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Hip replacement treatment in Germany requires an individualized approach in each case. The recovery period and the outcome of the surgery depend to a large extent on the experience and qualifications of the orthopedic surgeon. Therefore, it is strongly recommended to consult an orthopaedic surgeon who specializes in the treatment of the hip joint and has achieved a high level of expertise in hip replacement. Our clinics in Munich are staffed by orthopaedic surgeons who are world-renowned in the surgical treatment of joint diseases, in particular hip replacements, and who have a high percentage of successful surgeries.
The hip joint is made up of the femur, which has a femoral head at the end. It is connected to the pelvic bones at the acetabulum by ligaments and muscles. This joint is a hinge joint.
The hip joint may develop degenerative changes due to arthritis, accompanied by inflammation and pain. Surgery may be required to reduce the symptoms of the condition. There are many surgical options for treating hip pain due to arthritis, including total hip replacement and more.
While the basic steps of hip replacement surgery are similar, many variables depend on the patient, the surgeon, and the type of prosthesis used.
Minimally invasive method for hip replacement
Minimally invasive hip replacement surgery is defined differently by different specialists. Some surgeons define it by the actual size of the skin incision. Others define minimally invasive surgery as one that uses techniques and modified instruments to avoid incisions of certain muscles and other soft tissues around the hip; these approaches to the hip are theoretically more «economical.»
It is important to recognize that, however defined, minimally invasive surgery can be both technically challenging and presents a unique set of risks and complications if the surgeon is not trained in the specific surgical techniques used.
Computer-assisted hip replacement
Some surgeons use computer systems during surgery to ensure prosthesis alignment. Early studies show that computer-assisted surgery provides better prosthetic alignment than conventional approaches, although more research is needed regarding cinical exposure, long-term results, and efficacy.
Types of prostheses
The femoral cup and femoral stem are the two components in contact with the bone, most often made of some type of metal. The femoral head («ball») and insert, which is necessary for movement in the hip joint, are made of a combination of the following materials: metal, plastic (polyethylene) and/or ceramic.
There is no definitive scientific evidence showing that one type of hip prosthesis is better than another. Experts continue to research and debate this issue. However, recently there has been a growing number of studies showing complications associated with metal-on-metal surfaces (i.e., both metal femoral head and metal inlay). Ultimately, the type of prosthesis will depend on surgeon preference, patient age, patient anatomy, and patient lifestyle.
Cemented or cementless denture?
Another difference between prosthetic components is how they attach to the bone. Components can be attached with bone cement or they can be «cementless,» allowing existing bone to grow into them. Each type has relative advantages and disadvantages. Cement fixation is the most common method currently used for both primary and revision hip replacement in Germany.Whether the surgeon will use a cemented or non-cemented prosthesis (or a combination) depends on the surgeon’s preference, the patient’s lifestyle, and the patient’s physiology.
Patients will want to consider a variety of options, but it is important to keep in mind that surgical experience remains one of the most important factors. For example, an experienced surgeon with expertise in a traditional surgical approach may offer better results than a surgeon who utilizes the latest technology and techniques but has little experience.
Advantages and disadvantages of anterior access in hip replacement
Anterior access hip replacement is an example of how medicine is constantly evolving and trying to improve treatment outcomes. This operation is the subject of ongoing research and although thousands of operations are performed every year — it is estimated that only 15-20% of hip replacements in Germany currently use anterior access.
Potential advantages of anterior access in hip arthroplasty
Less damage to core muscles. The anterior approach avoids incisions in the area of large muscles. There are fewer muscles on the front side of the hip joint, and the surgeon works between them instead of cutting muscle fibers or detaching the muscles from the bones (and then stitching the areas together at the end of surgery).
Less postoperative pain. Because the surgery does not require cutting large muscles, patients typically experience less pain after surgery and require fewer pain medications.
Faster recovery. After surgery, the patient can bend the hip joint and bear weight as soon as it becomes comfortable. Most hip replacement patients can use crutches or walkers sooner than patients who had traditional surgery. A 2014 study of 54 patients found that patients with hip replacement through anterior access were able to walk unassisted 6 days sooner than other hip replacement patients.
