Complications Of Hip Replacement

Complications of THR (killer ap)

Eugene Sherry Bond University Australia

Categorize- 4 groups

z

Soft tissue

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Bone

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Implant

z

Whole Person

Soft Tissue z

DVT

z

Infection

z

Nerve damage

z

Chronic Pain

DVT

z z z z z

Can be devastating Well defined risk factors Incidence known Prevention is possible And treatment straight forward

DVT detail Incidence: 40-60% of THR or 0.19% (Fender et al,JBJS 1997) showed that the incidence of fatal PE (as diagnosed by postmortem examination) was 4 / 2111 patients (0.19%). Rule-of thumb: 50%(incidence)-10%(embolize)-2% (Die). With prevention- reduce by one fifth(10%-2%0.4%) (O’Reilly RF et al. The prevalence of venous thromboembolism after hip and knee replacement surgery. Med J Aust 2005; 182; 154-159.) 5999 patients.DVT after THR 8.9% with prophylaxis.Fatal in-hospital PE rare, 0.05%). Diagnosis: ultrasound prior to discharge and ? Repeat in high risk Prevention: aspirin- probably not enough. heparin and low molecular wt agents. reduces risk by 70%, start before incision -? pentasaccharides - warfarin adjusted- dose, INR 2.5 (2 to 3), 10 days post-op compressive devices ? proof vena cava filter MIS THR ? lower

DVT ctd z

Treatment: standard treatment algorithm (confirmation of DVT/PE, followed by IV heparin or SQ low molecular wt heparin, followed by oral warfarin (once started patient is OK).

Infection

A disaster Early /late presentation Preventable Hard to treat

Infection detail Incidence 0.5%-3% primary THR (4-6% of revisions) Leads to multiple operations/prolonged IV and oral antibiotics/long rehab/huge personal, professional and economic costs(4.8x that of primary THR; 2.8x of aseptic revision; U$50,000 to 60,000) z Risk factors: -patient(RA,DM,poor nutrition,obesity,sickel cell,transplants,steroids,decreased immunity,previous surgery,dental work). -procedure and surgeon( way use antibiotics, operative time, surgical technique/difficulty, surgical volume) -hospital( management of OR) z z

Infection ctd Diagnosis: Pain, swelling, redness, x rays changes, incr ESR/CRP( more obvious in early vs. late where need bones can to DD aseptic loosening XR: scalloped border on the endosteal surface of the cortex, marked periosteal reaction, or late dislocation; - may miss typical x ray signs in 2/3 of late infections, but in < 50 % of early infections). ( arthrography? value) Hip aspiration maybe useful Bone scans very useful

Infection ctd Management: -antibiotics after identify bug. -debridement and retension of components success rate 71% in early cases, < one month). Change the poly -one stage replanatation: (see revision THR);susceptible bug and good host response;77% success remove all foreign material/ implant the femoral component w/ antibiotic laden cement; -two stage replantation (allows a press fit revision component with out cement);97% success(all cement gone, wait 12 wks and 3 wks antibiotics) timing- big topic/basically when infection ? Gone - Resection arthroplasty

IMPORTANT z z

z z z

THIS IS ONE OF THE MAJOR PROBLEMS FACING MODERN ORTHOPAEDICS WE NEED TO RE VISIT THE WORK OF CHARNLEY,SURGICAL SCRUB TECHNIQUE/GOWNING/AGENTS, PREP AND DRAPING,MAYBE MIS DEVELOP BRAIN MODELS. LESS PASSIVE RELIANCE UPON INFECTION CONTROL PEOPLE. BASIC ISSUE IS TO CONTROL AND KEEP CLEAN YOUR SURGICAL AIR SPACE.

What to do for Infection control -INNATE IMMUNITY IN HUMAN BONE Patrick Warnke, Ingo Springer, Paul Russo, Jörg Wiltfang, Harald Essig, Eugene Sherry, Yahya Acil. Accepted BONE Sept 2005.

