**Author details**

table, is a fracture of the ankle while performing external rotation in order to dislocate the operated hip. This is why close monitoring of the torque applied to the fixed leg is necessary. In general, straight access to the femoral canal is limited in an anterior approach. The correct implant design and broaching instruments are essential and avoid malpositioning or fractures [46]. Perforation of the femur can occur when the direction of the femoral canal is not respected. The risk of postoperative complications in the hand of an experienced surgeon

The dislocation rate for the anterior THA is lower compared to the anterolateral and posterior approach [47]. Preserving the piriformis tendon, obturator externus tendon, and posterior capsule increases the stability when using the anterior approach. Therefore, the routine use of

The risk of postoperative hematoma can be minimized by routine exposure and proper ligation of the ascending branches of the lateral femoral circumflex vessels. The vessels are variable in number, location, and extend, but are usually found underneath the deep fascial layer of the tensor fasciae latae. At the end of the procedure, care should be taken for hemostasis. The risk of postoperative drainage can be reduced by meticulous capsular and tensor fasciae closure. Kasparek et al. describes the topical use of tranexamic acid (TXA) to reduce transfusion rates

performing an anterior approach is comparable to other approaches.

**Figure 14.** Intraoperative complication: calcar fracture fixed with two cerclages.

114 Total Hip Replacement - An Overview

hip precautions for the anterior approach is not recommended [32].

Ulrich Bechler, Bernhard Springer and Friedrich Boettner\*

\*Address all correspondence to: boettnerf@hss.edu

Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA

## **References**

[1] Berry DJ, Berger RA, Callaghan JJ, Dorr LD, Duwelius PJ, Hartzband MA, et al. Minimally invasive total hip arthroplasty. Development, early results, and a critical analysis. Presented at the Annual Meeting of the American Orthopaedic Association, Charleston, South Carolina, USA, June 14, 2003. The Journal of Bone and Joint Surgery. American Volume. 2003;**85-a**(11):2235-2246

in primary hip arthroplasty. A cross-sectional questionnaire study of 1,476 patients 1-3

Anterior Primary Total Hip Arthroplasty http://dx.doi.org/10.5772/intechopen.76070 117

[15] Sueyoshi T, Meding JB, Davis KE, Lackey WG, Malinzak RA, Ritter MA. Clinical predictors for possible failure after total hip arthroplasty. Hip International: The Journal of Clinical and Experimental Research on Hip Pathology and Therapy. 2016;**26**(6):531-536

[16] Smith-Petersen MN. Approach to and exposure of the hip joint for mold arthroplasty. The Journal of Bone and Joint Surgery. American Volume. 1949;**31a**(1):40-46

[17] Wagner H. Surface replacement arthroplasty of the hip. Clinical Orthopaedics and

[18] Berger RA. Total hip arthroplasty using the minimally invasive two-incision approach.

[19] Desser DR, Mitrick MF, Ulrich SD, Delanois RE, Mont MA. Total hip arthroplasty: Comparison of two-incision and standard techniques at an AOA-accredited community

hospital. The Journal of the American Osteopathic Association. 2010;**110**(1):12-15 [20] Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clinical Orthopaedics and Related Research.

[21] Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: A study of 1037 total hip replacements. Clinical Orthopaedics and Related

[22] Unger AS, Stronach BM, Bergin PF, Nogler M. Direct anterior total hip arthroplasty.

[23] McLaughlin JR, Lee KR. Long-term results of uncemented total hip arthroplasty with the Taperloc femoral component in patients with Dorr type C proximal femoral morphol-

[24] Zingg M, Boudabbous S, Hannouche D, Montet X, Boettner F. Standardized fluoroscopybased technique to measure intraoperative cup anteversion. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society. 2017;**35**(10):2307-2312

[25] Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: Perioperative findings. Journal of Orthopaedics and Traumatology: Official Journal of the Italian Society of Orthopaedics and Traumatology.

