Patients with advanced hip arthritis may be good candidates for either a traditional total hip replacement or a hip resurfacing. Each of these is a type of hip surgery, but they are not the same in important ways.
What is Hip Resurfacing?
In a traditional total hip replacement, the head of the thigh bone, known as the femoral head, and the damaged socket are both taken out and replaced with metal, plastic, or ceramic parts. However, in hip resurfacing, the femoral head is not taken off. Instead, it is cut down and capped with a smooth piece of metal, and just like a traditional total hip replacement, the damaged bone and cartilage in the socket are taken out and replaced with a metal shell.
The Benefits of Hip Resurfacing
There are many advantages to hip resurfacing over a total hip replacement. These include, but are not limited to:
- Easy to replace – Because hip resurfacing takes less bone from the thigh bone than a traditional hip replacement, many surgeons think it is easier to replace failed implants after hip resurfacing
- Decreased risk of dislocation – In hip resurfacing, the size of the ball is bigger than in a traditional hip replacement, and it is closer to the size of the natural ball of your hip. Since this is the case, it is harder to dislocate
- Better walking pattern – Hip resurfacing makes people walk more naturally than traditional hip replacement. But these differences in how people walk are very small, and you need special tools to measure them. However, these differences matter when it comes to recovery and pain levels
Minimally Invasive Hip Surgery
Implanting artificial joint implants with minimal collateral damage to the soft tissues and bone is desirable for quicker healing and a better outcome. The problem is that smaller incision surgery is more complicated for the surgeon and can lead to more errors if the surgeon does not have the necessary technical skills. Scientific studies have sometimes shown worse outcomes for minimally invasive surgery. Many claims for quicker recovery with certain techniques are not substantiated by results. In this arena, it is impossible to make general claims about the superiority of any technique. Results are more dependent on the individual surgeon than the specific technique. You must carefully look at an individual surgeon’s published track record to make a judgment.
Minimally Invasive Resurfacing
When we first started doing minimally invasive resurfacing, we compared the results to those we had gotten from bigger surgeries. We found that the new results were better and didn’t increase the risk of complications, so we published this. We have used a minimally invasive posterior approach for all hip surgeries since 2005.
Most hip resurfacings in the world are performed through a large posterior approach using an 8- to 12-inch incision. Our practices uses a minimally invasive, 4-5-inch approach.
What is the Anterolateral Approach
The next most common approach is the anterolateral approach. This approach is not recommended because it requires the detachment of a portion of the abductor’s muscles. Sometimes these don’t heal perfectly, leaving a permanent limp, and this is hard to fix later.
The direct anterior approach has become fashionable in total hip replacement. The claim is a lower dislocation rate and a quicker recovery. There is some evidence to support the first claim for small-bearing total hip replacements, but if large metal bearings are used, the dislocation rate is almost zero through a posterior approach. The claim of faster recovery is not supported by evidence. The mini-posterior approach has a similar recovery rate. There is no published data on hip resurfacing through a direct anterior approach. Several surgeons who use this approach had presentations showing a high rate of complications and another that showed little to no data.
Outpatient Joint Replacement Surgery
Using a combination of all of the above techniques has allowed us to substantially decrease the length of hospitalization for all hip surgeries.
Our average hospital stay has been 1.5 days for years. Minimally invasive surgery in combination with other techniques of perioperative management has now made it possible to achieve outpatient status more quickly. However, in some situations, there is significant hip pain when the articular (surface) cartilage is still mostly intact – which may require a slightly longer stay. Patients who have hip impingement, hip dysplasia, or osteonecrosis in the early stages of these conditions may be better served with other surgical options. Symptoms can often be significantly improved and the joint may be preserved for many years.
Arthroscopic Hip Surgery
Arthroscopic Hip Surgery was years old with minimal arthritic changes on their hip x-ray. In these cases, it is advisable to perform impingement surgery rather than hip replacement.
Exceptional Arthroscopic Hip surgeons:
- Allston Stubbs – Winston Salem, NC
- Thomas Byrd – Nashville, TN
- Marc Phillipon – Vail, CO
Impingement surgery can also be performed through mini-open anterior approaches or more extensive approaches. It has not been proven.
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Ganz Periacetabular Osteotomy
Ganz Periacetabular osteotomy is most useful for patients with hip dysplasia. Procedures that realign the position of the acetabulum (socket) are called osteotomies. Many different types have been promoted in the past for young patients with hip dysplasia. 90% of dysplasia cases occur in young women. These women were typically born with mild hip deformities that did not cause problems when they were children.
The elements of the dysplasia deformity are an oval shallow socket, a steeply oriented socket, a flattened oval head, a narrow valgus, and anteverted neck, and a hypertrophic labrum. Typically, these women have extremely loose ligaments and have much higher hip mobility than normal. They gravitate toward gymnastics and ballet because of their extreme flexibility. They start exhibiting mild hip symptoms in their 20s and 30s.
The hips start to fail early for two reasons: incongruence and instability. A normal hip is a spinning sphere. When an oval dysplastic hip rotates, abnormal forces are experienced by the articular cartilage, leading to deterioration. A shallow dysplastic hip is poorly contained. If the orientation is more vertical, the situation is worse. The labrum hypertrophies in an attempt to better contain the head.
