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Click for answers: (links to text locations) 1. What is a hip replacement? Hip replacement, or total hip arthroplasty, is a surgical procedure which replaces the worn out "ball and socket" hip joint with an artificial joint. The components of the joint are called the " implants" or the "prosthesis." Hip replacement is performed to alleviate pain, increase motion, and improve function. 2. Who should have hip replacement surgery? The most common reason for hip replacement surgery is arthritis. The most common variety of arthritis is osteoarthritis, sometimes also called "degenerative joint disease." Osteoarthritis is the " garden variety" of arthritis that almost everyone has to some degree by the age of 60. Less common causes of arthritis are rheumatoid arthritis, post-traumatic arthritis resulting from prior trauma, arthritis resulting from congenital/developmental disorders, and avascular necrosis (a loss of blood supply to the femoral head). Arthritis pain usually responds initially to conservative treatments such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, heat, ice, heating rubs, massage, and the use of a cane. When pain is not controlled by these measures, or when pain and stiffness interfere with a person's normal daily activities and ability to function, total hip replacement is often recommended. Historically, hip replacement surgery has not been recommended for patients under the age of 60. Standard total hip replacement components do not hold up well in younger, heavy, or more active patients. Recently, newer technologies have provided more durable implants for use even in younger, more active patients. Nevertheless, total hip replacement components will not last a lifetime in many patients, and these patients may require revision total hip replacement sometime down the road. 3. What are the alternatives to total hip replacement? Various non-surgical methods of treatment for hip arthritis should be utilized before resorting to surgery. These include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and the use of a cane. Newer NSAIDs, called Cox-2 inhibitors, tend to have fewer side effects than the older NSAIDs, although some have been taken off the market due to cardiovascular side effects. There has been no real evidence that these newer, more expensive Cox-2 inhibitors are any more effective in alleviating arthritis pain than the less expensive "non-selective" NSAIDs such as Motrin (ibuprofen) or Naprosyn (naproxen). Both Motrin and Naprosyn are available over the counter in the forms of Advil and Aleve, respectively. Occasionally, steroid injections may give temporary relief of arthritis pain. The hip joint is less often injected than the knee joint due to more difficulty and discomfort injecting the hip joint. Steroid injections reduce the inflammation that accompanies arthritis, thereby giving temporary partial relief of arthritis pain. When these methods no longer provide adequate pain relief, surgery is usually recommended. Younger patients with hip arthritis caused by congenital or developmental problems (such as congenital/developmental dysplasia of the hip) may be candidates for a procedure known as an "osteotomy." An osteotomy procedure essentially cuts and re-orients either the ball or socket of the hip joint to provide a better surface to bear the body's weight than the original joint surface. Osteotomies usually take longer to recover from than total hip replacement, but have the advantage of retaining one's own natural hip joint for a while, often 5-10 years; then conversion to a total hip is often necessary. These procedures are most commonly used in younger patients where it is desired to "buy some time" before total hip replacement. Total hip replacement surgery replaces the worn out ball and socket hip joint with an artificial joint. Using the minimally invasive technique, a 3-4 inch incision is made on the back of the hip. Through this incision, the worn out femoral head is removed. An artificial socket having a metal shell and a plastic or ceramic insert is implanted into the worn out socket, sometimes with the use of 1 or 2 screws to help secure the socket to the patient's bone. A metal stem with attached metal or ceramic ball is inserted into the femoral canal to replace the worn out femoral head. After the new joint has been implanted, the tissues surrounding the hip joint are repaired and the incision closed. Total hip replacement surgery using the minimally invasive technique usually takes around 1 hour to complete. Most artificial sockets ("acetabular components") are made of a titanium shell, which has a roughened outer surface that contacts the bone of the patients own hip socket. Titanium screws can be placed through the shell to help secure the socket in place during the first 6 weeks when bone grows into the pores on the roughened surface of the implant. This is called "porous ingrowth" or "cementless" technology. Inside the metal shell is attached a "liner" (or "insert") made of high-density polyethylene, or in some cases, a hard, smooth ceramic material. The artificial ball is made either of a hard cobalt-chromium alloy or a ceramic material. The ball is attached to a metal stem ("femoral component") often made of titanium that also has a roughened surface. The stem is inserted down inside the patient's femur bone, and over the following 6 weeks, the bone attaches to the stem to hold it in place permanently. Some surgeons use a special bone cement called " methacrylate" to attach the femoral stem (and sometimes the socket) to the patients bone. Controversy exists regarding when cement should be used in total hip replacement surgery. One of the main disadvantages of cemented total hip replacement is that the components are solid the day they are implanted, but then begin a gradual process of loosening every day thereafter. Although this is usually not a problem in patients with life expectancies less than 15-20 years, younger, heavy, or more active patients will develop loosening and require revision surgery even earlier. Therefore, cementless fixation is felt by most surgeons to be best for young, heavy, or