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Surgical Treatment Options

If you have not experienced adequate results with medication and other conservative treatments, surgery may provide the pain relief you long for, in addition to allowing you to return to the lifestyle and activities you enjoy. Your doctor can tell you whether you might benefit from joint replacement and explain the reasons why it may, or may not, be right for you.

If you and your doctor decide that surgery is an option to relieve your pain, your doctor will provide the specific-to-you details of which type of artificial joint he or she will use, what you need to know to prepare for the surgery, how the surgery will be performed, and what you can expect once you are up and moving again.

The orthopedic surgeon can evaluate your condition and tell you if hip replacement would be right for you. If your family physician, an internist, or a rheumatologist is currently treating your condition, you can ask them to refer you to an orthopedic surgeon for an evaluation.

If surgery is necessary to address your pain, your doctor may consider Total Hip Replacement or Hip Resurfacing.

Total Hip Replacement

Hip replacement surgery may be considered when arthritis limits your everyday activities such as walking and bending, when pain continues while resting, or stiffness in your hip limits your ability to move or lift your leg. Hip replacement may be recommended only after careful diagnosis of your joint problem. It is time to consider surgery if you have little pain relief from anti-inflammatory drugs or if other treatments, such as physical therapy, do not relieve hip pain.

Hip replacement surgery involves replacing the femur (head of the thighbone) and the acetabulum (hip socket). Typically, the artificial ball with its stem is made of a strong metal or ceramic, and the artificial socket is made of polyethylene (a durable, wear-resistant plastic) or metal backed with a plastic liner. The artificial joint may be cemented in position or held securely in the bone without cement. The ball and insert are designed to glide together to replicate the hip joint.

Success Rates

For the vast majority of patients, joint replacement can be successful in providing relief from pain and improved mobility for many years. According to the American Academy of Orthopaedic Surgeons, hip replacement procedures have been found to result in significant restoration of function and reduction of pain in over 90% of patients.1

Benefits of Hip Replacement

Hip Replacement surgery helps more than 200,000 Americans each year to relieve their hip pain,2 and get back to enjoying normal, everyday activities.

Over the past 25 years, minimally invasive surgery has revolutionized many fields of medicine. Its key characteristic is the use of specialized techniques and instrumentation that enable the physician to perform major surgery without a large incision. In this respect, MIS Hip Joint Replacement is indeed “minimally invasive,” requiring smaller incisions and potentially causing less trauma to the soft tissues than traditional techniques.

Benefits of Minimally Invasive Surgery

An MIS hip replacement procedure replaces the joint with a prosthesis, but requires an incision that is only 3 to 4 inches long. The procedure does not disturb as many muscles and tendons in the hip area as the classic total hip procedure.1 This allows for a potentially more natural reconstruction after the prosthesis is in place and the potential for a quicker return to normal function and activity.1,2 The smaller incision and reduced muscle disruption indicate that patients may have a shorter recovery time and less scarring.1 With MIS hip replacement, there may be less blood loss, less time in surgery and possibly a shorter hospital stay.3,4

Direct Anterior Approach (DAA)

The direct anterior approach is one of the minimally invasive techniques used in hip replacement surgery. Continuing orthopedic experience suggests that this procedure may offer several advantages over the more traditional surgical approaches to hip replacement.5

Traditional hip replacement techniques involve operating from the side (lateral) or the back (posterior) of the hip, which requires a significant disturbance of the joint and connecting tissues and an incision approximately 8-12 inches long. In comparison, the direct anterior approach requires an incision that is only 3-4 inches in length and located at the front of the hip.5 In this position, the surgeon does not need to detach any of the muscles or tendons.5

Benefits of the Direct Anterior Approach

  • Decreased hospital stay and quicker rehabilitation6
  • Average length of stay for the Coon Joint Replacement Institute for hip replacements is 1.5 days
  • Smaller incision and reduced muscle disruption may allow patients a shorter recovery time and less scarring5
  • Potential for less blood loss, less time in surgery, and reduced post-operative pain 5,7,8
  • Average infusion rate for the Coon Joint Replacement Institute is less than 3%
  • Risk of dislocation may be reduced6
  • No postoperative hip precautions
  • Ability to Use Intraoperative X-ray for Enhanced Accuracy (Fluoroscope)
  • During a posterior approach, patients are positioned on their side. As a result, x-ray imaging during surgery is difficult, sometimes impossible. A direct anterior approach is performed in the supine position (facing up lying on your back), often with a special tilt that allows for excellent imaging capabilities during the surgical procedure to enhance the positioning of all components.

