RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Revision Surgery for Hip & Knee Replacements

July 2022 v1.0

NB Primary hip and knee replacement guidance is covered under separate policies. 

The Hertfordshire & West Essex ICB will fund up to two revision operations after primary hip and knee replacement, if they meet the criteria specified below.

As per NHS England Service Specification (2013), specialised orthopaedic services should be provided by appropriately trained multi-disciplinary teams (MDTs) at a specialist centre or hub provider through networks which have a critical mass to ensure that the right clinical skills and expertise are in place to ensure excellent outcomes.

Hip and knee revisions are subsequent operations on a joint that has already had a primary arthroplasty (joint reconstruction) operation. This includes revision and conversion surgery (partial knee replacement revision i.e. revision with like for like prosthesis and revision to a total knee replacement i.e. conversion, are both described as revisions).  

Hip and knee revision surgery can be carried out by local Specialist Orthopaedic Units, with the required expertise, with the exception of patients requiring specialist procedures for massive bone defects, pelvic fractures, infection or complex segmental femoral reconstruction. These exceptional patients should be referred to a Specialist Orthopaedic Centre.

General referral guidance for hip and knee joint replacement revision surgery:

NHS ICB funding for referral and assessment for first or second revision of hip or knee joint replacement revision surgery should be recommended in patients in whom the following criteria are met:

1. The patient has persistent pain which may indicate the presence of joint infection. 


2. Where infection is not suspected the patient has: 

  • persistent joint pain and/or loss of range of movement and function AND 
  • X-ray confirms the presence of aseptic loosening of the prosthesis AND 
  • had the evidence for outcome from revision surgery explained to them and understands that the outcomes from revision surgery are not likely be as good as those from primary replacement surgery. 

3. All patients should be fit for surgery at the time of referral and meet local criteria for lifestyle recommendations, including weight loss and smoking cessation, as per the policy for elective primary hip and knee surgery.

Initial assessment should be based in primary care with referral for consideration of revision surgery offered to symptomatic patients as above. 

ICBs will normally require prior approval for all revision surgery. 

NHS England Prescribed Specialised Service ‘flag rule’ indicates that third revision and greater will be funded by NHS England (OPCS-4 code Y717 ‘Third or greater revisional operation NOC ‘National Clinical Coding Standards’). These patients who require third or greater revision surgery may need to be transferred to a designated centre.