active patients. Cement can have harmful effects. When cement is injected into the femur, it forces fat, clotting factors, and other debris into the circulation where it is filtered out by the lungs. This can result in difficulty breathing, blood clots, and rarely even death. Many surgeons choose to use a cementless fixation in all patients to avoid the harmful effects of cement. Some surgeons believe that cement is necessary to secure the femoral component to the femur in certain patients, particularly in older patients with softer bone. However, use of a femoral component design called the "tapered" design allows implantation in almost all patients without the use of cement, thereby avoiding its potentially harmful effects. Additionally, tapered stems allow immediate full weight bearing on the hip, unlike many other cementless designs. Therefore, tapered, cementless femoral components can be used in essentially all patients without delay in weight bearing or recovery. Patients wake up in the recovery room after total hip replacement surgery. Pain is minimized using a combination of a local anesthetic agent infused into the incision and intravenous pain medication controlled by the patient (PCA-"patient controlled analgesia"). Intravenous fluids are given to replace fluids lost during surgery. Once fully awake and comfortable, the patient is transferred to the patient care floor of the hospital. Often, the patient is allowed to sit on the edge of the bed for dinner the evening of surgery and even take a few steps if you desire. Physical therapy begins the first day after surgery. Most patients are quite comfortable, even on the first post-operative day. Often the pain from the new incision is less than that of the arthritis that has been alleviated by the surgery. The patient is allowed to place full weight on the new hip and will begin strengthening the muscles and work on getting in and out of bed, in and out of a chair, and will start walking with the aid of a walker or crutches, or even a cane. Walking, stair climbing, and exercises to strengthen the muscles of the hip are taught to the patient over the next day or two. Most patients are able to get up and around well with the use of crutches, walker or a cane within 2-3 days. At this point, the patient can usually be discharged home with visits from a home nurse and physical therapist 3 times per week. Rarely, a patient may need to go to a rehabilitation center for several days after leaving the hospital. This only happens if your walking or general mobility is not considered safe for discharge home by the 3rd or 4th post-op day, or if no one is able to stay with you (or at least check on you daily) for the first few days after you leave the hospital. The physical therapist will teach you stretching exercises to help cross your ankle over the opposite knee for handling shoes, socks, clipping toenails, etc. Always keep the knee rotated outward when you bend the hip past 90-degrees (such as reaching for something on the floor when sitting in a chair.) As a general rule, it is always safe to flex the hip past a 90-degree angle if you have rotated the knee outward enough that you can see the inside part of the knee-keep this rule in mind at all times; it will eventually become automatic when you bend over. Additionally, you will be given specific exercises by a Physical Therapist to help strengthen and stretch the muscles around the joint. Do these exercises regularly, at least 3 times daily, during the first 6 weeks after surgery. Stretching exercises are also important, particularly rotating the knee outward. You will be taught to sit in a chair with your feet together and press the knees outward while bending forward a bit. You will also begin to slide the operated ankle up the opposite leg with the knee rotated outward to eventually enable a “figure-4” position to allow easy access to your feet. Remember, as long as the knee is rotated outward, it is very difficult to dislocate the hip. (Note: these rules apply only to Dr. Swanson’s mini-incision technique with the capsular noose repair. If you have had a total hip replacement by another surgeon using a different technique, please follow their post-operative precautions.) Before you go home, you will be seen by an occupational therapist who will provide you some assistive devices such as a reacher, a long-handled shoehorn, and a sock applicator to assist with these functions during the first few weeks. The therapist will also teach you some tricks for caring for yourself during the first weeks of recovery. You will be discharged with a walker, crutches or cane and an elevated toilet seat for temporary use. You will be discharged with a pair of elastic stockings to minimize swelling in your legs and pooling of blood in your veins. You will also be instructed to take one coated aspirin twice daily, 2 or 3 iron pills each day, a non-steroidal anti-inflammatory drug such as Motrin, Advil or Aleve, and pain pills when you need them. You will continue the exercises taught you in the hospital on a daily basis and continue working on your walking. Patients undergoing minimally invasive total hip replacement generally recover quite quickly. The home nurse removes staples from the incision at 10-12 days. Advancement to the use of a cane for balance and support generally occurs within the first 1-2 weeks after surgery. Most patients are able to walk independently without the use of a walker, crutches, or cane by 3-6 weeks after surgery. At this time, most patients are comfortable, no longer requiring pain medication, and are returning to normal activities such as driving, work, shopping, and recreational activities such as swimming or golf. At 5-6 weeks after surgery, the patient is seen in the office and x-rays of the hip are taken. The exercise program that was taught to the patient in the hospital is modified to include use of a stationary bike to improve mobility of the hip. Over the next 6 weeks, the patient generally regains mobility allowing easy application of shoes and socks without assistive devices. An active lifestyle is usually resumed at 5-6 weeks post-operatively. The following also occur at 6 weeks:
