Hips :: Knees :: Shoulder :: Elbow :: Back & Spine
Foot & Ankle :: Paediatric Orthopaedics ::Sports Medicine
A detailed review of Dr. Solomon's hip and knee information is found by clicking here: http://www.sydneyhipandknee.com.au
Total Hip Replacement
A comprehensive summary of Dr. Solomon's recommendation for hip replacement surgery and the type of surgery performed is shown.
Further information on hip replacements and animations are found after the summary.
Information for patients needing a Total Hip Replacement or Hip Resurfacing Replacement
Timing of Surgery
The timing of hip replacement surgery is a decision that you as the patient must make. The need for surgery is a quality of life decision and the aim of the surgery is to eliminate your hip pain. As an added bonus you will likely get a better range of motion, your limp may reduce or disappear and your quality of life should improve significantly.
If you feel that you can manage with your current pain levels then there is no urgency to have your arthritic hip replaced. Simple analgesics (eg.Panadol) or anti-inflammatories (eg.voltaren, celbrex etc) may be sufficient to provide you with a relatively painfree hip. These drugs will not improve stiffness and the arthritis will continue to progress and at some point the drugs will no longer have their pain relief affect.
Alternative medicines (eg. Glucosamine and chondroitin, fish oil etc) may have a role in helping with pain but scientific studies have proven that the claim that they “prevent arthritis or progression of the disease” is false. These medicines whilst not doing you major harm will not stop your hip continuing to wear out.
If you are overweight, weight loss may help in reducing your hip pain. Low impact exercises (walking, cycling and swimming) help maintain muscle tone and thereby control the arthritis pain.
Physiotherapy is often useful in helping strengthen surrounding muscles and maintaining good muscle tone and pelvic balance. Try to avoid overstretching the joint as this will only cause discomfort.
Things you need to know about Hip Replacements and Hip Resurfacing Replacements
Total Hip Replacement, Hip Resurfacing Replacement or “mini stem” Hip Replacement are simply different designs of prosthesis. They all replace your hip and therefore are collectively termed Hip Replacements. Some prosthesis (Birmingham Hip Resurfacing) are more bone conserving but these prosthesis still replace the acetabulum (socket) and either resurface the femoral head (ball) or replace the head but preserve more bone lower down.
What Replacement should you have ?
This can be a most complex topic particularly in discussing the options and correct choice in a young patient.
It is important to get an understanding of what’s available and in which patient group you are best placed.
The key to a successful hip replacement is the surgical skill of the surgeon implanting the prosthesis and the type of bearing used in the ball and socket joint.
Modern day hip prosthesis may well last a patient a lifetime. It is most likely that a well recognized, tried and tested implant will not wear out in patients over the age of 70 provided the surgery is performed correctly. The key to implant longevity apart from good surgical technique is the materials used in the bearing (the actual parts that move).
Facts about bearings
The traditional hip bearing is a metal head (chrome cobalt ball) that moves on a polyethelene liner (“plastic” liner). Modern day plastic liners have very low wear rates unlike the material used 30 years ago. Studies show that modern day liners will probably take about 30 years to wear out. It is for this reason that it is likely that an artificial hip joint implanted in a patient over the age of 70 will last them a lifetime. Off course should the lining wear out sooner a new plastic lining can be inserted.
In an effort to develop bearings that last longer than the traditional “plastic” lining, a number of other alternatives are available. These include the following
Ceramic on Ceramic
Metal on Metal
Ceramic on Metal
These bearings were developed to allow younger patients to have hip replacements as they may last longer than traditional metal on plastic bearings and hopefully last a “lifetime”
Ceramic on Ceramic
The ceramic – ceramic bearings have been around for over 20 years. They have extremely low wear rates (1000 times less than plastic) and if implanted correctly may last 40 years or more.
Unfortunately ceramics are not perfect in that there is a 1 in 20 000 incidence of breakage / fracture (ceramic is more brittle than metal) and a very rare chance that the hip can develop a squeak.
In general however ceramic on ceramic bearings are an excellent choice to use in the young patient (under the age of 60). Surgical technique is critical.
Metal on Metal Bearings
These bearings have been around for over 30 years but have regained popularity with the introduction of modern designed hip resurfacing replacements.
