Less Invasive Hip Replacement

Patient Guide

Reclaim Your Active Lifestyle 
Hip Pain 
Hip Anatomy 
Hip Arthritis 
What is the Anterior Approach for Total Hip Replacement? 
Traditional vs. Anterior Hip Replacement 
Implant Components 
The Procedure 
The Approach 
New Materials for Longer Lasting Implants 
Hip Replacement: Pre-op and Surgery Day 
Surgery and Recovery  
Hip Rehabilitation after Surgery 
The Transition Period 
Rehabilitation and Exercise 
How Long Will Your Implant Last  
Preventing Hip Complications 

Less Invasive Hip Replacement

Reclaim Your Active Lifestyle

Men and women of all ages can be affected by hip arthritis, which may limit activities and recreation. The anterior approach for total hip replacement can have you back on your feet faster than ever before.

Thanks to a smaller incision, there is less trauma to underlying muscle and soft tissue resulting in a smaller scar, less post-operative pain, and a faster return to normal activities. In fact, the anterior approach for total hip replacement allows faster recovery compared to traditional hip replacement surgery.

To help you fully understand the process of the anterior approach for total hip replacement, this article provides a detailed explanation of less invasive replacement, its benefits, and what to expect during hospitalization and when you return home.
 


Hip Pain

Is it difficult for you to walk? To climb stairs? To do the most basic activities of daily living? Do you spend more time than not thinking about your hip pain? If you have answered yes to these questions, then it is time to do something about your pain. And if all other conservative treatment measures have failed, then it may be time to consider having joint replacement surgery.

Joint replacement surgery has been successful in over 90% of patients—helping them to gain mobility, relief from pain and an improved quality of life.

The anterior approach to this type of surgery, specifically has led to an even faster recovery enabling you to return to the life you used to have much sooner!
 
 

Hip Anatomy

To understand why you have hip pain, it helps to be familiar with the anatomy of your hip. The hip joint is designed for both mobility and stability, allowing the entire lower extremity to move in three planes of motion. The hip provides an important shock absorption function to the torso and upper body as well as stability during standing and other weight-bearing activities.

Bones

The hip is actually a ball and socket joint, uniting two separate bones, the femur (thighbone) with the pelvis. The pelvis features tow cup-shaded depressions called the acetabulum, one on either side of the body. The femur is the longest bone in the body and connects to the pelvis at the hip joint. The head of the femur, shaped like a ball, fits tightly into the acetabulum, forming the ball and socket joint of the hip, allowing the leg to move forward and backward, side to side, and rotate right and left.

Cartilage

The acetabulum is lined with cartilage, which cushions the bones during weight-bearing activities and allows the joint to rotate smoothly and freely in all planes of movement with minimal friction.

Ligaments

The complex system of ligaments that connect the femur to the pelvis are essential for stability, keeping the hip from moving outside of its normal planes of movement.

Muscles

The muscles of the hip joint have dual responsibilities working synergistically to provide the power for the hip to move in all directions, as well as to stabilize the entire lower extremity during standing, walking, or other weight-bearing activities.


Hip Arthritis

Arthritis of the hip is a disease which wears away the cartilage between the femoral head and the acetabulum, causing the two bones to scrape against each other, raw bone on raw bone. When this happens, the joint becomes pitted, eroded, and uneven, resulting in pain, stiffness, and instability. In some case, motion of the leg may be greatly restricted.

Osteoarthritis

Osteoarthritis is the most common form of arthritis in the United States. It is degenerative, and although it most often occurs in patients over the age of 50, it can occur at any age, especially if the joint is in some way damaged.

It is usually confined to the large weight-bearing joints of the lower extremities, including the hips and knees, but may also affect the spine and upper extremity joints. Patients with osteoarthritis often develop large bone spurs, or osteophytes, around the joint, further limiting motion.

Causes

Osteoarthritis of the hip is a condition commonly referred to as “wear and tear” arthritis. Although the degenerative process may accelerate in persons with a previous hip surgery, many cases of osteoarthritis occur when the hip simply wears out. Some experts believe there may exist a genetic predisposition in people who develop osteoarthritis of the hip. Abnormalities of the hip due to previous fractures or childhood disorders may also lead to a degenerative hip. Osteoarthritis of the hip is the most common cause for total hip replacement surgery.

