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Hip Replacements

Hip Replacement Surgery

When a hip joint is damaged by trauma or degenerative disease, hip replacement surgery can restore mobility and reduce pain. But not all hip implants are safe.

Hip replacement surgery involves replacing the hip joint with an artificial joint, also known as a prosthesis or implant. The procedure, called hip arthroplasty, is recommended when someone experiences extraordinary pain from arthritis, osteoporosis or a degenerative bone disease. An accident or fall that results in a hip fracture also may require a replacement, but doctors generally recommend surgery only after other treatments fail.

People who are considered for surgery are those who have pain that limits routine, everyday activities such as walking and bending. Those who experience pain while sitting, lying down or sleeping – indications of severe hip problems – are also candidates for replacement surgery. In addition, surgery is usually the best option for people with severe arthritis or bone degeneration around the hip. Although the preparation and recovery from replacement surgery can be arduous, surgery can eliminate pain and restore mobility in the joint.

Some hip replacement implants, such as metal-on-metal devices, carry additional risks beyond those associated with routine replacement surgery. Although metal-on-metal implants were approved by the U.S. Food and Drug Administration (FDA) in 1999, thousands of people incurred serious complications like infections, hip dislocation, implant failure and metallosis (metal poisoning).

In many cases, those serious complications from metal-on-metal hips necessitated a second hip replacement operation, called revision surgery. A growing number of implant patients are opting for legal action against hip implant manufacturers to recover the costs of surgery and to be compensated for pain and suffering.

Manufacturers of defective metal-on-metal hip implants include DePuy Orthopaedics, Stryker Orthopaedics, Zimmer Holdings, and Smith & Nephew. Biomet and Wright Medical Technology may also see similar complications arising from their metal-on-metal hip implants.

Preparing for Surgery

The preparation for a hip replacement surgery includes getting a medical evaluation and having a discussion with the surgeon and anesthesiologist. Patients are asked if they’re allergic to specific medicines and to provide details of any other medications, such as blood thinners, they are taking that might interfere with or complicate the surgery. Because bacteria can enter the bloodstream during dental work, doctors recommend any major dental procedures be performed well before a hip surgery to avoid infection. Infection is a common complication of hip replacement surgery.

Another important part of the pre-surgery preparation comes at home and has nothing to do with the surgery itself. Patients are encouraged to have an uncluttered living space. Walking during the first few weeks after surgery is a part of rehabilitation, but is also sometimes difficult and limited. Rooms should be cleaned, and walkways to the bathroom and kitchen should be clear.

Patients who live alone will want to line up a friend or family member to stay with them for the first week after surgery if they do not enter a rehabilitation facility. Patient assistants should expect to help prepare meals and to help the patient move about the home.

Surgery

Hip implants are made up of three main components: the stem (which fits into the femur), the ball (which replaces the spherical head of the femur), and the socket (a cup that replaces the hip socket). Some devices include a liner between the ball and cup. Modular hip systems offer several necks and stems with different sizes and lengths so that each patient can have a custom fit, but many designs have the stem and neck as one piece.

Orthopaedic surgeons can perform one of several hip implant surgeries, including total hip replacement, partial hip replacement and hip resurfacing. Total hip replacement (THR) involves removing the head of the femur (thigh bone), inserting a stem into the patient’s femur and inserting a ball on top of the stem. The socket is also replaced with a cup.

Partial hip replacement typically means replacing the head of the femur. In some cases, only the socket needs replacing. During a hip resurfacing, the head of the femur is left intact, and a component is cemented on top of it to prevent painful bone-on-bone contact.

Surgeons can choose between a cemented or cementless hip replacement. A cemented hip replacement secures the ball, stem and cup with bone cement. In a cementless hip replacement, these parts are covered with a material that is conducive to promoting new bone growth. The parts are secured in place once the surrounding bone grows into the surface of the implant. Some surgeons prefer using a combination of both, which is called a hybrid total hip replacement.

In addition to implant options, surgeons also have a few surgical approaches they can utilize. An anterior approach requires a small incision on the front of the upper thigh to access the hip area. Similar is the anterior-lateral technique, which requires an incision on the side of the thigh. Another technique is the posterior-lateral approach, which includes an incision on the back of the leg. Some surgeons may decide to make a frontal incision to implant the socket and a posterior (back) incision to implant the ball and stem.

