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A total hip replacement is a surgical procedure whereby the diseased cartilage and bone of the hip joint is surgically replaced with artificial materials. The normal hip joint is a ball and socket joint. The socket is a "cup- shaped" bone of the pelvis called the acetabulum. The ball is the head of the thigh bone (femur). Total hip joint replacement involves surgical removal of the diseased ball and socket, and replacing them with a metal ball and stem inserted into the femur bone and an artificial plastic cup socket. The metallic artificial ball and stem are referred to as the "prosthesis." Upon inserting the prosthesis into the central core of the femur, it is fixed with a bony cement called methylmethacrylate. Alternatively, a "cementless" prosthesis is used which has microscopic pores that allow bony ingrowth from the normal femur into the prosthesis stem. This "cementless" hip is felt to have a longer duration and is considered especially for younger patients.
Total hip replacements are performed most commonly because of progressively severe arthritis in the hip joint. The most common type of arthritis leading to total hip replacement is degenerative arthritis (osteoarthritis) of the hip joint. This type of arthritis is generally seen with aging, congenital abnormality of the hip joint, or prior trauma to the hip joint. Other conditions leading to total hip replacement include bony fractures of the hip joint, rheumatoid arthritis, and death (aseptic necrosis) of the hip bone. Hip bone necrosis can be caused by fracture of the hip, drugs (such as alcohol or prednisone and prednisolone), diseases (such as systemic lupus erythematosus), and conditions (such as kidney transplantation).
The progressively intense chronic pain together with impairment of daily function including walking, climbing stairs and even arising from a sitting position, eventually become reasons to consider a total hip replacement. Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of anti-inflammatory and/or pain medications. A total hip joint replacement is an elective procedure, which means that it is an option selected among other alternatives. It is a decision which is made with an understanding of the potential risks and benefits. A thorough understanding of both the procedure and anticipated outcome is an important part of the decision-making process.
The risks of total hip replacement include blood clots in the lower extremities that can travel to the lungs (pulmonary embolism). Severe cases of pulmonary embolism are rare, but can cause respiratory failure and shock. Other problems include difficulty with urination, local skin or joint infection, fracture of the bone during and after surgery, scarring and limitation of motion of the hip, and loosening of the prosthesis which eventually leads to prosthesis failure. Because total hip joint replacement requires anesthesia, the usual risks of anesthesia apply and include heart arrhythmias, liver toxicity, and pneumonia.
Total hip joint replacement can involve blood loss. Patients planning to undergo total hip replacement often will donate their own (autologous) blood to be banked for transfusion during the surgery. Should blood transfusion be required, the patient will have the advantage of having his or her own blood available, thus minimizing the risks of blood transfusions. The preoperative evaluation generally includes a review of all medications being taken by the patient. Anti-inflammatory medications, including aspirin, are often discontinued one week prior to surgery because of the effect of these medications on platelet function and blood clotting. They may be reinstituted after surgery. Other preoperative evaluations include complete blood counts, electrolytes (potassium, sodium, chloride, bicarbonate), blood tests for kidney and liver functions, urinalysis, chest x-ray, EKG, and a physical examination. Any indications of infection, severe heart or lung disease, or active metabolic disturbances such as uncontrolled diabetes, may postpone or defer total hip joint surgery.
A total hip joint replacement takes approximately two to four hours of surgical time. The preparation prior to surgery may take additional hours. After surgery, the patient is taken to a recovery room for immediate observation which generally lasts between one to four hours. The lower extremities will be closely observed for both adequate sensation and circulation. If unusual symptoms of numbness or tingling are noted by the patient, recovery room nurses are available and should be notified by the patient. Upon stabilization, the patient is transferred to a hospital room.
During the immediate recovery period, patients are given intravenous fluids. Intravenous fluids are important to maintain a patient's electrolytes as well as for administering antibiotics. Patients also will notice tubes draining fluid from the surgical wound site. The amount and character of the drainage is important to the doctor and can be monitored closely by the nurse in attendance. A dressing is applied in the operating room and will remain in place for two to four days to be later changed by the attending surgeon and staff.
