Treatment Guide: Hip Replacement
Forty years ago, hip joint replacement surgery was a radical new procedure. Today some 300,000 hips are replaced annually. New techniques, technologies and materials mean people no longer have to postpone hip surgery for fear the implant will wear out. Now the determination is made by need, not age. “This is probably the best operation in medicine,” says internationally known hip surgeon Dr. Richard Rothman, whose Rothman Institute at Jefferson Hospital is one of the country’s big players in the field.
[sidebar]There are several different techniques for hip surgery, but Rothman cautions that the key to a successful outcome is less how than who. “You want a good surgeon with a high volume who’s operating in a good hospital.”
Here are the variations:
Classic total hip replacement: Rothman dubs this “the gold standard.” Typically the surgeon makes an incision on the side of your thigh. After removing the diseased socket and replacing it with a new one of metal and polyethylene, he plants a stem in the femur (the long leg bone), puts a ball on top, checks the movement and sews you up. The big advance is the improvement in pain control. Rothman operates under an epidural and administers pain drugs during the surgery itself, which greatly reduces post-op suffering. “By the time the drugs wear off in 36 to 48 hours, the worst insult has passed,” he says. If you are considering a hip replacement, be sure to ask your surgeon what he does for pain control.
Minimal incision hip replacement: The first incarnation of minimal incision surgery was essentially the same as the classic version but with a smaller incision. Rothman stopped doing them after he conducted two research projects that showed pain and healing were at best marginally different, and that the procedure could lead to complications because the surgeon can’t see as much. But at Abington Hospital Dr. Andrew Starr believes that a new year-old variation, popular in Europe, could be the wave of the future– particularly for active adults. It uses an anterior (front of the thigh) rather than a posterior cut that doesn’t disrupt the important ligaments and tendons around the hip. “With a standard hip, you have to be careful for at least six weeks, “he says, “but this technique really cuts downtime. One of my patients, a landscaper, was back supervising his men two weeks after surgery.” It’s still considered experimental.
Hip resurfacing: Some active, 50ish men with significant arthritis that’s impinging on their lives may be candidates for this procedure, which got FDA approval two years ago. It shapes the joint and puts a new metal shell over the ball and socket instead of replacing them. The advantage is restoring hip function while preserving much of the original bone. And a total hip replacement is still an option down the road. Dr. William Hozack at the Rothman Institute does one or two a week and says, “The key is patient selection.”
Hip preservation: Rothman Institute orthopedist Dr. Jared Parvizi is the only surgeon doing this in Philadelphia. Most of his patients are dancers or athletes in their 20s and 30s suffering from early arthritis. He recommends it to any active young person experiencing abnormal pain in the groin area after activity. There are two types of surgeries, both technically difficult. One realigns the bones in people born with shallow hip sockets. The other smoothes and reshapes the surface of joint bones whose abnormal contact is the source of pain.
Gender hips: Because men and women have different sized and shaped bones that meet at different angles, some women may wind up with one shorter leg after hip surgery. A new customized gender hip introduced in February 2007 corrects that problem. Dr. David Nazarian, director of hip surgery at 3 B Orthopedics, is a consultant for the company that makes the system, and his group is the only one using it as of now. “It’s best for women under 5’1””, he says, “and we can usually predict who needs it by X-ray.”
Bloodless hip surgery: As many as 20 percent of hip replacement patients need blood transfusions after surgery, so most people donate a pint or two of their own blood about three weeks in advance. But it’s been found that red cells don’t carry oxygen as well after sitting on a shelf for a while. Nazarian is the only area surgeon who has his patients give their blood the day of surgery and it sits right next to them to be infused back when the new hip is in place, obviating any need for a transfusion. “This is perfect for Jehovah’s witnesses,” he says “and valuable for people with anemia, rheumatoid arthritis and fibramyalgia. And there’s no chance of getting back the wrong blood!”