Revision Hip Replacement in Turkey

Revision hip replacement (also called revision hip arthroplasty) is surgery in which some or all components of an artificial hip are removed and replaced with new ones. It is considered when the artificial hip stops working properly. It may loosen, its parts may wear, it may become infected or dislocate repeatedly, or the bone around it may fracture. The aim of surgery is to relieve pain and improve function and quality of life. The reasons an artificial hip fails differ from one patient to another, so the decision starts with identifying the cause.

Sometimes only some components are changed. In other cases the whole artificial hip is replaced and the surrounding bone is supported with metal augments or a bone graft where bone has been lost. Some cases, such as infection, may need more than one stage of surgery. This operation is relatively more complex than the first hip replacement and needs careful planning, specialised implants and special instruments. Recovery is usually relatively slower. The decision and the plan are made after a clinical examination, imaging and laboratory tests.

This article covers revision hip replacement only. For the basics of the first operation and the types of artificial hips, you can read our article on hip replacement surgery in Turkey.

• Revision hip replacement means replacing some or all components of an artificial hip after it has stopped working properly.
• Its indications include loosening, wear, infection, recurrent dislocation and fracture around the artificial hip.
• It is relatively more complex than the first operation, the risk of complications is relatively higher, and pain does not disappear completely in every patient.
• The decision starts by identifying why the artificial hip failed, using examination, imaging and tests.
• The evidence on the effect of surgeon experience and hospital volume is mixed, and it is reasonable to ask the surgeon specifically about his or her experience in revision surgery.
• Imaging and tests are an essential part of the assessment, and you should ask the surgical team which records it needs before the assessment.

What is revision hip replacement, and how does it differ from the first operation?

In the first operation, the damaged hip joint is replaced with an artificial hip. In revision surgery, the patient already has an artificial hip that was implanted earlier. The surgeon has to remove the old components carefully, preserving as much healthy bone as possible, and then prepare the bone to receive the new implants.

Patient-oriented medical sources explain that this surgery is relatively longer and more complex than the first operation, and that it needs extensive planning and specialised implants and instruments. The bone or the tissues around the hip may be damaged so that standard implants are not suitable, and the surgeon then uses implants designed to make up for the deficiency. Lost bone may be rebuilt with metal augments, a bone graft, or custom-made implants.

This does not mean that every case needs the whole artificial hip to be changed. In some cases only certain components need to be replaced. The surgeon decides this after assessing the case.

When is revision hip replacement considered?

Medical sources list several main reasons. The surgical team determines the cause in your case after examination and imaging.

• Loosening or wear of the artificial hip: Components that were firmly fixed in the bone can lose their attachment over time, causing pain. The plastic liner between the ball and the socket can wear, and particles from it collect around the joint. The immune system responds to these particles and weakens the bone around the artificial hip, a process known as osteolysis. The plastic has improved considerably over the years, so this cause is relatively less frequent with modern implants.
• Infection: Bacteria can attach to the surface of the artificial hip and the tissue around it, whether during the hospital stay, after discharge, or years later. Antibiotics alone are usually not enough to clear bacteria from an artificial joint, so surgery is mostly needed.
• Recurrent dislocation: If the ball repeatedly comes out of its socket, the joint may be realigned or an implant designed to prevent dislocation may be used.
• Fracture around the artificial hip: This most often follows a fall and may need surgery. The decision depends on where the fracture is, whether the components are stable, and how much bone remains.
• Reaction to metals: Metals used in some implants can break down, and the particles can damage bone and tissue. This is more often linked with artificial hips in which both the ball and the socket are metal. Health authorities advise people with this type of hip to have regular follow-up and to contact their medical team if they develop new pain, reduced movement, or a popping or clicking sound from the joint.

Factors linked to needing revision hip replacement

It is reported that people who had their first operation at a younger age may outlive their artificial hip, so their risk of needing a revision operation because of loosening or wear is relatively higher. It is also reported that people who are younger and more active are relatively more likely to have wear-related problems, and that obesity, some chronic diseases such as diabetes, and some previous operations are linked to infection or failure of the artificial hip. These factors relate to the likelihood of needing revision surgery after the first operation.

Who decides that revision surgery is needed?

The surgeon recommends revision hip replacement after determining the cause of the problem through examination, imaging and tests. It is not decided before the assessment.

How is the patient assessed before revision hip replacement?

The surgeon decides after gathering information from the examination, imaging and tests. Patient-oriented medical sources mention the following:

• A general health assessment: This includes a general medical examination well before surgery, and an assessment by a specialist if there are chronic conditions such as heart disease.
• X-rays: To look for loosening of the artificial hip or a change in the position of its components.
• Additional imaging when needed: A bone scan, MRI or CT scan, to find out why the joint failed and to assess the bone.
• Blood tests: To look for signs of infection or a reaction to the metal of the artificial hip.
• Joint aspiration: Fluid is drawn from the joint with a needle and tested in the laboratory to check for infection.

