Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry

Main Article Content

P Williams, FRCS(T+O), MSc A Hannah, FRCS(T+O) E Henley, MBChB C Frampton, PhD G Hooper, MD, FRACS


Introduction: This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one-year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates.

Methods: The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, body mass index (BMI) and American Society of Anesthesiologist (ASA) grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates.

Results: There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21-year period. There has been a statistically significant increase in both femoral fracture (4.1 - 14.9%, p<0.001) and pain (8.1 - 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection.

Conclusions: The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces.

Article Details

How to Cite
WILLIAMS, P et al. Trends in revision hip replacement surgery - a 21-year review of the New Zealand Joint Registry. Medical Research Archives, [S.l.], v. 12, n. 5, may 2024. ISSN 2375-1924. Available at: <>. Date accessed: 19 june 2024. doi:
Research Articles


1. Shan L, Shan B, Graham D, Saxena A. Total hip replacement: a systematic review and meta-analysis on mid-term quality of life. Osteoarthritis Cartilage. 2014;22:389-406. doi:10.1016/j.joca.2013.12.006

2. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. The Lancet. 2007;370(9597):1508-1519. doi:10.1016/S0140-6736(07)60457-7

3. Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-1497. doi:10.2106/JBJS.D.02441

4. Hooper G. The ageing population and the increasing demand for joint replacement | Request PDF. N Z Med J. 2013;126(1377):5-6. Accessed October 11, 2023.

5. Hip, Knee & Shoulder Arthroplasty - Annual Report 2020.; 202AD. Accessed October 11, 2023.

6. The New Zealand Joint Registry Twenty-One Year Report - January 1999 to December 2019.; 2020. Accessed February 27, 2024.

7. Hooper G, Lee AJJ, Rothwell A, Frampton C. Current trends and projections in the utilisation rates of hip and knee replacement in New Zealand from 2001 to 2026. New Zealand Medical Journal. 2014;127(1401):82-93. Accessed October 11, 2023.

8. Nemes S, Gordon M, Rogmark C, Rolfson O. Projections of total hip replacement in Sweden from 2013 to 2030. Acta Orthop. 2014; 85(3):238. doi:10.3109/17453674.2014.913224

9. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Journal of Bone and Joint Surgery. 2007;89(4):780-785. doi:10.2106/JBJS.F.00222

10. Patel A, Pavlou G, Mújica-Mota RE, Toms AD. The epidemiology of revision total knee and hip arthroplasty in England and Wales: A comparative analysis with projections for the United States. a study using the national joint registry dataset. Bone and Joint Journal. 2015;97-B(8):1076-1081. doi:10.1302/0301-620X.97B8.35170/LETTERTOEDITOR

11. Haynes J, Nam D, Barrack RL, Haynes  J.  Hip Arthroplasty: Avoiding and Managing Problems; Obesity in total hip arthroplasty does it make a difference? Bone Joint J. 2017; 99(1):31-36. doi:10.1302/0301-620X.99B1

12. Schreurs BW, Hannink G. Total joint arthroplasty in younger patients: heading for trouble? The Lancet. 2017;389(10077):1374-1375. doi:10.1016/S0140-6736(17)30190-3

13. Clough EJ, Clough TM. Metal on metal hip resurfacing arthroplasty: Where are we now? J Orthop. 2021;23:127. doi:10.1016/J.JOR.2020.12.036

14. Crowninshield RD, Maloney WJ, Wentz DH, Humphrey SM, Blanchard CR. Biomechanics of large femoral heads: What they do and don’t do. Clin Orthop Relat Res. 2004;429:102-107. doi:10.1097/01.BLO.0000150117.42360.F9

15. Jameson SS, Lees D, James P, et al. Lower rates of dislocation with increased femoral head size after primary total hip replacement: A five-year analysis of NHS patients in England. Journal of Bone and Joint Surgery - Series B. 2011;93 B(7):876-880. doi:10.1302/0301-620X.93B7.26657/LETTERTOEDITOR

16. Howie DW, Holubowycz OT, Middleton R, et al. Large femoral heads decrease the incidence of dislocation after total hip arthroplasty: A randomized controlled trial. Journal of Bone and Joint Surgery. 2012;94 (12):1095-1102. doi:10.2106/JBJS.K.00570

17. Peters CL, McPherson E, Jackson JD, Erickson JA. Reduction in Early Dislocation Rate With Large-Diameter Femoral Heads in Primary Total Hip Arthroplasty. Journal of Arthroplasty. 2007;22(6 SUPPL.):140-144. doi:10.1016/j.arth.2007.04.019

18. Callary SA, Field JR, Campbell DG. The rate of wear of second-generation highly crosslinked polyethylene liners five years post-operatively does not increase if large femoral heads are used. Bone and Joint Journal. 2016;98-B(12):1604-1610. doi:10.1302/0301-620X.98B12.37682/LETTERTOEDITOR

19. Callary SA, Solomon LB, Holubowycz OT, Campbell DG, Munn Z, Howie DW. Wear of highly crosslinked polyethylene acetabular components: A review of RSA studies. Acta Orthop. 2015;86(2):159.

