Can rhabdomyolysis (muscle breakdown) occur after hip surgery?

Rhabdomyolysis Following Hip Surgery

Yes, rhabdomyolysis can develop after hip surgery, particularly in patients who were immobilized for extended periods after falling or who undergo prolonged surgical procedures. 1

Pathophysiology and Risk Factors

Rhabdomyolysis after hip surgery can occur through several mechanisms:

1. Pre-operative factors:

   • Prolonged immobilization after falling before hospital admission 1
   • Pre-existing hyperkalaemia may indicate rhabdomyolysis in patients immobilized after falling 1

2. Intra-operative factors:

   • Prolonged surgical time (procedures >5-6 hours significantly increase risk) 2, 3
   • Positioning-related compression of muscle groups (particularly the "downside" hip/flank in lateral positioning) 2, 4
   • Use of kidney rests during positioning 2
   • Pneumatic tourniquets with prolonged application or excessive pressure 5

3. Post-operative factors:

   • Delayed mobilization
   • Compartment syndrome development

Clinical Presentation

Patients with post-hip surgery rhabdomyolysis typically present with:

• Excessive, immediate postoperative muscular pain in the affected limb or pressure points 2
• Tea or cola-colored urine (myoglobinuria) 6
• Muscle weakness in affected limbs 6
• Possible signs of compartment syndrome (pain, tension, paresthesia, and paresis) 6

Diagnosis

Early diagnosis is crucial to prevent complications:

• Serum CK levels: Diagnostic threshold is typically at least 10× the upper limit of normal 6

  • Peak levels occur 24-72 hours after muscle injury
  • Serial monitoring every 6-12 hours in acute phase

• Other laboratory findings:

  • Hyperkalemia (can be severe enough to cause cardiac arrest) 1
  • Elevated myoglobin (rises earlier than CK but has shorter half-life) 6
  • Urinalysis positive for blood on dipstick but negative for RBCs on microscopy 6

Management

Immediate Interventions

1. Aggressive fluid resuscitation:

   • Isotonic saline (0.9% NaCl) is the initial fluid of choice 6
   • Target urine output >300 mL/hour 6
   • Avoid potassium-containing fluids (e.g., Lactated Ringer's) 6

2. Electrolyte management:

   • Monitor and correct hyperkalemia urgently if present 6
   • Address hypocalcemia if symptomatic 6

3. Compartment syndrome assessment:

   • Monitor for signs of compartment syndrome (pain, tension, paresthesia, paresis) 6
   • Consider measuring compartment pressure if suspected (threshold >30 mmHg) 6
   • Urgent surgical consultation for fasciotomy if confirmed 6

Ongoing Management

1. Renal protection:

   • Continue aggressive hydration
   • Discontinue all nephrotoxic medications (NSAIDs, ACE inhibitors/ARBs, certain antibiotics) 6
   • Nephrology consultation for all cases with acute kidney injury 6

2. Monitoring:

   • Serial CK levels every 6-12 hours initially 6
   • Electrolyte monitoring (particularly potassium, calcium, phosphate)
   • Renal function tests

3. Renal replacement therapy considerations:

   • For severe hyperkalemia, acidosis, volume overload, or uremic symptoms 6
   • Intermittent hemodialysis preferred for most patients with crush-induced AKI 6

Prevention Strategies

1. Pre-operative:

   • Identify high-risk patients (elderly, prolonged immobilization after fall)
   • Check baseline electrolytes and renal function
   • Ensure adequate hydration

2. Intra-operative:

   • Minimize operative time 2
   • Pay attention to proper padding of the operative table 2
   • Limit or eliminate use of kidney rest 2
   • Consider periodic repositioning during lengthy procedures
   • Maintain adequate hydration

3. Post-operative:

   • Early mobilization when appropriate
   • Maintain vigilance for excessive muscular pain
   • Continue adequate hydration

Complications

Untreated rhabdomyolysis after hip surgery can lead to:

• Acute kidney injury/failure (occurs in up to 57% of cases) 2
• Electrolyte disturbances (potentially life-threatening)
• Compartment syndrome requiring fasciotomy 6, 2
• Extended recovery with difficulties including lower extremity weakness 2
• Long-term disability requiring wheelchair assistance 2

Key Pitfalls to Avoid

• Failing to recognize excessive postoperative pain as a potential sign of rhabdomyolysis
• Delaying fluid resuscitation
• Using potassium-containing fluids for resuscitation
• Continuing nephrotoxic medications
• Missing compartment syndrome development

Early recognition and aggressive management are essential to minimize complications and improve outcomes in patients who develop rhabdomyolysis after hip surgery.