Traditional vs. Direct Anterior Approach

Traditional Hip Replacement

  • Generally requires hip precautions postoperatively
  • 8-12 inch incision
  • Surgical approach - Posterior
  • Disturbance of the joint and connecting tissues

Direct Anterior Approach

  • Does not require hip precautions postoperatively
  • 3-4 inch incision
  • Surgical approach - front (anterior)5
  • Muscles or tendons not detached5

Typical Precautions: Traditional Posterior vs. Direct Anterior Approach

Traditional Hip Replacement

During a traditional posterior approach to the hip, the posterior soft tissue structures are detached to gain access to the joint. There are more posteriorly directed forces across the hip joint with normal activities (e.g. getting out of a chair). As a result, there is an increased potential for instability and dislocation of a posteriorly replaced hip. To avoid this complication, most patients are instructed to avoid the following after a posterior approach:

  • Do not cross legs9
  • Do not bend hip more than a right angle9
  • Do not turn feet excessively inward or outward9
  • Use a pillow between your legs when sleeping9

Direct Anterior Approach

With a direct anterior approach, the posterior structures are not detached, allowing for potentially greater stability posteriorly. As a result, our patients are instructed in the following precautions:

  • None - We do not restrict any position post postoperatively
  • The joint is immediately able to bear your full weight

Hip Resurfacing

With hip resurfacing, the end of the thigh bone (femur) is capped with a metal covering–a strong cobalt chromium metal–much like the capping of a tooth. This fits neatly into a metal cup that sits in the hip socket. The head swivels within the cup, gliding together to replicate the hip joint. The surfaces that rub against each other are both made from highly polished metal. This type of hip device is called a metal-on-metal hip resurfacing device.

Hip resurfacing may be appropriate for:

  • Younger, more active patients
  • Good bone quality
  • Osteoarthritis

Benefits of Hip Resurfacing

Another benefit of hip resurfacing is that it’s bone conserving – meaning more of your healthy bone is kept intact. The damaged area is simply resurfaced, not fully removed. You are better prepared for a later treatment - hip resurfacing removes less of your own bone, which may be important should you ever require a total hip replacement in the future. After one year, running and high impact activities are allowed.

Precautions regarding Hip Resurfacing

  • The manufacturer recommends this only for males < 65 yrs old and females < 55 yrs old.
  • There is a higher complication rate reported in female patients.
  • Hip resurfacing is a metal on metal implant. There has been recent controversy and concern regarding metal on metal implants and elevated levels of cobalt and chromium ions in some patients. Birmingham resurfacing, however, has an excellent track record of more than 12 years. Speak with your joint replacement specialist to help determine what is the best choice for you.

Hip resurfacing is not recommended for these conditions:

  • Poor bone quality which your surgeon feels could not support the implant
  • Any known allergy to metal (e.g., jewelry)
  • Extreme overweight (overload on device that would lead to failure)
  • Skeletal immaturity
  • Women in child-bearing years
  • Weak immune system due to disease or certain medications (e.g., corticosteroids)
  • Kidney failure

Discuss Your Options With Your Physician

Hip replacement, no matter how minimally invasive, is major surgery and patients are at risk for complications. However, the complication rate following joint replacement surgery is generally very low. Serious complications, such as joint infection, occur in less than 2% of patients.10 Besides infection, possible complications include blood clots, lung congestion or pneumonia. The risks that are normally encountered in conventional hip joint replacement remain. Recovery success depends on several factors including surgeon training and experience, the surgical approach, the implant and the patient’s health and commitment to post-operative physical therapy. Although the direct anterior approach may make sense for some patients, only your surgeon can help you decide what is best for you. Talk with your doctor if you have any questions about the direct anterior approach for total hip replacement or hip replacement in general.

Follow-Up Appointments

Follow-up visits with your surgeon after joint replacement surgery are important. Many of our patients travel great distances to have their procedure performed at our institute. Regardless of the distance to our location, post-operative follow-up with us is necessary. It is typical to have two to three routine follow-up visits post-surgery, but additional appointments may be required.

