Hip joint surgery is done when conservative therapy is ineffective or in case of emergency. Modern medicine has a wide range of techniques for joint treatment, and high quality rehabilitation methods can help you to return to a life of full value after an intervention.
Surgical treatment of the hip joint is required when bone tissue is severely damaged by progressive diseases of the musculoskeletal system. In this case, joint replacement is necessary. Before the intervention, additional examination is carried out to study the manifestations of pathology and reduce risk factors. For various types of hip joint surgery, contraindications can be different because they depend not only on general recommendations, but also on systemic factors, such as age, concomitant diseases, blood disorders and the nature of the intervention (primary or secondary).
But in most cases, surgery is not performed if a patient has one or more of the following diseases:
- Severe chronic cardiovascular diseases
- Cardiac or respiratory failure that can cause problems with anesthesia and other complications
- Open form of tuberculosis
- Purulent inflammation of the hip joint
- Progressive chronic infection in the body
- Neurological or mental disorders
- Metastatic cancer
Hip arthrotomy is any surgery involving hip joint opening and providing intraarticular access. It is used for:
- removing purulent exudates, free bodies and foreign bodies in the joints;
- correcting old or congenital joint dislocations;
- resection hip joint tumors or infectious foci;
- arthroplasty in case of ankylosis.
As already said, resection of the hip joints mostly is an atypical operation, often of a more extended type as that for closed coxitis. It should be performed with the utmost accuracy, adhering to the general rules reassigned in protocols.
Conservative treatment of patients with severe hip injuries is not very promising: it leads to complete immobilization for a long time, difficult rehabilitation, whilst there is no any guarantee of success. It is especially related to the older people with weakened calcium metabolism and osteoporosis. So, non-surgical options are used for them only when surgery is contraindicated.
Young people also hardly can like the complete immobilization. Therefore, always when possible, osteosynthesis of the femoral neck is considered in the first place.
Indications for osteosynthesis are following:
- Basal fractures of the femoral neck in patients with active lifestyle
- Transcervical damage in bone integrity (fractures) in people under 60
- Punctured fractures
- Subcapital neck of femur fractures (NOF)
- There are contraindications to joint replacement
There is a variety of concepts of metal osteosynthesis for the neck of the femur fractures. Many different factors influence the process of selection a particular method of reposition and osteosynthesis. Closed reduction of bone fragments with use of screw fixation is one of the well-proven techniques.
Closed reduction has a number of great advantages:
- It is a minimally invasive technique. As a rule, no more than three (sometimes two) screws are required.
- It does not take much time, which is important for combined injuries.
- It is just perfect for fixing fragments in case of intraarticular fractures.
- It provides a high level of reduction and immobilization of bone pieces.
- Titanium alloy does not cause rejection and complications in patients after surgery.
- The screws are easily removed after the consolidation of hip fracture.
The fixation, which is achieved by different ways, can be:
- Relatively stable: slight micro movements between bone fragments are possible, but they do not cause pain and, furthermore, contribute to coalescence of fragments by forming a periosteal callus.
- Absolutely stable: there are no any movements between bone fragments in the damaged area.
The core feature of the method is a special mode of screw fixation. Screws are screwed into the bone at the twisted thigh bones area, pass inside the femur neck in parallel to its surface and end in the central part of the femur head.
The start and end points were chosen not by chance, since the density of bone tissue is maximal in these areas, which ensures a high stability of the fixation of the bone fragments – what is needed for a better bone healing.
On practice, the best effect of osteosynthesis with screws is achieved for locomotor fractures, provided that displacements of the bone pieces are relatively small.
Ultrasonic osteosynthesis also deserves to be mentioned: with this method, connecting fractured fragments, filling the hip joint cavity and creating bone conglomerates in order to restore bone integrity are done by means of ultrasonic welding.
Joint surgery involving an excision or fracture of the bone with medical instruments to eliminate deformation is called hip osteotomy.
Osteotomy is performed on the hip joint when there are violations of the functions of the musculoskeletal system or deformations of the bones. For the hip joint, this surgery is performed in the case when the femoral head and the hip socket are not aligned properly.
Frequent causes of such pathology are cerebral palsy (CP), joint dysplasia, osteoarthritis, and Legg-Calve-Perthes disease.
During this operation, a surgeon corrects the shape of the femur neck and, then, rotates the acetabulum for a better alignment. Healthy cartilage is replaced and, due to this, the femur head has a good covering that does not allow it to move.
The surgery is performed under general anesthesia; its duration is about 2 hours. After the surgeon corrected the bone deformation, a plaster cast is applied to be worn for about 7-8 weeks. After it is removed, the patient, at first, moves with crutches in order not to overload the joint, but after some time he or she can return to normal activities.
Hip arthroscopy is a surgical procedure that is performed with a special device called an arthroscope. It is equipped with ultra-precise optics and light and used for diagnosing and treatment of diseases of the hip joint. The main advantage of arthroscopy is low trauma, since they are carried out through a small incision and minimally damage soft tissues.
Arthoscopy of the hip joint is indicated when the diagnosis requires extensive examinations and numerous studies. A regular pain in the groin or in the pelvic area can be an indication for arthroscopy. During this procedure, it is possible to remove free bodies and to eliminate damage cartilage from the hip joint.
During arthroscopy, the surgeon examines the space between the hollow of the thigh, the femur head and other areas of the hip. All manipulations are performed under general or local anesthesia. The operation is carried out with a stretched leg, which allows doctors to ease access to the damaged area.
The following diagnoses may be a reason for surgery:
- joint rupture;
- free bodies, namely cartilage fragments, in the joint;
- snapping of the hip joint;
- arthritis on early stage;
- cartilage damage of different origin.
The undisputed advantage of arthroscopy of the hip joint is quick recovery. It is much easier and with lesser pain than with open hip surgery. Starting from the very first day after surgery, patients have to do special exercises to restore joint mobility. The patients who have limp are advised to use crutches or walkers for one and a half to two months after the surgery. Later, patients can try to start light physical activities, such as cycling or swimming. Usually, the recovery takes from three to four months; however, in more complex cases, a longer recovery may be required.
Arthrodesis is a surgical technique intended to return or improve support ability of the joints by fixing them in an immobile state. There are some cases when, without this procedure, you can get limited ability to move, or even complete disability. This treatment has some specific features. Please note, that arthrodesis is not indicated to all patients, even though their symptoms are similar.
Hip arthrodesis is one of the possible surgical interventions to treat deforming osteoarthritis. This type of surgery is aimed to stabilize the joint by immobilization. Trauma surgeons use this a method when it is necessary to reduce or eliminate the symptoms of pain syndrome, but, for some reason, arthroplasty and hip replacement are contraindicated.
There are four methods of arthrodesis mostly used:
- compression (open or closed).
This procedure may be required at the following joint diseases and conditions:
- Dangling joint: complete or partial misalignment of the joint, causing limited or complete atrophy of intraarticular mobility (flaccid paralysis syndrome, ligament integrity damage, consequences of gunshot wound, genu recurvatum, etc.).
- Deforming arthritis: pathological deformity or tuberculosis of bones and osseous joints, acute purulent or traumatic arthritis.
- Complicated osteoarthrosis: degenerative dystrophic diseases of the joints, characterized by damage to the cartilaginous tissue of the articular surfaces.
- Consequences of poliomyelitis (cerebral palsy).
- Improperly fused / fusing fractures.
- Impossibility of plastic surgery on problematic joints using a partial / total endoprosthesis or plates;
- Other causes that lead to reducing of active movements in the joint and increasing of passive movements.
During the surgery, all functionally altered tissues are removed and cartilage of the femur head and acetabulum is excised, as well as the spongy layer of the bone. The articular surfaces are joined in such a way to provide later their reliable fusion. In case when the femur head and the main part of the femur are not viable, they have to be resected. After the surgery, a plaster cast is applied that are removed after not less than three months.
After the plaster cast is removed, an X-Ray scan is done for a check-up. With satisfactory fusion, another plaster bandage is applied for 3-4 months more. Six months after the surgery, the patient can walk.
Surgery to replace the hip joint with a prosthesis is often called endoprosthetics. It gives patients an opportunity to return to a full life without pain and limitations. It is recommended in case of a neck and/or head of the femur fracture, tumors of the proximal part of the femur, progressive bone diseases (deforming arthrosis, necrosis of the femoral head, Still's disease, etc.), and other pathologies that are not treatable with medication and may lead to disability. Modern prostheses have high wear resistance that can be estimated in dozens of years. In case of severe injuries of the femur and hip joint, and tumors, only leg amputation can help.
