Hip Replacements

Total hip replacement is a surgical procedure in which the damaged cartilage and bone is removed from the hip joint and replaced with artificial components.  The hip joint is one of the body's largest weight-bearing joints, located between the thigh bone (femur) and the pelvis (acetabulum). It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The joint surface is covered by a smooth articular cartilage which acts as a cushion and enables smooth movements of the joint.

Several diseases and conditions can cause damage to the articular cartilage. Total hip replacement surgery is an option to relieve severe arthritis pain that limits your daily activities.

Disease Overview

Arthritis is inflammation of the joints resulting in pain, swelling, stiffness and limited movement. Hip arthritis is a common cause of chronic hip pain and disability. The three most common types of arthritis that affect the hip are:

• Osteoarthritis: It is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage wears down, the bone ends rub against each other and cause pain in the hip.
• Rheumatoid arthritis: This is an autoimmune disease in which the tissue lining the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). This leads to loss of cartilage causing pain and stiffness.
• Traumatic arthritis: This is a type of arthritis resulting from a hip injury or fracture. Such injuries can damage the cartilage and cause hip pain and stiffness over a period.

Symptoms

The most common symptom of hip arthritis is joint pain and stiffness resulting in limited range of motion. Vigorous activity can increase the pain and stiffness which may cause limping while walking. 

Diagnosis

 Diagnosis is made by evaluating medical history, physical examination and X-rays.

Surgical Procedure

Surgery may be recommended, if conservative treatment options such as anti-inflammatory medications and physical therapy do not relieve the symptoms.

The surgery is performed under general anesthesia. During the procedure, a surgical cut is made over the hip to expose the hip joint and the femur is dislocated from the acetabulum. The surface of the socket is cleaned and the damaged or arthritic bone is removed using a reamer. The acetabular component is inserted into the socket using screws or occasionally bone cement. A liner made of plastic, ceramic or metal is placed inside the acetabular component. The femur or thigh bone is then prepared by removing the arthritic bone using special instruments, to exactly fit the new metal femoral component. The femoral component is then inserted to the femur either by a press fit or using bone cement. Then the femoral head component made of metal or ceramic is placed on the femoral stem. All the new parts are secured in place using special cement.  The muscles and tendons around the new joint are repaired and the incision is closed.

Post-operative care

After undergoing total hip replacement, you must take special care to prevent the new joint from dislocating and to ensure proper healing. Some of the common precautions to be taken include:

• Avoid combined movement of bending your hip and turning your foot inwards
• Keep a pillow between your legs while sleeping for 6 weeks
• Never cross your legs and bend your hips past a right angle (90)
• Avoid sitting on low chairs
• Avoid bending down to pick up things, instead a grabber can be used to do so
• Use an elevated toilet seat

Risks

As with any major surgical procedure, there are certain potential risks and complications involved with total hip replacement surgery. The possible complications after total hip replacement include:

• Infection
• Dislocation
• Fracture of the femur or pelvis
• Injury to nerves or blood vessels
• Formation of blood clots in the leg veins
• Leg length inequality
• Hip prosthesis may wear out
• Failure to relieve pain
• Scar formation
• Pressure sores

Total hip replacement is one of the most successful orthopedic procedures performed for patients with hip arthritis. This procedure can relieve pain, restore function, improve your movements at work and play, and provide you with a better quality of life.

Total joint replacement surgery is one of the most advanced successful procedures in patients dealing with severe hip and knee pain. The goal of the surgery is to relieve pain and restore the normal functioning of the joint and help patient resume normal activities.

Over the past few years, there have been great advances in the treatment options, implants, and minimally invasive techniques. The latest technique in joint replacement such as anterior hip replacement has resulted in a dramatic improvement in outcome.

What is direct anterior approach hip replacement surgery?

Direct Anterior Hip Replacement is a minimally invasive hip surgery to replace the hip joint without cutting through any muscles or tendons.  Traditional hip replacement involves cutting major muscles to access the hip joint. Normally, after a traditional hip replacement, your surgeon would give you instructions on hip precautions to allow the cut muscles to heal.

