MINI-SYMPOSIUM: PRIMARY HIP REPLACEMENT

(ii) Complications of total hip closed under sedation and image intensification. The position in
which it becomes unstable should be documented.

arthroplasty The further management of early dislocations includes

abduction hip spica bracing for patients who had an anterolateral
approach to the hip and hip bracing or a knee extension splint
James L Nutt
to reduce the hip flexion in patients with a posterior approach to
Kleomenis Papanikolaou the hip.
Catherine F Kellett Patient re-education and precautions with hip activity are
often necessary for a short period of time to prevent the dislo-
cation from becoming recurrent. Eighty four percent of the dis-
locations remain single.2
Abstract The factors contributing to dislocation are the orientation of the
Total hip replacement is a common procedure, but it is still classified as components as well as the combined orientation, the femoral head
major surgery. Despite advances in technology and patient safety, compli- size, discrepancy in leg lengths, abductor deficiency and acetabular
cations do exist. However, approximately 90% of hip arthroplasties per- impingement of the femoral neck on periacetabular osteophytes.
formed will be uncomplicated. Previously, it was thought that there was a higher dislocation rate
This paper aims to present the complications of total hip arthroplasty with the posterior approach, but recent literature suggests that there
and the principles of their management. Complications such as disloca- is no statistical difference in the dislocation rate between the ante-
tion, intraoperative fracture, infection, venous thromboembolism, rolateral and the posterior approach.1 Furthermore, in a random-
bleeding, neurovascular injury, leg length discrepancy along with the ized prospective study by Peak et al, post-op restrictions of patient’s
long-term complications of wear and loosening are discussed and their activities did not have any impact in reducing early dislocation.3
management outlined. Late dislocations can occur as a result of polyethylene wear,
low grade infection, aseptic loosening with migration of one of
Keywords arthroplasty; complication; hip; management; replacement the components, trauma or a new neurological condition. Late
dislocations usually require revision surgery.
The surgical treatment when necessary aims to address the
initial cause. The revision of one or both components is often
Dislocation necessary. There are cases where soft tissue reconstruction is
indicated. The use of constraint liners is becoming more frequent
Dislocation of the hip replacement is a complication which may
with good results in preventing further dislocation.
require prolonged rehabilitation and if it becomes recurrent then
it affects the patient’s quality of life and satisfaction with the
procedure. It may require revision surgery. The incidence of
dislocation ranges from 0 to 4.1% of patients undergoing total Infection
hip replacement.1
Infection is a complication which significantly increases the pa-
It can be classified as early or late depending on the time of
tient’s morbidity and reduces the function of the replaced hip. The
the incident and as single or recurrent.
long-term eradication of an infection is often difficult and despite
Early dislocation as a term was used to describe the incident
the initial high success rate with appropriate protocols and treat-
which occurred in the first year following the procedure, but
ments, the recurrence of the infection at any given time cannot be
specific time patterns have been noted and it seems that the
excluded. Therefore the prevention of infection is paramount.
majority of early dislocations occur in the first six weeks. This is
The introduction of clean air systems, the constant improve-
now widely considered the timeframe that defines whether a
ment of the surgical techniques and instruments and the conse-
dislocation can be considered early or late.
quent reduction of the mean operating time as well as the
The incidence of early dislocation varies in the literature.
optimization of the sterilization units, reduced the infection rates
Forty to seventy percent of the total number of dislocations are
of total hip replacement in the late 1970’s to about 2.5e3.1%.
categorized as early. Eighty five percent of them are reduced
The introduction of prophylactic antibiotics further reduced the
infection rates to 1e2% when laminar flow theatres were used as
well. The introduction of meticulous screening at pre-assessment
James L Nutt BSc (Hons) MBChB Core Surgical Trainee, The Royal Surrey clinics helped to identify patients who were at higher risk of
County Hospital NHS Foundation Trust, Kent, UK. infection either by recognizing the carriers of pathogenic bacteria
like MRSA or by identifying patients prone to infection due to any
Kleomenis Papanikolaou MD Clinical Fellow in Orthopaedics, Depart- other co-morbidity. The pre-assessment allows better preopera-
ment of Orthopaedic Surgery, Golden Jubilee National Hospital, Glas- tive planning and the optimization of a patient’s health status
gow, UK. prior to an elective procedure like total hip arthroplasty. Despite
the above measures, the occasional infection is inevitable and the
Catherine F Kellett BSc (Hons) BM BCh FRCS (T&O) Consultant Orthopaedic cause remains multifactorial.
Surgeon, Golden Jubilee National Hospital, Honorary Clinical Associate Periprosthetic infections can occur as a result of surgical
Professor, University of Glasgow, Department of Orthopaedic Surgery, contamination, haematogenous spread, and direct infection from
Glasgow, UK. inoculation or contiguous spread.

