Bone-Sparing, Total Hip Resurfacing Arthroplasty Surgery (Metal-on-Metal Device)
Last updated Thursday, August 20, 2009
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Successful story - a patient attend Triathlon after the surgery
Successful story - a patient finish Triathlon after the surgery
Summary
Overview
Edited By: Paul A. Manner, M.D.
Total hip resurfacing arthroplasty
is a bone-preserving procedure that helps restore comfort and function to patients’
hips damaged by degenerative joint disease (osteoarthritis, rheumatoid
arthritis, and traumatic arthritis), avascular necrosis, or developmental hip
dysplasia. It is viewed as an alternative to traditional hip replacements for
helping patients return to their active lifestyles.
There has been a recent surge in
interest in hip-resurfacing procedures.
Advocates have pointed to the bone-conserving nature of the procedure and
anticipated potential benefits related to post-operative activities and range
of motion. IMAGE 1 illustrates the difference in the
amount of bone removed for a resurfacing procedure versus a traditional total
hip replacement procedure. In this procedure, surgeons replace the acetabulum
(hip socket) in much the same way as a conventional total hip replacement but
the femoral head is resurfaced rather than removed (see VIDEO for more details).
Hip resurfacing is intended for
patients with high functional demands for whom traditional total hip
arthroplasty would be a poor option because of anticipated failure in the future
and subsequent revision surgery.
In these patients, the hip-joint
surface – the socket side on the pelvis, and the top end of the femur, which
fits into the socket – is destroyed by wear and tear, inflammation, or prior
injury (IMAGE 2). This leads to
stiffness, pain, and decreased ability to perform at work or enjoy leisure
activities such as sports.
The goal of hip resurfacing is to
restore the best possible function to the joint by replacing damaged joint
surfaces with artificial ones. After a clinical exam, an orthopedic surgeon
with training in hip-resurfacing can help a patient determine if this procedure
would be helpful.
Modern hip-resurfacing systems
involve placing a non-cemented, porous metal cup into the hip socket and
cementing a metal cap onto the femoral head. This results in an articulating,
metal-on-metal surface (IMAGE 3).
Only as recently as May 2006 did
the FDA approve the first U.S.-available device for the procedure, manufactured
by Smith & Nephew. Its device has been implanted in about 80,000 hips worldwide
since 1997. A similar device made by Corin Group was approved for U.S. use in
July 2007, and other manufacturers sell such devices around the world.
Total hip resurfacing arthroplasty
is a technical procedure best performed by a surgical team trained in this
surgery. Such a team can maximize the benefit and minimize risks. The procedure
is performed under general or spinal anesthesia.
Many individuals are not appropriate candidates
for total hip resurfacing arthroplasty. For example, patients with poor bone
stock, significant avascular necrosis of the femoral head, kidney dysfunction,
infection, leg-length discrepancy, or women of child-bearing age may not be suitable patients for this
procedure. A thorough discussion with your orthopedic surgeon is necessary to
determine whether this procedure is an option.
Possible benefits of total hip resurfacing arthroplasty
Hip resurfacing may lead to a
dramatic improvement in the quality of life of young, active patients who have
advanced arthritis of the hip. When combined with a thoughtful rehabilitation
program, total hip resurfacing arthroplasty allows patients with arthritic hips
to regain comfort and function. The procedure has been shown in intermediate
term studies (10 years of follow-up) to have met patient expectations, with an
extremely low failure rate. Many patients have returned to pre-symptomatic
levels of activities (sports, cycling, etc.) and occupation several months
after this procedure.
Hip resurfacing can improve the mechanics of the
hip, but cannot make the joint as good as it was before the onset of arthritis.
In many cases, the muscles and tissues around the hip have been weakened from prolonged
disuse before the hip-resurfacing procedure. After surgery, it usually takes
time for a patient to realize maximal improvement.Who should consider total hip resurfacing arthroplasty?
Young, active patients should
consider hip resurfacing when:
- arthritis
has been resistant to conservative measures;
- the
patient is sufficiently healthy to undergo the procedure;
- the
patient understands the risks and alternatives;
- the
surgeon is trained and experienced in hip-resurfacing surgery;
-
no medical or surgical contraindication to hip
resurfacing exists.
What happens without surgery?
Pain
can be managed with medicine, assistive devices, and some alternative
therapies. For some young, active patients, nonsurgical management of
debilitating, advanced hip arthritis is not satisfactory.Effectiveness
In the hands of an experienced
surgeon trained in hip resurfacing, total hip resurfacing arthroplasty is effective
in restoring comfort and function to the hip of a well-motivated patient. A
2007 study of 59 hips reported significant improvement in pain, function, range
of motion, and activity among patients who were, on average, six years
postoperative. The study, published in The
Journal of Bone and Joint Surgery by H.C. Amstutz and colleagues at the
Joint Replacement Institute, reported five cases (8 percent) of femoral
failure, requiring subsequent total hip arthroplasty.
