Most hip replacements work well for decades. But when a hip replacement fails, the experience is frustrating and often frightening. You may have expected your hip problem to be solved by surgery, and now you are dealing with pain, instability, or complications you did not anticipate.
Stanford Fellowship-Trained30+ PublicationsLong Beach & Greater LAVirtual Second Opinions
Dr. Leo Zalikha specializes in evaluating and treating failed hip replacements. His fellowship training in adult reconstruction at Stanford Medicine focused heavily on understanding why hip replacements fail and how to fix them. If you are experiencing problems with your hip replacement, the first step is a thorough evaluation to determine exactly what is going on.
By Dr. Leo Zalikha, MD — Stanford fellowship-trained in adult reconstruction, specializing in hip & knee replacement including complex revision · Long Beach, CA · Last updated June 11, 2026
A failed hip replacement is an implant that is no longer doing its job — most often because of loosening, instability, infection, implant wear, fracture around the implant, or a reaction to implant materials. The cause can almost always be identified with a careful history, an examination, X-rays compared over time, and targeted blood work — and not every painful hip replacement needs another operation.
Key Takeaways
Persistent pain is not the same as failure: across prospective studies, about 7% to 23% of patients report an unfavourable long-term pain outcome after hip replacement — 9% or more in the best-quality studies [1]. It always deserves an explanation, but it does not automatically mean your implant has failed.
In a US national database of more than 258,000 revision hip replacements, dislocation (17.3%) and mechanical loosening (16.8%) were the two leading reasons hips were redone [2].
The symptom patterns taken most seriously: pain that returns after a pain-free interval, start-up pain with the first steps, and a hip that feels like it will give way.
Infection must be ruled out before any revision — ESR and CRP blood tests, with aspiration of the joint when indicated.
If you have a metal-on-metal implant, the FDA recommends seeing your surgeon if you develop symptoms and continuing routine follow-up every 1 to 2 years even if you feel well [3].
Signs Your Hip Replacement May Be Failing
Pain
Pain is the most common reason patients seek evaluation for a potentially failed hip replacement. It is important to distinguish between expected discomfort (which resolves during normal recovery) and pain that suggests a problem with the implant. Concerning pain patterns include:
Pain that was improving after surgery but has returned or worsened
Start-up pain (groin or thigh pain with the first steps after sitting)
Pain at rest or at night that was not present before
A deep ache in the groin, thigh, or buttock that does not respond to typical treatments
Instability or Dislocation
If the hip feels like it slips, catches, or "gives way," the implant may be unstable. Recurrent dislocation (where the ball separates from the socket) is a clear sign that surgical intervention is needed. Even subtle instability can significantly affect confidence and function.
Leg Length Difference
A noticeable difference in leg length after hip replacement, particularly one that is getting worse or causing back pain and gait problems, can indicate component migration or loosening.
Mechanical Symptoms
Grinding, clicking, or clunking sensations that are new or progressive may indicate bearing wear, component loosening, or impingement between the implant parts.
Swelling, Warmth, or Drainage
Persistent or recurring swelling, warmth over the hip, or any drainage from the incision site raises concern for infection. These symptoms require prompt evaluation.
Declining Function
A gradual decline in what you can do, shorter walking distances, more difficulty with stairs, reluctance to leave the house, is a signal that something is not right.
Is New Groin or Thigh Pain a Sign My Hip Replacement Is Loosening?
Mechanical loosening accounts for 16.8% of revision hip replacements in a US national database of more than 258,000 cases — second only to dislocation [2]. The story that gets my attention is new or worsening pain, deep in the groin or in the thigh, in a hip that had been comfortable. As a general rule — useful, not absolute — groin pain points toward the socket (acetabular) side and thigh pain toward the stem (femoral) side. Pain at rest or at night, or a deep ache that has stopped responding to the usual measures, belongs on the same list. For a focused guide to this specific problem, see our article on loose hip replacement symptoms.
What Is Start-Up Pain, and Why Does It Matter?
Start-up pain is groin or thigh pain with the first few steps after sitting or lying down that eases somewhat as you keep walking. There is no verified statistic to attach to it, so I will say it plainly: it is the single symptom pattern that most makes me suspect a loose implant. An implant that has lost its bond with bone shifts slightly when it is first loaded, then settles — which is exactly what that pattern feels like from the inside. When a patient describes start-up pain, my next step is almost always the same: current X-rays compared side by side with every older film we can find.
Why Does My Hip Feel Unstable, Like It Will Give Way?