ORTHOPAEDICS AND TRAUMA 27:5 272 Ó 2013 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: PRIMARY HIP REPLACEMENT

Clinically an infection may present with pain, fever, malaise material is left in the wound and if necessary, this can become
and discharge from the wound resulting in the development of a the long-term solution for the patient.
sinus. Prolonged postoperative wound discharge could be an The other treatment strategy for the management of the infec-
indication of infection. The WBC, CRP and ESR should be tion is a one-stage revision with removal of the components and
monitored. The patient should be investigated for any other cement if used, meticulous debridement of the wound, thorough
source of infection with a full septic screen. An aspiration from irrigation and the immediate re-implantation. This offers suc-
the hip joint under sterile conditions may be helpful. In acute cessful results in 83% of the patients in contrast to the up to 99%
infections there are no radiological findings on the plain films. success of two-stage revision surgery. The adjuvant antibiotic
Technetium-99 scan has high sensitivity but low specificity. therapy should be a multidisciplinary decision involving the in-
Studies that used sequential scanning with indium-111 and fectious diseases and microbiology teams.
complementary scanning with technetium-99 seem to have very A definite surgical option with excellent results for eradicating
high sensitivity, specificity and accuracy.4 infection is a resection (Girdlestone) arthroplasty. Its main dis-
The timing of the infection is best classified using the modified advantages are that the patient may need ambulatory aids, will
Coventry Classification on which treatment plans have been have a Trendelenburg gait and will have a leg length discrepancy.
based and reviewed. Type 1 infection is described when positive It may be the best option for patients who are not suitable for re-
intraoperative cultures have been collected during the procedure. implantation while it also allows the re-implantation at a much
Type 2 is described as early postoperative infection, which oc- later stage if the patient’s comorbidities are resolved.
curs within the first month of surgery and justifies debridement Occasionally, the orthopaedic surgeon and team must adapt
with salvage of the prosthesis. Type 3 describes the acute hae- the treatment strategy to the needs of each patient. The preser-
matogenous infection of a previously well-functioning arthro- vation of function may be the primary goal of the patient with an
plasty where debridement is necessary with either salvage or infected hip arthroplasty and suppressive antibiotic therapy
removal of the prosthesis. Type 4 is the late chronic infection might be considered. The criteria may include patients with high
which necessitates the removal of the prosthesis. comorbidities in whom surgical treatment might be contra-
indicated, low pathogenicity of the responsible microorganism,
Treatment of early infection sensitivity to an oral antibiotic with good tolerance and low
In type 2 infections debridement and salvage of the prosthesis toxicity and finally a stable prosthesis.
with the systemic administration of antibiotics is usually under-
taken. This strategy is commonly known as DAIR (Debridement, Intraoperative fractures
Antibiotics and Implant Retention) and in the literature the suc-
cess rates for long-term eradication of the infection range from Intraoperative fractures during primary total hip arthroplasty can
14% to 100%. be divided into those involving the acetabulum and those
Byren et al reported a series of 120 patients who had an early involving the femur.
infection.5 Initially five samples were obtained for bacteriology
including fluid and tissue using a clean blade and forceps for Acetabular fractures
each sample. Then the wound was thoroughly debrided and These are rare but also under-diagnosed. If discovered, it is often
irrigated with aqueous chlorhexidine using pulsed lavage. on postoperative check X-rays. Cementless implants carry a
Modular components were exchanged and the fixed ones higher risk of acetabular fracture than cemented cups, especially
remained in place if they were still well fixed and biomechani- when the acetabulum is under-reamed.
cally sound. Treatment of acetabular fractures is dependent on when they
A small number of patients received arthroscopic debridement are diagnosed. Once discovered it is important to consider
and irrigation. whether the cup has enough stability and if biological ingrowth
All patients received oral antibiotics for a mean period of 1.5 can occur. Ultimately the fracture must be stable if the patient is
years and at a mean follow up of 2.3 years the failure rate was to avoid revision. If the fracture is discovered intra-operatively
18%. These results are impressive considering that 69% of these then supplemental fixation should be considered. Haidukewych
patients presented up to 90 days post-surgery and the remaining et al reviewed 5359 uncemented acetabular components and
31% presented over 90 days after their original surgery. The identified 21 fractures (0.4%).6 These can be classified either by
authors describe a fourfold increase in treatment failure rates the Vancouver Intraoperative Classification of fractures or by the
when antibiotics were stopped, but this evidence may to be classification system proposed by Della Valle et al.7 The man-
important for patients with a short life expectancy. agement of these fractures can be in the form of additional screw
fixation, placing of a pelvic plate or using a reconstruction cage.
Two-stage versus one-stage revision surgery It is important that postoperative management be adjusted
This is controversial. Patients with severe and established appropriately; this might include a modified mobilization
infection may benefit most from aggressive surgery. This in- regimen and weight bearing precautions.
volves a two-stage procedure, leaving the patient in the interim
with either an antibiotic-loaded spacer prosthesis or a Girdle- Femoral fractures
stone arthroplasty. The use of a spacer prosthesis has the The risk factors for femoral fracture during arthroplasty are
advantage of delivering antibiotics, maintaining some hip func- obesity, female, osteopenia, uncemented stems, over-vigorous
tion and keeping the tension of the muscular envelope. The preparation of the femur and applying excessive force or tor-
advantage of the Girdlestone procedure is that no foreign que to the femur during the surgery.

