# Why revision of total hip arthroplasty fails: a retrospective consecutive cohort study of 963 patients

Valentin Cascales, Constant Foissey, Marcelle Mercier, Remy Coulomb,

Michel-Henri Fessy, Sébastien Lustig, Pascal Kouyoumdjian

► To cite this version:

Valentin Cascales, Constant Foissey, Marcelle Mercier, Remy Coulomb, Michel-Henri Fessy, et al. Why revision of total hip arthroplasty fails: a retrospective consecutive cohort study of 963 patients. Bone & Joint Open, 2026, 7 (2), pp.148-157. 10.1302/2633-1462.72.BJO-2025-0295.R1. hal-05499899

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# Why revision of total hip arthroplasty fails: a retrospective consecutive cohort study of 963 patients

From Spine Surgery
Department, Orthopaedic and
Traumatological Surgery,
University Hospital of Nîmes
(CHU), Nîmes, France

Correspondence should be
sent to P. Kouyoumdjian
kouyoup@gmail.com

Cite this article:
Bone Jt Open 2026;7(2):
148–157.

DOI: 10.1302/2633-1462.72.BJO-2025-0295.R1

V. Cascales,¹ C. Foissey,² M. Mercier,³ R. Coulomb,¹ Writing Commitee, M-H. Fessy,³ S. Lustig,² P. Kouyoumdjian¹,⁴

¹Spine Surgery Department, University Hospital of Nîmes (CHU), Nîmes, France

²Orthopaedic Surgery Department, Croix Rousse Hospital, Hospices Civils de Lyon, Lyon Cedex, France

³Orthopaedic Surgery Department, Hospital Lyon Sud, Oullins-Pierre-Bénite, France

⁴University Mechanical and Civil Engineering Laboratory, Montpellier, France

## Aims

The aims of this study are to identify the causes and independent risk factors for failure following revision total hip arthroplasty (RTHA).

## Methods

We conducted a retrospective multicentre cohort study involving 963 patients who underwent RTHA between January 2016 and December 2021 across three French university hospitals, with a minimum follow-up of two years. Data collected included demographic details, revision rank (R1= first revision, R2= second revision, R ≥ 3=third or subsequent revision), surgical variables, complications, reoperations, re-revisions, and mortality. RTHA failure was defined as any reoperation or re-revision. Multivariate logistic regression was used to determine independent risk factors for failure.

## Results

The mean patient age was 72 years (14 to 104), with 55% of patients being female. The most common indications for RTHA were aseptic loosening (35.6%), periprosthetic fracture (32.0%), periprosthetic joint infection (PJI; 15.2%), and dislocation (5.7%). Failure occurred in 135 patients (14.0%), most frequently due to PJI (53%), of which 61% were new infections. Among patients revised for dislocation, recurrent instability accounted for 43.7% of failures. Most failures (70%) occurred within one year of revision. Independent risk factors included age ≥ 75 years (odds ratio (OR) 0.61), revision rank ≥ 3 (OR 1.96), PJI (OR 2.0), dislocation (OR 2.86), use of revision (OR 2.38), and constrained acetabular cups (OR 5.38).

## Conclusion

Aseptic loosening remains the leading indication for revision surgery, while PJI is the principal cause of failure following RTHA, both as a new infection and as iterative failure. Recurrent dislocation continues to pose a complex challenge despite modern implant strategies, underscoring the need for meticulous surgical planning in high-risk patients.

## Take home message

* This study identifies key patient-, pathology-, and implant-related factors associated with failure after revision total hip arthroplasty, highlighting the predominant roles of periprosthetic joint infection and recurrent instability.

* Recognition of these high-risk profiles may help surgeons refine preoperative planning, implant selection, and peri-operative strategies to reduce early re-failure.

* In particular, the findings underscore the need for meticulous management of infection and instability in complex revision cases.
## Introduction

Total hip arthroplasty (THA) is increasingly performed owing to the ageing population and the expansion of indications towards younger and more active patients.¹ While the initial aim of THA was to relieve pain in elderly patients with advanced coxarthrosis, expectations have evolved towards restoration of full function, including return to work and sporting activities,²,³ without restrictions imposed by the prosthesis.⁴ This change raises concern regarding implant longevity and the inevitable increase in revision total hip arthroplasty (RTHA).

In France, between January 2012 and December 2018, the number of THA procedures increased by 10.5%, encompassing both primary and revision procedures. In 2018, there were 150,060 primary THAs and 19,457 revisions, and these numbers are projected to almost double by 2050, reaching nearly 300,000 primary THAs annually. A 43% rise in RTHA is thus anticipated, amounting to approximately 28,000 procedures each year.⁵

Large national joint registries provide reliable data on THA outcomes but do not capture all aspects of revision surgery because of smaller numbers, difficulty in linking revisions to their primary procedures,⁶ and variability in terminology such as ‘revision’, ‘reoperation’, or ‘re-intervention’.⁷ Previous multicentre series in France have shown loosening to be the predominant cause of revision, while periprosthetic fracture and infection are increasingly reported.⁸

Revision surgery is associated with higher complication rates than primary procedures,⁹,¹⁰ longer hospital stays, greater costs,¹¹ and up to a five-fold increased risk of further revision.¹²,¹³

The aim of this study was therefore to describe the demographic characteristics of patients undergoing RTHA, to analyze the causes of failure, and to identify independent risk factors for iterative failure. We hypothesized that infection and instability would be the main contributors to failure following revision THA.