9. When can I return to activities like showering or driving a car?
Total hip replacement surgery is a relatively safe procedure. However, it is important that you understand that no surgery is without risks. Luckily, complications from total hip replacement are uncommon, and the risks appear to be even less with the Minimally Invasive technique. Additionally, choosing a surgeon with significant experience in total hip replacement reduces the risk of complications. In short, more than 95% of patient undergoing total hip replacement obtain a good result with absolutely no problems or complications. Although there is no way that all of the possible complications can be listed here, the most common and /or worrisome complications are:
Although the list of potential complications is long and many are not covered here, the risk of each specific complication is quite small. The anesthesiologist will discuss the potential risks of anesthesia with you. Overall, total hip replacement is a safe procedure with very predictable results, giving good pain relief and restoration of function while having a low risk of complications. Learn what to expect before, during and after surgery at http://www.minitotalhip.com/webpages/WhatToExpect.htm. For a comprehension list of tips for surgery preparation visit http://www.minitotalhip.com/webpages/SurgeryPreparationTips.htm. Also, ask Dr. Swanson for an information booklet on total hip replacement and the minimally invasive total hip. Keep yourself as fit as possible. Continue walking or spending some time walking or swimming in a pool if possible. The stronger you can keep your muscles, the quicker your recovery from surgery will be. Try to quit smoking if possible, at least a week or so before surgery. Dr. Swanson can give you a prescription for a nicotine patch or gum if you need it. Arrange your home for your return. Put things you will need frequently together and at arm level. Clear any objects that may cause you to trip and fall out of the areas where you will be walking. Consider installing grab bars and a hand held shower head in your bathroom. Also, stock up on food staples and consider making a few meals and freezing them for easy preparation when you first return home. If you live alone, try to arrange for someone to spend the first couple days with you when you return home. A friend or family member does not need to stay with you constantly, but should be available when needed and stay with you the first couple nights you are home. This is recommended mainly as a precaution as you will be quite independent and largely able to care for yourself when you go home. 12. What types of activities can I resume after total hip replacement surgery? Most patients resume normal, active lifestyles after total hip replacement. In fact, activity levels often improve due to absence of the arthritic hip pain and stiffness. Most activities are felt acceptable after total hip replacement surgery, and can generally be resumed at 6 weeks after surgery. Start slowly, and then progress as your body and common sense allow. Walking, swimming, cycling, cross-country skiing, golf, doubles tennis, rollerblading, gardening, and dancing are examples of activities that are well tolerated by the artificial hip joint. Working out in a gym is also OK as long as specific exercises are avoided (such as leg presses, squats, and Stairmaster), and providing that exercises are done in moderation. Activities that should be avoided after total hip replacement fall into 2 categories: 1) those that put excessive stress and wear on the hip, and 2) those that present a significant risk of dislocation. Activities that cause excessive wear and tear on the hip joint include activities such as jogging, singles tennis, racquetball, basketball, and any activity that involves running, jumping, or repetitive heavy lifting. These activities wear out the hip joint either because of excessive repetitive motion or high "impact loading" (the hard, jolting stress to the hip joint such as occurs with jumping or running). Think of your new hip joint as a new tire on your car: if you continuously drive it too fast or over rough terrain, the tire will wear out more quickly than if you drive it sensibly on smooth highways. Activities that present a significant risk of dislocation include activities where a fall is likely, such as skiing, horseback riding, and rock climbing. Of course, if one is an accomplished skier, for example, skiing the green or smooth blue runs may be safe. Likewise, if one is an accomplished horseback rider, riding on safe terrain on a well-trained horse may also be safe. One should use common sense when deciding whether an activity has a significant risk for a fall and possible dislocation. Modern technology allows most hip replacement surgeries to last a long time (15-20 years in most cases). Some newer technologies, such as ceramic-ceramic total hips or highly crosslinked polyethylene, may extend the life of a total hip replacement even longer, particularly in younger, heavier, or more active patients. However, revision surgery may be necessary when the hip socket wears out or if the prosthesis loosens. Luckily, this happens in only 10% or less of total hip replacements. Revision total hip surgery involves going in (generally through the original incision) and replacing the worn out parts. Sometimes, the plastic debris generated with wear of a plastic socket may cause a reaction in the bone called "osteolysis." Osteolysis is a process where bone cells act too aggressively and eat holes in the bone. When this happens, the revision surgery may include bone grafting of the holes using either artificial bone or donor bone from a bone bank. Most revision surgeries do quite well today, although the risks of surgery are a bit higher than with first time total hip replacement. 