Updated: 7/13/2019

THA Other Complications

Topic
Review Topic
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Questions
28
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Evidence
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Videos
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Cases
3
https://upload.orthobullets.com/topic/5030/images/leg length.jpg
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Introduction
  • This topic includes
    • heterotopic ossification
    • squeaking
    • blood transfusion
    • pseudotumor (metal reactions)
    • vascular injury
    • trunnionosis
  • Other THA Complication topics
    • periprosthetic infection 
    • THA dislocation 
    • periprosthetic fractures 
    • aseptic loosening 
    • limb length discrepancy 
    • sciatic nerve palsy 
Heterotopic Ossification
  • Introduction
    • frequent complication that may limit functional outcome following hip replacement  
    • risk factors
      • prolonged surgical time
      • excessive soft tissue handling during procedure
      • hypertrophic osteoarthritis
      • male gender
  • Treatment
    • surgical excision
      • indications
        • severe loss of motion
        • once heterotopic ossification is visible on radiographs, only surgical excision will eradicate 
      • technique
        • must wait 6 months after initial procedure to allow for maturation and formation of capsule
        • perioperative prophylaxis with perioperative radiation or NSAIDs
  • Prophylaxis
    • oral indomethacin
    • radiation therapy
      • 600-800 cGy administered ideally within 24-48 hours following procedure
Postoperative Anemia
  • Low preoperative hemoglobin
    • is the best predictor of the need for a blood transfusion postoperatively 
  • Prevention
    • TXA
  • Treatment
    • postoperative transfusion
      • indications
        • most centers have dropped to a hemoglobin of 7-8
Squeaking
  • Defined as a high pitched audible sound occurring during hip movement
  • Incidence
    • ceramic-on-ceramic 
      • 0.5-10%
    • metal-on-metal 
      • 4-5%
    • incidence of revision because of squeaking is 0.5%
  • Risks 
    • impingement
    • edge loading
    • component malposition
    • loss of fluid film lubrication
    • third body particles
    • thin, flexible (titanium) femoral stem 
Pseudotumor Hypersensitivity Response
  • Introduction
    • caused by metal-on-metal THA relating to metallic wear  
      • With metal-on-metal THA, current recommendations are to obtain serum metal ion levels (cobalt, chromium) at long-term followup visits
      • If any concerns, imaging of choice is MR with metal subtraction
      • In symptomatic patients, must first rule out infection, fracture or other causes of acute or chronic pain before presuming metallic wear and ordering metal ion levels
    • lesion, neither infective or neoplastic, which develops in the vicinity of a total hip replacement
  • Presentation
    • associated with pain, and bone erosion
Vascular Injury
  • Incidence
    • 0.1%-0.2%
  • Risk factors
    • acetabular screw placement in anterior-superior quadrant
    • inappropriate retractor placement 
Trunnionosis
  • Introduction
    • wear of the femoral head-neck junction 
  • Incidence
    • 3%
  • Risk factors
    • Modular designs
    • Large cobalt chrome femoral heads
    • Metal on metal 
      • no pathognomonic serum metal ion level for trunnionosis
      • serum cobalt >1.6 ng/ml (ppm) considered threshold for mechanically assisted crevice corrosion
  • Treatment
    • Revision to ceramic head with titanium sleeve and new polyethylene liner  
 

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Questions (28)
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(OBQ13.20) A 38-year-old female patient presents to your office three years after a hip resurfacing. She complains of worsening left hip discomfort for the last 6 months. Her ESR is 12 (normal 0-20) and CRP is 1.2 (0-5). A radiograph and axial and coronal MRI scans are shown in Figures A, B, and C. What is the most likely diagnosis? Review Topic

QID: 4655
FIGURES:
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1

Infection

1%

(40/3929)

2

Type I Hypersensitivity reaction

3%

(130/3929)

3

Femoral neck fracture

6%

(236/3929)

4

Prosthesis Loosening

10%

(386/3929)

5

Pseudotumor

79%

(3114/3929)

L 2

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(OBQ13.270) Figure A shows a radiograph of a 62-year-old female that underwent a left total hip arthroplasty 5 years ago. She presents to your office with insidious onset of left groin and buttock pain. She denies trauma, fever or chills. On physical examination, her left hip has mild pain with range of motion. She has a normal gait cycle, normal power across the hip and her vitals signs are stable. A left hip aspirate was performed and results are shown in Figure B. What is the most likely cause of her hip pain? Review Topic

QID: 4905
FIGURES:
Type in at least one full word to see suggestions list
1

Periprosthetic bacterial hip infection

9%

(276/3170)

2

Periprosthetic hip fracture

0%

(10/3170)

3

Large-particle wear debris disease

15%

(464/3170)

4

Pseudotumor hypersensitivity response

75%

(2370/3170)

5

Abductor tendon tear

1%

(32/3170)

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(OBQ13.121) A 55-year-old patient returns for followup 2 years after a left ceramic-on-ceramic total hip arthroplasty. He has no pain or symptoms of instability. The video in Figure V shows him ascending stairs. All of the following factors may contribute to this phenomenon EXCEPT Review Topic

QID: 4756
FIGURES:
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1

Impingement

5%

(145/3074)

2

Edge-loading

8%

(234/3074)

3

Loss of fluid film lubrication.