Pain control medications are commonly given through a patient- controlled analgesia (PCA) pump whereby patients can actually administer their own dose of medications on demand. Pain medications occasionally can cause nausea and vomiting. Anti-nausea medications may then be given.
Measures are taken to prevent blood clots in the lower extremities. Patients are placed in elastic hose (TEDs) after surgery. Compression stockings are often added which act by squeezing with circulating air in plastic bags wrapped around the legs, forcing blood circulation. Patients are encouraged to actively exercise the lower extremities in order to mobilize venous blood in the lower extremities to prevent blood clots. Medications are often given to thin the blood in order to further prevent blood clots.
Patients may also experience difficulty with urination. This difficulty can be a side effect of medications given for pain. As a result, catheters are often placed into the bladder to allow normal passage of urine.
Immediately after surgery, patients are encouraged to frequently perform deep breathing and coughing in order to avoid lung congestion and the collapse of tiny airways in the lungs. Patients are also given a "blow bottle," whereby active blowing against resistance maintains the opening of the breathing passages.
After total hip joint replacement surgery, patients often start physical therapy immediately! On the first day after surgery, it is common to begin some minor physical therapy while sitting in a chair. Eventually, rehabilitation incorporates stepping, walking, and climbing. Initially, supportive devices such as walker or crutches are used. Pain is monitored while exercise takes place. Some degree of discomfort is normal. It is often very gratifying for the patient to notice, even early on, substantial relief from the preoperative pain for which the total hip replacement was performed.
Physical therapy is extremely important in the overall outcome of any joint replacement surgery. The goals of physical therapy are to prevent contractures, improve patient education, and strengthen muscles around the hip joint through controlled exercises. Contractures result from scarring of the tissues around the joint. Contractures do not permit full range of motion, and therefore impede mobility of the replaced joint. Patients are instructed not to strain the hip joint with heavy lifting or other unusual activities at home. Specific techniques of body posturing, sitting, and using an elevated toilet seat can be extremely helpful. Patients are instructed not to cross the operated lower extremity across the midline of the body (not crossing the leg over the other leg) because of the risk of dislocating the replaced joint. They are discouraged from bending at the waist and are instructed to use a pillow between the legs when lying on the nonoperated side in order to prevent the operated lower extremity from crossing over the midline. Patients are given home exercise programs to strengthen the muscles around the buttock and thigh. Most patients attend outpatient physical therapy for a period of time while incorporating home exercises regularly into their daily living.
Occupational therapists are also part of the rehabilitation process. These therapists review precautions with the patients related to everyday activities. They also educate the patients about the adaptive equipment that is available and the proper ways to do their "ADL's" or of daily living.
Patients will continue to use supportive devices as monitored and recommended by the therapist and attending physician. Medications are likely to be given to further prevent blood clots in the legs. These include warfarin (Coumadin) or aspirin medications. Occasionally, heparin (Enoxaparin, Lovenox) can be given by self-injection. Medications are given for pain, sleep, and occasionally for muscle relaxation.
Gradually patients become more confident and less dependent on supportive devices. Patients are instructed to look for signs of infection including swelling, warmth, redness, or increased pain in or around the surgical site. The patient should notify the doctor's office immediately if these changes are noted, or if there is injury to the hip. The wound site will be inspected regularly by the attending physician. The sutures, which are usually staples, are removed several weeks after the operation.
Patient education is important to ensure longevity of the replaced hip. Strenuous exercises such as running or contact sports are discouraged, since these activities can re-injure the replaced hip. Swimming is ideal in improving muscle strength, and promoting mobility and endurance.
Patients should be aware and notify any caregivers that they have an artificial joint. Antibiotics are recommended during any invasive procedures, whether surgical, urological, gastroenterological, or dental. Infections elsewhere in the body should also be treated to prevent seeding of infection into the joint. This is important because bacteria can pass through the blood stream from these sites and cause infection of the hip prosthesis.
