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Hip Replacement Surgery and Revision Surgery

Hip replacement surgery is a process that the removes the femur and shapes the hip socket, then replaces them with a hip implant cup, ball and stem. Orthopedic surgeons can perform replacement using traditional or minimally invasive procedures. If there are severe complications, hip revision surgeries may be necessary and involve removing the failed hip implant, replacing it with another device and bone grafting if there is damage from the previous implant.

Facts about Hip Replacement 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.

People between the ages of 50 and 80 are most likely to have a hip replacement. Surgeons perform this procedure more and more as American baby boomers and seniors live longer, more active lives. More young people are getting total 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.

Reasons for Hip Replacement Surgery

An orthopedic surgeon will evaluate candidates to determine the level of disability caused by hip damage. While some candidates for hip surgery are older than 60 years, people who have aggravated hip conditions and are unable to maintain their previous level of physical activity may pursue replacement surgery.

Hip joint damage can disrupt everyday activities like walking and sitting, leaving normally active people in pain and immobilized. Stiffness that inhibits movement as well as inadequate relief from anti-inflammatory drugs are factors orthopedic surgeons will consider.

Doctors often recommend surgery once the problem has progressed to the point of excruciating and constant pain, decreased mobility and impaired quality of life. Common reasons for hip surgery as a result of existing damage include childhood hip disease, osteoarthritis, rheumatoid arthritis, osteonecrosis, avascular necrosis, injury, bone tumor and fractures.

Hip Replacement Diagram
Hip Anatomy
Hip Replacement Diagram
Hip Anatomy

The Hip Replacement Procedure

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:

1

Incision

An incision is made in the front, side or back of the upper leg, cutting through skin, tissue and muscle to access the joint. Surgeons may use general, regional or combination anesthesia for total hip replacements. Types of regional anesthesia include spinal, epidural and peripheral nerve blocks.

2

Dislocation

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.

3

Positioning

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.

4

Fitting

The hollow space of the femur bone is enlarged using tools so the implant stem fits.

5

Evaluation

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.

6

Completion

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.

What is the Average Hip Replacement Recovery Time?

The average hip replacement recovery time for patients receiving total hip replacement surgery is around 6 weeks. However, the recovery time can take several weeks or months, depending on the patient's health, age and type of hip surgery. Within 3 months, patients are often able to regain their level of activity prior to surgery.

Patients concerned about postoperative care may purchase hip replacement kits which include items that assist with dressing, bathing, exercising and sitting. Physical therapists will assist the patient in regaining range of motion, and walkers or canes will be necessary until the joint strengthens. Most hip implants are expected to last from 10 to 20 years, and implants will naturally wear down with age.

Dr. Bert J. Thomas, orthopaedic surgeon and chief of Joint Replacement Service at UCLA Medical Center, says the recovery period is worth the benefits.

“I have had patients (who had) been in wheelchairs for years,” Dr. Thomas says. “When you do the hip replacement, it’s a miracle for them. The pain is gone, and within a relatively short amount of time, they are up walking. And soon after that, they are back to being regular members of society.”

Complications

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.

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.

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.

Complications from hip replacement surgery may include:
Infection Blood clots
Unequal leg lengths Dislocation
Loosening and implant wear Nerve damage
Blood vessel injury Fracture
Stiffness in joint Metal sensitivity

How Can Patients Help Prevent Complications From Occurring?

Patients can help prevent complications by taking a few precautions during the recovery period following surgery. Dislocation and blood clots are the most common complications and both of these issues can occur if a patient moves too much or too little.

  • Dislocation. Artificial ball joints are smaller than the original hip bone and with over extending the hip, the ball may loosen from the socket. Patients should avoid crossing their legs or pulling knees up to the chest.
  • Blood Clots. After surgery, blood clots may develop in the hip or legs. If left unchecked, these clots may loosen and find their way to the lungs or brain, causing a stroke or blocking blood flow in the lungs. Doctors prescribe simple exercises that patients can perform to prevent clots from forming and may also prescribe blood thinners.
  • Infection. To prevent infection, patients should ensure they have proper hygiene and don't schedule any dental work or other invasive procedures for a few weeks around the surgery. If these procedures are necessary, the doctor will prescribe preventative antibiotics. Patients should let their doctors know of any infection symptoms immediately. These include: fever, chills and swelling and pain at the surgery site.

