Overview of complications following THR

1. By Hiren M Divecha (CT2)
NMGH
23/6/2010

2. Spinal General
Time & failure PONV 10-20%
Haematoma --- cord Drowsiness
compression Malignant hyperthermia
PDP headache Death 1:100 000
iv injection of LA ---
arrhythmia
Meningitis
< 0.1% spinal nerve injury
Total spinal

3. Nerve injury
Primary 1-2%; revision 3-4%; DDH 5-6% (Amstutz
JBJS Am 1991)
Sciatic peroneal (80%) (posterior); Femoral (10%);
Superior gluteal (lateral)
Fat embolism
Assoc with pressurisation of cement in femoral
canal
Esp. elderly patients
Hypoxia + hypotension

4. Leg length
Apparent – abductor spasm, scoliosis
Transverse ischial line
Up to 1cm tolerated
Sciatic palsy with 4-5cm (Edwards CORR 1987); 3cm
in DDH

6. Dislocation
1-2%
Posterior approach ??
0% with posterior capsular repair (Tsai BMC 2008)
Components
Head size, head:neck ratio
Alignment
Acetabulum (anteversion 10-20 ; abduction 35-45 )
Femoral (anteversion 10-15 )
Soft tissue tension
Offset, neck length
Soft tissue function
Central (stroke, Parkinson’s, MS, dementia)
Peripheral (lumbar stenosis, neuropathy, myopathy )

7. Infection
<1%
Coventry 1975 then Tsukayama 1996
Positive intra-op cultures
Early (< 4 weeks)
Debridement, head/liner exchange, 6/52 ABx
Acute Haematogenous (< 4 weeks from seeding)
Debridement, head/liner exchange, 6/52 ABx
Chronic (> 4 weeks)
Wide debridement, removal of prosthesis, ALC + Abx
MRC trial Lidwell 1984
ALC 11; iv Abx 4.8; ultra clean air 2.6; exhaust suits 2.2

8. DVT PTE
Total Proximal Symptomatic Asymptomatic Fatal
No Prophylaxis 42-57 18-36 3-20 0.5-3
Prophylaxis
Warfarin 20.7 4.8 1.1
LMWH 13.7 3.4 0.3 0.1
Fondaparinux 6.8

10. Hetertopic ossification
Risk factors
Male; hypertrophic OA; Post-traumatic OA; Ankylosing
spondylitis; contralateral hip; lateral approach; TBI
Prophylaxis
600-750cGy 48-72hrs post-op
NSAIDs (0.3-0.5 risk reduction); not aspirin (Fransen
Cochrane 2004)
Celecoxib superior to ibuprofen (Saudan JBJS 2007)

12. Aseptic loosening Modes of failure (Gruen 1979)

13. Osteolysis
Histiocytic response to PE adhesive wear debris
Activated macrophages, TNFα, IL-1, IL-6, osteoclasts ....
Pseudo tumour/ ALVAL
MOM wear debris; ? Metal sensitivity; ? Type 4
hypersensitivity
At 8yrs --- Male = 0.5%; female >40yrs = 6%; female
<40yrs = 13.1% (Glyn-Jones JBJS Br 2009)
Smaller implants; dysplasia
Periprosthetic fracture
1%