Understand the Potential Risks And Complications

The complication rate following joint replacement surgery is very low. Serious complications, such as joint infection, occur in less than 2% of patients.11 Nevertheless, as with any major surgical procedure, patients who undergo total joint replacement are at risk for certain complications — many of which can be successfully avoided and/or treated. Possible complications include:

Infection may occur in the wound or within the area around the new joint. It can occur in the hospital, after the patient returns home, or years later. Following surgery, joint replacement patients receive antibiotics to help prevent infection. Joint replacement patients may also need to take antibiotics before undergoing any medical procedures to reduce the chance of infection spreading to the artificial joint.

Treating a Joint Replacement Infection

People who develop infections within the first few months of joint replacement surgery are often treated successfully with intravenous antibiotics and a surgical technique that washes the infected implant. People who develop infections months or years after joint replacement appear to face more challenging treatment. Often these infections require surgical removal of the infected implant, use of a spacer impregnated with antibiotics to stabilize and treat the joint space, and longer-term intravenous antibiotics. Careful blood monitoring helps to determine when the infection is thoroughly cleared. A new joint replacement may be considered at that time.

Blood Clots

Blood clots can result from several factors, including the patient’s decreased mobility following surgery, which slows the movement of the blood. There are a number of ways to reduce the possibility of blood clots, including:

  • Blood thinning medications (anticoagulants)
  • Elastic support stockings that improve blood circulation in the legs
  • Plastic boots that inflate with air to promote blood flow in the legs
  • Elevating the feet and legs to keep blood from pooling
  • Walking hourly

Lung Congestion

Pneumonia is always a risk following major surgery. To help keep the lungs clear of congestion, patients are assigned a series of deep breathing exercises.

Dislocation

After a hip replacement, a complication that can arise is the ball dislocating from the socket. This risk is less than 1%.

Fracture

Fractures can occur in the bone around the replacement. This may occur during or after a hip replacement surgery. The risk is less than 1%.

Limb Length Difference

Every effort is made to match the length of one limb to the other. In a small percentage of patients, there can be a noticeable difference in limb length after the procedure.

1 NIAMS website, http://www.niams.nih.gov/Health_Info/Hip_Replacement/default.asp, accessed Nov. 2008.Minimally Invasive Surgery (MIS)

2 American Academy of Orthopaedic Surgeons website, http://www.aaos.org/research/stats/Joint_Replacements_all.pdf, accessed Oct. 2008.

3 Wenz, James F.,MD, Gurkan, Ilksen, MD, Jibodh, Stefan R., MD, “Mini- Incision Total Hip Arthroplasty: A Comparative Assessment of Peri-operative Outcomes,”Orthopedics Magazine, 2002.

4 Keggi, Kristaps J., “Total Hip Arthroplasty Through a Minimally Invasive Anterior Surgical Approach,” JBJS, Vol. 85-A, 2003.

5 Sikorski JM, Chauhan S. Computer- Assisted Orthopaedic Surgery: Do we need CAOS? J Bone Joint Surg 2003; 85-B:319-23.

6 Noble PC, Sugano N, Johnston JD, Thompson MT, Conditt MA, Engh CA Sr, Mathis KB. Computer Simulation: How can it help the surgeon optimize implant position? CORR. 2003 Dec; (417):242-52.

7 Widmer KH, Grutzner PA. Joint replacement-total hip replacement with CT-based navigation. Injury. 2004 Jun; 35 Suppl. 1:S-A84-9.

8 Klein GR, Parvizi J, Venkat RR, Mathew AS, HozackWJ. Evaluation of in vivo knee kinematics by a computerized navigation system during total knee arthroplasty. J Arthroplasty. 2004 Dec; Vol. 19:986-91.

9 Keggi, Kristaps. Total hip arthroplasty through a minimally invasive anterior surgical approach, JBJS, Vol. 85-A.

10 Hanssen, A.D., et al., “Evaluation and Treatment of Infection at the Site of Total Hip or Knee Arthroplasty,” JBJS, pp. 910-922.

11 Hanssen, A.D., et al., “Evaluation and Treatment of Infection at the Site of Total Hip or Knee Arthroplasty,” JBJS, Volume. 80-A, No. 6, June 1998, pp. 910-922.

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The Coon Joint Replacement Institute values your privacy and handles your personal information with care. Your email address and information is secure, confidential and will not be sold to any third party sources.

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