ORTHOPAEDICS AND TRAUMA 27:5 273 Ó 2013 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: PRIMARY HIP REPLACEMENT

Treatment is dependent on when the fracture is detected. The Bleeding within the operative site after closure of the wound
femoral fractures identified intra-operatively are classified by the should be expected even with excellent surgical technique.
Vancouver Intraoperative Classification of fractures as modified However, the formation of a large haematoma can be painful for
by Masri et al.8,9 Methods of repair include cerclage wiring or the the patient and can dramatically increase the risk of wound
use of a longer femoral stem if the implant is unstable and even complications and postoperative infection. Currently drains are
augmentation with cortical strut grafting. rarely used in primary hip arthroplasty. It should be considered
Postoperative recognition of a femoral fracture can increase that using a drain to reduce a potential haematoma, creates
the risk of fracture/implant displacement and secondary revision an entry point for micro-organisms and increases the risk of
surgery. Careful observation with weight bearing restrictions infection.12
postoperatively, must be communicated to the ward team. There is continued debate about managing extensive bleeding
arising during or after surgery. Goodnough (1999) described a
Thromboembolic disease wide variation in use of blood components, including FFP.13
Local blood transfusion protocols should be followed. Pharma-
Venous thromboembolism (VTE) is the formation of blood clots
cological agents such as tranexamic acid and fibrin spray, can be
in the veins of the limbs, which may also dislodge to form a
used either prophylactically or to curtail established bleeding.14
pulmonary embolus (PE). This can occur in patients who have
Erythrocyte salvaging and auto-transfusion give very good
had no surgery or operative procedure. However, total hip
results for restoring the blood volume and limiting the overall
arthroplasty is a high risk procedure for the development of VTE.
blood loss. These should be considered especially for complex
Blood clots are mainly the result of prolonged blood stasis in the
procedures where excessive bleeding is anticipated or for pa-
venous system as often occurs in bedbound patients. Subse-
tients whose religious beliefs do not permit the use of blood
quently, early mobilization of patients with the use of enhanced
products.
recovery protocols seems to give excellent results in the preven-
tion of VTE and should be encouraged. Mechanical measures such
Vascular injury
as the use of foot pumps and compression stockings (TEDS) should
also be used. Aspirin, low molecular weight heparin or factor Xa Vascular complications are reported at a rate of 0.2e0.3% with
inhibitors can be used and decrease the risk of VTE. However these the external iliac artery and the common femoral artery most
may increase perioperative bleeding. commonly injured. These can occur either by sharp instruments
The mainstay of management is prevention, however despite such as a scalpel or osteotome or indirectly by blunt instruments
best practice, thromboembolic disease can still occur. A 2012 such as retractors, which may stretch, tear or compress a vessel.
systematic review found that despite using current VTE pro- Manipulation of the limb or even postoperative dislocation can
phylaxis, approximately 1 in 200 patients undergoing primary also cause blood vessel damage. Intra-pelvic vascular injury can
hip arthroplasty develops symptomatic VTE prior to hospital also occur during the fixation of an uncemented acetabular cup
discharge.10 with screws. Wasielewski has proposed a system of quadrants
In patients who have significant leg swelling postoperatively, within the acetabulum that describes the safe quadrants for
VTE should be considered. The use of a D-Dimer assay is an screw placement and the inferior “danger” zone and ante-
unnecessary test as it will be elevated following surgery.11 Local romedial “death” zone in which screw placement should be
guidelines may differ but the use of a scoring system may be of avoided.15
assistance in deciding on investigation and treatment. Vascular injury should be controlled with immediate pressure
The use of Doppler ultrasound is useful in evaluation of the and ablation or ligation of the bleeding vessel. If serious vascular
veins of the legs and can confirm a diagnosis. injury has occurred or the surgeon is unable to control the
A CT pulmonary angiogram is the gold standard for investi- bleeding vessel, then assistance should be sought from a vascular
gation of PE. Confirmation of the diagnosis of either a VTE or PE, surgeon or interventional radiologist.
should result in treatment with anticoagulant medication ac-
cording to hospital guidelines, which is likely to start with low Nerve injury/palsy
molecular weight heparin and to be continued with oral antico-
The hip joint is surrounded by several nerves which can poten-
agulants such as warfarin or rivaroxaban, for a period of three to
tially be injured during the procedure. The incidence of nerve
six months.
palsy following primary total hip replacement is described by
Schmalzried to be 1.7% when he reviewed 3126 consecutive
Bleeding
cases. He also describes the incidence rising to 3.2% when it is a
Bleeding is a common risk during and immediately following revision procedure and further rising to 5.2% when the THR is
orthopaedic surgery. performed for developmental dysplasia of the hip.16
Patient selection and risk stratification is important in pre- The nerves which can be affected are the sciatic nerve, the
operative planning. Patients with pre-existing medical conditions femoral nerve, the superior gluteal nerve and the obturator
affecting their ability to clot must be identified; equally patients nerve. The mechanisms involved are described by Lewallen to be
who are taking anticoagulant medications must have their op- compression, traction or ischaemia of the nerve. A delayed nerve
tions considered prior to the surgery. injury may become apparent during the patient’s recovery and
Intraoperative bleeding is the responsibility of the surgeon. this should lead to suspicion of direct compression from a hae-
However it may be the anaesthetist who will act on information matoma. If a haematoma is thought to be the cause, an MRI scan
received. of the lumbar spine and the hip should be requested urgently.

