Health

There are a variety of hip surgeries involving hip arthritis including hip arthroscopy, osteotomy, and total hip arthroplasty.

Hip Arthroscopy

Hip arthroscopy is a surgical procedure which can be performed through small portal incisions using skinny instruments and a special camera to look inside the joint.

This procedure can be performed to remove loose pieces of cartilage, trim a torn labrum, or reshape part of the femoral head and neck for a condition called femoral- acetabular impingement. Hip arthroscopy is usually performed in an outpatient setting, meaning surgery can be performed and you can go home on the same day.

The benefits of hip arthroscopy is that it is less invasive compared to other surgical hip procedures, the recovery is relatively fast, the procedure may provide some pain relief from the arthritis, and the procedure can be performed as an outpatient surgery. The disadvantage is that it does not “cure” the arthritis, and the pain relief may only be temporary. The surgery is performed under an anesthetic which is selected by you and your anesthesiologist. Through several small incisions the surgeon introduces thin instruments and a camera called an “arthroscope” which is skinnier than a pencil. The arthroscope is connected to a TV screen so that the surgeon is able to see within the hip joint and to see the surgical instruments. The arthroscope also pumps sterile fluid into the hip joint which distends and opens up the hip joint to allow the surgeon to see. Sometimes there are loose pieces of cartilage or bone floating around in the hip which can be removed by the surgeon. There are a variety of different instruments that are available to the surgeon to cut, trim, shave, or grab torn cartilage or loose bone pieces. if the labrum is torn, the rough edge can be trimmed down to a smooth contour to avoid catching symptoms. Another procedure that can be performed is an “osteoplasty” or a reshaping of the femoral head and neck. Some people develop a sharp pain in the groin from a condition called femoral-acetabular impingement due to a femoral head and neck which are not shaped properly and looks like a pistol grip. Because of this anatomic deformity, as the hip is flexed, the neck of the femur bumps against the edge of the socket causing pain and may eventually progress to arthritis at an early age. By reshaping the femoral head and neck with special instruments, this impingement process is eliminated and may reduce the risk of developing early arthritis in that hip. At the end of the surgery, the instruments are removed, the fluid is drained, and the incisions are closed with a couple stitches. Recovery from arthroscopic hip surgery is dependent upon the type of surgery performed and your surgeon’s recommendations for postoperative care. Your surgeon will give you instructions about how much weight you can bear on your hip. Most patients will use a cane or crutches after surgery for a short period of time. Patients can expect to have some degree of soreness and pain medications are typically prescribed for a short period after surgery. Sutures are typically removed 10 to 14 days after surgery.

Osteotomy

An osteotomy is a procedure that realigns the socket to create a better bearing surface for the femoral head. An osteotomy is occasionally also performed to realign the femoral neck and head so they fit better with the hip socket. Some people are born with a condition called “hip dysplasia” which results in a misshapened socket and femur. The socket tends to be very shallow (like a saucer) which does not provide much coverage over the femoral head. As time goes on, because only a small portion of the socket and the femoral head bear the heavy weight of your body, this causes the cartilage to wear more quickly which often results in arthritis at an early age. This is analogous to tires on a car wearing out faster if the wheels are malaligned. The benefits of an osteotomy are that it restores a more normal alignment to the hip joint and minimizes the risk of needing a hip replacement at an early age.

This procedure is performed under a general or regional anesthetic. Depending on the anatomic abnormality of the hip joint, the surgeon will determine which bones need to be cut and realigned. The bone cuts are made with the aid of fluoroscopy, which is a live x-ray machine. With this machine, the surgeon is able to visualize the bones and the instruments that are used to cut the bones. Once the bone cuts are made and the leg is realigned, the position of the bones is held in place with special pins or screws.

Recovery from an osteotomy usually involves a hospital stay of several days. Just like a broken bone, an osteotomy takes several months to heal. Crutches are used to help you walk while the bones heal. Your surgeon will determine how quickly you can advance your activities and exercises after the procedure. Follow-up includes serial x-rays to check how the osteotomy is healing. Since the procedure is considered a joint salvage procedure for younger, more active patients, once the osteotomy is healed, most surgeons allow those patients to return to activities as tolerated.

