There are several major complications of total hip arthroplasty. These include thromboembolic disease or blood clots in the veins of the legs, dislocation of the total hip arthroplasty, bleeding, infection, loosening of the implants, wear of the components, osteolysis, and neurovascular injury.
Thromboembolic Disease
Thromboembolic disease is the formation of blood clots in the veins of the legs. This can occur in patients who have had no surgery or operative procedure. However, total hip arthroplasty and total knee arthroplasty are high risk procedures for the development of blood clots in the veins of the legs. Commonly, patients will be placed on blood thinning medications, such as Coumadin, aspirin or a low molecular weight heparin, around the time of surgery. After the early postoperative period, the patient may be placed on aspirin as this is easier to manage and administer, and can be effective at minimizing the risk of thromboembolic disease.
The exact regimen would be determined by your orthopaedic surgeon. The choice of which particular medication to use for each individual patient may be altered by other medical conditions. For example, patients who are significantly overweight, have a history of some form of cancer, or a history of a previous blood clot, may be placed on Coumadin or low molecular weight heparin for a longer period of time postoperatively.
The incidence of thromboembolic disease following total hip arthroplasty is approximately 10-20%. Patients who have significant swelling postoperatively, in particular swelling that does not respond to elevation of the legs, should undergo an ultrasound evaluation of the veins of the legs to look for the potential of a clot.
Once a clot is identified, this should be treated with anticoagulant medications, either low molecular weight heparin or Coumadin, for a period of three to six months.
Dislocation
Dislocation of a total hip arthroplasty involves the shifting of the replaced femoral head out of the replaced socket. A patient's natural hip prior to surgery has a ligament that links the ball into the socket. In addition, there is a very thick, dense tissue that surrounds the ball and socket joint, holding the ball within the socket. To perform the hip replacement surgery, both of these structures need to be removed. In addition, there is no mechanical linking of the replaced ball into the socket.
The ball is maintained in the socket by appropriate positioning of the components within the patient and by the muscles and ligaments that cross from the pelvis to the thigh. It is very important to maintain appropriate positioning in the early postoperative period. The patient should not bend the hip up to greater than a 90 degree angle, they should keep their knees and ankles apart, and should keep their feet essentially pointing straight in front of them. Following these precautions is essential in maintaining the femoral head within the acetabular component during the first six to eight weeks while the soft tissue structures that were cut at the time of the replacement are allowed to heal.
Dislocation can occur in 2-5% of patients undergoing total hip replacement. If the dislocation occurs within the first six weeks, it normally can be reduced by giving the patient sedating medications and then manually manipulating the leg to bring the ball back within the socket. Patients will frequently be placed in a brace for the six weeks after a dislocation to aid in stability while the soft tissues heal. When a dislocation does occur within the first six weeks, most commonly it is a single event.
However, approximately 20-25% of patients will be at risk to have the hip dislocate again. If the hip does dislocate again and cannot be made stable, additional surgery may be necessary to either change the positioning of the components or tighten the soft tissue around the hip to give the patient a stable hip.
Dislocations can also occur late after the replacement. A dislocation occurring more than six to twelve months after the surgery is at much higher risk of becoming a recurrent dislocation.
Revision surgery may be necessary in this setting to treat recurrent dislocation. Frequently, it is helpful to obtain a CT scan of the hip and pelvis to determine the exact orientation of the component prior to any revision surgery. If a definite mechanical factor can be identified prior to revision surgery the rate of recurrent dislocation after this procedure can be reduced to approximately 10-20%. If no specific identifiable factor can be identified, the rate of recurrent instability after revision surgery can be as high as 60%.
Bleeding
Bleeding is a common risk in orthopaedic surgery. For major orthopaedic procedures such as total hip and total knee replacement, patients may be asked to donate blood for themselves. This is referred to as autologous donation. Normally a surgeon will collect approximately two units of blood from a patient prior to surgery. The surgeon may want to place the patient on iron supplementation to help restore the blood count prior to surgery.