ORTHOPAEDICS AND TRAUMA 27:5 274 Ó 2013 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: PRIMARY HIP REPLACEMENT

The sciatic nerve is most commonly affected in cases with leg Large studies describe some degree of heterotopic ossification
lengthening. The femoral nerve is at risk from anterior retractors in 20e80% of the patients but fortunately only 5e10% experi-
when placed anteriorly to the acetabulum and the nerve itself or ence severe stiffness or pain.
its branches to sartorius and rectus femoris can be damaged from The pathogenesis remains unclear. Factors such as bone
inferior retractors used near or under the iliopsoas tendon during particles, muscle damage, haematoma formation, disruption of
an anterolateral approach. The superior gluteal nerve is endan- the periosteum and the subsequent release of BMPs seem to be
gered by the vertical muscle component of a Hardinge approach relevant.
when gluteus medius is split more than 4 cm. Interestingly, Heterotopic ossification is widely described using the classifi-
Kenny et al have demonstrated that 48% of the patients under- cation system of Brooker et al, which is based on the two-
going total hip replacement had chronic damage to the superior dimensional appearance of the ectopic bone in the anteroposterior
gluteal nerve, preoperatively.17 Finally the obturator nerve is at X-ray. Class I describes islands of bone in the soft tissues, class II is
risk in cases with penetration of the medial wall of the acetab- characterized by bony spurs from the pelvis or proximal femur
ulum. From a technical point of view, both the posterior which leave a gap over 1 cm in between the bony opposing surfaces.
approach to the hip and the anterolateral approach to the hip, Class III is characterized by bony spurs which allow a gap less than 1
seem to have comparable results of nerve injury.18 cm and finally class IV is the apparent ankylosing of the hip.
The prognosis depends on the aetiology and the recovery in a Heterotopic ossification can be prevented with either non-
period of 21 months can vary from complete (13%), partial with steroidal anti-inflammatory drugs (indomethacin, ibuprofen,
residual symptoms (62%) or partial with residual deficiencies diclofenac) or diphosphonate therapy or low dose (700e800 cGy)
(24%).16 external beam radiation as a single dose.
A multidisciplinary approach should be used for each patient The treatment of symptomatic Brooker III and IV patients is
on a case by case basis. Involvement of other specialities may be based on the surgical resection of the ectopic bone with adjuvant
crucial in obtaining an improved outcome for the patient. Nerve single dose irradiation and gives good results. It is potentially
conduction studies may be helpful in identifying the level of the difficult and requires careful planning with CT scans to identify
nerve lesion. Devices such as ankle-foot orthosis can significantly the exact location and pattern of the ectopic bone.
aid mobility in a patient with drop foot.
Wear
Leg length discrepancy
Regardless of the material of the prosthesis, the bearing surfaces
Leg length discrepancy is a well recognized problem in total hip have to move repeatedly under constant conditions of friction
