A TOTAL hIP rEPLACEMENT mANUAL
FOR THE PATIENTS OF
jOHN r. mORELAND, m. d.
2001 SANTA MONICA BOULEVARD
SUITE 1280W
SANTA MONICA, CALIFORNIA
PHONE (310) 453-1911
FAX (310) 453-6902
this booklet is the original work of John R. Moreland, M.D. Dr. Moreland requests that his material not be reproduced without his written permission. Additional booklets can be obtained by calling or writing his office. July 2013
WHERE AND WHAT IS THE HIP?...... 6
WHAT MAKES A HIP HURT?...... 6
WHAT IS ARTHRITIS?...... 7
OSTEONECROSIS OF THE HIP...... 8
OSTEOPOROSIS...... 9
WHERE WILL I FEEL HIP PAIN?...... 9
aCTIVITY AND HIP ARTHRITIS...... 11
MEDICATIONS USED FOR HIP ARTHRITIS...... 11
WHAT ABOUT NARCOTICS FOR HIP PAIN?...... 13
EXERCISE FOR PEOPLE WITH HIP ARTHRITIS...... 13
STEROID HIP INJECTIONS...... 14
WHAT CAUSES MY LIMP?...... 14
WHEN SHOULD A CANE BE USED?...... 14
SHOULD I LOSE WEIGHT?...... 15
OTHER nonoperative TREATMENTS...... 15
WHEN SHOULD I HAVE MY HIP REPLACED?...... 15
CAN I PUT OFF SURGERY?...... 16
OTHER SURGICAL TREATMENT ALTERNATIVES...... 17
HISTORY OF HIP REPLACEMENT SURGERY...... 17
WHY IS IT CALLED A TOTAL HIP REPLACEMENT?...... 18
PROBLEMS WITH CEMENTED HIP REPLACEMENT...... 19
ARE THERE MORE DURABLE ALTERNATIVES?...... 20
PROBLEMS WITH CEMENTLESS HIP REPLACEMENT...... 20
WHAT DETERMINES CHOICE OF TYPE OF FIXATION?...... 21
HYBRID HIP REPLACEMENT...... 21
SHOULD THE PATIENT DECIDE IMPLANT TYPE?...... 22
SURFACE REPLACEMENT...... 22
OTHER NEW TECHNIQUEs...... 24
COMPLICATIONS OF HIP REPLACEMENT...... 25
WEAR...... 26
HIP DISLOCATION and surgical approach...... 28
OTHER POSSIBLE COMPLICATIONS...... 29
WRONG SIDE SURGERY...... 31
MINMALLY INVASIVE hip replacement...... 31
WHEN WILL FULL WEIGHT BEARING bE ALLOWED?...... 32
SURGICAL APPROACH OPTIONS...... 33
BILATERAL SIMULTANEOUS HIP REPLACEMENT...... 35
Will Dr. Moreland do the surgery?...... 35
INITIAL CONSULTATION WITH DR. MORELAND...... 36
SURGICAL SCHEDULING...... 36
AUTOLOGOUS BLOOD DONATION...... 36
other preoperative considerations...... 37
THE PREOPERATIVE VISIT...... 38
WHAT DO I BRING TO THE HOSPITAL?...... 38
THE DAY OF SURGERY...... 39
NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES...... 40
THE HOSPITAL STAY...... 41
DISCHARGE FROM THE HOSPITAL...... 43
FOLLOW-UP APPOINTMENTS...... 44
HOW CAN I PREPARE MY HOME?...... 45
WHERE AND WHAT IS THE HIP?
In everyday language the buttock area is usually called the hip. In anatomical terms used by physicians, however, the hip is actually the ball and socket joint where the femur (thigh bone) meets the pelvis. The top end of the femur is shaped as a round ball (femoral head) which normally rotates in a shallow cup or socket (acetabulum) formed by the pelvic bones. In a healthy hip, the head of the femur is covered with a layer of a smooth and slippery white substance about one-eighth of an inch thick called articular cartilage. The acetabulum is also lined with this same articular cartilage. When the hip joint moves, the cartilage-covered femoral head rotates in the cartilage-lined acetabulum.
