วันศุกร์ที่ 8 พฤษภาคม พ.ศ. 2569

Complications of Total Hip Arthroplasty (THA)

Complications of Total Hip Arthroplasty (THA)

ภาพรวม

Complications หลัง THA แบ่งได้เป็น:

  • perioperative complications
  • intermediate/late complications

แม้อุบัติการณ์ส่วนใหญ่ต่ำ แต่บางภาวะ morbidity/mortality สูงมาก เช่น:

  • VTE/PE
  • PJI
  • vascular injury

PERIOPERATIVE COMPLICATIONS

1. Intraoperative Fracture

Incidence

  • Cemented stem: 0.1–1%
  • Cementless stem: 3–18%

ส่วนใหญ่เกิด femoral fracture ระหว่าง stem insertion

Risk factors

  • female
  • elderly
  • osteopenia
  • inflammatory arthritis
  • cementless fixation
  • revision surgery
  • long stem

Management

ขึ้นกับ severity:

  • observation
  • cable/wire fixation
  • revision component
  • plate/screw
  • bone graft

2. Nerve Injury

Incidence

1–2%

Most common:

  • sciatic nerve
    โดยเฉพาะ posterior approach

Peroneal division vulnerable มากที่สุด

Risk factors

  • previous hip surgery
  • DDH (developmental dysplasia of the hip)
  • limb lengthening
  • obesity
  • female
  • anterior approach → femoral/LFCN (lateral femoral cutaneous) nerve injury มากขึ้น

Causes

  • hematoma compression
  • retractor injury
  • traction/stretch
  • excessive lengthening
  • thermal injury from cement
  • hardware impingement
  • dislocation

Evaluation

ตรวจหา:

  • hematoma
  • dislocation
  • excessive lengthening
  • screw malposition

Imaging:

  • X-ray
  • CT
  • MARS (metal artifact reduction sequence) MRI
  • ultrasound

Management

Immediate

  • flex hip/knee ลด tension

Surgical exploration ถ้า

  • compressive hematoma
  • severe lengthening
  • laceration

Foot drop

→ ankle-foot orthosis

Femoral nerve palsy

→ knee immobilizer

Prognosis

  • complete recovery ~41%
  • mild residual deficit ~44%
  • poor outcome ~15%

Isolated peroneal injury prognosis ดีกว่า complete sciatic palsy

3. Leg Length Discrepancy

Incidence

1–27%

Important concept

แยก:

  • true discrepancy
    vs
  • apparent/functional discrepancy

Functional discrepancy:

  • muscle weakness
  • gait abnormality
  • มักดีขึ้นในไม่กี่เดือน

Clinical consequences

ถ้า significant:

  • limp
  • low back pain
  • cane dependence

Management

  • PT initially
  • shoe lift หลัง recovery stable

4. Vascular Injury

Incidence

0.2–0.3%

อาจ involve:

  • iliac vessels
  • femoral vessels
  • profunda femoris
  • obturator artery
  • superior gluteal artery

Causes

  • retractors
  • osteotome/saw/scalpel
  • acetabular screws
  • traction

Danger zones:

  • anterosuperior acetabulum → iliac vessels
  • anteroinferior → obturator neurovascular bundle

Management

  • immediate bleeding control
  • pressure/electrocautery
  • vascular repair if severe

5. Venous Thromboembolism (VTE)

หนึ่งใน complication ที่ mortality สูงที่สุด

Incidence (despite prophylaxis)

  • symptomatic VTE ~0.5%
  • DVT ~0.26%
  • PE ~0.14%

Risk factors for PE

  • obesity
  • COPD
  • AF
  • anemia
  • depression
  • postop DVT

Prevention (critical)

  • pharmacologic prophylaxis
  • early mobilization

ต้อง balance:

  • thrombosis risk
    vs
  • bleeding/hematoma risk

6. Surgical Site Infection (SSI)

Incidence

0.4–2.2%

แบ่ง:

  • superficial SSI
  • deep SSI/PJI

Clinical signs

  • fever
  • erythema
  • pain
  • discharge
  • swelling

Superficial infection อาจ progress เป็น deep infection ได้

7. Bone Cement Implantation Syndrome (BCIS)

Definition

ภาวะ hemodynamic collapse associated with polymethylmethacrylate cement

Mechanism

เชื่อว่าเกิดจาก:

  • fat/marrow embolization
    ร่วมกับ
  • cement toxicity
  • complement/prostaglandin activation

Risk factors

  • long-stem component

Clinical signs

  • hypoxia
  • hypotension
  • arrhythmia
  • neurologic symptoms
  • cardiac arrest

