What are the common complications and preventive measures for total hip arthroplasty?

Common Complications and Preventive Measures for Total Hip Arthroplasty

The most significant complications following total hip arthroplasty include bone cement implantation syndrome, venous thromboembolism, prosthetic joint infection, periprosthetic fracture, dislocation, and leg length inequality, which can be effectively prevented through proper perioperative management and surgical technique. 1

Intraoperative Complications

Bone Cement Implantation Syndrome (BCIS)

BCIS is a potentially life-threatening complication occurring during cemented hip arthroplasty with varying severity:

• Grade 1 (20% incidence): Arterial saturation <94% or >20% fall in systolic blood pressure
• Grade 2 (3% incidence): Arterial saturation <88% or hypotension >40% fall in systolic blood pressure or loss of consciousness
• Grade 3 (1% incidence): Cardiopulmonary resuscitation required 2

Prevention of BCIS:

1. Anesthetic Management:

   • Maintain vigilance for cardiorespiratory compromise
   • Use arterial line or non-invasive automated BP monitoring on "stat" mode during cement application
   • Aim for systolic BP within 20% of pre-induction value
   • Prepare vasopressors for potential cardiovascular collapse
   • Ensure adequate pre- and intra-operative fluid resuscitation 2

2. Surgical Technique:

   • Inform anesthetist before cement insertion
   • Thoroughly wash and dry the femoral canal
   • Apply cement in retrograde fashion using cement gun with suction catheter and intramedullary plug
   • Avoid vigorous pressurization in high-risk patients 2

Surgical Approach-Related Complications

The choice of surgical approach impacts complication rates:

• Posterior approach has the lowest overall complication rate (5.85%)
• Anterior approach has higher complication rates (8.5%) 3
• Despite historical concerns, modern posterior approaches with larger-diameter prosthetic heads and advanced soft-tissue repair techniques have mitigated dislocation risks 4

Postoperative Complications

Venous Thromboembolism (VTE)

Neuraxial anesthesia significantly reduces DVT risk compared to general anesthesia:

• Hip arthroplasty: OR 0.52,95% CI: 0.42-0.65
• Knee arthroplasty: OR 0.77,95% CI: 0.64-0.93 2

Infection

Neuraxial anesthesia reduces infection risk:

• Hip arthroplasty: OR 0.73,95% CI: 0.67-0.79
• Knee arthroplasty: OR 0.80,95% CI: 0.76-0.85 2

Dislocation

• Historically higher with posterior approach, but modern techniques have equalized rates
• Hip precautions after posterior approach THA may not significantly affect dislocation rates (RCTs: RR 1.8,95% CI 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5) 5

Comprehensive Prevention Strategy

Preoperative Measures

• Preoperative exercise and education (Grade A recommendation) 2
• Risk stratification for VTE and infection 1

Anesthetic Considerations

• Neuraxial anesthesia is strongly recommended over general anesthesia for hip arthroplasty given multiple outcome benefits including reduced mortality (OR: 0.67,95% CI: 0.57-0.80), pulmonary complications (OR: 0.65,95% CI: 0.52-0.80), acute renal failure (OR: 0.69,95% CI: 0.59-0.81), and blood transfusion requirements (OR: 0.85,95% CI: 0.82-0.89) 2

Pain Management Protocol

1. Baseline therapy:

   • Paracetamol (Grade A)
   • NSAIDs or COX-2 selective inhibitors (Grade A)
   • Dexamethasone 8-10 mg IV (Grade A)

2. Regional anesthesia:

   • Single-shot fascia iliaca block or local infiltration analgesia (Grade D)
   • Consider intrathecal morphine 0.1 mg if spinal anesthesia used (Grade D)

3. Postoperative:

   • Continue paracetamol and NSAIDs/COX-2 inhibitors
   • Reserve opioids for rescue analgesia (Grade D) 2, 6

Surgical Technique Considerations

• Surgical approach should depend on surgeon experience and patient factors, as evidence is inconclusive regarding superiority for pain outcomes 2, 7
• Proper component positioning to prevent impingement, dislocation, and instability 6
• Early mobilization and physical therapy on postoperative day 0-1 6

Special Considerations

Component Positioning

Improper positioning can lead to:

• Impingement
• Dislocation
• Instability 6

Early Mobilization

Begin physical therapy on postoperative day 0-1, focusing on:

• Weight-bearing exercises
• Hip abductor strengthening 6

By implementing these preventive measures and following evidence-based protocols, the risk of complications following total hip arthroplasty can be significantly reduced, improving patient outcomes and quality of life.