Traditional vs. Minimally Invasive Hip Replacement Surgery

There are two options for total hip replacement surgery: traditional and minimally invasive. The main difference between the two techniques is the incision size. Traditional surgery involves a fairly long cut on the hip about 10 to 12 inches long. While minimally invasive surgery uses to smaller cuts, from one to six inches.

Minimally invasive techniques typically offer benefits of shorter recovery times, less blood loss and less pain. But, they are not right for every patient, and the surgeon will discuss whether this technique is an option. Generally, thinner, younger patients are the best candidates for this type of surgery, and only the most experienced surgeons use this technique.

Doctors implant the same devices in both surgeries. However, minimally invasive surgery requires special instruments that allow the surgeon to prepare the socket and femur and to place the implant. Surgeons may make one three to six inch incision on the outside of the hip or two smaller incisions — each one to two inches long over the groin and over the buttock.

In both traditionally and minimally techniques, surgeons detach the muscles and tendons from the hip, but there is less cutting with minimally invasive surgery. The doctor repairs these tissues after placing the implant.

What is Hip Revision Surgery?

Hip revision surgery is when a doctor removes a problematic artificial hip and replaces is with a new implant. This risky and complex procedure can relieve pain from complications and offer a second chance at restoring mobility.

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.

Sometimes, patients can minimize the risk of revision surgery. Antibiotics can catch infections before they spread. Patients can also avoid dislocation by following the post-surgical instructions about caring for their new hip and how much activity is safe.

Reasons for Revision Surgery

Doctors perform revision surgery 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. Other reasons why a patient might need to have revision surgery include infection and repeated dislocation of the implant.

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.

The Revision Process

Re-incision

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.

Removal & Reconstruction

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.

Recovery

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.

Revision Complications

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.

Johnson & Johnson offered $4 billion in November 2013 to settle more than 7,000 of its DePuy ASR lawsuits. As of 2015, J&J set up a website for settlement participants with information on guidelines for submitting claims.  Stryker settled it's claims for an estimated $1.4 billion.

A number of manufacturers recalled hip devices and people injured by these implants filed lawsuits against several major manufacturers including:

Free Case Review

Many hip replacement devices have been linked to harmful injuries such as loosening, dislocation or metallosis. If you or your loved ones suffered from complications related to hip implants, you may have legal options. Tell us about your experience and we will provide you with a free case review.

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  1. Medenhall Associates, Inc (2011). Orthopedic News Network, volume 22, number 3.
  2. American Academy of Orthopaedic Surgeons. (2014, March 24). Total knee and hip replacement surgery projections show meteoric rise by 2030. [Press release]. Retrieved from http://www.prnewswire.com/news-releases/total-knee-and-hip-replacement-surgery-projections-show-meteoric-rise-by-2030-55519727.html
  3. Hospital for Special Surgery. (2010). Revision total hip replacement: An overview. Retrieved from http://www.hss.edu/conditions_revision-total-hip-replacement-overview.asp#Consider
  4. American Academy of Orthopaedic Surgeons (2007). Joint revision surgery – when do I need it? Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00510#A00510_R1_anchor
  5. Fehring, T.K., Odum, S.M., Fehring, K., Springer, B.D., Griffin, W.L. & Dennos, A.C. (2010). Mortality following revision joint arthroplasty: Is age a factor? Retrieved from http://www.healio.com/orthopedics/hip/journals/ortho/%7B5ef453f6-878f-4c45-bb9c-37d220b16d54%7D/mortality-following-revision-joint-arthroplasty-is-age-a-factor
  6. Mangan, D. (2013, July 20). Pricey hip, knee surgery no guarantee of better results. CNBC. Retrieved from http://www.cnbc.com/id/100893861
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