Reducing the risk of hip dislocation. The main postoperative concern for most hip replacement patients is that the new hip «ball» will dislocate. However, anterior access hip replacement surgery does not disrupt the muscle and soft tissue structures that naturally prevent hip dislocation, so these patients are less likely to have hip dislocation. Patients can lean or sit cross-legged without risking the development of dislocations. Most traditional hip replacement patients are advised to avoid sitting cross-legged for at least 6 to 8 weeks after surgery and, depending on the surgeon’s comments, to avoid deep hip flexion or excessive internal rotation of the hip joint.
A patient undergoing hip replacement through an anterior access usually has a shorter hospital stay than with the traditional approach, but much of this depends on the patient and the frequency of physical therapy sessions that patients have in the hospital. While anterior access in hip replacement may offer some advantages, there are also potential limitations or drawbacks to the method.
Potential disadvantages of hip replacement via anterior access.
Obese or very muscular individuals are not good candidates for this therapy. Depending on the surgeon’s experience, this surgery may not be appropriate for patients who are obese or very muscular, as the extra soft tissue may make it difficult for the surgeon to access the hip joint.
It’s a technically complex operation. Surgeons have a difficult time learning this technique. The anterior incision provides a limited view of the hip joint, making this technique a technically challenging procedure.
There are risks of nerve damage. There is a potential risk of nerve damage with any hip replacement approach. In anterior access hip replacement, the surgical field is located near the lateral cutaneous femoral nerve, which runs along the front of the pelvis and along the thigh. After anterior access hip surgery, there is a possibility of numbness in the hip and, in rare cases, painful skin irritation due to improper functioning of this nerve, known as paresthetic meralgia. This condition is rare and occurs in less than 1% of patients. Although research is limited, many studies have shown that the risk of damage to major nerves near the hip, particularly the sciatic nerve, is lower with the anterior approach than with the traditional approach. This is because the sciatic nerve runs behind the hip joint, so it is not exposed when using the anterior approach.
There may be problems with wound healing. Surgeons who routinely perform the anterior approach recognize that surgical incisions can become inflamed, especially in very large patients or patients with large amounts of abdominal fat. For example, one study found postoperative wound complications (attachment of infection) in 1.4% of patients who underwent anterior access prosthetics and 0.2% of patients who underwent posterior access prosthetics. However, these wound healing problems usually resolve quickly. To date, there is no evidence that either approach has a higher or lower likelihood of developing a hip infection, which is a much more serious problem than delayed wound healing.
It is important to remember that successful hip replacement surgery depends on many factors other than the surgical approach. For example, important factors include the surgeon’s knowledge and skill, the type of hip prosthesis, the patient’s weight and anatomy, and the patient’s ability and willingness to participate in surgical preparation and postoperative rehabilitation.
A patient considering anterior access for hip replacement should talk to their surgeon about the potential advantages and disadvantages in the context of the individual’s specific circumstances, such as, underlying disease (osteoarthritis), specific anatomy, general health, and lifestyle.
In any hip replacement surgery, the damaged hip joint is removed and replaced with prosthetic components, with the goal of:
— reducing hip pain,
— improving hip function.
But replacement can vary in its surgical approach.
«Surgical approach» — is how the surgeon provides the operative field, including the location of the incision and which muscles and other soft tissues need to be cut or pushed aside to make room for the joint replacement.
To date, experts have found that hip replacement through anterior access offers promising results, but not all surgeons are trained in the procedure, and not all patients are suitable candidates for surgery. Surgeons must have specialized training and have completed their fellowship. The anterior approach can be challenging for the surgeon, especially in the early stages of training. Therefore, it is preferable for a surgeon to have specialized training before performing a hip replacement through an anterior access. Studies show that a surgeon’s first 20-30 hip replacements through anterior access usually have a higher complication rate than traditional surgeries. Therefore, it is usually recommended that patients look for a surgeon who has extensive experience in performing this type of hip replacement.
Anesthesia
When people think of having anesthesia during surgery, they usually mean general anesthesia. However, local anesthesia can block sensation to a smaller area at the time of surgery or other medical procedures. Both general and local anesthesia can be used for orthopedic surgeries. People who smoke, abuse alcohol, or have other medical conditions are at greater risk for anesthesia-related complications. Patients concerned about their individual risks should talk to their doctor about this.
