Risks of Revision Surgery – Why It Is a Bigger Operation

Part of The Joint Replacement Guide — Phase 3: Understanding the Risks · Article 19 of 44 · Hip & Knee

Key Points

Revision surgery means operating again on a previous joint replacement. It may involve replacing one component, several components or the whole implant.
Revision surgery is often longer and more technically demanding than first-time joint replacement, although complexity varies greatly.
Risks and outcomes depend strongly on why revision is needed. Treating infection, fracture or major bone loss is generally more complex than exchanging a worn but accessible component.
Outcomes can still be worthwhile, but they are generally less predictable than after primary joint replacement.
Most modern primary hip and total knee replacements do not require revision within ten years.[2]
No single decision can guarantee that revision will be avoided. Appropriate implant selection, good surgical care, management of relevant health risks and prompt assessment of new symptoms can all contribute.

What Is Revision Surgery?

A primary joint replacement is the first replacement operation on that joint. A revision is a later operation that removes, exchanges or adds to one or more parts of the replacement.

Revision can range from a relatively limited procedure—such as exchanging a modular head, liner or bearing—to extensive reconstruction involving removal of all components and treatment of major bone or soft-tissue damage.

Common reasons include:

infection around the implant;
loosening;
wear or damage to a bearing surface;
recurrent hip dislocation;
knee instability;
fracture around the replacement;
component breakage or another implant problem;
stiffness;
significant component malposition; and
persistent pain where a treatable cause has been identified.

Pain alone does not automatically mean that revision is appropriate. Revision for unexplained pain has less predictable results, so the team should make reasonable efforts to establish a diagnosis before recommending further surgery.

Why Revision Is Often More Complex

The first operation changes the anatomy of the joint. At revision, the surgeon may have to manage:

scar tissue;
altered muscle and ligament function;
a previous surgical approach;
components fixed with cement or bone ingrowth;
loss or weakening of bone;
damage to soft tissues;
infection;
previous fractures or metalwork; and
less predictable anatomical landmarks.

Removing a well-fixed implant can sacrifice some surrounding bone even when performed carefully. The operation may therefore require specialised instruments and implants designed to obtain fixation beyond the damaged area.

Possible reconstructive techniques include:

longer stems extending into the bone;
metal augments, sleeves or cones;
bone graft;
more constrained implants;
fixation with plates, cables or screws; and
occasionally a custom-made component.

Not every revision requires all of these measures. The surgeon should explain the expected extent of your operation and the possibility that the final reconstruction may need to change according to what is found during surgery.

Why the Risks May Be Higher

Compared with primary replacement, revision surgery may involve a longer operation, more tissue dissection and greater blood loss. Relevant risks can include:

bleeding and blood transfusion;
infection or recurrent infection;
wound-healing problems;
blood clots;
fracture;
nerve or blood-vessel injury;
hip dislocation or knee instability;
stiffness;
medical complications;
a longer hospital stay or rehabilitation period; and
further revision in the future.

The increase is not identical for every revision. A limited planned component exchange in a medically well patient is different from emergency surgery for a fracture or staged treatment of a deep infection.

The team should explain risk in relation to the proposed operation rather than simply state that “revision is high risk”.

Infection-Related Revision

Deep infection around an implant is among the most challenging reasons for revision. Treatment depends on factors including:

how long symptoms have been present;
the organism involved;
whether the components remain well fixed;
the condition of the bone and soft tissues;
previous treatment; and
the patient’s general health.

Some early or acute infections may be treated by surgical washout with exchange of accessible modular components while retaining well-fixed implants. This is often called DAIR: debridement, antibiotics and implant retention.

Other infections require removal of the implant. A new replacement may be inserted during the same operation or at a later operation after an interval of treatment. These are commonly described as one-stage and two-stage revision.

Infection treatment can involve prolonged antibiotics and input from microbiology or infectious-disease specialists. Outcomes are generally less predictable than for revision undertaken for a non-infective mechanical problem. In revision knee surgery, pooled evidence shows higher complication, reoperation and failure rates for two-stage infection revision than for aseptic revision.[3]

Bone Loss and Fracture

Loosening, wear, infection and removal of previous components can all reduce the amount or quality of bone available for fixation.

