Total Hip Replacement Surgery | Richardson TX
Total hip replacement surgery, also known as total hip arthroplasty (or THA for short), is a surgery that replaces a painful, nonfunctional hip joint with metal implants, along with a plastic bearing surface to create a new, “prosthetic” hip joint. The goal of total hip replacement surgery is to restore a patient’s hip function, regain range of motion, and perhaps most importantly, to eliminate pain.
Why do I need a hip replacement?
The majority of hip replacements we do are elective surgeries. That is to say, a surgery that can be scheduled, and takes place at a time and on a date of mutual convenience. The benefits of elective joint replacement are that timing, and any factors that stand to complicate your surgery, can be altered to give you the very best potential for a wonderful outcome.
Sometimes a hip replacement may have to be done in more urgent circumstances. An example of this would be when a patient falls down and sustains a hip fracture that would require a hip replacement rather than repair. In this circumstance, the hip replacement surgery would take place in the shortest time possible after admission to the hospital.
What causes the conditions that lead to needing a hip replacement?
The most common factor leading to a need for elective hip replacement is osteoarthritis (OA) of the hip. OA results in the loss of the protective cartilage surface of the hip, resulting in the hip no longer functioning correctly. The previously smooth cartilage surface becomes rough and broken up, exposing the bone underneath. The bone is where the nerves live, and so OA becomes progressively more painful. With increasing pain becomes decreasing activity and subsequently, flexibility suffers. This becomes a vicious cycle of increasing damage, increasing pain, and decreasing motion that eventually results in a patient calling and scheduling an appointment for hip replacement surgery.
What is the surgical procedure for a hip replacement?
The hip is referred to as a “ball and socket” joint in that the round femoral head moves within the concave acetabular cup to allow for hip motion. A hip replacement refers to replacing both “the ball” and “the socket” sides of the hip joint. In hip replacement surgery, the patient is generally placed on their side under general anesthesia. The surgeon makes a cut in the skin over the hip that allows access to the joint deep within. The bone of the hip is removed and replaced by metal components; one a cup, the other a metal stem topped with a ball. These components are specially designed to allow bone to grow into their surfaces after the hip replacement surgery so as to be held tightly in place. The ball is then repositioned within the cup, making the new hip. The hip replacement surgical wound is then thoroughly cleaned and closed over the new hip, and the patient is ready to begin the road to recovery.
What are the risks of hip replacement surgery?
Many of the risks of elective hip replacement surgery are the same as those for any major surgery, namely infection, adverse reaction to general anesthesia or to medications given before, during, or after surgery, bleeding, blood clots, or even the very real risks of major complications including stroke, heart attack, or death.
Some of the risks attributable specifically to hip replacement surgery would include wound complications at the surgical site, possible fracture of the bone around the implants, loosening of the implants after the surgery, or damage to nerves or blood vessels.
How long does it take to recover from a hip replacement?
The postoperative recovery for elective hip replacement surgery is a gradual process. Technically, all patients are up and walking on their new hip joint the very same day as their surgery. This is slow, and with the assistance of a rolling walker and the careful coaching of a physical therapist. As a patient progresses, they can walk farther and with less assistance. Generally speaking, a patient can be expected to graduate from a walker to a cane or crutches in about 4-6 weeks. Most patients are able to abandon walking aids completely by 2-3 months.
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That is not to say that hip pain itself and its subsequent debility is a new phenomenon. On the contrary, joint destruction and the ensuing pain resulting in eventual disuse is something that has plagued man as long as we homo sapiens have walked this earth. For years untold, healers and eventually doctors and surgeons sought to offer relief to their patients with hip pain through pills, potions, and eventually surgical intervention. Certainly, prior to Dr. Charnley’s seminal advancements in the specialty, joint replacement had been tried before. Thermistocoles Gluck, regarded as the original pioneer of joint replacement, had replaced a patient’s knee destroyed from tuberculosis with an implanted a knee made of ivory and wood that actually worked to restore the ability of the patient to walk after the surgery in 1860. Even though the implant eventually failed due to complications of infection and failure of fixation, the idea of replacing the joint in which damage or disease had advanced beyond any hope of slowing its course had been born.
