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Orthopedic Surgery at Case Western Reserve University School of Medicine. "When I first started doing hip and knee surger y in 1980, it was at the 10-year time mark of the first joint replacements performed in Cleveland. Many of the devices of that era started failing after 7–10 years, so there were many revisions to do," he says. Since then, Dr. Stulberg estimates he has performed a "couple of thousand" joint revisions. He points out that early total joint prost heses were la rgely cemented devices which, when they loosened or fa iled, of ten resulted in severe bone loss. "The newer implants attach directly to bone and stress the bone in a way that bone loss is minimized," Dr. Stulberg says. "The entire science around hip and knee replacement is light-years ahead from what it used to be." Still, the American Joint Replacement Registry (AJRR) annual report released in 2014 by the American Association of Orthopaedic Surgeons indicates that 6.5 percent of TJRs (3.4 percent hip and 3.1 percent knee) fail in the first three months. Most, however, fail over the long term — after 10, 15 or 20 years of good function, according to Dr. Stulberg. Determining the Cause of Failure Infection is the leading cause of early TJR failure and the need for revision surger y. In fact, 37.8 percent of hip revisions and 45.7 percent of knee revi- sions are the direct result of infection, according to the AJRR report. For early hip replacement failures, the No. 2 cause is periprosthetic fracture around the prosthetic joint; for knee, it is progressive osteoarthrosis (primarily when partial replacement is performed). Other factors indicating a need for total hip and knee revision surger y include dislocation of the prosthetic joint and mechanical complications of the prosthesis. "Remember that a joint replacement is an operation," Dr. Stulberg explains. "You can have a device that's fine, but the operation didn't work. You can have an operation that was well done, but the device didn't work. Or you can have joints fail due to factors related to the patients themselves, such as poor bone integrity; immune-compromised health, which puts the patient at risk for infection; or levels of activity that are beyond what the device can handle. Or a combination of all of these may participate in the failure." Patients are likely to complain of persistent pain in the replaced joint or surrounding tissue, a feeling of instability, and/or a loss of function or motion. In the case of early TJR failure, patients' complaints may include not achieving the pain relief, function or motion they expected. "In general, patients are referred to me because their joint replacement isn't functioning as expected or their pain persists," Dr. Stulberg says. "Their doctors have tried multiple medication and therapy approaches, but without success. That's when the patient is ready to think about revision surgery." Planning the Approach The treatment approach is determined by the cause of the failed joint, and the Dr. Stulberg reviews a patient's progress with Melinda Dunn, RN, at St. Vincent's Spine and Orthopedic Institute. PHOTO © JOE SMITHBERGER, SMITHBERGER PHOTOGRAPHY, NORTH CANTON