Hip

Early Complications After Total Hip Arthroplasty

J a y Pa t e l , M D, M S 1 a n d Ke v i n B o z i c, M D, M B A 2
1. Resident, Department of Orthopaedic Surgery, University of California, Irvine; 2. Associate Professor and Vice Chair, Department of Orthopaedic Surgery, and Core Faculty, Philip R Lee Institute for Health Policy Studies, University of California, San Francisco

Abstract
The rising volume of total hip arthroplasty procedures will coincide with a rising burden of post-operative complications. Problems such as dislocation, limb length discrepancy, nerve palsy, and infection can occur early in the post-operative period, worsening long-term outcomes and requiring large healthcare expenditures. Continued improvements in prevention, recognition, and management of total hip arthroplasty complications are necessary as health resources become more limited.

Keywords
Hip replacement, limb length discrepancy, hip dislocation, sciatic nerve palsy, hip infection
Disclosure: Jay Patel, MD, MS, has no conflicts of interest to declare. Kevin Bozic, MD, MBA, is a board member, officer, or committee member of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and the California Orthopaedic Association, and a paid consultant to the Integrated Healthcare Association, the Blue Cross and Blue Shield Association, United Health Care, Center for Medicare and Medicaid Services (MedCAC), and the Pacific Business Group on Health. Received: March 19, 2009 Accepted: April 2, 2009 Correspondence: Kevin Bozic, MD, MBA, Associate Professor and Vice Chair, Department of Orthopaedic Surgery and Institute for Health Policy Studies, University of California, San Francisco, 500 Parnassus, MU 320W, San Francisco, CA 94143. E: bozick@orthosurg.ucsf.edu

Although total hip arthroplasty (THA) is regarded as a highly effective procedure in terms of reducing pain and improving quality of life, the associated complications are significant. As the volume of THA procedures is predicted to grow substantially in the next few decades, management of associated complications is going to place a significant burden on the healthcare system. Our discussion will focus on the early complications of THA, including dislocation, nerve injury, limb length discrepancy (LLD), and infection, as deep venous thrombosis and pulmonary embolus has previously been discussed by Salvati et al. in US Musculoskeletal Review 2006.

topic. The posterior approach has been the mainstay for most surgeons, but has an inherent risk for dislocation because most dislocations are posterior. The approach involves compromising the posterior soft tissues by splitting the gluteus maximus fibers, dividing the insertion of the external rotators off the femur, and opening the joint capsule. The dislocation rate for the posterior approach without capsule repair is 3.95%, and with repair is 2.05%.9 Others studies have found an eight-fold (0.49 versus 4.46%) increase in dislocation rate for the posterior approach if the soft tissues are not repaired.10 Comparisons of the posterior approach to the less commonly used lateral and anterolateral approaches have shown that the posterior approach has a comparable to slightly increased rate of dislocation. Kwon compared 11 studies on dislocation rates, finding that the rates of dislocation for the anterolateral, lateral, and posterior approaches is 0.7, 0.4, and 1.0% respectively.10 Matta has advocated the use of an anterior approach that does not involve division of any muscles or tendons to reduce dislocation rates. The technique was developed to reduce the softtissue involvement of the posterior and anterolateral approaches. Matta reported a dislocation rate of 0.6% with the anterior approach, with none of the dislocations requiring revision surgery.11 Minimal-incision THA has also been advocated because of its reduced soft-tissue involvement, but the data available regarding this technique are limited. A study of 1,037 THAs using a mini-incision anterior approach found a dislocation rate of 0.96%.12 Iorio et al. described the use of an enhanced posterior soft-tissue repair technique in which the capsule and external rotators are repaired

Dislocation
Dislocation is a complication that can lead to a poor result, patient dissatisfaction, and the need for revision surgery. A review of over 60,000 primary THA and 13,000 revision THA procedures from 1995 showed a dislocation rate of 3.9% in the first six months for primary THA and 14.4% for revision THA.1 Approximately two-thirds of dislocations occur in the first month after surgery. Patient factors, surgical technique, and implant design can all contribute to the risk for dislocation. Patient factors associated with an increased risk for dislocation include increased age, female gender, neuromuscular disease, dementia, alcohol abuse, previous hip surgery, history of fracture or osteonecrosis, and higher level of patient activity.24 Surgical factors that can affect dislocation include surgical approach and component alignment.58 Given the recent interest in minimally invasive techniques for THA, the effect of surgical approach on dislocation has become an increasingly important