General anesthesia. Usually, general anesthesia drugs are injected through a needle into a vein in the patient’s arm. The patient is rendered unconscious-often called «put to sleep»-without feeling any pain. Patients under general anesthesia are carefully monitored, and blood pressure, heart rate and breathing are measured. Sometimes a patient can choose whether to have general or local anesthesia during surgery, but more often medical indications and contraindications dictate this choice.
Local (or regional) anesthesia. This type of anesthesia can be used instead of or in combination with general anesthesia. There are two types of regional anesthesia: spinal and epidural anesthesia techniques, which anesthetize the entire lower half of the body. The drugs are injected between the vertebrae, and they soak the tissue around the spinal cord. Spinal anesthesia is done with a needle, the drug is delivered into the fluid that bathes the spinal cord. Epidural anesthesia is administered continuously through a catheter into the outer region of the spinal canal, known as the epidural space. People are most familiar with the epidural technique because of its frequent use in childbirth. Peripheral nerve blocks target the specific limb that the surgeon is working with. This approach allows sensation to be blocked at the nerve root level, where nerves branch off the spinal cord. For example, a nerve block is performed in the area of the lumbar plexus, a group of nerves that exit through the lumbar vertebrae and provide various sensations in the legs. When they are blocked, the patient stops feeling pain and pressure, which is necessary for a hip replacement.
Peripheral nerve blocks have become more common in recent years as medical technology has made them more accurate and reliable. Peripheral nerve block can be performed before surgery and can be used in conjunction with general anesthesia. Local anesthesia can be used for a short time after surgery. This allows the patient to come out of general anesthesia and regain consciousness without pain. Pain control with intravenous anesthesia is performed after surgery.
Postoperative pain differs from patient to patient. To explain these variations in pain, patients are sometimes given control of their own pain medication. The patient presses a button on a patient-controlled pump, which then injects the medication through a catheter into a vein. The pump is programmed to deliver patient-specific doses, so there is no risk of overdose.
The anterior access incision is made in front of the hip joint. This incision begins at the top of the pelvic bone (iliac crest) and extends down to the top of the hip. During a posterior hip replacement, the surgeon makes a curved incision on the side of the hip just behind the greater acetabulum, the tuberosity that is on the side of the top of the femur.
When performing an anterior access, the surgeon works between the muscles, with minimal or no muscle incisions. The use of this spacing between muscles is called the Hueter approach after the work of the German surgeon who first described this method of approach to the hip joint. It is truly an «interventional» approach, meaning the surgeon works between muscles supplied by different nerves, so it is a natural separation that allows access to the hip joint.
The traditional approach to hip replacement
requires surgeons to cut through muscle and other soft tissue at the back of the thigh to gain access to the hip joint. First, the surgeon cuts through the greater fascia, a wide piece of fibrous soft tissue at the top of the thigh and the large gluteal muscle that attaches to it. Next, the surgeon must cut the external rotators of the femur, which are small, short muscles that connect the top of the femur to the pelvis. These muscles provide stability to the hip joint, preventing posterior dislocation of the hip (posterior dislocation). These muscles are repaired and reattached at the end of surgery.
With anterior access, the surgeon has a limited view of the hip joint during surgery, making the operation technically challenging, especially for less experienced surgeons.
With posterior access, the field view is good and convenient access to the hip joint is possible.
Any hip replacement requires opening of the hip capsule and bone formation for implantation of prosthetic hip components.
A minimally invasive hip replacement procedure.
In traditional total hip replacement surgery, the surgeon makes a 10-12 cm incision along the lateral surface of the hip. The muscles are excised or disconnected from the bones, and the «ball» and «socket» of the hip joint are dislocated to give the surgeon full access to the femur and pelvis. Typically, invasive hip replacement techniques require incisions as small as 3 to 6 inches. A smaller incision reduces the surgeon’s access to the surgical area, so this type of surgery requires specialized instruments to access and isolate the hip and femur. Where the surgeon makes the surgical incision and accesses the hip joint determines the surgical approach.
