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Hip Resurfacing



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Introduction

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Hip replacement has become necessary for your arthritic hip: this is one of the most effective operations known and should give you many years of freedom from pain.

Once you have arthritis which has not responded to conservative treatment, you may well be a candidate for a resurfacing procedure of the hip.



Resurfacing

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A standard hip replacement replaces the acetabulum (hip socket) and the places a femoral component inside the femur (thigh bone).

Hip Resurfacing or bone conserving procedure replaces the acetabulum (hip socket) in the same way but resurfaces the femoral head. This means the femoral head has some or very little bone removed and replaced with the metal component. This spares the femoral canal.

Resurfacing procedures may be indicated in the young patient (usually less than 55 years) who has osteoarthritis and wishes to maintain an active lifestyle. It is a more conservative and less traumatic alternative to Total Hip Replacement (THR).




Arthritis

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Arthritis is a general term covering numerous conditions where the joint surface (cartilage) wear out. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint. This surface can wear out for a number of reasons, often the definite cause is not known.

When the articular cartilage wears out, the bone ends rub on one another and cause pain. There are numerous conditions that can cause arthritis and often the exact cause is never known. In general, but not always it affects people as they get older (Osteoarthritis).

Other causes include...

  • Childhood disorders e.g., dislocated hip, Perthe's disease, slipped epiphysis etc.
  • Growth abnormalities of the hip (such as a shallow socket) may lead to premature arthritis.
  • Trauma (fracture)
  • Increased stress e.g., overuse, overweight, etc.
  • Avascular necrosis (loss of blood supply)
  • Infection
  • Connective tissue disorders
  • Inactive lifestyle - e.g., obesity, as additional weight puts extra force through your joints which can lead to arthritis over a period of time.
  • Inflammation e.g., Rheumatoid Arthritis

In an arthritic hip...

  • The cartilage lining is thinner than normal or completely absent. The degree of cartilage damage and inflammation varies with the type and stage of arthritis.
  • The capsule of the arthritic hip is swollen
  • The joint space is narrowed and irregular in outline; this can be seen in an x-ray image.
  • Bone spurs or excessive bone can also build up around the edges of the joint.

The combinations of these factors make the arthritic hip stiff and limit activities due to pain or fatigue.

Diagnosis

The diagnosis of osteoarthritis is made on history, physical examination and x-rays. There is no blood test to diagnose Osteoarthritis (wear and tear arthritis).




The combinations of these factors make the arthritic hip stiff and limit activities due to pain or fatigue. The diagnosis of osteoarthritis is made on history, physical examination and x-rays. There is no blood test to diagnose Osteoarthritis (wear & tear arthritis).




Indications

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Resurfacing procedures may be indicated in the young patient (less than 55 years) who has osteoarthritis and wishes to maintain an active lifestyle. It is a more conservative and less traumatic alternative to Total Hip Replacement (THR).

Advantages

The main advantage is that it is bone sparing in that it does not violate the femoral canal. This allows a Total Hip Replacement to be performed at a later date, if required with little difficulty.

  • Higher activity levels allowed
  • Quicker recovery in hospital (2 to 5 days)
  • Reduced bone damage and osteolysis (erosion of bone) over time
  • Reduced complications especially reduced dislocation rate and reduced leg discrepancy.
 

Traditional THR v/s Hip Resurfacing

Conventional Hip Replacement  Hip Resurfacing
Suitable for older patients Suitable for younger patients
Femoral canal violation Femoral canal left intact 
Metal on polyethylene, metal on metal or ceramic on ceramic articulation Metal on metal articulation 
Can wear out rapidly    Potentially longer lasting, with better wear characteristics.  
Risk of dislocation Less risk of dislocation
Leg length discrepancy Minimal or no leg discrepancy 
Osteolysis (bone wearing out) Potentially less risk of osteolysis   
Thigh pain No thigh pain   
May require revision surgery Potentially lasts longer i.e., less chance of revision   
Requires restriction of activities   Able to be more active 



Pre-Operation

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  • Your surgeon will send you for routine blood tests and any other investigations required prior to your surgery.
  • You will asked to undertake a general medical check-up with a physician.
  • You should have any other medical, surgical or dental problems attended to prior to your surgery.
  • Make arrangements around the house prior to surgery.
  • Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding.
  • Cease any naturopathic or herbal medications 10 days before surgery.
  • Stop smoking as long as possible prior to surgery.



Day of your Surgery

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  • You will be admitted to hospital usually on the day of your surgery.
  • Further tests may be required on admission.
  • You will meet the nurses and answer some questions for the hospital records.
  • You will meet your anaesthetist, who will ask you a few questions.
  • You will be given hospital clothes to change into and have a shower prior to surgery.
  • The operation site will be shaved and cleaned.
  • Approximately 30 mins prior to surgery, you will be transferred to the operating theatre.



