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Total Hip Replacement/Direct Anterior Total Hip Replacement

Although we utilize many joint preservation techniques, there are times when the arthritis or general condition is severe enough to warrant a joint replacement. Joint replacement surgery is one of medicine's greatest advancements. People who are crippled to the point that they can't walk, stand, or participate in meaningful physical activity have the opportunity to significantly improve their ability to function while relieving their pain. All joint replacements remove the diseased bone and replace it with metal, ceramic, or plastic. The majority of the muscles, tendons, and other supporting structures of the joint are left in place.

Many of our patient's want to know what the latest advancements in joint replacement are, and if these options are available to them. Most of the advancements involve three areas: anterior total hip replacement (direct anterior approach), minimally invasive techniques, and pain control.

Knee Replacement

Minimally Invasive Techniques

When the phrase, "minimally invasive" gained popularity in the early 2000's, most surgeons and patients were speaking about the smaller size of the incision. We quickly learned that the size of the incision had little effect on the function of the joint replacement. In fact, incisions that were too small resulted in the incorrect positioning of implants.

Currently, "minimally invasive" surgery refers to "minimal damage" to surrounding tissues. It refers to handling deeper tissues (below the skin) such as muscle in a manner that results in the least amount of disruption possible. In our practice, every surgery we perform meets minimally invasive criteria. We put in a great deal of effort to make sure there is as little damage to the surrounding tissues as possible.

Although it is not commonly referred to as minimally invasive surgery, arthroscopy is the original minimally invasive surgery. Therefore, arthroscopy is the preferred treatment for many conditions such as tears of the meniscus, rotator cuff, and anterior cruciate ligament. Arthroscopy can also be performed on the hip to address labral tears and impingement. See section on Hip Arthroscopy.

However, the term "minimally invasive" is most commonly used when referring to total joint replacement surgery. In the 2000's, shoulder, knee and hip replacement patients used to stay in the hospital for 5-7 days. Now, most patients stay a few days, and many total joint replacement patients can go home the same day. This is primarily a result of changes in the surgical techniques that result in less damage to the surrounding tissues. This results in a more rapid return to activities.

For example, this advantage was clearly seen in the faster recovery times experienced by patients undergoing the anterior total hip replacement. My earliest experience with anterior total hip replacement was 2005. However, it wasn't until some of the techniques were modified that I noticed the advantages. It became part of my practice in 2008. At that time it was truly remarkable to see how quickly patients recovered by altering our technique. This operation taught us that the most important thing was minimizing damage to the surrounding structures. The lessons learned were then applied to other areas of the body and different types of surgeries including fracture repair. When we applied those same principles of minimizing damage to the soft tissues to posterior total hip replacement, the difference in outcomes between the anterior and posterior total hip replacement was minimized. Therefore, like all decisions in our clinic, the decision about what approach is made after considering all of the factors and a discussion with our patients. We feel that hip replacement, whether done anteriorly or posteriorly, is typically a positive life altering experience for patients.

We continue to keep a close watch on advancements in surgical techniques and implants. We strongly believe that there is a balance between new and established technology. New technology must be equal to, or better than what we currently use. With all new technology, the hope is that we can improve our current techniques. Shoulder, knee, and hip replacement surgeries have been some of the most successful surgeries in all of medicine. However, in the effort to improve those surgeries, there is always the potential that new techniques will result in outcomes that are not as good as what can be achieved with proven techniques. This is why academic studies that objectively evaluate new technologies and techniques are required

For example, one of the historical problems with hip replacement surgery was that the plastic liner between the femur and tibia components would wear out. In addition, the particles generated by the worn out plastic liner caused the patient's own white blood cells to react in such a way that they caused loosening of the implants. Unfortunately, this resulted in revision (repeat) hip surgery.

In response, ceramic implants were developed because they have superior wear characteristics to the traditional metal on plastic. However, it became clear that the ceramics were brittle and could fracture (break). Improvements were made to the ceramics, but then some patients noted squeaking. To address this issue the material used to manufacture the plastic liners was changed from polyethylene to cross-linked polyethylene. At the same time, metal-metal implants gained popularity. They gained popularity because they had superior wear characteristics to metal-on-plastic (polyethylene) implants. The metal was not prone to fracture. In addition, since metal was so durable, the head (ball) could be made larger. This had the potential to increase range of motion of the hip and reduce the chance of dislocation (where the ball pops out of the socket).

