EM@3AM: Total Hip Arthroplasty Complications

  • Nov 16th, 2024
  • Steven Wright
  • categories:
    em@3am

Authors: Steven Wright, MD (EM Resident Physician, UTSW – Dallas, TX); Samia Farooqi, MD (Assistant Professor of EM/Attending Physician, UTSW – Dallas, TX) // Reviewed by: Sophia Görgens, MD (EM Physician, BIDMC, MA); Cassandra Mackey, MD (Assistant Professor of Emergency Medicine, UMass Chan Medical School); Alex Koyfman, MD (@EMHighAK)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 75-year-old female with past medical history of osteoporosis and total hip arthroplasty (3 months prior) presents with acute left hip pain after ground level fall. Initial vital signs include T 36.8, HR of 91, BP 138/88, RR 16, SPO2 98% on RA. On exam she is found in moderate distress lying supine and still on the gurney. Left lower extremity (LLE) is shortened, adducted, and internally rotated. 2+ dorsalis pedis and posterior tibial pulses are palpable, and sensation is intact to light touch distally. The patient is able to plantarflex and dorsiflex the foot/toes but motor exam is otherwise limited due to pain.

Question: What is the most likely diagnosis?

Answer: Posterior dislocation of a periprosthetic hip

 

Epidemiology:

  • Total Hip Arthroplasty (THA) is the 4th most common surgical procedures in the United States (2.3% of adults over the age of 55).1-3
  • Despite its commonality it retains a relatively high rate of complications overall and patients frequently present to the ED for evaluation.
    • 10% of patient’s have an ED visit within 30 or 90 days following THA.4
  • Pain is the most common reason for presentation in the early post operative period.4
  • Dislocation is the most common complication after THA occurring at a rate of 0.2-10% of patients.5-7
    • Dislocation rate as high as 28% in revision THA.5
    • Highest risk of dislocation early in the post operative course due to laxity of the soft tissue after surgery.6
    • 75% of dislocations occur posteriorly.6
    • Anterior dislocations are more commonly seen after anterior approach to THA and are caused by flexion, abduction, and external rotation.6
    • Dislocation is the most common reason for revision THA at 21.85%.3
    • Trauma is the most common mechanism.6
    • Hip flexion or adduction in the early post-operative period can cause atraumatic dislocations (typically avoided for 6 weeks post-op).6
  • Periprosthetic fracture
    • Occurs at an estimated rate of 3.5-4.1%.7,8
    • Most commonly traumatic from ground level fall.7,8
    • Can occur spontaneously from osteolysis, implant loosening, or other mechanical replacement failure.8
  • Periprosthetic Joint Infection (PJI)
    • Estimated 0.6-2% of THA will have a post operative deep space infection.9=11
    • 70% monomicrobial, 25% poly-microbial, 5% culture-negative.12
    • Staph species most commonly isolated.9,12,13
    • Sinus tract to the joint increases likelihood of polymicrobial infection.12
  • Venous thromboembolism (VTE) occurs in approximately 1.2% of patients after THA.14

 

Evaluation:

  • Dislocations
    • History should include mechanism of injury, medical history, baseline functional status.
    • Evaluation of the position of the leg may give insight into the underlying dislocation.
      • Posterior – Shortened, adducted, internally rotated5,6
      • Anterior – Shortened, abducted, externally rotated5,6

    • As with all dislocations, perform and document distal neurovascular exam before and after management.
    • Plain radiographs of the pelvis, hip, femur, and knee (knee is important as it is used for fulcrum in many reduction techniques).5
    • CT if concern for occult fracture.
  • Periprosthetic Fractures
    • Pain prior to injury may point toward underlying pathology like infection, implant loosening, etc.8
    • Perform and document distal neurovascular exam.
    • Plain films of the hip, femur, and often knee should be obtained.
      • Unified classification system used to describe periprosthetic hip fractures.8,3
    • CT Pelvis may be useful if concern for acetabular fracture.15
  • Infection
    • Symptoms: Pain, swelling, redness, drainage, draining sinus tracts9,11,13,16

    • Intra-operative criteria: positive histology, 1 positive culture, positive purulence.3,11
    •  Imaging
      • Xray
        • Likely will get plain radiograph to assess the implant itself, however poor performance in assessing for PJI.
        • Periprosthetic radiolucency, osteolysis, or migration may be present but is not exclusive to PJI.11,13,16
      • US
        • May be helpful in evaluating for abscesses or sinus tracts.16
      • CT
        • Accuracy up to 84% in detecting PJI.16
        • Fluid collections/area of osteolysis may suggest PJI.16
      • MRI
        • Highly sensitive and specific (92%, 99%) for PJI.16
        • Findings include periosteal reaction, capsule edema, and intramuscular edema.16
        • Limited data on the use of MRI at present however modern prostheses are less ferromagnetic making this a promising diagnostic modality.16
    • US or CT guided biopsy/joint aspiration (typically performed by Orthopedic surgery or Interventional Radiology).
    • Gold standard for diagnosis is positive periprosthetic fluid cultures and/or operative tissue culture.13

 

Management:

  • Dislocation
    • As with all dislocation, early reduction improves outcomes.
      • Longer time to reduction increases likelihood of need for general anesthesia.21
      • In native hips, increased time to reduction associated with increased risk of avascular necrosis.24
    • Posterior dislocation
    • Anterior dislocation
      • With the patient supine one provider stabilizes the pelvis with two hands while the physician pulls axial traction and internally rotates the hip.6
    • One retrospective study showed high rate of successful closed reduction of prosthetic hip dislocations by ED physicians (77-91% of patients).18,19
      • Most of the remainder were close reduced by orthopedic surgeons.18
    • Fracture dislocations often managed operatively.
    • Be wary of intra-prosthetic dislocation (dislocation of prosthetic hardware).
      • More common in dual mobility implants.5
      • Requires early operative revision.5