Hip joint replacement surgery is one of the most successful joint surgeries performed today. In well-selected patients, who are appropriate candidates for total hip replacements, the procedure lasts at least 15 years in nearly 95 percent of patients. Long-term results have been improving impressively with new devices and techniques. The future will provide newer techniques which will further improve patient outcomes and lessen the potential for complications.
- The prosthesis for a total hip replacement can be inserted into the femur bone with or without cement.
- Chronic pain and impairment of daily function of patients with severe hip arthritis are reasons for considering treatment with total hip replacement.
- Complication and risks of total hip replacement surgery have been identified.
- Preoperative banking of the blood of patients planning total hip replacement is considered when possible.
- Physical therapy is an essential part of rehabilitation after a total hip replacement.
- Patients with artificial joints are recommended to take antibiotics before, during, and after any elective invasive procedures (including dental work).
More boomers have hip and knee replacements
By Theresa Agonvino
ASSOCIATED PRESS
NEW YORK -- When she felt a dull ache in her left hip three and a half years ago, Sarah Jane Francis knew instantly what lay ahead.
Osteoarthritis had forced her to have her right hip replaced in 1998 and doctors warned that her left hip would most likely meet the same fate. Eventually, the ache progressed to a constant throb that even a double dose of her pain medication didn't stop. She couldn't walk around the block, and even had to ask her husband to shave her legs.
"Just couldn't bend over anymore," said the 47-year Dallas homemaker, who had the operation last month. "It was time."
Advancements in surgery and prostheses combined with a dearth of medicines for osteoarthritis are nudging doctors to perform more hip and knee replacements on baby boomers. Although the procedures are still mostly performed on people over 65, a growing number of boomers, who range from 38 to 56, are getting implants.
According to the American Academy of Orthopaedic Surgeons, baby boomers had 35,000 hip replacements or 21 percent of the procedures in 2001, the last year for which figures are available. That's up from 16 percent of all procedures in 1997.
Likewise, boomers had 48,000 knee replacements or 15 percent of the total 2001, up from 12 percent in 1997.
Doctors estimate that over 90 percent of joint replacements are done because of osteoarthritis, which affects nearly 21 million people and is the most common form of arthritis. Osteoarthritis is a degenerative disease characterized by the breakdown of a joint's cartilage, and is caused by a variety of factors including injuries, obesity and genetics. The breakdown causes bones to rub against each other, resulting in pain and loss of movement.
The incidence of arthritis increases as people age. In 1997, the Centers for Disease Control and Prevention estimated 43 million Americans suffered with arthritis, up from 37.9 million in 1990. A 2001 report estimated 70 million Americans suffered with the disease although the study was conducted differently than earlier versions.
Doctors say baby boomers seem to have arthritis symptoms at a younger age than previous generations, probably because of their active lifestyles. With a motto of "no pain, no gain" boomers have embraced jogging, aerobics, skiing and other activities.
"This is a generation that played hard," said Dr. Nicholas DiNubile, an orthopedic surgeon in Havertown, Pa. "Their parents didn't play sports. They didn't get early injuries."
A decade or so ago, doctors and patients chose to put off implants as long as possible because prostheses would only last about 10 years and replacement surgery becomes less effective and more dangerous each time it is done. Now prostheses are expected to last 25 years, so doctors are more willing to give them to younger patients.
"We know the time will come when they may have to have a future operation but now it is 20 or 30 years down the line," said Dr. Robert Bucholz, chairman of the orthopedic surgery department at the University of Texas Southwestern Medical School in Dallas. "Now the boomers want to be able to keep up with their kids and grandkids."
While the implants have improved, arthritis medications have not. Over the last decade, new pain relievers that are gentler on the stomach, such as Vioxx and Celebrex, have been introduced, but there are no medicines to stop the progression of osteoarthritis. There are medicines for rheumatoid arthritis but it is a much less common form of the disease, affecting about 2 million Americans.
"Boomers are less willing to live with symptoms. They are more aggressive about their medical treatments," DiNubile said.
