Understanding hip replacement complications before the surgery

Prolotherapy Doctor WoznicaIn this article, David N. Woznica, MD discusses the long history of hip replacement complications and why we will recommend to most patients that they explore all non-surgical options first.

Do you have a questions about hip replacement options, do you stll have pain after hip replacement? Get help and information from our Caring Medical staff

All medical procedures come with risk of failure, hip replacement is no exception.

One of the greatest medical failures in recent times was the failure of metal-on-metal total hip replacements. Some recipients of these hip replacements suffered severe pain and immobility after tiny metal fragments chipped off and damaged surrounding tissue.

In 2003 doctors wrote in the Journal of orthopaedic research, of the wear debris Metal-on-metal total hip prostheses produced and the subsequent increase in the patient’s whole-blood metal levels, which caused adverse effects. Patients were recorded with blood concentration levels of Cobalt that were up to 50 times higher than normal, while chromium concentrations were up to 100 times higher. This 2003 research reported, “It is not known to what extent the problem has been overcome by advances in alloy technology.”1

Let’s now move to 2017.  In a new study from doctors in Vienna publishing in the Journal of orthopaedic research, wrote: “The sensitivity of cobalt and chromium ion-levels in detecting poorly performing metal-on-metal hip implants is low. This study proposes that serial changes in ion-levels are a more accurate marker of arthroplasties at risk.”2

What does that mean? It means these doctors are saying that the risk is greater and that 2017 technology is currently deficient is figuring out which patients with metal-on-metal hip replacement are still at risk. 

One more thing, in this study 285 patients were studies. Thirty-nine percent (39%) or 111 of them had a revision surgery to fix the metal-on-metal hip replacement. The researchers found “repeated measurement of ion-levels were higher in the revision group.”

Still from 2017, University researchers in Australia, compared the risk of heart failure in patients with conventional MoM (Metal on Metal) total hip replacements and in those with metal-on-polyethylene (MoP) total hip replacements. Their results led them to suggest: “an urgent need for further studies to investigate the possibility of systemic effects associated with Metal on Metal, total hip replacements.3

Complication with same-day out patient hip replacement procedure

Recently much has been made of the same-day out patient hip replacement procedure. For some patients this can be a viable option. It is important to note in a February 2017 study from the Anderson Orthopaedic Research Institute & Inova Center for Joint Replacement at Mount Vernon Hospital, The Rothman Institute, and Thomas Jefferson University Hospital, many same-day patients are “extended stay,” patients.

Outpatient total hip replacement (you go home before 12 hours) can be implemented in a defined patient population, but 24% (27 of 112 patients in the research) were not able to be discharged the same day. This was also a very select group of patients who were:

Please see our discussion on problems of joint replacement and healing with chronic opioid abuseFor our discussion with the problems of obesity and healing please see Obesity, diet and joint repair.

The point to this research is that there are so many factors prior to hip replacement, many unforeseen, that could cause complications afterwards.

Loosening, instability, dislocation, infection

But nowadays there are other complications that are troubling. Recent research from doctors in Spain examined 127 patients who had to have revision surgeries to fix something that went wrong in the total hip replacement .

An international team of researchers found that there are no clear answers in preventing dislocation of the new hip joint. The cause of dislocation is multifactorial.6

Study: Some patients need one to 15 hip surgeries because of infection

Metallosis of Right Hip seen on MRIDoctors in the United Kingdom reported on patients who had between 1 and 15 revision operations after their primary joint replacement. They found that these patients spent great amounts of time immobilized between and waiting on their next surgery and that this caused further health problems.7

Groin Pain after hip replacement

The  prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series.8 The complexity of hip and groin pain are discussed further in my article: Groin Pain Treatments.

Iliotibial Band Syndrome after hip replacement

In September 2016, Spanish researchers published their findings that more than 1 in 20 hip replacement patients would develop Iliotibial Band Syndrome. In their research after a minimum followup of 2 years, they found 5.5% (9 out of 164 patients) developed Iliotibial Band Syndrome within the first 45 postoperative days. Conservative treatment was successful in 6 of the 9 patients while 3 had to undergo further surgery.9

Impingement of the iliopsoas tendon

Doctors at the Mayo Clinic writing in the Journal of bone and joint surgery suggest that A potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoas tendon. Treatment options include conservative management, tenotomy, and acetabular revision.

