HIP

Possible Complications of Hip or Knee Surgery

This information about possible complications is critical and should be reviewed by anyone contemplating hip or knee surgery of any kind.

This list will serve as the beginning point of our discussion about your surgery. This may be more detail than you want to know, but please take the time to read this material and understand it thoroughly.

The odds of a complication occurring are very small. In the vast majority of surgical procedures, the outcomes are satisfactory; modern surgery is very safe. But, just as riding in a car or flying in an airplane, all risk cannot be eliminated.

Therefore, it is vital that you review the material below, and ask questions, before any surgery is planned. Your surgeon and medical team will proceed with your surgery with the assumption that you understand, accept, and recognize this information.

If these risks are unacceptable, then please postpone the procedure. Bear in mind that although many complications are listed, all surgical procedures have a small chance of unpredictable outcomes — complications that no one can reasonably predict.

Some complications include:

Blood Clots
Pneumonia
Nerve Injury
Blood Vessel Injury
Blood Transfusion Risks
Anesthetic Complications
Failure of Implants
Heart Attack and Other Cardiac Complications
Stroke
Dislocation of the Components
Infection
Fracture
Leg Length Inequality and Complications Related to Malalignment of the Leg

Your doctors will assume that you understand possible complications before embarking on surgery. More detailed information about the risks of hip or knee surgery can be found here.

Please understand that they may cancel a scheduled operation at any time up until the time of surgery if, in their judgment, you are unlikely to have a satisfactory result from the surgery or if the risk of a poor result or an adverse outcome exceeds their safe threshold for performing such surgery.

Types of Hip Surgery

What is hip resurfacing?

In hip resurfacing, a metal cap is glued on the arthritic ball instead of replacing the ball itself. Some implant companies and surgeons have promoted hip resurfacing in recent years, but hip resurfacing has been around for many decades.

How are hip resurfacing and hip replacement different?

Hip resurfacing and hip replacement are similar. Both replace all arthritic surfaces in the arthritic hip. On the socket side, both operations entail removing a layer of arthritic bone and cartilage from the pelvis, and replacing it with a metal cup.

The main difference between hip replacement and hip resurfacing is what is done to the femoral bone (thighbone).

In hip resurfacing, the arthritic ball is prepared such that a metal cap is glued onto your bone. The diameter of the metal cap matches that of the artificial socket.

In hip replacement, the arthritic femoral ball is cut and replaced with a new ball. The inside of the femur bone is prepared to implant a metal stem 3 to 5 inches in length. On this stem, a mechanism allows attachment of a metal or ceramic ball that matches the size of the socket. Once the ball is placed into the socket, the hip replacement is complete.

Do hip replacement and hip resurfacing cost the same?

A hip resurfacing is more expensive because surgical time is longer and the implants are more costly. At present, the parts for hip resurfacing cost about twice as much as hip replacement parts.

What are the advantages of hip resurfacing?

The advantage of hip resurfacing is preservation of 1 to 2 inches of bone, on top of the thighbone. In theory, if you need repeat surgery in the future, this bone is available to the surgeon to work with.

This made sense in previous decades, when the lifespan of hip replacements was limited by material quality; the older synthetic ball-socket would wear out in 10 to 15 years. The wear particles would result in inflammation and bone loss around the implants. As a result, the implants would loosen, requiring repeat surgery.

Modern hip replacement bearings and implants are much improved though, and should outlast the lifespan of most patients. This assumes of course that the prosthetic parts are properly implanted and accurately aligned during surgery.

Also, today, if repeat surgery is needed on a prosthetic hip, modern metal technologies allow us to rebuild and reconstitute missing skeletal bone.

Therefore, the only advantage of hip resurfacing (preservation of an insignificant amount of femoral bone) when compared to hip replacement, has little practical value.

Hip resurfacing and replacement feel the same to patients, and are equally effective in relieving pain, restoring function, and restoring the ability to participate in any activity.

What are the disadvantages of hip resurfacing?

One, the metal cap must be glued to the arthritic femoral head. This glue can loosen up over time, causing the resurfacing to fail. There is no cement-less version of the metal cap in hip resurfacing.

Two, the bone directly underneath the metal cap, called the femoral neck, can break, especially if it is weakened during implantation of the metal cap. If this happens, urgent surgery is needed to convert the hip resurfacing to a hip replacement.