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Early Complications After Total Hip Arthroplasty

in one sleeve. The authors found that if this technique was combined with a mini-incision approach, the rate of dislocation was 1.3%.13 Despite these studies, the mini-incision approaches are still met with much criticism.14 Finally, implant factors, including the prosthetic femoral head-to-neck ratio, also affect dislocation rates. The risk for dislocation is inversely proportional to the head-to-neck ratio. Smaller femoral head sizes (22 versus 28mm) and larger femoral neck sizes have been shown to be associated with higher rates of dislocation.5 For revision surgery, Morrey showed that revision THA dislocation rates are decreased with the use of elevated lip liners and 32 or 28mm femoral heads instead of 22mm heads.15

physical therapy to strengthen ankle dorsiflexion. Treatment of sensory deficits involves avoidance of foot trauma that may go unnoticed and lead to infections. If the presentation of the sciatic nerve injury has a delayed onset, there should be a higher suspicion for hematoma formation. In this case, the surgeon may consider decompression or reversal of anticoagulation. The use of somatosensory evoked potentials (SSEPs), which are commonly used during spine surgery to monitor neurological function, has been shown to have little benefit in THA to reduce the incidence of sciatic nerve injuries.21

Limb Length Discrepancy

Post-THA LLD can cause nerve palsy, low-back pain, and abnormal gait. Importantly, it is a major source of patient dissatisfaction and the most common cause of litigation against orthopaedic surgeons. Edwards found that in patients with a nerve palsy, 2.7cm of limb lengthening was associated with peroneal nerve palsy, and 4.4cm was associated with complete sciatic nerve palsy. 22 LLD increases patients oxygen consumption, heart rate, and quadriceps activity.23 In the elderly population these increased requirements can exacerbate underlying pulmonary and cardiac conditions. Pre-operative planning currently includes measuring the true limb lengths, or the distance from the anterior superior iliac spine to the medial malleolus. The apparent limb length, or distance from the umbilicus to the medial malleolus, takes into account soft-tissue contractures, pelvic obliquity, and compensatory spine deformities. Radiographic measurements and templating are also important to assess the level of the osteotomy, femoral offset, and neck length. Errors can occur if standard films with the femur internally rotated 20 are not obtained. Measuring from a film with externally rotated hips can mislead the pre-operative planning process. Additionally, pre-operative hip flexion contractures should be considered when measuring pre-operative radiographic LLDs. Various intraoperative techniques to measure LLD exist. Most are subjective and prone to error. Many assess limb lengths by aligning the knees in the same degree of flexion and then checking the level of the medial malleolus of the two limbs. In this technique the up leg is adducted and likely to seem shorter than the down leg. For this reason, the relative change of the limb lengths must be assessed intraoperatively. During the osteotomy, some measure the level of the cut to the lesser trochanter and cross-reference this with pre-operative templating.24 Various techniques also exist that involve placing a pin into the pelvis and checking the relative position of the pin to a landmark on the femur before and after the prosthesis is implanted. However, measurements from these techniques vary based on limb position. Woolson and Harris described a technique involving measuring from the femoral head to the neck cut to assess limb length. This technique, used in 408 THA cases, resulted in 97% of patients having <1cm LLD.25 Finally, various femoral offset options exist that may allow for intraoperative restoration of offset without limb lengthening. Post-operatively, LLD can be assessed after the initial three- to six-month recovery period. Patients should be advised that early post-operative limb length inequalities may be due to abductor muscle weakness and/or contractures. Fixed pelvic obliquity or spinal deformities may also contribute to continued perceived LLD. After three to six months, repeat clinical and radiographic assessment of LLD is indicated. Non-surgical

