Anterior Hip Replacement
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Hip replacement has become necessary for your arthritic hip: this is one of the most effective operations known and should give you many years of freedom from pain.
Once you have arthritis which has not responded to conservative treatment, you may well be a candidate for total hip replacement surgery.
Arthritis is a general term covering numerous conditions where the joint surface (cartilage) wears out. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint. This surface can wear out for a number of reasons, often the definite cause is not known. When the articular cartilage wears out, the bone ends rub on one another and cause pain. There are numerous conditions that can cause arthritis and often the exact cause is never known. In general, but not always, it affects people as they get older (Osteoarthritis).
Other causes include
- Childhood disorders e.g., dislocated hip, Perthe’s disease, slipped epiphysis etc.
- Growth abnormalities of the hip (such as a shallow socket) may lead to premature arthritis
- Trauma (fracture)
- Increased stress e.g., overuse, overweight, etc.
- Avascular necrosis (loss of blood supply)
- Connective tissue disorders
- Inactive lifestyle- e.g., Obesity, as additional weight puts extra force on your joints which can lead to arthritis over a period of time
- Inflammation e.g., Rheumatoid arthritis
In an Arthritic Hip
- The cartilage lining is thinner than normal or completely absent
- The degree of cartilage damage and inflammation varies with the type and stage of arthritis
- The capsule of the arthritic hip is swollen
- The joint space is narrowed and irregular in outline; this can be seen in an X-ray image
- Bone spurs or excessive bone can also build up around the edges of the joint
- The combinations of these factors make the arthritic hip stiff and limit activities due to pain or fatigue
The diagnosis of osteoarthritis is made on history, physical examination & X-rays. There is no blood test to diagnose Osteoarthritis (wear & tear arthritis)
THR is indicated for arthritis of the hip that has failed to respond to conservative (non-operative) treatment.
You should consider a THR when you have
- Arthritis confirmed on X-ray
- Pain not responding to analgesics or anti-inflammatories
- Limitations of activities of daily living including your leisure activities, sport or work
- Pain keeping you awake at night
- Stiffness in the hip making mobility difficult
Prior to surgery you will usually have tried some simple treatments such as simple analgesics, weight loss, anti-inflammatory medications, modification of your activities, walking sticks, physiotherapy.
The decision to proceed with THR surgery is a cooperative one between you, your surgeon, family and your local doctor. Benefits of surgery include
- Reduced hip pain
- Increased mobility and movement
- Correction of deformity
- Equalization of leg length (not guaranteed)
- Increased leg strength
- Improved quality of life, ability to return to normal activities
- Enables you to sleep without pain
- Your surgeon will send you for routine blood tests and any other investigations required prior to your surgery
- You will asked to undertake a general medical check-up with a physician
- You should have any other medical, surgical or dental problems attended to prior to your surgery
- Make arrangements around the house prior to surgery
- Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
- Cease any naturopathic or herbal medications 10 days before surgery
- Stop smoking as long as possible prior to surgery
- USE THE SOAP PROVIDED TO YOU TO CLEAN YOUR BODY.
Day of your surgery
- You will be admitted to the hospital usually on the day of your surgery
- Further tests may be required on admission
- You will meet the nurses and answer some questions for the hospital records
- You will meet your anesthetist, who will ask you a few questions
- The operation site will be clipped of hair and cleaned.
- Approximately 30 min prior to surgery, you will be transferred to the operating room
- An incision is made over the hip to expose the hip joint
- The acetabulum (socket) is prepared using a special instrument called a reamer. The acetabular component is then inserted into the socket. This is sometimes reinforced with screws or occasionally cemented. A liner which can be made of plastic, metal or ceramic material is then placed inside the acetabular component.
- The femur (thigh bone) is then prepared. The femoral head which is arthritic is cut off and the bone prepared using special instruments, to exactly fit the new metal femoral component. The femoral component is then inserted into the femur. This may be press fit relying on bone to grow into it or cemented depending on a number of factors such as bone quality and surgeon’s preference.
- The real femoral head component is then placed on the femoral stem. This can be made of metal or ceramic.
- The hip is then reduced again, for the last time.
- The muscles and soft tissues are then closed carefully.
- You will wake up in the recovery room with a number of monitors to record your vitals. (blood pressure, pulse, oxygen saturation, temperature, etc.) You will have a dressing on your hip coming out of your wound.
- Once you are stable and awake you will be taken back to the ward.
- On the day of surgery, will usually be allowed to sit at the edge of your bed or get out of bed and walk depending on what time your surgery was.
- Pain is normal, but if you are in a lot of pain, inform your nurse. We will do everything we can to make you comfortable.
- You will be able to put all your weight on your hip and your Physiotherapist will help you with the post-op hip exercises.
- You will be discharged to go home or a rehabilitation hospital approximately 1-3 days depending on your pain, mobility and home layout.
- Sutures are usually dissolvable but if not are removed at about 10 days.
- A post-operative visit will be arranged prior to your discharge.
- You will be advised about how to walk with crutches and or a walker. You should use these walking aids until you feel comfortable to transition to a cane and then no aids as your balance and strength improve.
- Grabbers are helpful as are shoe horns or slip on shoes
- Elevated toilet seat helpful
- You can shower once the wound has healed
- You can apply Vitamin E or moisturizing cream into the wound once the wound has healed
- If you have increasing redness or swelling in the wound or temperatures over 100.5° you should call your doctor
- If you are having any procedures such as dental work or any other surgery you should take antibiotics before and after to prevent infection in your new prosthesis. Consult your surgeon for details
- Your hip replacement may go off in a metal detector at the airport
Risks and complications
We have listed possible complications/problems, which have been reported with arthroscopic hip surgery.
