Total hip replacement

Overview

Walking or getting in and out of a chair may be uncomfortable and difficult if your hip has been injured by arthritis, a fracture, or other disorders. Your hip may feel stiff, making it difficult to put on shoes and socks. You could even feel uneasy while sleeping.

If drugs, changes in your daily activities, and the use of walking aids do not alleviate your symptoms, you may want to consider hip replacement surgery. Hip replacement surgery is a safe and successful operation that can reduce pain, enhance mobility, and help you go back to doing the things you like.

What is Total Hip Replacement?

Hip replacement surgery involves the removal and replacement of parts of the pelvis and femur (thighbone) that make up the hip joint. It is generally used to treat hip pain and stiffness caused by hip arthritis. This treatment is also used to address injuries such as a fractured or incorrectly developing hip, as well as other disorders.

Hip replacement surgery is one of the most effective procedures in medical history. Improvements in joint replacement surgical techniques and technology have considerably boosted the efficacy of complete hip replacement since the early 1960s. In the United States, around 450,000 complete hip replacements are performed each year.

Anatomy

The hip is one of the biggest joints in the body. A ball-and-socket joint is used. The acetabulum, which is a portion of the pelvic bone, forms the socket. The ball is the femoral head, which is the femur's upper end (thighbone)

The ball and socket bone surfaces are coated with articular cartilage, a smooth tissue that cushions the ends of the bones and allows them to move freely.

The hip joint is surrounded by a thin tissue called the synovial membrane. This membrane produces a little quantity of fluid that lubricates the cartilage and removes practically all friction during hip movement in a healthy hip. Ligaments (the hip capsule) are bands of tissue that attach the ball to the socket and offer support to the joint.

Common Causes of Hip Pain

Arthritis is the most prevalent cause of persistent hip pain and impairment. The most prevalent types of this illness include osteoarthritis, rheumatoid arthritis, and traumatic arthritis.

• Osteoarthritis. This kind of arthritis is caused by age-related wear and strain. It mainly affects persons over the age of 50, and it is more common in people who have a family history of arthritis. The cartilage that cushions the hip bones wears away. The bones then rub together, resulting in hip pain and stiffness. Osteoarthritis can also be induced or hastened by minor anomalies in the development of the hip throughout childhood.
• Rheumatoid arthritis. This is an autoimmune condition that causes inflammation and thickening of the synovial membrane. Chronic inflammation can cause cartilage degradation, resulting in discomfort and stiffness. Rheumatoid arthritis is the most frequent kind of an inflammatory arthritis condition.
• Posttraumatic arthritis. This can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
• Osteonecrosis. A hip injury, such as a dislocation or fracture, can cut off blood circulation to the femoral head. This is known as osteonecrosis (also sometimes referred to as avascular necrosis). A lack of circulation may cause the surface of the bone to crumble, resulting in arthritis. Some diseases can result in osteonecrosis.
• Childhood hip disease. Hip issues occur in certain newborns and youngsters. Even if the issues are properly managed throughout childhood, they may induce arthritis later in life. This occurs when the hip does not expand correctly and the joint surfaces are harmed.

When Surgery is Recommended?

Your doctor may prescribe hip replacement surgery for a variety of reasons. Individuals who benefit from hip replacement surgery frequently have:

• Hip pain that limits everyday activities, such as walking or bending
• Hip pain that continues while resting, either day or night
• Stiffness in a hip that limits the ability to move or lift the leg
• Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

Candidates for Surgery

Total hip replacements have no absolute age or weight restrictions.

Surgery is recommended based on a patient's pain and disability, not their age. The majority of patients who get total hip replacement are between the ages of 50 and 80, however, orthopedic surgeons examine each patient individually. Total hip replacements have been successfully performed on patients of all ages, from the young adolescent with juvenile arthritis to the elderly patient with degenerative arthritis.

What are the different types of hip replacement surgery?

The three major types of hip replacement are:

• Total hip replacement (most common)
• Partial hip replacement
• Hip resurfacing

A total hip replacement is the most common type of hip replacement surgery. Artificial implants are used to replace worn-out or damaged hip sections during this surgery. The socket is replaced with a strong plastic cup that may or may not have a titanium metal casing. Your femoral head will be removed and replaced with a ceramic or metal alloy ball. The replacement ball is linked to a metal stem that is placed into your femur's top.

Two other types of hip replacement surgeries are each generally appropriate for patients of specific age groups and activity levels:

• Partial hip replacement (also known as hemiarthroplasty) entails replacing only one side of the hip joint - the femoral head - rather than both sides as is the case with total hip replacement. This treatment is most typically performed on elderly individuals who have suffered a hip fracture.
• Hip resurfacing of the femoral head and socket is often performed on younger, more active patients.

The Orthopedic Evaluation

An evaluation with an orthopedic surgeon consists of several components:

• Medical history. Your orthopedic surgeon will ask you questions about your overall health and the level of your hip discomfort and how it impacts your ability to do daily activities.
• Physical examination. This will assess hip mobility, strength, and alignment.
• X-rays. These images help to determine the extent of damage or deformity in your hip.
• Other tests. Occasionally other tests, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.