There are many different types of surgical approaches called minimally invasive hip replacement surgery:
— posterior approach using an incision toward the back of the thigh,
— lateral (lateral) approach using an incision on the lateral surface,
— posterolateral approach, using an incision lateral to the hip joint, slightly toward the back of the body,
— an anterior approach using an incision at the front of the hip,
— an anterolateral approach, using an incision lateral to the hip joint, slightly anterior to the front of the thigh,
— a two incision approach, using small incisions both in the groin and on the side of the hip.
It should be noted that different approaches may have different potential benefits and risks, and over time, experts may learn that some minimal approaches produce better results than others. Currently, which type of surgical approach is recommended will depend on the patient’s anatomy and the surgeon’s experience and preference.
A great deal of research is constantly being conducted to improve treatment outcomes and techniques for hip replacement to reduce risks and complications.
Is anterior access considered minimally invasive?
When some patients hear about the anterior approach, they think it involves a small incision. However, surgeons have shown that it is not the length of the incision that makes a difference in recovery, but rather what the surgeon must do to the muscles to enter the hip joint that is indicative of a minimally invasive approach. Over the past two decades, studies have shown that attempting to shorten the surgical incision while using the same approach to hip replacement (and therefore the same muscle incision) does not actually result in any meaningful improvements for patients in terms of pain or recovery. However, the idea behind the anterior approach is that the muscle dissection inside is «minimally invasive,» which means a faster and less painful recovery for most patients.
A patient suffering from chronic joint pain due to arthritis needs to undergo joint replacement surgery. The surgeon will replace the existing joint surfaces with artificial joint prostheses. These prostheses or prosthetic components must adhere to the patient’s bone. How this adhesion is achieved depends on the type of prosthesis used: a cemented prosthesis uses a quick-drying bone cement to help attach it to the bone. A cementless prosthesis, sometimes called a clip-on prosthesis, is specially textured to allow the bone to grow into it, and it holds it in place for a period of time. Before a knee replacement, hip replacement, or shoulder replacement, the surgeon will talk to the patient and decide whether to use cemented prostheses, cementless prostheses, or a combination of the two. The type of components used may depend on the patient’s physiology, the type of surgery being performed, and the surgeon’s preference.
Cementless joint prostheses: advantages and disadvantages.
A cementless denture, also called a «tight fit» denture, has a rough surface or porous coating that encourages bone to grow into it. The new bone growth will only be 1 or 2 mm, so the surgeon must use special tools to shape the bone to fit snugly into the prosthesis. Some prosthetic components have screws or pins to help hold the bone and prosthesis in place until new bone grows in.
Some surgeons prefer cementless components because: they believe that cementless components provide a better long-term bond between the prosthesis and the bone. Cementless components eliminate concerns about possible cement failure. The disadvantages of cementless dentures are as follows:
Pressed dentures require healthy bones. Patients with low bone density due to osteoporosis may not be suitable for these components. It can take up to three months for the bone material to develop into a new joint component.
When natural bone is required to fully ingrow into the new joint components, experts debate whether patients should defer full weight bearing on the new joints while doing so.
How soon can a patient walk with a hip replacement with this prosthesis?
Patients are advised to avoid full joint loading with a cementless prosthesis for the first 4-12 weeks after surgery. Limited partial loading is allowed. This cautious approach lengthens the patient’s rehabilitation schedule, but protects against stress or loosening of the new joint, which can be painful and require a second surgery. Alternatively, some patients may be encouraged to begin applying full body weight to their new joints just a day or two after surgery. Studies of cementless prostheses support this approach, showing that well-supported cementless hip prostheses can handle the pressure. Full loading during early recovery and rehabilitation promotes muscle and bone health and reduces the risk of — deep vein thrombosis. However, research in this area is ongoing. Currently, surgeons must base their rehabilitation recommendations on many factors such as joint replacement, the specific component, patient physiology, and past experience. Patients who are concerned about this problem should talk to their physician.
Alternative methods of prosthetics. Researchers are constantly striving to improve existing prosthetic designs as well as methods of attaching prostheses to bone. For example, recent research has been conducted with components made from highly porous metals such as tantalum. Initial research suggests that tantalum can promote a strong bond between the bone and the prosthesis in a relatively short period of time. This research is still in very early stages and a more detailed clinical study is needed.