In total hip replacement the majority of the bleeding will commonly occur during the operative procedure. In total knee replacement the majority of bleeding will occur in the first twenty-four hours after the procedure. Additional bleeding may occur in the first day or two postoperatively. Normally, a drain will be placed in the wound to prevent this blood from collecting within the operative site. The patient may require transfusion of blood postoperatively. When available, we will use the patient's own autologous blood first and then, if necessary and after consultation with the patient or their family, we may use blood from the Blood Bank.
Infection
Infection is the most feared of all the complications in total hip and total knee arthroplasty. Fortunately, the incidence of infection is quite low. The rate of infection should be less than 1:250 to 1:500 joint replacement surgeries. The frequent causes for infection at the time of surgery are contamination during the operative procedure or bacteria being released into the blood from sources such as the urine, bowel, or lungs. Surgically, we make every attempt to maintain a perfect sterile field.
We will use body exhaust, or space suits, to keep the surgeons as sealed from the operative field as possible. In addition, we use a Water-Pic device to keep the wound meticulously clean. We will also use antibiotics around the time of surgery to reduce the incidence of infection.
If an infection is identified within the first two to four weeks after the surgery, initial attempts can be made to treat this with a surgical procedure to clean the wound thoroughly, and to place the patient on six weeks of intravenous antibiotics. The success rate of this is approximately 25-80% depending on the type of arthroplasty, the medical condition of the patient, and the specific bacteria causing the infection.
If the infection is identified after the first two to four weeks, the likelihood of success with cleaning out the wound and placing the patient on antibiotics is very low. In this setting, it is recommended to undergo what is referred to as a two-stage reconstruction. The first stage is to remove the total hip arthroplasty components to surgically clean the wound and remove all infected tissue, bone cement, and debris, to place an antibiotic impregnated spacer within the wound, and then to place the patient on intravenous antibiotics for six to eight weeks.
The patient is then taken off of antibiotics and will undergo an aspiration procedure. If this aspiration is negative and the patient is doing well clinically in terms of no drainage, no pain, and no fever, the patient can then undergo revision or re-replacement with new joint replacement components. The risk of recurrent infection with this procedure is approximately 10%.
Loosening
Both with cemented as well as with non-cemented fixation, the components may become loose over time. This is usually determined or identified first by the patient noting increased pain in the arthroplasty. On the x-rays, your surgeon may be able to identify areas of loosening or movement of the components relative to the bone. Once a component becomes loose, it will not regain fixation in the future. At that point, revision surgery is necessary to place a new total hip arthroplasty component to try and gain a well-fixed total hip replacement. What is required at the time of revision surgery varies greatly.
It may be as simple as changing a component and can be complex requiring bone graft plates and screws to obtain a well fixed component. The nature of what would be required should be reviewed with you by your surgeon and often several plans for reconstruction will be available at the time of surgery. This is necessary to address the specific problems that may be encountered at the time of surgery.
Wear
Total hip arthroplasty components are made of artificial materials. In that way, they are similar to parts within an automobile. Over time, as these parts move back and forth relative to each other, this will result in wear of the components. In most total hip replacements, there is a metal ball moving against a plastic socket. In that setting, the plastic socket may wear. This can be identified on x-rays. In addition, unlike your automobile which has an oil filter to filter wear debris from the engine out of the oil, there is no such filter in a hip replacement arthroplasty. Therefore, the wear debris that is produced remains within the tissue and fluid surrounding the total hip arthroplasty. This can occasionally lead to osteolysis, or the generation of bone cysts, around the replacement. Please refer to the section on Osteolysis for more details on this process.
Osteolysis
Osteolysis refers to a specific phenomenon that can occur after any form of total joint replacement. Osteolysis is a process where cysts are formed in the bone surrounding total joint replacement components. These cysts are formed when the body reacts to wear debris that is generated at the point of movement of the total joint arthroplasty.