## Methods

### Study design and participants

We conducted a retrospective multicentre cohort study at three French university hospitals (University Hospital of Nîmes (CHU), Montpellier, France; Croix Rousse Hospital, Hospices Civils de Lyon, Lyon Cedex, France; and Hospital Lyon Sud, Oullins-Pierre-Bénite, France) performing both primary and revision hip arthroplasty. All patients undergoing RTHA between January 2016 and December 2021 were eligible for inclusion, irrespective of aetiology. All patients received written information and gave non-opposition for the use of anonymized data for research purposes. The study protocol was approved by the local Bioethics Committee and Institutional Review Board (24/05/02).

Exclusion criteria were defined to ensure a homogeneous RTHA population and included: conversion or revision of hemiarthroplasty, isolated fixation of periprosthetic fractures, arthroplasty following failed internal fixation of femoral neck fractures, isolated debridement without exchange of bearing surfaces, and procedures that did not involve revision of any THA component. Patients without a minimum follow-up of two years were excluded from the final analysis.

Revision was defined as the exchange of one or more components of a THA. Reoperation was defined as any surgical procedure related to the operated hip that did not involve component exchange (e.g. evacuation of haematoma, fixation of periprosthetic fracture, iliopsoas tenotomy, arthrolysis, or closed reduction of dislocation). Re-revision was defined as an iterative revision following the failure of a prior revision. Planned two-stage procedures for periprosthetic joint infection (PJI) were not considered failures, unless an unplanned reoperation occurred between stages or re-implantation was not possible.

PJI was defined according to the Musculoskeletal Infection Society (MSIS) criteria.¹⁴ Failures were categorized as intraoperative, early (< one year) or late (> one year). Fixation anomaly referred to any intraoperative evidence of defective or insufficient implant anchorage, while ‘noises’ described audible abnormal mechanical sounds (such as clicking or squeaking) reported by patients or identified clinically.

The revision rank was classified according to the number of previous revisions: first revision (R1), second revision (R2), or third and subsequent revisions (R ≥ 3). Failure of RTHA was defined as any reoperation or re-revision.

### Study population

A total of 963 patients underwent RTHA between January 2016 and December 2021 and were included in the analysis. An additional 74 patients were excluded because of follow-up < two years or incomplete datasets, representing 7.1% of the initial cohort. The mean age at revision was 72 years (SD 13.2; 14 to 104), with 55% of patients being female. The mean BMI was 26.2 kg/m² (SD 5.3). The mean follow-up was 4.4 years (SD 1.8; maximum 9.6 years), and the mean interval from index THA to revision was 11.1 years (SD 9.8). Revision rank was R1 in 69%, R2 in 20.3%, and R ≥ 3 in 10.7%.

### Outcomes

Data collection: Patients were identified using PMSI (Programme de Médicalisation des Systèmes d'Information) national hospitalization databases in each centre, by applying French CCAM procedure codes for RTHA (see Supplementary Table i).

A senior surgeon at each centre (VC, CF, MM) collected data using a standardized proforma, generating a shared database. Operative reports, radiographs, and medical records were reviewed. The dataset included demographic details, year of index THA implantation, revision rank (R1, R2, R ≥ 3), RTHA aetiology, type of revision (full component revision, partial component revision, or modular component exchange only), surgical approach, implant type, fixation method, bearing surface, grafting, complications, reoperations, re-revisions, and mortality.

The causes of RTHA were classified as: loosening (including osteolysis and wear), periprosthetic fracture, PJI (with ‘new PJI’ denoting infection occurring after revision for a non-infectious cause), dislocation, adverse reactions to metal debris (ARMD), implant fracture, implant malposition, leg length discrepancy (LLD), prosthetic or soft-tissue impingement, fixation anomaly, heterotopic ossification, and noises. Revision, reoperation, death, and complications were categorized as intraoperative, early (< one year) or late (> one year). To identify risk factors for RTHA failure, variables of
<figure><img src="image_4.png" /><figcaption>Fig. 1</figcaption></figure>

Illustrative cases of re-revision following failed revision total hip arthroplasty (RTHA), shown on anteroposterior pelvic radiographs. Case 1: Re-revision for aseptic loosening. One-stage RTHA in a 67-year-old female for subacute haematogenous methicillin-sensitive *Staphylococcus aureus* infection with acetabular loosening (1a, 1b; shown on a 3D CT scan). Revision with acetabular reconstruction with Kerboull reinforcement ring and bone graft (1c). Septic recurrence at one month managed by modular exchange and intravenous antibiotics. Infection-free at 18 months. Case 2: Recurrent dislocation after uncemented modular dual-mobility THA in a 67-year-old female with prior lumbar fusion and sagittal imbalance (2a, 2b). After failed head exchange and intraprosthetic dislocation (2c) following closed reduction, a full revision was performed using a modular component and a non-modular dual-mobility cup (2d). No recurrence at 18 months.

interest were compared between patients with and without
failure.

**Statistical analysis**

Statistical analysis was performed using EasyMedStat v. 3.27 (EasyMedStat, France). Numerical variables were expressed as means (SDs), and discrete variables as absolute and relative frequencies (%). Patients were classified into two groups: those with re-revision and reoperation failure compared with those without. Basic demographic data were compared between groups. Risk factors for RTHA failure were sought through multivariate logistic regression. Data were checked for multicollinearity with the Belsey-Kuh-Welsch technique. Normality and heteroscedasticity of continuous data were evaluated using the Shapiro-Wilk and Leve tests, respectively. Continuous results were compared using unpaired t-test, Welch's t-test, or Mann-Whitney U test depending on the data distribution. Discrete results were compared using the chi-squared test of Fisher's exact test depending on the sample size. The α risk was set at 5%, and two-tailed tests were used. Statistical significance was set at p < 0.05.