The wear rate of metal on metal bearings is only slightly higher than ceramic on ceramic but like ceramics is significantly lower than metal on plastic bearings. Metal on metal bearings are very tough and are not susceptible to breakage (fracture).
The disadvantage of metal on metal bearings is that they produce metal ion particles and if the implant is not functioning properly these metal ions can invoke a significant inflammatory response in and around the hip joint which can cause hip pain and swelling.
Some patients are allergic to metal on metal implants but this is extremely rare. Some metal on metal bearings squeak but this is usually a temporary phenomenon.
Minimally Invasive Hip Surgery and Anterior Approach
Is this a marketing ploy or are the results better ??
There has been a lot of recent advertising press about the mini incision hip, anterior approach technique etc etc.
There are many approaches to implant a hip replacement. Over the last decade surgeons have become more skilled in making smaller incisions using refined techniques with better instrumentation.
Some approaches are more muscle sparing than others and recovery may be a little quicker HOWEVER the most important aspect of any hip surgery is to ensure that the prosthesis is implanted accurately and correctly, that the surgery is carried out in an efficient manner minimizing blood loss and reducing anaesthetic time and the risk of complications is kept to a minimum.
ANY approach will produce a good functional pain free outcome provided the surgeon is skilled at what he is doing.
The Anterior Approach (from the front) is more muscle sparing and allows a slightly quicker recovery. Patient selection is important and not all patients are suitable for this approach. This approach has a higher complication rate related to the technique and it is important that you choose a surgeon who is skilled in this technique. Whilst patients may recover quicker there is NO evidence to show that at 6 months post surgery there is any difference in functional outcome. Studies are on going to evaluate the long term benefit of this approach.
Total Hip Replacement surgery has now been in existence for almost 50 years. There are various surgical approaches that enable the surgeon to enter the hip joint and replace the arthritic hip.
Most surgical approaches involve splitting or dividing muscles / tendons and then repairing them at the end of the procedure.
The anterior approach to the hip joint was initially developed in 1949 / 1950 by Smith Peterson (USA) and Judet (France). The approach was developed to allow access to the hip joint by not dividing muscles or tendons and allowing exposure of the hip by going between muscles.
For 40 years the French used a traction table to perform hip replacement surgery however most of the orthopaedic world preferred to perform the surgery with the patient on their side allowing entry into the hip joint either through the side (transgluteal) or the back (posterior) approach. The posterior approach is the most popular approach used by surgeons all over the world as it is a very straight forward approach allowing good visualization of the hip joint.
The literature shows no evidence at 1 year post op that any approach is better than another with excellent clinical outcomes shown in all approaches.
In the last 7 years advances in technology in the design of equipment and instrumentation has allowed the surgeon to implant a hip through the anterior muscle sparing approach using a versatile traction table. The AMIS (Anterior Minimally Invasive Surgery) is a technique that uses a traction table to assist in implantation of the hip joint.
Published results have shown that a patient who undergoes a successful direct anterior approach hip replacement will recover quicker than conventional approaches. At this stage however there is no evidence that there is any long term advantage between approaches although should that patient require revision surgery in the future, there is a theoretical benefit as the anterior approach results in less internal scarring than other approaches.
Not all patients are suitable for the AMIS technique. Patients who are significantly overweight are at risk of having intraoperative complications due to limited visibility. Patients with abnormal hip joint anatomy are not suitable for the AMIS approach as this approach does not allow the correction of severe hip deformities. Some patients with very soft bone may not be suitable for the AMIS approach as there is a risk of fracture. Most revision hip surgery needs to be performed through conventional approaches.
The most important part of hip replacement surgery is that the surgeon implants the replacement safely and in excellent alignment to ensure optimum hip function, full pain relief and long term success of the implant.
Remember that ALL approaches if performed correctly will result in a successful pain free outcome that should last at least 20-30 years using modern day implants.
All patients would prefer a quicker recovery and therefore my approach is to use the AMIS procedure provided there are no contraindications.
Advantages of the AMIS approach include:
Less muscle damage
Surgery between muscle groups supplied by different nerves (internervous)
Earlier recovery with quicker return to function
Reduced incidence of hip dislocation
Ability to return to activities such as driving earlier
Reduced post operative precautions whilst the wound heals compared to other approaches.