The problem with giving boomers new hips and knees, doctors say, is convincing them to adjust active lifestyles that may have contributed to the need for surgery.
"You have to tell the patients all the time that these are not the joints that God gave you," said Dr. Frank Kelly, an orthopedic surgeon in Macon, Ga. "I tell them in person, I show them videos, I write it down. I hope they listen."
Copyright 2003 Union-Tribune Publishing Co.
More Americans Seeking Surgery Abroad
High Costs In U.S. Is Driving Some Patients To Seek Treatment In India And Elsewhere
WebMD
Dismayed by high surgical costs in the United States, increasing numbers of American patients are packing their bags to have necessary surgery performed in countries such as India, Thailand and Singapore.
"This is not what is sometimes snootily referred to as 'medical tourism,' in which people go abroad for elective plastic surgery," says Mark D. Smith, MD, MBA, president and chief executive officer of the California HealthCare Foundation in Oakland.
Today's "medical refugees," the term Smith uses in an article published in the Oct. 19 issue of The New England Journal of Medicine, are going to foreign countries for lifesaving procedures such as coronary bypass surgery and heart valve replacement, and also life-enhancing procedures such as hip and knee replacement.
"People are desperate," Smith tells WebMD. "This illustrates the growing unaffordability of the U.S. health care system, even to people who are by no means indigent."
The report by Smith and his colleague, Arnold Milstein, MD, MPH, documents the case of a self-employed carpenter who couldn't afford private health insurance and would have faced financial ruin if he had surgery in the U.S. It also shows how some insured workers are being steered toward receiving less-expensive procedures outside the U.S.
Indian Hospitals Booming
Vishal Bali, chief executive officer of the Wockhardt Hospitals Group in Mumbai, India, says there has been a 45 percent increase in the number of American patients seeking care at his 10 Indian hospitals during the past two years.
"Cost is a major factor," Bali tells WebMD. Some examples: Wockhardt Hospitals usually charge $6,000-$8,000 for coronary bypass surgery, $6,500 for a joint replacement, and $6,500 for a hip resurfacing, which represent a small fraction of the typical costs at U.S. hospitals.
"Another major factor is what we call 'the Indian advantage,' " Bali says. "At some point, most American patients have been treated by an Indian physician in the United States and they have tremendous faith in Indian clinicians."
Partly because of the influx of foreign patients, not all of them American, Bali plans to open 10 new hospitals in India during the next two to three years.
Safety Concerns May Be Overblown
"Our American patients don't just pack their bags and fly to India," Bali says. "They have multiple conversations with patient coordinators and clinicians, many of whom have been trained in the U.S. and have American board certifications."
All Wockhardt Hospitals are accredited by the international affiliate of the Joint Commission on Accreditation of Healthcare Organizations, the group that accredits U.S. hospitals, Bali says. More than 80 hospitals in India, Thailand, Singapore, China, Saudi Arabia, and other countries have received this accreditation, according to the new report.
"These institutions are reporting gross mortality rates of less than 1 percent," Smith says. "I'm unaware of any evidence that surgery at these institutions is less safe or of lower quality than that in the average American institution, and there's some reason to believe it may be better."
"The downside, however, is that if you are harmed in an Indian hospital, you have less legal recourse than if you are harmed at an American hospital," Smith says.
To compete with less-expensive offshore hospitals, the U.S. hospitals should do more to reduce costs, improve efficiency, and increase quality, Smith says. "Regrettably, I fear that some people's response to the offshore trend may be to moan and groan and try to shut it down or engage in scaremongering about quality."
A Sign of Globalization
"This trend shows that the world is flattening," Smith says. "We're no longer just outsourcing back-office functions such as the reading of X-rays, medical transcription, and billing. Now it's the actual clinical care that can be outsourced."
The report concludes that the trend is a "symptom of, not a solution to" America's affordability crisis. "I'm not suggesting it'll ever be the main way people get surgery," Smith says. "But it certainly is a wake-up call. If the cost of surgery continues to go up, particularly in settings where there's no relationship between cost and quality, this trend will continue."
