Hip Replacement Surgery: Candidacy, Absolute, and Relative Contraindications

Who is not a good candidate for hip replacement surgery?

Hip replacement surgery, or total hip arthroplasty (THA), is a highly effective procedure for alleviating severe hip pain and restoring function, primarily due to osteoarthritis. However, it is not suitable for everyone, as certain medical conditions, lifestyle factors, and anatomical considerations can significantly increase surgical risks or compromise long-term outcomes.

Understanding Hip Replacement Candidacy

Total Hip Arthroplasty (THA) involves replacing damaged bone and cartilage with prosthetic components. While remarkably successful for many, the decision to undergo such a major surgical intervention is complex and involves a thorough risk-benefit analysis. A multidisciplinary team, typically including orthopedic surgeons, anesthesiologists, and primary care physicians, evaluates potential candidates against a range of criteria to ensure the safest and most effective outcome. Understanding who might not be a good candidate is crucial for both patients and healthcare professionals.

Absolute Contraindications: When Surgery is Generally Not an Option

These conditions typically preclude hip replacement surgery due to excessively high risks or guaranteed poor outcomes.

• Active Infection:
  • Local Infection: An active infection within the hip joint (e.g., septic arthritis) or surrounding tissues. Performing surgery in an infected field dramatically increases the risk of prosthetic joint infection, which is a devastating complication often requiring multiple surgeries for eradication.
  • Systemic Infection: An active infection elsewhere in the body (e.g., pneumonia, urinary tract infection, dental abscess) can seed the new joint, leading to periprosthetic joint infection. Surgery is typically deferred until all infections are cleared.
• Severe Uncontrolled Medical Conditions:
  • Unstable Cardiovascular Disease: Conditions like recent myocardial infarction (heart attack), unstable angina, severe congestive heart failure, or uncontrolled arrhythmias significantly elevate the risk of perioperative cardiac events.
  • Severe Pulmonary Disease: Advanced chronic obstructive pulmonary disease (COPD) or other severe lung conditions can compromise respiratory function during and after anesthesia, increasing the risk of respiratory failure.
  • Uncontrolled Diabetes Mellitus: Poorly controlled blood glucose levels (high HbA1c) are associated with higher rates of surgical site infection, wound healing complications, and other systemic issues.
  • Severe Renal or Hepatic Failure: Compromised organ function can impair the body's ability to metabolize anesthesia, manage fluids, and heal, leading to significantly increased morbidity and mortality.
• Severe Neuromuscular Disorders:
  • Conditions like uncontrolled spasticity (e.g., severe cerebral palsy, advanced multiple sclerosis) or severe Parkinson's disease can lead to post-operative dislocation of the prosthetic joint due to uncontrolled muscle spasms. They can also significantly impede participation in necessary post-operative rehabilitation.
  • Neuropathic Arthropathy (Charcot Joint): This condition, often seen in advanced diabetes, leads to severe joint destruction and bone instability, making it extremely difficult to achieve stable fixation of prosthetic components.
• Insufficient Bone Stock or Quality:
  • Severe Osteoporosis: While not always an absolute contraindication, extremely brittle or poor-quality bone may not adequately support the prosthetic implants, increasing the risk of periprosthetic fractures and implant loosening.
  • Prior Extensive Bone Loss: In cases of severe trauma, tumor resection, or multiple failed previous surgeries, there may be insufficient healthy bone to securely anchor the new prosthetic components.
• Skeletal Immaturity:
  • Hip replacement is generally not performed in children or adolescents whose growth plates are still open, as it can interfere with bone growth and development.

Relative Contraindications: Factors Requiring Careful Consideration

These factors do not necessarily rule out surgery but significantly increase risks or may compromise outcomes, requiring careful discussion and often pre-operative optimization.

• Significant Obesity (BMI > 40-50):
  • Excessive body weight increases surgical complexity, operative time, and the risk of wound complications, infection, deep vein thrombosis (DVT), pulmonary embolism (PE), and prosthetic joint dislocation. It also places greater stress on the implant, potentially leading to earlier wear and failure. Surgeons often recommend weight loss prior to surgery.
• Active Smoking and Substance Abuse:
  • Smoking: Nicotine impairs blood flow, compromises wound healing, increases infection rates, and elevates the risk of respiratory complications and DVT. Patients are strongly advised to cease smoking several weeks or months before surgery.
  • Substance Abuse: Active alcohol or illicit drug abuse can lead to non-compliance with post-operative instructions, impaired pain management, and higher complication rates.
• Uncontrolled Chronic Diseases (e.g., Diabetes, Hypertension):
  • While not as severe as the "unstable" conditions listed above, poorly controlled chronic conditions, even if not immediately life-threatening, can increase surgical and post-operative risks. Optimization of these conditions is essential prior to surgery.
• Poor Skin Integrity Around the Surgical Site:
  • Conditions like severe psoriasis, eczema, or chronic skin ulcers near the hip can increase the risk of surgical site infection.
• Unrealistic Patient Expectations or Poor Compliance:
  • Patients who expect to return to high-impact sports immediately, or who are unwilling/unable to commit to the rigorous post-operative rehabilitation program, may be poor candidates. The success of THA heavily relies on patient adherence to physical therapy and activity restrictions.
• Advanced Age and Frailty:
  • While chronological age alone is not a contraindication (many healthy octogenarians and nonagenarians undergo successful THA), advanced age often correlates with increased frailty, multiple co-morbidities, and reduced physiological reserve. A comprehensive geriatric assessment is often performed to evaluate overall fitness for surgery rather than just age.
• Untreated Dental or Other Distant Infections:
  • Any potential source of infection in the body, even if seemingly minor (e.g., a tooth abscess, chronic sinusitis), must be treated before elective hip replacement to minimize the risk of bacterial seeding to the new joint.

The Critical Role of a Comprehensive Pre-Operative Evaluation

For every potential candidate, a thorough pre-operative assessment is paramount. This evaluation typically includes:

• Detailed Medical History: Review of all past and current medical conditions, medications, allergies, and previous surgeries.
• Physical Examination: Assessment of overall health, cardiovascular and pulmonary status, and specific hip joint evaluation.
• Diagnostic Imaging: X-rays are standard, and sometimes MRI or CT scans are used to assess bone quality, joint damage, and planning.
• Laboratory Tests: Blood tests (e.g., complete blood count, electrolytes, kidney and liver function, coagulation studies, HbA1c) and urine tests to screen for underlying conditions or infections.
• Consultations: Referrals to cardiologists, pulmonologists, endocrinologists, or other specialists may be necessary to optimize chronic conditions before surgery.
• Psychological Assessment: To evaluate the patient's understanding of the procedure, expectations, and ability to cope with recovery.

Conclusion: Shared Decision-Making

The decision for hip replacement surgery is a shared one between the patient, their family, and the medical team. While severe conditions can absolutely contraindicate the procedure, many relative contraindications can be managed or optimized pre-operatively to improve safety and outcomes. Patients who are not good candidates for THA may explore alternative pain management strategies, including physical therapy, medication, injections, or less invasive surgical options.

Important Disclaimer

The information provided in this article is for general educational purposes only and does not constitute medical advice. It is essential to consult with a qualified healthcare professional, such as an orthopedic surgeon, to discuss your specific medical condition and determine if hip replacement surgery is appropriate for you.