61: Total Hip Replacement

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CHAPTER 61

Total Hip Replacement

Juan A. Cabrera, MD; Alison L. Cabrera, MD

Synonyms

Total hip replacement

Bipolar hemiarthroplasty

Unipolar hemiarthroplasty

Revision arthroplasty

ICD-9 Codes

715.95  Osteoarthritis, hip

733.42  Aseptic necrosis of bone, head and neck of femur

820.09  Fracture of neck of femur, other (head of femur, subcapital)

820.8   Fracture of neck of femur, unspecified part of neck of femur, closed

835.00  Dislocation of hip

996.59  Loosening of total hip replacement

V43.64  Total hip replacement

ICD-10 Codes

M16.0 Bilateral primary osteoarthritis of hip

M16.10   Unilateral primary osteoarthritis, unspecified hip

M16.11   Unilateral primary osteoarthritis, right hip

M16.12   Unilateral primary osteoarthritis, left hip

M87.050  Idiopathic aseptic necrosis of pelvis

M87.051  Idiopathic aseptic necrosis of right femur

M87.052  Idiopathic aseptic necrosis of left femur

M87.059  Idiopathic aseptic necrosis of unspecified femur

S72.011   Unspecified intracapsular fracture of right femur

S72.012   Unspecified intracapsular fracture of left femur

S72.019   Unspecified intracapsular fracture of unspecified femur

S72.001   Fracture of unspecified part of neck of right femur

S72.002   Fracture of unspecified part of neck of left femur

S72.009   Fracture of unspecified part of neck of unspecified femur

S73.004   Unspecified dislocation of right hip

S73.005   Unspecified dislocation of left hip

S73.006   Unspecified dislocation of unspecified hip

T84.030   Mechanical loosening of internal right hip prosthetic joint

T84.031   Mechanical loosening of internal left hip prosthetic joint

Z96.641   Presence of right artificial hip joint

Z96.642   Presence of left artificial hip joint

Z96.643   Presence of artificial hip joint, bilateral

Add seventh character for categories S72, S73, and T84 for episode of care

Definition

Total hip arthroplasty (THA), commonly called hip replacement surgery, involves the reconstruction of a diseased, damaged, or ankylosed hip joint. The most common causes of adult hip disease are osteoarthritis, inflammatory arthritides, avascular necrosis, post-traumatic degenerative joint disease, congenital hip disease, oncologic bone disease, and infection involving the hip joint. The surgical treatment of hip arthritides has evolved from the first excisional arthroplasty by Anthony White in 1821 into the modern THA [1]. The modern era of hip joint replacement began in the late 1960s when Sir John Charnley combined a stainless steel femoral component with a polyethylene socket fixed to the adjacent acetabulum with polymethyl methacrylate (cement). Since that time, arthroplasty of the hip joint has become an accepted and standard treatment of common adult hip joint disease. Modern hip arthroplasty surgery has resulted in the restoration of pain-free motion and improved quality of life for millions [2]. Total joint arthroplasty, including hip and knee, has become the most common elective surgical procedure performed in the United States, with more than one million performed in 2009 [3]. The Centers for Disease Control and Prevention reported that 327,000 total hip replacements were performed in the United States in 2009 [3].

Hip joint arthroplasty can be divided into either THA, which provides a prosthetic replacement of the proximal femur and acetabulum, or hemiarthroplasty, which replaces the proximal femur while leaving the native acetabulum intact. Hip hemiarthroplasty is reserved for patients with a healthy articular surface in the acetabulum and is most commonly seen after proximal femur fractures. The focus of this chapter is on THA, which is the preferred surgical option for patients with degenerative changes affecting both the femur and acetabulum. Further categorization for hip arthroplasty can be made by prosthetic hardware components, surgical approach, or fixation method of the prosthesis (cement versus biologic or “press-fit” integration). Surgical decision-making for hardware type, approach, and prosthetic fixation is beyond the scope of this chapter, but it is important to note that there are no published consensus guidelines on best prostheses, approach, or fixation method among surgeons performing total hip arthroplasties.