Bali believes the trend represents a sea change in global health care economics. "This is only the beginning," he says. "This trend is not going to reverse. It's as strong a trend as the outsourcing of information technology because it is advantageous for patients."
Although most of Wockhardt Hospitals' American patients are uninsured, Bali predicts that will change. "Insurance companies are looking at this trend, their own viability, and the need to save money," he says. "They're telling patients that there are international destinations where they can be treated, which may mean paying much lower premiums than they're paying to receive treatment in the U.S."
A Call for Reform
"The need for American citizens to go abroad for care — and their willingness to do so — represents a crushing indictment of numerous myths about the U.S. health care system that have gained popular currency in recent years," says Peter Budetti, MD, JD, chairman of the department of health administration and policy at the University of Oklahoma Health Sciences Center. Budetti was not involved in the report.
Budetti says the report dispels the myths that "foreign systems of universal coverage are so flawed that people in those countries who can afford to do so flock to the U.S. for care; that our health care is the best in the world; that everyone in the U.S. will get the care they need whether they can afford to pay for it or not; and, most telling, that increased consumer cost-sharing will reduce cosmetic or other nonessential care, not medically necessary care.
"The profound irony of these myths is a sad commentary on the state of our health care coverage and delivery system," Budetti tells WebMD. "The understandable focus in the past decade or so on improving quality and promoting patient safety may have played a role in distracting us from paying sufficient attention to growing problems with access and equity. Perhaps the emerging sight of Middle America traveling thousands of miles for medical care will spur new attention to the need for universal coverage with adequate benefits in this country."
SOURCES: Mark D. Smith, MD, president and chief executive officer, California HealthCare Foundation, Oakland. Vishal Bali, chief executive officer, Wockhardt Hospitals Group, Mumbai, India. Peter P. Budetti, MD, JD, Edward E. and Helen T. Bartlett Foundation Professor of Public Health; chairman, department of health administration and policy, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City. Milstein, A and Smith, M. The New England Journal of Medicine, Oct. 19, 2006; pp 1637-1640.
By Rick Ansorge
Reviewed by Louise Chang
Copyright 2006, WebMD Inc. All rights reserved.
Boomers: It's not your grandma's hip replacement surgery
Medical advancements have more baby boomers turning to hip replacement surgery earlier in life, U-M expert says
ANN ARBOR, MI – Danny McIntire will be the first to tell you that hip replacements aren’t just for grandmas anymore.
A guitarist in a rock-and-roll band and avid sky diver, 54-year-old McIntire doesn’t plan to slow down any time soon. And thanks to recent hip replacement surgery, he won’t have to.
Advancements in hip replacement – from the procedure itself to the variety of hip prostheses available and shortened recovery times – have more and more baby boomers like McIntire turning to surgery earlier in life to stay active and better their quality of life, says Andrew Urquhart, M.D., chief, Joint Reconstruction Service in the Department of Orthopaedic Surgery at the University of Michigan Health System.
“Hip replacements were once reserved for the elderly, so younger adults with hips damaged by arthritis or past injury were told to wait to undergo replacement surgery until they were very old,” he says. “Baby boomers today, however, have higher expectations, and don’t want to let a damaged hip slow them down. They want to get back on the ski slopes, back on the jogging track and back to an active life.”
Every year, more than 300,000 hip replacement procedures are performed in the United States. With the procedure, the head of the leg bone, called the femur, and the hip socket are removed and replaced with an artificial joint that consists of a ball bearing.
One of the most common causes for hip replacement surgery is severe pain from osteoarthritis, which wears down of the hip joint and can limit mobility and significantly decrease a person’s quality of life, says Urquhart. Other candidates for hip replacement surgery often have rheumatoid arthritis, inflammatory arthritis, and damage to the hip from a previous injury such as a motor vehicle accident, or osteonecrosis, a bone disease that essentially destroys the joint.
The pain and stiffness caused by osteoarthritis that developed after a past pelvic injury is what brought McIntire to Urquhart’s office to discuss hip replacement surgery.