Total Hip Arthroplasty

Total hip arthroplasty is a successful procedure that been performed for nearly fifty years. At the present time, over 200,000 hips are replaced every year in the United States. This procedure is indicated for end-stage arthritis associated with disabling pain and dysfunction when non-operative measures have failed. Prior to considering hip replacement, most patients have tried medications, modified their lifestyle, and often have resorted to using gait aids such as a cane or walker.

Surgery

A hip replacement surgery involves replacing the arthritic surfaces of the hip with an artificial joint.

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This is performed under a regional or general anesthetic as determined by you and your anesthesiologist. An incision is placed on the side of the hip. After the hip joint is opened, the surgeon can then dislocate the femoral head from the socket. Using a special saw, the surgeon removes the arthritic femoral head (Click to play video). Your surgeon then prepares the socket with hemispherical reamers to shape the hip socket (acetabulum) to accommodate the acetabular component of the hip replacement (Click to play video). After the socket is prepared, the femur is prepared with special instruments to shape the canal of the femur to accommodate the femoral stem (Click to play video). Trial implants (dummy versions of the actual implants) are then placed in the hip. With these trial implants in place, the surgeon is able to perform a final check to determine if the sizes of the implants are appropriate and if the hip is stable. Once the surgeon is happy with the test run, the trial components are removed and the final components are fixed in place either with special bone cement or implants can be used where the bone can grow right onto the implant (Click to play first video  Click to play second video). The hip is then closed with sutures and staples. The choice of fixation (use of bone cement versus the bone ingrowth method) is made by the surgeon and is based on the age of the patient and quality of the patient’s bone at the time of the total hip replacement. both methods of fixation have been found to work very well for at least 10-15 years.

Various materials are currently available for the bearing surface (femoral ball and socket liner) of the artificial hip. Traditionally, a metal ball with a polyethylene-lined socket has been used with proven success. Recent technology has advanced the wear properties of these implants even further with bearing surfaces such as improved polyethylene materials, ceramic-on-ceramic (a ceramic ball with a ceramic-lined socket) and metal-on-metal (a metal ball with a metal-lined socket). These newer alternative bearing surfaces are now commonly being used in younger and more active patients.

Recovery

Your doctors will make sure that you are healthy enough to go home and your pain is under control before they discharge you from the hospital. Most patients are in the hospital for 2-4 days. a physical therapist will work closely with you to teach you how to walk with a walker or crutches, get in and out of bed, go up and down stairs, and how to avoid dislocation of the hip during the healing process. Most patients use a walker or two crutches for several weeks followed by a single cane. Your surgeon will give you specific instructions regarding how much weight you are allowed to place on your leg while you recover. Most patients feel like they have “recovered” from surgery at about the three month mark. At that point, most patients are walking unlimited distances and are able to return to recreational, non-impact loading activities. Even though most patients feel pretty good at three months, your body will continue to heal even a year after surgery. In that time period, you will still make gains in terms of your strength, and improvement in pain and swelling.

Activities after a Hip Replacement

A common concern about hip replacements revolves around the activities permitted after surgery. Most surgeons recommend avoiding high impact activities such as running, jumping, or any activity that places you at risk for falling or getting injured. Reasonable activities are walking, hiking, swimming, cycling, and golfing.

Complications

Just like with any surgery, complications, while infrequent, are always possible. Bleeding, nerve damage, infection, blood clots, and complications with anesthesia are all possible. Specific to hip replacement is the possibility of hip dislocation and leg length discrepancy. Precautions are taken to minimize risks but the risk is never completely eliminated. To avoid dislocation, patients are instructed on leg positions they should avoid during the three month healing process. If the patient adheres to these precautions, the chance of the hip dislocating is only about 1%.

Minimally Invasive Total Hip Arthroplasty

Recent advances in surgical technique have been made to perform hip replacements through smaller incisions and with lesser trauma to the soft tissues around the hip. Surgical instrument have also been improved to accommodate performing these procedures through smaller incisions. Some studies claim a quicker short term recovery and less pain. Other studies reveal no difference in the overall outcome.

Hip Resurfacing

A recent development in the arena of hip replacement surgery has been a procedure which resurfaces the arthritic femoral head with a metal cap instead of replacing the entire femoral head and neck with a metal stem.

Some studies are showing favorable early results while other studies are reporting complications such as loosening of the cap or fracture of the femoral neck. This procedure is not indicated for every patient. Allow your surgeon to determine if this procedure is appropriate for your hip condition.