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Bahri Orthopaedics

Total Hip Replacement

The hip joint can be damaged by arthritis and  fractures  making activities such as walking or getting in and out of a chair or car seat painful and difficult. Dressing activities may be problematic.  Sometimes, individuals may feel pain even at rest. Hip replacement surgery (partial or complete) may be necessary if the non-operative options (i.e. use of walking aids, medications, and activity modification) have failed. Hip replacement surgery can relieve pain, improve motion, and allow return to daily activities. More than 200,000 total hip replacements are performed each year in the United States.

Anatomy

 The hip is made up of two main parts: a ball (femoral head) at the top of  the femur that fits into a circular socket called the acetabulum in your pelvis. There are ligaments (hip capsule) that connect the femoral head to the acetabulum and provide stability for the hip joint.
The surfaces of the joint have articular cartilage that cushions the joint, reduces friction, and enables a smooth range of functional motion. The synovial membrane is soft tissue that covers all remaining surfaces of the hip joint. In normal hip joints, this membrane makes fluid that lubricates the hip joint (Figure 1).

Mechanical Properties of the Hip Joint

Figure 1: Mechanical Properties of Hip Joint

 

 

 

 

 

 

 

 

 

 

 

 

 

Causes of hip pain and loss of motion

The most common causes of chronic hip pain and motion loss are osteoarthritis, rheumatoid arthritis, and  post-traumatic arthritis. Osteoarthritis generally occurs in people over the age of 50 years. There is often a family history arthritis. With osteoarthritis, the articular cartilage of the hip wears away over time (Figure 2). Once the cartilage is gone, the hip becomes painful and stiff. Rheumatoid arthritis is an autoimmune disorder in which the synovial membrane becomes inflamed causing damage to the articular cartilage. Traumatic arthritis may follow a serious hip injury or fracture (i.e. femoral head or acetabular fracture). The articular cartilage may deteriorate over a shorter time frame requiring joint replacement surgery at an earlier age.

Orthopaedic referral and evaluation

 After your evaluation by our orthopaedist,  he or she will discuss whether hip replacement surgery is the best option to provide  pain  relief and improved  mobility. Non-operative treatment options such as medications, physical therapy  may be considered. A full discussion of the potential risks and complications of hip replacement surgery is held with the individual.  The orthopaedic evaluation includes a medical history,  physical examination, x-rays, and  blood tests. MRIs or bone scans may be necessary to determine the health of the bone and soft tissues of your hip joint.

Getting ready for surgery

Once you decide to  have hip replacement surgery, you will be asked to complete a physical examination by your primary care physician before your surgical procedure. This is required to determine if you would be medically fit to proceed with surgery.  Several lab tests may be necessary prior to  your surgery, such as blood and urine samples, EKG, and chest x-ray.  Your orthopaedic surgeon should be made aware of any and all medications you are taking. Either your orthopaedist or your primary care physician will advise you which medications you can continue prior to surgery.  Although infections after hip replacement are uncommon, an infection can occur if bacteria enter your bloodstream from a remote location like your mouth. It is strongly recommended that you get treatment for dental problems like tooth extractions and periodontal work  before your hip replacement surgery. Routine dental check-ups (cleaning) of your teeth should be delayed for at least 6 to 8 weeks after surgery.  Any patient with a history of recent or frequent urinary infections and  men with prostate disease should consider seeing a urologist prior to surgery. 

Surgery

Mechanical Deterioration of the Hip Joint
Figure 2: Mechanical deterioration of the Hip joint

You will be admitted to the hospital on the day of your surgery after intervention. The anesthesiologist  will discuss the anesthesia options with you. The most common types of anesthesia for hip replacement surgery are general anesthesia and spinal anesthesia. Sometimes regional blocks (femoral and sciatic nerve) are used in addition to general anesthesia to assist with postoperative pain control.  The surgical procedure  generally takes 2 to 3 hours. The surgery involves removal of  damaged cartilage and bone and then placement of metal, plastic, or ceramic joint components to restore the alignment and function of your hip.  There are different types of designs and materials that are in hip replacement surgery. They consist of two main components: the femoral head component (made of a highly polished metal or ceramic material) and the acetabular component, made of plastic, ceramic or metal (Figure 3). Though less common,  cement may be used to fill the gap between the prosthesis and  the bone to stabilize the joint.

A newer technique, called hip resurfacing, is used in younger individuals to preserve bone if future additional surgery is anticipated.  With hip resurfacing the femoral head is not removed, but is instead "smoothed" and capped with a spherical metal covering. The damaged bone and cartilage within the socket is removed and replaced with another metal shell (Figure 4). There are some potential advantages to this procedure: easier to revise to traditional replacement due to previous preservation of bone,  decreased risk of dislocation, greater hip motion, and a "more natural walking pattern".  Despite these advantages, there are some additional risks such as femoral neck fracture, metal ion release, and  increased surgical complexity. This procedure requires additional training and technical skill due to the increased complexity of the surgery.

Most people after surgery spend two to three days in the hospital.  Pain medication will be given to make you as comfortable as possible. To protect your hip after surgery an abduction pillow or knee immobilizer may be used. Your surgeon may impose restrictions for a defined period of time regarding the use of your new hip, such as limiting the amount of flexion and rotation. You are placed on medications to minimize the risk of blood clots. The duration of treatment with these medication is determined by your surgeon. Walking is important to your recovery and will begin the day after your surgery with the assistance of physical therapy.  Some patients requires additional supervised therapy and nursing care at an acute rehabilitation facility. The case manager/social service worker assists you in making the right decision regarding your discharge plans.

Hip Resurfacing
Figure 3: Hip Replacement

Expectations and recommendations after hip replacement surgery

Most people who have hip replacement surgery experience significant hip pain reduction and functional improvement.  Hip replacement surgery will not allow you to do more than you could do before your development of hip arthritis. Your surgeon will recommend avoiding certain activities such as jogging and high-impact sports for the duration of your life. Even with routine use , artificial joints can wear out over time. If you participate in high-impact activities such as running or basketball or are overweight, this wear lead to accelerated wear of the joint and cause the prosthesis to loosen and become painful. Your new hip joint may trigger metal detectors in airports and some buildings. Your orthopaedic surgeon may provided a card confirming that you have an artificial hip joint. 

Hip Resurfacing
Figure 4: Hip Resurfacing

We recommend that you participate in a regular light exercise program to maintain strength and mobility of your new hip. Precautions should be taken to avoid falls and injuries. Individuals who have undergone hip replacement surgery and experience a fracture may require additional surgery. You dentist or oral surgeon shoulder be made aware that you have had a hip replacement. You will need to take antibiotics before any dental procedure. Your orthopaedic surgeon will see you for routine follow-up examinations and x-rays even if your hip replacement is doing well.