Total Hip Replacement Surgery (Total Hip Arthroplasty)

Total hip replacement Surgery (THR) is a surgical procedure that relieves pain from most kinds of hip arthritis, improving the quality of life for the large majority of patients who undergo the operation.

Patients commonly undergo THR after non-operative treatments (such as activity modifications, medications for pain or inflammation, or use of a cane) have failed to provide relief from arthritis symptoms. Most scientific studies that have followed patients for more than 10 years have found “success rates” of 90 percent or more following traditional THR.
Distilled to its essentials, THR involves surgically removing the arthritic parts of the joint (cartilage and bone), replacing the “ball and socket” part of the joint with artificial components made from metal alloys, and placing high-performance bearing surface between the metal parts (see figures 1 and 2). Most commonly, the bearing surface is made from a very durable polyethylene plastic, but other materials (including ceramics, newer plastics, or metals) have been used. Patients typically spend a few days in the hospital after the procedure (3 to 5 days is most typical), and some patients benefit from a short inpatient stay in a rehabilitation facility after that to help transition back to living independently at home. Most patients will walk with a walker or crutches for 3 weeks and then use a cane for another 4 weeks; after that, the large majority of patients are able to walk freely.

A bewildering number of different implant designs, bearing surface materials, and surgical approaches have been tried to achieve one seemingly straightforward goal: improving the quality of life for patients who have hip arthritis. As with any important life decision, it makes good sense to get educated on those issues as they pertain to your hip.
The purpose of this article is to outline the essentials from a patient’s perspective: who should think about having THR done, what questions should a prospective patient ask the doctor, and why one surgical approach or type of THR implant might be good for one patient but not for another.
Hip replacement, also hip arthroplasty, is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Such joint replacement orthopaedic surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage as part of the hip fracture treatment.

Contents 1 History 2 Modern process 3 Costs 4 Complications 5 Indications 6 Techniques 7 Research 8 Alternatives to Hip Replacement 9 See also 10 References 11 External links

History

The earliest recorded attempts at hip replacement (Gluck T, 1891), which were carried out in Germany, used ivory to replace the femoral head (the ball on the femur).

In 1940, at Johns Hopkins hospital, Dr. Austin T. Moore (1899-1963), an American surgeon, reported and performed the first metallic hip replacement surgery. The original prosthesis he designed was a proximal femoral replacement, with a large fixed head, made of the Cobalt-Chrome alloy Vitallium. It was about a foot in length and it bolted to the resected end of the femoral shaft (hemi-athroplasty). This was unlike later (and current) hip replacement prostheses which are inserted within the medullary canal of the femur. A later version of Dr. Moore's prosthesis, the so-called 'Austin Moore', introduced in 1952 is still in use today.

In 1960 a Burmese orthopaedic surgeon, Dr. San Baw (29 June 1922—7 December 1984), pioneered the use of ivory hip prostheses to replace ununited fractures of the neck of femur ("hip bones"), when he first used an ivory prosthesis to replace the fractured hip bone of an 83 year old Burmese Buddhist nun, Daw Punya. This was done while Dr. San Baw was the chief of orthopaedic surgery at Mandalay General Hospital in Mandalay, Burma. Dr. San Baw used over 300 ivory hip replacements from the 1960s to 1980s. He presented a paper entitled "Ivory hip replacements for ununited fractures of the neck of femur" at the conference of the British Orthopaedic Association held in London in September 1969. An 88% success rate was discerned in that Dr. San Baw's patients ranging from the ages of 24 to 87 were able to walk, squat, ride a bicycle and play football a few weeks after their fractured hip bones were replaced with ivory prostheses. Ivory may have been used because it was cheaper than metal at that time in Burma and also was thought to have good biomechanical properties including "biological bonding" of ivory with the human tissues nearby. An extract from Dr San Baw's paper, which he presented at the British Orthopaedic Association's Conference in 1969, is published in Journal of Bone and Joint Surgery (British edition), February 1970. With modern hip replacement surgery, one can expect to walk, using crutches for support or even just a cane for balance, within a week.

Modern process

The modern artificial joint owes much to the work of John Charnley at Wrightington Hospital; his work in the field of tribology resulted in a design that almost completely replaced the other designs by the 1970s. Charnley's design consisted of three parts—

1. a metal (originally stainless steel) femoral component,
2. a teflon acetabular component, the wear debris of which resulted in a condition called Osteolysis, and so it was replaced by Ultra High Molecular Weight Polyethylene or UHMWPE in 1962, both of which were fixed to the bone using
3. PMMA (acrylic) bone cement, and/or screws.

The replacement joint, which was known as the Low Friction Arthroplasty, was lubricated with synovial fluid. The small femoral head (7/8" (22.2 mm)) was chosen for its decreased wear rate; however, this has relatively poor stability (the larger the head of a replacement the less likely it is to dislocate, but the more wear debris produced due to the increased surface area). For over two decades, the Charnley Low Friction Arthroplasty, and subsequent similar designs were the most used systems in the world, far surpassing the other available options (like McKee and Ring). Recently the use of a polished tapered cemented hip replacement (like Exeter) and uncemented hip replacements have become more popular. Cemented stems are commonly used in older patients due to their lower cost, including the Austin Moore proximal femoral replacement for Medicaid patients, while more modern and longer lasting 'cementless' stems, often coated in Hydroxy-Apatite Ceramic, are used in 'younger' and more physically active patients. Once an uncommon operation, hip replacement is now common, even among active athletes including racecar drivers Bobby Labonte and Dale Jarrett.