The incision can be up to 12 inches long, unless the surgeon chooses a minimally invasive technique that requires a much smaller incision. Computer-assisted surgery requires smaller incisions and offers a shorter rehabilitation period.

The steps of hip replacement surgery vary depending on the surgeon, the implant, the reason for surgery, and which procedure (total, partial or resurfacing) is being performed.

Generally, a total hip replacement surgery will include these steps:
An incision is made in the front, side or back of the upper leg. The surgeon will cut through the skin, tissue and muscle to access the hip joint.
The femur is dislocated from the socket, and the head of the femur is removed using a saw. The acetabulum (hip socket) is then reshaped so that it matches the shape of the new cup implant.
The cup is positioned in the patient and locked in place with bone cement or another material. A patient’s bone quality will determine whether cement or a cementless material is used to secure the implant.
The hollow space of the femur bone is enlarged using tools so it can receive the implant stem.
A temporary ball is placed on top of the stem, and the hip joint is evaluated for range of motion and stability to make sure the ball doesn’t dislocate from the socket.
A permanent ball is secured to the stem, and the hip joint is tested again for mobility and stability. The doctor will also verify the leg length is the same as the other leg before closing up the incision with stitches.

Revision Surgery

Some patients with him implants face a second or third surgery to fix problems related to the initial implant. These secondary procedures are called revision surgeries.

Revision surgery can become a reality for several reasons. For patients who have a hip implant for more than 10 years, a new one may be needed because of normal wear and tear. However, some hip implant recipients undergo revision surgery within a few years following the initial procedure. Reasons for this include infection, hip dislocation, loosening of the implant and metallosis. Metal-on-metal implants are especially prone to these complications and are associated with high failure rates.

Recovering from Surgery

Most patients spend three to five days in the hospital after hip replacement surgery, although some newer procedures can cut the stay to one day. Recovery during the first few weeks involves pain medication and physical therapy. Patients can expect to walk the day after surgery and be asked to work with a physical therapist two to three times a week. Patients who are covered by Medicaid generally leave the hospital and enter a rehabilitation facility for up to three weeks. Such facilities provide physical therapists, nursing assistance and even meals.

Other patients typically go home for more personal rehabilitation – and more planning. They need someone to drive them to their rehab and follow-up doctor appointments for several weeks. All patients can expect pain, swelling, bruising and difficulty walking during the first few weeks after surgery, but standing and placing weight on the hip during this time is crucial to recovery. If a patient trips and falls, he or she will need assistance. Post-surgery pain may be too much for even a short walk to the kitchen, so implant patients often need help with meals.

Doctors recommend exercises to strengthen the hip and restore movement in the joint. These can include walking, sitting up and lying down, climbing stairs, rising up on the toes and doing leg lifts. Implant patients often need the assistance of a walker, crutches or a physical therapist to perform these exercises. Small ankle movements during the first week after surgery can help reduce swelling and prevent blood clots.

Most people return to everyday activities – walking, driving, shopping, household chores and returning to work – four to six weeks after surgery. Full recovery can take as long as six months, although some implant recipients are fully recovered after three months. Much depends on how well muscle and other tissues heal and how the implant is received by the body.

Complications Following Surgery

The FDA warns patients and doctors about several adverse events that can occur within weeks, months or a few years following hip replacement surgery. They include implant dislocation, fracture, loosening of the implant and metallosis . Metallosis is associated with metal-on-metal implants and is a primary cause for revision surgeries. It occurs when tiny metal particles are shed from the implant, as the metal ball and metal cup (or metal neck and metal stem) slide against each other. Over time, the metal particles can cause damage to the bone and tissue surrounding the hip joint.

There are immediate complications that surgeons must check for before releasing a patient from the hospital, including:
Blood clots Skin or joint infection
Nerve damage Poor joint mobility
Different leg lengths

Hip Replacement Lawsuits

Thousands of patients received defective metal-on-metal hip implants, and many of them have undergone revision surgery after suffering a number of complications. Revision surgery can be very expensive, and patients may have legal options to help cover the costs.

Coping with ongoing injuries can also have a high emotional cost on patients and their families. Discomfort following hip replacement surgery and revision surgery can immobilize patients and prevent them from returning to work or engaging in other activities.

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