Risks and Complications of Hip Replacement Surgery in South Carolina

It’s important to recognize that all surgeries, including hip replacement, have inherent risks. These can be broadly categorized into two types: surgical complications, directly related to the operation, and medical complications, which arise from the body’s response to the surgical stress.

Medical complications can vary widely but may include heart attacks, strokes, and issues with kidney, bladder, or bowel function. The exact risk of these complications can be difficult to quantify and is influenced by any pre-existing medical conditions you may have.

It’s crucial for patients with significant health concerns, like recent heart attacks or those over 80 years of age, to consider the timing and feasibility of elective surgery carefully. We aim to avoid any unexpected issues during or after your procedure, ensuring the safest possible outcome for your hip replacement journey.

Rest assured, as your surgical team, led by Dr. Gross, we are committed to working closely with you and your medical providers to navigate these considerations thoughtfully and thoroughly, keeping your well-being at the forefront of all we do.

Both general and spinal anesthesia are considered safe and effective options for most individuals undergoing surgery. However, we’ve observed that the initial recovery phase tends to be smoother when patients opt for spinal anesthesia combined with sedation. For this reason, we generally recommend this approach for most of our patients. General anesthesia is typically reserved for the uncommon instances where spinal anesthesia is unsuccessful. Before your surgery, our anesthesiologist will review these options with you in detail, assisting you in choosing the one that best suits your needs and preferences.

In my approach to handling blood needs for hip replacement and resurfacing surgeries, I’ve been able to keep the need for transfusions very low, at less than 0.1%. This means that out of 1,000 patients, less than one might need a blood transfusion. To put this in perspective, 20-30 out of 100 people having hip surgery in the U.S. might need a transfusion.

It’s important to know that while blood transfusions are safe, there’s a small chance they could cause a reaction or pass on infections like hepatitis or AIDS. But, these risks are very low. For example, the chance of getting AIDS from a transfusion is about one in a million.

Before your surgery, if tests show your hemoglobin (a protein in your blood) is low, we might give you iron supplements or shots of a medicine called erythropoietin (Procrit) to help increase your hemoglobin levels. This helps avoid the need for donated blood, which can be expensive and unnecessary.

Here’s how we manage blood for surgeries:

• We check your hemoglobin level before surgery.
• If your hemoglobin is below 15, we’ll start you on iron pills.
• If it’s below 13, we’ll check it again about a month before surgery.
• If it’s still low, we’ll give you Procrit to boost it.
• During surgery, we use a special tool to minimize bleeding.

Our surgeries are designed to be less invasive, leading to less blood loss—usually under 150ml, much less than the typical 500-1000 ml in other cases.

This approach helps us avoid unnecessary blood transfusions, making your surgery safer and more efficient.

Learn more about our Comprehensive Blood Management Program

It’s important to note that patients living out of state who choose to have their care managed elsewhere may not achieve the same positive outcomes.

Patients at higher risk of infection include those with diabetes, weakened immune systems, obesity, or a history of hip surgery. To minimize the risk, we’ve developed a comprehensive prevention program that includes:

• Preoperative checks to ensure no active infections and good health status, including controlled blood sugar levels for diabetics.
• Preoperative skin preparation with antibacterial washes and shaves and nostril treatment to reduce bacteria.
• Intraoperative precautions like IV antibiotics, use of antiseptics, and a clean operating environment with specialized air filtration and protective clothing.
• Postoperative care involves specific antibiotics, wound care techniques, and protective dressings that don’t require changes, followed by daily antibacterial ointment applications after the initial dressing is removed.
• Our approach combines multiple strategies to address potential infection risks from various angles, including optimizing patient health, maintaining a sterile operating environment, and using antibiotics and antiseptics effectively.

In the rare event of a deep infection, prompt treatment usually allows for recovery without losing the implant.

Remember, keeping us informed and following postoperative care instructions are key to preventing infections and ensuring the best possible outcome from your hip surgery.

Blood clots are a concern after hip or knee replacement surgery due to the body’s natural reaction to heal the surgical area, which can cause clotting. While clotting helps stop bleeding, it can sometimes go too far, leading to clots in the veins of the legs and pelvis. This becomes a problem if a clot travels to the lungs, a condition known as a pulmonary embolism, which can be serious.

To minimize bleeding during surgery, we use special techniques and tools. However, to prevent excessive clotting after surgery, we also rely on measures including:

• Getting you moving as soon as possible after surgery.
• Using devices that gently compress your legs to help circulation.
• Prescribing medications known as anticoagulants or “blood thinners” to reduce the risk of harmful clotting.

Without any preventive measures, the risk of developing a clot in the legs or pelvis is quite high (50%-60%), and there’s a significant risk these clots can move to the lungs. Although leg clots can be treated and resolved, they might leave behind some lasting swelling in the leg.