IN GENERAL, HIP REPLACEMENT THROUGH THE DIRECT ANTERIOR APPROACH IS EXTREMELY SAFE, HIGHLY SUCCESSFUL, AND HAS MINIMAL COMPLICATIONS ASSOCIATED WITH THE PROCEDURE.
Certain risks may be increased or decreased depending upon the types of arthroscopic surgery and
the extent of the injury that you have.
- Postoperative bleeding within the hip joint and around incisions: The bone often bleeds and is not possible to effectively stop the bleeding bone. In some instances patients will need a transfusion after surgery if they lose too much blood during or after surgery.
- Postoperative infection: Superficial (skin) or deep (within the joint) infections can occur. The incidence is reported at 1 in 1050 surgeries. A skin infection generally is treated with oral antibiotics. If you develop a deep infection, you would require re-admission to the hospital, return to the operating room to wash out the infection, and a variable period of intravenous antibiotics. In many cases the implants have to be removed for the body for a period of time until the infection is eradicated and then new ones can be reimplanted.
- Phlebitis (blood clots): Deep vein thrombosis or blood clots can occur in hip replacement surgery. A blood clot may require re-admission to the hospital and a treatment with an injectable blood thinner and rivaroxaban (Xarelto(R) or coumadin (warfarin) for several days followed by a 3-month period of oral anticoagulants.
- Pulmonary Embolus: When a blood clot becomes dislodged it may travel to the lungs resulting in acute shortness of breath, rapid heartbeat, and in rare situations result in sudden death.
- Nerve injury: The approach to the hip is near a nerve that provides sensation to the front of the thigh (Lateral Femoral Cutaneous Nerve). The approach avoids this nerve but rarely simple moving the nerve causes it to stop working and can cause burning, tingling or numbness in the thigh. This often recovers over a period of weeks to months. In studies the risk of this injury is 4 in 1050 surgeries (0.4%). The length of the leg will be made to be equal to your other leg. Rarely the lengthening of a leg can cause a pulling injury to the sciatic nerve and result in weakness at your ankle and numbness burning or tingling in the foot. This injury is extremely rare.
- Vessel injury: Rarely the major artery/vein in the lower extremity is injured. If this occurs it is generally quickly detected. In a major injury to these vessels, which course through the back of the knee, immediate vascular repair by a vascular surgeon is required with a subsequent hospitalization. Extremely rarely, vascular injuries have resulted in an amputation of the extremity.
- Dislocation: One of the reasons to perform a total hip replacement is to be able to use x-ray during surgery to ensure the best placement of the socket as possible. In some instances despite adequate placement the hip can dislocate. The risk of hip dislocation after an anterior approach hip replacement is less than 1 in 100 surgeries
- Reflex sympathetic dystrophy: This rare entity is characterized by burning and hypersensitivity in the leg. If this occurred postoperatively it would require referral to a pain clinic, prolonged rehabilitation, and epidural spinal pain blocks. This could happen at the thigh, leg or just the ankle.
- Compartment syndrome: This rare complication occurs when fluid leaks out of the hip into the muscle compartments. Massive swelling could result in compromise of the neurovascular structures with a potential complication resulting. If this were suspected or detected, emergency surgical decompression of the muscular compartments is required.
- Implant failure: Joint replacement relies on using manufactured implants to replace natural joints. It is possible that these implants could fail due to wear, cracking, trauma, or dislocation. In some cases these types of implant failure require a repeat surgery to remove and replace the problematic implants. Again, hip replacement surgery is a very effective and successful surgery.
- Fracture: When placing these components in your body they are held in place by the bone. In some cases the pressure applied to insert the components can cause the bone to break. Often this is discovered in surgery and stabilized with plates screws and or wires. Rarely it will not be recognized and will require going back to surgery to fix the fracture.
- Ankle Injury: To move the leg, the foot is placed in a boot and traction and twisting are applied to the leg. It is a possibility, although rare, that the ankle joint or the nerves or vessels going across the ankle joint could be injured.
- Anesthesia Problems: You will meet with the anesthesiologist on the day of surgery. The will formulate an anesthetic plan with you and discuss the specific risks and benefits of each anesthetic option that is safe for your surgery.
- Medical Problems: Hip replacement surgery is a major surgery. It will stress your body. This stress can exacerbate underlying heart, lung, brain, kidney, and digestive conditions as well as uncover new conditions in your body. In rare instances patients have died suddenly due to the stress put on their body from the surgery and immediate recovery. In order to make surgery as safe as possible we ask that you meet with your primary care practitioner to have a full physical and make sure that all of your health conditions are under control.
- Bruising: Some patients will note bruising around the hip. This is not a complication.
- Hip flexor tendonitis: Some patients may develop new symptoms or exaggerated current symptoms during the course of their rehabilitation, hip flexor tendinitis is often the cause and is prevented with strictadherence to postoperative physical therapy protocols.
- Squeaking: This is not a common occurrence but can happen. The cause for this squeaking is uncertain.
- Swelling: It is common and in fact expected to have swelling about your hip after surgery. Icing your hip is extremely helpful. Specific complications include Infection
- Ankle and Knee Pain:During the surgery the leg is rotated and twisted to allow Dr. Faucett to access the necessary parts of the hip. These rotations are done in a controlled manner but sometimes can cause pain and or injury to the knee or ankle. These usually are minor injuries and recover quickly. In rare instances a major injury to knee or ankle occurs.
- Infection can occur with any operation: In the hip this can be superficial or deep. Infection rates are approximately 1%. If it occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.
Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan- it may help to restore function to your damaged joints as well as relieve pain.