Post operative rehabilitation is easier and quicker
Hip Resurfacing Replacements were designed to preserve bone so that should a patient require a revision in the future there was adequate bone left to revise the hip. This type of replacement is reserved for patients with good quality bone ie: no osteoporosis. It is therefore not suitable for elderly patients as there is a high risk of fracture of the bone that the implant is attached to.
THERE IS NO ADVANTAGE FOR A PATIENT OVER THE AGE OF 55 TO HAVE A HIP RESURFACING
Modern day resurfacings have been around for the past 12 years. The Birmingham Hip Resurfacing Replacement (Smith & Nephew Inc: www.smith-nephew.com) is the most successful of the Resurfacings on the market and has the longest track record (over 12 years) We have learned a great deal about resurfacings and the literature (including the Australian Joint Registry www.dmac.adelaide.edu.au/aoanjrr/) has outlined the best patients that are suited for this procedure.
Resurfacings do best in the young (less than 55 yr old) male or female with a large femoral head and who have primary osteoarthritis (ie primary osteoarthritis is wear and tear not due to underlying issues such as rheumatoid disease, shallow hip disease, avascular necrosis).
Most females however have smaller bones than males and therefore are not ideally suited to resurfacing replacement using available data.
In my practice I recommend hip resurfacing in the young active male with strong bone and a large femoral head.
Important facts to know about hip resurfacing:
Hip resurfacing patients take LONGER to recover than conventional total hip surgery patients. The reason for this is that in order to preserve the femoral head for resurfacing, more muscle and ligaments need to be released internally to allow the socket to be prepared. Patients are also advised to partial weight bear for 4 weeks post operatively to allow the bone to adapt to the new implant and not fracture. Conventional hip replacement patients are allowed to full weight bear immediately.
Hip Range of Motion in Resurfacing replacements is LESS than conventional total hip replacements using the same size ball and socket. The reason for this is that the resurfacing sits on the patient’s femoral head and neck and as such in maximal motion the femoral neck may impinge on bone preventing maximum movement compared to a ball that sits on a stemmed hip because the stemmed hip has a narrow neck allowing more impingement free motion (see drawing)
A good functioning hip resurfacing is very durable and whilst it is not recommended, there have been many reports of patients running and doing triathlons with resurfacings.
ALL hip replacements, resurfacing or conventional, allow the patient to partake in sporting activities including
Backyard running with the kids
As a general rule orthopaedic surgeons do not recommend high contact sports with ANY type of replacement (resurfacing or conventional) including rugby, competition soccer, competition basketball etc)
So what’s the advantage in having a resurfacing ??
Resurfacings preserve the femoral shaft and there are reports that some patients feel that the resurfaced hip “feels more natural”
It allows the possibility of a future revision to be done without to much difficulty HOWEVER it is likely that a well done standard total hip replacement with a modern day bearing will not need revising anyhow.
The BIGGEST issue with metal on metal resurfacings is accuracy in surgical technique. This fact has only recently come to our attention as it was thought that metal on metal implants are as “forgiving” as metal on plastic implants. Recent literature has shown that the metal on metal implants (and ceramic on ceramic bearings) are very susceptible to mal-alignment and if this occurs then these implants may fail.
Cemented or Uncemented prosthesis:
There is NO difference in the revision rates of either a cemented or uncemented femoral component (the hip stem that sits on the thigh bone). A well implanted cemented stem works just as well as a well implanted uncemented stem. As outlined above the key to longevity is in the bearing and NOT whether the stem is cemented or uncemented. A surgeon will choose what stem fits best into your bone quality. In general softer osteoporotic bone with thin cortices do better when cement is used to fixate the implant.
Most acetabular components (sockets) are uncemented and the bone will grow into the component. The lining is then placed in the metal shell and this lining is either plastic, ceramic or metal. Occasionally the bone is so soft that a plastic liner is cemented onto the bone instead of using and uncemented shell..
The Final word
I hope I have enlightened you on the basic facts about hip replacement surgery. I would summarize as follows:
Choose a surgeon who is well experienced in Hip Replacement Surgery
Be guided by the information presented above as to the types of hip replacements available, bearing options and operative approaches.