Dislocation is the single most common reason hip replacements are revised in the United States, accounting for 17.3% of revisions in a national database [2]. Instability runs on a spectrum. At one end is a vague sense that the hip cannot be trusted — patients describe slipping, catching, or a feeling of giving way on certain movements. At the other end is frank dislocation, where the ball leaves the socket and must be put back. A single early dislocation can sometimes be managed without surgery, but recurrent dislocation is a structural problem — component position, soft-tissue tension, or both — and it rarely fixes itself. If your hip has dislocated more than once, an evaluation for revision hip replacement is warranted.
Should I Worry About Clicking, Squeaking, or Clunking?
An occasional painless click is common after hip replacement and usually harmless — often soft tissue moving over the implant. There is no reliable published number tying noise to failure, so the honest guide is the clinical rule: noise that is new, progressive, or paired with pain deserves attention. A squeak with every step or a clunk on certain movements can reflect bearing wear, impingement between components, or early instability. Noise alone is rarely urgent. Noise plus pain is a reason for X-rays, not reassurance over the phone.
My Hip Worked Well for Years — Why Does It Hurt Now?
Across prospective studies, about 7% to 23% of patients report an unfavourable long-term pain outcome after hip replacement — 9% or more in the best-quality studies [1]. I separate two stories. The first is the hip that never felt right after the original operation; those numbers show it is more common than most patients are told, and the cause often lies outside the implant — the spine, bursitis, tendinitis, or a hip that was never the true source of pain. The second story is different: a hip that worked well for years and has now deteriorated. I treat late-onset pain after a long pain-free interval as an implant problem until proven otherwise — wear, loosening, and late infection seeded through the bloodstream can all present exactly this way. Either story deserves a systematic workup, not a shrug.
What Causes Hip Replacement Failure
Understanding the cause of failure is critical because the treatment depends on the diagnosis.
Aseptic loosening:
The implant can lose its bond with bone over time, particularly if wear particles trigger an inflammatory response. Loosening causes pain with weight-bearing, often with a progressive component.
Infection:
Bacteria on the implant surface cause chronic inflammation and pain
Instability:
Component malposition or soft tissue deficiency leads to recurrent dislocation
Periprosthetic fracture:
A break in the bone around the implant, often after a fall
Adverse local tissue reaction (ALTR):
Particularly with metal-on-metal bearings, metallic debris can damage surrounding tissue
Implant wear:
The bearing surfaces deteriorate, generating debris and causing pain
Component malposition:
Poorly positioned components can cause impingement, accelerated wear, or limited motion
What Are the Most Common Reasons Hip Replacements Get Revised?
In the National Inpatient Sample — more than 258,000 US revision hip replacements from 2009 to 2013 — dislocation led at 17.3%, followed by mechanical loosening at 16.8% [2]. Those two mechanical problems together account for roughly a third of all hip revisions, and in the same database the most common operation performed was an all-component revision (41.8%), meaning both the socket and the stem were exchanged [2]. I share these figures for calibration, not alarm: they describe hips that have already failed, not your odds of ever needing a revision. The practical lesson is more useful — because the leading causes are mechanical and diagnosable, a painful hip replacement is a solvable diagnostic problem. What I tell my patients: pain is a symptom, failure is a diagnosis, and the workup exists to connect the two or to keep them apart.
What About Metal-on-Metal Hip Implants?
The FDA recommends that patients with metal-on-metal hips who develop symptoms see their orthopaedic surgeon, and that even patients who feel well continue routine follow-up — a physical examination and X-rays — every 1 to 2 years [3]. A metal-on-metal implant is one in which both bearing surfaces, the ball and the socket lining, are made of metal; these designs were used in some hip replacements and hip resurfacings. According to FDA patient information, metal particles released from the bearing may cause a reaction around the joint that leads to deterioration of the surrounding tissue, loosening of the implant, and failure of the device, and metal ions from the implant will enter the bloodstream [3]. In practice, evaluating a painful metal-on-metal hip adds steps to the standard workup — typically blood metal-ion testing and cross-sectional imaging to look for soft-tissue reactions — on top of the examination, serial X-rays, and infection labs that every painful hip replacement gets. If you have a metal-on-metal hip and new groin pain, swelling, or a change in how you walk, see your surgeon. If you feel entirely well, you do not need to panic — you need follow-up.
How Dr. Zalikha Evaluates a Failed Hip Replacement
A systematic evaluation is essential. Dr. Zalikha follows a structured approach:
1. History and Symptoms
When did the pain start? Is it getting worse? What makes it better or worse? Was there a pain-free period after the original surgery? Was there a specific event (fall, illness, dental procedure) that preceded the symptoms?
2. Physical Examination
Assessment of gait, range of motion, leg length, hip stability, and provocative testing. Examination of the spine and surrounding structures to rule out non-hip sources of pain.