replacement. A discrepancy of 1e2 cm may be tolerated by the and inevitably are prone to wear.
patient, but a greater discrepancy usually causes problems. It The wear will result in joint instability as the worn surfaces
affects the patient’s gait and puts undesirable strain on the pelvis tend to sublux. This can be painful for the patient and the
and spine. It can be associated with sciatic nerve palsy. The frequent instability soon reduces his confidence around the joint
prevalence of limb length inequality of clinical importance replacement.
requiring correction with a shoe raise, is considered to be 5% To reduce the wear, numerous biomechanical studies have
following a total hip replacement. It is essential to consider the helped improve the composition of the components as well as the
presence of any fixed pelvic obliquity which may cause an biomechanical properties. It is known that a smaller femoral
apparent limb length discrepancy. head (less than 28 mm) is prone to less wear than larger ones,
Careful preoperative assessment and planning is therefore but unfortunately are also more unstable.
essential. Despite the constant improvement of the biomaterials, wear
Intra-operatively, leg length can be assessed either with the does occur and seems to be having specific characteristics
tension test, as described and performed by Charnley, or by using depending on the composition. Wear particles from polyethylene
direct skeletally fixed measuring systems. activate an immune response and this in turn can cause lysis of
Leg length discrepancy can be treated in the majority of the the bone and eventual loosening of the prosthesis.
patients using shoe lifts. If the discrepancy is extreme or symp- Metal on metal bearing surfaces do have better wear charac-
tomatic, revision surgery could be considered, especially if an teristics than metal on polyethylene but on the other hand metal
acute nerve injury is identified. In patients with developmental debris and ions can affect the surrounding tissue (pseudotu-
dysplasia of the hip, care should be taken not to over-lengthen mours and ALVAL) and metal ions may also be detected in the
the hip due to the risk of sciatic nerve damage. If necessary, a patient’s serum and urine.
subtrochanteric femoral osteotomy can be performed at the time Ceramic on ceramic bearings have lower friction and the best
of the initial arthroplasty surgery. wear properties and also cause inert particles. These bearings are
prone to stripe wear which is caused by contact between the femoral
Heterotopic ossification head and rim of the cup during partial subluxation and results in a
crescent shaped line on the femoral head. Ceramic bearings may
Heterotopic ossification is characterized by normal bone forma-
squeak and occasional fracture if subjected to high impacts.
tion at ectopic sites.
The formation of bone in the soft tissues around the hip
Loosening
following a total hip replacement can compromise the major
goals of the procedure as it may lead to reduced range of Loosening of the fixed components such as the cup or the
movement and occasionally unexpected postoperative pain. femoral stem is also inevitable. It is classified as aseptic or septic.