Costs

A titanium hip prosthesis, with a ceramic head and polyethylene acetabular cup.
In a paper published August 14, 2007 in The Japan Times, signed by K. Rogoff, it is mentioned that 250,000 hip replacements are performed in the U.S. each year, for an average cost of $6,000. This cost cited is likely that for the implant devices only. However, the total cost including the implants, the hospital charges and the surgeon's fee is probably what CNN-TV reported on Dec. 5, 2000, stating that the average cost of hip replacement surgery is $25,000.
In 2008, a source quoted US$7–9,000 in India at an internationally accredited hospital; in a county in Florida, USA, from $41,597-$56,258 , most likely the total costs for cementless devices, was quoted.
Surgery costs vary from country to country, with the US typically being among the highest-priced markets, and countries like Thailand, Cuba and Argentina, among the lowest.

Complications

Dislocated artificial hip.


Hip prosthesis displaying aseptic loosening (arrows).
Immediately after surgery, infection is a major concern with rates reported round 1%.[citation needed] Deep infection will often require one or two stage revision surgery with an extended hospital stay and antibiotics. Recurrent dislocation is another complication and may lead to revision surgery. This rate is also about 1%.[citation needed]
In the long term, many problems relate to osteolysis from acrylic bone cement debris, and/or wear debris. An inflammatory process causes bone resorption and subsequent loosening or fracture often requiring revision surgery. Very hard ceramic bearing surfaces are being used in the hope that they will have less wear and less osteolysis with better long term results. Large metal heads are also used for similar reasons as these also have excellent wear characteristics and benefit from a different mode of lubrication. However large fixed metal heads,such as the Austin Moore devices, can result in protrusio acetabuli. A greater head neck ratio also contributes to stability. These new prostheses do not always have the long term track record of established metal on poly bearings.
Post operative sciatic nerve palsy is another possible complication.
A few hip replacement patients suffer chronic pain after the surgery despite normal imaging. Some believe this pain is caused by nerve damage from the surgery.[citation needed]

Indications

Total hip replacement is most commonly used to treat joint failure caused by osteoarthritis. Other indications include rheumatoid arthritis, avascular necrosis, traumatic arthritis, protrusio acetabuli, certain hip fractures, benign and malignant bone tumors, arthritis associated with Paget's disease, ankylosing spondylitis and juvenile rheumatoid arthritis. The aims of the procedure are pain relief and improvement in hip function. Hip replacement is usually considered only once other therapies, such as physical therapy and pain medications, have failed.

Techniques

There are several different incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool), antero-lateral (Watson-Jones), anterior (Smith-Petersen) and greater trochanter osteotomy. There is no compelling evidence in the literature for any particular approach, but consensus of professional opinion favours either modified anterio-lateral (Hardinge) or posterior approach.[citation needed]

• The posterior (Moore) approach accesses the joint through the back, taking piriformis muscle and the short external rotators off the femur. This approach gives excellent access to the acetabulum and preserves the hip abductors. Critics cite a higher dislocation rate, although repair of the capsule and the short external rotators negates this risk.

• The lateral approach is also commonly used for hip replacement. The approach requires elevation of the hip abductors (gluteus medius and gluteus minimus) in order to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per Charnley),[citation needed] or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using sutures.

• The anterolateral approach develops the interval between the tensor fasciae latae and the gluteus medius.

• The anterior approach utilises an interval between the sartorius and tensor fascia latae.

The double incision surgery and minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However component positioning accuracy is impaired and surgeons using these approaches are advised to use computer guidance systems.[citation needed]

Research

instrumented hip prosthesis, with two 8-channel telemetry transmitters to measure three load components and the temperature distribution in vivo
Knowledge of the loads to which hip implants are subjected is a fundamental prerequisite for their optimal biomechanical design, long-term success, and improved rehabilitation outcomes. In vivo load measurements are made with instrumented implants and calculations by using mathematical musculoskeletal models which are performed at different research laboratories such as at the Julius Wolff Institut at the Charité - Universitätsmedizin Berlin.
Hip replacements undergo high levels of cyclical stress. This was shown in an experiment by Dr. Scott Schulz PhD.

Alternatives to Hip Replacement

Hip resurfacing is an alternative to hip replacement surgery. It is a bone conserving procedure that places a metal cap on the femoral head instead of amputating it. There is no long stem placed down the femur so it is more like a natural hip and allows patients a full return to all activities, including marathons and triathlons, some patients have even completed Ironman and Ultraman competitions following hip resurfacing surgery. You must have good bone quality to qualify for it. It has been used over in Europe for over 17 years and the first device, the BHR or Birmingham Hip Resurfacing device was approved by the FDA on May 9, 2006.
Current alternatives also include viscosupplementation, or the injection of artificial lubricants into the joint. Some believe the future of osteoarthritis treatment is bioengineering, targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al. have reported on the partial regeneration of an arthrtic human hip joint using mesenchymal stem cells in one single lucky patient. This is just entering the US and is not approved by the FDA, has not been shown in clinical trials to be effective, and costs over $7,000, which is not usually covered by insurance.[citation needed]