“The pain got to a point where I stopped doing certain activities that I had done for years, and needed to plan other activities around what my hip would react to,” recalls McIntire. “I finally decided that I needed surgery after I had fallen down the steps a couple of times in a three- or four-week period and severely injured my muscles.
After talking with my doctor, I just realized I couldn’t live like this anymore.”
Fortunately for McIntire, advances in hip replacement surgery have made the procedure less invasive and even shortened the length of time a patient needs to stay in the hospital following surgery.
At U-M, Urquhart and his team are working to develop a new navigation system, which will allow the surgeon to use a computer to help implant the new joint. Urquhart says with computer assistance and the use of better surgical instruments during the operation, he and his team will be able to implant hips and knees that will last well into the future.
 Plus, Urquhart says the improved materials used for the artificial joint – ceramics, metals and newer plastics – hold the promise of providing a safer and longer-term solution to total hip replacement, especially for younger and more active patients. In fact, the ceramic used in some of the implants is so strong that testing has shown that it can withstand the weight of a small boat.
“I typically tell my patients that the prosthesis we give them has about a 98 percent chance of functioning well mechanically for at least 15 years, if not longer,” Urquhart notes.
But patients don’t have to wait long to test out their new hip. Urquhart says he has most of his patients up and moving either the afternoon of the surgery or early the next day.
“Hip replacement, while originally thought of as a massive operation requiring significant length of stay in the hospital and recovery, certainly doesn’t have to be that way,” he says. “Six weeks after the surgery, patients are getting around pretty well with little assistance, and after eight to 12 weeks, they’re back to their normal lives.”
Only two weeks after his surgery, McIntire was driving his car and walking with the assistance of a walker. He began physical therapy about six weeks later, lifting weights and even riding the exercise bike. And in about three months, McIntire started getting back to doing all of the things he had previously enjoyed.
As an added bonus, McIntire says his new hip even helped to improve his musical career with the Jim Tate Band, based in Ann Arbor, Mich.
“The artificial hip has allowed me to concentrate more on my playing and technical ability, rather than worrying about tripping over a wire on stage or needing to sit down while performing because of the pain,” he says. “I think having the hip replacement surgery was the best decision that I could have made. I’m kind of disappointed in myself that I didn’t do it sooner.”
For more information, visit these web sites:
UMHS Health Topics A-Z: Total Hip Replacement Surgery
www.med.umich.edu/1libr/aha/aha_tothip_sha.htm
UMHS Department of Orthopaedic Surgery
www.med.umich.edu/ortho/
UMHS Press Release: A hip alternative: Ceramic-on-ceramic hip implant let patients stay active longer
www.med.umich.edu/opm/newspage/2003/hipreplacement.htm
National Institutes of Arthritis and Musculoskeletal and Skin Diseases: Hip Replacement
www.niams.nih.gov/hi/topics/hip/hiprepqa.htm
Written by Krista Hopson
| A Patient's Guide to Total Hip Replacement Surgery |
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Introduction
A painful hip can severely affect your ability to lead a full active life. Over the last twenty five years, major advancements in hip replacement have improved the outcome of the surgery greatly. Hip replacement surgery is becoming more and more common as the population of the world begins to age.
Causes For Hip Replacement
There are many conditions that can result in degeneration of the hip joint (image). Osteoarthritis is perhaps the most common cause for hip replacement surgery. This condition is commonly referred to as "wear and tear arthritis". Osteoarthritis can occur with no previous history of injury to the hip joint - the hip simply "wears out". There may be a genetic tendency in some people that increases their chances of developing osteoarthritis.
Avascular necrosis is another cause of degeneration of the hip joint. In this condition, the femoral head (the ball portion) looses a portion of its blood supply and actually dies. This leads to collapse of the femoral head and degeneration of the joint. Avascular necrosis (AVN) has been linked to alcoholism, hip fractures, dislocations of the hip, and long term cortisone treatment for other diseases.
