Gentle hip endoprosthesis in young patients
A hip endoprosthesis is almost only older people, many think that. But about 16 percent of patients are younger than 60 years. Statistically, therefore, they are facing several replacement operations by the end of their lives. In order to achieve maximum durability of the first implant, the AE - German Society of Endoprosthetics recommends a particularly gentle procedure for first intervention in otherwise healthy patients. It consists of a minimally invasive surgery and the use of a non-cemented short or straight stem prosthesis. The combination of femoral head and sliding cup should each consist of ceramic or ceramic and ultra-high crosslinked plastic (HXPE). Experts at a press conference in the run-up to the 19th congress of the AE on 30 November 2017 in Hamburg will discuss which empirical values exist and for whom this approach is appropriate.
With around 233,000 procedures, the implantation of a hip endoprosthesis was among the ten most common operations in 2016. Almost 37,000 of the patients were younger than 60 years. "These patients often suffer from congenital misaligned joints, circulatory disorders, have suffered accidental injuries or a rheumatic disease that has destroyed the articular cartilage of their hip joint," explains Prof. Dr. med. Karl-Dieter Heller, Secretary General of the AE.
Especially hip endoprosthesis for younger people should withstand the demands of everyday life for as long as possible. But there is still no material that comes close to the resilience and performance of the natural joint. Experience has shown, however, that hip prostheses last on average more than 15 years, sometimes 25 years.
"That's why we do everything we can to ensure a long service life for the first prosthesis," says Prof. Heller, the chief physician of the Orthopedic Clinic at the Duchess Elisabeth Hospital in Braunschweig. Particularly gentle here is a minimally invasive procedure: The muscles are not replaced by the bone, but completely spared. This is made possible by modern storage techniques and instruments. As a result, the surgical trauma is lower and rehabilitation is faster. Only the scar of the maximum twelve centimeters long skin incision remains. However, this method requires much experience on the part of the surgeon. Patients should inquire accordingly.
A short shaft prosthesis helps to "save" valuable bone substance in the thighbone: "For the daintier implant compared to normal bone, we need to remove less bone during implantation. As a result, we have more bones available for anchoring the replacement prosthesis in the event of subsequent interchangeable surgery, "explains Heller. Short stem prostheses are especially popular in Germany. However, they would only be used for about ten years. Since long-term results are missing so far, many surgeons still rely on decades of proven, but slightly longer straight dentures.
Since younger patients are on average more active than older patients, material wear is possible faster. For this reason, the topics of prosthesis wear and abrasion are central here, since abrasion particles can lead to prosthetic loosening. "We therefore recommend the pairings of ceramic ceramic and modern abrasion-reduced plastic (ultra high cross-linked polyethylene (HXPE)) with ceramics in younger patients for the femoral head and cup, as they produce the least amount of wear particles," says Heller.
With a hip endoprosthesis joint a normal active everyday life as well as the moderate exercise of sports such as skiing, running, swimming, golfing, cycling, hiking and Nordic walking is possible again. But the load capacity and life of a prosthesis are - despite significant improvements over previous dentures - limits. "It is important to us that our patients understand where the boundaries of an artificial joint are", emphasizes Prof. Dr. med. Henning Windhagen, President of the AE and Director of the Orthopedic Clinic of the Hannover Medical School (MHH) in the Diakovere Annastift. If you are unsure about what is allowed for sports, it is better to ask your orthopedist first.
Health tip: The hip joint prosthesis
New and gentle surgical procedures ensure that patients are mobile again faster.
The implantation of a hip joint endoprosthesis in a hip joint arthrosis is still the most successful surgical procedure, despite the success rate by far in medicine, despite the recurring "horror stories" in the tabloid press.
It is always impressive to see which quality of life, especially for younger patients, is reimbursed - regardless of whether the prosthesis was used as a result of degenerative or accidental wear on the hip joint. Also in veterinary medicine, the hip joint endoprosthesis has prevailed - especially in dogs. There are now decades of experience with total hip arthroplasty and the implants are so mature and reliable that hardly any further innovations are expected here.
Thus, the improvement of operational planning and technology for the further optimization of the surgical results is increasingly coming to the fore. In recent years, minimally invasive approaches to the hip joint have become increasingly popular due to the sparing of the hip musculature, lower postoperative pain, and associated shorter hospital stays. While usually the access to the hip joint takes place mainly from the outside of the hip joint, in a few centers slowly a new minimally invasive approach from the front to the hip joint is established.
In addition to the small skin incision, the anterior approach protects the hip-hugging musculature even better than the lateral access, so that patients recover much faster from their surgical intervention. They are thus faster mobile and less pain. This leads to a significantly shorter hospital stay. In some clinics, this procedure is already offered as a day surgery.
