Hip replacement refers to the procedure in which a damaged hip joint is surgically replaced with an artificial implant. Some implants can cause serious complications that lead to a more complex and risky procedure called revision surgery.
The goal of hip replacement surgery is to increase someone’s mobility, decrease pain and improve quality of life by replacing damaged and diseased bone and tissue with an artificial implant. Surgeons perform this procedure more and more as American baby boomers and seniors live longer, more active lives. More young people are getting hip replacements, typically because of sports injuries or trauma to joints.
One recent study presented at the 73rd Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) projected that primary hip replacement procedures will increase to 572,000 annually by 2030. With the increase in demand, manufacturers constantly compete to produce the best device on the market, and the technology of implants is more advanced now than ever.
Doctors recommend surgery for people with pain so severe that, despite anti-inflammatory drugs or physical therapy, it limits everyday activities or causes a loss of range of motion. The procedure takes several hours, during which the surgeon makes removes damaged cartilage and bone and then implants the prosthetic joint. The new joint may require cement or other hardware such as screws to hold it in place.
A total hip replacement surgery generally includes these steps:
- The surgeon makes an incision in the front, side or back of the upper leg, cutting through skin, tissue and muscle to access the joint.
- The doctor dislocates the femur from the socket and removes the head of the femur with a saw. The acetabulum (socket) is 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. A patient’s bone quality will determine whether cement is used to secure the implant.
- The hollow space of the femur bone is enlarged using tools so the implant stem fits.
- 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.
Recovery can take several weeks or months, depending on the patient’s health and age. Physical therapists will assist the patient in regaining range of motion, and walkers or canes will be necessary until the joint strengthens. Most patients can resume normal activity within several weeks. Most hip implants are expected to last from 10 to 20 years, and implants will naturally wear down with age.
Hip replacement surgery, like other surgical procedures, carries a risk of complications, although most doctors say they are rare. Major issues like infection occur in less than 2 percent of patients, and others like heart attack are even more rare.
|Complications from hip replacement surgery may include:|
|Unequal leg lengths||Dislocation|
|Loosening and implant wear||Nerve damage|
|Blood vessel injury||Fracture|
|Stiffness in joint||Metal sensitivity|
If any of these complications occurs, a doctor may suggest revision surgery to correct the problem. But sometimes a defect in the implant’s design may cause them to fail much earlier, forcing people to have a second surgery sooner.
The most troublesome implants are those with a metal ball and socket, or liner. These devices are called metal-on-metal implants because they are designed with two metal surfaces that rub against each other. According to several studies, these devices release microscopic metal particles into the body, causing a number of health problems that can lead to revision surgery.
These metal particles can collect in the area around the implant and cause tissue and bone death called metallosis. The implant can loosen, causing extreme pain. Fractures may also occur when the bone weakens. The only way to address these issues is to have the implant removed.
Revision surgery rates are higher with metal-on-metal implants because they have a tendency to fail sooner and cause more complications. For example, the average failure rate is 1 percent after a year and 5 percent at five years for most hip implants made of metal and plastic or ceramic and plastic. Johnson & Johnson’s DePuy ASR metal-on-metal hip implant, however, has a staggering 40 percent failure rate within the first 5 years.
Signs of implant failure include pain that comes on suddenly, swelling or trouble moving the joint. Anyone who experiences these symptoms should see a doctor immediately.
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Revision surgery comes when a failed hip implant can only be repaired by another surgery. Failure can stem from normal wear and tear or from a faulty device. These second procedures are consider complex and significantly invasive.
The Orthopedic News Network estimated that nearly 460,000 people had hip replacements in 2010, with about 56,000 of these surgeries being revisions. As demand for hip replacement continues to rise, doctors predict revisions will rise as well.
Often more complex and lengthy than the original surgery, revisions require more planning, more time to complete and more experience on the part of the surgeon. The risk of complications is also greater than for a primary hip replacement. Older patients face the highest risk of complications.
Prior to operating, the doctor will run several tests, including urine analysis, EKG, X-rays and bone scans. Because of the extensive blood loss that can occur during surgery, patients may donate blood so that they can use their own blood during the procedure. Patients will take antibiotics to prevent infections during the procedure.
First, the patient is put to sleep. The doctor may use the site of the old incision or make a new one. The incisions are usually longer and more extensive than those made during primary surgery.
Because scar tissue from the original surgery can alter the locations of nerves and blood vessels, doctors must cut around tissues carefully. Next, the doctor removes the failed implant parts and any old cement. The surgeon also removes any diseased bone and tissue and prepares the area for the new prosthesis. Depending on the extent of the damage, this may take a while.
If there is too much bone loss, the surgeon will reconstruct the bone using bone grafts, screws and metallic plates. Then, the surgeon implants the new device.
The doctor closes the incision and places tubes that will drain any fluids out of the joint. The patient may wear a brace or splint to help the healing process. Doctors usually recommend movement restrictions for six to 12 weeks. Strength in the joint may continue to improve for up to two years.
Complications after a second surgery are greater than after the original operation because the second operation is more complex. There are a few complications that are more likely after revision.
For instance, hip implants are more likely to migrate or loosen because the bone is more damaged. In addition, because the bones are already weak, fractures may occur during the surgery. Some people are forced to have more than one revision surgery.
Recalled Implants and Lawsuits
While doctors assure patients that complications are rare, people who received faulty implants may suffer from crippling complications.
A number of manufacturers recalled hip devices and people injured by these implants filed lawsuits against several major manufacturers including:
Johnson & Johnson offered $4 billion in November 2013 to settle more than 7,000 of its DePuy ASR lawsuits, but the settlement is still pending in court. Stryker settled a number of its New Jersey state court cases for an undisclosed amount.