Three, hip resurfacing is more invasive than hip replacement. Since the femoral head is preserved in hip resurfacing, the surgeon has less room to work; therefore, the incision is longer and the surgical exposure is more extensive with hip resurfacing. Some surgical methods, such as the anterior surgical approach, allow hip resurfacing through a less invasive approach, but the operation is still more extensive than a hip replacement.

Four, the only kind of bearing in hip resurfacing is metal-on-metal. In hip resurfacing, the inside of the socket is a polished metal, and so is the metal cap that covers the femoral head. Actual hip movement in hip resurfacing is from metal-metal contact; this bearing is the only one possible in all modern hip resurfacings. Recent studies have raised a worry that metal-metal hip bearings can cause a reaction in some patients, requiring more surgery.

What are the advantages of hip replacement?

A key advantage is its longevity and track record. The technology used in modern hip replacements is safe and well-proven in millions of patients. The nuances, complications, surgical techniques, and outcomes of this operation have been thoroughly investigated. A properly performed hip replacement should outlast the patient; this is significant since no one wants repeat surgery.

Of note, different bearing surfaces can be used in hip replacement. This is because there is more latitude in the engineering design of hip replacement components. In hip replacement, once the metal shell and the femoral stem are implanted, the surgeon and patient have a choice of bearing, including metal-metal, metal-plastic, metal-ceramic, ceramic-plastic, and ceramic-ceramic.

Also, hip replacement bearings can be changed out several years after the surgery; the bearings are removable independent of the implants. In contrast, hip resurfacing bearings cannot be changed; the entire component must be removed, along with some bone, if a change of bearing is desired for any reason in the future.

What are the disadvantages of hip replacement?

The disadvantage, when compared to hip resurfacing, is that an additional 1 to 2 inches of bone at the top of the femur must be sacrificed. However, removal of this bone is of little, if any, practical consequence. If a hip replacement should ever fail, repeat surgery is relatively straightforward and predictable in the hands of an experienced surgeon. Also, we have many ways of making up for lost bone today; saving an inch or two of bone is of no clinical consequence over the long-term.

What if I choose to have hip resurfacing based on what I have read?

If a hip resurfacing is your choice, then that is the operation your surgeon should perform for you. In our practice, there is no preference or bias, nor any financial inducement toward one procedure or the other. The above comments are presented to share information known to professionals in our field, and may differ from claims made by hospitals and surgeons promoting hip resurfacing.

Leg Length

Can hip replacement surgery change your height?

You’d be surprised how often this question is asked, and the answer may surprise you!

If both hips are replaced, can you add height to my body?

Yes. If both hips are replaced, it is possible to increase the leg length on one side and increase it by the same amount on the other side. But, any gain in height is about an inch or less. The limiting factor includes the muscles, tendons, and nerves, which only have so much stretch before there is injury or damage.

It is possible to replace both hips at the same time, if the patient is healthy enough for such surgery. Recovery from two hip replacements does not differ much from having one hip replaced, at least with newer, less-invasive surgical methods.

Will my leg be longer or shorter after hip replacement surgery?

This is an important topic, and should be understood before you embark on any hip replacement, no matter where you have the hip replacement done.

Hip resurfacing is an operation that is similar to replacement. During resurfacing, the arthritic ball is capped with metal, and an artificial socket is placed in the pelvis. Any bone removed is replaced with an equivalent thickness of metal in hip resurfacing, so there is no noticeable gain or loss in leg length during hip resurfacing.

In contrast to hip resurfacing, during hip replacement the arthritic ball is removed and replaced with a new ball. Since the artificial ball comes in different neck lengths, the surgeon is able to adjust muscle tension, leg length, and ball-socket stability during the hip replacement. These adjustments reflect complex decision-making and trade-offs during surgery. Rarely, because of anatomic constraints or other patient-specific reasons, slight leg lengthening may occur. If this is totally unacceptable, you should not consider hip replacement surgery.

In the overwhelming majority of cases, there is no change in leg length after hip replacement. In most cases where the patient feels a change in leg lengths, that perception will disappear over several months as the muscle and tissues stretch.

Can leg length be changed during hip replacement surgery?

Yes. An example would be a patient with a leg that was shortened from injuries after a motor vehicle accident, who now needs a new hip. In such cases, it is possible to restore the original leg length during surgery. The decision-making is complex, requires professional judgment, and is specific to each situation.

Likewise, if the patient has too long a leg before surgery, it is possible to shorten it during hip replacement, using specific surgical techniques that keep muscle tension within safe limits. Again, the exact steps taken and the decision-making are specific to each patient.

