Hip replacement, also
hip arthroplastyArthroplasty is an operative procedure of orthopedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure.-Background:Previously, a popular form of arthroplasty was...
, is a
surgicalSurgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, or sometimes for some other reason...
procedure in which the hip joint is replaced by a prosthetic
implantAn implant is a medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance and existing biological structure. Medical implants are man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue...
. Such joint replacement orthopaedic surgery generally is conducted to relieve
arthritisArthritis is a group of conditions involving damage to the joints of the body....
painPhysical Pain is the unpleasant feeling common to a headache and a stubbed toe. It typically consists of negative affect and aversion, and has location, duration, intensity and a distinctive quality...
or fix severe physical joint damage as part of
hip fracture treatmentHip fractures are treated in one of two ways: Traction or orthopedic surgery.-Non-operative treatment:If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal traction may be considered for long term treatment...
.
History
The earliest recorded attempts at hip replacement (Gluck T, 1891), which were carried out in Germany, used ivory to replace the femoral head (the ball on the femur).
In 1940, at
Johns HopkinsJohns Hopkins was a wealthy entrepreneur, philanthropist, and abolitionist of 19th century Baltimore, now most noted for his philanthropic creation of the institutions that bear his name, namely the Johns Hopkins Hospital, the Johns Hopkins University and its associated divisions, in particular...
hospital, Dr.Austin T. Moore(1899-1963), an American surgeon, reported and performed the first metallic hip replacement surgery. The original prosthesis he designed was a proximal femoral replacement, with a large fixed head, made of the Cobalt-Chrome alloy
VitalliumVitallium is a trademark for an alloy of 60% cobalt, 20% chromium, 5% molybdenum, and other substances. The alloy is used in dentistry and artificial joints, because of its light weight and resistance to corrosion. It is also used for components of turbochargers because of its thermal resistance....
. It was about a foot in length and it bolted to the resected end of the femoral shaft (hemi-athroplasty). This was unlike later (and current) hip replacement prostheses which are inserted within the medullary canal of the femur. A later version of Dr. Moore's prosthesis, the so-called 'Austin Moore', introduced in 1952 is still in use today.
In 1960 a Burmese orthopaedic surgeon, Dr. San Baw (29 June 1922—7 December 1984), pioneered the use of
ivoryIvory is formed from dentine and constitutes the bulk of the teeth and tusks of animals such as the elephant, hippopotamus, walrus, mammoth and narwhal....
hip prostheses to replace ununited fractures of the neck of
femurThe femur, or thigh bone, is the most proximal bone of the leg in vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs...
("hip bones"), when he first used an ivory prosthesis to replace the fractured hip bone of an 83 year old Burmese Buddhist nun, Daw Punya. This was done while Dr. San Baw was the chief of orthopaedic surgery at
Mandalay General HospitalThe University of Medicine, Mandalay , located in Mandalay is one of four medical universities in Myanmar. The university offers M.B.,B.S. degrees and graduate studies degrees in medical science...
in Mandalay, Burma. Dr. San Baw used over 300 ivory hip replacements from the 1960s to 1980s. He presented a paper entitled "Ivory hip replacements for ununited fractures of the neck of femur" at the conference of the British Orthopaedic Association held in London in September 1969. An 88% success rate was discerned in that Dr. San Baw's patients ranging from the ages of 24 to 87 were able to walk, squat, ride a bicycle and play football a few weeks after their fractured hip bones were replaced with ivory prostheses. Ivory may have been used because it was cheaper than metal at that time in Burma and also was thought to have good biomechanical properties including "biological bonding" of ivory with the human tissues nearby. An extract from Dr San Baw's paper, which he presented at the British Orthopaedic Association's Conference in 1969, is published in Journal of Bone and Joint Surgery (British edition), February 1970. With modern hip replacement surgery, one can expect to walk, using crutches for support or even just a cane for balance, within a week.
Modern process
The modern artificial joint owes much to the work of
John CharnleySir John Charnley was a British orthopaedic surgeon. He pioneered the hip replacement operation, which is now one of the most common operations both in the UK and elsewhere in the world...
at Wrightington Hospital; his work in the field of
tribologyTribology is the science and technology of interacting surfaces in relative motion. It includes the study and application of the principles of friction, lubrication and wear...
resulted in a design that almost completely replaced the other designs by the 1970s. Charnley's design consisted of three parts—
- a metal (originally stainless steel
In metallurgy, stainless steel, also known as inox steel or inox, is defined as a steel alloy with a minimum of 11% chromium content by mass. Stainless steel does not stain, corrode, or rust as easily as ordinary steel...
) femoral component,
- a teflon acetabular component, the wear debris of which resulted in a condition called Osteolysis, and so it was replaced by Ultra High Molecular Weight Polyethylene
Polyethylene or polythene is the most widely used plastic, with an annual production of approximately 80 million metric tons. Its primary use is within packaging .- Description :Polyethylene is a thermoplastic polymer consisting of long chains of the monomer ethylene...
or UHMWPE in 1962, both of which were fixed to the bone using
- PMMA (acrylic) bone cement
Bone cements have been used very successfully to anchor artificial joints for more than half a century. Artificial joints are anchored with bone cement. The bone cement fills the free space between the prosthesis and the bone and plays the important role of an elastic zone...
