Complications of Hip Replacement

8/14/2019 Complications of Hip Replacement

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Complications of THR(killer ap)

Eugene Sherry

Bond University

Australia

Categorize- 4 groups

Soft tissue

Bone

Implant

Whole Person



Soft Tissue

DVT

Infection

Nerve damage

Chronic Pain

DVT

Can be devastating

Well defined risk factors

Incidence known

Prevention is possible

And treatment straight forward



DVT detail

Incidence:40-60% of THR or 0.19% (Fender et al,JBJS 1997) showed that the incidence of fatal PE (as diagnosed bypostmortem examination) was 4 / 2111 patients (0.19%).

Rule-of thumb : 50%(incidence)-10%(embolize)-2% (Die). With prevention- reduce by one fifth(10%-2%-0.4%)

(O’Reilly RF et al. The prevalence of venous thromboembolism after hip and knee replacement surgery.Med J Aust 2005; 182; 154-159.) 5999 patients.DVT after THR 8.9% with prophylaxis.Fatal in-hospital PE rare, 0.05%).

Diagnosis:

ultrasound prior to discharge and ? Repeat in high riskPrevention:aspirin- probably not enough.heparin and low molecular wt agents.reduces risk by 70%, start before incision

-? pentasaccharides- warfarin adjusted- dose, INR 2.5 (2 to 3), 10 days post-op

compressive devices ? proof

vena cava filter

MIS THR ? lower

DVT ctd

Treatment:standard treatment algorithm (confirmation of DVT/PE, followed by IVheparin or SQ low molecular wt heparin, followed by oral warfarin (once started patient is OK).



Infection

A disaster

Early /late presentation

Preventable

Hard to treat

Infection detail Incidence 0.5%-3% primary THR (4-6% of revisions)

Leads to multiple operations/prolonged IV and oralantibiotics/long rehab/huge personal, professional and economic

costs(4.8x that of primary THR; 2.8x of aseptic revision; U$50,000to 60,000)

Risk factors:

-patient (RA,DM,poor nutrition,obesity,sickelcell,transplants,steroids,decreased immunity,previoussurgery,dental work).

-procedure and surgeon ( way use antibiotics, operative time,surgical technique/difficulty, surgical volume)

-hospital ( management of OR)



Infection ctd

Diagnosis:Pain, swelling, redness, x rays changes, incr ESR/CRP( more obviousin early vs. late where need bones can to DD aseptic loosening

XR: scalloped border on the endosteal surface of the cortex, markedperiosteal reaction, or late dislocation;

- may miss typical x ray signs in 2/3 of late infections, but in < 50 %of early infections).( arthrography? value)

Hip aspiration maybe useful

Bone scans very useful

Infection ctd

Management:-antibiotics after identify bug.

-debridement and retension of components success rate 71% in early cases,< one month). Change the poly

-one stage replanatation: (see revision THR);susceptible bug and good hostresponse;77% success

remove all foreign material/ implant the femoral component w/ antibioticladen cement;

-two stage replantation (allows a press fit revision component with outcement);97% success(all cement gone, wait 12 wks and 3 wks antibiotics)

timing- big topic/basically when infection ? Gone- Resection arthroplasty



IMPORTANT

THIS IS ONE OF THE MAJOR PROBLEMS FACINGMODERN ORTHOPAEDICS

WE NEED TO RE VISIT THE WORK OF

CHARNLEY,SURGICAL SCRUBTECHNIQUE/GOWNING/AGENTS, PREP AND

DRAPING,MAYBE MIS

DEVELOP BRAIN MODELS.

LESS PASSIVE RELIANCE UPON INFECTION CONTROLPEOPLE.

BASIC ISSUE IS TO CONTROL AND KEEP CLEAN YOUR

SURGICAL AIR SPACE.

What to do for Infection control

-INNATE IMMUNITY IN HUMAN BONE

Patrick Warnke, Ingo Springer, PaulRusso, Jörg Wiltfang, Harald Essig,Eugene Sherry, Yahya Acil. AcceptedBONE Sept 2005.

