Dr Solomon's Hip Replacement Recommendations
A comprehensive summary of Dr. Solomon's recommendation for hip replacement surgery and the type of surgery performed is shown.
Further information on hip replacements and animations are found after the summary.
Information for patients needing a Total Hip Replacement
If you have been diagnosed with an arthritic hip you may benefit from hip surgery.
Information for patients needing a Total Hip Replacement or Hip Resurfacing Replacement
Timing of Surgery
The timing of hip replacement surgery is a decision that you as the patient must make. The need for surgery is a quality of life decision and the aim of the surgery is to eliminate your hip pain. As an added bonus you will likely get a better range of motion, your limp may reduce or disappear and your quality of life should improve significantly. Hip Replacement Surgery has been well reported as one of the best quality of life outcome procedures that medical science has to offer.
If you feel that you can manage with your current pain and function levels then there is no urgency to have your arthritic hip replaced. Simple analgesics (eg.Panadol) or anti-inflammatories (eg.voltaren, celbrex etc) may be sufficient to provide you with a relatively painfree hip. These drugs will not improve stiffness and the arthritis will continue to progress and at some point the drugs will no longer have their pain relief affect.
Alternative medicines (eg. Glucosamine and chondroitin, fish oil etc) may have a role in helping with pain but scientific studies have proven that the claim that they "prevent arthritis or progression of the disease" is false. These medicines whilst not doing you major harm will not stop your hip continuing to wear out.
If you are overweight, weight loss may help in reducing your hip pain. Low impact exercises (walking, cycling and swimming) help maintain muscle tone and thereby control the arthritis pain.
Physiotherapy is often useful in helping strengthen surrounding muscles and maintaining good muscle tone and pelvic balance. Try to avoid overstretching the arthritic joint as this will only cause discomfort.
Things you need to know about Hip Replacements and Hip Resurfacing Replacements
Total Hip Replacement, Hip Resurfacing Replacement or "mini stem" Hip Replacement are simply different designs of prosthesis. They all replace your hip and therefore are collectively termed Hip Replacements. Some prosthesis (Birmingham Hip Resurfacing) are more bone conserving but these prosthesis still replace the acetabulum (socket) and either resurface the femoral head (ball) or replace the head but preserve more bone lower down.
What Replacement should you have ?
This can be a most complex topic particularly in discussing the options and correct choice in a young patient.
It is important to get an understanding of what's available and in which patient group you are best placed.
The key to a successful hip replacement is the surgical skill of the surgeon implanting the prosthesis and the type of bearing used in the ball and socket joint.
Modern day hip prosthesis may well last a patient a lifetime. It is most likely that a well recognized, tried and tested implant will not wear out in patients over the age of 65 provided the surgery is performed correctly. The key to implant longevity apart from good surgical technique is the materials used in the bearing (the actual parts that move).
Facts about bearings
The traditional hip bearing is a metal head (chrome cobalt ball) that moves on a polyethelene liner ("plastic" liner). Modern day plastic liners have very low wear rates unlike the material used 30 years ago. Laboratory Studies show that modern day liners will probably take about 30 years to wear out. Fifteen year clinical results are outstanding showing hardly any wear in a highly cross linked polyethelene liners. It is for this reason that it is likely that an artificial hip joint implanted in a patient over the age of 65 will last them a lifetime. Off course should the lining wear out sooner a new polyethelene lining can be inserted.
In an effort to develop bearings that last longer than the traditional "plastic" lining, a number of other alternatives are available. These include the following.
Ceramic on Ceramic
Metal on Metal
These bearings were developed to allow younger patients to have hip replacements as they may last longer than traditional metal on plastic bearings and hopefully last a "lifetime".
Ceramic on Ceramic
The ceramic ‐ ceramic bearings have been around for over 20 years. They have extremely low wear rates (1000 times less than polyethelene) and if implanted correctly may last 40 years or more.
Unfortunately ceramics are not perfect in that there is a 1 in 20 000 incidence of breakage / fracture (ceramic is more brittle than metal) and a very rare chance that the hip can develop a squeak. (Squeaks do not occur with a polyethelene liner due to the "hard on soft" bearing as apposed to a hard on hard bearing.)
In general however ceramic on ceramic bearings are an excellent choice to use in the young patient (under the age of 60-65). Surgical technique is critical.
Metal on Metal Bearings
These bearings have been around for over 30 years and regained popularity with the introduction of modern designed hip resurfacing replacements.
The wear rate of metal on metal bearings is only slightly higher than ceramic on ceramic but like ceramics is significantly lower than metal on plastic bearings. Metal on metal bearings are very tough and are not susceptible to breakage (fracture).
The disadvantage of metal on metal bearings is that they produce metal ion particles and if the implant is not functioning properly these metal ions can invoke a significant inflammatory response in and around the hip joint which can cause hip pain and swelling.