Abnormalities of hip joint function resulting from fractures of the hip and some types of hip conditions that appear in childhood can also lead to degeneration many years after an injury. The mechanical abnormality of the joint causes excessive wear and tear - just like the out-of-balance tire on your car that wears out too soon.
Symptoms
The symptoms of a degenerative hip joint usually begin as pain when bearing weight on the affected hip. You may limp, which is the body's way of reducing the forces that the hip has to deal with. The degeneration will lead to a reduction in the range-of-motion of the affected hip. Bone spurs will usually develop which limit movement of the hip joint. Finally, as the condition becomes worse, the pain may be present all the time and may keep you awake at night.
Diagnosis
The diagnosis of a degenerative hip joint starts with a complete history and physical examination by your doctor. Xrays will be taken to determine the extent of the degenerative process and suggest a cause for the degeneration. Other tests may be required if there is reason to believe that other conditions are contributing to the degenerative process. MRI Scanning may be necessary to determine whether avascular necrosis is causing your hip condition. Blood tests may be required to rule out systemic arthritis or infection in the hip.
Normal Hip Xrays - (.avi zipped 319K) or (.flc zipped 244K)
Degenerative Hip Xrays - (.avi zipped 387K) or (.flc zipped 287K)
Medical Treatment
Not all hip conditions require a hip replacement as the initial treatment. Your doctor may suggest several alternative treatments to put off replacing the hip as long as possible. Using a cane may help alleviate some of your pain and allow you to walk more comfortably. Anti-inflammatory medications may reduce the inflammation from the arthritis and reduce your pain.
Surgery
Most degenerative problems will eventually require replacement of the painful hip joint with an artificial hip joint, called a prosthesis. The decision to proceed with surgery should be made jointly by you, your family, and your doctor only after you feel that you understand as much about the procedure as possible.
Once the decision to proceed with surgery is made, there are several things to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with a Physical Therapist who will be managing your rehabilitation after the surgery. The therapist may begin the teaching process before the surgery to ensure that you are ready for the rehabilitation afterwards.
Finally, you may be asked to donate some of your blood before the operation. This blood can be donated once a week beginning about three to five weeks before the surgery. Your body will make new blood to replace the donated blood. If you need to have a blood transfusion at the time of surgery, you will receive your blood that has been stored in the blood bank.
The Artificial Hip Joint, called a prosthesis
There are two major types of artificial hip joint:
(3D animation of artificial hip .flc animation file 1.9K zipped)
- Cemented Prosthesis
- Uncemented Prosthesis
Both types are widely used. The type of prosthesis used for your surgery is usually decided upon by your surgeon based on your age, your lifestyle, and the surgeon's past experience.
Each prosthesis is made up of two parts(image):
- The acetabular component, or socket portion, which replaces the acetabulum.
- The femoral component, or stem portion, which replaces the femoral head.
The femoral component (image) is made of a metal stem with a metal ball on the end. Some prosthesis have a ceramic ball attached to the metal stem. The acetabular component (image) is a metal shell with a plastic inner socket liner that acts like a bearing. The type of plastic used is very tough and very slick - so slick and tough that you could ice skate on a sheet of the plastic without much damage to the plastic.
A cemented prosthesis (image) is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis (image) has a fine mesh of holes on the surface area that touches the bone. The mesh allows the bone to grow into the mesh and "become part of" the bone.
The Operation
You can download a surgical animation (.flc animation file 1.7K zipped) showing the steps used in replacing a diseased hip with an uncemented artificial hip. The steps for replacing the hip begin with making an incision about 8 inches long over the hip joint. There are several different approaches used to make the incision, usually based on your surgeon's training and preferences.
After the incision is made, the ligaments and muscles are separated to allow the surgeon access to the bones of the hip joint. It is this part of the surgery that makes the ligaments and muscles somewhat weak after surgery. Until they heal, which takes about a month to six weeks, you must follow special hip precautions to prevent dislocation of your new hip joint.
Removing the Femoral Head (image)
Once the hip joint is entered, the femoral head is dislocated from the acetabulum. Then the femoral head is removed by cutting through the femoral neck with a power saw.