**Results**

**Indication for revision**

The most common RTHA aetiology was aseptic loosening,
including osteolysis/wear (n = 343, 35.6%), followed by

periprosthetic fracture (n = 308, 32%), PJI (n = 146, 15.2%), and dislocation (n = 55, 5.7%) (Figures 1 and 2). Other causes (n = 111, 11.5%) included adverse reactions to metal debris (ARMD), implant fracture, malposition, leg length discrepancy, fixation anomaly, heterotopic ossification, and abnormal noises (Figure 3).

During follow-up, 135 patients (14.0%) experienced
failure, defined as re-operation or re-revision. The majority of
failures occurred within the first postoperative year (70%).

PJI accounted for 53% of all failures; 61% were classified as 'new infections', meaning infections that developed after a revision initially performed for a non-infectious cause. In contrast, patients revised for infection at baseline were also more likely to undergo re-revision for infection compared with other revision indications (p = 0.007).

Instability was responsible for 29% of failures in the
subgroup revised for dislocation, with recurrent dislocation
occurring in 43.7%. Among these, seven patients required a
second re-revision for repeated instability (Table I).

Fractures represented 30 cases, subdivided into
intraoperative fractures (n = 22, including femoral perfora-
tions, trochanteric and shaft fractures) and postoperative
periprosthetic fractures (n = 8, Vancouver B2 to B3). Six of
these led to subsequent failure.

In univariate analysis (Table II), age (p = 0.019), revision
rank > R1 (p < 0.001), revision for infection or dislocation (both
<figure><img src="image_5.png" /><figcaption>Fig. 2</figcaption></figure>

Case 3: Pelvic discontinuity following revision for corrosion in a metal-on-metal bearing (1a) in a 78-year-old female. The initial revision, using a cemented cone-shaped acetabular component and a modular femoral component, was complicated by a fall three weeks postoperatively (1b, 1c), resulting in an anterior column and quadrilateral plate fracture with cup protrusion. A combined surgical approach (posterior and modified Stoppa) enabled implant removal, open reduction and internal fixation with suprapectineal plate, Kerboull reinforcement ring, structural bone graft, and implantation of a cemented dual-mobility cup (1d). Full weightbearing was authorized. There were no complications at 12 months.

<figure><img src="image_6.png" /><figcaption>Fig. 3</figcaption></figure>

Aetiologies of revision total hip arthroplasty (RTHA). LLD, leg length discrepancy; ARMD, adverse reaction to metal debris.
<table><caption>**Table I.** Failure rate and cause according to the initial revision total hip arthroplasty aetiology.</caption><thead><tr><th>RTHA aetiology</th><th>Loosening (n = 343)</th><th>PPF (n = 308)</th><th>Infection (n = 146)</th><th>Dislocation (n = 55)</th><th>Other (n = 111)</th><th>Total (n = 963)</th></tr></thead><tbody><tr><td>Failure rate, n (%)</td><td>41/343 (12)</td><td>31/308 (10.1)</td><td>36/146 (24.7)</td><td>16/55 (29)</td><td>11/111 (9.9)</td><td>135/963 (14)</td></tr><tr><td><strong>Failure mode, n (%)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reoperation</td><td>1 (2.5)</td><td>5 (16.1)</td><td>3 (8.3)</td><td>4 (25)</td><td>2 (18.2)</td><td>15 (11.1)</td></tr><tr><td>Early re-revision &lt; 1 year</td><td>29 (70.7)</td><td>22 (71)</td><td>29 (80.6)</td><td>6 (37.5)</td><td>8 (72.7)</td><td>94 (69.6)</td></tr><tr><td>Late re-revision &gt; 1 year</td><td>11 (26.8)</td><td>4 (12.9)</td><td>4 (11.1)</td><td>6 (37.5)</td><td>1 (9.1)</td><td>26 (19.3)</td></tr><tr><td><strong>Failure cause, n (%)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Loosening</td><td>7 (17.1)</td><td>3 (9.7)</td><td>1 (2.8)</td><td>3 (18.8)</td><td>3 (27.2)</td><td>17 (12.6)</td></tr><tr><td>Periprosthetic fracture</td><td>5 (12.2)</td><td>4 (12.9)</td><td>1 (2.8)</td><td>1 (6.2)</td><td>1 (9.1)</td><td>12 (8.9)</td></tr><tr><td>Infection</td><td>17 (41.4)</td><td>18 (58.1)</td><td>28 (77.8)</td><td>5 (31.3)</td><td>4 (36.4)</td><td>72 (53.3)</td></tr><tr><td>Dislocation</td><td>5 (12.2)</td><td>5 (16.1)</td><td>5 (13.8)</td><td>7 (43.7)</td><td>2 (18.2)</td><td>24 (17.8)</td></tr><tr><td>Other</td><td>7 (17.1)</td><td>1 (3.2)</td><td>1 (2.8)</td><td>0</td><td>1 (9.1)</td><td>10 (7.4)</td></tr><tr><td><strong>Total iterative failure, n</strong></td><td>6</td><td>4</td><td>8</td><td>2</td><td>1</td><td></td></tr><tr><td>Loosening</td><td>1</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1 (4.8)</td></tr><tr><td>Fracture</td><td>1</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1 (4.8)</td></tr><tr><td>Infection</td><td>1</td><td>4</td><td>5</td><td>1</td><td>0</td><td>11 (52.4)</td></tr><tr><td>Dislocation</td><td>3</td><td>0</td><td>3</td><td>1</td><td>0</td><td>7 (33.2)</td></tr><tr><td>Other</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>1 (4.8)</td></tr><tr><td>Iterative failure rate, n (%)</td><td>14.6</td><td>12.9</td><td>22.2</td><td>12.5</td><td>9.1</td><td>15.6</td></tr></tbody></table>