Symptoms

The first and most common symptom of osteoarthritis is pain, usually occurring towards the groin area during weight-bearing activities such as walking. To decrease hip arthritis pain people usually compensate by limping, which reduces the force across the arthritic hip.

Hip osteoarthritis may also result in loss of motion of the hip joint, causing difficulty in doing daily living activities such as putting on socks and shoes. As a result of the cartilage degeneration, the hip loses its flexibility and strength, and may develop bone spurs. As the arthritis worsens, the pain may increase and may become constant, even during non weight-bearing activities.

Treatment

Before considering total hip replacement surgery, your doctor and you may try various non-surgical therapies. An appropriate weight reduction program may be beneficial in decreasing force across the hip joint. However, weight reduction can be difficult for people with hip arthritis since the arthritis pain precludes them from increasing their activity and burning calories. An exercise program may be instituted to improve the strength and flexibility of the hip and the other lower extremity joints. Lifestyle and activity modification may be undertaken in an attempt to minimize the activities that are associated with hip pain.

Finally, various medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and/or nutritional supplements (Chondroitin/Glucosamine) to reduce pain and inflammation associated with the disease may be considered.

Assistive devices like a cane or a crutch can help to reduce the force transmitted through the hip joint during walking and thereby may help to decrease hip arthritis pain. If non-surgical treatment is unsuccessful, you and your surgeon may decide that a total hip replacement is the best available treatment option.
 
Rheumatoid Arthritis

Unlike osteoarthritis which is a “wear and tear” phenomenon, rheumatoid arthritis is a chronic inflammatory disease that results in joint pain, stiffness, and swelling. The disease process leads to severe, and at times rapid, deterioration of multiple joints, resulting in severe pain and loss of function.

Causes

Although the exact cause of rheumatoid arthritis is unknown, some experts believe that a virus or bacteria may trigger the disease in people with a genetic predisposition to rheumatoid arthritis. Many doctors think rheumatoid arthritis is an autoimmune disease in which the synovial tissue of the joint has been attacked by the immune system. The onset of rheumatoid arthritis occurs most frequently in middle age and is more common among women.

Symptoms

The primary symptoms of rheumatoid arthritis are similar to osteoarthritis and include pain, swelling, and the loss of motion. Other symptoms may include loss of appetite, fever, energy loss, anemia, and rheumatoid nodules (lumps of tissue under the skin). People suffering with rheumatoid arthritis commonly experience periods of exacerbation or “flare-ups” involving pain and stiffness in multiple joints.

Treatment

Treatment of rheumatoid arthritis may involve medications such as NSAIDs, aspirin and analgesics. Corticosteroids, such as prednisone may be prescribed, and are effective in decreasing the inflammation associated with rheumatoid arthritis. Side effects can occur with the use of corticosteroids, and close monitoring by a physician is essential. Researchers have made progress in the treatment of rheumatoid arthritis and newer prescription drugs are now available.

If non-surgical measures fail, you and your surgeon may decide that total hip replacement is the best treatment option to relieve your pain and help you return to an improved function level.
 


What is the Anterior Approach
for Total Hip Replacement?

This less invasive surgery for hip replacement allows exposure from the front of the hip joint as opposed to the side (lateral) or to the back (posterior). In the anterior approach, the hip is replaced through a natural interval between muscles. The important muscles for hip function, the gluteal muscles that attach to the posterior and lateral pelvis and femur, are left undisturbed.

Lack of disturbance of the lateral and posterior soft tissues also accounts for immediate stability of the hip and low risk of dislocation. It is normal for patients undergoing posterior incisions to follow strict precautions that limit hip motion for the first two months after surgery. Most importantly, they are instructed to limit hip flexion to no more than 60 degrees. These limitations complicate a patient’s simple daily activities such as sitting in a chair or on the toilet or just getting in a car.

Following the anterior approach, however, patients are immediately allowed to bend their hip freely and to avoid these cumbersome restrictions. Additionally, if patients are sexually active before surgery, there are no limitations on resumption of normal sexual activity after surgery.

The anterior approach for total hip replacement is less invasive, is easier on the tissues and allows the procedure to be preformed through a smaller soft tissue “window”. With this approach, muscles are not cut. Instead, they are separated naturally which results in a far quicker recovery period and far less activity restrictions than traditional hip replacement surgery.

The payoff for patients is far less pain and a much faster recovery.