In this surgery in particular, the team assesses the condition and fixation of the artificial hip and the condition of the bone and tissues around it. You are therefore advised to ask the team which records and images it needs. A later section covers what to ask.

How is the surgery done?

Medical sources describe the following general steps:

• The surgeon often follows the old incision and may extend it to remove the old components.
• The surgeon examines the tissues around the hip for infection or a reaction to metal, and assesses which components have worn, loosened or shifted.
• The old components are removed carefully to preserve as much bone as possible. If they were fixed with cement, removing it takes time and adds to the complexity of the operation.
• Occasionally the surgeon makes a controlled fracture in the thigh bone to remove a stem that is firmly fixed, then fixes the bone again after the new stem is in place.
• The bone in the pelvis and thigh is prepared for the new implants. Where there is significant bone loss, a bone graft or metal augments are added.
• The specialised implants are inserted, and several screws may be used to hold the new socket until the bone grows around it. The surgeon then tests the movement and stability of the joint.

Revision surgery for infection

Treatment of infection varies according to the type of bacteria and the duration and severity of the infection:

• Cleaning the joint and exchanging the ball and the plastic liner: Components that are firmly fixed in the bone stay in place, and the patient then receives intravenous antibiotics for a period decided by the team.
• Staged surgery: If the components must be removed, the operation is usually done in two stages. In the first, the components are removed and a spacer of antibiotic-loaded cement is placed. After the infection has cleared, a second stage removes the spacer and implants a new artificial hip. It is reported that removing the components increases the chance of clearing the infection but lengthens recovery.
• Replacement in a single operation: This may be suitable in some cases.

One review states that in chronic infection, single-stage surgery is usually favored when difficult-to-treat bacteria are less likely and the tissues and bone are intact with no previous revision operations, and two-stage surgery is favored when there are difficult-to-treat bacteria, poor bone or tissue, a sinus tract, or multiple previous revision operations. The surgeon decides which approach is more suitable for your case.

The evidence comparing the two approaches in outcomes is relatively mixed:

• Earlier meta-analyses considered reinfection rates similar between the two approaches, but they rely on observational studies. One of these reviews notes that differences in patient selection criteria within each study, surgeons’ preferences, and different hospital protocols for allocating patients to each approach may influence the pooled results.
• A more recent meta-analysis, which pooled data from hip, knee and shoulder joints and mostly included observational studies, found a relatively lower rate of reinfection and of complications with single-stage surgery, with no clearly significant difference in reoperation or death. Its authors point to the limited quality of the evidence and say the results need cautious interpretation.
• A randomized trial was carried out specifically in patients with infection of an artificial hip, so it applies to that condition and not to all reasons for revision hip replacement. It found no difference between the two approaches in the main measure of pain and function at the planned follow-up. A relative difference favoring single-stage surgery appeared at early follow-up but did not last, intraoperative events were relatively fewer with it, and possible markers of ongoing infection did not differ between the two approaches. The trial was conducted in referral centers with high volumes, and it was open-label, without blinding.

The bottom line is that the choice between the two approaches is an individual decision based on your case.

What does the evidence say about outcomes?

Revision is relatively more complex than the first operation

Patient-oriented medical sources state that revision hip replacement carries a relatively higher risk of complications than the first operation because it is longer and more complex, and that the risk of infection is slightly higher. A recent national joint registry study agrees, describing it in its introduction as technically more demanding and relatively more associated with complications than the first operation.

Long-term results

Most people who have revision hip replacement achieve satisfactory long-term results in terms of pain relief, stability and function. However, it is not always possible to remove pain completely or to restore full function, and some patients keep some pain or impairment. For this reason, the procedure is not presented as making the joint like new.

Surgeon experience and hospital volume

A recent study analyzed data from a large national joint registry, looking at first revision hip replacement for loosening, performed as a single operation. It found that the relative risk of re-revision and of early death was higher with surgeons and hospitals that performed fewer of these operations, with wide uncertainty margins in some results. The risk of re-revision was relatively highest in a surgeon’s first cases, and the risk of early death was relatively highest in a hospital’s first cases.

This result should nevertheless be read with caution:

• The study is observational and cannot prove causation. Its authors acknowledge that surgeons and centers with good results may attract more cases, so that high volume is a result rather than a cause.
• The study covered a single reason for revision (loosening) and a single approach (one operation). Its authors state that the reasons for revision are diverse and that results may not carry over to reasons other than loosening.
• The study itself indicated that surgeons who have accumulated substantial experience may achieve good results even if their annual number of cases is low.
• The study noted that some other research found no association between hospital volume and early outcomes.
• The authors noted that patients who are able and willing to travel in pursuit of good results may differ in characteristics from other patients, and this may affect outcomes.

The practical conclusion: it is reasonable to ask the surgeon about his or her experience in revision hip replacement specifically, not in hip replacement in general, and you should not rely on a single number or a slogan.