NS, not significant; PPF, periprosthetic fracture; RTHA, revision total hip arthroplasty.

p < 0.001), use of a constrained cup (retentive design, distinct from dual-mobility) (p < 0.001) or acetabular reinforcement (ring, cages, or augments) (p = 0.011), and the occurrence of early or late complications (p < 0.001) were significantly associated with RTHA failure. No influence was observed for BMI, revision type, surgical approach, extended trochanteric osteotomy (ETO), fixation method, femoral implant, graft use, bearing surface, or intraoperative complications. Mortality was also not associated with RTHA failure.

In multivariate analysis (Figure 4), age ≥ 75 years (odds ratio (OR) 0.61, 95% CI 0.39 to 0.96; p = 0.033), revision rank ≥ R3 (OR 1.96, 95% CI 1.08 to 3.56; p = 0.026), revision for infection (OR 2.0, 95% CI 1.17 to 3.41; p = 0.011) or dislocation (OR 2.86, 95% CI 1.41 to 5.77; p = 0.004), long modular revision component (OR 2.38, 95% CI 1.17 to 4.85; p = 0.017), and constrained cups (OR 5.38, 95% CI 1.38 to 21.01; p = 0.016) remained independent risk factors for failure.

Discussion

This multicentre study of 963 patients undergoing RTHA provides contemporary insights into the causes and risk factors for failure after revision surgery. We observed an overall failure rate of 14%, with most failures occurring within the first postoperative year. This figure is consistent with contemporary series: Badarudeen et al¹⁵ reported a 15.8% iterative failure rate in a large Medicare cohort, while Jafari et al¹⁶ and Smith et al¹⁷ described re-revision rates between 12% and 20% in multicentre and registry studies, with infection and instability as the leading causes. Our findings therefore lie within the expected

range, while also underlining that the majority of failures occur early, as 70% arose during the first postoperative year. PJI was the leading cause of failure, while recurrent instability remained a major challenge despite the widespread use of dual-mobility (DM) constructs. These findings emphasize the complexity of RTHA and the need for tailored strategies for high-risk patients.

Our results confirm that PJI is now the most common cause of failure following RTHA, accounting for 53% of all failures, including 61% that were new infections after revision for a non-infectious indication. International comparisons show that infection has become a leading indication for revision: 22.7% in Australia, 21.5%, in Sweden, 10.5% in Italy,¹⁸,¹⁹ 15.2% in France, and 11.3% in the USA.²⁰

Similar to Jafari et al¹⁶ and Smith et al,¹⁷ who also identified PJI as the main cause of iterative failure, our findings highlight its growing impact. Recent registry data indicate that infection-related revisions have doubled in the past 15 years,²¹ particularly during the early postoperative period, as confirmed by Nordic and English series.²² Schwartz et al¹² further reported a 65% increase in revisions for PJI over the last decade.

Beyond incidence, a better understanding of pathophysiology has contributed to the apparent rise in PJI. Studies by Brochin et al²³ and Kurtz et al²⁴ have shown increasing detection rates, likely due to improved microbiological methods and systematic searches for low-virulence organisms such as *Staphylococcus epidermidis* and *Cutibacterium acnes*,²⁵ which were previously underestimated.²¹ Renard
<table><caption>**Table II.** Univariate analysis of risk factors for revision total hip arthroplasty (RTHA) failure. Comparison between patients who underwent revision of total hip arthroplasty with those without failure.</caption><thead><tr><th>Variable</th><th>RTHA (n = 828)</th><th>RTHA failure (n = 135)</th><th>p-value*</th></tr></thead><tbody><tr><td><strong>Sex, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Female</td><td>370 (44.7)</td><td>62 (45.9)</td><td></td></tr><tr><td>Male</td><td>458 (55.3)</td><td>73 (54.1)</td><td></td></tr><tr><td>Mean index PTH year (SD; range)</td><td>2007 (10.2; 1973 to 2021)</td><td>2009 (9.2; 1984 to 2021)</td><td>NS</td></tr><tr><td>Mean time to revision, yrs (SD; range)</td><td>11.3 (10; 0 to 45)</td><td>9.8 (8.8; 0 to 31)</td><td>NS</td></tr><tr><td>Mean age, yrs (SD; range)</td><td>73 (13.5; 14 to 104)</td><td>71 (10.6; 37 to 94)</td><td>0.019</td></tr><tr><td>Mean weight, kg (SD; range)</td><td>73.3 (17.9; 35 to 155)</td><td>73.7 (17.6; 43 to 127)</td><td>NS</td></tr><tr><td>Mean BMI, kg/m² (SD; range)</td><td>26.2 (5.4; 12.4 to 50)</td><td>26.2 (5.3; 17 to 44.3)</td><td>NS</td></tr><tr><td><strong>Revision rank, n (%)</strong></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>R1</td><td>588 (71)</td><td>76 (56.3)</td><td></td></tr><tr><td>R2</td><td>164 (19.8)</td><td>32 (23.7)</td><td></td></tr><tr><td>R ≥ 3</td><td>76 (9.1)</td><td>27 (20)</td><td></td></tr><tr><td><strong>Revision type, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Bipolar</td><td>433 (52.3)</td><td>73 (54.1)</td><td></td></tr><tr><td>Unipolar femur</td><td>139 (16.8)</td><td>20 (14.8)</td><td></td></tr><tr><td>Unipolar acetabulum</td><td>245 (29.6)</td><td>37 (27.4)</td><td></td></tr><tr><td>Modular components</td><td>11 (1.3)</td><td>5 (3.7)</td><td></td></tr><tr><td><strong>Atiology of revision, n (%)</strong></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Loosening</td><td>302 (36.5)</td><td>41 (30.4)</td><td></td></tr><tr><td>Fracture</td><td>277 (33.4)</td><td>31 (23)</td><td></td></tr><tr><td>Infection</td><td>110 (13.3)</td><td>36 (26.7)</td><td></td></tr><tr><td>Dislocation</td><td>39 (4.7)</td><td>16 (11.8)</td><td></td></tr><tr><td>Others</td><td>100 (12.1)</td><td>11 (8.1)</td><td></td></tr><tr><td><strong>Approach, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Posterior</td><td>818 (98.8)</td><td>133 (98.5)</td><td></td></tr><tr><td>Anterior</td><td>7 (0.8)</td><td>2 (1.5)</td><td></td></tr><tr><td>Lateral</td><td>3 (0.4)</td><td>0 (0.0)</td><td></td></tr><tr><td><strong>ETO, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Yes</td><td>53 (6.4)</td><td>8 (5.9)</td><td></td></tr><tr><td>No</td><td>775 (93.6)</td><td>127 (94.1)</td><td></td></tr><tr><td><strong>ETO fixation, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Cerclage</td><td>31 (58.5)</td><td>7 (87.5)</td><td></td></tr><tr><td>Plate</td><td>22 (41.5)</td><td>1 (12.5)</td><td></td></tr><tr><td><strong>Acetabular implant, n (%)</strong></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Standard cup</td><td>89 (10.7)</td><td>16 (11.9)</td><td></td></tr><tr><td>DM cup</td><td>735 (88.8)</td><td>113 (83.7)</td><td></td></tr><tr><td>Constrained cup</td><td>4 (0.5)</td><td>6 (4.4)</td><td></td></tr><tr><td><strong>Cup fixation, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Cement</td><td>164 (19.8)</td><td>34 (25.2)</td><td></td></tr><tr><td>Cementless</td><td>664 (80.2)</td><td>101 (74.8)</td><td></td></tr><tr><td><strong>Acetabular reinforcement, n (%)</strong></td><td></td><td></td><td>0.011</td></tr></tbody></table>