ORTHOPAEDICS AND TRAUMA 27:5 275 Ó 2013 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: PRIMARY HIP REPLACEMENT

Loosening causes start-up pain. Any loosening should be inves- 5 Byren, Bejon P, Atkins BL, et al. One hundred and twelve infected
tigated with blood tests, bone scanning and potentially hip arthroplasties treated with ‘DAIR’ (debridement, antibiotics and
aspiration to exclude sepsis. Aseptic loosening may require implant retention): antibiotic duration and outcome. J Antimicrob
revision surgery. Chemother 2009 June; 63: 1264e71.
The management of septic loosening is discussed earlier. 6 Haidukewych George J, Jacofsky David J, Hanssen Arlen D,
Lewallen David G. Intraoperative fractures of the acetabulum during
Perioperative mortality primary total hip arthroplasty. J Bone Joint Surg Am 2006; 88: 1952e6.
7 Della Valle CJ, Momberger NG, Paprosky WG. Periprosthetic fractures
Undoubtedly death is the most devastating complication of total
of the acetabulum associated with a total hip arthroplasty. Instr
hip replacement. The risk of sudden death during surgery for
Course Lect 2003; 5: 281e90.
elective arthroplasty is as low as 0.06%. Contributing factors are
8 Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation
considered to be the stress of a major operation, blood loss,
and treatment. Clin Orthop Relat Res 2004; 420: 80e95.
clotting disorders, anaesthesia, cardiovascular complications and
9 Gaski Greg E, Scully Sean P. In brief: classifications in brief: Van-
potentially contributing are the toxic effects of the cement and
couver classification of postoperative periprosthetic femur fractures.
embolism of air, fat and other content of the bone. The majority
Clin Orthop Relat Res 2011 May; 469: 1507e10.
of the incidents occur characteristically during the preparation
10 Januel JM, Chen G, Ruffieux C, et al. Symptomatic in-hospital deep
and pressurization of the bone. Death from cardiovascular and
vein thrombosis and pulmonary embolism following hip and knee
thromboembolic events typically occur in the first few weeks
arthroplasty among patients receiving recommended prophylaxis: a
after surgery.
systematic review. JAMA 2012 Jan 18; 307: 294e303.
11 Bounameaux H, Schneider PA, Slosman D, de Moerloose P, Reber G.
Conclusion Plasma D-dimer in suspected pulmonary embolism: a comparison
with pulmonary angiography and ventilationeperfusion scintigraphy.
Total hip replacement is a common procedure, but it is still
Blood Coagul Fibrinolysis 1990 Oct; 1: 577e9.
classified as major surgery. Several complications do exist, but
12 Parker MJ, Roberts CP, Hay DJ. Closed suction drainage for hip and
overall, approximately 90% of hip arthroplasties performed will
knee arthroplasty. A meta-analysis. Bone Joint Surg Am 2004 Jun;
be uncomplicated. A
86-A: 1146e52.
13 Goodnough LT. Transfusion medicine. N Engl J Med 1990; 340: 525e33.
14 McConnell JS, Shewale S, Munro NA, Shah K, Deakin AH,
REFERENCES Kinninmonth AW. Reduction of blood loss in primary hip arthroplasty
1 Ashley, Rogers Mark, Taylor Adrian H, Pattison Giles, with tranexamic acid or fibrin spray. Acta Orthop 2011 Dec; 82:
Whitehouse Sarah, Bannister Gordon C. Dislocation following total 660e3.
hip replacement: the Avon Orthopaedic Centre Experience. Ann R Coll 15 Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Acetabular
Surg Engl 2008 November; 90: 658e62. anatomy and the transacetabular fixation of screws in total hip
2 Joshi A, Lee CM, Markovic L, Vlatis G, Murphy JC. Prognosis of arthroplasty. J Bone Joint Surg Am 1990 Apr; 72: 501e8.
dislocation after total hip arthroplasty. J Arthroplasty 1998 Jan; 13: 16 Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy associated with
17e21. total hip replacement. Risk factors and prognosis. J Bone Joint Surg
3 Peak EL, Parvizi J, Ciminiello M, et al. The role of patient restrictions Am 1991; 73: 1074e80.
in reducing the prevalence of early dislocation following total hip 17 Kenny P, O’Brien CP, Synnott K, Walsh MG. Damage to the superior
arthroplasty. A randomized, prospective study. J Bone Joint Surg Am gluteal nerve after two different approaches to the hip. J Bone Joint
2005 Feb; 87: 247e53. Surg Br 1999 Nov; 81: 979e81.
4 Palestro CJ, Kim CK, Swyer AJ, et al. Total hip arthroplasty: peri- 18 Weale AE, Newman P, Ferguson IT, Bannister GC. Nerve injury after
prosthetic indium-111 labeled leucocyte activity and complementary posterior and direct lateral approaches for hip replacement. A clinical
technetium-99 sulfur colloid imaging in suspected infection. J Nucl and electrophysiological study. J Bone Joint Surg Br 1996 Nov; 78:
Med 1990; 31: 1959e65. 899e902.

ORTHOPAEDICS AND TRAUMA 27:5 276 Ó 2013 Elsevier Ltd. All rights reserved.