Hip Replacement Surgery: Contraindications, Risk Factors, and Candidacy

Who Cannot Have Hip Replacement Surgery?

While hip replacement surgery offers life-changing relief for many, certain medical conditions, lifestyle factors, and physiological states can render an individual unsuitable for the procedure due to unacceptably high risks or predicted poor outcomes.

Hip replacement surgery, or arthroplasty, is a highly effective orthopedic procedure designed to alleviate chronic hip pain and restore mobility, most commonly due to severe osteoarthritis. It involves replacing damaged bone and cartilage with prosthetic components. However, not everyone is a suitable candidate. The decision to proceed with surgery is a complex one, involving a thorough evaluation of a patient's overall health, specific medical conditions, and lifestyle, weighing the potential benefits against significant risks.

Absolute Contraindications: When Surgery is Almost Never an Option

These are conditions that typically make hip replacement surgery too dangerous or unlikely to succeed, posing immediate and severe risks to the patient.

• Active Infection (Local or Systemic):
  • Active Septic Arthritis or Osteomyelitis: Any ongoing infection in or around the hip joint is a primary contraindication. Introducing a prosthetic implant into an infected environment almost guarantees a severe and difficult-to-treat prosthetic joint infection (PJI), which can lead to implant failure, further surgery, limb loss, or even death.
  • Active Systemic Infection (Sepsis): A widespread infection in the body significantly increases the risk of surgical complications, including the spread of infection to the new joint.
• Severe, Uncontrolled Medical Comorbidities:
  • Unstable Cardiovascular Disease: Conditions such as recent myocardial infarction (heart attack), unstable angina, severe uncontrolled heart failure, or severe valvular heart disease significantly increase the risk of perioperative cardiac events.
  • Severe Uncontrolled Pulmonary Disease: Conditions like severe COPD or pulmonary hypertension can lead to respiratory failure during or after surgery.
  • Severe Uncontrolled Diabetes: Uncontrolled blood sugar levels dramatically increase the risk of infection, poor wound healing, and other complications.
  • Severe Renal or Hepatic Failure: These conditions impair the body's ability to metabolize medications, clot blood, and heal, leading to high surgical risk.
• Neuropathic Arthropathy (Charcot Joint): This condition, often seen in advanced diabetes, involves rapid and progressive joint destruction due to nerve damage. The bone quality is often too poor to support an implant, leading to high failure rates.
• Insufficient Bone Stock or Quality: In rare cases of severe osteoporosis or extensive bone loss due to tumors or previous trauma, the bone may be too fragile or insufficient to securely anchor the prosthetic components, making the surgery technically impossible or highly prone to early failure.
• Skeletal Immaturity: For adolescents, hip replacement is generally avoided until skeletal maturity is reached, as growth plates are still open. Other, less invasive options are typically explored first.

Relative Contraindications and Significant Risk Factors

These conditions do not necessarily preclude surgery but significantly increase the risk of complications or reduce the likelihood of a successful outcome. They require careful consideration, optimization, and often a multidisciplinary approach.

• Morbid Obesity (BMI > 40-45): While not an absolute contraindication, extreme obesity is a major risk factor. It increases:
  • Surgical Complexity: Longer operative time, increased blood loss, technical challenges.
  • Anesthesia Risks: Higher incidence of respiratory and cardiovascular complications.
  • Postoperative Complications: Increased rates of infection (especially wound infection), deep vein thrombosis (DVT), pulmonary embolism (PE), dislocation, and earlier implant loosening due to increased stress on the prosthesis. Many surgeons require significant weight loss prior to surgery.
• Active Smoking: Nicotine impairs blood flow and wound healing, significantly increasing the risk of infection, delayed bone healing, and overall complications. Patients are typically advised to cease smoking for several weeks or months before surgery.
• Poorly Controlled Chronic Diseases: While severe, uncontrolled disease is an absolute contraindication, even moderately controlled conditions like diabetes, hypertension, or cardiovascular disease can increase risk. Thorough pre-operative optimization is crucial.
• Significant Peripheral Vascular Disease: Impaired blood supply to the limb can compromise wound healing and increase infection risk.
• Severe Psychiatric Conditions or Cognitive Impairment: Unmanaged severe mental illness or significant cognitive deficits can impair a patient's ability to understand the surgical risks, adhere to pre-operative instructions, or comply with the rigorous post-operative rehabilitation protocol, which is critical for a successful outcome.
• Lack of Patient Motivation or Compliance: Successful hip replacement relies heavily on the patient's active participation in rehabilitation. A lack of motivation or willingness to comply with post-operative instructions can lead to poor functional outcomes, stiffness, or even complications like dislocation.
• History of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE): While not a contraindication, a history of blood clots significantly increases the risk of recurrence during and after surgery, requiring aggressive prophylactic measures.
• Skin Conditions or Lesions Near the Surgical Site: Active dermatological conditions (e.g., severe psoriasis, eczema) or open wounds near the hip can increase the risk of surgical site infection. These often need to be treated and cleared before surgery.

Age and Activity Level: Nuances in Candidacy

Historically, age was a more significant factor, with younger patients often discouraged due to concerns about implant longevity and the likelihood of revision surgery. However, advancements in implant materials and surgical techniques have made age less of an absolute barrier.

• Extremely Young Patients: While rare, hip replacement in very young individuals (e.g., for juvenile idiopathic arthritis) means a higher probability of needing one or more revision surgeries over their lifetime due to the normal wear and tear on the implant. The decision is made carefully, weighing quality of life against future surgical burden.
• Elderly Patients: Advanced age alone is not a contraindication. What matters more is the patient's physiological age, overall health status, and ability to withstand surgery and participate in rehabilitation. Many patients in their 80s and 90s successfully undergo hip replacement.

The Multidisciplinary Decision-Making Process

The ultimate decision regarding hip replacement candidacy is a shared one, involving the patient, orthopedic surgeon, anesthesiologist, primary care physician, and often other specialists (e.g., cardiologist, endocrinologist). A comprehensive pre-operative evaluation, including medical history, physical examination, imaging, and blood tests, is essential to identify and manage potential risks. In many cases, addressing and optimizing modifiable risk factors (e.g., weight loss, smoking cessation, diabetes control) can transform a "non-candidate" into a suitable one, significantly improving the chances of a successful and safe outcome.