(Continued)
(Continued)

<table><thead><tr><th>Variable</th><th>RTHA (n = 828)</th><th>RTHA failure (n = 135)</th><th>p-value*</th></tr></thead><tbody><tr><td>Kerboul ring</td><td>112 (13.5)</td><td>21 (15.6)</td><td></td></tr><tr><td>Bursch Schneider ring</td><td>25 (3.0)</td><td>11 (8.1)</td><td></td></tr><tr><td>Augment/custom</td><td>14 (1.7)</td><td>0 (0.0)</td><td></td></tr><tr><td>None</td><td>677 (81.8)</td><td>103 (76.3)</td><td></td></tr><tr><td><strong>Graft, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Allograft</td><td>174 (21)</td><td>35 (25.9)</td><td></td></tr><tr><td>Autograft</td><td>77 (9.3)</td><td>8 (5.9)</td><td></td></tr><tr><td>None</td><td>577 (69.7)</td><td>92 (68.2)</td><td></td></tr><tr><td><strong>Bearing, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Ceramic - polyethylene</td><td>57 (6.9)</td><td>10 (7.4)</td><td></td></tr><tr><td>Ceramic - ceramic</td><td>26 (3.1)</td><td>3 (2.2)</td><td></td></tr><tr><td>Metal polyethylene</td><td>745 (90.0)</td><td>122 (90.4)</td><td></td></tr><tr><td><strong>Femoral implant, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Standard component</td><td>364 (44.0)</td><td>52 (38.5)</td><td></td></tr><tr><td>Long monobloc component</td><td>187 (22.6)</td><td>22 (16.3)</td><td></td></tr><tr><td>Long modular metaphyseal component</td><td>192 (23.2)</td><td>42 (31.1)</td><td></td></tr><tr><td>Long modular neck component</td><td>85 (10.2)</td><td>19 (14.1)</td><td></td></tr><tr><td><strong>Component fixation, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Cement</td><td>71 (8.6)</td><td>12 (8.9)</td><td></td></tr><tr><td>Cementless</td><td>757 (91.4)</td><td>123 (91.1)</td><td></td></tr><tr><td><strong>Femoral component locking, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>Yes</td><td>179 (21.6)</td><td>30 (22.2)</td><td></td></tr><tr><td>No</td><td>649 (78.4)</td><td>105 (7.8)</td><td></td></tr><tr><td><strong>Intraoperative complication, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>False path</td><td>7 (0.9)</td><td>1 (0.7)</td><td></td></tr><tr><td>Fracture</td><td>25 (3.0)</td><td>5 (3.7)</td><td></td></tr><tr><td>None</td><td>796 (96.1%)</td><td>129 (95.6%)</td><td></td></tr><tr><td><strong>Early complication &lt; 1 year, n (%)</strong></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Loosening</td><td>3 (0.4)</td><td>10 (7.4)</td><td></td></tr><tr><td>Fracture</td><td>5 (0.6)</td><td>9 (6.7)</td><td></td></tr><tr><td>Infection</td><td>25 (3.0)</td><td>68 (50.4)</td><td></td></tr><tr><td>Dislocation</td><td>10 (1.2)</td><td>23 (17.0)</td><td></td></tr><tr><td>Other</td><td>13 (1.6)</td><td>8 (5.9)</td><td></td></tr><tr><td>None</td><td>772 (93.2)</td><td>17 (12.6)</td><td></td></tr><tr><td><strong>Late complication &gt; 1 year, n (%)</strong></td><td></td><td></td><td>&lt; 0.001</td></tr><tr><td>Loosening</td><td>2 (0.2)</td><td>8 (5.9)</td><td></td></tr><tr><td>Fracture</td><td>0 (0.0)</td><td>4 (3.0)</td><td></td></tr><tr><td>Infection</td><td>6 (0.7)</td><td>17 (12.6)</td><td></td></tr><tr><td>Dislocation</td><td>0 (0.0)</td><td>9 (6.7)</td><td></td></tr><tr><td>Others</td><td>7 (0.9)</td><td>3 (2.2)</td><td></td></tr><tr><td>None</td><td>813 (98.2)</td><td>94 (69.6)</td><td></td></tr></tbody></table>

