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33: Joint Replacement

Kevin McElroy; Caitlin Innerfield; Sara Cuccurullo; Roger P. Rossi

HIP REPLACEMENT

General Considerations

Approximately 330,000 total hip arthroplasties (THAs) were performed in the United States in 2010. The number of THA surgeries in this country has increased dramatically over the past four decades, and these procedures are expected to increase significantly by 2030.

A. Epidemiology

The majority of hip replacements are performed in individuals between 60 and 80 years of age. Women account for 62% of such surgeries in the United States and typically undergo the procedure between ages 75 and 84 years (compared with ages 65 and 74 years for men). However, procedures are increasingly being performed in patients who are younger or older than this cohort, and advanced age is not a contraindication to THA. Differences in access to care and insurance coverage, as well as socioeconomic level, influence the demographic profile of patients who undergo the procedure. White Americans are more likely than African Americans to undergo THA (at 4.2 versus 1.7 per 1000 individuals), and individuals with higher incomes are 22% more likely to have the surgery than those with low incomes.

B. Indications and Contraindications

Indications for THA are listed in Table 33–1. The main goals of THA are to improve pain and restore function. Candidates for THA should have moderate to severe pain or disability and radiographic evidence of joint damage, which has not been relieved by conservative treatment. This includes a trial of nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, weight loss, activity modification, walking aids, and disease-specific treatments where appropriate. Absolute and relative contraindications to THA are listed in Table 33–2.

Table 33–1Indications for total hip arthroplasty.
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Table 33–1 Indications for total hip arthroplasty.

  • Hip pain that requires medication stronger than aspirin, is worse with activity; night pain

  • Severe osteoarthritis

  • Severe inflammatory arthritis

  • Traumatic arthritis

  • Hip fractures, in particular, Garden stages III and IV

  • Avascular necrosis

  • Benign and malignant bone tumors

  • Arthritis associated with Paget’s disease

  • Juvenile rheumatoid arthritis

  • Ankylosing spondylitis

  • Functional limitations, eg, inability to walk more than several blocks without stopping, difficulty with stair climbing, difficulty performing lower extremity activities of daily living
Table 33–2Contraindications to total hip arthroplasty.
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Table 33–2 Contraindications to total hip arthroplasty.
Absolute Contraindications Relative Contraindications

  • Active local or systemic infection (most common absolute contraindication)

  • Skeletal immaturity

  • Inadequate bone to support the prosthesis (eg, severe osteoporosis or osteopenia)

  • Inability to follow preoperative and postoperative instructions (eg, dementia)

  • Significant medical comorbidities for which risk of surgery may outweigh benefits

  • Psychiatric disease

  • Previous history of local infection

  • Poor vascular supply

  • Neuropathic arthritis

  • Obesity (carries a higher risk for mechanical failure)

Clinical Findings

A. Symptoms and Signs

The patient ...

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