/j.arth.2017.09.047)
• [L3] [98] (10.1016/j.arth.2017.05.055)
• [L3] [99] (10.1097/corr.0000000000000710)
• [L3] Increasing BMI was associated with increasing risk of reoperation, implant revision or removal, infection, and early dislocation, with effects becoming progressively more pronounced for higher BMIs. [100] (10.2106/jbjs.o.00430)
• [L2] A PJI following THA is associated with a significantly higher mortality risk than major aseptic revisions. [104] (10.1016/j.arth.2025.06.011)
• [L3] Kaplan–Meier survival with revision for aseptic loosening as the endpoint was 85.9% at 13.5 years. [106] (10.1302/0301-620x.96b2.32121)
• [L4] [108] (10.1016/j.arth.2013.08.014)
• [L4] [109] (10.2106/jbjs.f.01047)
• [L5] [113] (10.2106/00004623-199903000-00017)
• [L3] This prospective clinical study demonstrated an increased rate of revision due to aseptic loosening of femoral components implanted with low-viscosity cement compared with high-viscosity cement. [115] (10.2106/00004623-199510000-00009)
• [L3] MoM THA with a 28-mm head showed a relatively low rate of aseptic implant loosening at a mean follow-up of 20 years. [118] (10.1016/j.arth.2018.02.089)
• [L3] Lumbar spinal surgery prior to THA is associated with less reduction of pain, worse health-related quality of life, and less satisfaction one year after THA. [131] (10.1302/0301-620x.99b6.bjj-2016-0577.r2)
• [L3] We found no evidence to support the notion that TM acetabular components used for PJI revisions reduced the subsequent risk of all-cause rerevision or the risk of rerevision for infection compared with non-TM implants from the same manufacturer. [132] (10.1097/corr.0000000000000570)
• [L4] The majority of the complications were related to wear of the polyethylene liner. [133] (10.2106/jbjs.d.02689)
• [L3] Within the limits of registry analysis, this study showed an association between the use of antibiotic-loaded bone cement and lower rates of revision due to PJI. [134] (10.1302/0301-620x.102b8.bjj-2020-0120.r1)
• [L3] There was a ten-fold increased risk of periprosthetic joint infection in patients with a history of septic arthritis who underwent THA compared with those who underwent THA for OA with a ten-year cumulative incidence of 7%. [135] (10.1302/0301-620x.104b2.bjj-2021-1209.r1)

See Also

• Hip resurfacing
• Femoroacetabular impingement
• Periacetabular osteotomy

References

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