Dr. Charnley (eventually, “Sir” John) was one of many pioneers of orthopedic surgery who sought to build on these early ideals to overcome the dilemma of end-stage joint destruction. For years, Sir John experimented, succeeded, failed, and succeeded again with his discoveries and never failing improvements on hip replacement surgery. We owe many of our modern day techniques in joint replacement to his discoveries. Dr. Charnley was the first to use personal protective body suits (so-called “astronaut suits”) to protect the patient, reducing the risk of infection. He also borrowed from his dental contemporaries in adopting acrylic cement to affix his implants to bone as the dentists had proven for fixation of teeth in dental implants. Just the right surface bearing for a hip joint, however, continued to elude his early efforts.
His eventual discovery did not come without setbacks, some of them significant. One of his later hip evolutions involved a metal ball articulating with a cup made of Teflon. Teflon was, after all, very slick; it makes sense that it should work. In point of fact, it did; up until the time the Teflon would delaminate (fall to pieces) at about four years after implantation. This resulted in an eventual catastrophic failure of the implant for Dr. Charnley’s surgical patients, which weighed greatly on him on a personal level. Remarkably, even with the possibility of only four years until failure, patients nonetheless filled his waiting rooms just for the possibility of life without the relentless, all-consuming pain of a destroyed hip joint.
In the late 1950s, he finally happened on his hip replacement discovery for which he will always be remembered. He had replaced his Teflon bearing surface with a polyethylene (plastic) bearing surface on the pelvic side (acetabulum) which would articulate with the metal ball on the femoral (thigh bone) side to replace the hip joint. His experiment worked. And, it lasted. He coined this iteration the “low friction arthroplasty,” owing to the fact that a metal ball which articulated with a plastic cup moved with a relatively low friction so as to prove durable and, perhaps more importantly, reproducible.
As mentioned that first successful total hip replacement was performed in England by (Sir) John Charnley in November of 1959 – he was actually knighted for his advancements in alleviating the suffering of patients affected by the pain of hip disease. His eureka moment resulted in the adoption by legions of surgeons the world over, who in turn began to offer this life-changing hip replacement procedure to the multitudes of global patients debilitated by end-stage arthritis and other forms of hip damage that had stolen their ability to walk or even move without unbearable pain. A surgeon in that day who wanted to learn Sir John’s technique was required to travel to England and study under Dr. Charnley in order to be “approved” to purchase implants from (at that time) the only implant manufacturer. These new hip implants came in three sizes; Small, Medium, or Large.
Many advancements have been made over the sixty or so years since Sir John’s remarkable hip replacement discovery. Great surgeons have improved on Dr. Charnley’s surgical procedure with innovative techniques and surgical approaches which benefited patients during and after hip replacement surgery. Cemented implantation of the prosthetic components were largely replaced by components that allowed for bony ingrowth, virtually eliminating the need for the addition of acrylic cement to fix them into place. Advancements have been made to further reduce complications in blood loss, infection, and postoperative complications. Scientific study has resulted in better pain control, affirmation of the benefits of postoperative physical therapy, and early mobilization has resulted in even further lowering the burden of perioperative complications seen with earlier hip replacement surgeries.
The story of successful hip replacement is today by no means complete. Changes continue to be advanced on a regular basis by inquisitive surgeons, engineers, and scientists that promise to benefit patients even more, and empower surgeons charged to treat them.
Surgical technique deserves a special moment of consideration. Much has changed in this regard since the time of Dr. Charnley’s preference of cutting the hip bone in order to gain access to the hip and replace the pertinent parts, then affixing the cut parts with wire in anticipation of their eventual healing. Subsequent hip replacement surgeons discovered alternative approaches that allowed access to the hip joint to perform hip replacement that no longer required cutting the bone and risking whether or not it might heal. Once that change had been proven beneficial, other pioneering surgeons began to look at other surgical approaches; from the back, from the side, from the front, and some that were variations. Proponents of a surgical approach for hip replacement from the front, termed “direct anterior approach” (DAA) have been able to demonstrate that patients benefited from the complex technique through earlier hospital discharges and lower pain scores and, combined with a not-inconsiderable marketing effort including the patented creation of an assistive surgical table, began a wide adoption across the United States and abroad as a preferable means by which to replace a hip joint.