This and other studies have helped
physicians better discern which patients have a better chance of a successful
outcome.
Although hip resurfacing can allow a patient to
resume some physical activities, high-impact activities such as running,
basketball, and singles tennis are more likely to lead to earlier loosening of
the implant and need for revision surgery.Urgency
Total hip resurfacing arthroplasty
is not considered urgent. It is an elective procedure that can be scheduled
when circumstances are optimal. The patient has time to become informed and to
select an experienced surgeon. Before
surgery is undertaken, the patient should:
- be
in optimal health;
- understand
and accept the risks and alternatives of surgery;
- understand
and be committed to the postoperative rehabilitation program.
Risks
The most common risk of hip
resurfacing is fracture of the femoral neck. In one study, the rate of fracture
was 1.46 percent. The procedure’s technical challenges, and patient selection,
might increase risk of fracture. Infection is a rare, but potentially
catastrophic risk. Component loosening is an infrequent complication, according
to published literature.
Potential risks exist from the
production of metal ions (cobalt and chromium) caused by the rubbing of the
metal implant’s components. Proper component positioning appears to be
essential to reducing significant production of metal ions. There is a
theoretical concern that these ions may pose a cancerous risk – though
long-term data does not currently support this assertion. But a patient who has
kidney problems might have difficulty filtering these ions from the blood; he
or she should avoid implantation of metal-based hip components.
For the same reason, hip
resurfacing also is not recommended for women of childbearing age who plan to
have children because of the uncertainty about the effects of metal ions on the
developing fetus.
Hypersensitivity to metal ions is a
risk that is being increasingly recognized and may lead to loosening of the
components. While little correlation appears to exist between skin
hypersensitivity and metal hypersensitivity in the hip joint, hip resurfacing
is not recommended for people with documented allergies to metal or jewelry.
A
thorough preoperative evaluation in preparation for surgery is important for
minimizing potential risks of hip resurfacing surgery. For example, some
patients will need a formal cardiology evaluation in addition to a general
orthopedic evaluation if there is a significant history of heart disease. An
experienced joint replacement team will use special techniques to minimize the
risk of many of the above mentioned complications, but cannot always totally
eliminate them.Managing risk
Many
of the risks of total hip resurfacing arthroplasty can be effectively managed
if they are promptly identified and treated. A coordinated effort at managing
risks should be undertaken by the orthopedic surgeon in conjunction with the
patient’s primary care doctor. Infection might require a washout in the
operating room or an exchange of components. Loosening of the components might
require revision surgery. Fracture usually requires revision to a conventional
total hip arthroplasty. This can be accomplished relatively easily by removing
the femoral resurfacing cap and implanting a standard, long-stemmed femoral
head and neck device, as with total hip replacement. The patient should contact
the surgeon with any questions or concerns about risks. Preparation
Total hip resurfacing arthroplasty
is an option for healthy, active, and motivated individuals in whom arthritis
interferes with hip function.
A successful outcome can be
influenced by good communication between the patient and the surgeon. Patients
should optimize their health prior to surgery. Smoking should be stopped a
month before surgery and not resumed for at least several months afterwards (if
ever). Any heart, lung, kidney, bladder, or dental problems should be managed
before surgery; infection could be a reason to postpone surgery. The hip
surgeon needs to be aware of all health issues, including allergies and the
non-prescription (herbal medicines, St. John’s wort, etc.) and prescription medications being taken.
Some of these medicines might need to be discontinued before surgery –
especially those that may increase a patient's likelihood to bleed. Since blood
transfusion might be necessary, patients may choose to have a blood bank draw
and store their own blood for a possible transfusion.
Before surgery, patients should
consider the limitations, alternatives and risks of surgery. Patients should
also recognize that the result of surgery depends in large part on their
efforts in rehabilitation after surgery.
It is recommended that patients
continue to walk and exercise, if possible, before surgery so that the muscles
around the hip are not overly deconditioned.
The
patient must plan to be less functional than normal immediately after surgery.
Driving, shopping and performing usual work or chores likely will be difficult
during this time. Plans for necessary assistance should be made before surgery.