Choosing a surgeon for total hip replacement.
It is essential to choose an experienced surgeon for a high likelihood of successful hip replacement surgery. In a study examining data from more than 20,000 Medicare beneficiaries who had hip replacement surgery, researchers found that surgeon experience influenced the likelihood that a patient had complications requiring a second «revision» surgery. Specifically, the authors found that: of patients whose surgeons performed 50 or more hip replacements per year, 0.7% required revision surgery. Of patients whose surgeons performed 6 to 25 hip replacements per year, 1.3% required revision surgery. The difference in revision surgery rates was observed in the first six months after hip replacement surgery. After this time, no significant differences were observed. The same study found no difference in rates between large hospitals and hospitals with low patient flow. Patients have the right to ask their surgeon how often he or she performs hip replacement and about his or her individual success and complication rates.
In addition to choosing a surgeon based on experience with hip replacement, the patient should also choose a surgeon with whom he or she is comfortable talking. The patient and surgeon should have a frank conversation about the time and effort that needs to be put into postoperative rehabilitation, as well as possible short- and long-term outcomes and complications. Patients with specific goals may want to ask about them. Patients who have realistic expectations tend to be more satisfied with surgery.
The decision to perform hip replacement surgery via anterior access should be made on a case-by-case basis. The patient and physician should consider whether the patient is a good candidate for surgery, the cost of surgery and recovery time, and the experience of the surgeon. Traditional hip replacement is available to any patient healthy enough for surgery, regardless of body type. In contrast, some surgeons believe that the best candidates for anterior access hip replacement surgery are patients who are not obese or have overdeveloped muscles. It is possible that even if a patient is considered a good candidate for anterior access hip replacement surgery, he or she should also decide to undergo any surgery.
Another potential benefit of hip replacement surgery through anterior access is financial. A faster recovery can potentially reduce thousands of dollars in medical bills compared to traditional surgery. In addition, patients who work can return to work sooner, shortening the period of disability.
Rehabilitation exercises
People recovering from hip replacement surgery are advised to perform daily hip strengthening exercises.
Exercise:
— increase muscle flexibility and strength, which helps protect joints;
— heal the wound by increasing blood flow. Six weeks after surgery, most patients can lean back and perform exercises 3 or 4 times a week.
It is recommended that patients perform 10 or 15 repetitions of each exercise several times a day.
Leg squeeze. The quadriceps muscles are located at the front of the thigh and help support and control the hip joints. To do the exercise, the patient needs to: lie on their back with their legs stretched out. Next, the quadriceps muscles on the front of the thigh bone should be contracted. During the contraction, the leg should be kept straight, so that it may seem that the back of the knee is pressed down. Hold this state for 5 seconds and then relax the leg. The contraction can strengthen the quadriceps muscles without moving or putting additional stress on the hips.
The gluteal muscles are located at the back of the thigh and also help support and control the hip joints. To do this exercise, the patient should lie on their back with their legs extended. Release the buttocks, contract the gluteal muscles for 5 seconds and relax. When these muscles are contracted, they are strengthened, and there is no additional load on the joint.
Ankle exercises
These exercises help to maintain strength and improve circulation. The patient should lie on their back with their legs and ankles outstretched. While doing so, place the ankles on a towel or blanket. Next, it is necessary to push off with the feet and point the toes up and towards the body for 5 seconds. Next, you should push off with your feet and point your toes down and away from your body for 5 seconds.
These exercises stimulate blood circulation and strength in the ankles to support the hip joint.
Heel slip
This exercise involves both quadriceps and gluteal muscles. To do these exercises, the patient needs to: lie on the back with legs extended. Fix the new joint and knee on the same side, move the knee off the bed and slide the leg along the bed. Lift the other leg straight up. Hold for 10 seconds. These exercises help to strengthen the quadriceps and knee muscles and also improve the patient’s range of motion.
Hip abduction.