However, for Anterior Hip Replacement patients, hip precautions are not necessary as no muscles are cut.

Advantages of both anterior hip replacements include:

• Less postoperative pain
• Minimal soft-tissue trauma
• Smaller incision
• Less scarring
• Minimal blood loss
• Shorter operative time
• Quicker recovery
• Early mobilization
• Less postoperative restrictions
• Quicker return to normal activities
• Short hospital stay

Revision hip replacement is a complex surgical procedure in which all or part of a previously implanted hip-joint is replaced with a new artificial hip-joint.  Total hip replacement surgery is an option to relieve severe arthritis pain that limits your daily activities. During total hip replacement, the damaged cartilage and bone is removed from the hip joint and replaced with artificial components.  At times, hip replacement implants can wear out for various reasons and may need to be replaced with the help of a surgical procedure known as revision hip replacement surgery.

Indications:

Revision hip replacement is advised in patients with the following conditions:

• Increasing pain in the affected hip
• Worn out plastic or polyethylene prosthesis
• Dislocation of previous implants
• Loosening of the femoral or acetabular component of the artificial hip joint
• Infection around the hip prosthesis causing pain and fever
• Weakening of bone around the hip replacement (Osteolysis)

Revision hip replacement surgery is performed under general anesthesia. During the procedure, your surgeon will make an incision over the hip to expose the hip joint. Then the femur is dislocated from the acetabulum so that the old plastic liner and the metal socket can be removed from the acetabulum.

After removal, the acetabulum is prepared using extra bone and wire mesh to make up for the socket space and shape. Then the new metal shell is inserted into the socket using screws or special cement. A liner made of plastic, ceramic or metal is placed inside the metal socket.

To prepare the femoral component, the top of the femur bone is cut into several pieces to remove the implant. The segments of bone are cleaned and the new femoral implant is inserted into the femur either by a press fit or using bone cement. The segments of the femur and the femoral component are held together with surgical wires. Then the femoral head component made of metal or ceramic is placed on the femoral stem.  All the new components are secured in place to form the new hip joint. The muscles and tendons around the new joint are repaired and the incision is closed.

After undergoing revision hip replacement, you must take special care to prevent the new joint from dislocating and to ensure proper healing. Some of the common precautions to be taken include:

• Avoid combined movement of bending your hip and turning your foot inwards because it can cause dislocation
• Keep a pillow between your legs while sleeping for 6 weeks
• Never cross your legs or bend your hips past a right angle (90 degrees)
• Avoid sitting on low chairs
• Avoid bending down to pick up things, instead a grabber can be used to do so
• Use an elevated toilet seat

Risks:

As with any major surgical procedure, there are certain potential risks and complications involved with revision hip replacement surgery. The possible complications after revision hip replacement include:

• Infection
• Dislocation
• Fracture of the femur or pelvis
• Injury to nerves or blood vessels
• Formation of blood clots in the leg veins
• Leg length inequality
• Hip prosthesis may wear out
• Failure to relieve pain

Robotic-assisted hip surgery is minimally invasive procedures where your surgeon is assisted by a robotic system to perform the surgery.

The robotic system consists of a surgeon's console, robotic arms, a high-performance vision system and special surgical instruments. A computed tomography (CT) scan is taken before the surgery to create a 3D model of the affected hip joint. This is interpreted by the system, which accurately guides your surgeon. Unlike a traditional surgery, this procedure is performed through small incisions. The 3D camera provides your surgeon with a magnified view of the operating area. Your surgeon sits on a console and controls the movement of the robotic arms holding the special surgical instruments. The movements of your surgeon’s hands are translated, by the robotic system, into precise movements of the miniaturized instrument that are held by the robotic arms.

The enhanced vision and superior control of the micro-instruments improves the precision of the surgery. This accuracy helps repair the damaged joint and optimally position any prosthetic implant for a more natural feeling joint after surgery, while ensuring minimal injury to neighboring tissues. Being a minimally invasive procedure, it facilitates less post-operative pain, shorter hospital stay, rapid recovery and faster return to daily activities when compared to traditional joint surgeries.