Do not be fooled by advertising and marketing hype.
My approach and recommendations to patients requiring a hip replacement. This is a GUIDE ONLY and each patient’s individual needs are taken into account before a final implant decision is made
Patients over the age of 75 usually have an uncemented stem (if bone quality good) or cemented stem (if bone quality poor) with an uncemented socket and polyethelene (plastic) liner. A metal head is used. This hip should last a lifetime
Patients between 65-75 usually have an uncemented stem and socket with either a ceramic on ceramic liner or ceramic on polyethelene liner. This hip should last a lifetime
Males under the age of 55 who are active and have excellent bone quality are candidates for a resurfacing HOWEVER we discuss the pros and cons of resurfacing vs total hip replacement with a ceramic bearing according to the patients individual circumstances.
Females under age 65 usually have an uncemented stem and socket with a ceramic on ceramic bearing
Males between 55-75 usually have an uncemented stem and socket with the bearing appropriate for their age.
Males under 55 have a resurfacing if they satisfy various criteria or an uncemented implant with a ceramic on ceramic bearing.
(Revised May Dec2012)
Click on the topics below
Normal Anatomy :: Hip Arthroscopy :: Anterior Hip Replacement
Femoroacetabular Impingement :: Total Hip Replacement THR
Hip Resurfacing :: Revision Hip Replacement
Complex Hip Surgery :: Periacetabular Osteotomy :: Prevent Osteoarthritis :: Hip Fracture
Normal Anatomy of the Hip joint
How does the Hip joint work?
Find out more in this web based movie.
Total Hip Replacement (THR)
Total Hip Replacement (THR) procedure replaces all or part of the hip joint with an artificial device (prosthesis) to eliminate pain and restore joint movement.
Find out more about Total Hip Replacement (THR) with the following links.
Anterior Hip Replacement
Direct Anterior Hip Replacement is a technique in which hip replacement surgery is performed through an alternative approach compared to conventional hip replacement surgery. Historically, hip replacement surgery was performed utilizing traditional posterior or lateral approaches. This necessitates that certain muscles or tendons are cut in order to access the hip joint and perform the surgery.
Find out more about Anterior Hip Replacement with the following links.
Hip Arthroscopy is a relatively new surgical technique that can be effectively employed to treat a variety of Hip conditions.
Find out more about Hip Arthroscopy with the following link
Femoro Acetabular Impingement FAI
Femoroacetabular Impingement FAI is a condition resulting from abnormal pressure and friction between the ball and socket of the Hip joint resulting in pain and progressive Hip dysfunction. This when left untreated leads to the development of secondary osteoarthritis of the hip.
Hip Resurfacing or bone conserving procedure replaces the acetabulum (hip socket) and resurfaces the femoral head. This means the femoral head has some or very little bone removed and replaced with the metal component. This spares the femoral canal. Find out more about Hip Resurfacing from the following options.
Find out more about Hip Resurfacing with the following links.
Revision Hip Replacement
This maybe because part or all of your previous hip replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone and hence is difficult to describe in full.
Find out more about Revision Hip Replacement with the following links.
Complex Hip Surgery
Find out more about Complex Hip Surgery with the following links.
Periacetabular osteotomy is the surgical procedure indicated in hip dysplasia and it involves cutting the bone around the acetabulum so as to fit the head of the femur bone into acetabular socket. This method was developed and performed by Professor Reinhold Ganz and therefore it is also called as Ganz osteotomy.
THE PERIACETABULAR OSTEOTOMY
Periacetabular Osteotomy is a hip preserving procedure performed to correct a congenital deficiency of the acetabulum:
Acetabular dysplasia is a condition defined by inadequate development of an individual's acetabulum. The resulting acetabulum is shallow and "dish shaped" rather than "cup shaped". The upper portion (roof of the acetabulum is obliquely inclined outward rather than having the normal horizontal orientation.
Because of these abnormalities, the superior and usually anterior femoral head are incompletely covered by this dysplastic acetabulum. Individuals with acetabular dysplasia usually develop through childhood and adolescence without symptoms or knowledge of their abnormality.