Risks of Hip Endoprosthetics
There is a long list of serious complications with possible harm to health. Pneumonia and thrombophlebitis may occur quite often after surgery. There is also a risk of revision in case of failed hip replacement surgery. Bleeding in the site of operation is another possible complication.
There is a small but not non-existing probability that surgery may lead to inflammation, due to infection in the wound, which will significantly complicate recovery.
But complications are rare in this kind of surgery, medical experts say. Also, during surgery, the vessels or nerves in the adjacent area may be affected.
Sometimes a surgical intervention causes a fracture of the femur.
It is important to know: even if the surgery was successful, the risk of complications in the hip joint exists even many years later. But many patients still agree to it in the hope that arthroplasty of the hip will give them relief from pain and the newly obtained mobility of the limbs. To date, there is no better way to restore the hip joint in case of irreversible alterations in the bone tissues.
The goals of rehabilitation are:
- to eliminate contracture, or limitation of movements;
- to reduce edema of soft tissues;
- to regain muscular strength and functionality of the joint;
- to prevent complications.
The postoperative period and its duration are of particular importance for successful treatment. The time needed for restoration of the normal functioning of the limbs varies in the medical literature.
The postoperative recovery usually lasts one day and, then, it is followed by a rehabilitation period. After surgery, a patient may stay is in a clinic about one week. There are two points of view on how to help to the patient in the first 24 hours. Mainly, everything depends on the patient's condition and hip joint surgery success. Often, patients do their first attempts to move with the help of medical staff already the same day surgery. On the average, people return to their normal physical activity in 3-6 months after surgery.
There is a special program of exercises for the hip joint and for general strengthening of the body that is mandatory for every patient. If the patient's condition does not improve, the length of his or her stay in the hospital after the operation, respectively, increases. After surgery, continuous measures are undertaken to increase daily activities of the patient. In general, the recovery lasts up to six months and during this time the functionality of the limbs and hip joint is completely restored, provided that the patient follows all the recommendations of the doctor.
Walking, swimming and cycling are not restricted in the rehabilitation period, as they contribute to a faster recovery of the hip joints. But you have to forget about energetic and contact sports because they may cause harm to the hip joint in the rehabilitation and even post-rehabilitation periods.
Coxarthrosis of the Hip Joint
Osteoarthritis is a disease inherent only to people. This is the price of a human upright posture. Since earliest humans began walking upright on two feet and made their hands free for work, they also had got this disease. Numerous archaeological excavations proved this many times. It happened because of the redistribution of the body weight to the articular surfaces that were not ready to that.
Coxarthrosis is arthrosis of the hip joint. The Latin word “coxa” means “thigh”, “articulation” is the joint, and “os” indicates a non-infectious nature of the disease. In other words, coxarthrosis is a degenerative disease of cartilage tissue of the hip joint.
When formation of the bony skeleton is finished, cartilage tissue ceases to regenerate. This means that any damage to the cartilage tissue leaves its traces. To old age, such damages are numerous and cartilage can be nearly gone: joint bones start rubbing against each other. This causes typical clinical manifestations of the disease.
Coxarthrosis of the hip is associated with the severe form of osteoarthritis. It is the most often occurring condition among all the diseases of the musculoskeletal system, accounting more than 40% of all cases. This disease, usually, starts developing after 40 both in men and women. However, women are affected by this disease more severely.
Coxarthrosis is a degenerative arthritis of the hip joint that can be successfully treated at the initial stage of development. But, unfortunately, people tend not to seek for the medical help immediately as soon as they feel the first pain in the hip joint, which allows the disease to progress.
At the heart of this pathology, there is the viscosity of the joint fluid, thinning of the cartilage tissue and reduction of the joint gap. All of the above leads to degeneration of the joint cavity as a whole.
Thick articular fluid cannot sufficiently lubricate the articular surfaces, which leads to the joint surface roughness, increased friction and thinning of the cartilage. The joint gap decreases and the bones are deformed. Violation of the blood circulation leads to the slump of nutrients to the joint and muscle atrophy.
Coxarthrosis can be bilateral (at two sides) or one-sided. The latter oftener occurs at the right joint. Left-sided coxarthrosis is less common.
All cases of this difficult disease can definitely be divided into two large groups: the primary and the secondary hip osteoarthritisis.
Primary coxarthrosis is disease that occurs without any cause, of itself. With the primary form of the disorder, the both joints usually affected, that is called bilateral coxarthrosis. Typically, this disease occurs in older people. In the development of this type of coxarthrosis, hereditary factor plays the significant role. So, in women whose mothers suffer from excess weight and coxarthrosis, the probability to get the disease is higher than in the population on the average.
Secondary coxarthrosis happens in an already altered joint as a consequence of any primary disease (for example, inflammation or trauma).This large group includes all possible causes of coxarthrosis and all risk factors. They can also be divided into several large groups.
1st Cause: Hereditary Factors
There are many hereditary diseases that may lead to coxarthrosis. As a rule, these are the conditions involving deterioration of connective tissue (ligaments, bones and joints), or collagenosis diseases, for example, Stickler syndrome.
2nd Cause: Age
Age is one more important risk factor. In younger people (under 30-35 years), this disease is very rare. Later, at 40-45 years it affects about 2-3 % of the population (the U.S. statistics). But then, after 65 years, the number of people with osteoarthrosis of the hip increases dramatically: at the age of 45-65 years, almost one third (30%) can suffer of the condition, and at the age of 65-70 years, the probability of degenerative osteoarthritis increases to 70 -75% or more! In other words, most of elderly have some signs of the degenerative joint disease, and with a high degree of probability, it can be hip arthrosis.
3rd Cause: Dysplasia
Hip dysplasia is a congenital joint disorder of the joint that has its origin in underdevelopment of the articular bones and ligaments, so that such children often develop subluxations and dislocations of the femur head.
Some people may have dysplasia and not even know, until they found it by accident, for example, when having X-Rays.
These patients can develop osteoarthritis caused by dysplasia. Mostly, it occurs in women from 25 to 55 years. This happens due to the reduced physical activity that helps the joint to work normally. In young women, the disease can develop during pregnancy and after childbirth, while in mature and elderly people it caused by decrease in physical activity after retirement.
So, if you know that you have dysplasia of the hip joints, you should, at least once a year, to see an orthopedist and have an examination including X-Rays, and very carefully follow doctor’s instructions: to avoid physical activity, such as weight lifting, but, at the same time, to do useful exercises that strengthens the hip (skiing, swimming, etc.).
4th Cause: Obesity
This is one of the most important risk factors contributing to the development of arthrosis, mainly of the knee, and, also, the hip joint. Indeed, all the extra 5-10-20 kg not needed to the body, literally, lying about like so much dead (and heavy!) weight and overloading the hip joints.
Under the circumstances, cartilage cannot withstand such heavy loads, and is not able to recover even at rest!
5th Cause: Metabolic Disorder
Many diseases and conditions associated with metabolic disorder can greatly affect the blood supply and nutrition of joint cartilage, and, unfortunately, not for the better.
Unlike the other tissues, the cells that produce the cartilaginous matrix – chondrocytes –get nutrients not from blood vessels, but directly from synovial fluid. This is a very subtle biochemical mechanism that can be violated easily, which often happens.
Diseases such as diabetes mellitus, ochronosis, primary and secondary gout, hemochromatosis, Wilson disease, as well as the lack of female sex hormones (estrogens) in menopause, can become the culprits of joint disorders.
Since estrogens regulate metabolism in bones, ligaments, joints and generally in connective tissue, the lack of these hormones can also become a trigger for the development of the disease.
6th Cause: Injuries and Surgeries
Very often injuries of the joint, that sometimes require surgery, contribute to the occurrence of coxarthrosis. As after such events, the joint becomes a bit “defective” (in the medical sense), deterioration of the cartilaginous tissue of the joint can begin due to any, even a weak risk factor, and, then, degenerative osteoarthrosis develops.
That is why, if you had a trauma or surgery in the hip area, you need to be especially careful choosing your lifestyle and avoid unfavorable factors described in this article, as much as you can.
7th Cause: Inflamations (coxitis)
The hip joint, like other parts and organs of our body, can be prone to inflammation. Inflammation of the joint (coxitis) can result from infection. In this case, the disease develops with massive damage of joint cartilage, and recovery can take quite a long time and, as a result, secondary coxarthrosis may begin.
In some cases, inflammation can occur not because of microorganisms – it is called aseptic inflammation. This inflammation often results from autoimmune disorders that can be caused by such diseases as systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA).