Some patients are allergic to metal on metal implants but this is extremely rare. Some metal on metal bearings squeak but this is usually a temporary phenomenon.
Metal on Metal Bearings should only be used in resurfacing replacements in young very active males. The Birmingham Hip Resurfacing is the best performing metal on metal bearing available.
Total Hip Replacement is an extremely successful surgical procedure to improve a patient's quality of life when arthritic hip pain becomes debilitating.
Hip replacement surgery offers patients the ability to return to their daily (and some sporting) activities without pain and with improvement in hip flexibility and movement. Patients with a significant limp as a result of an arthritic hip will often walk normally again after recovering from surgery.
The timing of surgery is a quality of life decision and it is never to late to replace the hip joint provided ones general health is satisfactory.
There are various approaches that surgeons use to replace the arthritic hip.
All recognized surgical approaches work and the most important determining factor in ensuring a successful hip replacement that should last well over 25 years is for the patient to choose a surgeon who is well skilled in hip replacement surgery.
The Australian Joint Replacement Registry and many publications show clear data confirming that more experienced surgeons have better patient outcomes.
The most important factor in determining long-term success of a hip replacement is to choose a skilled surgeon and be guided by his/her recommendations.
Every patient would like to recover as quickly as possible with as little pain as possible. Surgical and Anaesthetic techniques have improved significantly and these improved techniques have allowed an easier recovery.
GENERAL INFORMATION ON THE MINIMALLY INVASIVE DIRECT ANTERIOR APPROACH
The Minimally Invasive Direct Anterior Approach (often termed DAA or AMIS) is an approach that lends itself to a quicker short-term recovery due to the fact that the surgical approach uses intermuscular planes allowing exposure of the hip joint without detaching muscle off bone. This usually allows a patient the ability to recover quicker and return to function quicker compared to other approaches.
There are many published articles (references at end of this article) that have confirmed that the anterior approach leads to a quicker short term recovery HOWEVER all published articles also confirm that after 6-12 months patients having had a successful hip replacement function equally well no matter what approach is used.
The most commonly used worldwide approach to hip surgery is the Posterior Approach (ie from the back) and published results show there is no significant difference between a well done posterior approach and well done anterior approach at 6-12 months after surgery. The posterior approach requires splitting the gluteus maximus (buttock) muscle and detachment of the short external rotator muscles and then reattachment of these muscles/capsule and hence the slightly slower recovery compared to the anterior approach.
There are some short-term hip movement restrictions in the posterior approach (internal rotation of the hip beyond 90 degrees of flexion) for 6 weeks to prevent hip dislocation whilst the capsule/muscle repair recovers. The anterior approach is inherently a very stable approach not requiring muscle repair and movement restriction. Patients usually can return to driving within 7-10 days if they have had an anterior approach.
The Superior approach ("Superpath" ) still requires splitting of the Gluteus Maximus muscle and whilst more muscle sparing than the posterior approach it is not muscle sparing like the anterior approach.
As an experienced hip surgeon (over 20 years performing more than 3500 hip replacements) and I am very comfortable performing either the anterior or posterior approach for arthritic hip replacement surgery.
Not all patients may be suitable for the anterior approach due to many factors including:
- Abnormal anatomy (such as Hip Dysplasia, Perthes, previous fractures, abnormal bone structure etc.)
- Severe osteoporosis
- Significant muscular build resulting in very tight and limited joint visualization)
- Significant leg length discrepancy
- Deficient bone requiring bone grafting or augmentation of the socket
- Specialised hip implants needing to replace the hip joint
- Most revision hip surgery unless a simple head/liner exchange
The Responsible Approach :
Every patient I see has an individual assessment taking into account their hip pathology, degree of arthritis, day to day function, general health and body habitus. I will then advise what I believe to be the best surgical approach to achieve the best clinical outcome with the least chance of a complication.
Whilst I would prefer from a general recovery perspective to perform an anterior approach it is MORE IMPORTANT to ensure a safe recovery with appropriate attention to the underlying problems at hand. If I feel that the anterior approach is not suitable in your circumstance, I will perform a posterior approach AND will reassure you, the patient, that whilst there may be a slightly slower recovery compared to the anterior approach, the LONG TERM function will be identical.
The Final Word on approaches..........
The key to a successful hip replacement with the best chance of a good functional outcome and the least chance of complications is to choose an experienced and skilled hip surgeon. Whilst the Anterior Approach may afford a quicker short-term recovery, not all patients are suitable for this approach, yet be reassured that at 6-12 months the posterior approach performs equally well.
This type of replacement is reserved for active young male patients with good quality bone ie: no osteoporosis.