Despite all the euphoria, it should be borne in mind that even with minimally invasive technology, the implantation of a hip endoprosthesis still represents a major surgical intervention and thus a stationary stay for the safety of the patient and the surgical outcome is used. In any case, this new front access allows the implantation of short stem prostheses, which are optimal for this approach. However, it is also possible to use the conventional hip total endoprostheses available on the market by means of an appropriate surgical technique.
Nevertheless, it can not be used in all cases. In particular, when changing a relaxed total hip endoprosthesis or accompanying fractures, anatomical features, intraoperative complications and in very obese patients, the lateral access to the hip joint continues to be the better and, above all, safe procedure. Therefore, an individual consultation of the patient is still the alpha and omega in the surgical treatment of hip osteoarthritis.
Current highlight: First day clinical hip endoprosthesis surgery in one day
A new hip in the morning and back home in the evening? This is possible thanks to the so-called AMIS procedure and the Rapid Recovery program. As the first medical doctor in Germany, Dr. med. med. Manfred Krieger, Specialist in Orthopedics and Traumatology in the Network of Specialists Rhein-Main, in cooperation with the GPR Health and Care Center Rüsselsheim, the modern surgery and rehabilitation procedure "Hip in a day". The advantages for the patients are obvious: they are better fit again and usually have less pain.
Hip in a day in the media
The media are also very interested in Dr. med. med. Manfred Krieger Germany's first applied AMIS process and the Rapid Recovery program. The contributions illustrate the procedure and accompanying a patient - during hip endoprosthesis surgery and one year later.
Benefits of this hip joint endoprosthesis surgery method
- Protection of the existing muscles around the hip
- Blood saving technique
- medicines for blood loss (tranexamic acid)
- Good pain therapy (infiltration)
- No nausea (PONV prophylaxis)
- hygiene prophylaxis (oral and nasal swab)
- Showers with Hibiscrub
- dispensing with catheter (bladder catheter, wound drainage)
- Early energy intake (cola, ice cream in the recovery room)
- First getting up in the recovery room
- Physiotherapy every 2 hours
- Discharge criteria fulfilled after 8 hours
- Stair running before discharge
BGU Clinic Frankfurt provides information on osteoarthritis and hip endoprosthesis
More than 170,000 artificial knee joints and more than 200,000 artificial hip joints are used each year in Germany. Common cause is a joint wear, the so-called arthrosis. The BG Unfallklinik Frankfurt is launching a patient information event at the Main under the motto "Osteoarthritis and joint endoprosthesis". Head physician Prof. dr. Dr. Reinhard Hoffmann and his team inform in the conference center of the clinic, Friedberger Landstraße 430, 60389 Frankfurt am Main about osteoarthritis and the artificial hip endoprosthesis.
Osteoarthritis is widespread in Germany. Nearly half of all persons over the age of 65 suffer from the disease of wear, usually at the knee or hip.
"In addition to the age-related wear and tear of the articular cartilage, injuries, inflammation, incorrect or overstressing can trigger osteoarthritis," explains the medical director of the BG Unfallklinik, Prof. Dr. med. Dr. Reinhard Hoffmann. Those affected initially only have pain on exertion, and in advanced state also in rest. If conservative treatments such as physiotherapy can no longer relieve the pain, it makes sense to replace the damaged joint with an implant.
"Although artificial hip joint surgery is one of the routine procedures, choosing a hip endoprosthesis for the individual is often associated with uncertainty and anxiety. Comprehensive advice and information for our patients is therefore very important to us ", emphasizes the expert. In the patient information session, the instructors will inform about the preparation for the stay in the clinic, new surgical procedures, rehabilitation and living with an artificial hip joint.
In September 2015, the BG Trauma an Orthopedic Clinic in Frankfurt faced a first audit process defined by the endoCert initiative of the German Society for Orthopedics and Orthopedic Surgery (DGOOC). Following the recommendation of the experts and approval of the certification body, the BG Trauma Clinic is certified as the endoprosthetics center for maximum care, especially for the hip endoprosthesis.
This recognition underscores the high medical, surgical, nursing and rehabilitative quality of treatment at the BG Unfallklinik Frankfurt am Main under strict objective criteria. The designation EndoProthetikZentrum of the maximum supply for the hip endoprosthesis is u. a. after the performed operations and the high requirements of the criteria catalog. The aim of the certification is to improve the post-operative morbidity and mortality of our patients and to provide patients with an orientation opportunity to help them decide on the BG Trauma Clinic as a specialized specialist clinic.
Hip endoprosthesis in the BG Clinic Frankfurt
A specialized team carries out the entire range of primary and alternative hip endoprosthesis.
