Richard P. Emmanuel
ORTHOPEDIC EXCELLENCE

Minimally Invasive Hip Replacement

Total hip replacement is a common procedure. It involves removing the head of the thighbone (femur). The ball-and-socket mechanism of the hip is replaced with artificial implants.

As the population ages over the next decade, this procedure is expected to become even more common. Patients who undergo hip replacement are usually between 60 to 75 years of age. More than 90 percent of hip replacements last longer than 10 years. After hip replacement, pain and mobility improve noticeably. This allows patients to maintain their independence and quality of life.

Each year, newer techniques and implants have are developed that make hip replacement a less invasive operation and last longer. These new surgical techniques enable patients to recover faster from hip replacement surgery.

Diagnosis

Osteoarthritis of the hip is the most common diagnosis that leads to hip replacement. Osteoarthritis is caused by wear and tear. It affects the cartilage surfaces of the ball-and-socket joint of the hip. The cartilage wears out causing chronic joint pain and stiffness. Patients with hip arthritis have difficulty walking, climbing stairs and performing routine daily activities.

Conditions that can cause destruction of the hip joint include:

• Loss of the blood supply to the head of the thighbone (avascular necrosis)
• Osteoarthritis of the hip
• Rheumatoid arthritis (an inflammatory autoimmune disease)
• Previous injury or trauma to the hip
• Infection
• Developmental abnormalities of the hip

Talk to your orthopedic surgeon to diagnose hip arthritis. Many hip patients have difficulty with walking and day-to-day activities like putting on shoes and socks or climbing stairs. Tell your doctor what symptom you have. In addition to a physician examination, your physician may also recommend additional tests to confirm the diagnosis.

How to diagnose hip arthritis

1. X-ray of hip showing loss of cartilage space in hip socket. Xrays look like there is “bone-on-bone”. Xrays may also show bone spurs and bone cysts.
2. MRI (magnetic resonance imaging)
3. CT (computed tomography) scans.

Risk Factors/Prevention

Hip arthritis may happen if you have a previous injury or mechanical abnormalities related to how the hip developed. Most patients develop arthritis as a result of lifelong wear and tear. Arthritis develops slowly. It takes a period of years. Symptoms increase gradually over time.

Some bone diseases may contribute to the development of hip arthritis. Patients with arthritis may also have brittle bones (osteoporosis). But there is no direct relationship between bone density and the development of arthritis of the hip.

Symptoms of hip arthritis:

1. Pain that is dull and aching
2. Pain that may be constant or may come and go
3. Pain in the groin, thigh or buttock
4. Pain in the knee joint
5. Difficulty walking, especially longer distances, may cause a limp
6. Need for a cane, crutch or walker to help them get around
7. Pain has become worse with time and higher activity levels
8. Difficulty climbing stairs
9. Difficulty getting dressed, tying shoes, clipping toenails
10. Pain even when you rest
11. Pain interferes with sleeping at night

Treatment Options : Non-Surgical

1. Resting
2. Anti-inflammatory medications: i.e. Motrin, Advil, Tylenol, Aleve, Naproxen
3. Nutritional Supplements such as Glucosamine may give some relief
4. Short-term physical therapy to help with strength and stiffness

For more advanced arthritis:

1. May need to use a cane in the hand opposite the affected hip which will transfer weight away from the affected hip and will improve walking ability
2. Using a walker for patients who have trouble walking
3. Weight loss, if you are overweight, will decrease stress on all the joint

Treatment Options: Surgical

Even when you get all of the right non-surgical treatments, problems with pain and mobility sometimes get worse. In this case, the doctor may recommend surgery.

Surgical options include:

Minimally Invasive Hip Arthroscopy: Arthroscopy of the hip is a minimally invasive, outpatient procedure. The doctor may recommend it if the joint has evidence of torn cartilage or loose fragments of bone or cartilage.

Osteotomy: Candidates for osteotomy include younger patients with early arthritis, particularly those with abnormally shallow hip socket (dysplasia). The procedure involves cutting and realigning the bones of the hip socket and/or thighbone. This creates a more normal relationship between the ball and socket. It decreases pressure in the joint. In some cases, this may delay the need for replacement surgery for 10 to 20 years.

Minimally Invasive Hip Replacement: Minimal incision hip replacement surgery lets the surgeon perform hip replacement through one or two smaller incisions. Compared with most people getting hip replacements, candidates for minimal incision procedures are typically thinner, younger, healthier and more motivated to have a quick recovery. Before you decide to have a minimally invasive hip replacement, get a thorough evaluation from your orthopedic surgeon. Discuss the risks and benefits. Both traditional and minimally invasive hip replacement procedures are technically demanding. They require that the surgeon and operating team have considerable experience.

The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. Specially designed instruments are needed to prepare the socket and femur and to place the implants properly. The artificial hip is implanted in the same way. But there is less soft-tissue dissection than with longer incisions.

A single minimally invasive hip incision may measure only 3-inches to 6-inches. It depends on the size of the patient and the difficulty of the procedure. The incision is usually placed over the outside of the hip. The muscles and tendons are split or detached, but to a lesser extent than in the traditional hip replacement operation. They are routinely repaired after the surgeon places the implants. This helps healing. It helps prevent dislocation of the hip. Two-incision hip replacement involves making a 2-inch to 3-inch incision over the groin for placement of the socket and a 1-inch to 2-inch incision over the buttock for placement of the stem. To perform the two-incision procedure, the surgeon needs guidance from X-rays. It may take up to two or three times as long to perform this surgery, as it takes to perform traditional hip replacement surgery.

Reported benefits of less invasive hip replacement include:

• Less pain
• More cosmetic incisions
• Less muscle damage
• Rehabilitation is faster
• Hospital stays are shorter--For traditional hip replacement, hospital stays average four to five days. Many patients need extensive rehabilitation afterward. With less invasive procedures, the hospital stay may be as short as one or two days. Some patients can go home the day of surgery.

Early studies suggest that minimally invasive hip replacement surgery streamlines the recovery process. But the risks and long-term benefits of the less invasive techniques have not yet been documented to represent an improvement over traditional hip replacement surgery.

What can we expect in the future?

Extensive study and development are now underway to determine the long-term benefits of minimally invasive hip replacement. New technology for imaging and computer-assisted implant placement has been developed. It continues to be modified as experience with smaller incision surgery grows. This will allow more precise reconstruction of the hip with less direct visualization. In addition, new implant designs and materials are being developed to both facilitate minimally invasive surgery on the hip and to prolong the lifespan of replacements.

Dr. Emmanuel - Providing services in orthopedic surgery to the area of Culver City, Los Angeles and Beveraly Hills, California (CA).