Surgical Hip Replacement Options
I was frightened and bewildered when I first started to explore my options for surgery. And slightly sickened by the idea of what I was undertaking despite, or because of my medical training! I found a community of people, many of whom were strangers, who had already undergone total hip replacement (THR) surgery and were graciously available to answer questions and guide research and decisions. I am most grateful to the journalist Elisabeth Thomas-Matej for her incredibly well informed counsel and her web site: Hip Universe.
It was she who first told me that the surgery was "Easier done than said!" She added that the actual surgery and recovery were a lot easier than the torture of anticipation.
Table of contents
What improvement could I expect as a dancer?
Why are dancers so secretive about THR?
Famous people with THR
Total hip replacement (THR) options:
1. Materials to use for weight bearing surface:
Although metal is used for the stem of the prosthesis that fits into the femur, and for the acetabular shell (or cup) that fits into the pelvis, different materials are available for the articulating surfaces of the new ball and socket joint, i.e., the ball and the cup liner. This is an enormously complicated topic. Research is ongoing and confusing. The manufacturers have a lot at stake and the market is very competitive.
The main area of concern for patients under about age 55 is "wear" on the materials used. Wear is defined as the progressive shedding of minute amounts of material from the implant due to friction or rubbing.
To see why "Which implant is the best?" is such an impossible question, I refer you to hip patient Keith Brewster's FAQ section at Active Joints.
To explore this area in greater depth, visit Total Joints, a great reference source devoted to this subject matter and maintained by Valdemar Surin, MD, PhD, a retired Czech surgeon and researcher living in Sweden.*
In brief, the head (ball) and liner may be made of some combination of metal alloy (usually cobalt/chromium/molybdenum), medical grade ceramic (either aluminum oxide or zirconium oxide), or ultra-high molecular weight polyethylene (either "highly crosslinked" or "conventional").
The possible pairings or couplings for the ball/liner are as follows:
alumina ceramic/alumina ceramic
alumina or zirconia ceramic/polyethylene
In addition, trial designs include bearings made from oxidized zirconium/poly and an experimental alumina ceramic/metal coupling. (Oxidized zirconium is a metal alloy superheated at its surface till it melts and becomes ceramic.)
In considering bearing surfaces, it is helpful to acknowledge these facts:
The ceramic head /ceramic liner combination is the hardest wearing material and sheds the lowest volume of debris, followed by metal/metal, then ceramic/poly, and lastly, metal/poly (even with highly cross-linked poly).
Polymer industry specialists representatives like to emphasize that particles of ceramic and metal wear debris are much smaller than polyethylene particles, therefore more numerous. But their aggregate volume is actually far less, and the smaller particles provoke a lesser immune response. In addition, ceramic is biologically inert.
Couplings made entirely of metal omit any type of liner for the acetabular component, allowing a much greater diameter for the femoral head. All other factors being equal, a larger diameter head permits a greater range of motion and reduces the risk of dislocation. This fact may be of special interest to dancers. Some surgeons and researchers are concerned that all-metal bearings shed a high number of metal ions, which are biologically active. To date, no adverse systemic effects in healthy patients have been identified from this debris, although concern may exist during pregnancy and in patients with existing kidney dysfunction (since the ions are cleared by the kidneys). All THR stems and cups also shed metal ions to some degree.
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2. Cemented or non-cemented stem?
The prosthesis has a metal stem inserted into the femur. This can be held in place by cement or, more recently, simply "tight fitted" into the bone. In the past, if cement was not used, full weight bearing on the operated hip was delayed until some growth of bone around the stem could occur. Now with the "tight fit," even uncemented stems can be fully weighted immediately. The problem with cement is that it tends to degrade over time, especially if undue stress is put on the joint, as is often the case in the younger person. In these cases the cement loosens and the joint needs redoing.
Usually for older people for whom the wear of the joint is not the primary concern, or who have osteoporoetic or other poor quality bone, the metal stem in the femur is cemented in place. Some very active young people choose cement since it assures immediate weight bearing. Dancers and other young people with degenerative joints generally have good strong bones from exercise and are good candidates for the non-cemented press fit.
Cementing, especially using modern, "third generation" cementing techniques, still remains the "gold standard"for fixing stems in place. Research is now underway is see if the non-cemented (often now referred to as biologically fixed) stems do as well over time. Various different stem designs are being tried, as well as different treatment surfaces of the stems. The optimal stem design remains elusive.
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3. Surgical approaches:
Recent research on surgical options for hip replacement has resulted in not only new choices of materials, but also surgical approaches to the hip joint itself. These new techniques may result in improved outcome for the patients with smaller incisions, less blood loss, shorter hospital stays, etc.
A popular recent development is minimally invasive technique. There are basically 3 approaches.
The first is "single-incision" technique, which involves use of the traditional approaches (modified lateral or posterior); but the full-thickness incision (not just the skin incision) is typically 2/5 the traditional length.