A fracture around the implant may also involve poor bone quality, a loose component or both. Treatment may require fracture fixation, revision of the replacement or a combination of the two.

Bone loss and fracture can affect:

which implants can be used;
the duration of surgery;
how soon full weight-bearing is permitted;
the need for walking aids; and
the likely recovery and long-term outcome.

The surgeon may need additional imaging to plan the reconstruction. In selected complex cases, custom implants or three-dimensional planning may be considered.

Outcomes Are Less Predictable

Revision surgery often reduces pain or restores stability and function, but the average result is generally less predictable than after primary replacement.

This reflects several factors:

the joint has already undergone surgery;
bone and soft tissues may be compromised;
the reason for failure may be difficult to correct fully;
the operation is technically more demanding; and
the patient may have become older or developed additional health conditions since the primary procedure.

Outcome also depends heavily on the indication:

exchanging a worn component in an otherwise well-functioning joint may have a relatively favourable outlook;
recurrent instability may require more constrained implants but can sometimes be corrected effectively;
revision for stiffness or unexplained pain has less predictable results;
revision for infection or major fracture is generally more complex; and
severe bone or muscle damage may limit the result even when the new components are secure.

A successful revision does not necessarily mean that the joint will feel normal or become completely pain-free. The aim may instead be to control infection, restore stability, preserve the limb or achieve a worthwhile improvement in function.

Risk of Re-Revision

A revised replacement can itself require another operation. This is called re-revision.

NJR data show that the risk of re-revision depends partly on why and how soon the first revision occurred. For hip replacements, revisions performed within a year of the primary operation have had a higher subsequent re-revision rate than revisions performed after the primary implant had lasted at least ten years.[2]

This does not mean that early revision should be avoided when it is clinically necessary. Delaying treatment of infection, instability, fracture or another serious problem may cause greater harm. It illustrates that early failure often reflects a difficult underlying problem and has a different prognosis from late wear.

How Common Is Revision?

Registry figures vary by joint, implant, age, diagnosis and length of follow-up.

The 2025 National Joint Registry report gave a ten-year revision estimate of approximately 2.7% for primary hip replacements performed in 2014.[2] For total knee replacement, the NJR reports several widely used implant constructs with revision rates below 3% at ten years.[4]

These are reassuring population figures, but they are not a personal guarantee. Revision risk can be higher in younger patients because they live with the implant for longer, and it also varies according to the implant, procedure and individual clinical factors.

Partial knee replacement generally has a higher revision rate than total knee replacement, although it may offer other advantages for appropriately selected patients. Revision rate should therefore be considered alongside symptoms, recovery, function and the nature of any later revision—not used as the only measure of success.

Can Revision Be Prevented?

Some revisions are preventable; others are not. No patient or surgeon can eliminate the lifetime risk.

Measures that may contribute include:

using a well-established implant appropriate for the patient;
accurate component positioning and secure fixation;
infection-prevention measures;
appropriate management of diabetes, smoking, nutrition and other relevant risks;
maintaining muscle strength and general health where possible;
assessing and treating osteoporosis or falls risk where appropriate;
following advice about recovery and activity; and
seeking assessment for new or worsening symptoms.

These measures reduce or manage risk but cannot guarantee implant survival.

Does the Timing of Primary Surgery Prevent Revision?

There is no universally correct age or moment that prevents future revision.

Younger patients generally have a greater lifetime probability of revision because they are likely to use the implant for longer. That should be included in shared decision-making. However, delaying surgery solely to reach a particular age does not guarantee that revision will be avoided.

Waiting also has potential costs, including continuing pain, reduced mobility, loss of independence and deterioration in general fitness. The appropriate timing should balance:

the severity and effect of symptoms;
whether non-surgical options remain effective;
the likely benefit of surgery;
current surgical risk;
expected implant longevity; and
the patient’s priorities.

The decision should not be reduced to being “too young” or waiting until the joint becomes unbearable.

Implant Choice

Implant choice can influence revision risk, but no implant is best for every patient.