THERE IS NO ADVANTAGE FOR A PATIENT OVER THE AGE OF 55 TO HAVE A HIP RESURFACING
Modern day resurfacings have been around for the past 16 years. The Birmingham Hip Resurfacing Replacement (Smith & Nephew Inc: www.smith-nephew.com) is the most successful of the Resurfacings on the market and has the longest track record (over 16 years) We have learned a great deal about resurfacings and the literature (including the Australian Joint Registry www.dmac.adelaide.edu.au/aoanjrr/) has outlined the best patients that are suited for this procedure.
Important facts to know about hip resurfacing:
Hip resurfacing patients take LONGER to recover than conventional total hip surgery patients. The reason for this is that in order to preserve the femoral head for resurfacing, more muscle and ligaments need to be released internally to allow the socket to be prepared. Patients are also advised to partial weight bear for 4 weeks post operatively to allow the bone to adapt to the new implant and not fracture. Hip Range of Motion in Resurfacing replacements is LESS than conventional total hip replacements using the same size ball and socket. The reason for this is that the resurfacing sits on the patient's femoral head and neck and as such in maximal motion the femoral neck may impinge on bone preventing maximum movement compared to a ball that sits on a stemmed hip because the stemmed hip has a narrow neck allowing more impingement free motion (see drawing).
A good functioning hip resurfacing is very durable and whilst it is not recommended, there have been many reports of patients running and doing triathlons with resurfacings.
The best hip resurfacing implant (ie the Birmingham hip) has the same revision rate as the best performing Total hip replacement in a male with osteoarthritis under the age of 55 after 15 years of implantation. A Resurfaced hip has been shown in the literature to have better functional results with respect to impact sports compared to a conventional total hip in young male patients.
ALL hip replacements, resurfacing or conventional, allow the patient to partake in sporting activities including
- Backyard running with the kids
As a general rule orthopaedic surgeons do not recommend high contact sports with ANY type of replacement (resurfacing or conventional) including rugby, competition soccer, competition basketball etc)
So what's the advantage in having a resurfacing ??
Resurfacings preserve the femoral shaft and there are reports that some patients feel that the resurfaced hip "feels more natural" allowing the male patient to partake in impact type sports on a regular basis.
A Resurfacing still allows the possibility of a future revision to be done without to much difficulty HOWEVER it is likely that a well done standard total hip replacement with a modern day bearing will not need revising anyhow. A resurfacing needing a revision will ALWAYS need both components revised at the time of revision.
The BIGGEST issue with metal on metal resurfacings is accuracy in surgical technique. This fact has only recently come to our attention as it was thought that metal on metal implants are as "forgiving" as metal on plastic implants. Recent literature has shown that the metal on metal implants (and ceramic on ceramic bearings) are very susceptible to mal-alignment and if this occurs then these implants may fail.
Cemented or Uncemented prosthesis:
There is NO significant difference in the revision rates of either a cemented or uncemented femoral component (the hip stem that sits on the thigh bone). A well implanted cemented stem works just as well as a well implanted uncemented stem. As outlined above the key to longevity is in the bearing and NOT whether the stem is cemented or uncemented. A surgeon will choose what stem fits best into your bone depending on the bone shape, bone quality and your age. In general softer osteoporotic bone with thin cortices do better when cement is used to fixate the implant.
Registry studies have shown that patients over the age of 75 have a lower revision rate when the femoral component is cemented in place.
Most acetabular components (sockets) are uncemented and the bone will grow into the component. The lining is then placed in the metal shell and this lining is either made of highly cross- linked polyethelene ("plastic"), ceramic or metal in the case of a resurfacing. Occasionally the bone is so soft that a plastic liner is cemented onto the bone instead of using and uncemented shell.
The Final word
I hope I have enlightened you on the basic facts about hip replacement surgery. I would summarise as follows:
- Choose a surgeon who is well experienced in Hip Replacement Surgery
- Be guided by the information presented above as to the types of hip replacements available, bearing options and operative approaches.
- Do not be fooled by advertising and marketing hype.
My approach and recommendations to patients requiring a hip replacement. This is a GUIDE ONLY and each patient's individual needs are taken into account before a final implant and approach decision is made
Patients over the age of 75 usually have a cemented stem with an uncemented socket and polyethelene (plastic) liner. A metal or ceramic head is used. This hip should last a lifetime.
Patients between 60-75 usually have an uncemented stem and socket with a ceramic on highly cross-linked polyethelene liner. This hip should last a lifetime.
Patients under 60 usually have an uncemented stem and socket with a ceramic on ceramic liner. This hip may or may not last a life time and follow up with your surgeon every 5-10 years is important.
Males under the age of 55 who are active and have excellent bone quality are candidates for a Birmingham hip resurfacing HOWEVER we discuss the pros and cons of resurfacing vs total hip replacement with a ceramic bearing according to the patients individual circumstances.
Approaches: An individual assessment is made as to what surgical approach is best for you.