8th Cause: Overloads
Sports and physical work associated with high load on the joint, including standing at work without the possibility to sit down and “unload” the hip joints, can also contribute to the development of coxarthrosis.
Why is this happening? It is possible, because the delicate cartilage tissue is not intended to be exhausted by constant load or jumping for 18-20 hours a day. Unceasing movements in the joint together with a high load lead to cartilage wears out very quickly, whilst the rest time seems insufficient for joints to recover.
9th Cause: Environmental factors
Let’s slow down before saying that the “bad ecology” is what always blamed when the true cause of the disease cannot be found. In fact, many external factors can actually facilitate developing of coxarthrosis. These include, for example, poisoning with salts of heavy metals that is not uncommon in some cities.
Furthermore, such “trivial” things like smoking and drinking alcohol can also become the main triggering factor that contributes to the development of the disease. So, sometimes, it makes sense to do tests in order to reveal intoxication with harmful substances and, at the same time, quit smoking. In any case, your body will be thankful for this!
Symptoms of coxarthrosis are pronounced, so diagnosing is not difficult. However, you should remember that the symptoms of coxarthrosis depend on the degree of the disease. The main signs of the disease include:
- Pain in the joint, not passing even while rest, and also nocturnal pains. The pain intensifies even with little physical efforts and can go into the groin, knee joint, shin, and hip.
- Constant tension of the pelvic girdle muscles or hip muscles.
- Stiffness and significant limitation of joint mobility.
- Limping while walking.
- Crackling or snapping joints.
- Over time, the limb with the diseased becomes shorter and its muscles atrophy.
- Deformation of the joint.
The symptoms of bilateral, or symmetric, coxarthrosis are the same, but they are present in the both extremities. A specific feature is that the pathological process extends to the lumbosacral spine. Minor movements and lameness lead to the spine deflection and, over time, protrusion of intervertebral discs and bending of the spinal column occurs.
There are three degrees of coxarthrosis of the hip joint.
Coxarthrosis of the 1st degree is characterized by minimal changes in the joint. But the first signs of disorder appear already in this period. The joint sores after physical activities, such as long walking, or running. A pain is localized in the hip region or, rarely, in the thigh and knee. The condition can be improved while you rest and pain disappears. Movement range is not limited, gait is not affected, and muscles are not atrophied. X-Rays show bone growths that do not extend beyond the joint lip. There is a slight narrowing of the joint gap, whilst the other components of the femur have no changes.
Coxarthrosis of the 2nd degree: Pain intensifies significantly and its duration increases. Pain in the knee and inguinal areas is also possible. Lameness during prolonged walking is developing. There is a limitation of movements: it is impossible to move the hip to the side and turn it inward: the muscles do not work properly anymore. With the help of an X-Ray, it is possible to reveal bone growths that extend beyond the acetabular to its inner and outer boundaries. The head of the femur increases in size, shifts relative to the acetabulum, and its surface becomes rough. Cysts may appear. The joint gap is unequally narrowed all over.
Coxarthrosis of the 3rd degree: Pain is permanent and does not pass at rest and at night. Walking without a cane is hardly possible. Muscles of the thigh, calf and buttocks significantly atrophy. Due to this, the diseased limb becomes shorter. To compensate this, the patient walks on his toe, which leads to a significant increase in the load on the affected joint. X-Rays demonstrate massive growths of bone tissue on the head of the femur and the acetabulum, and a thickening of the cervix. The joint gap is severely narrowed.
Hip joint arthrosis can be diagnosed by a practicing doctor only with the help of X-ray techniques. The examination helps to define the degree of disease development and its etiology.
The first thing to pay attention to is doctor’s qualification: it matters a lot for disease diagnostics. Pretty often, a specialist develops the plan for spine treatment forgetting about hip joint examination and losing precious time.
Today, the following ways of diagnostics are used and considered to be the most informative:
- X-ray examination. It allows visualizing the state of hip head and reveals the symptoms of osteophyma.
- Ultrasound examination. This examination is necessary to define the stage of disease and the localization of degenerative-dystrophic source.
- Computer tomography or magnetic-resonance imaging Most often, MRI is preferred due to the absence of X-ray radiation and detailed view. The apparatus allows performing scanning layer by layer, reveal the stage of disease and find it out at early stages of development.
Patients should understand that coxarthrosis is a progressing disease. Even if it’s revealed at early stages and treated with medicaments, there’s no 100% guarantee that it’ll be eliminated fully. In most cases, the disease can be paused, but practice shows the mechanism of its development restarts within 5-10 years.
At the 1st stage of disease doctors prefer conservative treatment and apply different drugs and products (non-steroid anti-inflammatory medications, neuromuscular relaxants, cartilage protectors and other drugs).
NSAIDs (Non-steroid anti-inflammatory drugs) — are good pain-killers for coxarthrosis that reduce swelling and inflammation of the joint relieving pain.
Miorelaxants also reduce muscular spasm, stimulate blood flow, and cartilage protectors contribute to restoration of defected cartilage tissue.
These medications can be used as pills and injections depending on the degree of pain and doctor’s prescriptions.
Physical therapeutic methods are also important for coxarthrosis treatment (laser therapy, medicinal baths, acupuncture, mud treatment, massage, and gymnastics).
Exercises should be figured out very accurately by a specialist only so that not to traumatize the damaged joint.
At the first and the second stages of disease, arthroscopic debridement is used – it’s a surgical invasion during which tiny destroyed cartilage particles are removed. It allows reducing pain and constraint in the joint.
Juxtarticular osteotomy is a surgical invasion when the hip bone is cut in certain places and is re-joined under some certain angle, which allows decelerating development of coxarthrosis.
Surgical treatment of coxarthrosis
When the disease reaches the third stage, joint tissues hardly react to restorative therapy. Patient experiences permanent pains, and the ability to move is almost lost. At this stage, there’s no point to use cartilage protectors for treatment – it cannot be cured with conservative methods. In such cases, the doctor can decide to treat coxarthrosis with the help of an operation.
Why the operation cannot be avoided in 99% cases? As a rule, pain appears when the joint already has the 2nd stage of destruction. This is when nothing except joint removal can help. In other words, the main peculiarity of hip joint arthrosis is that it isn’t usually diagnosed at early stages, because a patient has no complaints.
Surgical treatment of coxarthrosis presupposes performing one of the following operations:
- Arthroplastics – modeling of joint surfaces. To perform this operation, a doctor needs to make an interlay that replicates cartilage tissue. It can be made either of synthetic materials, or with patient’s own tissues.
- Endoprosthetics. This operation is made in case of bilateral arthrosis of hip joint. During the operation, the hip joint is fully replaced. This hip joint surgery doesn’t imply cutting of muscles, so restoration after it is relatively quick. This and the above mentioned variants allow saving movement of the hip joint. Osteotomy is an operation that presupposes cutting bones, eliminating deformations and joining them the most beneficial way. In some cases, partial movement of joints can be preserved.
- Arthrodesia is the operation during which joint surfaces are interconnected rigidly with the help of plates and screws. This way, movement of the joint is reduced or fully eliminated. It is performed to restore at least the supporting function of legs and joints. This method is used in cases when all other options are impossible, for instance, if there’re no contraindications, or when the hip joint is seriously deformed.
Endoprosthetics for coxarthrosis
After endoprostetics operation for coxarthrosis, movement of joints is totally restored, pain subsides, and life quality is improved considerably. At the same time, the artificial joint cannot totally replicate the real one, and a patient has to face some restrictions. For example, it’s prohibited to do squats – it increases the risk of joint misplacement. Besides, one out of ten patients faces weak or moderate pain after the operation, but it can be helped with pain-killers, compresses and other means. Unfortunately, doctors cannot always understand why some patients still face pain after surgical treatment. However, the vast majority of people feel much better after the operation.
Sometimes, after surgical treatment of coxarthrosis, one leg becomes longer than another, but it can be corrected with the help of special inner soles.
Most often, artificial joints made of metal and plastics are used – it can be a metal sphere and a plastic jack socket (hip joint is a ball and socket joint where one surface is ball-like, and another is incurvate and is often called “socket”). More active young patients can have ceramic and plastic joints implanted (a ceramic ball and plastic socker), or joints made of ceramics only, or (in rare cases) – made of metal only.
Preparation for surgery
Prior to the operation, a doctor decides which joint should be implanted. Besides, two-three weeks before the surgery, the patient should go through detailed examination. For example, blood analysis, X-ray of the hip damaged by coxarthrosis, urine analysis and electrocardiography.