(Continued)
(Continued)

<table><thead><tr><th>Variable</th><th>RTHA (n = 828)</th><th>RTHA failure (n = 135)</th><th>p-value*</th></tr></thead><tbody><tr><td><strong>Death, n (%)</strong></td><td></td><td></td><td>NS</td></tr><tr><td>&lt; 1 year</td><td>27 (3.3)</td><td>2 (1.5)</td><td></td></tr><tr><td>1 to 3 years</td><td>10 (1.2)</td><td>4 (3.0)</td><td></td></tr><tr><td>&gt; 3 years</td><td>3 (0.4)</td><td>0 (0.0)</td><td></td></tr><tr><td>No</td><td>788 (95.1)</td><td>129 (95.5)</td><td></td></tr></tbody></table>

Bipolar revision = both acetabular and femoral component changed; unipolar femur = femoral component changed; unipolar acetabulum = acetabular component change; modular components = modular exchange of head and/or liner without shell/component change.

*Categorical variables were compared using chi-squared test or Fisher's exact test. Continuous variables were compared using Student's t-test, Welch's t-test, or Mann-Whitney U test, as appropriate.

DM, dual mobility; ETO, extensive trochanteric osteotomy; NS, not significant.

et al²⁶ reported occult infection in 7% of presumed aseptic revisions, underscoring the importance of systematic screening. Together, these findings emphasize that infection remains the foremost obstacle to long-term success in revision surgery and requires ongoing optimization of both prevention and management strategies.

Instability was the indication for revision in only 5.7% of our cohort, reflecting the widespread French adoption of DM cups, compared with more than 20% in the USA prior to Food and Drug Administration (FDA) approval of DM in 2009.²⁷,²⁸ In our series, the protective effect of DM constructs on RTHA survivorship was confirmed, consistent with international literature showing that DM significantly reduces dislocation risk without increasing loosening²⁹ or infection rates.³⁰

Nevertheless, dislocation remains a critical issue in selected cases. Revision for instability was associated with a 29% failure rate in our cohort, with recurrent dislocation occurring in 43.7% of cases, particularly in patients with chronic instability, multiple previous operations, or abductor deficiency. These results are consistent with published iterative dislocation rates ranging from 21% to 39%.³¹ Intraprosthetic dislocation, although rare, was also observed in two cases (0.2%), both involving modular DM cups, in line with reported rates around 1%.³²

When recurrent instability persists, constrained acetabular components are often considered. However, their use was associated with a 60% failure rate in our series, mainly due to loosening and infection. This reflects both the inherent complexity of these cases and the known limitations of constrained designs, as previously reported by Della Valle et al,³³ Hernandez et al,³⁴ and others.³³ While constrained liners may prevent dislocation in the short term, they should be reserved for highly selected patients given their poor long-term durability.

Finally, periprosthetic fracture, often under-reported in international series, emerged as the second most common indication for revision in our cohort (32%). This proportion is higher than in Australia (21.8%) or Sweden (9.2%), and represents a striking increase compared with a previous French multicentre study reporting 11.8% in 2010.³⁵ This trend likely reflects demographic changes, longer life expectancy, and the growing prevalence of hip arthroplasty,

<figure><img src="image_7.png" /><figcaption>Fig. 4</figcaption></figure>

Forest plot showing risk factors influencing failure of revision total hip arthroplasty (RTHA), as determined by multivariate analysis. DM, dual mobility.

and underlines the need to anticipate an increasing burden of fracture-related revisions in the future.

The strengths of this work include its large sample size, multicentre design, and comprehensive dataset, which captures both reoperations and re-revisions, events often missed by national registries. Our study also distinguishes
between early and late failures and identifies new compared with recurrent infections, offering clinically relevant granularity.

Limitations include its retrospective nature and reliance on coding systems, with potential classification bias and incomplete data for comorbidities, functional outcomes, and mortality beyond one year. Another limitation relates to implant design data. Although we documented the use of dual-mobility constructs and identified intraprosthetic dislocations in two modular cups (MDM X3; Stryker, USA), detailed information on the breakdown between monobloc and modular dual-mobility implants, as well as manufacturer-specific data, was not consistently available across all centres. As a result, our analysis could not explore potential differences in outcomes according to implant subtype. This limitation should be considered when interpreting our results.

Importantly, failures after revision are time-dependent events, but due to incomplete availability of index THA dates across centres, Kaplan-Meier or Cox regression analyses could not be performed. We therefore relied on logistic regression, and our results should be interpreted within this context. Nonetheless, the finding that 70% of failures occurred within the first year provides valuable information about the critical early postoperative period.