[26] Miller LE, Gondusky JS, Bhattacharyya S, Kamath AF, Boettner F, Wright J. Does surgical approach affect outcomes in total hip arthroplasty through 90 days of follow-up? A systematic review with meta-analysis. The Journal of Arthroplasty. 2017;**33**(4):1296-1302

[27] Mayr E, Nogler M, Benedetti MG, Kessler O, Reinthaler A, Krismer M, et al. A prospective randomized assessment of earlier functional recovery in THA patients treated

years after surgery. Acta Orthopaedica. 2014;**85**(5):463-469

Clinical Orthopaedics and Related Research. 2003;**417**:232-241

Related Research. 1978;**134**:102-130

2005;**441**:115-124

2011;**12**(3):123-129

Research. 2004;**426**:164-173

Instructional Course Lectures. 2014;**63**:227-238

ogy. The Bone & Joint Journal. 2016;**98-b**(5):595-600


in primary hip arthroplasty. A cross-sectional questionnaire study of 1,476 patients 1-3 years after surgery. Acta Orthopaedica. 2014;**85**(5):463-469

[15] Sueyoshi T, Meding JB, Davis KE, Lackey WG, Malinzak RA, Ritter MA. Clinical predictors for possible failure after total hip arthroplasty. Hip International: The Journal of Clinical and Experimental Research on Hip Pathology and Therapy. 2016;**26**(6):531-536

Charleston, South Carolina, USA, June 14, 2003. The Journal of Bone and Joint Surgery.

[2] Woolson ST, Rahimtoola ZO. Risk factors for dislocation during the first 3 months after primary total hip replacement. The Journal of Arthroplasty. 1999;**14**(6):662-668

[3] L'Hommedieu CE, Gera JJ, Rupp G, Salin JW, Cox JS, Duwelius PJ. Impact of anterior vs posterior approach for total hip arthroplasty on post-acute care service utilization. The

[4] Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates? Clinical Orthopaedics and

[5] Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. The Journal of Bone and Joint Surgery. American

[6] Boettner F, Zingg M, Emara AK, Waldstein W, Faschingbauer M, Kasparek MF. The accuracy of acetabular component position using a novel method to determine antever-

[7] Lin TJ, Bendich I, Ha AS, Keeney BJ, Moschetti WE, Tomek IM. A comparison of radiographic outcomes after total hip arthroplasty between the posterior approach and direct anterior approach with intraoperative fluoroscopy. The Journal of Arthroplasty. 2016

[8] Little NJ, Busch CA, Gallagher JA, Rorabeck CH, Bourne RB. Acetabular polyethylene wear and acetabular inclination and femoral offset. Clinical Orthopaedics and Related

[9] Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. The Journal

[10] Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA. Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior

[11] Hardinge K. The direct lateral approach to the hip. The Journal of Bone and Joint Surgery.

[12] Nakai T, Liu N, Fudo K, Mohri T, Kakiuchi M. Early complications of primary total hip arthroplasty in the supine position with a modified Watson-Jones anterolateral

[13] Hendel D, Yasin M, Garti A, Weisbort M, Beloosesky Y. Fracture of the greater trochanter during hip replacement: A retrospective analysis of 21/372 cases. Acta Orthopaedica

[14] Amlie E, Havelin LI, Furnes O, Baste V, Nordsletten L, Hovik O, et al. Worse patientreported outcome after lateral approach than after anterior and posterolateral approach

approach? Clinical Orthopaedics and Related Research. 2014;**472**(6):1877-1885

of Bone and Joint Surgery. American Volume. 2007;**89**(8):1832-1842

American Volume. 2003;**85-a**(11):2235-2246

116 Total Hip Replacement - An Overview

Journal of Arthroplasty. 2016;**31**(9 Suppl):73-77

sion. The Journal of Arthroplasty. 2016;**32**(4):1180-1185

approach. Journal of Orthopaedics. 2014;**11**(4):166-169

Related Research. 2006;**447**:34-38

Research. 2009;**467**(11):2895-2900

British Volume. 1982;**64**(1):17-19

Scandinavica. 2002;**73**(3):295-297

Volume. 1978;**60**(2):217-220


by minimally invasive direct anterior approach: A gait analysis study. Clinical Biomechanics. 2009;**24**(10):812-818

