OTHER COMPLICATIONS OF THE TOTAL HIP SURGERY
CONTENTS:
Ossifications around the total hip
Fracture of the bone around the total hip device
Impingement of iliopsoas muscle
Mechanical failures of the total hip device
There is a host of possible complications that may occur after a total hip surgery but they occur with exceeding rarity. When I discuss these complications here, it is not to scare you. This information is destined for this very occasional patient who experienced some such very rare complication and seeks information about it.
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Heterotopic ossifications
or Ectopic ossifications
What is it
It is a deposition of new bone around the total hip joint. The reported occurrence of this complication varies widely from 5 to 50 %. It is thus one of the most frequent complications of total hip surgery. (Neal 2000)
| No ossifications | 70 % |
| Mild ossifications | 21 % |
| Moderate ossifications | 6 % |
| Severe ossifications | 3% |
Only few patients, however, develop sufficiently large masses of bone tissues around the replaced hip joint to produce noticeable limitation of the movements in the total hip joint. In the majority of patients, with only isolated small islands of bone tissue in the thigh muscles, the ossifications do not cause any symptoms.
Why it develops
Bone tissue forms often between muscle fibers after trauma to muscles. So it develops also after the muscle trauma caused by the total hip surgery. The precise mechanism by which bone forms in muscles around the hip joint is unknown. The scientists believe that the development of ossifications starts already during the total hip operation, so that the preventive treatment should start also during the operation itself.
Who is at risk:
Statistics indicate that muscular male patients with severe grades of osteoarthritis in both hips are at greater risk for developing ectopic ossifications after total hip replacement. Also patients with ankylosing spondylitis (see Hip joint disease) are at greater risk for ectopic ossification. Ectopic ossification are rare in rheumatoid arthritis patients.
What are the symptoms
The majority of patients get the first symptoms of ectopic ossifications some two to three weeks after the operation. The onset of this complication is usually characterized by rest pain in the thigh muscles, tenderness of the muscles with an occasional spasm, sometimes also reddening of the skin.
Some patients may also have a low grade fever for some days.
So the symptoms look like the symptoms of postoperative infection and deep vein thrombosis. The surgeon must exclude these latter complications, because their treatment is different.
After some weeks the bone tissue matures and the acute symptoms disappear.
In patients with widespread ossifications there remains a considerable limitation of all movements in the total hip joint. The movements are also painful. The majority of patients with a severe grade of ossification are dissatisfied with the outcome of their total hip operation.(Eggli 2000)
Diagosis
The patient with developing ossifications may have falsely positive laboratory tests for infection (high values of C reactive proteins and sedimentation rate). Because the ossifications develop early after the surgery, a period when the risk of postoperative infection is high, the surgeon must always keep this alternative in mind.
The surgeon must also exclude another source of intensive pain, such as nerve compression.
Definite diagnosis is be x-ray examination.
The prevention:
Should start during the operation or directly afterwards. Two methods have been used:
Irradiation of the operative wound and thigh muscles
NSAID drugs (Indomethacine)
There are problems with both prevention methods
Irradiation may damage the tissues and cause complications in the healing of the operative wound. Such damages were, however, not reported in the available statistics.
NSAID drugs must be applied in high doses and usually for 6 weeks to be effective. NSAID used in high doses under so long period may cause severe problems. About one third of all patients receiving NSAID drugs for prophylaxis of ossifications developed stomach bleeding and the prophylaxis was stooped ((2) Neal 2000).
Treatment:
The majority of ossifications is small and need not be treated.
Treatment of pain is by non steroid anti-inflammatory medicines. Unfortunately, not always successful. The pain in many patients declines also without treatment.
In patients with severe ossifications, limiting movement in the replaced hip and causing pain, the surgeon may recommend surgical treatment - removal of ossifications by operation.
The operation causes, however, a new trauma so that the ossification may recur. There are, however, no reliable statistics how often this happens.
The results of the treatment:
The majority of surgeons uses some form of preventive treatment after the excision of ossifications, either irradiation, non-steroid drugs (Indomethacin), or both.
All surgeons agree that the range of movement in the total hip improves after the excision operation significantly.
When it comes to the alleviation of pain after excision of heterotopic ossifications, which is the main worry for many patients, the surgeons disagree.
Only in one report of three (Wick 1999) 90% of all operated on patients had excellent relief of pain.