Deciding to Have Hip Replacement Surgery

Your orthopedic surgeon will go through the results of your examination with you and decide whether hip replacement surgery is the best option for relieving pain and improving mobility. Other treatment options, such as medicines, physical therapy, or surgery, may also be explored.

Furthermore, your orthopedic physician will describe the possible risks and consequences of hip replacement surgery, including those connected to the operation itself as well as those that might develop thereafter.

When you don't understand something, don't be afraid to ask your doctor. The more you know, the better you'll be able to deal with the changes that hip replacement surgery will bring to your life.

Preparing for Surgery

Medical Evaluation

If you elect to have hip replacement surgery, your orthopedic surgeon may request that you have a thorough physical examination by your primary care physician prior to the procedure. This is required to ensure that you are in good enough health to have surgery and recover fully. Before surgery, many individuals with chronic medical issues, such as heart disease, may be assessed by a specialist, such as a cardiologist.

Tests

A blood and urine sample, an electrocardiogram (EKG), and chest x-rays may be required to assist plan your surgery.

Preparing Your Skin

Before surgery, your skin should be free of any infections or irritations. Contact your orthopedic surgeon for therapy to improve your skin before surgery if either is present.

Medications

Inform your orthopedic surgeon about any drugs you are currently taking. They or your primary care physician will advise you on which drugs to discontinue and which to continue taking prior to surgery.

Weight Loss

If you are overweight, your doctor may advise you to drop some weight before surgery in order to reduce the load on your new hip and, perhaps, the hazards of surgery.

Dental Evaluation

Infections after hip replacement are uncommon, but they can occur if bacteria enter your bloodstream. Because dental procedures can introduce bacteria into the bloodstream, major dental procedures (such as tooth extractions and periodontal work) should be completed prior to hip replacement surgery. Routine tooth cleaning should be postponed for many weeks following surgery.

Urinary Evaluation

Individuals having a history of recent or frequent urinary infections should be evaluated by a urologist prior to surgery. Older men with prostate disease should think about finishing their therapy before undergoing surgery.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

• Securely fastened safety bars or handrails in your shower or bath
• Secure handrails along all stairways
• A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms
• A raised toilet seat
• A stable shower bench or chair for bathing
• A long-handled sponge and shower hose
• A dressing stick, a sock assist, and a long-handled shoehorn for putting on and removing shoes and socks without bending your new hip unduly.
• A reacher that allows you to grab stuff without bending your hips too much.
• Firm cushions for chairs, couches, and automobiles that allow you to sit with your knees lower than your hips.
• Remove all loose carpeting and electrical cables from the areas of your home where you walk.

Surgical Technique

Approaches

The THA surgery can be carried out in a variety of ways. The following are the three most common approaches:

1. Posterior

This is the most popular method for treating initial and revision THA problems. This dissection does not make use of a real intervertebral plane. The intermuscular gap is created by blunt dissection of the gluteus maximus fibers and distal sharp incision of the fascia lata. The short external rotators and capsule are meticulously dissected during the deep dissection. These structures are carefully protected before being restored back to the proximal femur through trans-osseous tunnels.

The avoiding of hip abductors is a significant benefit of this strategy. Other advantages include the great exposure afforded for both the acetabulum and the femur, as well as the choice of proximal or distal extensile conversion. Historically, several studies comparing this method to the direct anterior (DA) approach found that the former had a greater dislocation rate.

    2. Direct Anterior (DA)

THA surgeons are increasingly using the DA method. The internervous interval is defined as the distance between the tensor fascia lata (TFL, superior gluteal nerve) and the sartorius (femoral nerve) on the superficial end and the gluteus medius (superficial gluteal nerve) and the rectus femoris (RF, femoral nerve) on the deep side. Advocates of DA THA point to theoretically lower postoperative hip dislocation rates and avoidance of the hip abduction musculature.

The disadvantages include the learning curve associated with the approach, as the literature shows that complication rates decrease after a surgeon has performed more than 100 cases. Other disadvantages include an increased risk of wound complications in obese patients with large panni (without the use of an abdominal binder), difficult femoral exposure, the risk of lateral femoral cutaneous nerve (LFCN) paresthesias, and a potentially higher rate of intra-operative femur fractures. Finally, many surgeons require access to a specialized operating table staffed by adequately qualified people and surgical technicians.

    3. Anterolateral (Watson-Jones)

The anterolateral (AL) method is the least usually employed of the three procedures since it violates the hip abductor mechanism. The period used comprises the muscle of the TFL and gluteus medius. This may result in a postoperative limp in exchange for a theoretically lower dislocation rate.

 How long does it last?

The average answer to this question is that complete joint replacement lasts about 15-20 years. The annual failure rates are a more accurate way to think about longevity.

According to the most recent data, both hip and knee replacements have an annual failure rate of 0.5-1.0%. This indicates that if you get your complete joint replaced today, you have a 90-95% probability of it lasting 10 years and an 80-85% chance of it lasting 20 years. These figures may improve as technology advances.

Despite these advancements, it is critical to keep a long-term follow-up with your surgeon to ensure that your replacement is operating properly.