Less Pain

Trauma caused by tissue damage causes pain and swelling as part of the healing process. Since anterior hip replacement requires a much smaller incision and dissection of normal tissue, the end result is less pain during recovery.

Faster Recovery

With minimally invasive anterior hip surgery, the time needed in the hospital to gain independence and to achieve comfort is considerably shortened. One clinical
study found:
Traditional vs. Anterior Hip Replacement
   Traditional   Anterior
Incision Size  8 – 10 inches   3 – 5 inches
Hospital Stay  5 – 7 days   2 – 3 days
Recovery Time  12 weeks   2 – 6 weeks
 
 

Who is a Candidate for the Anterior Approach for Total Hip Replacement?

In general, anyone can benefit from a less invasive surgical technique. In some cases, due to the size or weight of the patient, the incision must be extended, but the trauma to the surrounding tissues will still be reduced when compared to traditional surgery. Your surgeon will try to keep the incision as small as possible, but there are times when the patient is best served by a larger incision. Patients with severe deformities, heterotopic bone formation due to trauma, or previous hip replacement are not candidates for the anterior approach.


Total Hip Replacement

If you and your surgeon have exhausted all conservative measures for treating your hip arthritis, you may be a candidate for the anterior approach for total hip replacement. This procedure is often the only option for reducing pain and restoring an active, pain-free life. If your doctor decides a total hip replacement is right for you, the following information will give you an understanding about what to expect.

Total hip replacement is a surgical procedure for replacing the hip joint. During the procedure, the two parts of the hip joint, the hip socket (acetabulum) and the ball (femoral head), are removed and replaced with smooth artificial surfaces. The artificial socket is commonly made of metal with a high density plastic liner, and the artificial ball is made out of metal or ceramic.

Implant Components

In total hip replacement surgery, the prosthesis or implant, is made up of three components. The femoral stem is made out of a metal, such as titanium, and is implanted down the shaft of the thighbone or femur. The ball, or femoral head, is attached to the stem and is designed to replace the artificial femoral head. The third part, the acetabular component, is a metal shell with a plastic inner socket liner.

These components are implanted into the pelvis and thighbone, and are designed to closely approximate the mobility of the natural hip joint.
 


The Procedure

Following anesthesia, the patient is placed supine on a special orthopedic table. The carbon fiber struts that support the legs, move appropriately and manipulate the operated leg during surgery. The unique capabilities of the table facilitate surgery through this smaller and less invasive approach.
 


The Approach

Following a natural plane between muscles and without detachment of muscle or tendons from the bone, the hip is exposed. The femoral neck is cut and the arthritic femoral head and neck are then removed.

Next, the arthritic acetabulum undergoes a procedure called reaming. Reamers of gradually increasing diameter accurately shape the bone of the acetabulum to accept the acetabular prosthesis. An acetabular prosthesis slightly larger in diameter than the prepared acetabular cavity is inserted with a press fit that produces initial stability. During insertion, x-ray is used to position the prosthesis accurately. One or more screws may also be used to enhance stability. Following insertion of the acetabular shell, the bearing surface is then inserted.
 
Preparing the femur requires that the table rotate the leg externally, extend the hip, and drop the foot toward the floor to allow for access through this small approach. A special broach is inserted into the femoral canal. Progressively larger broaches are inserted with the size being limited by the outer cortical bone.

Following insertion of the final broach, the driving handle is then removed. The broach is temporarily left in as a “trial” femoral prosthesis and its upper end is capped with a trial femoral head. The table repositions the leg to its normal position and the trial head is “reduced” into the acetabulum.
 
X-ray is now used for sizing. Side by side television monitors compare the x-ray image of the patient’s opposite hip to the operated hip. This comparison gives immediate information regarding equality of length and femoral offset (horizontal distance of the femur from the pelvis). The leg and hip are moved by the table to check for stability. If the initial trial shows undesirable length, offset, or stability, adjustments are made.

The femoral prosthesis can be secured with cement, or by press-fit with subsequent bone on-growth. Whether cement is used or not, a femoral prosthesis of specific size is accurately inserted to reproduce the fit, length, and offset indicated by trial.

The final result is achieved by reducing the hip resulting in the femoral head being placed into the acetabulum. The wound is then washed with antibiotic solution and closed.
 