Well, we all know what happened next. After some time the reports of failed metal-metal hips increased and, the percentage of successful outcomes of the most successful operation in all of medicine (total hip replacement) decreased. Rather, this was a classic case of science trying to make something that was good even better. In science, often advances initially have these types of consequences. It's part of the learning process that ultimately results in permanent achievements.

At the Evangelista Orthopedic Clinic, we strongly support the scientific process. Without it, there wouldn't be any advances. However, in our practice, we feel that it is important that the techniques and implants we use have an established track record. That means we like to see that they have been used successfully, without any new or increased incidence of complications, for years. We will consider the use a new technique or device if there is a clear benefit with little or no patient risk.

Most hip replacements now use metal on cross-linked polyethylene. Studies suggest that the cross-linked polyethylene has outstanding long-term results without the problems associated with regular polyethylene. Hip replacements are now expected to last throughout the patient's lifetime.

Many patients have questions about the type of implants used or the manufacturer. Like all big businesses, competition among the manufacturers has resulted in large marketing campaigns. There are reports of improved motion, gender specific knees, as well as other claims. The truth is that all of the major manufacturers have great products. Furthermore, although there are some differences, they all provide implants that have good long-term results. They all can achieve excellent range of motion. In the early days of knee replacement, there were only a few sizes to choose from. Now, most of the manufacturers have many sizes to choose from. It is the different sizes that are most important, not whether they are labeled male or female. We have experience with all of the major manufacturers. We do not have any consulting agreements with the joint replacement companies and we do not receive any royalties. We use the implants we use because we feel they give our patients the best results. If you are having a joint replacement, we recommend you choose a surgeon based on whatever criteria are important to you, but we don't think that criteria should include whether they use a particular company or product.

Pain Control

Any discussion about joint replacement must include pain control. All of the joint replacements (total shoulder replacement, reverse total shoulder replacement, total knee replacement, partial knee replacement, anterior total hip replacement, posterior total hip replacement) have benefitted from advances in pain control.

As discussed above, minimally invasive surgery refers to the handling of the deeper tissues in the body. With less damage to surrounding tissues, the pain is decreased and recovery is faster. The other portion involves the things we can do before, during, or after surgery to decrease pain and speed recovery.

In the following section, we include a brief discussion about anesthesia because we feel it is a critical and often overlooked component in surgery. Anesthesia has evolved from a time when it was enough to put the patient asleep for a procedure and then wake them up. Today, anesthesia is much more complex. In addition, orthopedic surgery is unique, and the skills required of the anesthesiologist are different than some of the other surgical specialties

One of the fundamental principles guiding modern day orthopedic surgery is early mobilization (getting patients out of bed and moving). We know that the incidence of complications (blood clots, pneumonia, nausea) is decreased when patients begin walking as soon as possible. Anesthesia plays a critical role in this. The more general anesthesia someone receives, the more likely they are to be tired, dizzy, and nauseous. The more pain someone has, the less likely they are to want to get out of bed.

We have worked very hard to decrease the amount of general anesthesia patients receive. In order to achieve this, we select anesthesiologists who are experienced in total joint replacement. When possible, we prefer spinal anesthesia. This allows the anesthesiologist to use less anesthesia during the surgery, decreasing nausea as well as the post-operative requirements for narcotics.

The combination of various oral and topical medications also decreases the pain following surgery. Oral medications account for many of the undesired effects following surgery (sedation, nausea, constipation). However, by using multiple oral medications (anti-inflammatory, muscle relaxer, narcotic) and topical medications, we can decrease those undesired effects.

In our opinion, the use of special anesthesiologists and different combinations of oral and topical medications, has fundamentally changed joint replacement surgery. With less pain, patients begin working with a physical therapist the day of surgery. We expect all of our patients to walk the day of surgery. We believe this decreases the risk of complications and makes the transition home easier. Patients no longer need to stay in the hospital more than a few days. Some patients will choose to go home the same day.