The authors of the two other reports point out that of the patients operated on solely because of pain none had complete alleviation of pain and about 20 % still have had severe pain (Cobb 1999, Wahl 2002).
The numbers of the studied patients in these reports vary between 21 to 53 patients; obviously few surgeons have any bigger experience with surgical excision of heterotopic ossifications after total hip replacement.
Questions to ask your surgeon:
How large is the ossification around my total hip?
Do you believe that surgical excision seems warranted?
What are your experiences with surgical treatment of this complication?
Do you believe that the operation may relieve my pain?
What postoperative treatment will you suggest?
References :
Wick M, et al:. Arch Orthop Trauma Surg. 1999; 119(3-4):151-5.
Cobb TK et al.: Clin Orthop. 1999 Apr;(361):131-9.
Wahl B et al.: Unfallchirurg. 2002 Jun;105(6):523-6.
Neal et al: Acta Orthop Scand 2000;71:129-34
Neal et al (2): Cochrane Database Syst Rev 2000;(3) CD001160
Eggli et al.: Acta Orthop Belg 2000; 66:174-80)
Nerve damage after the total hip replacement:
"Nerve palsy is the most distressing complication of total hip replacement. No amount of preoperative discussion or postoperative consultation decreased the high degree of dissatisfaction that was expressed by these patients.
Although objective measurements of stability and range of motion indicated that the hip arthroplasty was successful the patient’s dissatisfaction with nerve damage precluded good rating of the result". (Schmalzried 1991)
What is it?:
It is a damage to one or more of the four main nerves that cross the area of the hip joint.
In the absolute majority of cases, the damage occurred on the largest nerve, the nervus ischiadicus.
Damage to the ischiadicus nerve
The ischiadicus nerve consists of a thick nerve trunk that crosses the back of the hip joint, relatively close to the joint capsule. Actually, there are two separate nerves (tibial and peroneal nerve) combined into one large nerve trunk by a common connective tissue sheath in the area of the hip joint.
For some, as yet not fully clear reasons, the peroneal nerve is the part of the ischiadicus trunk that is damaged most often during total hip operations.
The common peroneal nerve supplies the skin area of the lower leg and foot and the muscles that stretch the foot upwards.
Thus, patients with partial damage of of the sciatic nerve in the hip area have drop foot, tingling pain and loss of sensitivity down in the foot area only.
How often does it occurs?:
In primary Total hip surgery in 1 %
In revision operations in 3,2 %
In total hip operations done for hip dysplasia in 5,2 %
What causes it?
Patients with this troublesome complications wish to know what caused the nerve damage. Actually, in more than half of all cases of nerve ischiadicus damage the surgeon could not find any apparent cause.
Only in 4 % of all cases there was found direct damage to the nerve during the operation (pressure from wound retractors, but also pressure of the lumps of bone cement that escaped in soft tissues, etc.)
Damage from too much tension of the ischiadic nerve by leg lengthening was found in about 25 % of all cases of damage.
In about 15 % of the cases, the damage was caused by the pressure of the collected blood (hematoma) on the nerve.
When it appears?
The majority of sciatic nerve damages has been recognized on the operation day. As soon as the effects of anesthesia disappear the surgeon should control the nerve function in the limb. The damage of the sciaticc nerve presents in most cases as a drop foot (more or less complete), disturbance of the sensitivity in the foot area, sense of numbness, tingling, and pain in the foot area.
About 15 % of all cases of ischiadicus nerve damage has been recognized later, on the 2 -6th postoperative day. These patients usually have severe pain in the thigh, heralding the collection of the blood (hematoma) beneath the thigh musculature that pressures on the ischiadicus nerve). This condition must be managed acutely.
Note that a drop foot and tingling in the foot that appear at the second or third day after the surgery may be caused by direct pressure on the peroneus nerve in the knee area. This happens in patients placed on knee braces who are badly cushioned. Somnolent, heavy sedated patients may be prone to this nerve damage
Signs of sciatic nerve damage:
The patient complains of increasing pain, tingling, sticking, and numbness in the leg and foot with increasing muscle weakness.
Neurological evaluation with special examinations such as EMG (elctromyography) may reveal whether the nerve damage is complete or partial.
Usually (in about 75 % of all cases), the patient has a drop foot, 25% of the patients have even weakness of other muscles in the leg.
Treatment:
Acute operation is necessary in case of a postoperative hematoma (blood pool) compressing the nerve, after careful neurological evaluation to locate the cause and the place for the nerve damage. The consultation with a neurological specialist may be necessary.