Am I Candidate for Robotic-assisted Surgery?

Candidates for robotic-assisted surgery include:

• Degenerative hip disease
• No relief from pain and disability with non-surgical treatment and medication
• Total hip replacement

Being a minimally invasive approach, robotic orthopedic surgery offers the following benefits:

• Smaller incisions leading to reduced scarring and minimal blood loss
• Less post-operative pain
• Shorter hospital stay and recovery period
• Quicker return to daily normal activities
• Lower incidence of complications

The hip joint is one of the body's largest weight-bearing joints and is the point where the thigh bone (femur) and the pelvis (acetabulum) join. It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The joint surface is covered by a smooth articular cartilage that cushions and enables smooth movements of the joint.

Hip arthritis is one of the painful and common diseases of the hip joint caused by damage to the cartilage. Total hip replacement surgery is an option to relieve severe arthritis pain that limits your daily activities.

Traditionally, total hip replacement will be performed through a 10–12-inch-long incision made on the side of the hip. A minimally invasive approach has been developed in recent years where surgery is performed through one or two smaller incisions rather than the single long incision as in the traditional approach. Advantages of the newer approach are lesser muscle dissection, minimal pain, quicker recovery, and faster rehabilitation.

Arthritis is inflammation of the joints resulting in pain, swelling, stiffness and limited movement. Hip arthritis is a common cause of chronic hip pain and disability. The most common type of arthritis affecting the hip is osteoarthritis which is characterized by progressive wearing away of the joint cartilage. As the protective cartilage wears down, the bone ends rub against each other and cause pain in the hip. It is more common in individuals aged above 50 years and tends to run in families.

Symptoms

The most common symptom of hip arthritis is dull, aching joint pain and stiffness resulting in limited mobility.  There may be pain in the groin, thigh and buttock area and sometimes pain may be referred to the knee. Vigorous activity and walking for long distances can increase the pain and stiffness which may cause limping while walking. 

Diagnosis

Diagnosis is made by evaluating your symptoms, medical history, physical examination and X-rays. Sometimes, additional imaging tests such as MRI and CT scans may be needed to confirm the diagnosis.

Surgical procedure

Surgery may be recommended in patients with severe cartilage damage and if conservative treatment options such as anti-inflammatory medications and physical therapy do not relieve the symptoms.

For minimally invasive hip replacement, the surgical technique and artificial implants remain the same as traditional hip replacement however the difference is smaller incisions and minimal soft tissue dissection. The surgery is performed through either one or two smaller incisions. The procedure is performed under general anesthesia.

In single incision minimally invasive approach, your surgeon makes a 3–6-inch incision over the side of the hip to expose the hip joint. The muscles are minimally dissected to reach the joint. The femur is dislocated from the acetabulum. The surface of the socket is cleaned and the arthritic bone is removed using a reamer. The acetabular implant is inserted into the socket using screws or special cement. A liner material of plastic, ceramic or metal is placed inside the acetabular component. The femur or thigh bone is then prepared by removing the arthritic bone using special instruments and shaped to exactly fit the new metal femoral component. The femoral stem is then inserted into the femur either by a press fit or using bone cement. Then the femoral head component made of metal or ceramic is placed on the femoral stem. All the new parts are secured in place using special cement.  The muscles and tendons around the new joint are repaired and the incision is closed.

If the surgeon uses the two-incision technique, a 2- to 3-inch incision is made over the groin for placement of the socket and a 1- to 2-inch incision is made over the buttock for placement of the femoral stem. This technique requires longer operative time and is performed under X-ray guidance.

Advantages

The advantages of minimally invasive total hip replacement as compared with traditional total hip replacement may include:

• Smaller incisions
• Shorter hospital stay
• Less trauma to the surrounding tissues
• Quicker recovery
• Less blood loss
• Less scarring
• Faster rehabilitation
• Minimal post-operative pain

Post-operative precautions

After undergoing minimally invasive total hip replacement, you must take special care to prevent dislocation of the new joint and to ensure proper healing.

