Revision Surgery: Why Some Patients Need a ‘Redo’ Surgery

No one ever wants a second surgery to fix something that should have been taken care of the first time. Unfortunately, not all procedures go as planned, and nothing lasts forever, including the metal and plastic parts used in a hip, knee, or shoulder replacement surgery.

In fact, any type of surgery, particularly joint replacements, can require what is known as “revision surgery.” “Revision surgery is any surgery that, for whatever reason, needs to be redone. It’s essentially a ‘redo,’” explains Thomas Hickernell MD, a Yale Medicine orthopaedic surgeon who specializes in hips and knees.

“There is an increasing need for revision surgery because of the increasing number of joint replacements being done,” says Kenneth W. Donohue, MD, MS, a Yale Medicine orthopaedic surgeon who specializes in shoulder and elbow surgery. Here in the United States, approximately 790,000 total knee replacements, more than 450,000 hip replacements, and about 150,000 shoulder replacements are performed annually. And these numbers continue to grow as the Boomer population ages.

Fortunately, newer technology means that parts used in joint replacements are lasting longer than they used to, but it’s important for patients to know that any replacement might require a revision at some point.

Other common surgeries, including rotator cuff repair and procedures for shoulder instability, may occasionally require revision, either due to a new injury or some other characteristic of the shoulder that caused the initial surgery to fail, Dr. Donohue adds. “There are a number of new technologies available to help with these revisions, including biologic grafts to enhance rotator cuff healing and different implants or techniques to stabilize an unstable shoulder,” he says.

Below, we talk more with Yale Medicine orthopaedic surgeons about revision surgery, including when to seek a second opinion about whether or not a revision is necessary.

There are many reasons why a patient may need a revision surgery, but Dr. Donohue says the most common ones have to do with implants (often made from man-made materials, which are used to replace damaged joint surfaces) that have worn down over time and need to be fixed or replaced, and those related to surgery that didn’t properly take a patient’s unique anatomy into account.

“Patients with deviations in anatomy—because of either bone loss or developmental abnormalities—may have a more complicated and difficult surgery, especially if these differences weren’t properly taken into account,” he says. “That can explain the need for a revision.”

The key for these patients is having a surgeon who recognizes these anatomy differences and knows how to tailor their surgical plan to them, Dr. Donohue says. ”For patients undergoing shoulder replacement, I often use computer software to create a 3D model of the shoulder, and I will simulate surgery before we enter the operating room,” he says. “When significant bone loss is present, I will design custom implants and use intraoperative computer navigation or patient-specific guides to make sure I can make the precise corrections required for these patients to have a good and lasting result.”

Infection is another reason a patient might require revision surgery. Signs of infection can be obvious, with symptoms such as “red-hot,” swollen joints or something more “slow-brewing” in which the patient feels achy, Dr. Hickernell adds.

“Usually, you’ll see signs of an infection in the first several months after surgery, but it can also happen many years out,” he says. “Sometimes, people have an infection somewhere else in the body that can travel through the bloodstream and into the joint in question.”

And even if an initial surgery was done perfectly, a patient can still sustain another injury. “For example, if someone had a successful ACL [anterior cruciate ligament] repair, they might tear it again in the future,” says Andrew Jimenez, MD, a Yale Medicine orthopaedic surgeon who specializes in hip preservation and sports medicine. “Re-injury is a real thing, especially in sports medicine.”

Experiencing pain soon after a joint replacement does not necessarily mean you need revision surgery. While some problems arise in the weeks or months after surgery, it often can be years or decades before a patient starts to experience pain or other troubles with their initial replacement.

“In everything we do, surgery is never really the first-line treatment,” Dr. Hickernell says. “In the case of knee or hip pain after a replacement, it could be a simple tendonitis issue, and it’s important that we work through the symptoms.”

The first step is listening to the patient, he explains.

“You want to know what triggers the pain. Do you get up in the morning and things are hurting, but once you get going, it gets better, and you can get through the day?” Dr. Hickernell asks. “Is the pain constant? Is it only at night? Where does it hurt? What activities make it worse? Often, just the answers to these questions can help figure out what’s happening.”

Because many times symptoms are subtle, it’s important for doctors to thoroughly evaluate each patient before making the decision to recommend revision surgery, explains Dr. Hickernell.

A physical exam, which can include imaging, will provide important clues about whether revision surgery is needed. Dr. Hickernell says he looks to see if the joint is swollen or feels unstable during a physical exam. “Or, there might be a problem with the soft tissue tension around the implants, which could have been there since the original surgery or developed over time,” he says.

Imaging, he adds, is key. “We typically start with X-rays and sometimes need more advanced imaging, such as CT scans or an MRI, to help determine the reason for the patient’s symptoms,” Dr. Hickernell says.