14. What new technologies and developments are on the horizon? The most promising new technologies being developed are bearing surfaces that do not wear out quickly, even with high stress activities. Three main technologies are now either being used or are in the final stages of testing: Highly crosslinked polyethylene is a new type of plastic used in total hip sockets. This new plastic has been available for a few years and is approved by the FDA. Although the wear studies from the laboratory look very promising, there have been a few reports of problems with certain brands of crosslinked polyethylene. However, the new material holds promise of lasting much longer than standard polyethylene, and may allow the use of larger prosthetic heads and should decrease the risk of dislocation. Nevertheless, some caution is still exercised when deciding to use crosslinked polyethylene due to the fact that it has just not been in clinical use for long. Metal-on-metal total hips utilize a ball and socket both made of a cobalt-chromium metal alloy. The patient's own joint fluid lubricates the surfaces of the joint to give the hip smooth motion. Metal-on-metal hips have been used in various forms for several years and are approved by the FDA. The main controversy with metal-metal hips is the high concentration of metal ions found in the blood, tissues, and urine of patients having metal-metal hips. Unfortunately, we do not know the long-term consequences of high tissue concentrations of cobalt or chromium, but many believe that they could lead to problems including cancer (click here for article). Nevertheless, those receiving a metal-metal hip (even young, heavy, or active patients) can expect to see minimal wear of the bearing surface over many years. Ceramic-on-ceramic total hips utilize a ball and socket both made of alumina, a very hard, smooth material. Ceramic-ceramic hips differ from metal-metal hips in that ceramic is extremely biocompatible and debris does not spread into the tissues, blood, or urine of the patient. The risk of a systemic problem, such as cancer, is not a worry. Ceramic-ceramic hips have been used in various forms for several years and were approved for general use by the FDA in February of 2003. The main concern with ceramic-ceramic has been breakage of the brittle material, particularly if a patient falls, landing on the hip. This risk of breakage has significantly decreased over the years due to improvements in manufacturing techniques. Recent studies suggest that the risk of a ceramic fracture is around 1 in 10,000 or so. However, it is critical that the components be positioned correctly because any malpositioning of the components can increase the risk of fracture. Ceramic-ceramic total hip replacement holds promise for becoming the bearing surface of choice in the future, providing years of use with negligible wear. The second area of development in total hip replacement is the surgical technique. Minimally invasive techniques are used in many other areas of surgery including arthroscopy, laparoscopy, some types of spine surgery, and even some open-heart surgeries. Minimally invasive techniques have now been developed for total hip replacement surgery as well. The advantages of minimally invasive surgery are:
Nearly every patient undergoing total hip replacement with Dr. Swanson is a candidate for the minimally invasive technique as the incision length used is based on patient size and weight and may vary from 3 inches in the very thin, petite patient to 5 inches in the large, heavy patient. Most patients require a 3 1/2 to 4 inch incision. 15. Where can I get more general information on total hip replacement surgery? Link Library http://www.minitotalhip.com/webpages/Links.htm General Information http://www.minitotalhip.com/webpages/GenInfoPatients.htm What to Expect http://www.minitotalhip.com/webpages/WhatToExpect.htm Surgery Preparation Tips http://www.minitotalhip.com/webpages/SurgeryPreparationTips.htm Patient Stories http://www.minitotalhip.com/webpages/PatientStories.htm Patient Post-Op Videos http://www.minitotalhip.com/webpages/PatientVideos.htm Surgery Video http://www.minitotalhip.com/webpages/Video.htm Discussion Board http://disc.server.com/Indices/216603.html Disclaimer:The information provided here is intended to educate the reader about certain medical conditions and certain possible treatment. It is not a substitute for examination, diagnosis, and medical care provided by a licensed and qualified health professional. If you believe you, your child, or someone you know, suffer from the conditions described herein, please see your health care provider immediately. Do not attempt to treat yourself, your child or anyone else without proper medical supervision. ©2006 Todd Swanson, M.D. The minimally invasive total hip replacement was developed by Dr. Swanson after being introduced to the concept in early 1997. Dr. Swanson began using the technique in May of 1997 and has continued to make improvements that now allow reliable surgery and reproducibly good results in most patients. Standardization of the technique has allowed teaching to other surgeons. Numerous physicians and orthopedic companies have shown interest in promoting “minimally invasive surgery” for total hip replacements. The minimally invasive technique utilizes a 3-4 inch incision, much smaller than the 8-10 inch approach historically used for hip replacement. Patients require less anesthesia and pain medication, and mobilize more quickly. This results in both quicker recovery for the patient and a lower incidence of complications. Patients typically recover from minimally invasive surgery in about half the time it takes to recover from standard incision surgery (6 weeks vs. 12 weeks). |
  
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