What should I expect after hip replacement surgery?

After the procedure, you will most likely be hospitalized for a few days. Most patients will be urged to walk with the assistance of a walking support as soon as possible following surgery. You will be given instructions on how to care for your new hip and avoid hip dislocation. For the first three months, you should avoid sitting on low seats, as well as sprinting, crouching, and leaping.

Rehabilitation, including physiotherapy and occupational therapy, will be required to strengthen the replacement joint and increase flexibility. After around 3 months, you should be able to resume most of your typical activities, which may be simpler because your hip discomfort has subsided. Some people require 6 to 12 months to fully appreciate the benefits of a hip replacement.

Your surgeon will tell you what activities you can perform following the procedure, although you should probably avoid high-impact sports.

Are surgery and recovery very painful?

Pain after the total hip replacement has come a long way in the last 10-15 years, thanks to increased use of regional nerve blocks, spinal blocks, and other pain-controlling modalities. Total hip replacement is thought to be less painful than total knee replacement. Early range of motion and quick rehabilitation methods are also aimed to lessen early stiffness and discomfort, making the treatment less uncomfortable in general than in the past.

You may experience relatively minimal discomfort after the treatment, or you may experience more difficulty than others. Everyone is different, and everyone manages and experiences pain differently. Remember that, while pain management has considerably improved, pain-free surgery is still rare. You should take your pain relievers exactly as prescribed by your surgeon.

What is minimally invasive surgery?

Minimally invasive surgery refers to a combination of shortening the incision and minimizing tissue disturbance underneath the incision. This entails removing less muscle and separating less tendon from bone. Additionally, advances in anesthetic and pain management during and after surgery have occurred. All of these techniques enable you to feel better, experience less discomfort, and restore function more quickly than in the past. While minimally invasive surgery may have some early advantages, as long as the components are properly positioned, standard surgery eventually results in identical outcomes three months after surgery.

FAQ

• How long will I stay in the hospital?

You will most likely be hospitalized for one to three days, depending on your rehabilitation plan and how quickly you improve through physical therapy. This is mainly dependent on your condition before to surgery, your age, and any medical issues that may affect your recovery. The orthopedic experts will create a safe discharge plan for you.

• When can I shower?

Most surgeons prefer not to expose the incision to water for five to seven days; however, more doctors are employing waterproof coverings that allow patients to wash the day following surgery. The dressing can be removed seven to 10 days following surgery. After removing the dressings, you should not wet the site for three to four weeks, or until the incision is entirely healed. In any case, it is critical to consult with your surgeon about when it is safe to shower and what wound closure technique/dressings will be utilized for your surgical wound.

• When can I walk after surgery?

Nowadays, most surgeons and hospitals place a premium on getting you out of bed as soon as possible. On the day after surgery, most patients are walking with the help of a walker. Early ambulation reduces the chance of a post-operative blood clot and is an important aspect of your rehabilitation. Progression to needing a cane or nothing at all usually occurs within the first month or two of surgery and is dependent on the progress of each individual. Despite the quick improvement to movement without help, it is not usually suggested that you return to sports until the third month after surgery.

• When can I drive?

Most surgeons allow patients to drive four to six weeks following surgery, or sooner if the operated limb is the left leg. According to some research, your response speed will not return to normal for at least six weeks. You should not drive while on drugs and should consult with your operating surgeon before returning to driving.

• When can I return to work?

Returning to work is heavily reliant on your overall health, activity level, and job expectations. You can anticipate to return to work in four to six weeks if you have a sedentary job, such as computer work. If you have a more demanding work that entails lifting, walking, or travel, complete recovery might take up to three months.

• What restrictions will I have after surgery?

Your rehabilitation instructions, including limits, may change slightly depending on how your physician conducts your operation. In general, most surgeons recommend that you avoid certain hip postures that might raise your risk of hip dislocation for around six weeks after surgery. After six weeks, the surgical soft tissues have healed, and limitations are frequently eased, allowing for more rigorous activities.

Many surgeons recommend avoiding any repetitive impact sports that might cause the implant to wear out, such as long distance running, basketball, or mogul skiing. Otherwise, there are few limits following hip replacement surgery; nevertheless, the better you care for your replacement, the longer it will last.

• Will I need physical therapy, and if so, for how long?

You will first undergo physical therapy while in the hospital. Depending on your preoperative conditioning and assistance, you may or may not require extra outpatient therapy. Walking with general stretching and thigh muscle strengthening is a large part of the rehabilitation after hip replacement that you may accomplish on your own without the aid of a physical therapist.

Conclusion 

A total hip replacement involves the removal of a problematic hip joint and the insertion of a new ball and socket into the arthritic hip joint, therefore relieving hip pain and restoring mobility. The treatment is normally performed under a spinal anesthetic, although it can be paired with sedation to put you to sleep. Damaged bone and cartilage (tissue at the end of the bone that cushions the joint) are removed from the hip joint during hip replacement surgery. These are replaced with metal or plastic components. Hip replacement surgery typically takes between 1 and 2 hours. A general anesthetic, which renders you completely unconscious, or a spinal anesthetic, which numbs the lower half of your body, will be administered.