The result is a highly mobile hip. But the labrum eventually gets overloaded and fails. Depending on the severity of the deformity and possibly activity level, the first symptoms usually appear in the 20s and 30s. At this point, the articular cartilage may still be relatively normal.
If the angle of their socket is too steep, a Ganz periacetabular osteotomy can help by reorienting the whole socket and making the head fit better in it. If socket orientation is acceptable, sometimes the early symptoms are due to a tear of the hypertrophied labrum that can be repaired arthroscopically. Removing a torn labrum for hip dysplasia is not advisable because this destabilizes the head and may speed up hip degeneration.
Studies on acetabular osteotomies have shown over 90% success in symptom relief if there is only minor articular cartilage damage at the time of surgery. The hope is that the hip joint will be preserved by this intervention, but this has not yet been proven. The ideal patient for osteotomy surgery is under 40 years old with minimal arthritic changes on their hip x-ray. The problem is that there is no way to completely correct the deformity. You can’t make the socket deeper or the bearing round without hurting the cartilage. A hip resurfacing procedure does accomplish these goals, but this requires an artificial implant.
Experts in Ganz Osteotomy:
- Michael Millis – Boston, MA
- Robert Trousdale – Rochester, MN
Free Vascularized Fibular Graft
The femoral head is by far the most common bone in the body to develop osteonecrosis. It is most often caused by excess alcohol consumption, prolonged high-dose steroid use (prednisone type, not muscle-building steroids), major hip trauma (fracture or dislocation, not a hard fall on the hip), or sickle cell disease. Exactly why these cause necrosis is not known. Osteonecrosis only happens in a small number of people who drink alcohol or take steroids, so it’s clear that some people are more likely to get it than others. About 1/3 of cases do not have any associated risk factors and are labeled “idiopathic.”
In the earlier stages, before the collapse, there are often mild symptoms. Several operations have been promoted to induce new blood flow to the femoral head to heal it before it collapses. The free vascularized fibular graft is the most effective. It is a complicated operation that only a few surgeons routinely perform.
The fibula is a small bone in the leg that is removed along with its blood supply. The bone is inserted through a large hole drilled through the femoral neck into the femoral head. The blood vessels are re-connected to new vessels near the hip. New blood flow is now brought directly into contact with the dead bone in the femoral head. In 95% of cases, when this operation is performed before a head collapse, the dead bone can heal and the hip joint is preserved. If the head is already collapsed, there is no point in this operation because the joint cartilage has already lost its support and will always fail.
The problems with this operation are its complexity, long recovery, and donor site morbidity. This is a long and complicated operation that requires multiple surgeons and is very expensive. Patients are usually required to stay on crutches for months after the operation. It is relatively safe to remove a 3–4-inch section of fibula from just above the ankle because the larger tibia can take the load. But some residual leg or ankle pain may be present permanently. Also, clawing of the toes may result in a complication of removing the fibula. In stages 1 and 2 of necrosis in a young patient, it is worthwhile to consider this option.
Duke University Orthopedics has the most experience with this operation. After this operation, the hip pain goes away, but the person will always have a severe limp because they can no longer move their hip. After many years, arthritis in the knee and back begin to develop because these joints are overstressed.
Hemi resurfacing was once used for stage 3 osteonecrosis but now that total resurfacing is available, there is no longer any role for hemi-resurfacing. When only the femoral side is resurfaced, even if the acetabular cartilage is normal, active people don’t get full pain relief.
Endoprosthesis is still a useful option for elderly people who suffer a femoral neck (hip) fracture. If the patient is very active, a stemmed total hip is superior, but if the patient is not very active, an endoprosthesis is a better solution.
Who is a Good Candidate for Hip Resurfacing?
Hip resurfacing is not as good for all patients as hip replacement. In general, the best candidates for hip resurfacing are people who are younger than 60, have a larger body size, and have strong, healthy bones. Patients who are older, female, smaller in size, or have weaker or damaged bones are at a higher risk of complications. It’s important to review all of your options with your doctor, and here at Midlands Orthopedics & Neurosurgery, our specialists are here to determine your best course of treatment.
Hip Resurfacing Recovery
Most people go home between 1 and 4 days after surgery. Depending on what your doctor wants and how strong your bones are, you may be able to put weight on your leg right away after surgery. You may need a walker, cane, or crutches for the first few days or weeks until you feel confident enough to walk without help.
After surgery, you can expect to feel uncomfortable and have pain for a few weeks. If you need it, there are many kinds of pain medications, such as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics, that can help control pain. Taking painkillers can help you feel better, which will help your body heal faster and recover more quickly from surgery, as long as they are taken as directed by your doctor.
After surgery, you may be required to participate in physical therapy. The physical therapist will give you exercises to help you maintain your strength and range of motion. You will keep going back to your surgeon’s office for follow-up visits at regular times. Most likely, you will be back to doing the things you normally do in about 6 weeks after surgery.
Choosing The Best Approach for Patients
Depending on your situation, there are several steps you can take to make sure your surgery goes better than you expected. Learn more about our hip surgery practice, or contact Midlands Orthopaedics & Neurosurgery to start your booking today.