[40] Homma Y, Baba T, Kobayashi H, Desroches A, Ozaki Y, Ochi H, et al. Safety in early experience with a direct anterior approach using fluoroscopic guidance with manual leg control for primary total hip arthroplasty: A consecutive one hundred and twenty case

Anterior Primary Total Hip Arthroplasty http://dx.doi.org/10.5772/intechopen.76070 119

[41] Lovell TP. Single-incision direct anterior approach for total hip arthroplasty using a standard operating table. The Journal of Arthroplasty. 2008;**23**(7 Suppl):64-68

[42] Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. The Journal of Arthroplasty. 2010;**25**(5):671.

[43] Bhargava T, Goytia RN, Jones LC, Hungerford MW. Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty. Orthopedics.

[44] Goulding K, Beaule PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clinical Orthopaedics and Related

[45] Agten CA, Sutter R, Dora C, Pfirrmann CW. MR imaging of soft tissue alterations after total hip arthroplasty: Comparison of classic surgical approaches. European Radiology.

[46] Homma Y, Baba T, Ochi H, Ozaki Y, Kobayashi H, Matsumoto M, et al. Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty. European Journal of Orthopaedic Surgery & Traumatology: Orthopedie Traumatologie. 2016;**26**(6):605-611

[47] Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. The Journal of Arthroplasty.

[48] Kasparek MF, Faschingbauer M, Waldstein W, Boettner CS, Boettner F. Topical tranexamic acid is equivalent to targeted preoperative autologous blood donation in

total hip arthroplasty. The Journal of Arthroplasty. 2016;**32**(4):1176-1179

series. International Orthopaedics. 2016;**40**(12):2487-2494

e1-679.e1

2010;**33**(7):472

2017;**27**(3):1312-1321

2015;**30**(3):419-434

Research. 2010;**468**(9):2397-2404


[40] Homma Y, Baba T, Kobayashi H, Desroches A, Ozaki Y, Ochi H, et al. Safety in early experience with a direct anterior approach using fluoroscopic guidance with manual leg control for primary total hip arthroplasty: A consecutive one hundred and twenty case series. International Orthopaedics. 2016;**40**(12):2487-2494

by minimally invasive direct anterior approach: A gait analysis study. Clinical Bio-

[28] Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior with mini-posterior approach: Two consecutive series. The

[29] Rodriguez JA, Deshmukh AJ, Rathod PA, Greiz ML, Deshmane PP, Hepinstall MS, et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clinical Orthopaedics and Related Research.

[30] Prietzel T, Hammer N, Schleifenbaum S, Adler D, Pretzsch M, Kohler L, et al. The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: A retrospective analysis of 1972 cases. Zeitschrift für Orthopädie und Unfallchirurgie.

[31] Schmidt-Braekling T, Waldstein W, Akalin E, Benavente P, Frykberg B, Boettner F. Minimal invasive posterior total hip arthroplasty: Are 6 weeks of hip precautions really

[32] Restrepo C, Mortazavi SM, Brothers J, Parvizi J, Rothman RH. Hip dislocation: Are hip precautions necessary in anterior approaches? Clinical Orthopaedics and Related

[33] Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. The Journal

[34] Tamaki T, Oinuma K, Miura Y, Higashi H, Kaneyama R, Shiratsuchi H. Epidemiology of dislocation following direct anterior total hip arthroplasty: A minimum 5-year follow-

[35] de Steiger RN, Lorimer M, Solomon M. What is the learning curve for the anterior approach for total hip arthroplasty? Clinical Orthopaedics and Related Research.

[36] Goytia RN, Jones LC, Hungerford MW. Learning curve for the anterior approach total hip arthroplasty. Journal of Surgical Orthopaedic Advances. 2012;**21**(2):78-83

[37] Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior-supine minimally invasive total hip arthroplasty: Defining the learning curve. The Orthopedic Clinics of North

[38] Masonis J, Thompson C, Odum S. Safe and accurate: Learning the direct anterior total

[39] Rudin D, Manestar M, Ullrich O, Erhardt J, Grob K. The anatomical course of the lateral femoral cutaneous nerve with special attention to the anterior approach to the hip joint.