For individuals who live alone or those without readily available help,
arrangements for home help should be made well in advance.Timing
Total
hip resurfacing arthroplasty can be delayed until the time that is best for the
patient’s overall well-being.Costs
The patient’s insurance provider
can provide a reasonable estimate of the following:
- the
surgeon's fee
- the
hospital fee
-
the degree to which these should be covered by
the patient's insurance
Surgical team
Total
hip resurfacing arthroplasty is a technically demanding procedure that should
be performed by an experienced surgeon in a medical center accustomed to
performing hip replacements at least several times a month.Finding an experienced surgeon
Because
the resurfacing-arthroplasty devices have received approval only recently in
the United States, many communities do not have surgeons trained in this
procedure. The device manufacturers require that surgeons who implant their
devices be properly trained for technique. Surgeons specializing in hip joint
replacement may be located through the American
Academy of Orthopedic Surgeons Web site, university schools of medicine,
county or state medical or orthopedic organizations.Facilities
Total
hip resurfacing arthroplasty is usually performed in a major medical center whose
surgeons perform these procedures on a regular basis. These centers have
surgical teams and facilities specially designed for such surgery. They also
have nurses and therapists accustomed to assisting patients in their recovery
from hip-replacement surgery.Technical details
After the anesthetic has been
administered and the hip is prepared, the surgeon makes an incision. Most
surgeons approach the joint from the posterior (rear); others prefer a lateral (side)
or anterior (front) approach. During the posterior approach, fibers of the gluteus
maximus muscle are split. The tendinous insertion of the gluteus maximus is
recessed or divided to allow movement of the femur bone.
The interval between the gluteus
minimus and the superior acetabulum (hip socket) is developed and the
piriformis tendon is released from its femoral attachment. A 360-degree
capsulotomy is then performed.
The acetabulum is prepared. Bone
spurs are removed. Reamers are used to enlarge the acetabulum in preparation
for placement of the cup, whose position is crucial for a successful outcome.
The cup is impacted into place.
The femur is prepared by using an
alignment guide. A guide wire ensures that the spherical metal cap is
positioned correctly on the femoral head. The surgeon, with a chamfering
router-like instrument, removes only the outer layer of the femoral head, so
that the cap will fit snugly (IMAGE 4).
After the femur has been prepared, cement is mixed and the femoral cap component
is impacted into place, also secured by a metal stem that extends into the
femoral neck. (The femoral neck is left intact.)
With the femur and acetabulum completed, the hip
joint is re-established (IMAGE 5)
and taken through a range of motion to test stability. The soft tissues are
repaired, and the remainder tissues are closed, in layers, and a dressing
applied to the wound.Anesthetic
Hip-resurfacing
surgery can be performed under a general anesthetic or under a regional block
(epidural or spinal). A spinal block can provide anesthesia for several hours
after the surgery. The patient may wish to discuss their preferences with the
anesthesiologist before surgery.Length of total hip resurfacing arthroplasty
The
procedure usually takes about two hours, however the preoperative preparation
and postoperative recovery may add several hours of time. Patients often spend
two hours in the recovery room and, on average, three days in the hospital after surgery.Pain and pain management
Hip-resurfacing
surgery is a major surgical procedure that involves cutting of skin,
preparation of bone, as well as suturing of tendons. The pain from this surgery
is managed by the anesthetic and by pain medications. Immediately after
surgery, strong medications (such as morphine or Demerol) may be given by
injection. Within a day or so, oral pain medications – strong painkillers and
non-narcotic painkillers such as Tylenol (acetaminophen) – are usually
sufficient.Use of medications
Initially
pain medication usually is administered intravenously or intramuscularly – and
sometimes patients are allowed to administer the medication as they need.
Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous pain
medications are usually needed only for the first day or two after the
procedure. Oral pain medications are usually needed only for the first two
weeks after the procedure.Effectiveness of medications
Pain
medications can be very powerful and effective. Their proper use lies in
balancing their pain-relieving effect and their other, less desirable effects.
Good pain control is an important part of the postoperative management.Important side effects
Pain
medications can cause drowsiness, slowed breathing, difficulties in emptying
the bladder and bowel, nausea, vomiting and allergic reactions. Patients who
have taken substantial narcotic medications in the recent past may find that
usual doses of pain medication are less effective. For some patients, balancing
the benefit and the side effects of pain medication is challenging. Patients
should notify their surgeon if they have had previous difficulties with pain
medication or pain control.Hospital stay
After surgery the patient spends an
hour or so in the recovery room. A drainage tube may be used to remove excess
fluid from the surgical area. Such a drain would be removed on the first or
second day after surgery. Bandages cover the incision. They are usually changed
the second day after surgery.
Patients are discharged as soon as the incision
is dry, the hip’s pain is manageable with oral pain medications, the patient
can perform the range-of-motion exercises, and support systems are in place at
the patient’s home. Discharge is usually on the third day after surgery.Recovery and rehabilitation in the hospital
Early mobilization after total hip
resurfacing arthroplasty helps achieve the best possible hip function.
Arthritic hips are stiff, and one major goal of hip resurfacing is to relieve
much of this stiffness. However, after surgery scar tissue will tend to recur
and limit movement unless mobilization is started immediately. This early mobilization
is facilitated by the complete surgical release of the tight tissues.
The night of surgery, patients are
encouraged to get up to use a commode or walk to the bathroom with assistance.
