According to an OECD study, as many artificial hip joints are used in Germany as in hardly any other country. Only Switzerland is still ahead in the ranking. In numbers, this means that over 200,000 patients receive hip replacement surgery each year. According to the results of the Federal Statistical Office, this accounts for around 12 percent of all treatment cases in hospitals. The most common reason for using a joint replacement is hip pain. This is usually related to suspected arthrosis. Contrary to popular belief, it is not osteoarthritis itself that causes the pain, but tension in muscles and fascia. This is not the only reason why the decision for a hip replacement should be carefully considered. Because: This step can no longer be undone!
Since 2007, the frequency of surgeries among the over 70s has not increased for both hip replacement and knee replacement. Regional differences show that fewer hip endoprostheses are used, especially in Saxony-Anhalt, Hamburg and Berlin. The German Endoprosthesis Register (EPRD) will provide even more precise data in the future.
Every year, 1% of those over 70 years old get a new hip joint due to arthrosis and around 0.7% a knee replacement. "The frequency of first interventions on the hip has been stable since 2007, we even see a slight decrease in the knee," says Bertram Häussler, head of the IGES Institute. 80% of the first interventions on the hip and around 96% on the knee can be attributed to mostly age-related arthrosis. The second most common reason for hip surgery is fractures of the femur in 13% of cases. Around 40% of patients are between 70 and 79 years old during a first intervention.
Why are artificial hip joints used so often?
Most of the patients have a long history of suffering before the operation is ready to go. The complaints are getting worse, nothing seems to help and even the prescribed pain relievers do not bring the desired pain-free effect. They often do not work long term and only treat the symptoms. The real cause usually remains hidden - or worse: it is never found! The pain then returns after stopping the medication.
Precisely because the use of artificial hip joints (hip replacement) is considered one of the greatest success stories in surgery, the inhibition threshold for using an implant seems to continue to decrease. In addition, an experienced surgeon does not even need an hour for this standard procedure.
Most of the patients have hip osteoarthritis (coxarthrosis), around a quarter of the patients have previously had a broken femoral neck. These numbers can easily give the impression that doctors simply like to perform operations. But it is usually not quite that simple: Statements such as "There is nothing more we can do than use an artificial hip joint (hip replacement)" testify to the helplessness of the doctors. For many patients, this "diagnosis" is a shock, for many doctors it is unsatisfactory. However, they believe that they cannot help their patients in any other way.
Hip Replacement Surgery
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.
When is a Hip Replacement Surgery useful
There are no general rules as of which exact point in the case of a hip joint disease the installation of an artificial joint makes sense. In addition to the extent of joint damage and the resulting limitations, subjective factors influence the decision. This includes, above all, the willingness of patients to undergo surgery. This depends on the personal suffering, the willingness to deal with possible risks and the expectation of the achievable result. Therefore, the personal conversation with the attending physicians and the best possible information about the course of the operation as well as the general conditions are of great importance.
In general, the recommendation is that after the onset of hip problems over a period of three to six months conservative treatment should be done (pain and inflammation-inhibiting drugs, physiotherapy, adjustment of the burden, etc.). Also, in younger and middle age, it must always be examined whether other joint preserving surgical procedures (e.g., conversion surgery) are still possible. If this is not the case or if discomfort persists after conservative treatment, there is a significant reduction in quality of life and is the cause of hip replacement if the decision to replace the joint is made.
When choosing the right time for the operation, neither too early nor too late should be reacted. The degree of improvement of complaints through an artificial joint is always about the same size - regardless of the level of existing complaints. The following figure illustrates how the improvement comes from an operation: operating too soon does not fully exhaust the potential for improvement. On the other hand, if you operate too late, a full recovery may not be achievable (for example, because the degree of stiffening is already too advanced or the patient has developed a persistent pain memory).
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.
Minimally Invasive and Traditional Hip Replacement Surgery
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.
Preparing for Hip Replacement Surgery
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.
Before Hip Replacement Surgery
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.
Hip Arthroplasty: Procedure
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.
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.
For Whom Hip Resurfacing Appears to be Suitable?
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
Indications for Partial Hip Replacement
- 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!
Can the Total Hip Replacement be Avoided?
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
McMinn or Birmingham Hip Resurfacing (BHR)
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.
Hip Resurfacing with McMinn Technique
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.
Hip Resurfacing Quality is Time-tested
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.
Supply capacities in Germany, hip joint arthroplasty
Hip or knee replacement is one of the comparatively frequently performed procedures in the inpatient sector. Measured against the population of 18,531,819 patients treated fully inpatient in the DRG statistics 2013, patients with first-time hip and knee replacement represented a share of around 2%.
In 2013, around 1,075 hospitals were selected as part of the AQUA Institute's federal evaluations of external hip quality assurance for the elective hip TEP implantation who performed a hip TEP implantation.
1,031 hospitals performed the first implantation of a knee endoprosthesis. Overall, more than half of the German hospitals carried out first interventions for a hip or knee replacement in 2013. Between 2009 and 2013, there was a decrease in the number of hospitals that performed hip TEP implantations. However, it should be noted that the total number of all hospitals also declined. There was a slight increase in the number of hospitals performing initial knee TEP surgery from 2009-2010, after which it remained relatively constant until 2013. The percentage of implanting centers in relation to the total number of hospitals increased from 49.0% to 51.7%. By changing the counting of the individual hospitals in external inpatient quality assurance, which takes into account the different locations of a clinic, the number of implanting hospitals mentioned will increase from 2014 to 1,229 hospitals with hip TEP implantations and to 1,160 hospitals with knee TEP implantations.
Revision operations could be further reduced
The evaluation by the IGES Institute has also shown a stable frequency since 2007 for follow-up procedures. Follow-up procedures occur in 0.2% of hip endoprostheses, in 0.1% of the knee endoprostheses over the age of 70. The main reason for changing a prosthesis is the limited service life and premature complications. After 15 years, 90% of the hip and knee implants are still functional.
The rate of reoperation has already been halved due to better implants in the past 20 years. Nevertheless, Reichel sees further potential for improvement - but not through even better implants. We need better structures and processes at the clinics, which could be guaranteed by nationwide participation in the EPRD. ”This enabled the Scandinavian countries to reduce their revision rates by 10%, and even halved Sweden. The EPRD could also act as an early warning system. Which implant and which clinic works how well? The problem with metal-on-metal prostheses would have appeared earlier.
Currently 587, mainly large hospitals, voluntarily feed data into the EPRD. That is about half of all clinics that are active in the field of hip replacement or knee replacement.
In rare exceptional cases, the damaged hip joint head is only crowned instead of the implantation of a femoral shaft. As a result, the prosthetic head placed on the femoral neck is relatively large. In order to keep the loss of substance in the pool low, the thinnest pan pan made of metal is used. This creates a sliding pairing of metal (femoral head) and metal (joint socket). The advantages of this concept are the lower bone loss of substance, the lack of plastic abrasion and the low tendency to dislocation. A disadvantage is the metal abrasion, which can lead to local (granulomas) or systemic (allergy, heavy metal poisoning) foreign body reactions. The method currently represents a rarely chosen alternative to classic hip TEP.