-Re design OR (see over)

re-design the OR/change your technique

OR

Old

NEW

Vol. air

4000 cu ft

2 cu ft., (ratio= 2,000)

Cut size

30cm

5cm (ratio= 1/6)

(multiplying) Risk inf. ?

1/2000

ratio= 1/12,000

x1/6

Nerve damage z z

Incidence of sciatic &/or femoral palsies:1-3% ( 3-4% after revision; 56% in THR for CDH). Also lat cut n thigh, obturator n. most are incomplete/partial and will resolve; if dense then investigate early with EMG and MRI.May need to explore.

z

(?sub clinical injury to the superior and inferior gluteal innervated muscles with use of posterior and lateral approaches). Recovery Incomplete/partial- weeks/months Axonal/severe one to two years

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Early management: if limb lengthened flex over pillow.

z z z

Bone Tissue z z z

Dislocation Fracture Heterotypic ossification

Dislocation z

1-10%(16% in revisions); ¾ posterior

z

Causes: malposition components(acet ante version +femoral ante version = 45 degrees), test ROM at surgery; soft tissue balance( ? Less with MIS);impingement( < larger head); posterior approach;sepsis;patient factors(lack of cooperation/understanding);revisions;coxa vera. Treat- acute: reduce under II. - Repeated assess and ? Revise

z

TIP : Get it right on the table and get soft tissue

balance then

Fracture B3

Incidence z Treatment: unstable Fx then ORIF +/stem unstable z

z

“Vancouver classification system…the ideal…the fracture configuration, the stability of the implant and the quality of the bone stock. When the stem is stable, open reduction and internal fixation is suggested..otherwise revise to longer stem”.

(The management of periprosthetic femoral fractures around hip

replacements. Tsiridis et al. Injury 2003 Feb; 34(2):95-105)

Heterotopic ossification,HO z

z

5-50% revision surgery/anterior approach,previous HO,AS,DISH,neuropathic,Pagets Treat: radiation, NSAIDs

Chronic Pain after THR z z z z z z z

Exclude above causes then consider: LBP Trochanteric bursitis Loose cup early) Slipped liner early) Hairline crack around stem(early) Impingement of femoral stem tip(late)

Implant z z z

Generation of wear particles/osteolysis Breakage: now rare(? Where distal fixation only). Loosening-acetabular: Uncemented, RD Bloebaum et al 1997, bone ingrowth into component averages only 12%; radiographic signs radiolucent lines that initially appeared after two years/ progression of radiolucent lines after two years/in all three zones/ 2 mm or wider in any zone/ migration; Cemented radiolucency upto 2 mm wide with or without a surrounding fine line of density may develop in one or more of the the three zones about cement mass in the pelvis. Radiolucency= dense fibrous membrane and fibro cartilage. femoral see radiographic Stem Loosening: definite loosening: - stem fracture - cement fractrure - radiolucency at the cement component interface > 1 mm.; - changes in stem position/pistoning/medial midstem pivot/calcar pivot/subsidence/distal pivot probable loosening: possible loosening: -radiolucent lines at cement bone interface from 50-100% of the total bone cement interface;

Osteolysis z

Focal endosteal erosion, due wear debris, gasket theory

Miscellaneous z

Revision Surgery: complication 3 to 4x

z

MIS Surgery: ? Less/more, yet to see

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Re-surfacing: yet to see

And the list goes on Vascular damage (risk: 0.1% for primary replacements; less than 1% for revision replacements Cortical perforation (risk: up to 4.5%) Leg length inequality (risk: 6% for primary replacements; 7.5% for revision replacements) Entrapped drain Cement extrusion Impingement of ilio-psoas tendon Anesthetic complications/ respiratory complications (risk: 1%)/cardiovascular complications Bowel complications (risk: 1%) Urinary complications (risk: up to 35%) Haematoma formation (risk: 3%) Wound dehiscence Knee pain Swollen ankles Skin complications (risk: less than 1%) Metabolic complications (risk: less than 1%) Death (risk: 1%) Bone stock loss

Thank you (eat your heart out)

Darling, on my way home