My leg ended up too long after a hip replacement. Can anything be done?

In most cases, with exercise, stretching, and healing over 6 to 12 months, the perception of a leg length difference will disappear on its own. During this time, to avoid a limp and facilitate walking, a shoe-lift built into the shoe can help.

The reason for waiting is that the majority of leg-length discrepancy after hip replacement is not a true difference in skeletal lengths. Rather, the discrepancy is from pelvic tilt, tight muscles, altered biomechanics, and even spinal arthritis that can lead to a curvature in the back. With muscles stretching, exercises, and time, such discrepancy will likely resolve in a few months.

If leg length discrepancy is permanent, additional surgery may be an option. During such surgery, the femoral stem component is removed, and the bone at the top of the femur is removed to equalize the leg lengths. Then, a new femoral stem is implanted.

While this sounds easy, additional steps must be taken to avoid improper muscle tensioning and to reduce the risk of creating hip instability and a limp. Recovery from this type of surgery is about 6 to 12 weeks.

How can we know if my leg is truly longer after a hip replacement?

Special X-ray studies can help determine if the perceived difference in leg lengths is really in the bone or arising from some other source, such as a tilted pelvis, a curvature in the back, or tight muscles. These X-rays, called scanograms, involve imaging the entire length of both legs with a measuring ruler that leaves no doubt about the actual length of each leg, from the top of the pelvis to the ankle.

Treating Hip Arthritis

We compiled a list of some frequently asked questions about treatment for hip arthritis and hope you find it useful!

Will exercise help an arthritic hip?

Yes. Exercises strengthen the muscles around the hip joint. Weak muscles mean higher forces across an arthritic hip joint, and more pain. That is why regular, light aerobic exercise helps to relieve pain from arthritic hips. Recommended exercises include walking, swimming, elliptical exercisers, and similar activities.

Reasonable levels of exercise will not accelerate the wear and tear of an arthritic hip joint. Stronger and more conditioned muscles reduce the loads placed on the hip, and relieve pain. Exercise may help postpone hip replacement surgery.

One caveat: If exercise hurts, then refrain from that activity and try another form of exercise.

Does a cane help with an arthritic hip?

Yes. A cane in either hand helps, but is most effective if used in the hand opposite the painful hip. A cane reduces the load across the arthritic hip, thereby relieving pain and improving walking ability.

Will injections into the hip joint ease arthritic pain?

Yes, cortisone injections placed into an arthritic hip will ease pain temporarily. For mild cases of arthritis the injections may help for many months. However, injections cannot build up cartilage or otherwise cure arthritis.

Cortisone injections can also help pinpoint the source of hip pain, if there is any doubt where hip pain is coming from. If hip pain is really from hip arthritis, and not referred from a bad back or another source, then cortisone injections should relieve pain, even if temporarily.

Hip joint injections require X-ray imaging to guide the needle into the hip joint. This is why such injections must be done in a special procedure room, equipped with X-ray imaging equipment. If done in the clinic, these injections can be guided by ultrasound technology.

Lubricant injections that are marketed as “visco-supplementation” can help arthritic hip joints temporarily. However, they are more commonly used for treating arthritic knees.

Research to alleviate the pain and inflammation of hip arthritis is ongoing and exciting, such as injections using gold nanoparticles with mild radioactivity.

Is there surgery for hip bursitis?

Yes, if injections in the hip bursa do not work reliably, there is an arthroscopic technique, done as outpatient, that works very well using only a couple of small holes made in the skin. Pain relief is predictable with this small operation. Again, this applies to hip bursitis, which is very different from hip arthritis.

What else, other than surgery, can help an arthritic hip?

If possible, avoid stairs and concrete floors; weight lifting; deep bending at the hip; and repetitive impact exercises such as jogging, golf, and racquetball. Reasonable exercises include walking on a treadmill, swimming, low-impact activities, and upper-body conditioning. There are no effective braces for hip arthritis.

Will arthroscopic surgery help hip arthritis?

In mild or early hip arthritis, yes. Mild hip arthritis can result in hip cartilage tearing; this condition, called a torn labrum, can be addressed with hip arthroscopy. Arthroscopy refers to an outpatient operation, involving small skin openings through which a small camera and surgical instruments are introduced to trim torn pieces and clean up the joint. At the same time, the surgeon can remove bone spurs that physically impinge against each other, causing pain and stiffness.