Our current approach to prevention has successfully reduced the risk of these clots to less than 1% in over a thousand patients, with no cases of clots moving to the lungs. Our protocol includes:

• Techniques that avoid disturbing the bone marrow.
• Using compression devices right from surgery and continuing for 24 hours.
• Choosing spinal anesthesia for the operation.
• Encouraging you to move around soon after surgery.
• Prescribing Xarelto, a once-a-day oral medication for 2 to 4 weeks, depending on your risk level, without requiring injections or regular blood monitoring.
• Recommending aspirin as an additional precaution.

By carefully balancing the risks and benefits of anticoagulation therapy, we aim to protect you from the dangers of blood clots while minimizing the risk of excessive bleeding and other complications.

In hip replacement surgery, there’s a small risk to the sciatic nerve, which could be stretched, leading to numbness or difficulty lifting the toes (known as foot drop). This typically happens right after surgery; any numbness or foot drop developing later is likely due to other reasons, such as back issues.

Recovery for the nerve is uncertain, with no specific treatment to hasten it. However, younger patients may have a better chance of recovery, which can take up to 18 months, as nerves regrow slowly.

Initially, some patients experience a burning pain, manageable with medications like Lyrica. A special ankle brace can also be recommended to help with walking.

Often, there is some degree of recovery. If there’s no significant improvement after 18 months, a tendon transfer surgery might be an option to improve foot function.

Statistically, the occurrence of sciatic nerve injury in total hip replacement (THR) is between 1-2%. In my practice, the rate was 1% in the first 500 hip resurfacing arthroplasties (HRA) and has been reduced to 0% in the latest 2500 cases. For total hip arthroplasty (THA), my rate is significantly lower at 0.1%.

Hip replacement surgery can sometimes lead to dislocation, where the artificial hip joint comes out of its socket. This risk is higher with smaller artificial components but can be minimized with larger or anatomically sized bearings. Dislocation, requiring immediate medical intervention, is the most common reason for revision surgeries in the US. Certain health conditions, surgical approaches, and implant designs can increase this risk.

To reduce complications, precise implant positioning and the use of well-designed metal bearings are essential. Recent findings suggest that specific positioning can virtually eliminate the risk of dislocation and adverse wear failures (AWF) related to metal debris. For those sensitive to metal, a ceramic head on a titanium stem offers a low-risk alternative, though patients should avoid high-impact activities.

Patients must avoid extreme hip movements post-surgery to prevent dislocation, with restrictions varying based on the implant type and size. Larger bearings typically allow for more flexibility after healing.

Leg length inequality after hip surgery is generally minor and manageable. Up to 5mm lengthening is common as it compensates for the loss of cartilage. Patients typically adjust to increases up to 1 cm within six months through natural pelvic tilt. Lengthening beyond 1cm is rare and usually associated with specific deformities.

Significant lengthening, defined as more than 1 cm, occurs in about 5% of total hip replacements. Despite concerns, a difference in leg lengths does not cause joint issues elsewhere. The body is adept at compensating for minor differences, as evidenced by studies showing that many people naturally have a slight discrepancy without any adverse effects.

In cases where the leg is lengthened by more than 2cm, a simple shoe lift of 1 cm can help balance the discrepancy without being noticeable to others. Significant lengthening is uncommon for hip resurfacing due to the minimal bone alteration involved. Major discrepancies cannot be corrected with resurfacing but may be addressed with total hip replacement, depending on the patient’s priorities.

Before surgery, perceived leg length changes can be due to arthritis-related pelvic tilt, not actual growth or shortening. Post-surgery, pelvic tilt may continue temporarily, affecting perceived leg length. However, x-rays provide accurate measurements, clarifying any changes in leg length.

After hip surgery, sometimes your body can form new bones in the areas around the joint. This doesn’t usually hurt, but if a lot of new bone grows, it might make it harder for you to move that joint as much as before. People whose hips were stiff and didn’t move well because of arthritis often see a big improvement in how much they can move after surgery, especially a year after a hip resurfacing procedure. However, you might not get all that motion back if you had a stiff hip before surgery or certain hip shapes. Also, in rare cases, if a lot of these unexpected bones form, it could limit how well you can move.

To help stop this extra bone from growing, we do a few things:

• Use protective covers on the muscles around your hip while we work on the bone.
• Clean the hip area with a powerful spray before we finish the surgery.
• Give you a medication like Celebrex or Mobic for two weeks.

Offer a one-time radiation treatment after surgery if we think there’s a high chance of this extra bone forming.

These steps help most people avoid problems with new bone growth after surgery.

Sometimes, small cracks can occur when placing implants into the bone during surgery. This happens because the bone is prepared to fit the implant very snugly.

During a hip resurfacing procedure, it’s very rare to see any fractures on the femoral side (the top part of your thigh bone). Fractures of the socket wall (part of your hip bone where the implant sits) are also extremely rare. If they do occur, they’re usually stable, meaning they don’t move around much. In these cases, patients might just need to use crutches for a bit longer while they heal.