Besides, a patient should also be examined by a dentist and, if necessary, go through dental treatment. Some dental problems are connected with a high risk of developing an infection after the operation.
In some clinics, patients also can consult with their physicians and ask how to put clothes on, wash oneselves and perform daily activities at home. Before the operation, a specialist can recommend patient bying some devices that will help to move around and perform usual tasks.
Since this operation is usually performed under general anesthesia, a patient isn’t allowed to drink and eat in the morning before it.
After the operation
After the surgery, most patients stay in the hospital for 4-8 days. During this time, they start walking and learn to climb the stairs and perform simple exercises which will promote recovery process. In 6-12 weeks after the surgery, a patient will have to go through examination for the doctor to make sure that recovery process is going well.
Possible side effects after coxarthrosis operation:
- Thrombosis of deep veins. The risk of thrombosis can be reduced with the help of compression stockings, blood thinners and some other means;
- embolia of lungs – a disease during which the blood clots formed in veins advance into lung vessels. Luckily, this is a rare complication that can be easily dealt with by anticoagulants;
- Misplacement of artificial joint happens less often than in one case out of twenty. These patients need one more operation to put the joint on its place;
- Infection. Although doctors take all necessary measures to perform the operation in safe and sterile conditions, one patient out of hundred develops infection after hip joint replacement. Infection diseases are easily treated, but artificial joints have to be removed and re-implanted after treatment of infection;
- Weakening of the artificial joint. Most often, it takes place 10-15 years after the operation. Weakening of the new joint is typically connected with thinning of bone around the implant, which reduces the risk of fractures;
- Bleeding and hematomas. As a rule, bleeding ceases two days after the operation, but sometimes it continues, and blood collects under the skin. In some cases, simple operations are required to remove the collected blood.
First two-three months after the operation a patient should move accurately to avoid misplacement of the new joint. However, it doesn’t mean that the patient should move as less as possible – vice versa, muscles should be strengthened to make the joint more flexible. During 4-6 weeks after the operation, patients usually walk resting against a walking pole or crutches. During first few months, patients aren’t recommended to use bicycle, run over solid surfaces and perform sports that require sudden turns and squats – such as tennis and squash. Those who have hip joints replaced should obtain from sports connected with a high risk of falling – for instance, mountain skis.
Generally, people with a new joint can live active and fully-fledged lives without experiencing pain for years. In 80% of patients, artificial joints serve for at least twenty years.
Hip arthroplasty (hip replacement) is normally done to relieve pain and restore motor function in a severely damaged hip joint. Sometimes, a joint replacement isthe only way to restore joint function effectively and improve the life quality of a patient.
During asurgery, diseased joint components are replaced by an orthopedic prosthesis (an implant) that anatomically replicates a healthy joint and enables a full range of movements. Modern endoprostheses are made of ceramic, metal or high-strength polymers with high biological compatibility with the human body, and their lifetime is 15-20 yearson the average. When an artificial hip wears out, it is replaced with a new one.
Many patients have an opinion that joint replacement can be only total. This is far from being truth. There are also some other types of surgeries. Let's have a brief survey of each method.
Total Joint Replacement
Total joint arthroplastyis the most common kind of replacement surgeries. It is performed when not only cartilage, but also bone tissue is severely damaged. It involves a complete removal of the joint and its replacement with an implant, including both the acetabular cup and femoral component.
This procedure is performed in case of secondary contracture, which may occur due to the poor quality of primary surgery or patient’s wrong actions in a rehabilitation period. Prosthesis failure, poor fixation of the implant and dislocation of the femoral and acetabular components of the artificial joint are the main causes of revisions. The purpose of this procedure is to replace damaged components and improve joint fixation.
As the name implies, this surgery involves resurfacing of a diseased joint. If only joint cartilage is damaged, but the femoral head is not affected, your doctor may decide on a joint resurfacing (an articular surface replacement), which allows maximal preservation of bone tissue and provides maximum amplitude of motions. In this case, only the upper cartilaginous layer is removed from the femoral head and, then, a metal cap is placed on the top of it. The acetabulum is replaced in the same way as with total arthroplasty.
Bilateral Joint Replacement
This is a simultaneous replacement of both joints in a single surgical intervention, if a patient's condition allows such a large-scale operation. It may benefit the patient, since there is the only one rehabilitation period instead of two as with consecutive surgeries.
Joint replacement can be done using traditional open surgery or by a minimally invasive method. With the minimally invasive technique, a smaller incision (not more than 8 cm) made via aposterolateral or anterolateral approach to the articular cavity. The main advantage is lesser tissue damage, which leads to faster recovery. However, minimally invasive hip arthroplasty is not widely used, as it is more demanding in terms of surgeon skill, because access to the joint is more difficult and visibility of the operational site is worse, and all this increases complication risks.
By the type of fixation, there are two kinds of endoprostheses:
- cemented fixation implants;
- cementless fixation implants.
When choosing a suitable hip joint prosthesis and the type of attachment, bone quality, physical activity, age and health status play an important role.
Cemented hip endoprosthesis: fixation of an artificial hip joint with bone cement
In the case of a cemented hip endoprosthesis, the leg of the artificial hip joint and the acetabulum are fixed with bone cement in the femur and pelvis. This method allows the patient to quickly return to physical activity and provides maximum stability of the hip joint prosthesis.
Cementless hip endoprosthesis: fixing an artificial hip joint using a press fit
In the case of an uncemented hip joint prosthesis, the thigh and acetabulum are pressed or screwed into the femoral and pelvic bones. The material of the components, to which bone responds well, stimulates the growth of surrounding bone tissue. Such a prosthesis of the hip joint requires a long fixation. However, it promotes quality bone healing.
Hybrid Hip Endoprosthesis
This combination of both methods, which includes the advantages of cemented and cementless fixation of the artificial hip joint. The acetabulum is screwed or pressed into the pelvis, while the leg of the prosthesis is attached to the femur using cement.
After hip replacement is considered and a day of an operation is assigned, you need some preparations, as listed below:
- Full clinic examination, including tests and consultations witha range of specialists.
- In case of concomitant diseases, such as cardiovascular diseases, diabetes mellitus, gastric ulcers and others, make sure they are in the phase ofremission.
- Foci of chronic diseases, such as e.g.,infections of the urinary and respiratory tractmust be eliminated. There should be also no any skin damages (abrasions, ulcers, cracks). Consult a doctor ifit is necessary.
- Dental check-up, and treatment, if required. If you had a tooth extraction recently, please wait at least two weeks to heal the wound.
- Check your weight and BMI (body mass index), which is calculated by the formula: mass (kg) / height2 (m2). BMI should not exceed 35-40. If you are overweight, you may be advised to reduce your weight before hip joint surgery. Please, take this advice seriously, because weight reduction lowers the risk of postoperative complications, significantly improves an outcome and extends the artificial joint lifespan.
- Smoking weakens the blood circulation. You should stop smoking one month before the operation.
What you need to do at home before going to a hospital for surgery,in order to make you more comfortable and safe on return:
- Place the items you use regularly to make them accessible, so you do not have to stretch or bend to take them.
- If you live in a housewith stairs, consider how you can avoid unnecessary climbing. For example, you can temporarily switch room designations and use a living room as a bedroom.
- Rearrange the furniture to have enough space to walk on crutches or with walkers.
- Get a suitable chair, the durable one and high enough to keepyour knees lower than your hips, and with armrests to make it easier to get out of the chair.
- To make your moving safer after your discharge from a hospital, examine your place together with your relatives so as if you are a detective or security specialist: remove or glue with double-sided adhesive tape the corners of all rugs so that you cannot stumble over them. Remove loose wires from the floor, if any. If you have parquet floor in your home, check all the planks to make sure that none falls out. Cover the sharp corners of tables and other furniture with special soft pads sold in children's stores. Ensure you have proper lighting everywhere in your home.
- Prepare your bathroom. If you normally take a shower standing in a bathtub,find a reliable stool without armpits. If you have a shower cabin, you can use a chairof any style but steady enough.
- The chair must have legs with rubber pads that prevent slipping.
- Fix secure hand rails on a bathroom wall or in a shower.
You arrive to a hospital for arthroplasty one day before the scheduled surgery. In a waiting room you will see a general physician and an orthopedist. They will explain all what you need to know about the upcoming surgery. If necessary, an additional examination can be done, such as tests, radiography, and functional examination. Then, you will have a consultation with an anesthesiologist.
After the examination you also will meet a rehabilitation physician who explains you:
- How to use crutches
- How to walk with supports without excessive load on the limb
- How to sit down, sit and get up
You may have a massage or functional electric stimulation (FES) of the lower limb muscles, if necessary.