• Avoid combined movement of bending your hip and turning your foot inwards
• Keep a pillow between your legs while sleeping for 6 weeks
• Never cross your legs and bend your hips past a right angle (90°)
• Avoid sitting on low chairs
• Avoid bending down to pick up things, instead use a grabber device.
• Use an elevated toilet seat

Risks and Complications

As with any major surgical procedure, there are certain potential risks and complications involved with total hip replacement surgery. They include:

• Infection
• Injury to nerves and blood vessels
• Formation of blood clots in the leg veins
• Implant malposition

• Fracture of the femur or pelvis

Hip replacement surgery is the most common orthopedic surgery performed. It involves the replacement of the damaged hip bone (ball shaped upper end of the femur) with a metal ball attached to a metal stem that is fixed into the femur and attached to the pelvic region. Traditionally, the surgery was performed with a large, open incision and required the patient to stay in the hospital for several days. With advanced techniques, it is now possible to perform this surgery on an outpatient basis, where the patient goes home on the same day. Outpatient hip surgery uses the same implants as traditional surgery, but involves a smaller incision and newer exposure techniques when compared to the traditional procedure. This type of surgery is less invasive to the tissues and bones and involves a much shorter hospitalization time, where the patient can go home the same day.

Indication

Outpatient hip surgery is mainly targeted at treating the joints damaged by arthritis and injuries. Chronic joint pain due to erosion of cartilage, damage due to accidents and autoimmune diseases, or bone death leading to the destruction of cartilage, are also treated with the help of this surgery.

Procedure

Outpatient hip surgery is designed to allow surgeons to replace the damaged hip bones through 1 or 2 small incisions. The single incision measures around 3 to 6 inches compared to 10 to 12 inches for traditional surgery and is usually placed on the outside of the thigh. If two incisions are used, there will be a 2 to 3 inch cut over the groin and a 1 to 2 inch cut over the buttocks. The muscles and tendons are separated to expose the hip socket and femoral head, like traditional surgery, but to a lesser extent. The head of the damaged femur is removed and the hip socket is cleaned. The stem and ball prosthetics are then fitted into the end of the femur and cement may be used to secure them. The hip is then rejoined and the surrounding tissues are brought back to the normal position. As the incision is very small, fewer muscles and tendons are traumatized.

Advantages

The benefits of outpatient hip surgery are:

• Smaller incisions
• Less scarring
• Less blood loss
• Shorter hospitalization
• Early return to work
• Shorter rehabilitation
• Less tissue trauma

Complications

Complications in outpatient hip surgery mostly arise due to difficulty in performing the surgery within the restricted visual field. Some of the complications include, tearing of skin and soft tissues, superficial nerve injury and bone fracture during implant insertions.

Posterior hip replacement is a minimally invasive hip surgery performed to replace the hip joint.  It is also referred to as muscle sparing surgery because no muscles are cut to access the hip joint, enabling a quicker return to normal activity.

The posterior approach is traditionally the most common approach used to perform total hip replacement.

In posterior hip replacement, the surgeon makes the hip incision at the back of the hip close to the buttocks.  The incision is placed so the abductor muscles, the major walking muscles, are not cut.  

Indications

Hip replacement is indicated in patients with arthritis of the hip joint.

Arthritis is a condition in which the articular cartilage that covers the joint surface is damaged or worn out causing pain and inflammation. Some of the causes of arthritis include:

• Advancing age
• Congenital or developmental hip diseases
• Obesity
• Previous history of hip injury or fracture
• Increased stress on hip because of overuse

Symptoms

Patients with arthritis may have a thinner articular cartilage lining, a narrowed joint space, presence of bone spurs or excessive bone growth around the edges of the hip joint. Because of all these factors arthritis patients can experience pain, stiffness, and restricted movements.

