Howard J Kapp, Orthopedic Surgeon
Kapp Revision Surgery

Revision Surgery

In the early 1960s, Sir John Charnley of Great Britain pioneered an operation that would come to be known as the most successful operation in the field of orthopedic surgery. For the first time in the history of orthopedics, surgeons were able to take patients with an arthritic hip or no hip and create a ball and socket that allowed the patient to walk without pain. To create a new hip, a plastic socket was cemented into the patient's pelvic bone. A metal ball attached to a stem was cemented into the hollow portion of the thigh bone known as the medullary canal. With the metal ball placed inside the plastic socket, a new joint was formed and the results were nothing short of miraculous for the patients who previously had no good options for hip function.

During the next two decades, this operation was learned by surgeons around the world. During the first 20 years, much of the focus was concentrated on teaching surgeons how to perform this operation correctly by safely getting inside the patient's hip and placing these parts in the correct position.

The initial results were so good that it seemed that most surgeons and patients did not consider that these moving parts, subjected to all the forces of walking, would eventually wear out or loosen or fail as a result of wear and tear. It was believed that if the operation was performed perfectly in a well selected patient, one operation would last the lifetime of the patient. The operation was recommended only for patients 65 years or older. Eventually both patients and surgeons realized that younger and more active patients needed good hips too. By the mid 1970s and early 1980s, the orthopedic world began to realize that it would require special techniques and experience as well as specialized implants to deal with the emerging problem of failed total hip replacements.

Revision total hip arthroplasty has now become a subspecialty of joint replacement surgery, and it is usually performed by a surgeon with special interest and experience in revision surgery. All surgeons who perform hip replacement surgery do not perform revision hip replacement surgery. Dr Kapp. specializes in both primary joint replacement and revision joint surgery.

A hip can fail because the parts were put in incorrectly. Incorrect placement of the parts can leave the patient with a limb that is too long, too short, or with a ball that separates from the socket causing a dislocation. The bone around the socket or the ball can break or fracture. Some fractures are catastrophic and the bone can be broken completely in half or into many pieces due to an accident or a fall, or the crack can be very subtle and difficult to detect. An infection can be obvious because of drainage of pus, or it can be difficult to detect and the patient may complain of constant pain. The older hips that were placed years ago may fail because the cement holding the implant has cracked and the parts become loose from the bone. The plastic liner can wear out and produce debris which destroys bone, and this can lead to failure. Until the correct diagnosis is made and the patient and surgeon know what caused the failure, it is not possible to plan the correct solution to the problem. Most of the time the correct diagnosis is made by a careful history and physical exam by the physician. Diagnostic tests are usually a supplement that confirms the correct diagnosis. The combination of a competent surgeon and the proper use of available modern technology will usually lead to the correct diagnosis.

Revision hip arthroplasty is usually a more serious operation than primary hip replacement surgery, and the preparation for surgery is critical. Each patient who has a revision operation planned must be evaluated to make sure that they are in the best condition to survive and recover from the operation, and this takes the input from an experienced group of internal medicine doctors and anesthesiologists. Most patients will want to avoid any unnecessary blood transfusion, and this can be accomplished by building up the blood count with medication or by donating blood that can be given back to the patient after surgery. Patient education is important to prepare the patient for any special needs that might be necessary, such as prolonged use of crutches, the need for a brace or a cast, or special modifications to the home that were not necessary for the primary joint replacement.

While neither the patient nor the surgeon want to go back and reoperate on a previously placed hip replacement, revision surgery does offer the opportunity to upgrade the prosthetic components to newer, more durable or better parts. It is possible to reinforce the bone so that the bone can become bigger and stronger after the revision operation. A patient who abused the first joint and did not take care of it has the opportunity to learn the proper care of a joint replacement if they did not learn it the first time. Revision hip replacement also offers the opportunity to correct leg lengths that have become unequal or were unequal to begin with, and at times an unsightly scar can be revised to a better looking scar.

Once the new hip is in and the patient has recovered from the operation, learning how to use the new hip can be challenging as the patient's muscles may be weak and require special work to recover. The role of physical therapy and occupational therapy is different for patients after revision surgery than it is after a primary hip replacement operation. The hospital stay may be longer, and therefore the contributions of an experienced team of nurses, occupational therapists and physical therapists is very important to give the revision patient the best chance for a full recovery. Modifications to the home must also be considered for the special needs of a patient as they recover from hip replacement surgery, and this is all considered part of the revision hip replacement experience.

Revision hip replacement surgery involves much more than just placing fresh parts. By making the proper diagnosis, preparing the patient physically and psychologically, performing the correct operation successfully, and having a coordinated plan for recovery and restoration of function, it is possible for patients to recover from revision hip replacement surgery and even have an outcome better than their initial experience.

