Why Did These THAs Fail?

    What lessons can be learned from total hip arthroplasty (THA) cases that seemed fine at the time of surgery but ultimately failed due to patient or surgical factors?

    That’s the question faculty answered during a session on failed THA at ICJR’s Winter Hip & Knee Course. Bryan D. Springer, MD, from OrthoCarolina in Charlotte, North Carolina, moderated the case-based panel discussion, which highlighted 5 failed THAs. Faculty presented their cases, solicited feedback from the panel members, and then revealed how the cases resolved.

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    These cases show that even the most experienced orthopaedic surgeons have patients whose hip replacements fail, and they fail for a variety of reasons.

    Case 1: Infection
    Case presented by
    Richard W. McCalden, MD, FRCSC, London Health Sciences Centre, London, Ontario, Canada

    • 68-year-old female with a painful left hip
    • Thin, healthy; failed non-operative treatment
    • Primary cementless THA through the direct lateral approach under spinal anesthesia
    • Perioperative cefazolin, tranexamic acid
    • Discharged with cefazolin and dalteparin
    • Returned to the emergency department 10 days later with increased hip pain, redness, wound discharge; complaining of feeling unwell, chills at night

    Case 2: Dislocation
    Case presented by
    Jonathan M. Vigdorchik, MD, NYU Langone Orthopedic Hospital, New York, New York

    • 67-year-old female with right hip osteoarthritis
    • Past history of spine surgery
    • Felt a “pop” when turning over in bed 2 weeks after primary THA; closed reduction in the emergency department
    • Dislocated 2 days later, then 3 days after that

    Case 3: Infection with Vancomycin-Resistant Enterococci
    Presented by Michael P.
    Nett, MD, Northwell Health, New York, New York

    • 75-year-old female with severe, intractable pain of the right hip, worsening over prior 6 months
    • BMI: 43; history of diabetes (hemoglobin A1c 7.0), hypertension, sleep apnea
    • Limited mobility, using a wheelchair
    • Limited pain relief from 2 cortisone injections
    • MRI: Subchondral collapse of femoral head with severe osseous edema
    • Uneventful THA, discharged to skilled nursing facility (SNF) on POD3 with enoxaparin for deep vein thrombosis prophylaxis
    • Sent to the emergency department after falling 2 times at the SNF
    • Incision healed without drainage; local erythema with no obvious infection
    • Revised with a modular stem and wires around a periprosthetic fracture, discharged to inpatient rehab with enoxaparin and vancomycin
    • Hematoma rupture on POD12, producing serosanguinous drainage
    • Cultures from subsequent surgery positive for vancomycin-resistant enterococci

    Case 4: Metal-on-Metal Implant
    Presented by James A. Browne, MD, University of Virginia, Charlottesville

    • 59-year-old healthy male with left hip pain
    • Had undergone THA at another institution; metal-on-metal implant
    • Uncomplicated postoperative course
    • Insidious onset of hip pain over the prior few months, mostly when walking on hard floors and when playing softball
    • No limp, 5/5 abductor strength, no pain on range of motion of the hip
    • Cobalt level 8.4, chromium level 6.1
    • MRI: No fluid collection or evidence of adverse local tissue reaction
    • Bone scan: Mildly increased radiotracer uptake around the hip implant
    • Patient elected observation over surgery
    • 1 year later, presents with slowly progressive start-up pain in the thigh
    • Serum cobalt level 12, serum chromium level 7.4
    • MRI: Effusion

    Case 5: Corrosion at the Modular Junction, Pseudotumor
    Presented by David G. Lewallen, MD, Mayo Clinic, Rochester, Minnesota

    • 63-year-old active female with occasional mild to moderate hip pain
    • THA 15 months prior with a ceramic-on-highly cross-linked polyethylene implant
    • 12 months of increasing pain
    • Recently developed femoral nerve palsy
    • Serum chromium level 1.1, serum cobalt level 5.1
    • Synovial fluid chromium level 397, synovial cobalt level 1472

    Click the image above to watch the presentation and find out how the panel members would manage these patients and how the cases were eventually resolved.


    The faculty have no disclosures relevant to this article.