By the age of 30 however the patient typically experiences pain from their hip and they often seek medical evaluation and an X-ray discloses the abnormality (acetabular dysplasia). Other patients may have been treated for hip problems as an infant or child.
Acetabular dysplasia is often also associated with abnormalities in the shape of the upper femur which may contribute to the patient's hip symptoms.
Acetabular dysplasia is associated with an abnormally high stress on the outer edge (rim) of the acetabulum which leads to degeneration of the articular cartilage (arthritis). It is also possible for breakdown of the acetabular labrum (rim cartilage of the acetabulum) or a fatigue fracture of the rim of the acetabulum to occur as a result of this rim overload. Any one or a combination of these conditions can cause hip pain sufficient for the patient to seek medical evaluation and treatment.
When the diagnosis of acetabular dysplasia is made, the X-ray also usually shows a sign of arthritis which is most commonly an acetabular cyst though increased bone density, a femoral head cyst, osteophytes (bone spurs), and/or cartilage thinning may also be present. If the dysplasia is left uncorrected worsening of the arthritis is predictable and often progresses to a severe status within a few years and sometimes even a few months. For the patient, this means increasing hip pain, progressive loss of hip motion, and worsening
Periacetabular Osteotomy (PAO) is a surgical treatment for acetabular dysplasia that preserves and enhances the patient's own hip joint rather than replacing it with an artificial part. The goal is to alleviate the patient's pain, restore function, and maximize the functional life of their dysplastic hip.
PAO is a procedure that was developed and first performed in 1984 in Bern, Switzerland by Professor Reinhold Ganz.
Two parts comprise the hip joint: a ball on the upper end of the thigh bone (femur), called the head of the femur, and a socket in the pelvis known as the acetabulum. The hip joint, like other joints, is made up of specialized structural elements that serve as precisely fitting moving parts. The head of the femur rotates freely within the smooth, concentric surface of the acetabulum. An extremely low friction tissue, hyaline cartilage, lines this joint as well as others in the human body. The friction between two hyaline cartilage surfaces is much less than the best man-made bearing.
A normal acetabulum "covers" the upper (superior) portion of the head of the femur as well as a partial portion of the front (anterior) and back (posterior) of the femoral head "Periacetabular" means around the acetabulum. "Osteotomy" means to cut bone. Simply put, the PAO cuts the bone around the acetabulum that joins the acetabulum to the pelvis. Once the acetabulum is detached from the rest of the pelvis by a series of carefully controlled cuts, it is rotated to a position of ideal coverage as dictated by the specific acetabulum's unique anatomy. PAO thereby re-orientates the acetabulum by changing its rotational position. The dysplastic roof that incompletely covers the femoral head is brought over the head to give the head a normal coverage and also brings the roof from an oblique to a horizontal position.
Other subtle changes typically also occur. Anterior coverage may increase. Also the shortening of the extremity and lateralization of the joint which are often a part of acetabular dysplasia can also be improved. Individual cases of dysplasia however present with their own unique deficiencies and the PAO must often be tailored to solve these unique problems. X-rays take during surgery confirm the correct position of the acetabulum and screws (typically 3) are inserted into the bone to maintain the acetabulum's new corrected position during bone healing.
A proximal femoral osteotomy (cutting and repositioning the bone of the upper femur) is also advisable in about one out of 10 patients who undergo PAO surgery in order to correct abnormalities related to the femur. The indication for this is not always known until during the PAO operation. The femoral osteotomy is then completed during the same surgery though a second incision is necessary.
As with any other major hip surgery, there is some risk of complications. Surgical wound infection and injury to major nerves or arteries is possible. Non-union (lack of healing) of the bone following the osteotomy is also possible.
Studies have shown PAO to be a relatively safe operation with the chance for any one of these complications to be less than one percent.
The Natural History of an untreated shallow hip is to develop osteoarthritis in the patients 30’s or 40’s
The periacetabular osteotomy is designed to delay the onset and progression of hip arthritis. There is still a possibility that despite the surgery hip arthritis will continue to progress and very rarely may develop sooner if a complication arises
The Operation and Aftercare:
A cell saver is used in the operation to reduce the degree of blood loss.