In the night before surgery you need to take a bath or shower. After 6 p.m. you should not eat any more, and after midnight you also do not drink.
In the morning before surgery you need to remove false teeth, hairpins, contact lenses, glasses, watches, rings, earrings, chains and other jewelry and wash off the nail polish.
Before starting hip replacement surgery, a surgeon introduces a catheter to your vein. Regardless the method, surgery may be performed under general anesthesia or regional spinal anesthesia. With the latter, an injection is made in the lumbar region, after which the low extremities become numb for several hours. After the anesthesia, a urinary catheter is introduced. During all surgery, you will be conscious, but you can sleep if you want.
The duration of hip replacement is 1 hour on average.
Let us consider the traditional procedure for hip arthroplasty.
- The surgery area is extensively treated with an antiseptic; a tourniquet is applied.
- Next, the joint is opened without crossing the muscles and ligaments, using an anterior or posterior approach. Minimally invasive techniques have many advantages, but open surgeryis also widely applied.
- A surgeon accurately pushes aside soft tissues and fixes them with a clamp, then, reaches the articular capsule and removes it.
For different types of implant fixation further procedure may be different.
Cemented Fixation Implantation
- A surgeon cuts off the diseased bone of the femoral head and neck using a bone saw.
- The femoral canal is drilled by pasps or reamed with special surgical reamers to widen the canal and prepare it for stem insertion; sometimes, the procedure can be done without reaming with broachers only.
- The surgeon fits a stem of an implant to the canal, puts an artificial femoral head on and checks if the joint moves properly.
- When the fitting is done, the canal is plugged and filled with cement with a tool called a caulking gun.
- After this a centralizer is introduced.
- Excess cement is removed after 5-8 minutes.
Cementless Fixation Implantation
A procedure is nearly the same as above, but a stem is inserted into the canal without cementing. In this case, a special rough surface of the femoral stem ensures adhesion of an implant with the bone and their further fusion.
Having convinced that the new joint works perfectly, the surgeon washes the surgery area, installs drainage and suture the wound. At the end, the leg had surgery is fixed with an elastic bandage in a comfortable position.
If necessary, surgeons drain the joint introducing 1-2 thin plastic tubes (drains) so that the post-operative blood does not accumulate in the articular cavity. Flowing through the drains, the blood is collected in removable plastic containers changed by nurses until the drains are removed. The wound is stitched.
Before moving to a ward, you will spend some time in the postoperative care unit. You will have an intravenous catheter in one of your veins.
Please be ready that you will encounter pain in the first time after surgery, but you will be given injections to manage it. If you had spinal anesthesia, you will not able move and feel your legs for some time after surgery. However, the sensitivity and mobility will begradually recovered within 2-4 hours.
The treatment you will receive at the Medical Center depends on the implant type and doctor prescriptions.
The first few days after surgery are the most important. Your body is exhausted, and you have not yet fully recovered from anesthesia, but already in the first hours after you have come to consciousness, try to remember about the operated leg more often to be mindful about its position. As a rule, immediately after the operation, the operated leg is placed in a slightly flexed position. There will be a special bolster between your knees placed so to ensure their moderate spreading. The active regime in bed is allowed already in the first day after the surgery.
The first time you need to change bandaging is the next day after the surgery, and later on it will be done when needed, but at least once every 2-3 days until complete healing. 12-14 days after the operation, the stitches are removed. Sometimes, the wound is sutured with absorbable threads andyou don’t need to remove them.
In the first 2 days after the operation, a light diet consisting of porridge on water, jellies and fermented milk products is prescribed. Food, boiled or steamed, is given in semi-liquid or puree form, with the limitation of refined sugars and salt. Products promoting bloating and fermentation processes should be excludedfrom the ration. Next, one of standard diet plans is prescribed, considering the concomitant diseases.
Any operation has a risk of blood clots in the leg veins. You will be prevented from this complication by elastic bandaging of the lower extremities, and the prescription of anti-clotting medications.
Please remember that:
- In the first days after surgery,you should sleep only on your back.
- When turning in bed on a healthy side, you have to use a bolster between the legs, holding it with your knee slightly bent and ankle joints.
- In the first days, you should reduce a range of movements in the operated joint, and, especially, avoid bending in the knee and hip joints for more than 90 degrees, sharp turns of the leg, and rotation in the hip joint.
Recommended loads on the operated leg:
In case of cemented fixation:
- Partial load: from the first days after surgery
- Full load: by the end of the 1st month
In case of cementless but strong fixation:
- Partial load (15% of body weight):after 7-10 days
- Partial load (50% of body weight): by the end of the 3rd week
- Full load: by the end of the 2nd month
In severely weakened patients (suffering from acute cerebrovascular disease, severe somatic pathologies, cancer patients, and in people older than 90 years):
Full load: immediately after surgery
In patients with acute pain:
Immediate load limitation (in any period of time)
Try to devote all your free time to physical therapy. At first it will be accompanied by a moderate pain, but every day it will become easier.
The main goal of physical therapy is to improve the blood circulation to the operated hip, to prevent thrombosis, reduce edema, and speedup wound healing.
Another important task of physical therapy is strengthening the muscles of the operated limb, restoration of the normal range of movements and ability of the joint to support the entire body weight. Remember that anartificial joint is a bearing with an ideal slipping and minimal friction force. And that is why it is better to exercise actively in order to strengthen the muscles surrounding the joint rather than passive rocking and stretching.
In the first 2-3 weeks after the surgery, you should exercise lying in bed. All exercises must be performed slowly, evenly, and avoiding sudden movements and excessive muscle tension. To breathe correctly while exercising is also very important: breathe in when you strain muscles and breathe out when you relax.
1st exercise is to the gastrocnemius muscles. Gently push your feet up and down. Do this with both feet for several minutes up to 5-6 times in an hour. You can do this exercise immediately after awakening from anesthesia. Clench and unclench your toes.
Starting from the second day after the operation, continue with the following exercises:
2nd exercise is for the hip muscles. Keep your legs straight. Strengthen your knee pressing the knee pits to the bed and hold this tension for 5-7 seconds, then slowly relax.
Buttocks muscle strengthening:
- Toning up the back part of the thigh and lower leg: press the heels to the bed for 5-7 seconds, then, slowly relax
- Moving the leg aside along the bed surface and bringing it back
3rd exercise: Cautiously slide your foot on the surface of the bed toward your buttocks bending the leg in the hip and knee joints. Then slowly slide it back. When doing this exercise, at the beginning you can use with a diaper or elastic tourniquet, by placing it under the knee. Remember that the angle of bending at the hip and knee joints should not exceed 90 degrees!
4th exercise: Put a small pillow under your knee (not more than 10-12 centimeters) and try to strain the muscles of the thigh slowly and straighten the leg at the knee joint. Hold the straightened leg for 5-6 seconds, and then slowly lower it to its original position.
Do all the above exercises through out the day, for several minutes every hour (5-6 repetitions each).
From the second day you can sit down on the edge of the bed, leaning on your elbows, or holding on to the handrails with your feet lowered to the floor. First, you should gradually move the healthy leg, and, then, drag the operated one over it. Your legs should be moderately apart; you can ensure this using a bolster. To move the operated leg, you can use a special elastic bandage. When you move the operated hip to the side, keep the body straight and do not let your leg roll outward.
Always remember to bandage your feet with elastic bandages before you sit down or get up, or wear special elastic stockings to prevent thrombosis of the veins of the lower extremities. To restore normal movement of the joint, from the second day you will start a physiotherapy course with the help ofmechano-therapy appliances, special devices that, according to a specially designed program, will bend and unbend your leg in the hip joint. However, although those simulators are effective, they will not replace your own efforts. You will need to practice and develop your muscles so that they are ready by the time when you are able to walk without help.
The purpose of this rehabilitation period is to learn how to get out of bed, stand, sit and walk without help and safely.
As a rule, you are allowed to get up on your own on the second day after surgery. The first time you should get up only under supervision of medical staff. You are still weak and someone must help and assist you. You may feel slightly dizzy, but try to rely on your own strength as much as possible. Remember, the earlier you get up, the earlier you start walking by yourself.
Get out of bed from the side of the healthy leg. Sit on the edge of the bed, keeping the operated leg straight and extended forward. Place both feet on the floor. Using crutches, step on the non-operated leg and try to stand up. Leaning on the healthy leg, move the crutches forward. Then, slightly bend the operated leg in all joints and move it too. Leaning on the crutches, transfer your weight to them and push forward the healthy leg. Repeat all movements in the same order.
