Total Hip Arthroplasty

Resolving pain and restoring quality of life

Anterior Total Hip Arthroplasty

Some call it minimally invasive, which is an undefined term. Some call it muscle sparing, which is reasonably true. If you read the randomized controlled trials, meta-analyses of the RCTs, and non-RCT trials and synthesize all the material, including the two recent JAMA and BJJ articles, then the anterior total hip replacement surgery yields a faster recovery in the first 3 months and lower dislocation risk with minor risk trade-offs including slightly higher bleeding risk, fracture or femoral stem loosening, and risk of lateral thigh numbness. Many posterior hip approach surgeons defend their approach by citing the JAMA and BJJ retrospective papers. I offer both surgeries, especially if a previous surgery was done. I believe the anterior approach is a better operation when done correctly.

 

Total Hip Arthroplasty (THA) or Replacement

I will try my best to answer the questions you have as a patient. I love questions, patients with long lists of questions, and difficult or challenging questions. If I cannot answer your questions, that is my fault, as I should know the answer. This desire to be challenged likely comes from my academic background, while on faculty at University of California Davis Medical Center.

The #1 question patients will ask is “Do I need a hip replacement?” To that, I answer: In order to qualify for THA, you must fulfill 2 metrics. First, you must radiographically qualify. This means you must have “bone-on-bone” arthritis on the weight bearing hip xrays. If you are not “bone-on-bone” then you should not get a replacement. Secondly, the patient must have failed conservative treatment and the pain and lack of function is having a severe effect on their activities of enjoyment and daily living.

Often times, I will be consulted as a second opinion for a joint replacement whom is dissatisfied or painful after their replacement. I always ask for pre-operative xrays of the joint prior to their surgery. Many times, the pre-operative xray did not show '“bone-on-bone” arthritis (or AVN), and the previous surgeon may have been too hasty to replace the joint. Additionally, patients may be dissatisfied if they were quite functional prior to their replacement. There are patients out in the community, with “bone-on-bone” radiographs who have never set foot inside an orthopaedic surgeons office! If the pain does not severely affect their life in a negative way, then there is no reason to proceed with surgery.

Lastly, patients want to know who to select as a surgeon! When they meet the patient, they are trying to vet out the orthopaedic surgeon, to see if they are good, if they have done many, if they understand the patient’s concerns and show care and empathy towards their situation. I think these are all very valid concerns. I would say the #1 important quality for the surgeon is that they have done many of these procedures. Complication rates for THA vary, depending what is defined as a major (deep infection, reoperation, dislocation, DVT) or minor complication (superficial infection treated with oral antibiotics, stitch abscess, UTI, post-operative ileus). A hip replacement surgeon who does more than 100 per year, or over 500 total will be better than someone who does less. They will have seen and managed complications, and understand how to best avoid complications or best manage them. No one has 0 complications unless they have done the procedure 0 times. I would also recommend someone who is fellowship trained in that field, as they are even more specialized. Whoever the patient chooses, I would ensure they feel confident and comfortable with that surgeon and their team.

Selected readings:

  1. Zhao HY, Kang PD, Xia YY, Shi XJ, Nie Y, Pei FX. Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial. J Arthroplasty. 2017 Nov;32(11):3421-3428.

    https://pubmed.ncbi.nlm.nih.gov/28662957/

  2. Miller LE, Gondusky JS, Bhattacharyya S, Kamath AF, Boettner F, Wright J. Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis. J Arthroplasty. 2018 Apr;33(4):1296-1302

    https://pubmed.ncbi.nlm.nih.gov/29195848/

  3. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct anterior total hip arthroplasty yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty. 2014 Sep;29(9 Suppl):169-72.

    https://pubmed.ncbi.nlm.nih.gov/25007723/

  4. Kahn TL, Kellam PJ, Anderson LA, Pelt CE, Peters CL, Gililland JM. Can Dislocation Rates Be Decreased Using the Anterior Approach in Patients With Lumbar Spondylosis or Lumbar Instrumented Fusion? J Arthroplasty. 2021 Jan;36(1):217-221.

    https://pubmed.ncbi.nlm.nih.gov/32919847/

  5. Pincus D, Jenkinson R, Paterson M, Leroux T, Ravi B. Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty. JAMA. 2020 Mar 17;323(11):1070-1076.

    https://pubmed.ncbi.nlm.nih.gov/32181847/

  6. Aggarwal VK, Elbuluk A, Dundon J, Herrero C, Hernandez C, Vigdorchik JM, Schwarzkopf R, Iorio R, Long WJ. Surgical approach significantly affects the complication rates associated with total hip arthroplasty. Bone Joint J. 2019 Jun;101-B(6):646-651.

    https://pubmed.ncbi.nlm.nih.gov/31154834/

Hip Resurfacing

What is hip resurfacing and why is it different than total hip arthroplasty?

While total hip arthroplasty (THA) is a great procedure, it does have its limitations. Our academy of hip and knee surgeons does not recommend certain activities such as running, jumping, and heavy weight lifting after hip replacement. Lower impact activities such as cycling, elliptical and swimming are encouraged. Tennis, golf, skiing or snowboarding and water sports are all fine. However, younger patients who want to be more active, and elite level or professional level athletes may benefit from hip resurfacing, as it may allow patients to run, jog, jump, or play extreme sports.

Hip resurfacing is not for everyone

Like everything, there are significant risks that are associated with hip resurfacing that do not exist for hip replacement.

  1. It is a metal on metal bearing. This means there are risks of developing reactions to the metal debris that may affect the soft tissue around your hip

  2. Usually annual metal ion levels are required to make sure your body is not reacting to the metal debris

  3. If you are of child bearing age, we know the metal ions generated can cross the placental barrier and we do not know the long term side effects of this on the fetus

  4. Certain patients, such as females have, increased risk for femoral neck fracture

The benefits

The benefits of hip resurfacing are vast and wide.

Patients after hip resurfacing are able to function at a higher level than a hip replacement. They are able to run, jump, squat, and perform extreme activities.

Examples such as Isiah Thomas (NBA), Andy Murray (ATP), Ed Jovanovski (NHL), Nicklas Backstrom (NHL) are some of the most professional and elite level athletes who have received treatment and returned to play to the sport.

Again, there are risks with hip resurfacing, but if athletic performance at a very high level is a top priority for you, this may be an option. Feel free to reach out to discuss your options further.