3. Imaging
Current X-rays are compared to prior films to look for changes in component position, signs of loosening, bone loss, or fracture. A CT scan with metal artifact reduction may be ordered to better evaluate bone stock.
4. Laboratory Tests
Blood tests (ESR, CRP, and sometimes D-dimer) screen for infection. Elevated inflammatory markers prompt further investigation.
5. Joint Aspiration
If infection is suspected, fluid is aspirated from the hip joint and sent for cell count, culture, and sometimes molecular testing. Identifying or ruling out infection is one of the most important steps in the workup because it fundamentally changes the treatment plan.
6. Assessment of the Original Surgery
Reviewing the operative report, implant records, and any available imaging from the original surgery helps Dr. Zalikha understand what was done and what may have contributed to the failure.
Two principles anchor this workup. First, serial X-rays beat single X-rays: a component that has changed position between films taken months or years apart is loose, even when any single film looks acceptable. This is why I ask patients to bring, or help us request, every prior image — ideally back to the original surgery. Second, infection is ruled out, never assumed away. ESR and CRP blood tests are the screening gate; when they are elevated, or when suspicion stays high despite normal labs, aspiration of the joint for cell count and culture settles the question. A missed prosthetic joint infection turns a one-operation problem into a multi-operation problem, so this step is non-negotiable. And through all of it, one habit: treat the patient, not the X-ray. An imaging finding matters only when it explains your symptoms.
What Happens Next
Once the cause of failure is identified, Dr. Zalikha discusses the options. In many cases, revision hip replacement is recommended. The specifics of the revision, which components are changed, what approach is used, and how bone loss is managed, depend entirely on the diagnosis.
For patients with confirmed or suspected prosthetic joint infection, the treatment pathway is different and may involve staged surgery with an interim period of antibiotics.
Not every painful hip replacement requires revision. Some problems can be managed with observation, physical therapy, injections, or treatment of non-hip sources of pain. Dr. Zalikha is honest about what revision surgery can and cannot accomplish.
References
Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435. PMID: 22357571.
Gwam CU, Mistry JB, Mohamed NS, et al. Current Epidemiology of Revision Total Hip Arthroplasty in the United States: National Inpatient Sample 2009 to 2013. J Arthroplasty. 2017;32(7):2088-2092. PMID: 28336249.
U.S. Food and Drug Administration. Metal-on-Metal Hip Implants: Information for Patients. https://www.fda.gov/medical-devices/metal-metal-hip-implants/metal-metal-hip-implants-information-patients
FAQ
Frequently Asked Questions
No single symptom proves failure. The patterns that most warrant evaluation are new or worsening groin or thigh pain after a pain-free interval, start-up pain with the first steps after sitting, a feeling of instability or an actual dislocation, new noise that comes with pain, swelling or warmth around the hip, and declining function. The diagnosis is made with an examination, X-rays compared over time, and blood tests, not with symptoms alone.
Start-up pain is the classic early sign: pain in the groin or thigh with the first few steps after sitting or lying down that eases somewhat as you keep walking. As a general rule, groin pain points toward a loose socket and thigh pain toward a loose stem. Loosening is usually confirmed by comparing current X-rays with older films to look for changes in implant position.
Sometimes. Not every painful hip replacement is a failed one. Pain coming from the spine, bursitis, or tendinitis can be treated without touching the implant, and some implant findings can be safely observed. But a truly failed implant, recurrent dislocation, or a confirmed infection generally requires surgery. The honest answer depends entirely on the diagnosis, which is why a systematic workup comes first.
Screening starts with ESR and CRP blood tests, which measure inflammation. If they are elevated, or if suspicion remains high despite normal results, fluid is aspirated from the hip joint and sent for cell count and culture. Identifying or excluding infection is essential because it fundamentally changes the treatment plan.
Not necessarily. Many metal-on-metal hips continue to function well. The FDA recommends that patients who develop symptoms such as pain, swelling, or a change in walking ability see their orthopaedic surgeon, and that patients who feel well continue routine follow-up with a physical examination and X-rays every 1 to 2 years. Evaluation may include blood metal-ion testing and additional imaging, and revision is recommended only when the findings justify it.
It is not rare, but it should never be dismissed. Across prospective studies, about 7% to 23% of patients report an unfavourable long-term pain outcome after hip replacement, and the figure was 9% or more in the best-quality studies. Persistent pain at a year deserves a systematic evaluation rather than reassurance, and a second opinion is reasonable if you are not getting answers.
Ready for answers about your hip or knee? Request an appointment with Dr. Zalikha.