Risks and complications

According to patient-oriented medical sources, the possible complications of revision hip replacement include:

• Dislocation.
• Infection.
• Blood clots, and pulmonary embolism (a clot that travels to the lung).
• Difference in leg length.
• New bone forming in an unusual place (heterotopic ossification).
• Fracture.
• Nerve or blood vessel injury.
• Failure of the bone to bond with the metal implant.
• Loosening of the artificial hip.

Health authorities, speaking about hip replacement in general, say that artificial hips can wear over time and may cause pain or swelling, and that dislocation or wear may call for another operation. Studies track re-revision after a first revision operation, which means that the need for further surgery later is a real possibility and should not be played down. Asking the surgeon how the joint will be followed up after surgery, and what the plan is if a problem arises in the future, is an essential part of the decision.

Recovery and return to daily life

Recovery after revision hip replacement is usually relatively slower than after the first operation, although the type of care is similar.

• Pain relief: The team may use a combination of medicines to relieve pain while reducing the need for opioid painkillers. Opioids can be addictive and should be used only as directed by the doctor, in the smallest amount and for the shortest time possible.
• Physical therapy: Exercises to strengthen the leg and restore function, with weight-bearing possibly restricted at first depending on the complexity of the surgery, and with movement precautions to prevent dislocation.
• Preventing blood clots: This may include compression stockings, inflatable leg wraps and blood thinners according to the team’s plan, with early foot and ankle movement encouraged.
• Preventing infection: Antibiotics before and after surgery.
• Needing help: You may need someone to help at home, and a cane or walker. Some patients may need a period in a care or rehabilitation facility, depending on their condition.
• Wound care: Follow the team’s instructions to keep the wound from soaking in water until it has healed and dried, and about when stitches or staples are removed, if there are any.

When to seek urgent medical care after surgery

Health authorities, speaking about hip replacement in general, say that urgent care should be sought by anyone who has recently had the operation and develops:

• Throbbing or cramping pain in the hip or leg.
• A high temperature, or feeling hot, cold or shivery.
• Oozing or pus from the wound.
• Redness, tenderness, swelling or pain in the hip or leg that is not improving or is getting worse.

These may be signs of infection or a blood clot. If pain and swelling in the hip or leg occur together with difficulty breathing or chest pain, a clot may have reached the lung, and this requires calling emergency services immediately in the country where you are.

If you will be traveling after surgery, it is useful to know in advance whom to contact if any of these signs appear in your own country.

What to ask the team to bring before the assessment

What is needed varies from one team to another, so ask the team what it needs before the assessment. Items you may be asked about include:

• X-rays and imaging done for your artificial hip, in digital form if possible.
• The results of tests that have been done.
• Any available information or reports about the previous operation.
• A list of your medicines and chronic conditions.
• An organized description of your symptoms and how they have developed.

This information is useful because the assessment relies on imaging and tests to find out why the artificial hip failed and in what condition the bone is.

Having the operation in Turkey with O9 Medical

Having the operation in Turkey does not mean that revision hip replacement is available to the same degree from every surgeon or every center. Surgeons’ experience in this type of surgery may vary, and the studies this article draws on do not address specific centers in Turkey. So do not assume that experience is available until you have asked and received a clear answer.

O9 Medical’s service is to help you understand your options, gather the images, tests and medical records you already have, arrange for them to be presented for assessment, and coordinate the communication steps, without promising any particular outcome and without pressure. The medical decision rests with the surgeon after assessing your case. For an overview of the specialty, see our page on Orthopedic and Joint Surgery in Turkey, and when comparing doctors you can consult our Orthopedic Surgery page.

When comparing centers you can consult our page on orthopedic and joint surgery hospitals in Turkey, bearing in mind that no list replaces asking the surgeon directly about his or her experience. Before any travel arrangements, it is advisable that the surgical team has looked at your images and records, and that you have a clear plan for following up the artificial hip after you return to your own country.

Cost of revision hip replacement in Turkey

The estimated cost of revision hip replacement at O9 Medical ranges from approximately USD 8,000 to USD 15,000. This is a preliminary, non-binding estimate, not a final offer.

The range is wide because cases differ greatly. General factors that affect it include:

• The reason for revision and the complexity of the case.
• Whether certain components or the whole artificial hip are replaced.
• The type of implant and the supporting parts required.
• The length of the operation and of the hospital stay.
• Tests and imaging.
• Management of infection, if present.
• Physical therapy.
• The patient’s condition.

The final price is determined only after the case, the records and the imaging have been assessed, and it may change if unexpected complications appear during the assessment or the operation. Always ask what the package includes and what it does not.

Questions to ask your surgeon before deciding

• How many revision hip replacements have you performed, and have you treated cases like mine in cause and complexity?
• In your assessment, why did my current artificial hip fail?
• How will you identify the type of artificial hip I have, and are the right parts available for my case?
• What is your plan if the cause is infection? Will I need several stages or a longer stay?
• Is my condition suitable for travelling for surgery, or does it need other arrangements?
• What complications could occur in my case, and how are they managed?
• What is the plan for follow-up and imaging after I return to my own country, and whom do I contact if a problem arises?
• Will I receive a written report on the type of the new artificial hip and the details of the surgery?

Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.