Painful hip replacement: Revision

Reasons | Examination | Surgery | Follow-up | Consultation

The problems of a painful hip replacement can occur shortly after the surgery or at a later time. For most patients, the pain is foremost. This can occur at rest, bearing loads or when moving. The pain can occur suddenly or become stronger with time. The type of pain can also vary: burning, wrenching, stabbing, electrifying or aching.

A revision of the hip joint means that, depending on the cause and pain, a renewed surgical procedure must be performed on the artificial hip joint. For example, to remove scar tissue, to reattach a piece of bone or tendon or to remove or replace a part of or the entire artificial joint.

WHAT ARE THE REASONS FOR A PAINFUL HIP REPLACEMENT?

The causes of a painful hip replacement are highly varied and can be caused by the surgery the replacement hip or the patient themself: Falls, infections, loosening of the replacement hip, overloading or excessive expectations. For example, a fall may break the bone in the upper thigh or pelvis where the artificial hip joint is fixed. This can also loosen the artificial hip joint. Further causes of loosening of the hip joint (shaft and/or socket) can include an infection, an increase of the osteoporosis or severe abrasion (metal or plastic) with ingrowth of scar tissue or an allergy. Patients report a dull, stress- and movement-dependent ache in the event of a loosening, as well as an unstable gait. These worsen with time.

Further causes for the pain and problems around the hip joint include: impinged scar tissue, too much or too little tension in the hip musculature, suboptimal positioning of the hip socket or hip shaft, bursitis, inflamed tendons, torn muscle fibres, detachments of bone or of important stabilising tendon insertions of the hip musculature, formation of bone spurs, wearing of the plastic inlay of the socket, etc.

If the hip pain increases despite rest and does not improve over a certain time, it should be investigated carefully by a specialist.

HOW ARE THE CAUSES OF THE PAIN INVESTIGATED MORE CLOSELY?

If a patient presents with a painful hip replacement for investigation, detailed questioning and the examination are very important. The following questions should be clarified:

How: How can the pain be triggered? Is there a certain movement which triggers the pain? Is it present at rest or only during exertions?
When: How long has the pain been present? When was the artificial hip implanted? Is a prosthesis pass available? Are there known allergies to metal (nickel) or cement?
Where: Where can the pain be localised? On the side of the hip joint or inside?
What: What type of pain is it: burning, wrenching, aching, stabbing, pulsing or electrifying? What has provided relief so far?

The affected hip joint will be further examined with regard to reddening, overheating and swelling. The mobility of the hip joint will then be tested. Is the pain provoked by certain movements or does this lead to a tendon snapping? Are there painful pressure points? Testing the strength of the hip muscles and the gait follows.

Standard X-rays of the hip joint are then taken. If the cause has not been clarified by this point, further special examinations can be prescribed: SPECT-CT (a combination of scintigraphy and computed tomography for imaging the current bone activity anatomically), CT (illustration of the bone in slices), ultrasound and allergy clarifications.

HOW CAN THE PAINFUL REPLACEMENT HIP BE FIXED?

Different therapies are recommended depending on the cause. These begin with conservative measures such as physiotherapy and anti-inflammatory medications.

If these do not help or have already been exhausted, surgical treatment of the problem is recommended. Depending on the diagnosis, this can be a joint-preserving surgery, a partial replacement or complete exchange of the prosthesis in question.

• Removal of painful scars or exposed joint parts
• Fixation of detached tendons or broken off bones
• Rinsing of the joint and taking of tissue samples for a microbiological examination to exclude an infection

• Exchange of the femoral head either to increase or relieve the muscle tension
• Exchange of the socket inlay to restore a stable joint

In certain cases it is necessary to exchange the hip shaft and socket, or even the entire replacement hip. Depending on the problem, the same model of prosthesis may be selected. Alternately, a so-called revision prosthesis which is larger and longer can be used.

If the bone quality is too weak (advanced osteoporosis), the loss of bone too large or there are muscular weaknesses, the hip joint can be replaced with a double-mobility femoral head to stabilise the joint. For brittle bones and advanced osteoporosis, the hip components are cemented into the bones, allowing load-bearing sooner. However, if an allergy is determined (metal, cement), the new artificial hip can be replaced with a cement-free replacement hip as the hip shaft and socket are made of titanium and a ceramic-ceramic pairing can be used.

In the event of a chronic infection, the artificial hip must be removed and/or replaced with a cement spacer. Targeted antibiotic therapy follows, which can last for six to nine weeks depending on the pathogen. In such cases, we work together with an experienced infectious diseases specialist who determines the personalised antibiotic therapy. If the inflammatory values are back within the normal range two weeks after stopping the antibiotics and the hip joint is clinically normal, a new artificial hip can be implanted.

For revision procedures, the same minimally invasive methods are largely used as for the initial surgery. If this is not possible for individual reasons, conventional surgical methods are used. This means that the hip joint must be exposed from the side using a roughly 15 centimetre incision with splitting of the corresponding hip musculature. The type of operation and its procedure are explained in a prior discussion. As the exact proportions in the joint are only fully visible during the procedure, it may be that a deviation from the surgical procedure as discussed is required during the surgery.

WHAT HAPPENS IN FOLLOW-UP?

The follow-up for revisions can vary greatly and depends on what exactly needs to be done. If a new artificial hip must be implanted, the same requirements apply in principle as for the primary replacement hip, only the stay in the clinic and rehabilitation time are longer. This means using walking sticks for at least six weeks, with only partial loads and thrombosis prophylaxis.

Facts and figures

Operation

Surgery lasts between 1.5 and 4 hours, under general anaesthetic

Length of stay at the clinic

Hospitalisation in the clinic for around 7 days

After the treatment

12 weeks of physiotherapy

Back to work

Depending on the activity, 7 to 10 weeks

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