With each step after total hip arthroplasty, it has been estimated that approximately 100,000 to 1,000,000 particles of plastic are released into the tissues around the arthroplasty. As the body tries to get rid of the debris, there are cells that act similar to a vacuum cleaner to try and clean up this material. The human body has no enzymes that can digest plastic and metal. These materials will then build up within the cell until the cell ruptures. When the cell bursts, it releases large amounts of enzymes into the local tissue that will then dissolve the tissue and bone in that area. As this occurs, a cyst will be generated. This is a benign process that will only attack the bone locally in the area of the arthroplasty or joint replacement.
The incidence of osteolysis varies from less than 1% to as high as 10% in some types of replacement. Current techniques in the manufacture of the plastic components as well as the femoral head balls should result in a reduced rate of production of wear debris and therefore a reduced rate of osteolysis. Loosening, wear, and osteolysis are the primary three reasons why, after total joint replacement, a patient should be followed on a regular basis with a radiograph repeated every two years to identify these conditions, if they are occurring.
Neurovascular Injury
During total hip arthroplasty an incision is made on the outer portion of the leg. All attempts are made to preserve all the nerves and blood vessels that surround this area. However, occasionally, a nerve may be stretched or injured, or a vessel cut during the procedure. The incidence of this complication is quite low. In one series reported in the literature, the rate was less than 1:1,000 patients. When this does occur, the nature of the injury, the resulting deficit, and the possibility of full recovery will need to be discussed on an individual basis with your surgeon.
Alteration of Limb Length Postoperatively
While all attempts are made during the hip replacement surgery to restore a patient to a limb length equal to the opposite leg, occasionally it may be necessary to lengthen the leg. This may be necessary to achieve appropriate soft tissue tension to reduce the risk of dislocation. Your surgeon will make every attempt to restore every patient to equal limb length. However, in certain anatomic conditions, and also due occasionally to unforeseen anatomic variations, it may be necessary to lengthen the leg at the time of total hip arthroplasty.
If this occurs, normally your surgeon can notify you of this in the early postoperative period. It is rare to lengthen the leg during total knee replacement. Two critical ligaments linking the femur and tibia are maintained during the surgery. These ligaments limit the amount of material that can be placed between the bones. If the patient does have significant deformity of the knee prior to surgery when the deformity is corrected and the leg straightened at the time of the surgery the relative length of the leg will be increased.
Reflex Sympathetic Dystrophy
Reflex sympathetic dystrophy is an abnormal pain reflex that can occur after surgery on the upper or lower extremities. It is more common after total knee replacement than after total hip. This process can result in a significant protracted pain in the knee. It is also commonly accompanied by significant stiffness in the knee. The skin will change to a very thin frail-appearing skin that can be of varying colors; from purple to reddish to pink.
In addition, it is frequently noted that there will be no hair growth in the area affected by a reflex sympathetic dystrophy. The skin will be exquisitely sensitive and painful to even light touch. There may be some remaining warmth within the leg.
The diagnosis of this condition can be extremely difficult. It is most commonly a diagnosis of exclusion. A patient must be evaluated for the possibility of loosening of the components, infection, or other mechanical problem with the replacement prior to being diagnosed with reflex sympathetic dystrophy. Occasionally, a three phase bone scan can be helpful in determining the diagnosis of a reflex sympathetic dystrophy.
When a patient is diagnosed with a reflex sympathetic dystrophy it is important to note that additional surgery on the leg will most commonly result in worsening of the condition. Occasionally, the condition can be benefited from a sympathetic blockade which is usually carried out by an interventional neuroradiologist. In this procedure, a long-acting local anesthetic or nerve blocking agent is placed near the lower lumbar spine where the sympathetic nerves originate.
These nerves control the pain reflex and control blood flow through the skin of the lower extremities. The injection may result in a blush of color in the area involved with the reflex sympathetic dystrophy, and frequently can result in significant relief of the pain of a reflex sympathetic dystrophy. If the injection is successful, a more permanent blockage may be necessary to maintain long term relief for the patient.
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