The second one is the "2-incision" technique, which uses one incision for preparation and insertion of the acetabular component and the other for the preparation and insertion of the ball and stem. This procedure is done without dislocating the natural hip (the damaged bone is broken up and removed piecemeal). For visualization, the "2-incision technique" must be done under fluoroscopy (real-time x-ray), which delivers a high dose of radiation. Currently it is available only with metal ball/poly liner.
This site has good illustrations of the differences between the "single-incision" and the "2-incision" technique and a FAQs section.
A third technique is the anterior approach, which is accomplished with the help of a special table to correctly position the patient.
The standard hip replacement surgery is done through a long (greater than 8 inches) incision from the side (lateral), from the back (posterior) or occasionally down the front (anterolateral). The goal is to reveal all the anatomy critical to the procedure, that is, the pelvic acetabulum and the top portion of the femur. Surgeons who favor this technique feel that the large field allows for superior positioning of the prosthetic components.
Click here to watch a video of the posterior single mini-incision procedure. Stephen Zabriski, MD (of Shore Memorial Hospital, New Jersey) provides helpful narration.
For other videos see the links below.
Because minimally invasive surgical techniques are still investigational, there are few short-term and no long-term results published in the literature. It is a hot topic at orthopedic conventions.
A good reference to review many of the current surgical options is at Hip Universe:
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4. Aftercare: Home or Rehab Facility?
Older people may go to a rehabilitation facility after hospital discharge, especially if they have no one at home to care for them. There they will get training in the tasks of daily living such as dressing, washing walking etc. Younger people with unilateral hip replacement can usually go straight home. If you go directly home, be sure to get an occupational therapist to work with you before discharge or just when you get home to be sure you can safely dress, shower, reach objects etc. You may need raised seating that keeps your hips higher than your knees. This chair should have arms that can support you as you sit and rise from sitting. A cushion, several pillows or folded blankets can be used on a stable chair with arms instead. I found that the Barossa Chair from Crate and Barrel works perfectly! I use two folded yoga blankets to sit on.
I think it is a good idea to get the raised toilet seat, long shoehorn and reacher long before the surgery since these items make life a lot easier for people who have trouble bending.
I found that I did need some help at home, especially the first week after surgery when I had very limited mobility. Later it was helpful to have someone reliable who would walk with me on the busy New York City streets and help with marketing and other chores.
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5. Physical Therapy: yes or no?
Some surgeons do not recommend physical therapy after surgery. They think that the rudimentary exercises taught in the hospital are adequate (e.g., heel pumps, quad and glut contraction, ankle circles, internal rotation to neutral, bending the leg to 45 degrees while lying on one's back, seated knee extension, leg abduction and a few other standing exercises). (See these exercises illustrated here). After that, their usual recommendation is just to walk as much as possible.
I think for dancers, and for active younger people in general, this is a big mistake. We dancers have a much more subtle relationship to our bodies. Additionally, many young patients in need of THR have limped for years (because of developmental hip problems, trauma, and often prior surgery) and they also need careful and comprehensive physical therapy evalation and individualized treatment plans. I am glad that I have a physical therapist, Chris Bratton, who is experienced working with dancers. Under her guidance I am consciously working to attain core stabilization (i.e., utilizing the abdominal and back muscles that attach to the spine to stabilize the spine and pelvis and to maintain proper form and alignment), increase range of motion and improve proprioception (i.e., retrain the nervous system impulses that inform our bodies where we are in space and how to react; this relay is disrupted by surgery and needs time and training to respond maximally). I set up a portable massage table in my living room to do my home PT.
It is advisable, as soon as the position can be managed, to roll the outer thigh up and down a foam "log," to iron out chronic tightness in the iliotibial band (ITB). Tight ITBs seems to plague a lot of THR patients.
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Hip restrictions post-op:
Depending on the surgical approach you will not be allowed to move in certain ways for 4-6 weeks post-operatively, in order to prevent dislocation of the new joint. Some modification of these will apply for the rest of the life of the joint. For a posterolateral approach these restrictions mirror the actions taken to get access to the femoral head during surgery and thus should be avoided until the muscles heal. The precautions are:
1. Don't bring your knees above your hips (i.e. maintain less than 90-degrees of flexion to the hips at all times).
2. Don't cross the legs (i.e., don't bring the operated leg across the midline of the body).
3. Do not turn the operated leg inwards.
This page has good illustrations of how to move after surgery.
After these restrictions are lifted it is important to recall that stress on the joint, real or prosthetic, wears it out. Less stress (e.g. low body weight, low impact sports) means increased longevity. Of great interest to me is what this really means in terms of athletic activity. Most of the reading I've done suggests avoiding "impact loading" sports, such as jogging, downhill skiing and high impact aerobics. Activities that involve quick stop-start motion, twisting or impact stresses are also of concern. I would think this would include singles tennis, racquetball, badminton, football, baseball and some martial arts styles. Heavy lifting, especially repetitively as in body building, would put excessive stress on the joint. And I imagine you don't want to fall off a horse!