In point of fact, the direct anterior hip replacement approach benefits patients perhaps most significantly in that it avoids a part of the anatomy important to ambulation that was commonly violated with earlier approaches to the hip joint (the iliotibial band), and by so doing allowed patients to walk sooner and with less pain following their surgery. Given that no surgery is without risk, the direct anterior hip replacement approach is represented by risks inherent in the challenges faced by surgeons seeking to master the technique, not the least of which is working very close to some very large blood vessels which also reside in the area where the surgery is going on. Additionally, access to the femur (thigh bone) during the DAA can be difficult and require extensive cutting and surgical release in order to place the implant for that part of the procedure. Some hip replacement patients have unfortunately had fractures attributable to the assistive table as well, including breaks in the thigh bone and even the ankle, which is secured in a boot attached to the table to facilitate the surgery.
Avoidance of the iliotibial band has also been advanced in the adoption of alternative surgical techniques, one of which has been coined the “SuperPATH” technique. The SuperPATH hip replacement was the creation of James (Jimmy) Chow, MD, of Phoenix, Arizona. Dr. Chow had studied a supercapsular or “SuperCap” approach for total hip replacement during his fellowship training under Stephen Murphy, MD of New England Baptist, and had also come to appreciate the benefits of a percutaneously-assisted total hip replacement (PATH) technique which was the creation of west coast surgical pioneer Brad Penenburg, MD. With the SuperPATH technique for hip replacement, Dr. Chow sought to combine what he saw as the greatest strengths of the two techniques for surgical hip replacement into a single strategy that allowed for minimization of surgical and postoperative complications, while still offering rapid recovery and lower pain scores noted when violation of the iliotibial band could be avoided. Many other surgeons, including Dr. Blair, have adopted Dr. Chow’s SuperPATH technique so that even more patients could benefit from these significant advances.
Whether the SuperPATH technique for total hip replacement or the direct anterior approach may prove most beneficial for superior patient outcomes is not as important as the fact that these continued advances in replacement of the hip joint represent the fact that great minds continue to improve outcomes and hold promise for continued future improvements. A well done total hip replacement, regardless of the surgical technique employed, remains a good surgery.
Some might say that a good outcome is a direct result of a particular surgical technique or approach. Still, others may hold that the surgeon himself (or herself) may be the reason for superior results. An argument could be made that the improvements made that have resulted in contemporary implants are the reason for the advantage of today’s total hip replacement. I would offer, in all modesty, my belief that it is a combination of all of these, in addition to the attention now paid to both preoperative optimization and postoperative rehabilitation that offer patients the best opportunity for successful replacement of a hip joint in today’s world.
Most patients who undergo an elective hip replacement today can expect to leave the hospital after staying one or two nights. Patients are encouraged to walk the same day as their procedure. Nurses attend to any pain and medication needs, and physical therapists meet with patients following the completion of their surgery. Early mobility has proven beneficial in pain reduction as well as minimizing the risk of postoperative complications, such as blood clots and reduced circulation. Most patients are discharged from the hospital the day following their surgery, provided that they are able to mobilize reasonably and understand their follow up instructions. If not, they stay another night in the hospital. Patients will be discharged with instructions for follow up as well as prescriptions for pain medication, continued physical therapy, and anticoagulation medication to reduce the risks of blood clots. Continued ambulation and mobility is encouraged. Any restrictions are thoroughly discussed, and follow-up appointments are scheduled before ever leaving the hospital. Patients can expect to go home with a walker for assistance with walking and stabilization, with graduation from a walker to a cane, and eventually to no assistive devices. The elimination of assistive walking devices, as well as weaning of postoperative medications, will be an individualized endeavor.
In the specialty of joint replacement and hip replacement, great advancements have been made. We are, however, still and ever shall be learning. As alluded to before, what is past may well be only the prologue to what is yet to come for even greater advances in joint and hip replacement. What the future brings we shall discover together, as patient and surgeon.
– Christopher Blair, DO, MBA, Texas Orthopedic Surgery Consultants