An Epidural Anaesthetic as well as a General Anaesthetic is used during the surgery. The Epidural is for pain relief and is usually kept in for 3 days. A urinary catheter is placed in your bladder for 3 to 4 days. It is common for the vaginal or scrotal skin to swell for about 1 week post operatively. The swelling will always resolve. Patients spend the two hours following surgery in the recovery room where nurses closely monitor them.
The same team of medical specialists and nursing staff cares for each patient pre- and post-operatively. Included among the team's post-surgical priorities are pain management, preventing infection, and the prevention of deep vein thrombosis (blood clots in large veins), and pulmonary emboli (blood clots traveling through veins to the lungs).
Patients begin physical therapy as soon as possible to improve hip motion and muscle function and to learn to use appropriate assistive devices such as crutches or a walker. During the first eight weeks following surgery, the operated hip should bear no more than a limited weight of 10Kg’s. Placing full weight on the operated side prior healing may lead to screw breakage and for the osteotomy to lose its position. Too vigorous exercise such as resistive exercise against weights can also cause failure. If failure occurs, re-operation may be necessary and the chance of developing arthritis is greatly increased.
The usual hospital stay is 5 to 7 days and depends on how rapidly pain subsides and progress in physical therapy. At discharge pain medication is prescribed as well as an anticoagulant to prevent blood clots. Some degree of pain after discharge is natural which may increase or decrease on different days but the general trend should be toward decreasing pain. Some patients may sense an occasional "click" or "pop" in or around the hip. Numbness and a tingling sensation is common around the incision area. It is usual to feel numb on the outer aspect of the thigh due to bruising of a small skin nerve. This usually resolves but if not it does not cause any functional problems in the future.
After discharge if you experience severe or consistent pain or have redness, swelling and/or wound drainage please contact the hospital
Follow-up outpatient visits are necessary to monitor progress by X-ray and physical examination. The first follow-up visit is usually scheduled about 6 weeks after surgery and the second at 12 weeks.
At 8 weeks after the surgery the patient is allowed to be full weight bearing and work toward discontinuing use of the crutches. Muscle strengthening exercises often with the help of a physical therapist are also started. Progress in walking depends on return of muscle strength. The majority of patients are walking without support by 3 months after the surgery Subsequent follow-up visits are at 6 months, I year and 2 years after surgery and then at 2 year intervals. Screws are usually removed after 6 to 8 months as a small day only procedure with minimal discomfort.
Osteotomy should not be thought of as an inferior second choice to total hip replacement that the young patient with early arthritis must undergo because he or she is too young for total hip replacement. The results after PAO, which preserves the patient's own hip, justify its use and the long term results can be better than what the patient could have obtained from a hip replacement. The patient's own hip is a living tissue with self-maintenance capabilities, whereas deterioration with time is inevitable for an artificial part. The sensory capabilities of the joint are preserved and the patient can continue to remain as active as symptoms or their lack of permits. The patient with a total hip replacement, however, always must be cautioned and restricted from vigorous activity.
Appropriately selected patients have an 85% chance of a successful operation and pain free hip 20 years after the surgery.
Results of periacetabular ostetomies show the majority of patients with poor results did not have an immediate poor result but were benefited by the PAO for a variable period (up to 12 years) before requiring further surgery.
For patients who develop a poor result some time after their PAO surgery the cause is typically advancing hip arthritis. These patients are almost always best treated by total hip replacement surgery. For these patients the previous PAO has typically enhanced the acetabular bone with the increased femoral head coverage. Enhancement of a dysplastic acetabulum contributes to the success of a later total hip replacement by making the stability of the prosthetic acetabulum more reliable.
I trust the information provided in this handout will give you a better understanding about your hip problem and the surgical treatment available. Please do not hesitate to ask any questions.
Find out more about Prevent Osteoarthritis with the following links.
Hip fracture is a break in the upper end of the thigh bone forms the hip joint. It usually occurs in elderly people aged over 65 years either due to a fall or a direct blow to the hip. Certain medical conditions such as osteoporosis, cancer and stress injuries weaken the bone and increase the risk of hip fractures in elderly people. Often, hip fractures require surgical correction and the surgery depends on the part of the upper femur bone affected.
Find out more about Hip Fracture with the following links.