10%

(302/3074)

4

Third-body particles

4%

(113/3074)

5

Subclinical infection

73%

(2258/3074)

L 3

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(OBQ12.234) A 67-year-old female complains of anterior groin pain one year following a primary, uncemented total hip arthroplasty. The pain is exacerbated when she tries to climb stairs or get up from a seated position. She denies any recent fevers or chills. On physical exam, the pain is reproduced with resisted seated hip flexion. Laboratory analysis, including WBC, ESR, and CRP are within normal limits. Radiographs reveal that the components are appropriately positioned without evidence of loosening or fracture. Which of the following is the most appropriate at this time? Review Topic

QID: 4594
Type in at least one full word to see suggestions list
1

Revision of the acetabular component

1%

(25/3291)

2

Image-guided diagnostic injection of lidocaine into the iliopsoas tendon sheath

77%

(2544/3291)

3

Hip aspiration

3%

(110/3291)

4

Bone scan

5%

(179/3291)

5

Conservative management including activity modifications, NSAIDs, and physical therapy

13%

(417/3291)

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(OBQ12.164) A 45-year-old man has had the gait disturbance shown in Video A ever since a total hip replacement two years ago. Since then he has undergone physical therapy and nerve exploration without any clinical improvement. Extensive AFO bracing was attempted but was not tolerated by the patient. A recent ankle radiograph is shown in Figure A. The Silfverskiold test reveals dorsiflexion of 20 degrees with knee flexion, and 10 degrees with full knee extension. The results of muscle testing using a Cybex dynamometer are shown in Figure B. What is the most appropriate next step in in treatment. Review Topic

QID: 4524
FIGURES:
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1

Ankle arthrodesis in 30 degrees of dorsiflexion

1%

(33/3287)

2

Posterior tibial tendon transfer to the lateral cuneiform through the interosseous membrane

75%

(2463/3287)

3

Split anterior tibial tendon transfer to the cuboid

3%

(109/3287)

4

Peroneus longus transfer to the navicular and gastrocnemius recession

6%

(203/3287)

5

Flexor hallucis transfer to the navicular and tendo Achilles lengthening (TAL)

14%

(457/3287)

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(SAE07HK.47) A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now reports pain in his hips and difficulty with ambulation to the point where he now uses crutches. A radiograph of the hip and pelvis is shown in Figure 26. What is the best treatment option for this patient? Review Topic

QID: 6007
FIGURES:
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1

Revision hip arthroplasty with a bipolar implant

1%

(1/103)

2

Revision hip arthroplasty with impaction grafting on the femoral and acetabular side

5%

(5/103)

3

Revision hip arthroplasty with a cemented jumbo acetabular component

34%

(35/103)

4

Revision hip arthroplasty with a cementless acetabular component

49%

(50/103)

5

Acetabular component revision with a tri-flange protrusio ring

12%

(12/103)

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(SAE07HK.41) Figure 23 shows failure of the femoral stem in a patient. What is the most likely reason for the failure? Review Topic

QID: 6001
FIGURES:
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1

Torsional loading

4%

(3/78)

2

Cantilever bending

76%

(59/78)

3

Pistoning

6%

(5/78)

4

Subsidence

5%

(4/78)

5

Torque

4%

(3/78)

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(SAE07HK.85) A 62-year-old patient is seen for routine follow-up after undergoing cementless total hip arthroplasty 2 years ago. The patient reports limited range of motion that severely affects daily activities. A radiograph is shown in Figure 51. Management should now consist of Review Topic

QID: 6045
FIGURES:
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1

observation only.

0%

(0/94)

2

nonsteroidal anti-inflammatory drugs and protected weight bearing.

2%

(2/94)

3

irradiation to the affected area.

3%

(3/94)

4

surgical excision.

6%

(6/94)

5

surgical excision and postoperative irradiation.

85%

(80/94)

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(SAE07HK.80) Figure 49 shows a histologic section of the lung in a patient who died during total hip arthroplasty. What unexpected finding is seen in the pulmonary capillaries? Review Topic

QID: 6040
FIGURES:
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1

Pulmonary embolism

27%

(29/106)

2

Methylmethacrylate cement

62%

(66/106)

3

Hemorrhagic infarct

6%

(6/106)

4

Granuloma formation

1%

(1/106)

5

Amyloid

1%

(1/106)

N/A

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(SAE07HK.3) A metal-on-metal bearing used for total hip arthroplasty shows which of the following properties? Review Topic

QID: 5963
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1

Baseline serum ion levels increase with increasing activity levels.

22%

(19/86)

2

The risk of cancer is substantially increased.

0%

(0/86)

3

Linear ion production increases over time.

20%

(17/86)

4

Ions produced are excreted primarily through the kidney.

52%

(45/86)

5

Nickel is the most prevalent ion released into circulation.

1%

(1/86)

N/A

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(OBQ06.141) The preoperative pelvic radiograph of a 63-year-old female with osteoarthritis is shown in Figure A. She undergoes an uncomplicated total hip replacement. Six weeks post-operatively she complains that her right leg is longer than her left, and an AP pelvic radiograph is obtained which is shown in Figure B. Physical exam shows normal post-operative range of motion and strength in both hips. What is the most likely etiology for this patients gait impairment? Review Topic

QID: 327
FIGURES:
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1

Hip flexion contracture

3%

(57/1994)

2

Excessive medialization of the acetabular component

1%

(24/1994)

3

Patient's perceived leg length discrepancy

88%

(1750/1994)

4

Hip adduction contracture

6%

(123/1994)

5

Malpositioning of the femoral component

2%

(34/1994)

L 1

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