Reaming the Acetabulum (image)
After the femoral head is removed, the cartilage is removed from the acetabulum using a power drill and a special reamer. The reamer forms the bone in a hemispherical shape to exactly fit the metal shell of the acetabular component.
Inserting the Acetabular Component (image)
A trial component, which is an exact duplicate of your hip prosthesis, is used to ensure that the joint you receive will be the right size and fit for you. Once the right size and shape is determined for the acetabulum, the acetabular component is inserted into place. In the uncemented variety of artificial hip replacement, the metal shell is simply held in place by the tightness of the fit or with screws to hold the metal shell in place. In the cemented variety, a special epoxy type cement is used to "glue" the acetabular component to the bone.
Preparing the Femoral Canal (image)
To begin replacing the femoral head, special rasps are used to shape and hollow out femur to the exact shape of the metal stem of the femoral component. Once again, a trial component is used to ensure the correct size and shape. The surgeon will also test the movement of the hip joint.
Inserting the Femoral Stem (image)
Once the size and shape of the canal exactly fit the femoral component, the stem is inserted into the femoral canal. Again, in the uncemented variety of femoral component the stem is held in place by the tightness of the fit into the bone (similar to the friction that holds a nail driven into a hole drilled into wooden board - with a slightly smaller diameter than the nail). In the cemented variety, the femoral canal is rasped to a size slightly larger than the femoral stem. Then the epoxy type cement is used to bond the metal stem to the bone.
Your surgeon will make every effort to maintain the leg length that you had before surgery, but there is no guarantee. Once you are up and walking around, you may find that your leg is now a fraction of an inch longer or shorter than it was before surgery.
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- Attaching the Femoral Head (image)
- The metal ball that replaces the femoral head is attached to the femoral stem.
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- The Completed Hip Replacement (image)
- You now have a new weight bearing surface to replace your diseased hip. Before your incision is closed, an xray (image) is made to make sure your new prosthesis is in the correct position.
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Complications of Total Hip Replacement
As with all major surgical procedures, complications can occur. The most common complications following hip replacement are:
- Thrombophlebitis
- Infection in the joint
- Dislocation of the joint
- Loosening of the joint
This is not intended to be a complete list of the possible complications, but these are the most common.
Thrombophlebitis
Thrombophlebitis, sometimes called Deep Venous Thrombosis (DVT), can occur after any operation. It is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots within the veins. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart they can travel to the lung. Once in the lung they get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. Pulmonary means "lung". An embolism is a fragment of something traveling through the vascular system. Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving around as soon as possible!
Some of the commonly used preventative measures include:
- Pressure stockings to keep the blood in the legs moving.
- Medications that thin the blood and prevent blood clots from forming.
Infection
Infection can be a very serious complication following an artificial joint replacement. The chance of getting an infection following total hip replacement is probably around 1 in 100 total hip replacements. Some infections may show up very early - before you leave the hospital. Others may not show up for months, or even years, after the operation.
Also, an infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work, or surgical procedures on your bladder or colon to reduce the risk of spreading germs to your new joint.
Dislocation
Just like your real hip, an artificial hip can dislocate. Dislocation is when the ball comes out of the socket. There is a greater risk of dislocation right after surgery, before the muscles and tendons around the new joint have healed. However, there is always a risk of dislocation.
The therapist will carefully instruct you on how to avoid activities and positions which increase the risk of hip dislocation. A hip that dislocates more than once may have to be revised, which means another operation, to make the joint more stable.
Loosening
The major reason that artificial joints eventually fail continues to be loosening of the joint where the metal or cement meets the bone. There have been great advances in extending the life of an artificial joint. Still, most joints will eventually loosen and require a revision. Hopefully, you can expect 12-15 years of service from your artificial hip. In some cases the hip will loosen earlier than that. Just like your diseased hip, a loose joint causes pain. Once the pain becomes unbearable, another operation will probably be required to replace the hip.
Information from:
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