Diagnosis

Your doctor will evaluate arthritis based on the characteristic symptoms and diagnostic tests.  Your orthopedic surgeon will perform a physical examination; order X-rays and other scans, and some blood tests to rule out any other conditions that may cause similar symptoms.

Procedure

Posterior hip replacement surgery involves the following steps:

• The procedure is performed under general anesthesia.
• You will lie face down on a special operating table that enables the surgeon to perform the surgery from the back of the hip.
• An incision is made close to the buttocks beyond the abductor muscles.
• The surgeon separates the muscles and tendons to gain access to the hip joint.
• The thigh bone or femur is separated from the hip socket, acetabulum.
• The damaged femoral head is cut off and the bone is prepared to receive the femoral component of the prosthesis.
• Then the new femoral component is inserted into the femur bone and the femoral head component is placed on the stem.
• The acetabular surface is then prepared and the acetabular component of the prosthesis is inserted.
• A liner made up of plastic, metal or ceramic is placed inside the acetabular component to provide a smooth, gliding surface.
• Once the artificial components are fixed in place, the instruments are withdrawn, soft tissues are re-approximated, and the incisions are closed with sutures and covered with a sterile dressing.

The advantages of the muscle sparing posterior approach include:

• High success rate
• Minimally invasive
• No muscle damage
• More precise placement of implants
• Allows excellent visibility of the joint

Risks and Complications

All surgeries carry an element of risk whether it is related to the anesthesia or the procedure itself.  Risks and complications are rare but can occur.  Below is a list of complications that can occur following any hip replacement procedure:

• Dislocation
• Infection at the incision site or in the joint space
• Fracture
• Nerve damage
• Hemarthrosis - excess bleeding into the joint after the surgery.
• Deep vein thrombosis (blood clot)
• Leg length inequality

Degenerative joint disease (DJD), a common cause of hip pain, is a chronic condition hampering the quality of life of affected individuals. There are different types of DJD and the most common include osteoarthritis (OA), post-traumatic arthritis, rheumatoid arthritis (RA), avascular necrosis (AVN), and hip dysplasia.

MAKOplasty® Total Hip Replacement is a novel surgical alternative for patients with degenerative joint disease (DJD).  In this procedure a Robotic Arm Interactive Orthopedic System (RIO®) assists the surgeon in aligning and positioning implants more precisely.   

MAKOplasty can be considered in patients with pain while bearing weight on the affected joint, pain or stiffness in the hip while walking or performing other activities, and also in patients not responding to a conservative line of management.

Makoplasty procedure

Accurate placement and alignment of the hip implant is crucial in hip replacement surgery. MAKOplasty® Total Hip Replacement utilizes a CT scan of the patient’s hip to generate a 3-D model of their pelvis and femur. This aids the surgeon in planning your surgery.

During surgery, the RIO® software provides dynamic information to enhance accuracy of the procedure. Such real-time information assists the surgeon in precise placement of the implant, which can be difficult to achieve with traditional surgical techniques.

The benefits of MAKOplasty® Total Hip Replacement include:

• Precise placement of the hip implant using the surgeon-controlled robotic arm system with a decline in the possible risk of hip dislocation
• Uniformity in leg length, reducing the requirement of a shoe lift
• Increased longevity of the implant due to a reduction in abnormal rubbing between implant and bone

Robotic Arm Interactive Orthopedic System (RIO®)

The RIO® Robotic Arm Interactive Orthopedic System has three dimensional pre-surgical planning. During surgery, the RIO® provides the surgeon with real-time visual, tactile and auditory feedback to facilitate optimal joint resurfacing and implant positioning. Such optimal placement can result in a more natural hip motion following surgery.

RIO® Features

• Accurately plan implant size, orientation and alignment utilizing CT-derived 3-D modeling
• Enabling the pre-resection capture of patient-specific kinematic tracking through full flexion and extension
• Real-time intra-operative adjustments for correct hip kinematics and soft-tissue balance

Minimally invasive and bone sparing, with minimal tissue trauma for faster recovery