In the first 7-10 days, you can only touch the floor with the foot of your operated leg. Then, slightly increase the load through your leg, trying to step on it with a force equal to the weight of your foot, or 20% of your body weight. You should regulate the time you walk taking into consideration how you feel andcondition of your leg, and without reducing exercise therapytime. If you exercise not enough or do it incorrectly, and, at the same time, walk too long, by the end of the day you will have swollenfeet. In this case, consult a doctor. Concomitant diseases also may contribute to swelling.
After you have learned to stand steady and walk without help, you may start exercising whilst standing, with your hands on a support.
1st exercise: Moving a straightened leg forward
Stand on the healthy leg with your hand resting on the back of a bed or chair. Slowly move the operated leg forward by 20-30 cm. Make sure that the thigh, knee and foot directed forward. Keeping the same pose, slowly bring your foot back to its original position.
2nd exercise: Moving the legaside
Standing on the healthy leg with your hand resting on the back of a bed, slowly move the operated leg to the side for 20-30 cm. Make sure that the thigh, knee and foot directed forward. Keeping the same pose, slowly bring your foot back to its original position.
3rd exercise: Moving your foot back
Standing on a healthy leg with your hand placed on your loin, slowly move the operated leg back. Make sure that the waist does not bend. Slowly return to the original position.
4th exercise: Raising the knees
Slowly bend the operated leg in the hip and knee joints by an angle not exceeding 90 degrees and raise the foot to a height of 20-30 cm above the floor. Try to hold the raised leg for a few seconds, then, slowly lower the foot and put it on the floor.
The above exercises are recommended to do up to 10 times a day for 5-15 repetitions.
So, you walk on crutches quite confidently in the ward and hospital corridor. But in everyday life,it is not enough. You need also walk up and down the stairs. If you have only one joint replaced, you start climbing should be from the un-operated leg. Leaning on crutches, transfer the leg to the next step. Move the crutches over it and transfer the weight of the body to the un-operated leg that is now standing a step higher. Then lift the operated leg and put it on the same step. Crutches are moved last or simultaneously with the operated leg. When descending, you should first move the crutches, then, the operated leg, and, finally, the un-operated one.
More exercises to restore motor functions
1. Lower leg muscles
Take a position lying on your backwith arms and legs spread out. Tighten the abdominal muscles. Pull the toes up and press the heels to the floor. For a few seconds, keep the tension in the lower leg muscles and, then, relax.
2. Extensor muscles
Take a comfortable position lying on your back, with your arms and legs spread out. Tighten the abdominal muscles. Press the knee pit to the pillow under your knees, and pull the toes up. For a few seconds, keep the tension and, then, relax.
3. Muscles of the buttocks
Take a position lying on your back with arms and legs straightened. Tighten the abdominal muscles. Pull the toes up. Do not bend your knees. For a few seconds, strain the buttock muscles, and, then, relax.
4. Bendingat the hip
Place something you can slide on it (for example, a towel) under the foot of the operated leg. Raise the operated limb bending it in the knee, while simultaneously pressing the heel to the towel and pulling it toward the buttocks. When you do it, the toes are moved up. Hold the limb in that position for a while, and, then, return the foot to its original position.
5. Moving the legaside
Take the position lying on your back, stretching your legs. Place something you can slide on it (for example, a towel) under the foot of the operated leg. The toes should point to the ceiling. Slightly move your leg to the side, then, slowly return it to its original position. During the exercises, the knees should not touch each other.
6. Bendingat the hip joint
Take the position lying on the back, so that the operated leg is slightly bent. After this, raise the limb bending the knee at 90°, and keep this position for some time. Slowly return the bent leg to its original position. During the exercise, the healthy leg should be straight and remain on the floor. The toes are pointed upwards.
7. Moving your leg to the side
Take a comfortable lying position on the healthy side. Place a pillow between your legs. Bend the healthy leg and place a bent arm under the head. Put your head on your arm. Raise the operated leg, hold on for some time, and then return to its original position. When lifting your legs, keep them straight. Do not straighten your toes and keep your feet parallel to the floor.
8. Moving a bent leg to the side
Take a comfortable position lying on a healthy side. Place a pillow between your legs. Bend both legs in the knees. Slowly raise the operated one up, hold on for some time, and, then, return it to its original position. Do not straighten your toes, while the knee should be pointed forward.
9. Moving your leg to the side
Place a durable object of a small heighton the floor, and stand on it with a healthy foot. It is necessary that you stand slightly up so that the operated leg does not touch the floor. To keep balance, your hand is resting onthe chair back. Move the operated leg aside, and then return it back. The leg should be straight, but the toesare not stretched.
10. Unbending in the hip joint
Stand in front of the chair with your hands on its back. Move the weight of the body to a healthy limb. Slowly move the operated leg back without bending, and then return it to its original position. When doing the exercise, the upper body should be straightened.
11. Bending the knee
Stand in front of the chair with your hands on its back. Slowly bend the leg at the knee and lift it. Keep such a tense position for some time, and, then slowly lower your leg. The knee should be directed forward, and the foot should be parallel to the floor.
12. Straightening at the hip joint
Take the position lying on the abdomen, while the legs are straightened and the arms are stretched above the head. Bend the operated leg in the knee. Raise the hip upward with the knee bent. Keep this position for some time. Slowly lower your foot to the floor, still keeping the knee bent. Finally, straighten the leg, returning to its original position. Relax for a moment and, then, repeat the exercise.
13. Extension in the knee and hip joints
Ask a doctor if you can do this exercise. Take a position lying on your stomach with a pillow under it to prevent the waist from excessive bending. Stretch your arms above your head. Place the roller under the feet, so that the toes are pointing towards the floor. Raise the knee above the floor with the back of the knee toward to the ceiling. Raise the straightened leg until you feel the tension in the muscles of the thigh. Hold the limb in this position for a while, then relax and return the leg to its original position on the roller.
Every third urban resident over 55 years has some signs of joint diseases. Often, a pain in the hip joint and limited mobility is considered as the age norm, and people do not worry about it. Only when the pain becomes intense and prolonged and causes the gait changes, it becomes clear that it is a time to see a doctor.
With any diseases of the hip joint, whether it is arthritis or arthrosis, there is a certain risk of disability. Of course, if the treatment is started timely and a patient is under constant supervision of experienced doctors, there is a good chance to keep the mobility of the joint long enough.
But it also happens that conservative treatment is unsuccessful, the patient gradually loses the ability to move normally, and hip endoprosthesis surgery seems the only reasonable option.
Arthrosis and osteoporosis are constant companions of elderly people, with women suffering from functional pathologies 2 times oftener than men. In the main, the both diseases are associated with age hormonal changes in the body and decrease in the synthesis of bone cells. With osteoporosis, the bones become brittle, whilst with arthrosis, joint cartilage thins out. Both these forms of joint dysfunction are not inflammatory.
Destructive processes develop slowly, revealing themselves occasionally in attacks of sharp pain or difficulties to make usual movements, such as squatting, lifting, or turning. Gradually, the cartilage loses its elasticity and becomes thinner and thinner. Finally, the joint bones start rubbing against each other when walking, which leads to rapid deterioration of the joint surfaces. Excess weight, overloading the musculoskeletal system, makes the situation even worse.
An orthopedist can determine the degree of arthrosis or osteoporosis by the patient’s gait, but the final conclusions can be made only based on an X-ray or MRI scan. If conservative treatment cannot help to restore the joint ligament function, scheduled hip replacement is considered, as further development of the disease may lead to disability. Emergent hip replacement for elderly is often done in case of the femoral neck fracture.
The X-Ray or MRI scan clearly shows the degree of degenerative changes in the bones and articular cartilage, as well as types of deformities and other abnormalities that can be eliminated with surgery by replacing a damaged part of the joint with a prosthesis.
If your surgeon has concluded the surgery as the only effective method of treatment for joint degeneration, it is not that sad, as you may think first.
If the components of the joint are severely damaged, radical surgery is not recommended. Fragile bones and atrophied ligaments may not be strong enough to hold an endoprosthesis, which leads to further deterioration of the joint and can cause a trauma. Therefore, if your doctor finds the hip joint surgery possible and beneficial, it can be considered good news.