In looking to suggest treatment options the Mayo doctors looked at 49 patients with a diagnosis of iliopsoas impingement after primary total hip replacement:

At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution compared with 22 patients (76%) in the operative group

Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. In patients with minimal acetabular component prominence, iliopsoas release provided a high rate of success. The greater the hardware problem the greater the need for surgical resolution.13

Assessing the patient’s post treatment success – Surgery

The decision to go to any joint replacement is a big one. In medicine, a great deal of emphasis is placed on scores to help clinicians decide before a joint replacement who had the best chance for surgical success. A recent study looked at the “Oxford” scoring system of over 3000 patients who had a hip or knee replacement. The purpose of the study was to help doctors identify and prioritize those patients who had best chance of success. At the end of the study the doctors found that pre-operative Oxford scores have no predictive accuracy in distinguishing satisfied from dissatisfied patients. Further, Oxford hip and knee scores have no predictive accuracy in relation to post-operative patient satisfaction. This evidence does not support their current use in prioritising (sp) access to care.10,11

Japanese researchers examined the fall risk in patients following hip replacement. They found an increased risk for falls and fall-induced injuries mostly associated with medication and shorter postoperative duration.12

For a discussion of options before hip replacement please see my article Hip Replacement alternatives | Regenerating a dying hip.

For a discussion of options before hip replacement please see my article Hip Replacement alternatives | Regenerating a dying hip.

Do you have a questions about hip replacement options, do you stll have pain after hip replacement? Get help and information from our Caring Medical staff

1 Lhotka, C., Szekeres, T., Steffan, I., Zhuber, K. and  Zweym BCllerK. (2003), Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total hip replacements. J Orthop Res. 2003 Mar;21(2):189-95. [Pubmed] [Google Scholar]
2 McHugh G, Merchant R, Kelly GE, Bergin KM, McCoy GF, Wozniak AP, Quinlan JF. The value of serial metal ion levels in following up patients with metal-on-metal hip arthroplasty. Hip Int. 2017 Jan 20:0. doi: 10.5301/hipint.5000432. [Pubmed] [Google Scholar]
3 Gillam MH, Pratt NL, Inacio MC, Roughead EE, Shakib S, Nicholls SJ, Graves SE. Heart failure after conventional metal-on-metal hip replacements: A retrospective cohort study. Acta orthopaedica. 2017 Jan 2;88(1):2-9. [Pubmed] [Google Scholar]
4 Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH Jr, Hamilton WG, Hozack WJ. Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty. Clin Orthop Relat Res. 2017 Feb;475(2):364-372. doi: 10.1007/s11999-016-4915-z. [Pubmed] [Google Scholar]
5. Capón-García D, López-Pardo A, Alves-Pérez MT. Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis. Rev Esp Cir Ortop Traumatol. 2016 Mar 1. pii: S1888-4415(16)00004-7. [Pubmed] [Google Scholar]
6. Timperley AJ, Biau D, Chew D, Whitehouse SL. Dislocation after total hip replacement – there is no such thing as a safe zone for socket placement with the posterior approach. Hip Int. 2016 Mar 23;26(2):121-7. [Pubmed] [Google Scholar]
7. Beard D, Carr AJ, Dawson J, Fitzpatrick R, Field RE. Assessing patients for joint replacement: can pre-operative Oxford hip and knee scores be used to predict patient satisfaction following joint replacement surgery and to guide patient selection? J Bone Joint Surg Br. 2011 Dec;93(12):1660-4. [Pubmed] [Google Scholar]
8. Forster-Horvath C, Egloff C, Valderrabano V, Nowakowski AM. The painful primary hip replacement – review of the literature. Swiss Med Wkly. 2014 Oct 8;144:w13974. [Pubmed] [Google Scholar]
 Seijas R, Sallent A, Galán M, Alvarez-Diaz P, Ares O, Cugat R. Iliotibial band syndrome following hip arthroscopy: An unreported complication. Indian Journal of Orthopaedics. 2016;50(5):486-491. [Pubmed]
10. Moore AJ, Blom AW, Whitehouse MR, Gooberman-Hill R. Deep prosthetic joint infection: a qualitative study of the impact on patients and their experiences of revision surgery. BMJ Open. 2015 Dec 7;5(12):e009495. doi: 10.1136/bmjopen-2015-009495. [British Medical Journal]
11. Matharu GS, McBryde CW, Robb CA, Pynsent PB. An analysis of Oxford hip and knee scores following primary hip and knee replacement performed at a specialist centre. Bone Joint J. 2014 Jul;96-B(7):928-35. doi: 10.1302/0301-620X.96B7.32479. [Pubmed]
12. Ikutomo H, Nagai K, Nakagawa N, Masuhara K. Falls in patients after total hip arthroplasty in Japan. J Orthop Sci. 2015 Mar 24. [Pubmed]
13 Chalmers BP, Sculco PK, Sierra RJ, Trousdale RT, Berry DJ. Iliopsoas Impingement After Primary Total Hip Arthroplasty: Operative and Nonoperative Treatment Outcomes. J Bone Joint Surg Am. 2017 Apr 5;99(7):557-564. [Pubmed]


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