In the case of a total hip replacement where the implant is inserted into the thigh bone, about 1-2% of patients might experience a crack at the top of the femur during the procedure. This is manageable by securing the area with a special cable during surgery. Patients with this issue will also likely need to use crutches for an extended period post-surgery to ensure proper healing.

In hip resurfacing surgery, there’s a small chance the femoral neck (the part of your thigh bone just below the ball of the hip) could fracture, or the femoral head (the ball part of the hip joint) might gradually collapse during the first six months after surgery. Together, these issues are known as early femoral failure. Initially, I encountered this in about 2.5% of my cases. However, after thorough research, we’ve identified that weak bone quality and higher patient weight are key factors in these complications. Now, we conduct a bone density test using a DEXA scan before surgery to assess bone strength.

For patients with lower bone density or a BMI over 30, we recommend using crutches longer and/or taking bone-strengthening medication for six months. With these measures, we’ve significantly reduced the rate of early femoral failures to 0.1% in our last 1000 cases. Such fractures can develop slowly from too much activity too soon or from a minor fall within the first six months post-surgery. If this happens, we may need to convert the resurfacing to a traditional total hip replacement (THR) with a stem.

For those undergoing stemmed THR, there’s a 0.7% chance of experiencing fractures in the femoral trochanter (the part of the thigh bone to which muscles attach) or the shaft of the femur. I don’t have my personal data available as we’re still analyzing the figures. Trochanteric fractures are typically fixed with a clamp, and shaft fractures may require a switch to a longer stem implant secured with cables. We haven’t yet explored the use of bone-strengthening medications for patients with THR.

For hip implants to work properly, they must be securely attached to the bone. They can move against the bone if they aren’t, causing discomfort. There are two main ways to attach implants: using cement or encouraging the bone to grow into the implant, known as bone ingrowth. Cement offers immediate stability but tends to be less durable over time. I prefer using bone ingrowth implants due to their long-term stability, even though there’s a small chance the bone might not grow into the implant as expected.

In the United States, most surgeons choose bone ingrowth implants for total hip replacements (THR), except in cases of very old or weak bones where cement might be better.

For both hip resurfacing arthroplasty (HRA) and THR, I use the same type of socket component. We faced some challenges with bone ingrowth in patients with dysplasia (a condition where the hip joint is not formed properly) and other severe deformities until 2007.

Since introducing a new component design with extra fixation (called Trispike Magnum) for these challenging cases, we’ve significantly reduced the rate of bone ingrowth failure in the socket to 0.2%. In the last five years, we haven’t seen any failures in bone ingrowth into the femoral component (the part that fits into your thigh bone) in either HRA or THR surgeries.

Implants are designed to be securely attached to the bone. However, over time, this attachment can weaken, a process known as loosening. When implants become loose, they may move against the bone, causing pain. Uncemented implants are initially held in place through a tight fit, but they rely on the growth of bone into the implant for a permanent fix. This bone ingrowth can take some time to confirm, often only after two years post-surgery, judged by the absence of pain and stability in X-rays. Loosening after this point is very rare, but it can happen sometimes due to inflammation caused by wear debris from the implant materials.

In our experience with the Corin Cormet 2000 Hip Resurfacing Arthroplasty (HRA), we observed that the porous coating detached from the uncemented acetabular component in 1.3% of cases (5 out of 373), leading to loosening seven years after surgery.

For cemented femoral components in HRA, there’s a 3% chance of loosening at the ten-year mark. This issue will likely be less likely with uncemented components, which we started using in 2007. While it’s too early to statistically confirm a difference in loosening rates between the two types of components for the overall patient population, we’ve already seen promising results in a small group of high-risk patients suffering from osteonecrosis of the femoral head.

We have never seen this in HRA, except one broken femoral stem in an implant still functioning many years after we saw this on the x-ray. The implant is fixed to the bone by cement under the bearing; the stem did not provide any fixation.

Implant breakage was a known cause of failure when THR stems were made of stainless steel. It is rarely seen with cobalt chrome stems. It is exceedingly rare with the titanium stems I have used for years. I have never personally seen one fracture. But if young athletic patients run on these for years, this may become a late failure mode. Extracting a broken stem is quite difficult.
Therefore, I recommend running at most 1-2 miles simultaneously with a stemmed THR.

All implants wear over time, releasing debris into the body. Hip Resurfacing Arthroplasty (HRA) uses durable cobalt-chrome metal-on-metal bearings, minimizing wear. In Total Hip Replacement (THR), various bearing surfaces exist, including metal on plastic, ceramic on plastic, and metal on metal, each with its own wear rate and potential for debris generation. Advances in material technology have reduced wear rates, especially in polyethylene plastics, enhancing implant longevity. Monitoring for adverse wear reactions (AWR) is critical, with blood metal ion levels being a key indicator. Proper implant selection and placement can mitigate AWR risks, ensuring better outcomes. We serve patients from Columbia, SC, Irmo, SC, Lexington, SC, and surrounding areas.