Symptoms

The primary symptom of hip disease is groin pain, but patients may also have associated back and knee pain. Patients may describe a decline in mobility, self-care, and activities of daily living. They may present with an abnormal gait or may describe difficulty in walking long distances and need for an assistive device. Donning their shoes or socks and taking them off and getting in and out of the seated position may be difficult daily activities. Inability to participate in recreational activities or light sports may be a presenting complaint.

Physical Examination

Patients with hip disease are likely to have physical examination findings that will require continued attention postoperatively (Table 61.1). The examiner should examine both hips, knees, and back for range of motion. Decreased range of motion of the affected hip will be found and may be the first physical examination finding in cases of mild disease. Also, a thorough neurovascular examination of all extremities should be performed. One of the most commonly observed examination findings is an antalgic (painful) gait pattern representing a combination of pain that inhibits motion, structural loss of joint motion, avoidance behavior, and weakness. Hip pain or weakness of the hip abductors can result in contralateral pelvic tilt or drop (Trendelenburg sign) with ipsilateral weight bearing (Fig. 61.1). Muscle weakness is typically not true neurologic weakness but rather represents a disuse weakness associated with pain and avoidance. A hip flexion contracture may be observed with the Thomas test (Fig. 61.2), and accentuated lumbar lordosis may be seen in those with a hip flexion contracture, which may result in secondary mechanical low back pain due to alteration of normal spine mechanics. A limb length discrepancy may be observed, with the affected hip being the shorter limb.

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FIGURE 61.1 Trendelenburg sign. (From Goldstein B, Chavez F. Applied anatomy of the lower extremities. Phys Med Rehabil State Art Rev 1996;10:601-630.)
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FIGURE 61.2 Thomas test to assess a hip flexion contracture. The patient lies supine while a hip is flexed, bringing the knee to the chest and flattening the lumbar spine. The patient holds the flexed knee and hip against the chest. If there is a flexion contracture of the hip, the patient’s other leg will rise off the table.

Functional Limitations

Functional limitations from severe hip disease include difficulty in walking and with all mobility, even rising from a seated position, because of pain and weakness. This may affect a patient’s ability to dress, to bathe, to perform household chores, to participate in recreational activities, and to work outside the home. The goal of THA is to improve pain and consequently to improve function with activities of daily living.

Diagnostic Studies

Plain radiography remains the primary imaging tool for evaluation of hip disease and for postoperative assessment of THA. On radiographic examination, significant loss of joint cartilage as demonstrated by joint space narrowing, joint incongruity, osteophyte formation, subchondral cysts, and sclerosis are seen in individuals being considered for THA (Fig. 61.3). Many postoperative complications after THA can be evaluated by plain radiography. In patients thought to have a dislocation after THA, radiographs should be obtained urgently because a true dislocation must be relocated expediently (Fig. 61.4). Plain radiographs are also obtained in patients thought to have prosthetic loosening or periprosthetic fracture (Fig. 61.5). If plain radiographs do not show pathologic changes in a patient with enigmatic hip pain after THA, magnetic resonance imaging can be done with minimal artifact and can demonstrate disease in the periprosthetic soft tissues, including synovitis, periprosthetic inflammation, osteolysis, and iliopsoas tendinitis [4]. A computed tomography scan or bone scan may be part of the evaluation for osteolysis or loosening and infection.

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FIGURE 61.3 Anteroposterior pelvis radiograph showing moderate to severe degenerative changes of the hips. Notice the sclerotic changes at the acetabular and femoral heads. Note the loss of joint space, especially inferiorly, and osteophytes.
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FIGURE 61.4 Total hip replacement—dislocation. The femur has dislocated superiorly and laterally relative to the acetabulum. This dislocation is due to abnormal (vertical) position of the acetabular cup that occurred from loosening (see widened cement-bone interface). (From Katz DS, Math KR, Groskin SA. Radiology Secrets. Philadelphia, Hanley & Belfus, 1998.)
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FIGURE 61.5 Total hip replacement—loose femoral component. There is a wide area of lucency between the opaque cement (C)

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