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The authors reviewed the complication records following total hip arthroplasty at their institution between January 1976 and July 1989. Forty-two patients (12 men and 30 women) with 45 neurologic complications were identified following 7,133 consecutive total hip arthroplasties; an incidence rate of 0.63%. The average age of these patients was 58 years (range, 27-81 years). Thirty-four nerve injuries were noted in the lower extremity (0.48% incidence rate) and 11 in the upper extremity (0.15% incidence rate). The majority of patients (64%) with neurologic injury to the upper extremity had the diagnosis of inflammatory arthritis. The common peroneal was most often involved in the lower extremity. The ulnar nerve was most commonly involved in the upper extremity. The pathogenetic factors leading to neurologic injury in the majority of patients were not clearly established. Leg lengthening did not seem to be a major cause. The prognosis of patients with nerve palsy of the upper extremity is favorable compared with injury to the lower extremity. Similarly, the percentage of patients with a permanent neurologic deficit was lower in the primary surgery group (27%) compared with the revision/reoperation group (43%). The overall percentage of permanent nerve palsy was 33%. Female patients, for unclear reasons, appear to have a higher risk for neurologic injury. Also, the risk of neurologic injury following total hip arthroplasty appears to be higher with revisions/reoperations and with an inexperienced surgeon.

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Somatosensory evoked potential (SSEP) was used to continuously monitor the sciatic nerve intraoperatively during revision or reoperation for total hip arthroplasty. Of 25 cases monitored, eight patients (32%) exhibited 12 instances of SSEP deterioration, indicating neurologic compromise. These neurologic problems were due to retraction in seven cases and limb positioning in five. No postoperative neurologic deficits were noted in this group. Two of 35 patients (5.7%) not monitored had postoperative neurologic deficits. SSEP monitoring is a useful method for minimizing the intraoperative risks of clinical neurologic deficits during revisions or difficult reoperations.

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Total hip arthroplasty was performed in 13 hips with acetabular bone grafts for secure component fixation. The incorporation and healing of acetabular bone grafts were investigated with the aid of roentgenograms, planar bone scans, and a newer scintigraphic technique, three-dimensional single photon emission computed tomography (SPECT). Conventional roentgenograms proved unreliable in evaluating bone graft reconstitution because of overlapping trabecular bone patterns of the graft and iliac wing. There was no evidence of graft failure or acetabular loosening. Bone grafts in the late follow-up group (four to seven years postoperation) exhibited normal radionuclide activity, whereas grafts less than one year postsurgery demonstrated patterns of increased activity. SPECT was helpful in producing an anatomic reconstruction of the acetabulum. The observation that bone grafts exhibited normal biological viability is crucial for ensuring secure acetabular component fixation on a long-term basis.

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Sciatic nerve function was monitored intraoperatively by somatosensory evoked potentials (SEP) in 50 patients during total hip arthroplasty. There were 12 instances of temporary nerve compromise in ten patients: three during acetabular preparation due to retraction, one due to reamer contact, six during femoral reaming due to positioning, and two during trial reduction due to inadequate shortening of the femoral neck. The technique for monitoring, causes, and incidence of nerve compromise during total hip arthroplasty are discussed. SEP monitoring may be especially useful in revision surgery.

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Total hip arthroplasty was performed for unilateral hip disease in 26 patients with trochanteric osteotomy (TS) and 27 patients without osteotomy (NS). Early postoperative recovery of function, pain, mobility, radiographic changes, and abduction torques were recorded and evaluated. Theoretic analysis of hip mechanics based on radiographic measurements was compared with measured abduction torques for each patient. Function, pain, and mobility ratings were similar for both groups pre- and postoperation. Radiographic measurements demonstrated better mechanical reconstruction of hips in both groups. There was a trend, but no statistically significant correlation, of mechanical parameters and measured isokinetic or isometric abduction torques at the hip joint in the TS group. In the NS group, no correlation was found between mechanical parameters and measured torques. A significant improvement in recovery of torque was found in the NS group when compared to the TS patients.

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Late deep wound infection secondary to hematogenous spread of bacteria from a distant focus is an infrequent but devastating complication of total joint replacement. Nine patients (ten implants) with documented late hematogenous infection are reported, all of whom demonstrated several characteristic features. The initial operation was free of clinical evidence of infection and a long asymptomatic interval ensued, followed by a definite febrile illness and acute joint pain. The source of the infection often was not recognized until late and prophylactic antibiotics were not given when it was identified. Seven of the ten implants had to be removed. The primary responsibility for the prevention of this devastating complication lies with the surgeon, who must inform each patient of the risk of late hematogenous seeding from infection elsewhere in the body. It is also important to pay special attention to patients who are at particularly high risk, such as those with rheumatoid arthritis or other systemic diseases. A knowledge of the bacterial flora of the various areas of the human body is essential in choosing the appropriate prophylactic antibiotic.

