Orthopedic Hip Surgery

Who should consider total hip arthroplasty, hip resurfacing, and minimally-invasive hip surgery?
It is usually reasonable to try a number of non-operative interventions before considering hip replacement surgery for arthritis. Prior to surgery, an orthopedic surgeon may offer pills (either non-steroidal anti-inflammatory medications or analgesics like acetaminophen, also known as Tylenol), knee injections, or exercises. Your surgeon may talk to you about activity modification, weight loss, or use of a cane.

The decision to undergo a hip replacement is a “quality of life” choice. Patients typically have the procedure when they find themselves avoiding activities that they used to enjoy because of hip pain. When basic activities of daily life--like walking, shopping, or reasonable recreational pastimes--are inhibited or prevented by the hip pain, it may be reasonable to consider the surgery. Very rarely, the arthritis can cause a destructive pattern of bone loss. In this instance, a surgeon might recommend the surgery in order to prevent a type of pelvic fracture (called protrusio acetabuli), even if your symptoms are otherwise manageable non-surgically. But again, this is quite uncommon.

In almost all instances, the decision and timing of hip replacement surgery for arthritis are a personal decision to be made by the patient, not by the surgeon. The decision should be made in consultation with a trusted surgeon who can help educate the patient as to risks, benefits, alternatives, and issues related to recovery from surgery. If a surgeon says you "need" a hip replacement for arthritis, without discussing alternatives or asking you about quality-of-life issues, it might be worth considering getting a second opinion.

"Traditional" or "minimally-invasive" hip replacement?
Traditional hip replacement--using an incision that varies proportionally with the size of the patient, and may be between 5 and 8 inches long--has been done, with a few modifications of surgical technique, for over 40 years. The results of this approach have been published by literally thousands of surgeon-scientists, from hundreds of medical centers, in dozens of countries. There is a known success rate from this surgery, and it is above 90% with more than 10 years of follow-up after the operation. It is predictable, and considered one of the great surgical innovations of the 20th century. It would appear from this that we ought to set the bar fairly high before trying something radically new or experimental.

In contrast, “minimally-invasive” hip replacement is a new surgical approach; few surgeons have even been doing it for two years. “Minimally-invasive” means different things to different surgeons. There is no accepted definition--it can be the same operation done through a slightly smaller incision than the surgeon used to use (say 5 inches rather than 6 or 8 inches), a much shorter incision (an approach calling for a 3 inch incision is popular in some places), or even two 1.5-inch incisions using an x-ray machine to find the bones and put the components in the right place. Surgeons who perform these approaches often say that the shorter incision results in a number of benefits: shorter recovery time, less blood loss, less post-operative pain, or fewer days in the hospital.

The minimally-invasive partial knee replacement, which has been around only a few years longer than the hip technique, already has a number of studies proving patients recover faster, and that surgeons are able to get the components properly positioned through the smaller incision. On the other hand, innovation and new approaches are essential to the improvement of techniques in all areas of medicine. It seems very possible that some, if not all, of the benefits of “minimally-invasive” hip replacement may be realized. It is quite likely that we will learn much more about this technique in the near future. At this point, it is reasonable for patients who are attracted to the idea of a more cosmetic appearance of the shorter incision, and who are not troubled by the as-yet-unanswered questions about this approach, to consider “minimally-invasive” hip replacement. Others might consider going with a traditional surgical approach.

Effectiveness
Current evidence suggests that traditional total hip replacements last more than 10 years in more than 90% of patients. More than 90% of patients report having either no pain, or pain that is manageable with use of occasional over-the-counter medications. The large majority of hip replacement patients are able to walk unassisted (i.e. without use of a cane), without any limp, for reasonably long distances. Many have no distance restrictions at all, and resume hiking, golfing, bicycling, and other non-impact recreational activities.

As mentioned, there are no studies to date documenting the short-term or long-term effectiveness of minimally-invasive hip replacement, and there are no studies that have proved that the joint replacement components can be reliably inserted with equal success or safety through the smaller incision used in minimally-invasive hip replacement techniques.

In the event that a total hip replacement requires re-operation sometime in the future, the results are generally good--although often not as good as one typically gets with an uncomplicated first-time hip replacement. The results of repeat hip replacements (called “revisions”) often depend on a number of factors that are not in the surgeon’s (or the patient’s) control, such as: infection, bone loss, and condition of the muscles and other soft tissues around the hip joint. But in general, revision hip replacement can achieve a durable result and provide substantial relief of pain.

There is good evidence that the experience of the surgeon correlates with outcome in all kinds of joint replacements, including total hip replacements. It is important that the surgeon performing the technique be not just a good general orthopedic surgeon, but an expert, experienced total hip replacement surgeon, as well. It is reasonable to ask a surgeon whether they concentrates their practice on joint replacements, or whether they do all kinds of orthopedic surgery.