The epidemiology of revision total hip arthroplasty: rising demand, younger patients, and the maintaining value

The incidence of revision total hip arthroplasty (rTHA) is increasing. The number of rTHA procedures performed is expected to rise by 43–70% in the USA alone between 2014 and 2030 (1). This is in keeping with the increased incidence of primary total hip arthroplasty (THA) and is reflection that patients presenting for primary arthroplasty procedures are younger and present with a greater comorbidity profile. Patients also wish to return to a higher level of activity as part of restoration of function and quality of life. The burden of rTHA is 50% greater than that of revision total knee arthroplasty (2). The increasing numbers of patients presenting for revision surgery poses distinct surgical, logistical, and economic challenges to treating institutions as well as to society as a whole. This is in addition to the psychological burden it places on patients, families and the treating clinicians.

Once considered the domain of elderly patients, rTHA is now increasingly performed in younger, more active individuals, often with longer life expectancies and greater biomechanical demands. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) has reported a revision burden of 12%, with increasing rates in patients <65 years. Current literature suggests that patients between 45–64 years old now constitute the fastest-growing demographic undergoing rTHA, accounting for over 35% of revision cases. This shift poses unique challenges, particularly with respect to implant longevity, activity-related failure, and cost burden over a patient’s lifetime (3,4).

The main indications across the world for rTHA procedures are instability, aseptic loosening and infection. Indications for rTHA vary by region. In the United Kingdom (UK) the main indications for rTHA include aseptic loosening, osteolysis, adverse tissue reactions to particulate debris and infection while in the USA dislocation, infection and implant loosening account for most revisions. This variation is presented in Table 1. The indications for revision also vary with time post index surgery (Figure 1).

Figure 1 Indications for revision total hip arthroplasty at 1 year and beyond 10 years following index primary total hip arthroplasty illustrating the differences in the indications for revision.

Revision procedures are technically challenging for the surgeon, resource intensive for the treating institution and psychologically stressful for patients and their families. It is therefore imperative for the treating surgeon to understand the options available to them in order to optimise outcomes while minimising the impact of these procedures to the patients and the cost to treating institutions.

The costs of rTHA are significantly higher than primary procedures. The reasons for this include prolonged operative times, the requirement for specialized implants, extended hospital stays, and postoperative complications. The average cost of a revision procedure in the USA has been estimated to be $33,000–$47,000 USD (5,6). The annual burden of rTHA to Medicare alone is estimated to be $1.85 billion (6). The cost of rTHA for prosthetic joint infection is up to 2–3× more than aseptic revisions (7). Globally, this imposes significant strain on public health systems, especially in aging populations with increasing levels of comorbidity.

One of the nuances of revision surgery is understanding the diagnosis and implications of the indication for revision. This is one of the most important factors which informs the surgical strategy. Indication for revision does not only vary by region, but also over time in the same region. this is illustrated clearly an establish registries such as the New Zealand joint registry (8). Intraoperative issues such as iatrogenic or unexpected bone loss can also dictate a change in the approach or strategy required. For these reasons surgeons undertaking revision procedures need to have a variety of surgical techniques at their disposal.

In this special series we will examine the epidemiological trends driving the rising demand. We will also review technical aspects and surgical techniques for managing challenging situations such as bone loss in rTHA. Our aim is to provide a comprehensive overview of the subject for the less experienced surgeon and an informed update for the more experienced surgeon.

Nemandra Amir Sandifor

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Joint for the series “Revision Total Hip Arthroplasty”. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-69/coif). The series “Revision Total Hip Arthroplasty” was commissioned by the editorial office without any funding or sponsorship. N.A.S. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Joint from June 2025 to December 2027. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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