With imaging in hand, doctors can see if an implant has degraded or if stabilizing pins or rods have shifted and are causing pain. “Or sometimes, the ligaments get stretched out or aren’t tensioned properly. These are mechanical issues,” Dr. Hickernell says.

Other symptoms patients should look for include sudden pain in the area where the joint was replaced, trouble getting around, and clicking or popping sounds, Dr. Jimenez says.

“You should also be aware of any changes in your functional status. Maybe your strength is diminished or your range of motion is decreased,” he says. “But any decrease in functional status after you had previously recovered would be a concern.”

Many patients mistakenly think that their first, or “primary,” joint replacement will wear out in a decade or so, Dr. Hickernell says.

“That’s because, for hip and knee replacements, there is commonly a plastic liner between the metal parts implanted to replace the damaged joint surfaces. Historically, this liner would wear down at an average rate of 10 to 15 years,” he says. “But the newer generation of plastic liners we started using around the year 2000 aren’t wearing down like that. Today, we hope joint replacements will last 20 or 30 years—maybe longer.”

But even with the newer technology, today’s joint replacements may not last as long if placed in younger patients.

“The younger and more active you are when you have a joint replacement, the less likely it will last the rest of your life,” Dr. Hickernell says. “Therefore, we try to manage conditions such as arthritis conservatively, without surgery, for as long as those treatments are successful. We want to get as much use out of a patient’s native parts as possible.”

Generally, revision surgeries are more complex than primary surgeries.

“Even if it’s not more technically difficult, the thought process and planning are going to be more involved,” Dr. Jimenez says. “Revision surgery can require dealing with prior scar tissue or excisions from the original surgery. We might also need to do bone grafting, using a different type of graft, or treating other associated injuries.”

Dr. Jimenez says he often sees patients who had a prior hip labral repair that tore again or degenerated. (A hip labral tear is an injury to the tissue that holds the “ball-and-socket” parts of the hip together.) “In that setting, revision surgery can be a bit more complicated because when you go in to address the labrum, the tissue quality may be poor, and a repeat repair usually does not work.”

If that’s the case, Dr. Jimenez says he would typically do a labral reconstruction, which entails rebuilding the labrum tissue with graft tissue.

“And if the labral repair wasn't particularly long ago and there wasn't a re-injury, I have to determine why it tore again,” he says. “To help me answer that question, we will make 3D models of the patient's hips, something unique to Yale. We upload a 3D CT scan into surgical-planning software that will highlight a patient’s specific anatomic measurements. It will show areas where bone may need to be further resected to give the patient a better outcome and ideally give them a longer-lasting labral repair or reconstruction.”

Likewise, 3D-printed models can be used for other joint replacements, including the knee. The 3D planning allows surgeons to place the implant more precisely, which leads to better biomechanics and makes movement feel more natural. A 3D model can be created with cutting guides, which help the surgeon avoid positioning errors.

If a patient has concerns about a prior surgery, they should first speak to the surgeon who performed the operation.

“And if a patient is being told that nothing's wrong, but they have friends or family who have had the same surgery and have had a different result, that's the time to seek a second opinion and see if there's anything else that can be diagnosed with more advanced imaging studies,” Dr. Donohue says. “Surgeons should be open to their patients seeking second opinions. My mindset is that I want what's best for my patients.”

He advises reading surgeon profiles online, talking with friends and family for recommendations, and asking surgeons how often they perform a particular revision surgery. “Waiting for an appointment with a surgeon who does that surgery frequently and making sure you're in the best possible hands for a life-changing and lifelong procedure are very important,” he says.

Dr. Hickernell agrees. “If possible, find a surgeon who specializes in the revision surgery you are seeking. For example, if you had a hip surgery done by a generalist, I would choose someone who specializes in hip surgery for the revision. They can anticipate potential complications, needs, and further treatments for that redo surgery,” he says.

“At Yale, we deal with complex cases and take a multidisciplinary approach to our treatments,” adds Dr. Hickernell. “I think that having familiarity with complicated cases or ones that involve multiple steps or procedures makes you better prepared to perform a revision surgery.”

Another idea, Dr. Jimenez says, is to look for physicians who not only perform the surgery, but who are experts in a particular field, which means they publish research on it. And if you do seek a second opinion, bring any images from your previous doctor’s office, as well as medical notes or an office report from your prior surgery, he adds.

At the end of the day, a revision surgery for a painful or poorly functioning previously operated-on joint may not be necessary, Dr. Hickernell says. “But you should have it evaluated to better understand the issue and the nonsurgical and surgical options to make it better,” he says.