It is very common, in daily practice, for the orthopedic surgeon to be asked to answer a series of patients’ questions on total hip arthroplasty. Many of these have been created by some “myths” that are prevalent on the Internet, or even by human fears in connection with surgical procedures.

 

What is the anatomical structure of the hip?

The hip joint serves as a bridge between the pelvis and the lower limb. It is formed between the head of the femur and the acetabulum. The head is hemispherical and the acetabulum concave, while the bone surfaces are covered with articular cartilage.

 

What is Total Hip Arthroplasty?

Total hip arthroplasty aims at replacing the damaged joint with an artificial one. During surgery, the worn head of the femur is removed and a metallic rod is fixed in its place and the acetabulum is prepared so that a hemispherical artificial acetabulum can be adjusted. A metallic or ceramic head is attached on the femoral metallic rod, while a polyethylene, ceramic or metallic prosthesis is placed on the acetabulum.

Usually the metallic rod is inserted into the femur without the application of synthetic material (“cement”). The surfaces of the materials are appropriately treated and coated to facilitate the incorporation of the material into the bone. In some cases, no metallic rod is inserted in the femur, but a special metallic coating (surface arthroplasty) is applied.

 

What Is the Minimally Invasive Total Hip Arthroplasty?

It is a surgical technique where the surgery is performed with smaller incisions on the skin. Apart from this, there is no difference from the standard arthroplasty. Minor surgical trauma facilitates the recovery of the patient immediately after surgery. But after the first month of surgery there is no difference between the two surgical techniques. Minimally invasive techniques should be performed by specialized surgeons, as otherwise there is high probability of serious complications. Younger, thin, healthy patients with strong motivation for rapid recovery are usually selected. The advantages of this technique include less pain, smaller incisions, less damage to healthy tissues and, perhaps, faster recovery. In the long run, there is no difference between the two techniques.

 

Is it possible to undergo arthroplasty on both hips simultaneously?

Bilateral arthroplasty can be performed, but it is avoided on the knees, as opposed to the hips due to the increased likelihood of complications. The burden of recovery, of course, and the burden of surgery are significantly higher. It is usually preferred to perform the procedures in succession with an interval of 3-6 months.

 

Does arthroplasty on one hip imply that the other hip will need arthroplasty as well?

In most cases arthritis is unilateral, that is, it is limited to just one knee or hip joint. Correcting the problem, however, does delay arthroplasty on the other side of the body.

 

What are the most common causes leading to total arthroplasty?

Arthroplasty is performed to treat hip arthritis. The most common causes of hip arthritis are the following:

  • Osteoarthritis, primary, secondary and congenital
  • Rheumatoid arthritis
  • Traumatic arthritis
  • Aseptic necrosis
  • Tumors

 

What are the indications for hip arthroplasty?

Arthroplasty is performed in patients with severe hip arthritis and significant symptoms, such as:

  • Significant pain that limits the ability to work and leisure, significantly affecting the quality of the patient’s life
  • Moderate or severe pain during rest, day or night
  • Pain that does not subside with analgesics, physiotherapy or the use of a walking cane
  • Stiffness with significant reduction in knee mobility
  • Deformation of the lower extremities
  • Complications due to drug use
  • Failure of conservative treatment

Patients are usually over 60 years of age and report significant pain, especially when moving, as well as limited functionality.

 

What are the goals of the surgical procedure?

Arthroplasty is performed to treat pain, stiffness and decreased functionality, as well as to improve the quality of the patient’s life. After surgery, the patient may return to the normal daily activities, but joint over-charging is not desirable.

 

What are the success rates of total hip replacement?

Studies have shown that more than 97% of patients undergoing such surgery were very satisfied with the result.

 

What is and how is arthroplasty dislocation treated?

A dislocation may occur in 3% of arthroplasty surgeries. It is often due to the patient’s non-compliance with post-operative instructions or due to loose tissues and muscles or improper placement of materials. The first dislocation is treated with a closed reduction, while in the case of multiple relapses, it is necessary to repeat the arthroplasty procedure.