But, if the arthritis is too advanced, then arthroscopic surgery may not be too helpful.

One benefit of arthroscopic surgery is the ability to look directly inside the joint and understand the extent of arthritic damage. With this information, a surgeon can advise on further treatment.

What is osteotomy of the hip?

Osteotomy refers to cutting bone and realigning the leg, to relieve the pain of an arthritic hip. By altering biomechanics favorably, the loads across the ball and socket joint are lessened. Osteotomy was once a commonly used surgical option in young patients, back when hip replacements were not suitable for young and active people.

In cases where the socket or ball is mis-shapen since birth and the arthritis is diagnosed early, osteotomy can help, especially in young patients. The surgeon can cut the femur and the pelvis to create a more aligned hip joint, thereby slowing the progress of arthritis.

Osteotomy is a complex, major procedure, and requires special skills that we offer in our practice. The goal of osteotomy in such cases is to preserve the patient’s own hip joint. Few patients are candidates for such a procedure, because in most instances, hip arthritis has progressed enough that a hip replacement is more desirable.

What is a hip fusion?

This is another hip operation that was more common in the past. It involves eliminating the hip joint, by surgically welding, or fusing, the ball to the socket. By eliminating movement in the hip joint, pain is relieved without using implants.

Hip fusion is also called an arthrodesis. Increased movement in the back and knee usually compensates for the stiff hip after the fusion.

Hip fusion is nearly obsolete now, since hip replacement surgery is so durable and predictable. But back in the days when hip replacements were not quite as advanced, hip fusion was worth considering for young patients.

Does weight loss help relieve arthritic pain?

Yes. Biomechanical studies show that body weight is multiplied 2 to 3 fold across the hip joint. Losing excess body weight relieves arthritic pain by unloading the joint. Weight loss also decreases surgical risks should hip replacement be necessary.

Will chiropractic manipulations help hip arthritis?

For some patients, chiropractic manipulations seem to help arthritic pain. Alternative remedies, such as glucosamine, vitamins, oils, yoga, hypnotism, herbal supplements, heat packs, ice packs, massage, aromatherapy, aqua therapy, prolotherapy, and acupuncture might also help. Use these remedies if you feel that they are helpful, and if you are familiar with their proper use.

If you are scheduled for surgery, stop all alternative medications and vitamin supplements at least 10 days before surgery. This is to avoid excess bleeding and risky interactions with the anesthetic drugs.

What about injections for hip bursitis?

Injections to the outside of the thigh are commonly used to treat hip bursitis. These injections do not enter the hip joint, and do not need X-ray guidance for accurate placement.

Hip bursitis is not related to hip arthritis. Bursitis is a local inflammation in the tissues near the hip joint, caused by muscles and tendons rubbing against each other. The pain from hip bursitis is located on the outside of the thigh, making it hard to walk or lie on that side. Hip arthritis, in contrast, is deterioration and inflammation of the ball-and-socket joint itself.

A visit to the doctor can usually help determine if you have bursitis or arthritis.

Should I use pain medicine for hip arthritis?

Medicines such as aspirin, acetaminophen, ibuprofen, naprosyn, and other anti-inflammatory drugs can be taken for a long time, within proper dose range. These medicines are not addictive. Your primary physician should monitor any possible side effects, especially if you take such medicines regularly.

Alternative remedies, such as glucosamine chondroitin, are available over the counter. These can help arthritic hips and can be used without risk of addiction.

Narcotic drugs can also relieve pain, but can create dependence and related psychological problems. Long-term use of narcotic drugs before surgery will make pain relief after surgery more difficult. If you regularly require narcotic medicines to control hip pain, it may be time to consider hip replacement surgery.

Why not replace the hip instead of trying nonsurgical measures?

Patients who invest the time to understand all options will know what to expect, and usually have the most satisfying outcomes. Nonsurgical treatment can give you time to learn more about hip arthritis and assess all treatment options.

Also, nonsurgical means of pain relief can work for a long time, at least for some patients; hip replacement surgery should be the last step.

Will arthroscopic surgery buy some time with an arthritic hip?

It could, depending on the extent of arthritis. In mild cases, with cartilage tears in the hip joint causing catching and pain, arthroscopy can buy time before a hip replacement. But if X-rays show advanced hip arthritis, arthroscopic surgery will probably not have any lasting benefit.

What is a hip resection, or Girdlestone, procedure?