Articular cartilage has no nerve endings to transmit signals to the brain and thus we are not aware of movement between the two cartilage layers. Little friction is generated and no discomfort is felt. Since cartilage does not stop x-rays and thus does not show up on x-ray film, an x-ray of the hip will normally show about a one-quarter inch space between the bony edge of the femoral head and the bony edge of the socket.
WHAT MAKES A HIP HURT?
In almost all types of hip disease, the articular cartilage has deteriorated and is partially or completely absent. Without the articular cartilage layer, the bone of the femoral head will rub on the acetabular bone of the pelvis. Radiographs will then show the femoral bone touching the acetabular bone, since the cartilage layers are absent. Bone, as opposed to cartilage, does have nerve endings and this bone-on-bone contact usually causes pain.
Early in the course of hip arthritis the cartilage space will narrow and patients usually have mild pain. As the disease process progresses, the bones will gradually move closer together on the radiograph as the cartilage layersare lost. As the bones gradually touch over larger areas, the pain usually will worsen. A hip replacement is simply a mechanical replacement for the missing cartilage, so that the bones do not rub together and cause pain.
The cartilage-covered femoral head can be compared to a man’s head covered with hair. During the process of balding, the man first gets a thinned area of hair, and then the thin area gradually progresses to a small bald spot. Later, the bald spot enlarges. Cartilage loss from the femoral head is similar. At the time of hip replacement surgery the femoral head usually is found to have large areas devoid of cartilage, but may still have some peripheral cartilage left even though the patient has severe symptoms.
Many people are surprised to hear that bones are alive and can hurt. As stated, cartilage does not have nerve ending and thus when cartilage rubs on cartilage there is no feeling. But inside the calcium crystalline structure of bone there are nerve endings, which can transmit pain signals to the brain when the bones touch. In addition, this bone-on-bone touching can flatten the femoral head by grinding away some of the bone surface and releasing bone and cartilage fragments to the joint cavity. These released fragments irritate the lining of the joint (synovium) and cause a painful inflammation of the joint lining (synovitis).
At times patients can even hear a creaking noise (crepitation) coming from the hip caused by the bone-on-bone contact. The bone surfaces often become highly polished and denser and harder from this repetitive rubbing. The body usually attempts to heal the diseased joint by forming extra bone at the edges of the joint. These extra bone formations can be seen on the radiograph and are often called spurs butmore correctly should be called osteophytes.
As the cartilage layer wears out, normal hip flexibility is often decreased by various mechanisms (pain, high friction, lack of head roundness, osteophyte formation and muscle stiffness). This lack of normal hip flexibility can make it difficult to position the legs when bending over for tasks such as tying shoes or cutting toenails. Many patients with hip stiffness cannot separate their legs very well, making sexual intercourse difficult for women. Horseback riding also is commonly uncomfortable, if not impossible. Stiffness can even be so severe as to interfere with personal hygiene.
The hip stiffness can make standing up straight difficult and this stiffness may aggravate back problems, since extra back movement is needed to compensate for the lack of hip flexibility. Hip stiffness can cause an exaggerated curvature in the lower back called (hyperlordosis) and can cause spinal curvature (scoliosis). Hip stiffness also can cause the pelvis to be held in a tilted position, resulting in extra stress on the lumbar spine and making the leg lengths functionally unequal.
WHAT IS ARTHRITIS?
Joint pain is called arthritis (arthr means joint and itis means inflammation). Thus, patients with arthritis simply have at least one joint causing pain. There are many types of hip arthritis. The most common type is called primary osteoarthritis, which results from wearing out the articular cartilage of the joint for no identifiable reason. Secondary osteoarthritis is that due to an identifiable cause.
Secondary osteoarthritis can be due to an old hip injury, to conditions with which one is born, such as developmental dysplasia of the hip (DDH: a problem of shallow sockets, usually in women), to conditions that develop during childhood such as slipped capital femoral epiphysis (SCFE-usually in boys ages 10-13) and Legg-Calve-Perthes disease (LCP: usually in boys ages 3-9), or to arthrocatydesis (Otto pelvis: a condition usually in young women with extra-deep sockets and usually causing more hip stiffness than pain). The tendency for the hips to wear out during a patient’s lifetime runs in families.