, and/or screws.
The replacement joint, which was known as the Low Friction
ArthroplastyArthroplasty is an operative procedure of orthopedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure.-Background:Previously, a popular form of arthroplasty was...
, was lubricated with
synovial fluidSynovial fluid is a thick, stringy fluid found in the cavities of synovial joints. With its sperm-like consistency , synovial fluid reduces friction between the articular cartilage and other tissues in joints to lubricate and cushion them during movement.-Overview:The inner membrane of synovial...
. The small femoral head (7/8" (22.2 mm)) was chosen for its decreased wear rate; however, this has relatively poor stability (the larger the head of a replacement the less likely it is to dislocate, but the more wear debris produced due to the increased surface area). For over two decades, the Charnley Low Friction Arthroplasty, and subsequent similar designs were the most used systems in the world, far surpassing the other available options (like McKee and Ring). Recently the use of a polished tapered cemented hip replacement (like Exeter) and uncemented hip replacements have become more popular. Cemented stems are commonly used in older patients due to their lower cost, including the Austin Moore proximal femoral replacement for Medicaid patients, while more modern and longer lasting 'cementless' stems, often coated in Hydroxy-Apatite Ceramic, are used in 'younger' and more physically active patients. Once an uncommon operation, hip replacement is now common, even among active athletes including racecar drivers
Bobby LabonteRobert Alan Labonte is an American race car driver in the Nascar Sprint Cup Series. He currently drives the #96 Ask.com/Texas Instruments DLP HDTV/Academy Sports + Outdoors Ford Fusion for Hall of Fame Racing, in an association with Yates Racing and the #71 TaxSlayer.com car for The Racer's Group....
and
Dale JarrettDale Arnold Jarrett is a former American race car driver. He is the 1999 NASCAR Winston Cup Champion and the son of two-time NASCAR Grand National Champion Ned Jarrett. He is the younger brother of Glenn Jarrett, a former NASCAR driver himself and pit commentator. He is also the father of former...
.
Costs
IN 2008, hip replacements in the U.S. cost about $45,000.
In 2008, a source quoted US$7–9,000 in India at an internationally accredited hospital; in a county in
FloridaFlorida is a state located in the southeastern region of the United States, bordering Alabama to the northwest and Georgia to the north. It was the 27th state admitted to the United States...
, USA, from $41,597-$56,258 , most likely the total costs for cementless devices, was quoted.
Surgery costs vary from country to country, with the US typically being among the highest-priced markets, and countries like Thailand, Cuba and Argentina, among the lowest.
Complications
In the long term, many problems relate to osteolysis from acrylic bone cement debris, and/or wear debris. An
inflammatoryInflammation is the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli as well as initiate the healing process for the tissue. Inflammation is not a...
process causes bone resorption and subsequent loosening or fracture often requiring revision surgery. Very hard ceramic bearing surfaces are being used in the hope that they will have less wear and less osteolysis with better long term results. Large metal heads are also used for similar reasons as these also have excellent wear characteristics and benefit from a different mode of lubrication. However large fixed metal heads,such as the Austin Moore devices, can result in
protrusio acetabuliProtrusio acetabuli is an uncommon defect of the acetabulum. The acetabulum is the socket that receives the femoral head to make the hip joint. It is composed of three bones, the ilium, the ischium and the pubis. The socket is too deep and may protrude into the pelvis...
. A greater head neck ratio also contributes to stability. These new prostheses do not always have the long term track record of established metal on poly bearings.
Post operative sciatic nerve palsy is another possible complication.
A few patients who have had a hip replacement suffer chronic pain after the surgery despite normal imaging.
Indications
Total hip replacement is most commonly used to treat joint failure caused by
osteoarthritisOsteoarthritis , is a group of diseases and mechanical abnormalities involving degradation of joints, including articular cartilage and the subchondral bone next to it...
. Other indications include
rheumatoid arthritisRheumatoid arthritis is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks the joints producing an inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints...
,
avascular necrosisAvascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to an area of bone. Without blood, the bone tissue dies and the bone collapses...
, traumatic arthritis,
protrusio acetabuliProtrusio acetabuli is an uncommon defect of the acetabulum. The acetabulum is the socket that receives the femoral head to make the hip joint. It is composed of three bones, the ilium, the ischium and the pubis. The socket is too deep and may protrude into the pelvis...
, certain
hip fractureA hip fracture is a fracture in the proximal end of the femur , near the hip joint.The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall or minor...
s, benign and malignant
bone tumorA bone tumor refers to a neoplastic growth of tissue in bone. It can be used for both benign and malignant abnormal growths found in bone, but is most commonly used for primary tumors of bone, such as osteosarcoma. It is may be applied to secondary bone tumors, i.e...
s, arthritis associated with
Paget's diseaseSir James Paget, a prolific surgeon and pathologist, described several diseases, including:* Paget's disease of bone * Paget's disease of the breast* Paget-Schroetter disease* Extramammary Paget's disease...