Proper treatment of a failed hip or knee replacement requires a correct diagnosis in order to define the underlying cause of the failed operation. The variety and complexity of problems that lead to a failed operation can vary to very simple and obvious to very complicated and mysterious. For example, a common cause of dissatisfaction with hip replacement is that the operated limb was fixed so that it is too long or too short. In this circumstance, the problem is usually obvious. Another example is a hip or a knee that is unstable and dislocates or comes out of socket. The cause of dislocation is not always obvious because parts can dislocate for a variety of reasons including weak muscles, improper positioning of the hip or knee components, or broken or worn out parts. The appropriate solution is based on defining the cause of the problem. An infection can be obvious due to high fever, pain, and draining pus, or it may be difficult to detect in a patient who has no drainage or redness, but complains of constant pain and night pain. Joint replacements that were put in 10 or 20 years ago will sometimes fail because the parts have worn out. In particular, old plastic bearing surfaces can wear and the debris that is generated by the worn plastic can make the bone weak or even destroy the bone. Old plastic can also fail because loss of material will eventually make a hip or knee unstable to the point where it will not move properly and it may dislocate. Most of the time, the correct diagnosis can be made by carefully interviewing and examining the patient and correlating these findings with x-rays. In cases where the diagnosis is not obvious, then special diagnostic tests may be necessary. In other cases, consultants from specialties outside of orthopedics are called upon to assist making the proper diagnosis. The combination of a careful history and physical examination, proper use of diagnostic tests, and contributions from specialists will usually lead to the correct diagnosis.

Preoperative education and preparation

Preparation for revision hip and knee replacement is different than preparation for primary joint replacement surgery. As with all of Dr. Kapp's patients, each patient must be evaluated by an internist to make sure that they are in good physical condition to undergo an operation. If special diagnostic tests are required this may add time to the preparation for surgery. At times a period of observation is required prior to performing the operation. The treating surgeon may want to examine the patient's response to nonoperative treatment prior to committing to revision surgery. Most patients will want to avoid any unnecessary blood transfusion, and this can be accomplished by donating ones own blood or having ones loved ones donate blood. The blood count can also be built up using special medications that are given prior to surgery. Revision surgery may require special education that is not required for patients undergoing primary surgery. After surgery the chance of needing a brace, a cast, or assistive devices, such as crutches or a walker, is increased. Special modifications to the home may be required to assist patients in living independently during the recovery phase of revision hip or knee replacement.

The surgical plan

Preoperative planning by the surgical team is more complicated with revision surgery than with primary surgery. It is necessary to identify the make and model of the old implants. Many revisions do not require removing all of the implants. If it is possible to fix the problem by removing one part then matching parts must be made available. In addition to a plan that includes removing only one part, it is also necessary for the operative team to have a back-up plan. If the initial plan calls for removal of one part, but in surgery it is determined that all parts must be removed, then the new replacement parts must be available at the time of the revision surgery. This increased inventory requires space and the use of less familiar implant systems and requires special training and preparation by the operating room team. The physician assistants, surgical technicians, and nurses must prepare for revision surgery by becoming familiar with the systems that will be used on that day, as well as the back up system. Special machines to visualize the bone during surgery or remove old parts must be ordered and checked so that they are in excellent working condition. Bone grafts, reinforced metal parts, and special machines to remove or replace implants are all included as part of the plan for revision surgery. Revision surgery provides an opportunity to improve the prosthetic components by providing new materials that were unavailable at the time of the primary surgery. An unsightly scar can be revised to a new better looking incision.

Hospital stay and recovery

Recovery from revision surgery is often longer and more challenging than recovery from primary surgery. A major determining factor on recovery is whether implants must be removed from the bone. At times implants do not have to be removed from the bone and at other times, they must. Operations that require removal of implants from the bone require a longer recovery period, longer incisions a longer time on the operating room table, and more extensive dissection usually correlates to a longer hospital stay. The longer hospital stay expands the relationship with nurses, physical therapists, occupational therapists, and the discharge planner. Services that a patient receives in the hospital must be balanced with the services that can be provided to the patient at home. If a patient is to go home sooner, then modifications to the home are sometimes required in order to allow the patient to become independent after revision joint replacement surgery. In contrast, some revisions only require replacing the a liner into well fixed joint replacement parts. The attachment of the components to the bone is not disturbed. In these cases the recovery is much easier than the original operation.

Summary

Revision hip and knee replacement surgery is a special type of joint replacement surgery. The patient is usually more knowledgeable regarding joint replacement and the patient brings with them their previous experience whether it is good or bad. The operation may be less extensive than the primary surgery, but in most cases it is more extensive. The operation allows the opportunity to correct unequal leg lengths or upgrade parts to newer and better parts. We offer an experienced team, and modern technology to address the challenging problem of failed joint replacement surgery. Patients who face the possibility of revision surgery are welcome to come into our office for an opinion and discuss the options that are available to help restore healthy joint function.