Revision Hip Replacement

Not every pain after hip replacement means revision is necessary. Symptoms may come from the joint and implant, but also the spine, muscles, tendons or other structures. The decision should follow agreement between symptoms, examination and appropriate investigations.

Why may a replacement need revision?

Important causes include aseptic loosening, periprosthetic infection, recurrent dislocation or other instability, periprosthetic fracture, component wear or damage, implant position, bone loss and soft-tissue problems. More than one problem may coexist.

Time since the first operation and symptom onset also matter. Sudden pain after injury, gradually increasing pain after several years, and pain with fever, wound discharge or other possible infection signs require different approaches.

A painful replacement: establish the cause first

Assessment begins with a detailed history, examination of the hip and whole limb, and review of previous surgical records if available. Earlier X-rays, implant details, healing history, infections, dislocations and other operations are important.

Symptoms that may suggest loosening

Loosening may cause increasing weight-bearing pain and limping. Femoral component problems may produce thigh pain and so-called start-up pain: worse during the first steps after rising and sometimes easing with movement. Groin pain, especially when initiating movement or activity, may suggest an acetabular problem. None of these patterns confirms loosening on its own — similar symptoms may have other causes.

According to ACR criteria and a 2026 international consensus, radiographs are usually the initial investigation for symptoms after hip replacement. Comparison with earlier images is particularly valuable: progressive radiolucencies, osteolysis, component migration, broken screws or increasing cortical thickening may support the diagnosis. A single X-ray does not always resolve the problem. CT complements radiographs when findings remain unclear or more detailed assessment of position and bone stock is needed. MRI with metal artefact reduction can help with selected tissue problems and periprosthetic reactions; ultrasound may help with some soft-tissue conditions and targeted procedures.

Before describing a problem as “aseptic”, periprosthetic infection must be assessed — the international consensus identified this as the first diagnostic step. Tests usually include CRP and ESR, but normal results do not exclude every infection, especially chronic low-grade infection. Persistent suspicion from symptoms, history or imaging may require joint aspiration with fluid analysis and cultures. A single result should not replace comprehensive assessment.

More about symptoms requiring investigation: Prosthetic Joint Infection — Which Symptoms Are Concerning? (in Polish)

How is revision surgery planned?

Planning depends on the identified cause, stability and position of existing components, bone defects, muscles and other tissues, and infection risk. General health, previous incisions and scars, and availability of the necessary implants and reconstructive options must also be considered.

Not every revision requires removing every component. A well-positioned, stable component that is not responsible for the problem may be retained in selected cases. Others require replacement of one or both main components, more extensive revision implants, bone grafts or other reconstruction. For recurrent instability, dual mobility or, in selected difficult cases, constrained liners may be considered according to the cause and tissue condition.

What changes when infection is suspected or diagnosed?

Periprosthetic infection requires a separate plan. Management depends on symptom duration, implant stability and position, soft tissues, the organism and general health. The EBJIS position paper identifies debridement with implant retention and appropriate antimicrobial treatment as an option for carefully selected acute infections with well-fixed, functioning implants and favourable tissues. Other situations require component exchange in one or more operations.

There is no single strategy for every infection. Planning should be individual; difficult cases require collaboration with a team experienced in periprosthetic infection.

For clinicians: One-stage or two-stage revision of an infected hip replacement? (in Polish)

Is revision more complex than primary replacement?

Often, but difficulty varies widely. Surgery may require removal of well-integrated components, reconstruction of bone loss, restoration of stability, limb length and biomechanics, and protection of weakened bone. Scars and soft-tissue condition also matter.

The first days and rehabilitation after revision

Postoperative instructions depend more on the extent of surgery than after a typical primary replacement. Weight-bearing, crutches, exercise and activity progression reflect reconstruction stability, bone and tissue quality and any additional procedures.

After extensive reconstruction, bone grafting or fracture treatment, restrictions may last longer. Clinical and imaging reviews assess healing and stability. General advice for an uncomplicated primary replacement should not automatically be applied to revision surgery.

When is urgent assessment needed?

Rapidly increasing pain, fever with systemic deterioration, wound discharge, sudden deformity or limb shortening, loss of walking or weight-bearing after injury, or another abrupt deterioration requires urgent consultation. Sudden breathlessness or chest pain requires urgent medical help.

Questions to discuss with an orthopaedic surgeon

Does every painful replacement mean loosening?

No. Pain may arise from the implant, infection, fracture, soft tissues, spine or elsewhere. The most likely cause must be established before considering revision.

Do normal CRP and ESR exclude prosthetic joint infection?

No. Normal inflammatory markers reduce the likelihood but do not exclude every chronic infection. If symptoms, history or X-rays remain concerning, further investigation including aspiration may be needed.

Are CT and MRI always necessary?

No. Assessment usually begins with examination and X-rays. Additional investigations answer specific questions or support surgical planning.

Is the entire replacement always exchanged?

No. The extent depends on the cause of failure and condition of each component. A properly fixed component may be retained while only the problematic part is exchanged.

Is rehabilitation the same as after the first operation?

Not always. Restrictions and recovery after revision more often depend on reconstruction extent, bone quality and implant stability.

Related resources

• Prosthetic Joint Infection — Symptoms and Diagnosis (in Polish)
• How Long Does a Hip Replacement Last? (in Polish)
• One-Stage or Two-Stage Revision of an Infected Hip Replacement? — A Clinician Resource (in Polish)
• Hip Replacement — A Guide to the First Operation

References and standards

The sources below cover guidelines and position papers on diagnosis and treatment of selected complications after hip replacement.

1. Weissman BN, Palestro CJ, Fox MG, et al. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol. 2023;20(11S):S413-S432. DOI: 10.1016/j.jacr.2023.08.015. ACR.
2. American Academy of Orthopaedic Surgeons. Diagnosis and Prevention of Periprosthetic Joint Infections. Evidence-Based Clinical Practice Guideline. Published March 11, 2019. AAOS.
3. Sigmund IK, Ferry T, Sousa R, et al. Debridement, antimicrobial therapy, and implant retention (DAIR) as curative strategy for acute periprosthetic hip and knee infections: a position paper of the European Bone & Joint Infection Society (EBJIS). J Bone Joint Infect. 2025;10:101-138. DOI: 10.5194/jbji-10-101-2025.
4. Hopman AGM, Blankevoort L, Lustig S, et al. Diagnosis of aseptic loosening after hip arthroplasty: international Delphi consensus. Bone Joint J. 2026;108-B(6):758–765. DOI: 10.1302/0301-620X.108B6.BJJ-2025-1732.R1. PubMed.

This educational material does not replace individual diagnosis or assessment for treatment.