New Materials for Longer Lasting Implants

Engineers have developed materials that may extend the life of an implant. OXINIUM material, an innovation exclusively from Smith & Nephew, is a Zirconium-based alloy, similar to titanium, with a ceramic surface that provides superior wear resistance without brittleness. Because of its superior hardness, smoothness and resistance to scratching and abrasion, an OXINIUM replacement may provide an answer to patients who would otherwise delay joint replacement due to concerns about implant life.

When zirconium is subjected to high temperature in the presence of oxygen, the result is OXINIUM material, which has a smooth ceramic surface. Since OXINIUM material is a metal, breakage is not necessarily a problem. In fact, OXINIUM material can reduce wear by as much as 98% without risking breakage.

As there are many choices of prosthetic implants available, your surgeon will find the best choice for you depending on your age and anatomy.
 


Hip Replacement: Pre-op and Surgery Day

Once you and your surgeon decide that total hip replacement is right for you, the days and weeks leading up to surgery, as well as the day of surgery, require preparation. The following is a description of what you might expect.


Pre-operative Procedure

You and your orthopedic surgeon may participate in an initial surgical consultation. This appointment may include pre-operative x-rays, a complete medical and surgical history, physical examination, and a comprehensive list of medications and allergies. During this visit, your orthopedic surgeon will likely review the procedure and answer any questions you may have.
 
Your orthopedic surgeon may require that you have a complete physical examination by your internist or family physician, as you will need to be cleared medically before undergoing this procedure. You will also need to have several tests done prior to your surgery. Please check with your surgeon for a list of the tests required.
 


Preparation for the Hospital

Before surgery, you should adhere to the following:
   • You should eat your regular diet on the day before surgery.
   • No food or water after midnight the night before your surgery.
   • Follow your doctor’s instructions regarding use of medication in the days leading to your surgery. Aspirin and other non-steroidal anti-inflammatories should not be taken 7 days prior to surgery as well as all vitamins and herbal medications. If you need to take something for pain, acetaminophen is fine.
   • Try to get long, restful nights of sleep. If you need a sleeping medication to help you, please let your doctor know.


Day of Surgery

On the morning of surgery, once you are admitted to the hospital, you will be taken to the pre-surgical area where the nursing staff will take your vital signs, start intravenous fluids, and administer medications as needed. You will be asked to empty your bladder just prior to surgery, and to remove all jewelry, contacts, dentures, etc. You will change into a hospital gown and be placed on a stretcher. You will be instructed on certain breathing techniques to use when you wake up after surgery.

You will meet with your anesthesiologist who will review your medical history, current medications, and the type of anesthesia to be used during the procedure. Your surgeon will also identify you and the appropriate hip will be marked. Your family and friends will be given instructions on where to wait. At that time, you will be taken via stretcher to the operating room.
 


Surgery and Recovery

When surgery is completed, you will be taken to the recovery room for a period of close observation. Your blood pressure, heart rate, respirations, and body temperature will be closely monitored by the recovery room staff. Special attention will be given to your circulation and sensation in your feet and legs. Your level of pain will also be closely assessed. When you awaken and your condition is stabilized, you will be transferred to your room. Although protocols may vary, you may awaken to some or all of the following:
   • A large dressing will have been applied to the surgical area.
   • You may see a hemovac suction container with tubes leading directly into the surgical area. This device allows the nurses to measure and record the amount of drainage from the wound following surgery.
   • An IV will continue post-operatively in order to provide adequate fluids. The IV may also be used for administration of antibiotics and other medications.
   • A catheter may have been placed into your bladder as the side effects of some medications make it difficult to urinate.
   • An elastic hose may be applied to decrease the risk of deep vein thrombosis (DVT). A compression device may also be applied to your feet to further
prevent DVT.
   • You may have a patient-controlled analgesia (PCA) device or an epidural pump which will administer pain medication to you post-operatively. Only the patient is allowed to press the button on the PCA to prevent complications from occurring. To prevent overdose, the units are programmed to deliver a pre-defined amount of pain medication anytime the button is pressed.

You will typically be placed on a floor of the hospital with other patients who have had orthopedic surgery. As a result, the nursing staff is well trained to manage the post-operative program following anterior hip replacement.
 


Hip Rehabilitation after Surgery

One of the most critical factors in achieving successful total hip replacement depends upon your diligence in physical rehabilitation. You must actively participate in the rehab process, working diligently on your own, as well as with the physical therapists, to achieve optimal results.
 