  • Periprosthetic fractures
    • Managed in consultation with Orthopedic surgery.
      • Some non-displaced fractures and patients with poor baseline functional status may be managed non-operatively.7,8
      • Majority are managed operatively.7,8
    • Consider fascia iliaca block for symptomatic pain relief.
  • Infections
    • For stable patients, obtain microbiologic samples prior to antibiotics (per the American Academy of Orthopedic surgery and The Infectious Diseases Society of America).21
    • US or CT guided sampling is required for diagnosis, and patient may need operative tissue sampling.9,10,13,16,19
    • Early consultation with Orthopaedic Surgery if history/initial imaging/lab workup concerning for PJI.
    • Operative management is required in majority of cases.9,10,13
    • No clear data or guidelines have been established for antibiotic duration or choice, although Vancomycin (15mg/kg Q12H) + Cefepime (2g Q12H) is usually a good starting point.9,23

 

Disposition:

  • Dislocation: If successfully reduced in the emergency department may discharge with strict mobility restrictions and Orthopedic follow up.
    • 24 of rest followed by protected weight bearing and 6 weeks of protected mobility (limited flexion, adduction, rotation).6
  • Periprosthetic fracture: Admission for operative management.
  • Periprosthetic Joint Infect: Admission for invasive testing/operative management.

 

Pearls:

  • Dislocation:
    • Posterior dislocation is the most common complication of THA and can occur without traumatic mechanisms.
  • Periprosthetic Fracture:
    • Diagnostic imaging should include xray of the hip/pelvis, femur, and knee.
    • Have a low threshold to obtain a CT of the affected extremity if there is concern for occult or acetabular fracture.
  • Periprosthetic Joint Infection:
    • Diagnosis requires joint fluid sampling, which is typically obtained in consultation with Interventional Radiology and Orthopedic Surgery.
    • In stable patients, fluid/tissue cultures should be obtained prior to administration of antibiotics.

An 80-year-old man with a history of hip arthroplasty presents by ambulance after falling at home. It is reported that the patient has been unable to ambulate since the fall. His X-ray is shown above. This type of injury generally occurs with the patient’s extremity in what position?

A) Extension, adduction, and external rotation

B) Extension, abduction, and internal rotation

C) Flexion, abduction, and external rotation

D) Flexion, adduction, and internal rotation

 

 

 

 

Answer: D

Hip dislocations are true orthopedic emergencies. The hip has a large network of ligamentous and muscular structures that provide stability to the joint. Because of this, a considerable amount of force is needed to dislocate the hip. All patients with a dislocation of a native hip should undergo a thorough physical examination for other associated injuries. A posterior hip dislocation is the most common type of dislocation, and the vast majority of these occur secondary to motor vehicle collisions. A seated vehicle occupant normally has the hip flexed, adducted, andinternally rotated. When the knee strikes the dashboard, the force is transmitted up the femur, which can cause a posterior dislocation of the femoral head.

Patients who have a history of prior total hip arthroplasty are at significantly increased risk for hip dislocation. Posterior hip dislocations occur in about 2% of patients with a total hip arthroplasty. The patient will usually present saying they’ve heard a “pop” or “clunk” with the extremity internally rotated and shortened, which can cause significant pain. X-ray is the best initial imaging technique.

A thorough neurovascular exam should be performed on all patients with hip dislocations. Sciatic nerve palsy occurs in up to 10% of patients with hip dislocations. The peroneal nerve branch is most commonly affected and can be examined by testing for weakness of the extensor hallucis longus, weakness with dorsiflexion, and paresthesias over the dorsum of the foot. The femoral artery, vein, and nerve can be damaged with anterior hip dislocations.

Hip dislocations should be reduced within 6 hours of injury and will require procedural sedation for the patient to relax their musculature and comply with the reduction movements. Delays in reduction increase the incidence of avascular necrosis of the femoral head (in patients with native joints) and permanent sciatic nerve palsy. There are several techniques to reduce a posteriorly dislocated hip, but the goal is to apply traction anteriorly to the flexed hip and knee along with external and internal rotation of the lower leg to facilitate reduction. Open reduction in the operating room may be required if closed reduction is unsuccessful.

Flexion, abduction, and external rotation (C) should not lead to dislocation, and a fall in this manner may lead to a fracture.

Extension, abduction, and internal rotation (B) of the lower extremity may also lead to fracture but is less likely to cause dislocation.

Extension, adduction, and external rotation (A) may lead to an anterior hip dislocation. These dislocations occur less frequently than posterior hip dislocations.

References:

  1. McDermott KW, Liang L. Overview of Operating Room Procedures During Inpatient Stays in U.S. Hospitals, 2018. 2021 Aug 31. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #281. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574416/
  2. Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone and Joint Surgery-American Volume. 2015;97(17):1386-1397. doi:https://doi.org/10.2106/jbjs.n.01141
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  14. Simon SJ, Patell R, Zwicker JI, Kazi DS, Hollenbeck BL. Venous Thromboembolism in Total Hip and Total Knee Arthroplasty. JAMA Netw Open. 2023 Dec 1;6(12):e2345883. doi: 10.1001/jamanetworkopen.2023.45883. PMID: 38039005; PMCID: PMC10692868.
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