What is a problematic total hip replacement?
There is no doubt a total hip replacement is the operation of the century. It is one of the top three interventions that can be performed in any branch of medicine including cataract surgery and renal transplantation surgery.
The problematic total hip replacement is one which continues to be painful or is unstable. Sometimes other issues such as a leg length inequality may be causing a problem.
The problem may be clinically silent and is sometimes only picked up on X-ray such as wear or osteolysis. Your surgeon will advise you if this is the case.
Patients can present with a vague non-specific pain in and around the hip. Alternatively, they can present with a more specific pain often related to the groin. Patients with instability or dislocation often present in a much more dramatic fashion by dislocating their hips and reduction is invariably required in hospital. Patients with leg length discrepancy often present early and may require a shoe raise to equalise their leg lengths. In rare situations, patients with an infection can become acutely unwell and require an urgent debridement of the hip.
What can cause it?
The problematic total hip replacement can be divided into those extrinsic to the hip replacement, such as concomitant spinal issues leading to referred pain. Causes intrinsic to the hip replacement include:-
- Periprosthetic infection
- loosening, impingement
- squeaking, trochanteric bursitis
- leg length discrepancy
- septic or aseptic loosening
- recurrent dislocation
- prosthetic or periprosthetic fracture
- adverse reactions to wear
- debris such as osteolysis and metallosis.
Can the problem get worse?
If untreated the problem can become worse. Surgery is not always required.
Surgery is not always essential. Patient fitness and suitability to undertake a lengthy, complex and technically demanding procedure is carefully assessed in the office. If the risks:benefits ratio of surgery is deemed unfavourable, then there is an array of non-operative options one can consider.
In the case of chronic infection, one can encourage the host, ie the patient, to live in symbiosis with the infection by way of long-term suppression antibiotic therapy. In the case of leg length discrepancy, simple measures such as fitting a shoe raise can help solve the problem. In situations of chronic loosening, one can pursue measures such as activity modification followed by careful assessment and adaptation of the patient’s home environment. In cases of chronic instability, one can consider the use of a hip brace to see if this can help contain the hip on a long-term basis.
What investigations may be required?
Identification of the underlying cause often requires a number of investigations including:
- Blood tests (ESR and CRP)
- Serial X-rays
- Bone scan
- Diagnostic injections under Ultrasound guidance.
It should be borne in mind that complications may result from a condition with or without surgery. Complications of non-operative treatment include: worsening pain, increased stiffness, increasing deformity, adjacent joint disease, pain elsewhere, for example in knee, hip or lower back (due to abnormal gait and compensatory mechanisms). Complications can occur with any type of surgery.
Potential general complications: risks and complications of anaesthesia, bleeding, infection, blood clots, failure to fully correct a deformity, the need for further surgery, persistent pain, complex regional pain syndrome and wound healing problems, genito-urinary and cardiovascular complications.
Potential complications which are specific to the surgery mentioned above include:
Nerve damage/foot drop, intraoperative fracture, stiffness, instability/dislocation, loosening, wear, leg length discrepancy, the need for revision surgery, non-resolution of symptoms and partial resolution of symptoms.
If develop sudden onset of chest pain, breathlessness/ breathing changes or sweating please call 999 immediately since this could be an undetected clot which has travelled to the lungs. This is an emergency and requires immediate treatment. This is a very rare complication.
Postoperative period and recovery
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
After your operation, a routine enhanced programme of recovery will commence. The main parallel work streams of this programme are as follows:
This depends on the postoperative weight-bearing status. Sometimes protected weight bearing is required for six weeks after the operation. It can take a while before the muscles around the hip regain full control. Therefore normally you will be seen at six weeks after the operation before being advised to wean off any walking aids.