During the hospitalization, the
patient learns a simple rehabilitation program that will help maintain mobility
at home after discharge. On the day of surgery or the day after, the physical
therapist teaches the patient gentle exercises. The patient usually is shown
how to prevent stiffness and adhesions.
Walking and strengthening exercises are
encouraged soon after surgery. Many patients return to leisure activities
within 3-6 months after surgery.Hospital discharge
At the time of discharge, the patient
should be relatively comfortable on oral medications, should have a dry
incision, should understand their exercises and should feel comfortable with
the plans for walking. For the first month or so after this procedure, the
operated leg may be less useful than it was immediately beforehand.
Limitations can be specified only by
the surgeon who performed the procedure. It is important that the repaired
tissues not be challenged until they have had a chance to heal.
The patient must plan to manage the activities
of daily living during the period of recovery.Convalescent assistance
Patients usually require assistance
with self-care, activities of daily living, shopping and driving for four to
six weeks after surgery. In the absence of home support, a convalescent
facility may provide a safe environment for recovery.
Recovery of comfort and function after hip
resurfacing continues for many months after the surgery. Improvement in some
activities may be evident as early as two weeks. With persistent effort,
patients make progress for as long as three to six months after surgery.Physical therapy
Early mobilization after hip
resurfacing is critical for achieving optimal function.
Arthritic hips are stiff. One of the major goals
of total hip resurfacing arthroplasty surgery is to relieve much of this
stiffness. However, after surgery, scar tissue will tend to emerge and will limit
movement unless mobilization is started immediately. This early mobilization is
facilitated by the complete surgical release of the tight tissues so that after
surgery the patient has only to maintain the motion achieved at the operation.
Later on, after the hip is comfortable and more flexible, strengthening
exercises and additional activities are started.Rehabilitation options
It
is often most effective for the patient to carry out his or her own exercises
so that they are done frequently, effectively and comfortably. Usually, a
physical therapist or the surgeon instructs the patient in the exercise program
and advances it at a rate that is comfortable and beneficial for the patient.
For the first six weeks after surgery, emphasis is placed on optimizing mobility
and strengthening. At six weeks, the strengthening exercises may be gradually
increased in intensity.Can rehabilitation be done at home?
In
general the exercises are best performed by the patient at home. Occasional
visits to the surgeon or therapist may be useful to check the progress and to
review the program.Usual response
Patients
often experience significant increases in range of motion, comfort and function
with this procedure, and those benefits could be aided by rehabilitation. If
the exercises are uncomfortable, difficult, or painful, the patient should
contact the therapist or surgeon promptly.Risks
This
is a safe rehabilitation program with little risk.Duration of rehabilitation
Once
the range of motion and strength goals are achieved, the exercise program can
be cut back to a minimal level. However, gentle stretching is recommended on an
ongoing basis.Returning to ordinary daily activities
In general, patients are able to
perform gentle activities with the operated leg the day after surgery. Walking
with assistance is strongly encouraged. Driving should wait until the patient
can perform the necessary functions comfortably and confidently.
With the surgeon’s consent, patients
can often return to activities such as swimming, light hiking, bicycling, golf,
and doubles tennis in three to six months after surgery.
Stressful activities and activities with the leg
in extreme positions must be avoided until several months after the surgery and
then only if the hip is comfortable and strong.Long-term patient limitations
Many
surgeons allow patients to return to pre-surgery activities (bicycling, hiking)
and an active lifestyle. While
hip resurfacing implants may be more durable in the long run than traditional
total hip replacement implants, there are still several restrictions that should
be observed.
For example, high impact loading (contact sports, jogging, etc.) on the
operated hip is not recommended. If
there are questions about certain activities, they should be discussed directly
with the surgeon.Costs
The
therapist and the patient’s insurance provider should have the information on
the usual cost of the rehabilitation program.Summary of total hip resurfacing arthroplasty for total hip resurfacing arthroplasty
Total hip resurfacing arthroplasty
helps restore comfort and function to hip joints damaged by arthritis or other
degenerative disorders.
Hip resurfacing is a bone-preserving
procedure that is an alternative to traditional total hip replacement. However
resurfacing procedure is actually more invasive than a total hip replacement
surgery, requiring a larger incision and a greater disturbance of soft tissue.
The main benefits of resurfacing
are that the patient can be more active postoperatively than is the case with a
traditional replacement, and the patient is left with more bone, should total
hip replacement be necessary later in life.
Hip resurfacing is indicated for a
subset of the population, especially young, active individuals. A discussion
with your surgeon is necessary to determine if this surgery is appropriate for
you.
A motivated patient and persistent
rehabilitation efforts will help to assure the best possible results.
Surgery for Total Hip Resurfacing Arthroplasty at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 to make an appointment. Our clinical center is located in Seattle Washington, USA