,
ankylosing spondylitisAnkylosing spondylitis , previously known as Bechterew's disease, Bechterew syndrome, and Marie Strümpell disease, a form of Spondyloarthritis, is a chronic, inflammatory arthritis and autoimmune disease...
and juvenile rheumatoid arthritis. The aims of the procedure are pain relief and improvement in hip function. Hip replacement is usually considered only once other therapies, such as
physical therapyPhysical therapy is a health care profession which provides services to individuals in order to develop, maintain and restore maximum movement and functional ability throughout life...
and pain medications, have failed.
Techniques
There are several different incisions, defined by their relation to the gluteus medius. The approaches are posterior (Moore), lateral (Hardinge or Liverpool), antero-lateral (Watson-Jones), anterior (Smith-Petersen) and
greater trochanterThe greater trochanter of the femur is a large, irregular, quadrilateral eminence and a part of the skeletal system.It is directed a little lateralward and backward, and, in the adult, is about 1 cm lower than the head...
osteotomy. There is no compelling evidence in the literature for any particular approach, but consensus of professional opinion favours either modified anterio-lateral (Hardinge) or posterior approach.
- The posterior (Moore) approach accesses the joint through the back, taking piriformis muscle
The piriformis is a muscle in the gluteal region of the lower limb.-Origin and insertion:It originates from the anterior part of the sacrum, the part of the spine in the gluteal region, and from the superior margin of the greater sciatic notch...
and the short external rotators off the femur. This approach gives excellent access to the acetabulum and preserves the hip abductors. Critics cite a higher dislocation rate, although repair of the capsule and the short external rotators negates this risk.
- The lateral approach is also commonly used for hip replacement. The approach requires elevation of the hip abductors (gluteus medius and gluteus minimus) in order to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires (as per Charnley), or may be divided at their tendinous portion, or through the functional tendon (as per Hardinge) and repaired using sutures.
- The anterolateral approach develops the interval between the tensor fasciae latae
The tensor fasciae latae or tensor fasciæ latæ is a muscle of the thigh.-Origin and insertion:It arises from the anterior part of the outer lip of the iliac crest; from the outer surface of the anterior superior iliac spine, and part of the outer border of the notch below it, between the gluteus...
and the gluteus medius.
- The anterior approach utilises an interval between the sartorius and tensor fascia latae.
The double incision surgery and minimally invasive surgery seeks to reduce soft tissue damage through reducing the size of the incision. However component positioning accuracy is impaired and surgeons using these approaches are advised to use computer guidance systems.
Alternatives to Hip Replacement
The first line approach as an alternative to hip replacement is conservative management which involves a multimodal approach of medication, activity modification and physical therapy. Conservative management can prevent or delay the need for hip replacement.
Hip resurfacingHip resurfacing is a form of arthroplasty which has been developed as an earlier intervention alternative to total hip replacement . The potential advantages of hip resurfacing include less bone removal , a potentially lower number of hip dislocations due to a relatively larger femoral head size,...
is an alternative to hip replacement surgery. It is a bone conserving procedure that places a metal cap on the femoral head instead of amputating it. There is no long stem placed down the femur so it is more like a natural hip and allows patients a full return to all activities, including marathons and triathlons, some patients have even completed Ironman and Ultraman competitions following hip resurfacing surgery although patients must have good bone quality to qualify for it. It has been used in Europe for over 17 years and the first device, the BHR or Birmingham Hip Resurfacing device was approved by the FDA on May 9, 2006.
Current alternatives also include viscosupplementation, or the injection of artificial lubricants into the joint. Some believe the future of osteoarthritis treatment is bioengineering, targeting the growth and/or repair of the damaged, arthritic joint. Centeno et al. have reported on the partial regeneration of an arthritic human hip joint using mesenchymal stem cells in one patient. It is yet to be shown that this result will apply to a larger group of patients and result in significant benefits.
The FDA has stated that this procedure is being practiced without conforming to regulations, but Centeno claims it is exempt from FDA regulation. It has not been shown in controlled clinical trials to be effective, and costs over $7,000.
See also
- Hip examination
In medicine, the hip examination, or hip exam, is undertaken when a patient has a complaint of hip pain and/or signs and/or symptoms suggestive of hip joint pathology...
- Hemiarthroplasty
Hemiarthroplasty is a surgical procedure which replaces one half of the joint with an artificial surface and leaves the other part in its natural state. This class of procedure is most commonly performed on the hip after a subcapital fracture the neck of the femur...
- Femoral Acetabular Impingement
Femoral Acetabular Impingement is a condition affecting the hip joint.-Overview:This affliction, not yet accepted in its entirety by the medical field, is characterised by abnormal contact between the proximal femur and rim of the acetabulum...
- Abductor wedge
An abductor wedge is designed to separate the legs of a patient. It is often used after hip surgery to prevent the new hip from "popping out"....
External links