There are a number of diagnoses that are absolute contraindications to joint surgery:
- Chronic diseases in the stage of decompensation, including heart failure, ventricular and atrial arrhythmias, stroke complicated by neurological disorders, and impaired liver or kidney function;
- Diseases of the respiratory system (particularly, the lungs), accompanied by pulmonary ventilation disorders, such as bronchial asthma, pneumosclerosis, and bronchiectasis;
- Inflammation of the skin, muscles or bones in the area of the hip joint;
- Paresis or paralysis of the limb;
- Osteoporosis of the third or fourth degree (in this case, surgery is inexpedient, since a repeated fracture can occur even when simply walking);
- Hematopoiesis disorders;
- Severe mental disorders;
- Childhood age (when musculoskeletal system in the stage of development).
Relative contraindications to joint replacement surgery are functional chronic diseases in the stage of remission, neurosis, diabetes mellitus, bone and joint deformities, inclination to allergic reactions, and excess weight.
You should take your time when choosing an artificial hip joint, or endoprosthesis, as your quality of life after surgery depends on the properties of this medical device. But you have also another option: to choose the right clinic you can trust. Taking into account that German surgeons do not use materials of poor quality, you can minimize your risks. If you add to this high skill and experience of the doctors underlying their professional success, you will see why services of German orthopedists are in demand.
During the preparation for the surgery, a doctor will tell you which hip prosthesis can be used in every particular case and will explain the advantages and possible disadvantages of different designs. You will get comprehensive information about artificial joints used in the clinic and advice of an expert, which can help you to make a well-thought-out decision.
Modern hip endoprostheses are complex devices. “Eternal” artificial hip joint has not been invented yet, but today there are some high-end models on the market with lifetime 15-20 years or even more. There are also cheaper analogues, with lifetime about 5-10 years. An artificial hip joint with cementless fixation consists of a ball (head), a stem, a cup and, also, an insert. Endoprosthesis with cement fixation consists of the same elements, but acetabular component is solid and not divided into the cup and insert. Each of the elements has its own size range. During replacement surgery, a surgeon selects and inserts the appropriate size individually for every patient.
There are a few types of fixations of the artificial hip joint:
- Cementless fixation;
- Cemented fixation;
- Hybrid fixation.
Depending on whether all the joint parts are replaced or not, there are total hip implants and partial hip implants.
The bearing is what provides rotation and movement in the artificial joint. The lifetime of the endoprosthesis depends on the type and quality of bearing materials.
Hip joint implants can be split into the following categories based on the bearing materials:
- Metal-on-metal (MOM)
- Metal-on-polyethylene (MOP)
- Ceramic-on-ceramic (COC)
- Ceramics-on-polyethylene (COP)
Same as with people’s faces, all of which different, there are no two identical joints in nature. Each person has specific anatomical features of the skeletal system, such as differences in size, shape and proportions of muscles, tendons and ligaments. That is why a number of sizes of implants are produced: a variety of models allows you to choose the option appropriate just for you. The ideal fitting of the implant stem and the joint is achieved by the femoral canal preparation.
A stem for cementless fixation has a rough surface, which allows the bone tissue to ingrow into the prosthesis. This type of prostheses is called a “press-fit” implant, which means the stem is simply inserted into the femoral canal after the preparation purposed to make it fitting to the prosthesis.
For cementless joint implants, titanium-based alloys with the best biocompatibility are used. The stem of the prosthesis is covered with calcium hydroxyapatite or another porous compound to accelerate the process of bone ingrowth into the artificial material.
All implant manufacturers have their own specifications to feature the prosthesis to the specific purposes. For better fitting in the bone canal, the stem can be finished with protruding elements, as pins and wings, and others. Selection of the stems is based on an X-rays scan. An orthopedist fits prepared femoral stem necks in order to choose the best one, meeting the femur morphology.
The stems may have cylindrical, conical or curved shape. As well as, their cross sections may be round or quadrangular. Whatever the implant design, it should meet the main task which is to ensure uniform distribution of load to the bone, along the length of the femoral canal and circumferentially.
A cup (socket) of the hip implant is a part of the prosthesis fixed in the acetabulum by a cement or cementless method. Acetabular component can be hemispherical or low profile (with a smaller bulge).
Low profile designs provide a wider range of movements, but, at the same time, they are less reliable at high loads, since low rims cannot prevent the dislocation of the femoral head from the endoprosthesis socket. In recent years, modernized designs have become widespread, in which the sides of the cup are strengthened.
The cement fixation cups are made of high molecular weight polyethylene; cementless sockets are made of an alloy of titanium with aluminum and niobium. The surface of the cementless cups is rough with a porous coating. There are also holes for fixing rods on the surface of the socket of hip implant.
Hip joint arthroplasty is an operation to replace a part of the joint with an artificial component (an implant). A variety of surgeries in this area can be divided into two groups: partial and total joint replacement. Hip hemiarthroplasty (partial replacement) is the replacement of the femoral head, while the acetabulum is kept. With total arthroplasty, both the acetabulum and femoral head are replaced.
The type of surgery treatment is decided by an orthopedic surgeon with consideration the following factors:
- Patient’s age
- Condition of bones and cartilage
- Kind and origin of joint deterioration (trauma or disease)
- General health of the patient
Older patients are more likely to have partial arthroplasty, since this type surgery is more sparing, and is not associated with excessive blood loss. But it has such disadvantage as a relatively short life of the endoprosthesis (5-6 years).
Total hip arthroplasty is a complex surgery. First, cartilage and subchondral bone tissue are removed and the joint surfaces are sawed, after which an implant is installed applying cement or cementless fixation. There are some disadvantages:
- the patient is under general anesthesia for a long time
- soft tissue damage
- significant blood loss
The main advantages are a long life of the implant and complete restoration of the joint functioning.
The method and surgical approach to the joint are selected during the preparation, taking into account several factors:
- Nature and extent of pathology;
- Condition of osteoarticular tissue;
- Health and age of the patient;
- Experience and skill of the surgeon.
The surgical technique depends much on the chosen approach to the joint. The incision can be anterior, anterolateral, posterior, and combined.
Posterior approach – which is the most physiological and causes minimal damage to the soft tissues, nerves and muscles – is the most common for hip arthroplasty. It also reduces the probable damage to the outflow mechanism.
For secondary surgeries that are required in case of surgeon’s mistake, implant rejection or repeated trauma, longer incisions are normally used. Open access provides a better view of the femur. It can be a longitudinal straight incision, or curved cut.
After the incision is made, the surgeon gently pushes the muscles and fascia aside, opens the joint capsule, and performs a resection of the damaged fragments. Then, the femoral head is removed and the acetabulum is thoroughly cleaned (With the total arthroplasty, the acetabulum is removed together with the femoral head).
The next step is the femoral component fixation with metal rods or cement, and, then, testing the distal area of the artificial joint. If there are no any deviations, the surgeon treats the medullary canal where the implant stem is inserted, and the implant head is attached to the acetabulum (an artificial hemispherical cup). After the total or partial prosthesis is placed, the wound is sutured layer by layer, and drainage is inserted.
Complications after hip arthroplasty are rare, but you should be aware of the possible consequences, among which the most likely are:
- Wound Infection
- Blood clots
- Implant rejection
- Implant Dislocation
- Exacerbation of chronic diseases
After hip surgery, the patient is under constant monitoring by a medical team, so the risks of adverse effects are minimized. Today, surgery and recovery are performed according to the detailed step-by-step procedures, which reduces the likelihood of unforeseen situations.
Revision hip surgery is a secondary operation that is used in case of serious complications after implant placement, including:
- Aseptic loosening of the joint components;
- Purulent infection;
- Fracture of the implant stem;
- Scarring in the area of the joint cup.
Hip joint revision techniques are fundamentally different from those applied in the primary surgery. Hip joint replacement is carried out according to standardized protocols, but revision method is decided individually every time and every surgery is unique.
A complicating factor is a significant loss of bone tissue surrounding the endoprosthesis. The surgeon must remove the cement joint, clean the articular surfaces, and, then, install new implant components.
With the development of total purulent process, it is not always possible to perform joint restoration with an implant, since sepsis spreads quickly to soft tissues and organs. Fortunately, purulent infection is an extremely rare complication after surgery. Basically, revision is possible to eliminate all defects appeared after primary surgery.
According to statistics, hip joint replacement surgery mostly has positive reviews. Patients are satisfied with the results. When performing surgery in relatively young age and without concomitant diseases, functioning of the hip joint can be fully restored. You can walk and even exercise, avoiding overloading the artificial joint. Active sports are contraindicated. There are also some unsatisfactory results after hip arthroplasty. Most often they happen in old age, if there are any concomitant pathologies. The patients' feedbacks show disappointment with the surgery results in 20% of patients who had hip joint replacement.
Partial Hip Replacement Surgery
Evolving hip joint arthrosis / arthritis is an indication for either a traditional total, or complete, hip replacement or hip resurfacing (arthroplasty). These kinds of operations are variations of the hip replacement, but differ from each other significantly.
