Vice Chairman and Head of Department, Orthopaedics, BLK-Max Super Speciality Hospital, New Delhi, India
Part 2 of 9 in Management of Complex Total Hip Arthroplasty
What Makes a Hip Replacement "Complex": Causes and Indications
November 2, 2025
A range of distinct problems can turn a hip replacement from a routine primary procedure into a complex reconstruction. Trauma is one major route: severe, unstable acetabular fractures that malunite or fail to unite can progress to established traumatic arthritis, and subcapital femoral neck fractures carry a high risk of avascular necrosis even when the fracture itself heals, because the blood supply to the femoral head, largely from the profunda femoris artery and capsular vessels, is easily damaged.
Young patients and developmental conditions
In younger, more active patients, sports-related cartilage or labral damage, including femoroacetabular impingement, can progress to arthritis, and extensive bone loss or acetabular erosion can follow. Developmental dysplasia of the hip, previously called congenital dislocation of the hip, is another route: an undetected or poorly managed dislocation at birth can leave the femoral head growing outside the acetabulum into an enlarged, poorly matched joint.
Failed prior surgery and long-standing joint damage
A large share of complex cases follow a previous surgery. Aseptic loosening of a prior implant, subsidence of the stem in osteoporotic bone, and dislocation, about 90% of which occur within the first three months of a primary replacement if the implant geometry or version was not right, all require complex revision. Weak hip abductors, whether from old polio, neurological conditions or infection, cause instability that is managed with a tripolar or constrained liner design that limits range of motion in exchange for stability. Long-standing conditions such as a childhood septic hip that led to osteolysis or a fused, ankylosed hip also fall into this category, along with cases with significant pre-existing bone loss or deformity.
This article is based on a Jivo Masterclass session conducted by Dr. Rakesh Mahajan, Principal Director & HOD, Orthopaedics, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass — Dr. Rakesh Mahajan taught doctors across Africa on November 2, 2025.
FROM THE LIVE Q&A
Dr. Dinaw (Ethiopia)
What is the success rate for athletes returning to their profession after hip replacement, and how early can they resume training and sport?
Dr. Rakesh Mahajan
It depends on the pathology and the type of activity. A well-selected hip replacement lets most patients resume daily activities and many general activities, but for physically demanding sports like football or basketball a total hip replacement is not really compatible with returning to the same sport, and changing to a less demanding sport is usually the better path. Where the underlying problem is femoroacetabular impingement rather than true arthritis, hip arthroscopy to clean up the impingement and cartilage, combined with stem cell therapy, allows the hip to regenerate over about six months with good results on repeat MRI.
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Frequently Asked Questions
In patients with advanced hip osteoarthritis who have pain but still have sufficient mobility, is there a place for conservative management, and when should surgery be recommended?▼
The X-ray tells the story: if the joint space and cartilage are still maintained, surgery is not the first answer even if pain has started. Arthroscopic cleanup of osteochondral bone formation or damaged cartilage combined with stem cell therapy is a good option at that stage. Hip replacement is reserved for once the cartilage is completely damaged and there is no blood flow left to the femoral head.
Do you have expertise in hip arthroplasty for children with sickle cell disease, and is hip replacement recommended in children generally?▼
Hip arthroplasty is not recommended below 17 to 18 years of age because the skeleton has not matured. For sickle cell disease specifically, bone marrow transplant, ideally done early in childhood, remains the standard curative treatment and gives the best results. In children who do need hip intervention before that age, arthroscopy and osteotomy techniques that reshape the weight-bearing surface of the hip are used instead of replacement, relieving pain while the child grows.
How long can patients generally expect their hip implants to last, and what factors influence the longevity of these implants?▼
A well-fitted hip replacement lasts 30 to 35 years, and since most hip replacement candidates are older, most will not need it again in their lifetime. Longevity depends on the patient avoiding certain positions and activities that stress the implant, including sitting cross-legged or squatting on the floor, and avoiding high-energy sport activity.
Can you briefly describe how stem cell therapy is used in hip disorders?▼
Stem cells are osteoprogenitor cells capable of turning into bone, cartilage or other tissue types. For damaged islands of hip cartilage, the area is cleaned up arthroscopically and stem cells are injected. On follow-up MRI over about six months, the cartilage visibly starts regrowing, similar to grass regrowing, and the damaged area shrinks along with the patient's symptoms.
How are these stem cells harvested, and how long does the harvesting process take?▼
In orthopaedics, stem cells are harvested from the iliac crest using a Jamshidi needle, taking around 120 ml of bone marrow blood from either a posterior or anterior approach to the pelvis. This is then centrifuged for around 45 minutes to an hour to concentrate the stem cells before they are injected.
What trauma-related conditions can lead to a complex hip replacement?▼
Severe, unstable acetabular fractures that malunite or fail to unite, and subcapital femoral neck fractures, which carry a high risk of avascular necrosis of the femoral head even after the fracture itself heals, since the blood supply is easily damaged.
Why do hip replacement dislocations mostly happen early?▼
About 90% of dislocations after a primary hip replacement occur within the first three months, which usually points to a problem with implant geometry, version, or abductor muscle weakness rather than a later cause.
In This Series: Management of Complex Total Hip Arthroplasty
- 1.Management of Complex Total Hip Arthroplasty
- 2.What Makes a Hip Replacement "Complex": Causes and Indications
- 3.Planning a Complex Hip Replacement: Examination and Imaging
- 4.Implant Options for Severe Bone Loss in Hip Revision Surgery
- 5.Surgical Anatomy and Approach in Revision Hip Surgery
- 6.Hip Replacement in Young Patients and Sickle Cell Disease
- 7.Stem Cell Therapy and Cartilage Preservation in the Hip
- 8.Implant Longevity and Life After Hip Replacement
- 9.Cost, Referral and Cross-Border Care for Complex Hip Surgery