Artificial hip replacement

the total hip replacement surgery that associated with severe hip arthrosis, is considered as reliable and effective operation, which aims to reduce pain, increase mobility and functionality and increase quality of life.

Introduction to artificial hip replacement

Total Hip Replacement surgery has become so successful that it has come to be known as the operation of the century. It is the main surgical procedure in orthopedics and a cost-effective treatment to restore pain-free movement in patients with degenerative bone and joint diseases such as degenerative arthritis. .⁽¹⁾

process can be considered changing Full hip joint Overall a safe intervention that results in a high level of patient satisfaction, more than 90% patients with osteoarthritis reported that they were satisfied with the results. Total hip replacement surgery After one year of surgery, most of them can return to their normal lives. This success has led to high expectations for the results of surgery among patients, orthopedic surgeons, and researchers.⁽¹⁾

Patients will have to understand and accept that total hip replacement surgery “marks the beginning, not the end of treatment” even though there will be almost immediate pain relief and gaining mobility after surgery.⁽¹⁾

The improvement of surgical techniques and the introduction of new prosthetic surgical techniques and materials have turned total hip replacement into one of the most successful contemporary treatment modalities.⁽²⁾

Hip osteoarthrosisOsteoarthritis) is a degenerative disease that affects the synovial joints, and is considered the most common disease in the musculoskeletal system. It is prevalent among middle-aged and elderly adults. In this age group of the population, there is a clear relationship between this disease and weight gain and physical activities.⁽³⁾

The affected hip joint is characterized by: focal degeneration of the articular cartilage, microfractures, abscesses, sclerosis of the subchondral bones, the appearance of bony growths at the articular borders, post-arthritic deformity, and progressive loss of joint movements. Radiograph.⁽³⁾

There is no cure for degenerative arthritis at the present time, and the available treatments focus on controlling pain and improving functions (physiotherapy is one of these treatments). daily and even to carry out work.⁽³⁾

Reasons to perform an artificial hip replacement

Symptomatic end-stage degenerative hip arthritis is the most common reason for total hip replacement.⁽⁴⁾

Occurrence of degenerative hip arthritis is associated with both aging and strenuous physical activity as the cartilage becomes less elastic over time, and it accounts for more than two-thirds of total hip replacement cases.⁽¹⁾

The second most common is rheumatoid arthritis, a systemic inflammatory disorder that may be caused by a systemic autoimmune response. Severely affected joints are candidates for joint replacement when medications (including painkillers, anti-inflammatory drugs, and steroids) fail to control symptoms.⁽¹⁾

Other indications for total hip replacement are:

• Dysfunction of the tissues of the hip joints
• Orthopedic defects caused by accidents or diseases
• Avascular necrosis (necrosis of bone tissue due to interruption of blood supply)
• Other rare diseases that impair the function of the hip area.⁽¹⁾

Hip osteochondrosis appears on average in the younger age group 35-50 years and accounts for about 10% total hip replacements annually.⁽⁴⁾

contraindications

Total hip replacement is contraindicated in the following clinical scenarios:

• Local: Hip infection or sepsis
• Remote (i.e. extra-articular) active, ongoing infection or bacteremia
• Severe cases of vascular disease ⁽⁴⁾

Preoperative evaluation before total hip replacement

Clinical Examination

A thorough clinical examination and medical history are performed before a total hip replacement is performed. Previous interventions and treatments should also be asked.⁽⁴⁾

Previous joint replacements, arthroscopic procedures or other surgeries around the pelvic joint should be considered before deciding to perform surgery, in addition to the fact that the presence of prostheses in the femur or joint socket can significantly affect the planned and/or surgical procedure Or choose an artificial joint replacement.⁽⁴⁾

A thorough medical evaluation, medical clearance and potential risks must also be conducted before the decision to have a total hip replacement is made.⁽⁴⁾

Other things to consider prior to surgery include: the patient's body habits, previous functional activity, postoperative goals or expectations, pattern of arthritis, and any history of traumatic hip injury.⁽⁴⁾

The hip should be examined for any skin discolorations, previous cuts or scars, and the soft tissues should be examined for severe atrophy, general symmetry and stability of the hip.⁽⁴⁾

An evaluation of the mechanical axis and overall alignment of the limb should be carried out. It is important to ensure that diseases of the spine and/or the knee are excluded or at least considered before any surgery around the hip. Any discrepancy in leg length should also be investigated.⁽⁴⁾

Atypical leg discomfort and pain at rest are common symptoms of peripheral vascular disease, while these symptoms are absent in about 50% patients. Therefore, clinical suspicion of the presence of these diseases may require consultation with a vascular surgeon before deciding on total hip replacement.⁽⁴⁾

Radiographs

Preoperative radiographic evaluation including anteroposterior and lateral pelvic imaging of the affected hip is recommended, and 1 mm section CT is recommended when the surgeon encounters cases of severe hip dysplasia.⁽⁴⁾

In the radiological evaluation of the hip joint, narrowing of the inter-articular space, presence of bony growths, presence of subchondral sclerosis and/or degenerative cysts are investigated.⁽⁴⁾

The Surgical Procedure for Total Hip Replacement

In a total hip replacement, damaged bone and cartilage are replaced with ceramic, metal, or plastic surfaces to restore movement and function of the hip.⁽⁵⁾

An articular socket and a prosthetic femoral head replace the damaged normal articular surfaces in the affected hip joint, so the prosthetic materials must have low friction and withstand wear and mechanical load during movement.⁽¹⁾

The total hip replacement prosthesis consists of two parts:

• Acetabular component (cup) that fits into the pelvic bone/hip socket.
• The femoral (tibia) component that fits into the thigh bone. ⁽⁵⁾

The surgical steps

• An incision is usually made over the top of the thigh bone (femur).
• The muscles that hold the hip in place are partially detached and the surgeon exposes the end of the femur and the pelvis socket (acetabulum).
• The damaged cartilage and bone in the pelvis socket are cleaned away.
• The acetabular component (cup) and a high-grade polyethylene liner (new cartilage) is fixed in place.
• The head of the femur is removed.
• The inside of the femur is prepared for the femoral component (metal stem) which is fixed in place and a femoral head (ball component) is placed on the stem.