The Journal of Bone and Joint Surgery. American Volume. 2016;**98**(7):561-567

necessary? Archives of Orthopaedic and Trauma Surgery. 2015;**135**(2):271-274

mechanics. 2009;**24**(10):812-818

2014;**472**(2):455-463

118 Total Hip Replacement - An Overview

2014;**152**(2):130-143

Research. 2011;**469**(2):417-422

2015;**473**(12):3860-3866

America. 2009;**40**(3):343-350

of Arthroplasty. 2016;**31**(9 Suppl):127-130

up study. The Journal of Arthroplasty. 2016;**31**(12):2886-2888

hip arthroplasty. Orthopedics. 2008;**31**(12 Suppl 2):129-143

Journal of Arthroplasty. 2009;**24**(5):698-704


**Section 5**

**Complications in Hip Arthroplasty**

**Complications in Hip Arthroplasty**

**Chapter 8**

**Provisional chapter**

**Complications of Total Hip Replacement**

**Complications of Total Hip Replacement**

DOI: 10.5772/intechopen.76574

Total hip replacement is a highly effective surgical procedure for patients suffering from end stage osteoarthritis and its success in improving symptoms of osteoarthritis has meant that its use has increased across many healthcare systems. Although in experienced hands the procedure provides very effective outcomes one must be aware of the potential complications of the procedure. These can be divided into general and procedure specific. General complications include infections, postoperative pulmonary issues and thromboembolic complications. Procedural specific complications include a surgical site infection, haemorrhage, nerve injury, dislocation, leg length discrepancy, periprosthetic fractures and heterotrophic ossification. This chapter explores and describes the complications a surgeon may face when performing a total hip replacement and how

Total hip replacement is a highly effective surgical procedure for patients suffering from end stage osteoarthritis [1]. Its success in improving pain, mobility and quality of life for patients

As like any surgical procedure however, total hip replacements have associated surgical complications. Thanks to advances in technology, surgical awareness and anaesthetic techniques the overall rates of complications have been declining despite an increasing burden of comorbidities in the population [4]. The complications encountered can be divided into general and procedure specific. This chapter will explore both aspects of complications that the sur-

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Chang Park and Irfan Merchant

Chang Park and Irfan Merchant

http://dx.doi.org/10.5772/intechopen.76574

one may avoid and address these.

**Keywords:** complication, hip, arthroplasty

has meant its use has increased since its introduction [2, 3].

geon may encounter when performing total hip replacements.

**Abstract**

**1. Introduction**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

#### **Complications of Total Hip Replacement Complications of Total Hip Replacement**

#### Chang Park and Irfan Merchant Chang Park and Irfan Merchant

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76574

**Abstract**

Total hip replacement is a highly effective surgical procedure for patients suffering from end stage osteoarthritis and its success in improving symptoms of osteoarthritis has meant that its use has increased across many healthcare systems. Although in experienced hands the procedure provides very effective outcomes one must be aware of the potential complications of the procedure. These can be divided into general and procedure specific. General complications include infections, postoperative pulmonary issues and thromboembolic complications. Procedural specific complications include a surgical site infection, haemorrhage, nerve injury, dislocation, leg length discrepancy, periprosthetic fractures and heterotrophic ossification. This chapter explores and describes the complications a surgeon may face when performing a total hip replacement and how one may avoid and address these.

DOI: 10.5772/intechopen.76574

**Keywords:** complication, hip, arthroplasty

#### **1. Introduction**

Total hip replacement is a highly effective surgical procedure for patients suffering from end stage osteoarthritis [1]. Its success in improving pain, mobility and quality of life for patients has meant its use has increased since its introduction [2, 3].

As like any surgical procedure however, total hip replacements have associated surgical complications. Thanks to advances in technology, surgical awareness and anaesthetic techniques the overall rates of complications have been declining despite an increasing burden of comorbidities in the population [4]. The complications encountered can be divided into general and procedure specific. This chapter will explore both aspects of complications that the surgeon may encounter when performing total hip replacements.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