Physical therapy and bracing of the weak muscles if no obvious cause of nerve damage was found.
Healing of the sciatic (ischiadicus) nerve damage
Healing of the sciatic nerve damage is finished within 24 months after the damage was inflicted. After this time period the state of the lameness and pain does not change .
75 % of all patients will regain normal function in the extremity or will be left with only a mild deficit of nerve function causing no distress
25 % patients will have persistent severe deficit causing much distress (unfortunately, the young patients have more often dissatisfying recovery).
Damage to other nerves
The damage to other nerves around the hip joint during the total hip surgery is very rare, but the pain caused by the damage of these nerves is sometimes misinterpreted and the patient is suffering unnecessary long time before the right cause of pain is discovered.
The damage of the lateral cutaneous nerve
This nerve crosses the hip joint area on the upper frontal side, where it emerges from the pelvis. The nerve lies directly beneath the skin and is vulnerable also to pressure on this area. The nerve may be damaged during anterior approach to the hip joint.
The damage causes numbness, paresthesias, and pain in the anterolateral (front and side) thigh area up to the pelvic spine. Actually the spread of the pain area is typical for the injury of this nerve. The characteristic pain in this area is sometimes called meralgia paresthetica. Relief of pain and paresthesias after injection of a local anesthetic agent is helpful in establishing the diagnosis. Although nonoperative management usually results in satisfactory results, if the surgeon suspects that the nerve is entrapped in scar tissue he should explore the nerve and free it from entrapment.
Femoral nerve damage
Damage to the femoral nerve causes pain and numbness over the anterior aspect of thigh and weakness of muscles that stretch the knee joint (quadriceps muscle group. The nerve passes/ lies on the outside of the hip socket and then passes the groin on its way to the inside and front side of the thigh.
It follows that this nerve is vulnerable in total hip operations done from the anterior (anterolateral) access; consequently, the femoral nerve damage has been reported in patients operated on through the "two incisions" MIS (minimal incision hip surgery).
Also in cases when the surgeon drills a hole through the osseous wall of the hip socket, the drill tip, the screw, or cement may come through the hole and damage the femoral nerve.
Fortunately, the damages to the femoral nerve recover better than damages to the ischiadicus nerve.
The damage of the obturator nerve
This nerve lies close to the pelvic bone on the back side of the hip socket and may be damaged by protruding screws or lumps of bone cement that escaped during cementing of the total hip prosthesis. The X-rays of the total hip may give suspicion of the damage of this nerve if they show protruding screws or large large clumps of bone cement on the inside of pelvic bone.
The damage of this nerve causes pain in the groin and on the inside of the thigh, the muscle strength is diminished in adductor muscles (the muscles that move the limb to the midline.
The treatment is by operation with removal of all protruding screws or lumps of cement impinging on the nerves after careful neurological evaluation to locate the cause and the place for the nerve damage.
Other causes of nerve damage
spinal anesthesia
Patients may have occasional pain or paresthesia in their feet after spinal anesthesia although no nerve damage can be discovered with examination. These patients need consultation with neurological specialist and anesthesiologist.
Patients with tight spinal canal in low back spine (spinal stenosis) may be prone to this type of complication.
Patients on blood thinning medicines (Coumadine)
are at risk to have bleeding in the spinal canal after spinal anesthesia with following signs of nerve damage.
If you know that you have changes in your back spine such as spondylos (worn out lumbar spine ), narrow spinal canal, or ankylosing spondylitis (bamboo spine) discuss this condition with your anesthesiologist before the surgery. These condition predispose for spinal nerve damage.
Please note that this short chapter cannot be a textbook on nerve damages after total hip surgery and their diagnosis. Remember that whenever you have any suspicion of nerve damage, such as numbness, paresthesias, and pain in the hip and leg areas, weakness or lameness of muscles, especially if this pain is constant, you should consult your doctor for more close examination, diagnosis and treatment.
References
Schmalzried TP et al, J Bone Joint Surg-Am 1991; 73-A, 1074-80
Bone fractures around the total hip prosthesis
Bone fractures around the total hip devices are on the rise. Current estimates of their frequency vary between 0.1 to 3.2% for cementless primary total hip replacements. The fractures are more frequent after revision operations (3 to 12%) (Parvizi 2004). The introduction of uncemented press-fit stems resulted in substantial increase in intraoperative fracture rates, ranging from 3% to 46%! This rate is anticipated to increase even further in the future.
