THR Complications

Factors that increase the risk of complications

1. Previous hip operations
2. Severe deformity
3. Osteoporosis
4. Lack of pre-operative planning
Complications
1. Immediate – within the surgery itself
2. Early – within first 6 weeks of surgery
3. Late- beyond six weeks for the lifetime of implant
Immediate
1. Anesthetic related – airway problems
2. Anaphylaxis e.g., to antibiotics, anesthetics
3. Blood loss and hemorrhage
4. Fracture / perforation
5. Nerve Injury
6. LLD
Early
1. VTE
2. Late Bleeding
3. Urinary retention
4. Cardio/respiratory issues
5. Poor wound healing
6. Early PJI
7. Dislocation
8. Fracture
Late
1. Heterotrophic ossification
2. Wear and osteolysis
3. Aseptic implant loosening
4. Dislocation and recurrent instability
5. Late PJI
6. Periprosthetic fracture
7. Heterotrophic bone formation
DVT and PE
1. Clinical Diagnosis
2. Venography, duplex USG, compression USG. For PE- helical CT
3. Prophylaxis- Mechanical, Pharmacological, Surgical
4. Treatment: Therapeutic anticoagulation, Embolectomy, IVC filter, respiratory support
Late bleeding ~ 1 weeks postop
1. False aneurysm
2. Iliopsoas impingement
Risk factors for vascular injury
1. Revision Surgery
2. Intrapelvic migration of components
3. Transacetabular screw fixation
Mechanisms of vascular injury
1. Laceration
2. Traction
3. Retraction
4. Direct trauma
5. Compression
Heterotrophic Ossification
1. Definition: Abnormal growth of bone in non-skeletal tissues including muscles,tendons
and other soft tissues
2. Incidence: 3-50%
3. Pathology:
a. Inappropriate differentiation of pluripotent mesenchymal stem cells into
osteoblastic cells.
b. Research suggests overexpression of BMP-4 and PGE2.
4. Risk factors:
a. High risk: previous history, hypertrophic post-traumatic arthritis in males
b. Moderate risk: AS, DISH, Paget disease
c. Surgical risk factors
i. Intraoperative muscle ischaemia
ii. Direct lateral approach> anterior
iii. Extent of soft-tissue dissection
iv. Bone trauma
v. Persistence of bone debris (reamings, marrow within the surgical field)

5. Clinical features:
a. Asymptomatic
 b. Pain
c. Restricted ROM
6. Classification (Brooker et.al.)
a. Grade I: islands of bone within soft tissues
b. Grade II: bone spurs from the proximal femur or pelvis with at least 1 cm
between opposing bone surfaces
c. Grade III: bone spurs from the proximal femur or pelvis with less than 1 cm
between opposing bone surfaces
d. Grade IV: ankylosis
7. Prevention:
a. External beam radiation therapy 700–800 rads single dose (<4 h preop or 72 h
postop)
b. Indomethacin 75 mg for 6 weeks. Acts by inhibiting the production of
prostaglandins.
8. Treatment
a. Resection. Indication – significant loss of motion
Wear
1. Mechanisms:
a. Adhesive wear: produced by shearing off of asperities as one surface slides over
another
b. Abrasive: Due to asperities cut on softer material by harder material
c. Fatigue: due to cyclical loading and accumulation of microdamage
d. Erosive
e. Corrosive: surface damage
2. McKellop’s classification- wear of artificial joints is divided into four modes

3. Factors that determine wear

a. CoF of the substance and finishing surfaces
b. Boundary lubrication
 c. Applied load
d. The sliding distance per each cycle
e. The hardness of the material
f. The number of cycles of movements
4. Osteolysis is a histiocytic response to wear debris
Aseptic implant loosening
1. Gruen et al for femur and DeLee and Charnley zones for acetabulum
a. zone 1:   greater trochanter, first site of osteolysis
b. zone 4:   tip
c. zone 7:   lesser trochanter
d. lateral 8-14
e. zone 8:   anterior-superior
f. zone 11: tip
g. zone 14: posterior-superior
2. Acetabulum
a. zone 1:  superior 1/3
b. zone 2:  middle 1/3
c. zone 3:  inferior 1/3, most common area for
osteolysis.
3. Harris et.al. criteria
a. Definite Loosening
b. Probable
c. Possible
Infections
1. Fitzgerald/Trampuz and Zimmerli
a. Acute postoperative period (up to 3 months)
b. Delayed deep infection (3–24 months)
c. Late haematogenous >24 months
2. Tsukayama et.al.
a. Early postoperative: <1 month after surgery
b. Late chronic postoperative: >1 month after surgery
c. Acute hematogenous: several years after surgery
d. Fourth type with positive intraoperative culture
Treatment options
1. Antibiotic therapy
2. Debridement and irrigation of the hip with component retention
3. Debridement and irrigation of the hip with component removal
i. One-stage or two-stage reimplantation of total hip arthroplasty
4. Arthrodesis
5. Amputation
Dislocations
1. Epidemiology
1. Incidence 1-3%
2. 70% occur within first month
3. 75-90% posterior
2. Risk factors

1. Patient related
2. Implant related
3. Surgery related
Wera et.al. etiological classification of recurrent dislocation
1.Type I: acetabular component malposition
2.Type II: femoral component malposition
3.Type III: abductor deficiency
4.Type IV: impingement
5.Type V: late wear
6.Type VI: unresolved
Treatment according to classifications

Radiographic findings
1. Increased acetabular inclination > 60°
2. Increased acetabular anteversion > 20°
3. Aceabular retroversion
4. Eccentric position of femoral head (indication of polyethylene wear and risk for
impending dislocation)
Treatment
1. Closed reduction and immobilization
a. 2/3 rds can be treated this way
b. Immobilization – hip spica cast, hip abduction brace, knee immobilizer
2. Operative
a. Polyethylene exchange
b. Revision THA
c. Conversion to hemiarthroplasty with larger femoral head
 d. Resection arthroplasty – last resort
Periprosthetic fractures

Limb Length Discrepancy

1. Etiology:
a. Contracture: abduction and adduction
b. Weakness
2. Treatment: Operative and Non-operative