In conclusion, despite advances in implant technology and surgical techniques, revision THA remains associated with substantial risk of iterative failure. PJI has emerged as the predominant challenge, while recurrent instability continues to pose difficulties in selected patients. The widespread use of DM cups in France has reduced the burden of dislocation, but constrained liners and modular components remain associated with high failure rates. The rising incidence of periprosthetic fractures adds further complexity.

These findings underline the need for meticulous preoperative planning, rigorous infection prevention, and tailored implant selection, particularly in high-risk patients. Future prospective studies incorporating survival analyses and functional outcomes will be essential to refine predictive models and improve long-term durability after revision arthroplasty.

## Supplementary material

Tables showing the Common Classification of Medical Acts of French Health Insurance codes, the failure rate and cause according to the initial revision total hip arthroplasty (RTHA) aetiology, and a univariate analysis of risk factors for RTHA failure.

## References

1. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. *Clin Orthop Relat Res.* 2009;467(10):2606-2612.

2. Ollivier M, Frey S, Parratte S, Flecher X, Argenson JN. Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement. *Bone Joint J.* 2014;96-B(8):1041-1046.

3. Hoorntje A, Janssen KY, Bolder SBT, et al. The effect of total hip arthroplasty on sports and work participation: a systematic review and meta-analysis. *Sports Med.* 2018;48(7):1695-1726.

4. Hamilton DF, Loth FL, Giesinger JM, et al. Validation of the English language Forgotten Joint Score-12 as an outcome measure for total hip

and knee arthroplasty in a British population. *Bone Joint J.* 2017;99-B(2): 218-224.

5. Erivan R, Villatte G, Dartus J, Reina N, Descamps S, Boisgard S. Progression and projection for hip surgery in France, 2008-2070: epidemiologic study with trend and projection analysis. *Orthop Traumatol Surg Res.* 2019;105(7):1227-1235.

6. Prokopetz JJ, Losina E, Bliss RL, Wright J, Baron JA, Katz JN. Risk factors for revision of primary total hip arthroplasty: a systematic review. *BMC Musculoskelet Disord.* 2012;13:251.

7. de Steiger RN, Lewis PL, Harris I, Lorimer MF, Graves SE. What is the outcome of the first revision procedure of primary THA for osteoarthritis? A study from the Australian Orthopaedic Association National Joint Replacement Registry. *Clin Orthop Relat Res.* 2022;480(10):1952-1970.

8. Delaunay C, Hamadouche M, Girard J, Duhamel A, SoFCOT Group. What are the causes for failures of primary hip arthroplasties in France? *Clin Orthop Relat Res.* 2013;471(12):3863-3869.

9. Bohl DD, Samuel AM, Basques BA, Della Valle CJ, Levine BR, Grauer JN. How much do adverse event rates differ between primary and revision total joint arthroplasty? *J Arthroplasty.* 2016;31(3):596-602.

10. Boddapati V, Fu MC, Tetreault MW, Blevins JL, Richardson SS, Su EP. Short-term complications after revision hip arthroplasty for prosthetic joint infection are increased relative to noninfectious revisions. *J Arthroplasty.* 2018;33(9):2997-3002.

11. Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. *J Arthroplasty.* 2016;31(7): 1400-1406.

12. Schwartz AM, Farley KX, Guild GN, Bradbury TL. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. *J Arthroplasty.* 2020;35(6S):S79-S85.

13. Ong KL, Lau E, Suggs J, Kurtz SM, Manley MT. Risk of subsequent revision after primary and revision total joint arthroplasty. *Clin Orthop Relat Res.* 2010;468(11):3070-3076.

14. Bingham JS, Salib CG, McQuivey K, Temkit M, Spangehl MJ. An evidence-based clinical prediction algorithm for the Musculoskeletal Infection Society minor criteria. *J Arthroplasty.* 2018;33(9):2993-2996.

15. Badarudeen S, Shu AC, Ong KL, Baykal D, Lau E, Malkani AL. Complications after revision total hip arthroplasty in the medicare population. *J Arthroplasty.* 2017;32(6):1954-1958.

16. Jafari SM, Coyle C, Mortazavi SMJ, Sharkey PF, Parvizi J. Revision hip arthroplasty: infection is the most common cause of failure. *Clin Orthop Relat Res.* 2010;468(8):2046-2051.

17. Smith MA, Deakin AH, Allen D, Baines J. Midterm outcomes of revision total hip arthroplasty using a modular revision hip system. *J Arthroplasty.* 2016;31(2):446-450.

18. Longo UG, Papalia R, Salvatore G, et al. Epidemiology of revision hip replacement in Italy: a 15-year study. *BMC Surg.* 2022;22(1):355.

19. Kenney C, Dick S, Lea J, Liu J, Ebraheim NA. A systematic review of the causes of failure of revision total hip arthroplasty. *J Orthop.* 2019;16(5): 393-395.

20. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. *J Bone Joint Surg Am.* 2009;91-A(1):128-133.

21. Dale H, Fenstad AM, Hallan G, et al. Increasing risk of revision due to infection after primary total hip arthroplasty: results from the Nordic Arthroplasty Register Association. *Acta Orthop.* 2023;94:307-315.

22. 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):391-398.

23. 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.

24. Kurtz SM, Lau EC, Son M-S, Chang ET, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population. *J Arthroplasty.* 2018;33(10):3238-3245.

25. Cochrane NH, Kim BI, Wu M, O'Donnell JA, Seidelman JL, Jiranek WA. Cutibacterium positive cultures in total hip arthroplasty: contaminant or pathogen? *J Arthroplasty.* 2022;37(7S):S642-S646.