Rheumatoid arthritis (RA) is another frequent cause of hip deterioration. The inflammation of rheumatoid arthritis is a generalized rather than a localized condition, usually affecting many joints in the body as well as causing a general ill feeling. The severity of rheumatoid arthritis is variable and most RA patients are under the regular care of a rheumatologist (an internal medicine doctor specially trained in diseases which cause joint problems but who does not do surgery). Rheumatologists and orthopedists often work together in the care of patients with RA.
Certain powerful drugs such as gold, methotrexate, penicillamine and prednisone have long been used by rheumatologists to control the joint pain and swelling. Patients, who chronically take the steroid drug, prednisone, need usually extra amounts of steroid during the surgical period, because of adrenal suppression.
Somequite effective drugs to combat rheumatoid arthritis are now available.These medicines are called disease-modifying antirheumatic drugs (DMARDs) and can slow or sometimes prevent joint destruction. Starting treatment early with DMARDs can reduce the severity of the disease. DMARDs are also called immunosuppressivedrugsor slow-acting antirheumatic drugs (SAARDs). Common onesare Humira, Enbrel, and Remicade.These medicines work best when taken over a long period to help control the disease. These powerful drugs have the potential for significant side effects and require regular follow-up with a rheumatologist.
RA is probably an autoimmune disease (a disorder of the immune system in which the patient’s tissues come under attack by the patient’s own immune system). Patients with RA sometimes develop deterioration of the neck bones causing spinal instability and have an increased risk of spinal cord damage during general anesthesia. Neck stability x-rays before surgery and special anesthesia techniques may be necessary. Patients with RA also sometimes have arthritis of the jaw joint (temporomandibular joint) causing difficulty in opening the mouth wide enough for the usual anesthesia techniques. Special anesthesia equipment and techniques may be needed for such patients.
Children can get a variation of RA called juvenile rheumatoid arthritis (JRA). These children suffer joint inflammation with resultant damage during childhood and may need hip replacement even as a child but more commonly when they become young adults.
Ankylosing spondylitis (AS) is another type of inflammatory arthritis that can damage the hips. Ankylosing spondylitis usually affects men. Patients suffer stiffening of the back and neck, making it difficult sometimes to see straight ahead. The neck stiffness of AS can make the job of the anesthesiologist difficult and special anesthetic techniques and instrumentation may be necessary.
Other inflammatory conditions such as systemic lupus erythematosis (SLEorlupus), psoriatic arthritis, and inflammatory bowel arthritis can also cause hip disease.
OSTEONECROSIS OF THE HIP
Hip osteonecrosis is a condition in which parts of the femoral head die (osteo means bone and necrosis means death). If affected area of bone is extensive, the dead bone sometimes cannot support the forces on the femoral head and the head surface may fracture, lose its roundness and generate pain. The most common causes of osteonecrosis (also called aseptic necrosis and ischemic necrosis) are oral steroid intake (such as prednisone), excessive alcohol intake and trauma. Other causes are hyperuricemia, systemic lupus erythematosis(SLE), sickle cell syndrome, Gaucher’s disease, pancreatitis, pregnancy, liver disease, the bends, caisson disease, polycythemia, diabetes, obesity, and hyperlipidemia. Sometimes, no reason can be found for osteonecrosis (termed idiopathic osteonecrosis).
It is helpful to understand osteonecrosis by using the analogy of a building. Buildings are dead but the people inside are alive and maintain the building. Window breakage is repaired and roof leaks are fixed as these problems occur. Without such maintenance, buildings will decay and eventually fall down. The calcium crystal structure of the femoral head is not alive but the tiny bone cells in the bone are. These bone cells maintain the bones just as humans maintain buildings. When a portion of a bone dies, what really happens is the bone cells die. Without bone maintenance by the bone cells the bone structure usually deteriorates in a year or two. Thus, there is usually a delay between bone death and the onset of symptoms.
