Complications of total hip replacement

Dr. Olu Akinbo, HDN special contributor
Oluwaseun Akinbo

Total hip replacement represents one of the most successful procedures in orthopedic surgery. It is able to restore quality of life, and the recovery is usually quicker that it is for a total knee replacement. There have been multiple advancements in hip replacement over the years but nevertheless, it remains a major surgery. There are numerous potential complications that can occur after a total hip replacement. We would consider some major complications here. We have grouped these in three categories: early post-operative complications, late postoperative complications, and the complications that can occur at any time. We conclude this series this week with complications that can occur at any time.

Can occur at any time

Infection: Infection can occur from soon after hip replacement surgery to decades after initial replacement surgery. Infection typically causes pain; it can also cause draining wounds, dislocations, redness, increased warmth, and loss of function. Patients that develop significant pain with functional limitations in a previously well-functioning hip should seek immediate/emergent consultation with their surgeon/a joint replacement surgeon. Concerns for hip infection will usually trigger laboratory work up, imaging studies, and could trigger a hip aspiration if there remains a question about infection. When infection is confirmed, management is almost always surgical. Surgical management could be a wash out with revision of the components that are easily removed (head and plastic), it could be a wash out with one stage exchange (removing all components and implanting new components in the same setting). It could also be a wash out with a two-stage exchange (removing all components, implanting an antibiotic spacer, and returning several weeks later to replant new components). All surgical measures are typically accompanied by at least 6 weeks of intravenous antibiotics. The surgical option chosen depends on the time from symptoms/infection, patient health, bug causing infection, patient and surgeon shared decision making.

Dislocation: Dislocation can occur at any time after a hip replacement. It can occur as early as in the recovery room following the surgery to as late as decades after the hip replacement surgery. It can occur due to component malpositioning at the time of initial surgery; other causes include metallosis, trauma, osteolysis, infection, and neurologic problems. Initial dislocation is usually managed with closed reduction measures. Hip bracing usually follows for a few weeks. Failure of closed reduction will merit an open reduction and likely revision. Recurrent dislocations that have failed multiple closed reductions merit an open revision. Before commencing on a revision for hip dislocation, the surgeon will want to rule out an infection with laboratory markers or a hip aspiration. Other measures before surgery will include x-rays or a CT scan to look for component malpositioning, fractures, or other factors responsible for the dislocation. Lumbar spine fusion significantly increases the risk of dislocation of a hip replacement. Surgical measures include revising the modular components (head and liner); it can also involve revising all the components of the hip replacement. The actual measure taken would depend on what is thought to be the cause of the dislocation and how best to address the cause of the dislocation.

Femoral/acetabular fracture: Fractures around hip replacement components can occur in the operating room during the hip replacement. They can also occur many years after the hip replacement. Causes are typically traumatic, but can also occur from significant osteolysis which can result in fractures without trauma. Management measures involve ascertaining the stability of the components; if stable, the fracture (broken bone) can be fixed without revision of the hip replacement components. If the components are not stable then the fracture is best managed with revision of the unstable component and fixation of the fracture. Weight bearing can be limited after surgery for a fracture around a hip replacement. Limitation of weight bearing would depend on the type of surgery performed, stability of fixation/revision, and surgeon preference.