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This study examines the effect of three different hypocaloric diets on the patterns of muscle and plasma amino acids in patients undergoing total hip replacement. Group I (seven patients) received 90 g/day of glucose, Group II (seven patients) received 70 g/day of amino acids, Group III (eight patients) received both 90 g of glucose and 70 grams of amino acids per day. Utilizing the percutaneous biopsy technique of Bergström, free amino acid patterns in muscle and plasma were analyzed pre- and postoperatively (day 4). The postoperative pattern of amino acids was characterized by elevated levels in muscle and plasma of the branched chain amino acids, phenylalanine, tyrosine and methionine. There was a marked decrease in muscle glutamine and smaller decreases in the basic amino acids in both muscle and plasma. Muscle:plasma concentration ratios increased for the neutral amino acids, decreased for glutamine and the basic amino acids and were unchanged for the acidic amino acids. The patterns seen after hip replacement are almost identical to those seen after colectomy or accidental injury. There was little effect of diet on amino acid concentrations in muscle. In plasma, concentrations of leucine, isoleucine, valine and proline were higher in Group II in the absence of glucose intake, than in the other groups. Lysine was lower in Group I with no amino acid intake than in the other groups. Thus, there is a unique amino acid pattern associated with operative trauma which is relatively unaffected by hypocaloric, intravenous nutrition.

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The prime therapeutic objective of prophylactic anticoagulation for patients undergoing total hip replacement is to reduce to a minimum fatalities from pulmonary embolism. Our low-dose heparin-warfarin prophylactic anticoagulation protocol affords significant protection in this regard (one fatal pulmonary embolism in 796 cases) without the use of venography or other objective tests to check for deep venous thrombosis and for all patients including those with venous disease or a history of prior thromboembolic disease. The 13.1% hematoma rate (5.0% late major) is a small, nonlethal, and acceptable price to pay for this protection.

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This report presents an initial clinical experience with arterial embolization as adjuvent therapy in the surgical treatment of selected benign primary bone tumors in childhood. Embolization was dramatically effective in 4 children with spinal or pelvic vascular tumors. This technique facilitated local surgical resection and/or curettage. No child had evidence of local recurrence. Three of the 4 children had spinal cord or nerve root compression resulting in various degrees of paralysis prior to surgery. All treated patients had complete recovery from their paralysis. There were no complications of embolization or surgery. The treatment of benign primary bone tumors of the spine and pelvis is immeasurably improved by the adjuvant arterial embolization procedure. The immediate surgical treatment of these difficult tumors now becomes feasible with the greatly diminished blood flow resulting from embolization.

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Metabolic changes in 10 patients undergoing total hip replacement were studied. Metabolic expenditure postoperatively remained within 5--10% of preoperative values. Net nitrogen loss for the postoperative period was less than 35 gm for the first 4 postoperative days, well below changes seen in major nonsurgical trauma. Fluid balance was positive in all patients for the first 4 postoperative days. Patients not in negative fluid balance by the fourth postoperative day should be closely monitored for complications. Recognition of delayed fluid excretion is essential in order to avoid the complications of further fluid loading in the postoperative period. Muscle composition reveals predictable changes in extracellular water, sodium, and chloride composition following surgery. Our data showed that metabolic changes following total hip replacement are in the order of major general surgical procedures and well below that observed with major trauma.

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Of five patients in who sciatic paresis developed as the result of hemorrhage and hematoma following hip surgery, four were receiving prophylactic or therapeutic anticoagulants. The patient who was managed expectantly still had disabling motor and sensory deficity at follow-up. Three patients who had early operative decompression showed more complete return of nerve function. The fifth patient died three weeks after onset with the neuropathy still present. Severe low-back and buttock pain, ecchymosis over these regions, marked swelling in the thigh, sciatic-nerve tenderness, and a distal sciatic neural deficit in the ipsilateral lower limb of a patient who has had hip surgery are evidence of hemorrhage in the vicinity of the sciatic nerve. Early recognition and prompt surgical decompression can prevent irreversible nerve damage.

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The amino acid pattern following total hip replacement is characterized by increases in muscle of the branched chain amino acids (leucine, isoleucine and valine), the aromatics (phenylalanine and tyrosine) as well as methionine. The nonessential amino acids in muscle tend to decline, glutamine having the most marked change. Plasma levels of the essential amino acids increase while the nonessentials tend to decrease. This pattern differs from that observed in other catabolic states (uremia, starvation, untreated diabetes) and is significantly different from the effects of inactivity and starvation combined. This suggests that injury can be characterized by a unique pattern of muscle and plasma amino acids.

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In a consecutive retrospective study of 1,500 total hip replacements, analysis of cultures taken at the time of operation revealed that positive cultures obtained in primary arthroplasties are not significant. In our series, no statistical difference could be demonstrated between primary and revision arthroplasty cultures as related to joint infection, but on the basis of other clinical studies and the higher incidence of positive cultures in revision arthroplasty cultures as related to joint infection, but on the basis of other clinical studies and the higher incidence of positive cultures in revision arthroplasties, it is believed that these cultures should be treated vigorously. Further studies are being carried out to help clarify the role of prophylactic antibiotics in hip replacement operations in the prevention of postoperative hip joint infection. Antibiotic therapy for the treatment of potentially contaminated hips is also being reviewed. Such studies must be performed over a long term period.

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