26. Renard G, Laffosse J-M, Tibbo M, et al. Periprosthetic joint infection in aseptic total hip arthroplasty revision. *Int Orthop.* 2020;44(4):735-741.
27. **Abdel MP.** Dual-mobility constructs in revision total hip arthroplasties. *J Arthroplasty*. 2018;33(5):1328-1330.

28. **Grace TR, Goh GS, Lee G-C, Kamath AF, Kurtz SM, Courtney PM.** Dual mobility reduces dislocations-why I use it in all revisions. *J Arthroplasty*. 2021;36(7S):S63-S69.

29. **Schmidt A, Batailler C, Fary C, Servien E, Lustig S.** Dual mobility cups in revision total hip arthroplasty: efficient strategy to decrease dislocation risk. *J Arthroplasty*. 2020;35(2):500-507.

30. **Prudhon JL, Desmarchelier R, Hamadouche M, Delaunay C, Verdier R.** Is dual mobility associated with an increased risk of revision for infection? Matched cohort of 231 cases of dual-mobility cups and 231 fixed cups. *Hip Int*. 2018;28(2):200-204.

31. **Jo S, Jimenez Almonte JH, Sierra RJ.** The cumulative risk of re-dislocation after revision THA performed for instability increases close to 35% at 15 years. *J Arthroplasty*. 2015;30(7):1177-1182.

32. **De Martino I, D'Apolito R, Soranoglou VG, Poultside LA, Sculco PK, Sculco TP.** Dislocation following total hip arthroplasty using dual mobility acetabular components: a systematic review. *Bone Joint J*. 2017;99-B(ASuppl1):18-24.

33. **Della Valle CJ, Chang D, Sporer S, Berger RA, Rosenberg AG, Paprosky WG.** High failure rate of a constrained acetabular liner in revision total hip arthroplasty. *J Arthroplasty*. 2005;20(7 Suppl 3):103-107.

34. **Hernandez NM, Sierra RJ, Trousdale RT.** Constrained liner revision is less effective with each subsequent constrained liner revision at preventing instability. *J Arthroplasty*. 2019;34(7S):S282-S286.

35. **Ehlinger M, Delaunay C, Karoubi M, et al.** Revision of primary total hip arthroplasty for peri-prosthetic fracture: a prospective epidemiological study of 249 consecutive cases in France. *Orthop Traumatol Surg Res*. 2014;100(6):657-662.

## Author information

V. Cascales, MD, Senior Clinical Fellow

R. Coulomb, MD, Consultant Orthopaedic and Traumatological Surgeon

Department of Orthopaedic and Traumatological Surgery, Spine Surgery Unit, University Hospital of Nîmes (CHU), Nîmes, France.

C. Foissey, MD, Consultant Orthopaedic Surgeon

S. Lustig, MD, PhD, Professor of Orthopaedic Surgery, Head of Department

Orthopaedic Surgery Department, Croix Rousse Hospital, Hospices Civils de Lyon, Lyon Cedex, France.

M. Mercier, MD, Consultant Orthopaedic Surgeon

M-H. Fessy, MD, PhD, Professor of Orthopaedic Surgery, Head of Department

Orthopaedic Surgery Department, Hospital Lyon Sud, Oullins-Pierre-Bénite, France.

P. Kouyoumdjian, MD, PhD, Professor of Orthopaedic Surgery, Head of Department, Department of Orthopaedic and Traumatological Surgery, Spine Surgery Unit, University Hospital of Nîmes (CHU), Nîmes, France; University Mechanical and Civil Engineering Laboratory, Montpellier, France.

## Author contributions

V. Cascales: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft.

C. Foissey: Conceptualization, Data curation, Formal analysis.

M. Mercier: Conceptualization, Data curation, Formal analysis.

R. Coulomb: Formal analysis, Methodology.

M-H. Fessy: Investigation, Supervision, Validation.

S. Lustig: Investigation, Supervision, Validation.

P. Kouyoumdjian: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing.

## Funding statement

The author(s) received no financial or material support for the research, authorship, and/or publication of this article, other than the open access funding outlined below.

## ICMJE COI statement

R. Coulomb is a faculty instructor for Stryker education programmes, and is a member of the French Society of Orthopaedics and Traumatology (SOFCOT), the French Hip & Knee Surgery Society (SFHG), and a faculty member of the French College of Orthopaedic Surgery, all of which are unrelated to this work. M-H Fessy discloses unrelated royalties or licenses from Stryker, Johnson & Johnson and Groupe Lépine. P. Kouyoumdjian declares unrelated consulting fees; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events; and support for attending meetings and/or travel from Stryker and Groupe Lépine, as well as being a faculty member of the French College of Orthopaedic Surgery, a board member of SOFCOT, the European Hip Society, the SFHG, a member of the American Association of Hip and Knee Surgeons and the French Society of Spinal Surgery, and French National Academy of Surgery.

## Data sharing

The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.

## Acknowledgements

### The Writing Committee:

Jean L. Prudhon, MD, Senior Orthopaedic Surgeon, Orthopaedic Surgery Department, Orthocèdres Hospital, Echirolles, France.

Roger Badet, MD, Senior Orthopaedic Surgeon, Orthopaedic Surgery Department, Orthocèdres Hospital, Echirolles, France.

## Open access funding

The open access fee was funded by the Department of Orthopaedic Surgery, University Hospital of Nîmes (CHU), Nîmes, France.

© 2026 Cascales et al. This article is distributed under the terms of the Creative Commons Attributions (CC BY 4.0) licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original author and source are credited.