 

What is and how is arthroplasty loosening treated?

Arthroplasty loosening is the detachment of the prosthetic materials from either the bone or each other. The patient feels pain that did not exist before and functional limitation. This problem is addressed by a revision of the procedure.

 

Is it correct that hip arthroplasty should be delayed as much as possible?

This is completely wrong. It is preferable for the patient to undergo surgery earlier in life in order to achieve a better functional outcome. Delaying surgery reduces quality of life both before and after surgery. There is also no conservative treatment for osteoarthritis. The condition will evolve and the patient may need to undergo surgery at an older age and possibly with more complications.

What parts and materials are used in total hip arthroplasty?

Hip arthroplasty consists of the acetabulum, the plastic cup, the head and the femoral metallic rod.

The metallic parts are made of titanium or chromium-cobalt, the cup is made of polyethylene and the head is either metallic or ceramic.

There are many types of arthroplasty with different design, size and materials. In selected patients it is possible to fabricate materials that fully apply to their own bones.

 

What is the longevity of total hip replacement components?

The longevity of arthroplasty depends on the wear resistance of the materials, especially of polyethylene, the weight charging, the quality of the bone, etc. The lifespan of materials statistically ranges from 1 month to 35 years. In general, however, hip arthroplasty is expected to last 20 years in 80% of patients.

 

What happens if the artificial joint is damaged?

If the artificial joint is worn, it can be restored 1 or 2 times with revision surgery.

 

What does preparation for total hip arthroplasty involve?

Preparing for surgery involves improving the patient’s overall physical condition and health. It is useful to improve the patient’s mobility and muscular strength before surgery, in order to improve post-operative recovery. Before surgery the patient is examined by an internist, a cardiologist and an anesthesiologist, while all necessary blood and urine tests are performed to prepare the patient physically and psychologically for surgery.

It is often necessary to discontinue some medications pre-operatively, such as anticoagulants (aspirin, Sintrom, Plavix), anti-inflammatory and cytostatic drugs.

 

Is blood transfusion necessary during surgery?

Usually, in most patients, blood transfusions are not necessary due to modern atraumatic surgical techniques that reduce intraoperative bleeding. However, it is always required to deposit 1-2 units of blood for safety reasons.

Preoperatively, it is possible to raise blood hemoglobin by administering erythropoietin, a hormone that increases the production of red blood cells. It is administered subcutaneously for 3 weeks before surgery along with iron supplements. Some patients may donate autologous blood between 42 and 7 days before surgery. This blood is stored and transfused, if necessary.

An intraoperative self-transfusion device is used during the procedure in which the blood collected from the surgical field is filtered and re-administered. Many patients receive intraoperatively tranexamic acid, a substance that reduces bleeding. Postoperatively, the blood collected from the wound drainage for 4-6 days is re-administered.

 

What kind of anesthesia is used during surgery?

Epidural anesthesia and analgesia are commonly used. The anesthesiologist inserts a catheter under local anesthesia and painlessly into the epidural space, which is located far from the spinal nerves. Through this catheter a local anesthetic is administered to anesthetize the lower extremities. This catheter is connected to a small pump for continuous infusion of local anesthetic, throughout the postoperative period, thus achieving excellent analgesia. During the operation, anesthesia is provided so that the patient is asleep and does not hear the annoying noises in the operating room.

 

How is hip arthroplasty performed?

During surgery, a small incision is made in the hip area and the neck and head of the femur are removed. The acetabulum is slightly enlarged to remove the damaged articular cartilage and the new metallic hemispherical acetabulum and the polyethylene cup are inserted.

In the femur the lumen is enlarged and the metallic rod is inserted with or without synthetic cement. Then, the hip joint is reduced and its length and stability are tested. Finally, the head is properly positioned and the hip joint is permanently recomposed. The wound is stitched and the patient is transferred to recovery. The duration of the operation is between 45 and 60 minutes.

 

What do I need to bring to the clinic with me?