Surgeons consider factors including:

age and activity;
anatomy;
bone quality;
the underlying diagnosis;
fixation method;
bearing surface;
implant track record; and
familiarity with the system.

NJR and ODEP data help clinicians select implants with established performance. A newer, more expensive or heavily marketed implant is not automatically better than one with a long and reliable evidence base.

Follow-Up and New Symptoms

There is currently insufficient evidence to specify one routine long-term follow-up schedule for every person with a joint replacement. NICE was therefore unable to recommend a universal surveillance programme.[1] Hospitals may use different schedules according to the implant, patient and local pathway.

Attend any follow-up appointments offered by your team. More importantly, do not wait for a routine appointment if you develop:

new or worsening joint pain;
a new limp or loss of function;
a feeling of instability;
recurrent swelling;
wound drainage or signs of infection;
a change in leg alignment;
a new clicking or mechanical symptom associated with pain; or
difficulty bearing weight after a fall.

NICE advises primary-care practitioners to refer people with new or worsening pain, limp or loss of function related to a joint replacement back to an orthopaedic service.[1]

Early assessment does not always prevent revision, but it may identify conditions where timely treatment matters.

Specialist Teams and Revision Networks

Complex revision surgery may require:

surgeons who regularly perform revision procedures;
specialist anaesthetic and perioperative care;
infection and microbiology expertise;
plastic-surgery support for difficult wounds;
fracture expertise;
access to specialised implants, bone grafts and equipment; and
multidisciplinary review.

Revision knee networks have been developed within the NHS, supported by GIRFT, so that complex cases can be discussed and treated in an appropriate setting.[5] Some revisions can safely be performed in experienced local units, while major infection, extensive bone loss or other complex reconstruction may be referred to a specialist centre.

Referral elsewhere does not necessarily mean that the original surgeon or hospital has done something wrong. It may reflect the resources and multidisciplinary expertise required for a particular reconstruction.

Questions to Ask Before Revision Surgery

Useful questions include:

What is the likely cause of the problem?
Has infection been considered and investigated?
Which components need to be removed or replaced?
How much bone or soft-tissue damage is expected?
Could the planned operation change depending on the findings?
What improvement is realistic?
What are the main risks in my case?
Might I need restricted weight-bearing or a longer rehabilitation period?
What alternatives are available, including no surgery?
Will my case be discussed by a revision multidisciplinary team?
What is the possibility of further revision?

The Bottom Line

Revision joint replacement is not one operation but a broad range of procedures. Some are limited; others involve major reconstruction over one or several operations.

Compared with primary replacement, revision is generally more complex and its outcomes are less predictable. Nevertheless, it can provide substantial benefit when there is a clear diagnosis, realistic objective and appropriately experienced multidisciplinary team.

This article provides general information and does not replace individual advice. The risks and expected outcomes of revision depend heavily on the reason for surgery, the condition of the implant and surrounding tissues, and your general health.

References

National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. NICE guideline NG157. London: NICE; 2020. Section 1.11. Available from: https://www.nice.org.uk/guidance/ng157/chapter/Recommendations
National Joint Registry. Outcomes after joint replacement 2003 to 2024. In: 22nd Annual Report 2025. London: NJR; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK618761/
Kim SG, Kim HP, Bae JH. Clinical outcomes and complications of two-stage septic versus aseptic revision total knee arthroplasty: a systematic review and meta-analysis. J Bone Joint Surg Am. 2024;106(2):158–168. doi:10.2106/JBJS.23.00519. Available from: https://pubmed.ncbi.nlm.nih.gov/37943574/
National Joint Registry. Executive summary: 22nd Annual Report 2025. London: NJR; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK618758/
Oxford University Hospitals NHS Foundation Trust. Revision Knee Service: Thames Valley Network. Updated September 2024. Available from: https://www.ouh.nhs.uk/services/referrals/orthopaedics/hip-and-knee/revision/
Getting It Right First Time. Orthopaedic surgery follow-up report. London: GIRFT; 2020. Available from: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2020/02/GIRFT-orthopaedics-follow-up-report-February-2020.pdf

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