Femoral (thighbone) fractures at the upper end:
Fractures occurring at the upper end of thighbone during the operation may occur at any stage of the operation but particularly when
A - the surgeon enlarges a narrow marrow hole (diaphyseal canal) of the thigh bone with forceful blows on the reamer or blows in the femoral shaft component into the socket. The press-fit total hip devices demand reaming of the marrow hole with large reamers. The pressure from large reamers then causes small or larger cracks in the trochanter skeleton.
At risk are patients with fragile bones such as elderly patients and patients with rheumatoid arthritis.
B - Cracks pass through the upper part of the thighbone, parts of the skeleton called larger and smaller trochanter. These cracks usually heal without further surgery with limitation of weight bearing only - use of crutches only. Some surgeons even believe that such cracks actually are beneficial - they promote bone ingrowth into the porous surface of the total hip joint.
C - Large fracture cracks going through the whole trochanter area need stabilization. The muscle pull on the fragments will namely prevent their healing to the thighbone otherwise. The surgeons use most often simple wire cables for fixation of these fractures to the thighbone.
Fractures through the upper part of thighbone (trochanter area) Click on the icon for full size picture
Fractures through the shaft of the thighbone
Osteolysis
These fractures are most often the result of the osteolysis disease. A - A well fixed shaft component in a healthy thighbone is enclosed by a strong corticalis bone (white outer layer) and enclosed in retained sponge bone.
B - Osteolysis enlarges (balloons) the marrow cavity so that the shaft component wobbles in the enormous cavity (yellow circle). The corticalis bone is changed into an eggshell thin structure so that the lover tip of the shaft component makes an opening in it.
C - x-ray picture of the thighbone destructed by the osteolysis. You may see that the lover end of shaft device protrudes outside the thighbone.
Osteolysis of the thighbone shaft around the shaft component (blue). Click on the icon for a fullsize picture
Such destructed bones have lost their mechanical stability and fracture with even a relatively small trauma. Again, osteolysis is relatively frequent in cementless total hips some 5 - 7 years after the original surgery.
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Reparation of shaft fractures.
Fractures through the shaft of the thighbone need revision operation that is usually complicated.
A - Fracture through the shaft of the thighbone around the lower end of the prosthesis. Schematic B - X ray picture of such fracture. The skeleton may be more splintered than on this picture
C - Picture of a repaired fracture.
At operation the surgeon must follow some principles:
First, the surgeon must fill the void after destruction of the skeletal tissue. There are special sturdy total hip devices that at least partially fill the void. The remaining free space between the ballooned shaft of the thighbone and the prosthesis may be filled with bone tissue taken from other places of the patient's own skeleton.
The new total hip device must be also extra long to bridge the weak skeleton destructed by osteolysis. Such device is thus anchored in the still healthy lower part of the thighbone
Revision operation of the shaft fracture around a failed total hip. ReachTM total hip (Biomet)
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Acetabulum (pelvic socket)
may be injured when the surgeon prepares (reams) the place for a cup component.
Small cracks usually heal with limitation of weight bearing only - use of crutches only.
In the (very seldom) case of large fracture lines through the pelvic skeleton the surgeon uses special cups with attached plates and screws to stabilize the fracture cracks.
Fractures occurring after the operation:
they occur usually in patients with fragile bones and after accidents.
Small cracks engaging only parts of the skeleton usually heal with limitation of weightbearing - use of crutches.
Larger fractures through the whole skeleton may need operative treatment.
The surgeon stabilizes the fracture site with screws, plates, and wiring, followed by non weightbearing regime, traction and / or brace.
Sometimes the surgeon will remove the original femoral component and replaces it with an extra long femoral stem component. Such component fixes together the fragments of the broken femoral bone.
Long term follow up after the fractures is necessary, because the risk of prosthetic loosening is higher in these patients.
Fatigue fractures
typical is the fatigue fracture of the os pubis (the bone close to the genitals). This is a painful lesion, causing pain in the groin. The fracture initially does not appear on the X-ray pictures. If the surgeon excludes infection and loosening and repeats the X-ray examination after six weeks, the fracture will appear on the X-ray pictures.
This fracture does not engage the skeleton supporting the total hip joint and will heal with non weight bearing regime.