Management

  • aggressive fluid resuscitation
  • oxygen
  • supportive care

INTERMEDIATE & LONG-TERM COMPLICATIONS

8. Prosthetic Joint Infection (PJI)

Incidence

~1%

Diagnostic major criteria

  • sinus tract communicating with joint
    หรือ
  • ≥2 cultures same organism

Management

  • DAIR
  • exchange arthroplasty
  • antibiotics

ถ้า implant loose → มักต้อง remove implant

9. Dislocation

หนึ่งในสาเหตุ revision ที่พบบ่อยที่สุด

Incidence

<5%

Most common:

  • posterior dislocation

Mechanism:

  • flexion + adduction + internal rotation

Risk factors

Surgical

  • posterior approach
  • malalignment
  • soft tissue insufficiency

Patient

  • elderly
  • female
  • Parkinson disease
  • alcohol use disorder
  • prior hip surgery

Clinical presentation

  • sudden pop/clunk
  • severe pain
  • shortened rotated limb
  • unable to bear weight

Diagnosis

  • plain X-ray

Management

First-time dislocation

  • closed reduction
  • sedation/anesthesia

หลัง reduction:

  • X-ray/CT confirm reduction
  • dislocation precautions

Brace effectiveness limited

Recurrent dislocation

→ revision surgery

Options:

  • constrained acetabular component
  • dual mobility construct

10. Osteolysis & Wear

Mechanism

wear particles (especially polyethylene)
→ macrophage activation
→ osteoclast activation
→ bone resorption

Clinical

มัก asymptomatic จนเกิด:

  • loosening
  • fracture
  • synovitis

Diagnosis

X-ray:

  • endosteal/cancellous bone destruction

CT metal suppression เห็น defect ดีกว่า

Management

Surgical:

  • liner exchange
  • revision
  • remove granulomatous tissue

Delay surgery → revision harder

11. Aseptic Loosening

Most common cause of late revision

Causes

  • wear
  • failed fixation
  • poor biologic ingrowth
  • cement failure

Symptoms

deep aching pain:

  • worse with weightbearing
  • better with rest

Diagnosis

  • radiolucent line
  • migration
  • pedestal sign

Important:

ต้องแยกจาก PJI

Definitive evaluation:

  • aspiration + culture

12. Metal-on-Metal (MOM) Complications

Problems

  • accelerated wear
  • ALTR
  • pseudotumor
  • metallosis
  • trunnionosis

Adverse Local Tissue Reaction (ALTR)

เกิด:

  • fluid collection
  • synovitis
  • tissue necrosis

อาจต้อง revision

Trunnionosis

Corrosion at head-neck junction

Risk ลดลงมากเมื่อใช้ ceramic head

Monitoring MOM implants

Asymptomatic

  • follow-up every ≤5 years
  • cobalt/chromium levels

Symptomatic

  • cobalt/chromium
  • ultrasound/MARS MRI

13. Periprosthetic Fracture

Incidence

<1%

Most common:
femoral side

Vancouver Classification

Type A

trochanteric

Type B

around stem

  • B1: stem stable
  • B2: loose stem
  • B3: loose + bone loss

Type C

distal to stem

Management

Stable/well-fixed

→ nonoperative possible

Loose stem

→ revision arthroplasty with long stem

14. Implant Failure / Component Fracture

Incidence

~0.3%

Causes

  • fatigue fracture
  • repetitive loading
  • obesity
  • high activity
  • poor fixation

15. Heterotopic Ossification (HO)

Incidence

  • radiographic HO สูงมาก
  • clinically significant ~10%

Clinical

  • stiffness
  • pain
  • ↓ ROM

อาจ mimic infection:

  • warmth
  • swelling
  • erythema

Diagnosis

X-ray:
เห็นได้ตั้งแต่ 3–4 weeks

Maturation:
1–2 years

Brooker Classification

Grade

Description

I

islands of bone

II

spur >1 cm apart

III

spur <1 cm apart

IV

ankylosis

Management

  • mild → observation
  • severe symptomatic → surgical excision

High-yield Clinical Pearls

  • Cementless stem → intraoperative fracture risk สูงกว่า
  • Posterior approach → posterior dislocation risk สูงกว่า
  • New foot drop postop → evaluate sciatic/peroneal injury immediately
  • Persistent pain after THA → ต้องแยก aseptic loosening vs PJI
  • First-time dislocation → usually closed reduction ได้
  • Polyethylene wear → major driver ของ osteolysis
  • MOM implant → ระวัง pseudotumor และ trunnionosis
  • Loose stem + fracture = think Vancouver B2/B3 → revision arthroplasty
  • PE ยังเกิดได้แม้มี prophylaxis
  • BCIS แม้ rare แต่ potentially fatal during cemented THA

 

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