This refers to a removal, or resection, of the diseased hip ball, and replacing it with nothing. Historically, this operation was done for conditions like tuberculosis of the hip, long before the days of modern hip replacement. The infected bone would be removed, and the hip cavity would be left empty.

Over time, the empty hip cavity would fill with scar tissue and the leg would shorten by a couple of inches, making walking very difficult. But, removal of the infected ball would give the patient a chance at healing the tuberculosis infection, and relieve pain.

Today, a Girdlestone resection in the hip is done very rarely. Circumstances in which the procedure is considered include a serious infection that cannot be eliminated otherwise, severe bone loss from multiple failed operations, muscle paralysis, or advanced cancer.

Arthritis and the Hip Joint

Here are commonly asked questions about arthritis and your hip joint.

What is hip arthritis?

Arthritis is the roughening and destruction of the cartilage that lines the ball and socket. These rough surfaces generate friction and inflammation, causing pain and stiffness.

How do you diagnose arthritis or degeneration of the hip joint?

In many cases, a diagnosis can be made by X-ray studies and a physical examination. Damage to the hip creates a narrowing of the space between the ball and socket. Eventually, the hip can lose so much cartilage that bone touches bone, which can be very painful.

Early arthritis of the hip may not show up on an X-ray. In these cases, other studies, such MRI or CT scans, or an operation called hip arthroscopy, can help diagnose arthritis.

Where does one feel the pain of an arthritic hip?

Typically, pain from an arthritic hip will be felt in front of the thigh, to the buttock, or to the outside of the thigh. Pain may also travel to the knee due to overlapping nerves in the hip and knee joints. The pain and stiffness can usually be reproduced by rotating the leg. A painful hip can feel like a pulled groin muscle, or like a toothache in the groin.

Does hip arthritis always develop with old age?

Most people never develop hip arthritis, no matter their age. That said, everything in the body wears down with age, and hip cartilage is no exception. Those who need hip replacement surgery generally have a faster progression of hip arthritis because of injury, underlying inflammatory problems, genetic predisposition to arthritis, or a congenital abnormality of the hip joint.

What keeps the hip ball from popping out of the socket?

Muscles, tendons, and ligaments hold the ball in the socket, preventing it from slipping or dislocating. Hip dislocation, usually associated with severe physical trauma, is a serious condition requiring immediate medical treatment.

Rarely, the hip joint is predisposed to dislocation and premature arthritis due to a congenital deformity. Newborns are now routinely checked to make sure their hip joints are properly formed.

What is a degenerative hip joint?

A hip joint is referred to as degenerative when the cartilage is damaged due to injury or a disease process, such as osteoarthritis or rheumatoid arthritis.

How does the hip joint get lubricated?

The hip joint is sealed in a capsule. This capsule is a tough tissue envelope surrounding the hip joint, much like the rubber seal surrounding a steering or suspension joint in a car. Cells inside the hip capsule secrete synovial fluid, which is a natural lubricant. In a healthy hip joint, there is always a small amount of this synovial fluid. The fluid serves as biological grease, and lubricates the joint.

Can hip pain be coming from other places?

Yes. What people think of as hip pain can come from other sources, like poor circulation to the leg, an arthritic back, an arthritic knee, painful sacroiliac joints, and other abdominal or pelvic problems. In other words, the problem may be elsewhere, but the patient may sense pain in the hip.

In older patients, hip pain can reflect more than one problem. For example, hip arthritis and back arthritis can occur together. In such patients, hip replacement surgery may help one source of pain, but other areas may also need treatment later.

Diagnosing Arthritis

Radiograph

Another word for an X-ray, which shows a silhouette of the skeleton. Although helpful for seeing bone, X-rays do not show muscles, tendons, and ligaments. An X-ray is usually the first imaging study of the hip joint when arthritis is suspected.

CT Scan

Also called a CAT scan. This is a computer-driven study that shows the three-dimension-al bone anatomy of the hip in greater detail than an X-ray, which is two dimensional. With contrast dye, CT scans can even show soft-tissue structure.

Indium/Gallium Scan

A specialized imaging study that can diagnose subtle infections in the joints, especially after the hip has been replaced with prosthetic components

Magnetic Resonance Imaging

Also called MRI, this study shows soft tissues such as tendons, muscles, and ligaments surrounding the joint.

Bone Scan

In this type of study, a radioisotope is injected into the body, with the goal of detecting infection, fracture, or related inflammatory conditions of bone.