References: Parvizi J et al: J Bone Joint Surg-Am 2004; 86-A Supplement 2: 8 - 16.
Mechanical failures of the total hip prosthesis
Fracture of the shaft component of the prosthesis
Fracture of the shaft of the femoral component is rare nowadays. It occurs in excessive weight patients. Symptoms are increasing pain. Diagnosis is by X -ray pictures.
The cause is prosthetic loosening of the shaft. The loose shaft is not longer supported by the thigh skeleton. Repeated cyclic stresses will successively bend and then break the metallic shaft. The treatment is by revision operation: removal of the broken shaft and replacement with a new, possibly stronger component.
Symptoms of broken stems
The breakage affected only the anchoring stem of the total hip joint whereas the rest of the total hip joint, its ball and cup components were left intact. The breakage occurred usually in the lover and middle parts of the stem where the stem was slimmer and thus less resistant to fatigue fracture. The breakages in the upper part of the stem were less frequent because the stem was there more robust and resistant to fatigue. Photo of a broken stem
Roentgenograms of stems broken in their upper parts showed dramatic pictures of a spectacular catastrophe as on this Picture. Both broken parts of the stem lay apart; this is a picture of a catastrophe much like the pictures of broken bridges and collapsed buildings. Patients with such breakage of their stems usually presented with sudden, excruciating pain in the operated on total hip. Roentgenogram of a broken stem For the majority of patients with stem breakages located in the middle and lower parts of the stem, however, the pain in the replaced total hip was less severe but increased insidiously. Sometimes the surgeon even suspected a loose total hip initially (which it in reality was). The roentgenograms of these patients’ total hips showed less dramatic pictures. The breakage of the stem looked like a rather fine black line through the stem component. On roentgenograms of some patients the breakage line was almost invisible so that an inexperienced eye could miss it.
For the unhappy patients with such “invisible lines” the pain in their hips could continue for months and even years. These patients were told repeatedly the usual phrase “your x-ray pictures show nothing wrong”. Eventually an experienced radiologist scrutinized carefully the whole series of the x-ray pictures. And there it was, the cause of the nagging pain: the hair-fine fracture through the stem.
For more facts and history see also the chapter Fatigue fractures of the total hip shafts
Polyethylene liner failure
Fracture of the modular polyethylene liner of the acetabulum is caused by excessive wear. See the following pictures:
Click here for the picture Usually the failure starts by dislodgement of the polyethylene liner from its metallic sleeve. ( 1)The ball component then moves up toward the upper rim of the polyethylene liner. The stress on the liner is asymmetric and high. The high localized stress causes initially increased wear. (2)The asymmetrically placed ball thus wears successively out a hole in the polyethylene liner. (3) Eventually, the increased stress overrides the stress resistance of the polyethylene material and the liner breaks.
The liner must be exchanged. The metallic sleeve may be still well attached to the skeleton, even if the liner is totally destructed. The opinions differ as to whether whole cup, inclusive of the well fixed sleeve should be exchanged or whether it suffices with a "small " surgery - exchange of the broken liner only. (Lie 2007)
Other possible mechanical failures of the total hip prosthesis
Disassembly of modular components on the femoral or acetabular side of the prosthesis. It is caused by either bad construction of the prosthesis or by bad assembly of the components during the operation.
Chipping off the rim of the ceramic socket during insertion of the component
Fracture of the ceramic components
All these prosthetic failures need a revision operation.
Impingement of iliopsoas muscle
Soft tissues may be impinged between the rim of the cup component and the neck of the shaft component when the patient flexes the leg. These patients feel pain in the groin when flexing the leg in the hip joint.
The most often observed impingement is Iliopsoas muscle impingement
Anatomy of iliopsoas muscle
A - The muscle called iliopsoas arises from the spine and pelvis bone and attaches to the lesser trochanter of the thighbone. The iliopsoas muscle bends (flexes) the lower limb in the hip joint (and bends the spine to the side). You may palpate this muscle in the groin: just flex the thigh against resistance with bent knee and you will feel the muscle's lower end tighten in the groin. B - The iliopsoas muscle is placed on the bottom of the pelvis in the area that is sometimes poetically called "iliopsoas valley". It passes there directly over the hip joint and its capsule.
C - The iliopsoas muscle is an important muscle for lifting (flexing) the leg forward in the hip joint. It collaborates, however, together with other muscles with similar function, so that after dividing / lengthening of the tendon of iliopsoas muscle, plane walking is usually not affected.