Early Rehabilitation

Physical therapists will begin treatment as early as 2-4 hours after surgery. They will teach you to ambulate with an assistive device such as a rolling walker, teach you to perform activities of daily living and instruct you on how to climb stairs safely. They will also instruct you on certain exercises that you can do on your own to help strengthen your atrophied muscles.

When you are ready to leave the hospital, the physical therapists will review a series of progressive exercises for you to do at home. These are aimed at slowly strengthening the muscles and returning you to pain free movement. The most important activity you can do for your new hip is to walk as much as possible. This will help tremendously with flexibility and strengthening of your new hip!
 


Rehabilitation and Exercise
At Home

Following surgery, your physical therapist may help you with your rehabilitation protocol. In addition to the exercises done with the therapist, you should continue to work on the hip exercises in your free time. It is also important to continue to walk on a regular basis to further strengthen your hip muscles. An exercise and walking program helps to enhance your recovery from surgery and helps make activities of daily living easier to manage. Here is a list of potential exercises that you may be asked to perform:
   • Ankle Pumps
   • Quadricep Sets
   • Gluteal Sets
   • Heel Slides
   • Leg lifts
   • Knee Extensions
   • Hip Abduction


How Long Will Your Implant Last

It is difficult to predict the length of time a total hip implant will last as its life span depends on many factors. Unfortunately, surgical complications can occur and in some cases implants last only a short time. However, the vast majority of implants last for years, providing patients with pain relief and improved function. By following hip precautions and moderating your activity level, you may enhance the function and longevity of your artificial hip.

Surgeons, researchers and implant manufacturers continue to work diligently to improve both the short term and long term outcomes of total hip replacement. For example, OXINIUM technology from Smith & Nephew is a new high performance material shown to reduce acetabular component wear by as much as 98-percent. Less implant wear may extend the life of the implant and reduce the need for future corrective surgeries.


Preventing Hip Replacement Complications

As with any major surgical procedure, post-operative complications can occur following total hip replacement surgery. Below is a list of some of the more common complications that can occur after hip replacement surgery. This list is not meant to be all inclusive.
 
Thrombophlebitis

This condition, also commonly referred to as deep vein thrombosis, occurs when blood clots are formed in the large veins of the legs. In some cases, these clots can become dislodged from the veins, travel through the circulatory system, and become stuck in the critical arteries of the lungs. This scenario, called a pulmonary embolism, is a serious medical condition.

The following steps may be taken by you and your physician to avoid or prevent thrombophlebitis:
   • Adhere strictly to the protocol of Lovenox prescribed by your physician. Do not discontinue without first checking with your physician.
   • Wear your TED hose for at least two weeks after surgery.
   • Elevate the affected foot to prevent swelling.
   • Perform foot and ankle exercises to optimize blood flow.
   • If you develop swelling, redness, pain and/or tenderness in the calf muscle, report these symptoms immediately to your physician.

Infection

Infections occur in a small percentage of patients undergoing hip replacement surgery. Unfortunately, infections can occur even when every effort is made to prevent them.

The following steps may help to minimize the risk of post-operative infections:
   • Closely monitor the incision and immediately report any signs of redness, swelling, tenderness, drainage, foul odor, increasing pain, or persistent fever.
   • Always wash your hand before and after handling your incision site, especially when the staples are still in place.

Pneumonia

A possible side effect of surgery is the development of pneumonia.

The following steps may help minimize the risk:
   • Deep breathing exercises: A simple analogy to illustrate proper deep breathing is to: “smell the roses…and blow out the candles.” In other words, inhale slowly and deeply through your nose, and exhale slowly through your mouth at a slow and controlled rate. A simple rule of thumb may be to perform these deep breathing exercises 8-10 times every waking hour.
   • Coughing: This activity helps to loosen the secretions in your lungs and excrete them from your pulmonary system.
   • Incentive spirometer: This simple device provides visual feedback while performing deep breathing exercises. Your nurse or respiratory specialist will demonstrate the proper technique.
 


Hip Dislocation

One of the most common problems following total hip replacement is hip dislocation or subluxation. Because the prosthetic ball and socket are smaller than the natural anatomy, the ball can become dislodged from the socket if the hip is placed in certain positions. Remember to avoid extending your leg back and externally rotating it at the same time. Also keep in mind while sitting to avoid extreme internal rotation of the affected leg.

If you have any questions, please do not hesitate to call your doctor.
 

 

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