Complications of total hip replacement
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 would group these in three categories: early post-operative complications, late post-operative complications, and the complications that can occur at any time. We continue this week with early post-operative complications.
Early post-operative complications
Nerve injury: This is a rare complication with injury rate from 0.7 to 3.5% in primary hip replacement. Different approaches to performing hip replacement present risk to different nerves. The posterior approaches pose a risk to the sciatic nerve. The lateral based approaches pose a risk to the superior gluteal nerve, and the anterior based approaches pose the highest risk to the lateral femoral cutaneous nerve and the femoral nerve.
Nerve injuries from hip replacements are usually from compression (retractors, hematoma), traction (manipulation, lengthening), ischemia (compromised blood flow), or transection. There are no identifiable causes in 50% of the cases. Risk factors for nerve injury include post-traumatic arthritis, revision hip replacement, previous hip surgery, limb lengthening, and spine issues with pre-existing nerve injury. Nerve injuries are usually managed expectantly as most patients will have a good recovery albeit not complete especially with sciatic and femoral nerve injuries. Most lateral femoral cutaneous nerve injuries, which result in painless numbness of the thigh, resolve by 2 years from the surgery.
Thromboembolism: This is a fancy word for blood clot. Blood clots can develop after total hip replacement surgery. Blood clots are prevented by taking anticoagulant medications for a few weeks after surgery; the most commonly used of these medications include Aspirin, Eliquis, Lovenox, Xarelto, and Warfarin. These medications can decrease the risk of blood clots but do not completely eliminate the occurrence. Without these medications, the risk is about 70%.
One is at greatest risk of developing a blood clot within the first few days following hip replacement surgeries. DVT (Deep Vein Thrombosis) is a condition that develops when a blood clot forms in a deep vein. PE (Pulmonary Embolism) is a condition that develops when a blood clot is in a pulmonary (lung) artery; these often occur from blood clots in deep veins in the legs. PEs are potentially fatal. When a blood clot is detected, it can be treated with some of the medications above. The treatment is usually for a few months. Other measures to help decrease the risk of developing a blood clot include early and frequent mobilization (walking, moving the extremities) as well as using compression devices.
Post-operative bleeding: Post-operative bleeding is concerning when it is persistent and results in a draining wound. This can occur from not achieving good hemostasis (stopping active bleeding) at the time of surgery, but is more likely to occur as a result of anticoagulation medications. Anticoagulation medications are necessary to decrease the risk of developing a blood clot after total hip replacement but it is a fine balance between preventing a blood clot and preventing the development of a draining wound.
A draining wound significantly increases the risk of infection which can doom a previously well-functioning hip replacement. Management measures include stopping the anticoagulation medication. Other measures can include stopping physical therapy and applying a negative pressure dressing/wound vac to help seal the wound. If persistent drainage after a week or so, a return to the operating room to manage the bleeding/draining wound and prevent an infection is usually necessary as a persistently draining wound can result in a wound infection with devastating consequences.
Dr. Oluwaseun Akinbo M.D. is an orthopedic surgeon at HaysMed. For more information, see www.haysmed.com/oluwaseun-akinbo