Elbow crutches or a walking frame, pajamas or nightgown, flat shoes with non-slip soles, a basin lift and personal hygiene products.

 

 

Does the patient feel pain during hospitalization and afterwards?

In most cases, patients do not feel any pain or minimal pain is experienced during the first hours and days after surgery. In the following weeks the pain almost totally subsides.

As a surgical operation, total hip arthroplasty cannot be completely painless and bloodless, since artificial materials need to be inserted into the body. However, as noted above, the pain is now minimized for the patient, while with the new available techniques blood loss is usually insignificant.

 

What happens after surgery?

The patient remains in the recovery room for approximately 1 hour. Bed mobilization begins in the afternoon of the operating day and the following day walking with the supervision of physiotherapists is recommended. Antibiotics are administered for 48 hours, during which the presence of a urinary catheter is required. Hospitalization lasts for 3-4 days. The use of a walking cane is necessary for 4-6 weeks after surgery.

 

What should the patient expect from hip arthroplasty?

Arthroplasty is performed to achieve analgesia, which is achieved in 95% of patients. It allows patients to carry out their daily activities comfortably. Under certain circumstances, sports activities may also be permitted. Most patients regain the mobility they had lost.

 

When can I walk after surgery?

The patient is able to stand up on the same day. The next day he/she shall take the first steps, and usually on the second day he/she is able to climb stairs. The patient can use the toilet without help.

 

When can I drive?

Driving is generally not recommended during the first weeks after surgery, not only for medical, but also for legal reasons (e.g. involvement in a car accident).

 

 

 

 

When can I get back to work?

Someone who works in an office can return to work after 3 to 6 weeks. For manual labor, the return is personalized depending on the patient and the particular circumstances of his / her work, but is generally recommended after 3 months.

 

How many days do I need to be hospitalized in the clinic?

The duration of hospitalization depends on the patient’s age and other potential pathological problems that co-exist. However, in general, hospitalization in the clinic lasts from 2 to 4 days.

 

Are muscles cut during surgery?

The muscles are not cut but separated, and at the end of the procedure they are relocated to their original position. This is why the patient is able to stand and walk immediately after surgery.

 

Do I need to be admitted to a rehabilitation center postoperatively?

This is rarely needed, especially in young patients. But in cases of elderly patients, or when there is no family support, it is preferable to stay in a rehabilitation center for a few weeks.

 

Are there any risks and complications connected to this surgical procedure?

As with all surgeries in medicine, so there is always the possibility of some complications. But nowadays their percentage is very low, ranging from about 1 to 1.5%.

 

For how long will the materials in my body be in good condition?

Recent studies have shown that the vast majority of patients, about 95 in 100, will keep these materials for 10 years. For some of the materials we use, studies have proven durability up to 90% in 30 years. Thus, an average patient can expect good condition of the arthroplasty materials for 15 to 25 years.

 

 

 

 

Can I get involved in sports after surgery?

In most cases, patients can do everything. However, non-vibration training (e.g. avoiding basketball, soccer) is generally recommended and engaging in less weight-charging activities (e.g. double tennis, cycling, dancing).

 

When can I have sex postoperatively?

It is recommended after a period of about 3 to 6 weeks, depending on the patient, and with special attention to posture. However, especially after 3 months, the person can return to normal sexual activity.

 

If I suffer from osteoarthritis on both hips, what is the best strategy for me?

Can I undergo bilateral hip arthroplasty simultaneously? It is generally recommended to operate one hip at first and after 3 to 6 months to operate the other one. Bilateral hip arthroplasty is rarely performed, because it is very difficult to position the patient after surgery. However, after the first surgery the patient will notice that the operated side is longer than the other, as elongation is almost unavoidable. However, this disequilibrium is usually not significant, and is of course corrected when the other hip is operated.

 

Does the above information apply to all cases?

The above information provides a general idea of ​​the total hip arthroplasty surgery. However, as each patient is a unique case, you should discuss with your orthopedist about the particular conditions and risks.