20. Campbell DG, Callary SA. Highly Crosslinked Polyethylene Liners Have Negligible Wear at 10 Years: A Radiostereometric Analysis Study. Clin Orthop Relat Res. 2022;480(3):485. doi:10.1097/CORR.0000000000002002

21. Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg Am. 1990;72(4):518-528.

22. Moore KD, Beck PR, Petersen DW, Cuckler JM, Lemons JE, Eberhardt AW. Early Failure of a Cross-Linked Polyethylene Acetabular Liner: A Case Report. J Bone Joint Surg Am. 2008;90(11):2499. doi:10.2106/JBJS.G.01304

23. Duffy GP, Wannomae KK, Rowell SL, Muratoglu OK. Fracture of a cross-linked polyethylene liner due to impingement. J Arthroplasty. 2009;24(1):158.e15-158.e19. doi:10.1016/J.ARTH.2007.12.020

24. Blumenfeld TJ, McKellop HA, Schmalzried TP, Billi F. Fracture of a cross-linked polyethylene liner: a multifactorial issue. J Arthroplasty. 2011;26(4):666.e5-666.e8. doi:10.1016/J.ARTH.2010.07.009

25. Devane PA, Horne JG, Ashmore A, Mutimer J, Kim W, Stanley J. Highly Cross-Linked Polyethylene Reduces Wear and Revision Rates in Total Hip Arthroplasty A 10-Year Double-Blinded Randomized Controlled Trial. J Bone Joint Surg. 2017;99(A):1703-1714. doi:10.2106/JBJS.16.00878

26. McKellop H, Shen FW, Lu B, Campbell P, Salovey R. Development of an extremely wear-resistant ultra high molecular weight polyethylene for total hip replacements. Journal of Orthopaedic Research. 1999; 17(2):157-167. doi:10.1002/JOR.1100170203

27. Khoshbin A, Wu J, Ward S, et al. Wear Rates of XLPE Nearly 50% Lower Than Previously Thought After Adjusting for Initial Creep: An RCT Comparing 4 Bearing Combinations. JBJS Open Access. 2020;5(2). doi:10.2106/JBJS.OA.19.00066

28. Wechter J, Comfort TK, Tatman P, Mehle S, Gioe TJ. Improved Survival of Uncemented versus Cemented Femoral Stems in Patients Aged < 70 Years in a Community Total Joint Registry. Clin Orthop Relat Res. 2013;471 (11):3595. doi:10.1007/S11999-013-3182-5

29. Lenguerrand E, Whitehouse MR, Beswick AD, Jones SA, Porter ML, Blom AW. Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry. Bone Joint Res. 2017;6(6):398. doi:10.1302/2046-3758.66.BJR-2017-0003.R1

30. Brochin RL, Phan K, Poeran J, Zubizarreta N, Galatz LM, Moucha CS. Trends in Periprosthetic Hip Infection and Associated Costs: A Population-Based Study Assessing the Impact of Hospital Factors Using National Data. J Arthroplasty. 2018;33(7S):S233-S238. doi:10.1016/J.ARTH.2018.02.062

31. Dale H, Høvding P, Tveit SM, et al. Increasing but levelling out risk of revision due to infection after total hip arthroplasty: a study on 108,854 primary THAs in the Norwegian Arthroplasty Register from 2005 to 2019. Acta Orthop. 2021;92(2):214. doi:10.1080/17453674.2020.1851533

32. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? The ten-year results of the New Zealand joint registry. Journal of Bone and Joint Surgery - Series B. 2011;93 B(1):85-90. doi:10.1302/0301-620X.93B1.24862/LETTERTOEDITOR

33. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: A 40-year experience. Bone and Joint Journal. 2016;98B(4):461-467. doi:10.1302/0301-620X.98B4.37201/LETTERTOEDITOR

34. Lindberg-Larsen M, Jørgensen CC, Solgaard S, Kjersgaard AG, Kehlet H. Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with uncemented stems: 7,169 total hip arthroplasties from 8 Danish centers. Acta Orthop. 2017;88(4):394. doi:10.1080/17453674.2017.1302908