Click on the icon for a full size picture According to some reports, about 6% of all patients with pain in the groin after total hip replacement are suffering from this complication.
Signs of iliopsoas muscle impingement.
The patients usually develop pain some months after the operation, The pain is located in the groin, the pain is aggravated when the patient bends (flexes) the hip against resistance. The pain is worse during activity, may be almost absent during rest.
Attempted straight-leg rising in the hip produces severe pain, which is aggravated when the patient attempts to rotate the leg outwards. Putting the leg in or out of the car ("he car sign"), or rising from the chair with straight leg produces severe pain in the groin. Also the pain elicited on a sitting patient, when he/ she flexes the affected hip against resistance is a typical sign of iliopsoas muscle impingement.
Local infiltration of the painful tendon with local anesthetics relieves the pain immediately, but unfortunately only temporary.
Mechanism of iliopsoas muscle impingement / encroachement
If the cup's rim protrudes too much from the skeletal socket then when the patient bends in the hip joint, the muscle tendon may be impinged between the protruding cup and the neck of the femoral component. When the cup protrudes too much from the pelvic bone socket, its rim is fraying at the muscle and tendon fibers that pass over it. Every contraction of the muscle (lifting straight leg e.g.) increases encroachment of the I-Psoas muscle and causes more faying, irritation, and pain in the groin.
This is probably the most frequent cause of "impingement" of the IP muscle. The muscle and its tendon may be strung over the protruding rim of the cup component, but also over the protruding screw, or bone cement lump as a "banjo string".
Similarly, If the leg is lengthened after TH operation by use of a femoral component with a too long neck the iliopsoas muscle may be strung over the total hip area with pain in the groin as consequence.
IP muscle stretched as "banjo string" over protruding cup Click on the icon for a full size picture
X-ray signs:
Close inspection of X-ray pictures may give suspicion of iliopsoas muscle impingement / encroaching. Protruding cup, protruding screws, or large cement lumps present in places where the iliopsoas muscle passes should arise suspicion damage to the iliopsoas muscle.
All these structures may encroach / impinge the iliopsoas muscle and cause pain in the groin on the operated site.
The protrusion of the cup component's edge over the skeletal socket is the x-ray change most often associated with iliopsoas muscles impingement / encroaching. Such protrusion may not be seen on ordinary x-ray pictures and is better revealed on CT (computer tomography) scans. A - shows the the conventional x-ray picture of the metal- backed cup component. Close study reveals that the metal backing cup protrudes from the skeletal bed made in the pelvic bone.
B - a CT (Computer Tomography) scan makes a sort of transverse section through the total joint and its osseous bed. The protrusion of the metallic cup out of the pelvic bone bed is seen much better on these CT pictures.
C - schematic view that renders in color the black & white CT scan picture. You see the pelvic bone and within it the cup component. The cup component is made of a polyethylene inner layer embedded in the metallic back-up. Placed inside the cup you may see the ball component.
X-ray and CT scan pictures of protruding cup component Adapted from Dora et al 2007.
Click on the icon for a full size picture
Also a too long neck of the femoral component may increase tension in the iliopsoas muscle and cause typical groin pain, even if there is no protrusion of the cup. Such too long neck may be seen on ordinary X-ray pictures.
The impingement appears more often in cementless cups, because these components have larger diameter of the outer metallic shell and are more difficult to place flush within the acetabulum skeleton.
A report on x-ray changes of patients with iliopsoas impingement showed that
62% had an extruding rim of a cementless cup
11% had protruding screws from their cementless cup
27% patients had large cement lumps around their cup.
Treatment:
The treatment usually starts with local injections of cortisone into the tendon and stretching of the tendon. This treatment is seldom successful.
If pain continues in spite of the conservative treatment, the surgeon usually dividel / lengthens the tendon of the iliopsoas muscle, This operation usually brings lasting pain relief and very little, if any, weakening of the flexion force in the hip joint.
Only in cases of continuing pain, in spite of the tendon release, the surgeon will be forced to remove the old cup and replace it with a lesser cup fixed in better position, or exchange the too long femoral component for a shorter one. But these are all major surgeries with risks for other complications.