Nerve Injury
Nerve injury during THA is usually caused by a combination of compression and traction forces. Compression can be caused by retractor placement or hematoma formation. Traction can be caused by lengthening the limb by more than than 4cm and intraoperative hip dislocation.16 Although these mechanisms make intuitive sense, over 50% of patients who experience a nerve palsy following THA have an unknown cause.17 Ranawat used magnetic resonance imaging (MRI) to suggest that in cases with unknown cause, the nerve palsy may be due to tethering of the sciatic nerve around the gluteus maximus tendon.18 The sciatic nerve accounts for 90% of nerve injuries following THA. The peroneal division of the sciatic nerve is affected in 94% of sciatic nerves, in part because it is tethered at the sciatic notch and fibular head.17 In addition, its tightly packed fascicles with little surrounding soft tissue make it more prone to injury during compression or tension than the tibial division of the sciatic nerve. Femoral and obturator nerve palsies are rare occurrences and are often attributed to cement extrusion, aberrant acetabulum screw placement, and hematoma formation. The rate of sciatic nerve injury after THA has been reported to be 0.673.7%. 17,19 Rates of nerve injury are higher in patients with developmental dysplasia of the hip (DDH) (5.8%) or who are undergoing revision THA (38%).17 This is thought to be due to a greater amount of scar in the soft-tissue bed and reduced vascularity, which makes the nerve more susceptible to ischemia. In addition, patients undergoing revision THA or THA for DDH are more likely to undergo limb lengthening, which places traction on the nerve. The diagnosis of nerve injury is usually clinical. The most common presentation of injury to the peroneal division of the sciatic nerve is weakness in dorsiflexion of the ankle and paresthesias in the first dorsal web space. Damage to tibial division presents as weakness to knee flexors and ankle plantarflexion. The incidence of permanent and transient nerve damage is 0.5 and 2.0%, respectively.20 Schmalzried reviewed over 3,000 THA cases and found that most patients with a sciatic nerve injury recovered function by seven months.17 Patients with injuries to both the tibial and peroneal division, with initial motor deficits, and with injuries secondary to limb lengthening had a worse prognosis.17 The treatment of nerve injuries is tailored to the cause of the injury. In most cases, the cause is unknown and treatment is directed toward managing symptoms rather than reversing the nerve injury. For those patients with a sciatic nerve motor palsy, treatment involves the use of an ankle foot orthosis to prevent equinus contractures of the foot and

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treatments of LLD include the use of shoe lifts and physical therapy. One study demonstrated that 24% of THA patients require a shoe lift.26 However, this is typically reserved for patients with 12cm of discrepancy. Surgical treatment must be approached with caution because revision surgery can cause further problems. Surgeons can correct true limb lengths but not apparent LLD. As described by Maloney, attempts to correct apparent lengths can cause shortening or lengthening of true limb lengths, which can, in turn, cause hip instability or nerve injury, respectively.24 The relative indication for surgical treatment is unmanageable hip or back pain, paresthesias, and foot drop. Revision for LLD may involve changing the modular head, using an offset acetabular liner, revising the femoral component to one with increased offset, and/or trochanteric advancement to increase abductor muscle tension. Treatment of infection commonly involves six weeks of intravenous (IV) antibiotics with monitoring of infectious markers. Unfortunately, treatment with IV antibiotics alone is rarely sufficient. Surgical treatment for early infection involves incision and debridement and exchange of the modular parts (femoral head and acetabular liner). In the case of a late infection, treatment may involve resection arthroplasty with placement of antibiotic-impregnated cement spacer, followed by six weeks of intravenous antibiotics and possible reimplantation during a second-stage procedure. For early infections, efforts are usually made to salvage the recently placed components.

Conclusion
Dislocation, nerve injury, LLD, and early infection are all early complications of THA that can be minimized through careful pre-operative planning, meticulous surgical technique, and close post-operative diligence. As the volume of THA procedures continues to rise in the US, the management of these complications will require adequate healthcare resource allocation to prevent longer-term consequences. I

Infection
Infection is a complication that can occur in both the early and late postoperative periods: 0.2% of patients develop deep hip infections in the first three months after THA.1 Fitzgerald described three types of THA infection: acute post-operative infections, delayed infections, and late hematogenous infections. The detection of infection during the acute post-operative period is difficult because many of the laboratory and radiographic diagnostic tests used to detect infection do not differentiate between infection and post-operative inflammation. The differentiation of superficial and deep infection can be difficult because both can present as a chronically draining wound. Chronic drainage and hematoma formation are often caused or exacerbated by DVT chemoprophylaxis agents. Clinical judgment, laboratory testing (including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein), and nuclear medicine imaging (gallium- and indium-111-tagged white blood cell scans) are the most useful tools to evaluate for infection. If a high suspicion for infection is present, the surgeon can consider a hip aspiration or taking the patient back to the operating room to evacuate hematoma and evaluate for fascial defects.27 The causative microorganism is typically Staphylococcus epidermidis or Staphylococcus aureus, with the latter commonly being methicillin-resistant.

Jay Patel, MD, MS, is a Resident in Orthopaedic Surgery at the University of California, Irvine. He has an interest in orthopaedic device design, with over five patents pending. He graduated summa cum laude from Harvard College. He obtained his MD and MS in mechanical engineering from Stanford University. Prior to medical school, Dr Patel was a management consultant for McKinsey & Company in their Silicon Valley office.

Kevin J Bozic, MD, MBA, is an Associate Professor and Vice Chair of the Department of Orthopaedic Surgery and a member of the core faculty of the Philip R Lee Institute for Health Policy Studies at the University of California, San Francisco (UCSF). He is a graduate of the UCSF School of Medicine and the Harvard Combined Orthopaedic Residency Program. Additionally, he holds a MBA from Harvard Business School.

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