Very early in the problem of osteonecrosis when the femoral head is still round, a procedure called core decompression is sometimes performed in which a hole is drilled up into the femoral head to decrease the usually abnormally elevated pressure in the femoral head. This treatment may relieve pain as well as allow blood supply to return to the femoral head. Core decompression is controversial and is not universally accepted by orthopedic surgeons as a valid treatment.
When the femoral head loses its roundness from osteonecrosis, the usual treatment is hip replacement, if the symptoms are sufficiently severe. Rarely, surgery is performed in which the bones are purposely broken (osteotomy) and their position rearranged to take advantage of those portions of the femoral ball which are still intact.
Bone grafting is also sometimes used for osteonecrosis. Bone from cadavers or from other parts of the patient’s body (usually the fibula) is placed in the femoral head through a hole drilled into the femoral head. This highly complex, technically difficult, and long (six to eight hours) surgical technique is rarely performed. It involves placing a piece of the fibula with its blood vessels into the femoral head with the blood vessels then connected to hip area blood vessels. This procedure, developed at DukeUniversity, is not generally accepted by the orthopedic community and is considered unproven and experimental.
OSTEOPOROSIS
The terms osteoporosis (literally “porous bone”) and osteoarthritis are often confused. Osteoarthritis, as explained above, is a problem with a joint. Osteoporosis is a condition of soft bones. Osteoarthritis involves pain coming from the joints. Osteoporosis does not hurt unless the softened bones fracture, as they frequently do if the osteoporosis becomes severe.
Bone is not a solid structure, but instead has small holes in it similar to a sponge or to bread. The more holes there are and the larger the holes, the more osteoporotic the bone and the less strong the bone.
Patients develop osteoporosisfor various reasons. As we grow older, all of us have skeletons which are becoming more porotic or osteoporotic. Patients with low activity levels do not stimulate their skeleton to be strong and often develop osteoporosis. People with low calcium and vitamin D intake and other metabolic deficiencies will develop osteoporosis. Lighter skinned people have a greater tendency to develop osteoporosis than darker skinned people do. Women as a group have a higher propensity to osteoporosis, which seems to accelerate after menopause. Thus, lighter skinned women after menopause are at particular risk for osteoporosis.
Osteoporosis can be treated in various ways but treatments are mainly directed against minimizing further bone loss. All of us should have an adequate calcium intake in our diet and if you do not, calcium supplements should be taken. In the past many women after menopause took estrogen for a variety of reasons, one of which was to maintain bone strength. One can detect osteoporosis by a variety of techniques but usually a reasonable assessment of the quality of the bones can be madesimply by a review of the hip radiographs. Dr. Moreland can tell you whether you have significant osteoporosis and if so, further consultation and treatment for this with the appropriate specialist can be arranged.
WHERE WILL I FEEL HIP PAIN?
Pain from the hip joint is usually felt in the groin (in the front of the body where the thigh joins the torso). The pain often radiates down the front of the thigh to the knee and sometimes to the mid-shin. Pain, which is perceived in areas of the body remote from the actual problem, is termed referred pain. You may be aware that referred pain from the heart is usually felt in the left side of the neck and in the left arm, and referred pain from the diaphragm is felt in the shoulder. The referred pain of the hip to the anterior thigh and knee occurs because the nerve root supply to the hip and the anterior thigh and knee are the same. In some cases, the referred pain to the knee area is so prominent that the patient, and sometimes even the physician, thinks the knee itself is diseased, when really the hip is the problem.
Lower back pain is often confused with hip disease. Pain from the spine is usually felt across the low back, in the buttock, down the back of the thigh, and often down to the foot. Pain radiating in these areas from the spine is called sciatica. Sciatica is often accompanied by numbness and tingling, whereas hip pain is not. Most pain felt in the back of the body in the buttockarea is coming from the spine. Most pain felt in the front of the body in the groin and in the front part of the thigh is coming from the hip. Patients often expect the hip to cause pain in the buttock, but buttock pain isusually coming from the low back or the sacroiliac joint. The buttock is not the anatomical hip, although the buttock is usually referred to as the hip in everyday language.Patients with hip problems also often have lower back pain since the accompanying hip stiffness puts extra stress on the spine and since back pain, even without hip arthritis, is very common.