The summary of the reports on treatment of this complication shows that
27% of all patients were treated with local injection of corticosteroids only, with lasting success
46% of all patients were treated with detachment (release) of the iliopsoas muscle tendon or with lengthening of the tendon with lasting success
19% of all patients were treated with removal of cement lumps with success
8% of all patients were treated with revision of cup component with success
References
Ala Edine T et al.: Rev Chir Orthop Reparatrice Appar Mot 2001;87: 815-19
Bricteux S et al.: Rev Chir Orthop Reparatrice Appar Mot 2001; 87: 820-5
Della Valle CJ et al: J Arthroplasty 2001; 16: 923 - 26
Dora C et al:J Bone Joint Surg-Br 2007; 89-B: 1031-5
Heaton K and Dorr LD. : J Arthroplasty 2002; 17: 779-81
Jasani V et al.: J Bone Joint Surg-Br 2002; 84-B: 991-3
Longjohn D et al.: J Arthroplasty 1998;13: 97-9
Trousdale RT et al.: J Arthroplasty 1995; 10: 546
Contractures of muscles and soft tissues
When the muscles and soft tissues were not / could not be balanced correctly during the total hip operation, the patient may have pain and hip joint contracture after the operation. The most often observed is
Contracture of the hip abductor musculature
This contracture causes the "Too long leg" syndrome. See this chapter.
Short iliopsoas muscle
Many patients have lack of complete extension (stretching) in the hip joint before the surgery because the iliopsoas muscle is short (contracted). This contracture should be removed during surgery by lengthening of the short iliopsoas muscle.
If the contracture is not removed when after the total hip surgery the mobility returns into the hip joint the iliopsoas muscle stays short, becomes overstretched and painful. The total hip joint demonstrates flexion contracture.
It is well easy to discover the contracture of the iliopsoas muscle. Patient lies with both legs straight on the examination table, legs are usually bent in the knees hanging over the edge of the table. The PT forces the healthy leg to flexion in the healthy hip joint. (Patient's right hip on this picture). This maneuver places the pelvis "flat-back" on the table and unmask the flexion contracture in the opposite hip joint (patient's left hip in this picture): The left leg moves upward from the table.
By pushing the knee down (while the other hand stabilizes the pelvis) the PT stretches the shortened iliopsoas muscle.
Unmasking the short iliopsoas muscle on left side. Adapted from Bhave 2005 Click on the icon for a full size picture
Because more muscles than iliopsoas muscle bend the leg in the hip joint, also these other muscles may be shortened (contracted). There are special examination technique that will show which of these muscles is contracted.
Treatment:
Is usually conservative by stretching. There are well evolved techniques how to do this. In principle, with the pelvis flat on the table the PT can stretch the contracted (shortened) iliopsoas muscle , and even the other short flexor muscles. Usually, the surgeon should anesthetize the shortened iliopsoae muscle before this manipulation with local anaesthetic injection.
If the flexion contracture of the total hip is not remitting the surgeon may lengthen or even divide the tendon of the short iliopsoas muscle.
References:
Bhave A et al: Bone Joint Surg-Am 2005; 87-A-Supplement 2: 9 -21
Jasani V et al.: J Bone Joint Surg-Br 2002; 84-B: 991- 3
Trousdale J Arthroplasty 1995, 546-9
Ala Eddine et al. Rev Chir Orthop Reparatrice Appar Mot 2001; 87: 815-9 (sorry, French)
Vascular injuries
are rare (0,1 -0,2 %) and occur mainly at revision operations.
Signs are increasing pain in the operation wound, swelling and tension of the operation wound, sometimes with blood oozing from the wound.
The bleeding may be situated in the abdominal cavity, however, in which case the signs from the wound are lacking.
With greater blood loss there appear signs of general circulation failure (a quick pulse, fall of the blood pressure, low hemoglobin values).
The vascular surgeon must be consulted immediately in every case of suspected vascular lesion. He / she decides on further examinations such as arteriogram. This complication must be handled acutely.
(UNCLEAR) PAIN IN YOUR TOTAL HIP
Occasional pain in a replaced total hip is not unusual.
Lasting or increasing pain in your total hip, however, needs thorough examination and treatment.
When the surgeon excluded the most common causes of pain in the total hip, such as loosening, infection, nerve damage, there still remain some rare causes of pain in the total hip that may be treated with success.
This pain may be caused by changes and complications in the total hip itself
or be projected into the total hip area from diseases of other organs.
For more information visit please the chapter Pain in the total hip
References:
Grant P et al, Acta Orthop Scand 2001; 72: 537-40
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