Nevertheless, if any of these is a sport you love or excel in, you may be able to practice it intelligently. This is an important conversation that we must each have with our individual surgeons. On the Internet I read of a horsewoman who used to jump competitively and now does dressage. How about Kangoo boots for people who used to jog? And what about tennis doubles?
I am in the process of researching this area and will post my findings.
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Post operative Symptoms
In the first post-operative weeks I was surprised by some of my symptoms:
1. Painless swelling of the operated leg
This occurs because when walking, the muscles in front of the lower leg (which I wasn't then using), stimulate the venous return of blood from the legs. The swelling can also be the result of epidural anesthesia. (This would explain why the un-operated leg was also a bit swollen.) The swelling resolved in a few days with the following treatment:
1.Seated in a chair, drop a towel flat on the floor and then accordion it up and spread it out again using the grabbing and releasing action of the toes.
2. Lying flat on your back, push knees toward the floor and then flex and point your feet 20x. (Called ankle or heel pumps, this exercise is a standard post-op exercise).
3. Elevate your lower leg while resting: Lying down with your head slightly elevated as if you were reading, use a double pillow to elevate your foot to the height of your nose. Putting the pillow the long way, from the knee to the foot, worked best for me.
4. Breathing deeply encourages venous blood's return to the heart.
Some surgeons also recommend TEDs-type graduated compression stockings.
Please note that painful swelling is NOT normal and can denote a blood clot, which is a medical emergency
2. Weakness of pelvic and thigh muscles
I was appalled when I could not contract my whole quadriceps and gluteal muscles postoperatively. All the muscles that attach to the pelvis, including the pelvic floor (through which pass the urethra, anus and genital openings) take time to recover from the shock of the surgery. It is invaluable to do the Kegel pelvic floor exercises both alone and incorporated into PT exercises. Read how to perform Kegel's pelvic floor exercises on this The National Kidney and Urologic Diseases Information Clearinghouse site on bladder control. These instructions apply to men as well as women.
3. Discomfort along the outside of the operated thigh
I had a lot of tightness and discomfort along the outside of my thigh. My physical therapist told me that this area corresponds to the linea quadrata, an anatomical ridge on the femur bone where various thigh muscles attach. Tightness along the outside of the thigh can relate to the trauma of surgical dislocation and to the leg re-lengthening produced by a correctly fitted prosthesis. To treat this I had a lot of acupuncture along this area during the first post-operative weeks . The lateral side of the thigh involved exactly corresponds to the Gall Bladder meridian in Chinese Medicine.
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Hip resurfacing: An alternative to THR
This approach preserves the femoral neck and avoids exposing the femoral canal. Rather than being removed, the femoral head is planed down to a stump, in order to accept a metal cap on a small guide stem. A metal cup is set into the pelvis to receive it. This surgery met with early failure when a polyethylene-lined cup was used, but advocates of the all-metal devices now in use expect high longevity, even in younger patients. The rate of dislocation is almost nil. The NICE (National Institute for Clinical Excellence) report from England concludes:
"...there is sufficient short-term [my emphasis] evidence of the effectiveness of MoM hip resurfacing devices to conclude that they are at least as effective as conventional THRs for patients younger than 55 years."
The FDA approved Hip Resurfacing with the BHR in the US on May 9, 2006.
Read more here.
Update: The New York Times, 11/08/08 reports on studies showing problems with resurfacing in women.
Read that post, For Women, Red Flags About a Hip Device, here.
A patient's review of this option is on the ActiveJoints site:
And a comprehensive analysis is posted at Total Joints:
Surface Hippy.Info provides information about different types of hips, surgeons that perform hip resurfacing and basic information about hip resurfacing.
The dancer William Starrett had this procedure.
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Note: I am not affiliated with any of the companies mentioned on this website.
HipUniverse Elisabeth's site with Jeff Cranston
Mini-Incision THR Dr. Todd V. Swanson's site with contributions by Pauline van Betten
Total Joints a great reference
(*Note: This website is part of a non-commercial project to investigate how patient information influences and improves the results of total joint operations. The text is translated from Swedish.)
ActiveJoints another good resource especially for younger people
hipsandknees.com Dr. Huddleston's informative manual Arthritis of the Hip Joint and information about THR
Anatomy Atlas from the University of Washington, Seattle
Videos of THR surgery (all single incision):
Shore Memorial Hospital, New Jersey. Stephen Zabriski, MD.
Desert Orthopaedic Center, Las Vegas. Todd V. Swenson, MD.
Good Samaritan Hospital, Baltimore, MD. Marc Hungerford, MD and Harpal Khanuja, MD.
Hospital for Special Surgery, NY,NY. Thomas Sculco, MD.
This one for has just a few minutes of an op. (Click on mini incision for hip surgery on the left.)
Hartford Hospital Steven Schutzer, MD.
Thomas Jefferson University Hospital, Philadelphia, PA. Richard H. Rothman, MD, PhD, and William J. Hozack, MD.
St. Francis Hospital, Merrill A. Ritter, M.D. Beech Grove, Indiana.
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Site llustrations from www.zimmer.com