Only the highest quality implants for hip endoprosthesis with long-term proven materials and material combinations are used. If required, special and special prostheses are implanted to partial or full hip endoprosthesis (e.g., short-shaft hip, "female knee", hypoallergenic implants, partial or full thigh endoprosthesis). In appropriate cases, implantation may be performed at the hip using minimally invasive technique (MIS).
A study has shown that femoral and knee endoprostheses can serve more than 25 years
8 out of 10 knee prostheses and 6 out of 10 hip prostheses currently have a service life of 25 years or more. In developed countries the endoprosthesis of hip and knee joints is one of the most frequently performed surgeries. In Germany, every year more than 400,000 patients have a hip or knee joint prosthesis implanted. Many patients before surgery ask about the service life of the prosthesis.
Jonathan Evans from Bristol Medical School and his staff analyzed data of case series and patient registers to answer this question. The results of the analysis of case series are considered less reliable, since they are often based on the experience of individual centres. This easily leads to a biased selection (patients with good initial risks are selected) or the publication of distorted information (the preferred publication of positive results). Formed in recent years in many countries, the registers of joint endoprosthesis prevent the occurrence of such distortions, as they tend to include all patients.
In fact, the results of the analysis of case series were better than the data of the registers. What concerns hip joint prostheses, British scientists, when analyzing case series, found out that up to 77.6% (with a 95% confidence interval from 76.0 to 79.2) have a 25-year service life. According to the register of joint endoprosthesis, 57.9% have a 25-year service life. With a 95% confidence interval from 57.1% to 58.7%, an accurate forecast is made (this, of course, does not exclude the fact that sometimes premature endoprosthesis is required because of infections and/ or loosening). The most important limitation for Evans’s calculations is that the 25-year data is based just on one patient register (from Finland).
Hip prosthesis: Prosthetic Model More Important Than Surgical Method
The joint endoprosthesis increases the quality of life of patients. Complications can occur if the surgical method does not fit the implant. The latter is more important for long-term success.
The implantation of knee or hip joints is considered routine by experts. On average, orthopedists used about 230,000 hip endoprostheses in 2016. The joint endoprosthesis frees the patient from pain, increases the quality of life and ensures mobility into old age. Most often, a total endoprosthesis of the corresponding joint is made. Around 40% of endoprosthetic hip operations fall into the 70-79 age group; Women are affected twice as often as men. Hip endoprosthesis is considered one of the most common and successful operations ever. Nevertheless, there are always failures. These are estimated to be more common in artificial knees at 20%. In hip endoprosthesis, there are also at least two out of every hundred patients who are dissatisfied with the long-term post-procedure.
Sometimes the prosthesis relaxes, sometimes it comes to infections. A not uncommon reason for a failed implantation is that in patients the prosthetic model does not fit the surgical method. For a long-term success, according to the current state of knowledge, the implant model plays a greater role than the surgical method. The German Society of Endoprosthetics (AE) therefore advises not to prioritize the operation method, but to give priority to an optimally suitable implant.
Many patients want a minimally invasive approach (MIS). And in fact, studies available to date prove benefits, especially in the first six weeks after surgery. After a year at the latest, however, examinations no longer show differences between MIS and the classic open procedure. The keyhole technique comes with tiny cuts in skin and soft tissues. In MIS, surgeons use the natural gaps between the muscles to get to the hip joint. "We push muscles, tendons, vessels and nerves aside as far as possible, instead of severing them as usual and then suturing them again," explains Professor Dr. med. Dieter C. Wirtz, Medical Director of the Clinic and Polyclinic for Orthopedics and Traumatology at the University Hospital Bonn.
According to the specialist, MIS also protects important nerve receptors at the tendon-bone and tendon-muscle transition. The mechanoreceptors provided depth sensitivity and thus gait stability and balance. "If these structures remain intact during prosthesis implantation, patients can begin their rehabilitation sooner after the procedure," says Wirtz.
Minimally invasive hip endoprosthesis may sound uncomplicated, but it is not suitable for every patient. "The hip joint geometry has to fit, the patient should not be too muscled or too obese," explains the member of the AE presidency. At the same time, especially the prosthesis model must be carefully selected. Minimally invasive access is associated with limited vision. "Being able to carry out the individual surgical steps with the necessary care always has priority." Summary of the expert: The surgical method should be chosen so that the hip endoprosthesis does not cause long-term discomfort. If patients bring with them the individual requirements for a minimally invasive, muscle-sparing procedure, this should also be chosen. But rather promises the classic open surgery long-term success must be open surgery. "The aim of every surgeon should be to operate as gently as possible," confirms Wirtz.