Hip resurfacing implies the maximal preservation of the hip bone. In this case only the surface damaged layer of the bone tissue is removed, and the whirlbone is covered with a metal cap to avoid further damage.
Hip resurfacing benefits
Today, a number of studies are conducted on the subject. The orthopedic surgeons all over the world acknowledge the benefits of hip resurfacing over the traditional method.
- Hip resurfacing facilitates revision (repeated) operation. As far as those endoprostheses that are used in the hip replacement consist of mechanical components, it is marked that with time the whole implant unavoidably wears out and gets loose. As a rule, it takes place in 10-20 years after the operation.
- The risk of the hip endoprosthesis displacement is less. Hip resurfacing implies the usage of more massive femoral components that fit the size of the real whirlbone in a greater degree. For this reason, their displacement occurs more rarely. But this statement is contradictory, as the risk of the hip endoprosthesis displacement after the operation depends on a number of other factors, including the applied surgical method, as well as the size and type of the utilized endoprosthesis components.
- Hip resurfacing makes walking after the operation easier. In some studies it is shown that the patients after hip resurfacing walk more naturally than after the traditional operation. However, such differences are barely noticeable and their detection requires the usage of special instruments.
- Hip resurfacing provides a greater range of the joint motion. As a rule, the patients after this operation have a greater range of motion than those after the traditional hip replacement. Nevertheless, several types of modern total endoprostheses allow achieving results that are similar to hip resurfacing ones.
Surgical intervention is recommended in the case of evolving osteoarthritis, when conservative (non-surgical) treatment is ineffective. The operation is performed only if the state of the hip joint affects the patient’s life quality significantly and disrupts the performance of his daily activities.
This method is recommended for the treatment of young and active patients. Generally, the patients under the age of 60 years, with a well-developed bony frame (often, but not always are male) and a satisfactory bone tissue state are the most suitable for hip resurfacing. The female patients of an older age with an underdeveloped skeletal system in conjunction with the fragility of the bone tissue have a high risk of complications, e.g. a femoral neck fracture.
Hip resurfacing surgery. General information for patients:
- The duration of hospital stay: 5 days
- Inpatient and outpatient rehabilitation in Germany: 10-14 days
- The earliest home departure time: 10-12 days
- Postoperative control: X-rays in 6 months after the operation, then in 12 months
- The duration of disability: 6 weeks
- The cost of the operation: 16.700–20.000 Euros
- Large cysts in fumeral head as indication for partial hip replacement
- Partial atrophy of fumeral head (avascular necrosis of fumeral head)
- Dysplasia and deformations of fumeral head and neck. Advanced form of inflammatory arthrosis causing tissue loss
Resurfacing surgery/ partial hip replacement in Germany is an effective and sparing form of joint replacement. Orthopedic clinics of Germany are among the best in the world offering joint surgeries. Doctors of our orthopedic department in Germany have great experience and are highly competent. This, together with clinic’s world-standard technical equipment, allows them to conduct such kind of surgeries. The cost of partial hip replacement makes up about 10 000-10 000 euro.
Another important aspect is that our clinic collaborates with different research institutes which share their new achievements and designs of joint implants with us. Institute specialists whose work is aimed at improvement of existing implants and creating new types of them try to make them more reliable and also find new methods of joint replacement surgeries.
We will do everything to restore full functioning of your joints!
Premature joint aging in young people can be caused by various factors, for example, by hereditary hip joint deformation, blood flow disorder during physical growth or in adulthood, consequences of accidents, excess weight, different kinds of inflammation, predisposition to disease of cartilaginous tissue, etc.
In this case, there is a reasonable solution to this problem: young, active people are offered resurfacing surgery in Germany. A special type of hip endoprosthesis was created in 1980s in Britain – it replaces only the surface of femoral head and coxal cavity joints. It also secures that interacting metal surfaces of prosthesis are fitting.
Polymer materials prevent superficial endoprosthesis from wearing, and fully imitated anatomical ratio of hip joint makes it stable and reliable. As much bone stock as possible is saved, which allows conducting and considerably simplifying revision prosthesis transplantation surgeries, thus in Germany resurfacing surgeries are preferably chosen for young people. After successful prosthesis implantation patients are able not only to move around without pain, but also do sports.
Nowadays there are various techniques of joint resurfacing in Germany:
- Resurfacing surgery in Germany according to Mc Minn or Birmingham Hip Resurfacing (BHR)
- Partial fumeral head replacement in Germany according to Mc Minn or Birmingham Mid Head Resection
This method has a distinctive feature: during this surgery only destructive joint surfaces are separated, while fumeral head and neck are left intact. Fumeral head is covered with a so-called metal cap made of cobalt, chrome and molybdenum alloys. Partial hip replacement (Resurfacing) surgery in Germany is a way to avoid extensive surgery
Partial hip replacement (Resurfacing surgery) in Germany according to Mc Minn: main advantages of resurfacing surgery compared to conventional protheses:
- Resurfacing does not affect leg and hip muscles length
- Feels like a natural joint
- Anatomical size of the implant maintains natural range of motions and reduces dislocation frequency
- Natural load distribution on thigh and hip bones and femoral head prevents bones from deformation and destruction
- Resurfacing allows to keep paraarticular tissues of hip bone and creates best possible conditions for repeated replacement
- Resurfacing does not require massive removal of bone material
- Metal-metal sliding pair is totally wear-resistant
Sometimes considerable loss of femoral head substance is found in patients, whose age and physical training conditions make them perfect for resurfacing surgeries, but this defect, of course, is fraught with risk. Until lately it was impossible to conduct this surgery in such patients. Thanks to partial fumeral head replacement or mid head resection available in German clinics, such patients with considerable loss of bone stock now have a chance to get back to normal everyday life. Partial fumeral head prostheses are short and conic cementless titanium nails which are fixed in the lower segment of fumeral head and neck. Medullary canal of hip bone is not opened.
The most recognized method of sparing bone-preserving endoprosthesis replacement is McMinn’s method. Due to its sparing nature, this operation has become one of the most popular orthopaedic surgeries in Germany. Its effectiveness is proved by impressive long term results of more than 200,000 surgeries made all over the world. McMinn method also bears the name of Birmingham resurfacing prosthesis.
This surgery preserves the bone, and the most of the natural joint remains undamaged. During the total (full) hip endoprosthesis replacement the femur head (hip ball-and-socket joint) is completely replaced by a long pin. In McMinn surgery only a few centimeters of femoral bone surface is removed.
McMinn surgery/hip resurfacing at the Clinical center GKH in Bonn, Germany
GKH Clinic in Bonn is a multi-field specialized health care center in Germany that provides high-level medical services with the use of the newest equipment and technologies. This clinic is able to provide 100% reliable treatment in all medical areas for foreign patients. Tight cross-disciplinary collaboration of doctors from different medical areas is a fundamental basis of full complex therapy for our patients. The McMinn surgery has been performed at the orthopedic unit of the hospital GKH since 2001. The Head of the department is a talented surgeon, Holger Haas, who has been monitoring the department activity since 1999.
McMinn surgery allows thousands of patients, including world renowned sportsmen to forget about pains from hip joint arthrosis and return high quality of life. Prof. Winter, the medical director of Friedrichshafen Clinic, is one of the most experienced surgeons in the world working by McMinn method. Over the last 8 years he has performed more than 100 surgeries of such kind with excellent, long-term results. Moreover, Prof. Winter conducts a wide-scale scientific research dedicated to McMinn surgery.
These are only two of numerous orthopedic centers in Germany, where the top level hip resurfacing is offered. The authoritative clinics and centers of the arthroplasty in Germany, in particular Friedrichshafen clinic, meet the highest standards of modern medicine, so the quality of the operations of the hip joint replacement in German hospitals is very high.
More than 10 years this method is used in Germany. The sufficient statistic, accumulated during this time, convinces of the benefits of this method. Its essence is in the substitution of only the surface of the whirlbone for the endoprosthesis, but not its complete removal together with the femoral neck as in the complete arthroplasty. Working on the principle of “Why remove a tooth when you can leave its part and crown it?”, hip resurfacing saves much larger part of the bone than the standard method does.
These are important factors affecting the success of the hip joint operations:
- the right choice of the prosthesis type and the method of its attachment;
- the fitness of the prostheses size and the individual anatomical features;
- the usage of high-quality and reliable types of the prostheses;
- the exact positioning of the prosthesis;
- ensuring timely postoperative rehabilitation and subsequent recovery.