The exercises require moving the limb away from the body. The patient should: lie on the back with legs extended. Extend the operated leg straight, toes pointing up, then move the leg to the side, moving away from the body centerline. After that, move the leg back to the centerline of the body (you must not go behind the body centerline, this can lead to dislocation). Keep the other leg straight. The exercise can be done standing with the arms resting against the back of a chair. When and if the patient is ready, the physical therapist can demonstrate how to add resistance with an elastic band, making the exercise more challenging. Such exercises help stabilize the pelvis and encourage normal walking.
In fact, there are dozens of hip strengthening exercises that may be appropriate for patients after prosthetics. An orthotist or physical therapist can design an exercise program tailored to the needs of the individual patient.
Indications for total hip replacement.
Moderate to severe arthritis of the hip, including osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis that causes pain and/or interferes with living. For example: walking, climbing up stairs.
Pain, moderate to severe, even at rest, which can affect sleep.
Degeneration of the joint causes stiffness that affects the patient’s range of motion during normal activities;
Symptoms that cannot be adequately managed by non-surgical methods such as: nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, steroid injections, or the use of a walker.
About 90% of patients who have had a hip replacement have hip osteoarthritis.
In addition to arthritis, some patients have surgery for fractures (e.g., «broken hip») or other conditions such as osteonecrosis (bone death caused by inadequate blood supply).
Contraindications
Choosing the right patient can improve the chances of successful surgery and reduce the risk of complications after surgery. Some patients are not indicated for surgery, while others may have an increased risk of postoperative complications.
The reasons for this are.
Infection. Preexisting infection is an absolute contraindication, and patients who are prone to infection may not be allowed to undergo surgery. Serious cases of postoperative infection may result in the patient being transferred to the hospital, require prolonged courses of intravenous antibiotics, and in some cases require removal of the artificial hip.
Nicotine. Smokers and other tobacco users face a higher incidence of medical complications and a higher risk of needing subsequent surgery or revision. To reduce postoperative risks, candidates for total hip replacement are advised to quit smoking or reduce the frequency of tobacco use.
Osteoporosis. Severe osteoporosis may be a contraindication for surgery because the bones may be too fragile to properly support and hold the new prosthesis. Mild to moderate osteoporosis is not a contraindication for hip replacement surgery; however, it may affect how the surgeon plans the surgery. The surgeon may prefer to use bone cement rather than cement adhesion to attach the new prosthesis to the existing bone. The surgeon may want to take steps to improve bone density before surgery. This treatment may continue after surgery to increase the life of the hip joint.
Other factors. For example, people with dementia or alcoholism are more prone to dangerous falls and cannot reliably follow surgeons’ recommendations. Both factors can jeopardize the success of the procedure if the implant does not press against the bones, the bones around the implants break, or dislocation occurs.
Weight and age requirements. People who are 19 years of age and up to 90 years of age can have hip replacements. Although the upper limit increases, patients who are older often have medical conditions such as type II diabetes or cardiovascular disease that can increase the risk of postoperative complications. There are no set weight limits at which hip replacement surgery can be performed; however, excessive weight can reduce the lifespan of the joint implant. In addition, obese patients are more prone to complications, postoperative infections and wound healing complications. Although the risk of infection in obese patients is still relatively low, it is recommended that overweight patients reduce their weight before surgery.
Pain management after surgery.
In the post-surgical days, some patients’ pain is as bad or worse than their initial arthritic pain. This post-surgical pain is temporary, but it can cause prolonged recovery and rehabilitation if left untreated.
The benefits of pain relief include increased comfort for the patient.
Every patient has some degree of post-surgical pain, and effective management of this pain can make a significant difference in patient comfort.
Earlier rehabilitation. A patient whose pain is under control and is more likely to get out of bed and perform rehabilitation exercises sooner. When performed under the guidance and supervision of a surgeon and physical therapist, postoperative exercises can help reduce scar tissue development, increase range of motion, and increase the likelihood of a successful recovery. Reduced risk of deep vein thrombosis (DVT). Patients who have undergone joint replacement are at greater risk of developing a blood clot in the deep veins. When a patient’s pain is under control, he or she can move around and perform rehabilitation exercises that improve circulation and therefore reduce the risk of DVT. The sooner the patient’s pain is under control, the sooner he or she can be discharged from the hospital. Increased risk of infection. Because of the threat of hospital infections such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), early rehabilitation can reduce the chances of infection.