-Re design OR (see over)



re-design the OR/change your technique

ratio= 1/12,0001/2000

x1/6(multiplying)

Risk inf. ?

5cm

(ratio=

1/6)

30cmCut size

2 cu ft.,

(ratio= 2,000)

4000 cuft

Vol. air

NEWOldOR

Nerve damage

Incidence of sciatic &/or femoral palsies:1-3% ( 3-4% after revision; 5-6% in THR for CDH). Also lat cut n thigh, obturator n.

most are incomplete/partial and will resolve; if dense then investigateearly with EMG and MRI.May need to explore.

(?sub clinical injury to the superior and inferior gluteal innervatedmuscles with use of posterior and lateral approaches).

Recovery Incomplete/partial- weeks/months Axonal/severe one to two years

Early management: if limb lengthened flex over pillow.



Bone Tissue

Dislocation

Fracture

Heterotypic ossification

Dislocation

1-10%(16% in revisions); ¾ posterior

Causes: malposition components(acet ante version +femoral anteversion = 45 degrees), test ROM at surgery; soft tissue balance( ?Less with MIS);impingement( < larger head); posteriorapproach;sepsis;patient factors(lack ofcooperation/understanding);revisions;coxa vera.

Treat- acute: reduce under II.- Repeated assess and ? Revise

TIP : Get it right on the table and get soft tissue balance then



Fracture

Incidence

Treatment: unstable Fx then ORIF +/-stem unstable

“Vancouver classification system…the ideal…the fracture configuration, thestability of the implant and the quality of the bone stock. When the stem isstable, open reduction and internal fixation is suggested..otherwise revise to

longer stem”. (The management of periprosthetic femoral fractures around hip

replacements. Tsiridis et al. Injury 2003 Feb; 34(2):95-105)

B 3

Heterotopic ossification,HO

5-50% revision surgery/anterior

approach,previousHO,AS,DISH,neuropathic,Pagets

Treat: radiation, NSAIDs



Chronic Pain after THR

Exclude above causes then consider :

LBP

Trochanteric bursitis

Loose cup early)

Slipped liner early)

Hairline crack around stem(early)

Impingement of femoral stem tip(late)

Implant

Generation of wear particles/osteolysis Breakage: now rare(? Where distal fixation only).

Loosening--acetabular: Uncemented, RD Bloebaum et al 1997, bone ingrowth into componentaverages only 12%; radiographic signs radiolucent lines that initially appeared after twoyears/ progression of radiolucent lines after two years/in all three zones/ 2 mm or wider in anyzone/ migration;

Cemented radiolucency upto 2 mm wide with or without a surrounding fine lineof density may develop inone or more of the the three zones about cement mass in the pelvis.

Radiolucency= dense fibrous membrane and fibro cartilage.

femoral see radiographic Stem Loosening:definite loosening:- stem fracture- cement fractrure- radiolucency at the cement component interface > 1 mm.;- changes in stem position/pistoning/medial midstem pivot/calcar

pivot/subsidence/distal pivotprobable loosening:possible loosening:-radiolucent lines at cement bone interface from 50-100% of the total bone cement

interface;



Osteolysis

Focal endosteal erosion, due wear debris,gasket theory

Miscellaneous

Revision Surgery: complication 3 to 4x

MIS Surgery: ? Less/more, yet to see

Re-surfacing: yet to see



And the list goes on

Vascular damage (risk: 0.1% for primary replacements; less than 1% for revision replacements

Cortical perforation (risk: up to 4.5%)

Leg length inequality (risk: 6% for primary replacements; 7.5% for revision replacements)

Entrapped drainCement extrusionImpingement of ilio-psoas tendon

Anesthetic complications/ respiratory complications (risk: 1%)/cardiovascular complications

Bowel complications (risk: 1%)

Urinary complications (risk: up to 35%)

Haematoma formation (risk: 3%)

Wound dehiscenceKnee pain

Swollen ankles

Skin complications (risk: less than 1%)

Metabolic complications (risk: less than 1%)

Death (risk: 1%)

Bone stock loss

Thank you(eat your heart out )

Darling,on my way home

Complications of Hip Replacement

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