Surgical Procedure

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  • An incision is made over the hip to expose the hip joint.
  • The acetabulum (socket) is prepared using a special instrument called a reamer.
  • The acetabular component is then inserted into the socket.
  • A liner which can be made of plastic, metal or ceramic material is then placed inside the acetabular component.
  • The femoral head is then prepared using special reamers taking very little bone.
  • The femoral component is then inserted into the prepared femoral head.
  • The hip is then reduced and then the muscles and the soft tissues carefully closed.


Post Operative

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  • You will wake up in the recovery room with a number of monitors to record your vitals (blood pressure, pulse, oxygen saturation, temperature, etc). You will have a dressing on your hip and drains coming out of your wound.
  • Post-operative x-rays will be performed in recovery.
  • Once you are stable and awake you will be taken back to the ward.
  • You will have one or two drips in your arm for fluid and pain relief. This will be explained to you by your anaesthetist.
  • On the day following surgery, your drains will usually be removed and you will be allowed to sit out of bed or walk depending on your surgeons preference.
  • Pain is normal but if you are in a lot of pain, inform your nurse.
  • You will be able to put all your weight on your hip and your physiotherapist will help you with the post-op hip exercises.
  • You will be discharged to go home or a rehabilitation hospital after approximately 3-7 days depending on your pain and help at home.
  • Sutures are usually dissolvable but if not are removed at about 10 days.
  • A post-operative visit will be arranged prior to your discharge.
  • You will be advised to start walking with crutches two weeks following surgery and walking stick from then on till 6 weeks.



Post-Op Precautions 

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Remember - this is an artificial hip and must be treated with care.

AVOID THE COMBINED MOVEMENT OF BENDING YOUR HIP AND TURNING YOUR FOOT IN. This can cause DISLOCATION. Other precautions to avoid dislocation are...

  • You should sleep with a pillow between your legs for 6 weeks. Avoid crossing your legs and bending your hip past a right angle
  • Avoid low chairs
  • Avoid bending over to pick things up. Grabbers are helpful as are shoe horns or slip on shoes.
  • Elevated toilet seats are helpful.
  • You can shower once the wound has healed.
  • You can apply Vitamin E or moisturizing cream into the wound once the wound has healed.
  • If you have increasing redness or swelling in the wound or temperatures over 38°C you should call your doctor.
  • If you are having any procedures such as dental work or any other surgery you should take antibiotics before and after to prevent infection in your new prosthesis. Consult your surgeon for details.
  • Your hip replacement may go off in a metal detector at the airport.



Risks and Complications 

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As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to the hip:

Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reactions to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
  • Complications from nerve blocks such as infection or nerve damage.
  • Serious medical problems can lead to ongoing health concerns,
  • Prolonged hospitalization or rarely death.

Remember - this is an artificial hip and must be treated with care. AVOID THE COMBINED MOVEMENT OF BENDING YOUR HIP AND TURNING YOUR FOOT IN. This can cause DISLOCATION. Other precautions to avoid dislocation are... As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include...

Specific complications

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates are approximately 1%, if it occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Dislocation

This means the hip comes out of its socket. Precautions need to be taken with your new hip forever.

If a dislocation occurs it needs to be put back into place with an anaesthetic. Rarely this becomes a recurrent problem needing further surgery.

Fractures (break) of the femur (thigh bone) or pelvis (hipbone)

This is also rare but can occur during or after surgery. This may prolong your recovery, or require further surgery. If the femoral neck fractures, then it is a simple surgical procedure to place a routine femoral stem component.

Damage to nerves or blood vessels 
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Also rare but can lead to weakness and loss of sensation in part of the leg. Damage to blood vessels may require further surgery if bleeding is ongoing.

Blood clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.

Wound irritation

Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint.

Leg length inequality

It is very difficult to make the leg exactly the same length as the other one. Occasionally the leg is deliberately lengthened to make the hip stable during surgery. There are some occasions when it is simply not possible to match the leg lengths. All leg length inequalities can be treated by a simple shoe raise on the shorter side.

Leg length inequalities are less likely to occur with a resurfacing procedure.

Wear

All joints eventually wear out. The more active you are, the quicker this will occur. In general 80-90% of hip survive 15 years.
Resurfacing procedures should last longer, but this has to be proven by long term studies and with the latest designs.

Failure to relieve pain

Very rare but may occur especially if some pain is coming from other areas such as the spine.

Unsightly or thickened scar.

Pressure or bed sores.

Limp due to muscle weakness.

Metal Ions

One of the great unknowns with metal on metal articulations is do the metal ions released in the body cause any damage.

The potential concern is that they may cause cancer or affect the immune system. This has never been proven and although not impossible to rule out is unlikely to be of major clinical significance.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery. 


Summary

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Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition.

Surgery can be regarded as part of your treatment plan - it may help to restore function to your damaged joints as well as relieve pain.

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan - it may help to restore function to your damaged joints as well as relieve pain.

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