Total Hip Replacement: Needed But Not Always Possible

Even though hip pain from osteoarthritis can be very debilitating and disabling, hip replacement is still an elective procedure. Elective means it is not required because of a life-threatening condition, but rather, a choice based on personal needs and preferences.

Many more older adults are choosing (even demanding!) this surgery in order to stay active longer. In fact, it is anticipated that there will be an almost 200 per cent increase in the number of hip replacements done in the United States over the next 20 years.

But not everyone who wants a new hip is a good candidate for surgery or in particular, hip replacement surgery. In this review article, surgeons from Ohio State University present for us, what is known about risks related to total hip arthroplasty (THA, another name for total hip replacement).

First, studies show there is up to a 7.4 per cent risk of major problems during or after surgery. And more significantly, there is even a 0.8 per cent risk of death after joint replacement (hip or knee). With the new upcoming pay-for-performance Medicare program to control costs, surgeons will be penalized for poor results and rewarded for good outcomes. That means patient selection (choosing patients likely to have the best results) will become increasingly important. And the opposite is true, too — identifying patients at increased risk for complications with surgery will dictate who might not qualify for the procedure.

Just what are the risk factors that put patients in danger of complications, problems, and adverse events associated with total hip arthroplasty (THA)? Heart disease is the number one health problem that complicates elective surgery. Three-fourths of all major problems after joint replacement surgery (hip or knee) are directly linked with the cardiovascular system. High blood pressure, blood clots, valve disease, heart attacks, previous history or heart surgery such as the implantation of a stent or balloon angioplasty top the list of significant (and potentially life-threatening) risk factors.

Other health conditions surgeons must watch for in patients considering total hip replacement include rheumatoid arthritis (RA) with psoriasis (skin lesions increase risk of infection, drugs for poor wound healing), organ transplantation, alcohol abuse, HIV, obesity, blood clotting disorders, and eating disorders or malnutrition. Even things like dental disease (cavities, abscesses, gingivitis) can put you on the sidelines.

And there’s more! Tobacco use (especially smoking), kidney disease, sleep apnea, history of cancer, long-term use of steroid medications, diseases of the blood vessels in the legs, diabetes, and lung diseases must all be taken into consideration as potential risk factors. The authors carefully describe the details of each category of risks and the possible influence these factors have on adverse events after hip replacement.

Finally, it may seem like anyone of any age can get a hip replacement. But older age does put adults at increased risk for medical complications (and death) associated with joint replacement. Sixty-five years of age seems to be the cut-off point for low-to-high risk. Risk starts to increase after age 65 to the point that by age 85, the risk of death after hip replacement is nine times higher in adults 85 and older.

Paying attention to risks before agreeing to perform surgery is called risk stratification. This is something surgeons are giving more and more attention to as older adults who have multiple health problems ask for joint replacements. Patient safety is everyone’s concern.

Knowing that most complications occur in the first few days after surgery puts the burden of prevention on surgeons first to select the best candidates for surgery. But as the authors note in their final conclusion — less than half of all patients who end up with life-threatening complications after surgery have any obvious risk factors beforehand. To use a gambling term — that certainly “ups the ante.” More studies are needed to provide an evidence-based risk stratification model that can be used to prevent and reduce all post-operative problems, but especially life-threatening complications.