Once the components are in place, the hip is returned to its place, then the movement and stability of the joint is tested, and then the surgical incision is closed. The surgery usually takes 45-90 minutes.⁽⁵⁾

Surgical approaches

The three most common approaches are as follows:

Posterior

It is the most common method for performing total hip replacements and correction procedures, the main advantage of this approach is the avoidance of the hip abductor muscles, as well as excellent exposure of both the acetabular hollow of the hip and the femur and elective extension diversion in the proximal or distal direction.⁽⁴⁾

Direct Anterior (DA)

This method has become increasingly popular among surgeons. Proponents cite the low theoretical rates of hip dislocation in the postoperative period and the avoidance of the hip abductor muscles. Problems with this overlap include increased wound complications in particularly obese patients. Difficulty exposing the thigh. The risk of numbness in the lateral femoral cutaneous nerve, and the possibility of a high rate of femur fractures during surgery.⁽⁴⁾

Anterolateral (Watson-Jones)

The anterolateral approach is the least frequently used method compared to other intervention methods due to its direct effect on the hip abductor muscles.⁽⁴⁾

Choice of prosthesis

Reports indicate that the most common prosthetic materials used to fabricate the femoral head and acetabular cavity in an artificial hip joint are metal-on-metal (MoM), ceramic-on-ceramic (CoC), or the classic metal-on-polyethylene (MoP) blend.⁽¹⁾

The first decision to be made regarding an artificial hip joint is whether or not it will be fixed with bony fixation materials (cement). Currently, fixation materials are mainly used in patients over 60-65 years of age with poor bone quality. Not using immobilizers in younger patients with good bone quality.⁽¹⁾

Recovery and rehabilitation after total hip replacement

Postoperative rehabilitation is of utmost importance after total hip replacement surgery in order to ensure pain-free function of the joint and improve the patient's quality of life. Timely and appropriate rehabilitation is very important to speed up the recovery process and prevent complications.⁽²⁾

If the rehabilitation program is not applied to patients who have undergone total hip replacement surgery, they will develop functional problems within one year after the surgeries. Physiotherapy plays an important role in caring for these patients, as it improves strength and walking speed after total hip replacement and helps prevent recurring complications. Which include joint dislocation and thromboembolic disease.⁽³⁾

In addition, physiotherapy increases the patient's movement and provides education about the necessary exercises and precautions during hospitalization and after discharge home, although there is no consensus on the type of physical therapy program that is most effective in this field.⁽³⁾

Early mobilization after total hip replacement

Early movement is an essential component of the recovery program after total hip replacement surgery. Prolonged bed rest has adverse physiological effects such as increased insulin resistance, myopathy, decreased lung function, impaired tissue oxygenation and increased risk of blood clots. Safe and effective analgesia is a prerequisite. Essential to encourage the patient to move early after surgery.⁽⁶⁾

There is good evidence that early mobility facilitates recovery after total hip replacement surgery. Recent meta-analyses show a significant reduction in hospital stay (by 1.8 days) when patients move within 24 hours of total hip replacement surgery. It also helps to improve recovery. function and reduce the incidence of deep venous thrombosis.⁽⁶⁾

Pain after total hip replacement

It is normal to have pain, swelling and even some bruising after surgery. In time, the intensity and amount of pain that you experience will start to decrease. It may take up to 6 months before all the pain and swelling is completely gone.⁽⁶⁾

Before leaving the hospital, patient will be given a prescription for a combination of pain medications to help him manage pain. Patient may be prescribed or advised to take the following:

• A pain medication to be taken regularly for 4 days and then on an as needed basis
• A stronger pain medication that you can take every 2 hours as needed
• A non-steroidal anti-inflammatory drug (such as ibuprofen) is taken regularly for 4 days⁽⁶⁾

Physical therapy at home

Some patients may choose to attend special physical therapy sessions after discharge from the hospital to go home, while most patients can carry out the exercise regimen independently, and a basic home exercise program begins after direct total hip replacement surgery with the aim of restoring range of motion and strength in the joint, these must be practiced Exercises before replacement surgery to familiarize yourself with them.⁽⁶⁾

Nutrition after surgery

A healthy diet helps prepare the body for surgery. The body needs good nutrition to heal bones, muscles, and skin after replacement surgery. People who are well-nourished are less likely to develop infections after replacement surgery.⁽⁶⁾

The goal of a healthy diet is to have a source of protein, vegetables or fruits, and grains at every meal. Protein can be especially important after a total hip replacement as protein needs will increase because it can help the healing process.⁽⁶⁾

Complications/complications after total hip replacement

Joint dislocation: The incidence of this complication is about 1-3%, and recurrent dislocations usually lead to re-hip replacement surgery (corrective surgery) with a change in the articular components.⁽⁴⁾

Fracture around the prosthetic hip: Fractures can occur intraoperatively and involve either the acetabular hollow and/or the femur, acetabular hollow fractures occur in 0.4% and often during component implantation, and intraoperative femur fractures occur in up to 5% replacements Full hip joint.⁽⁴⁾

Aseptic dislocation: Occurs after total hip replacement as a result of a confluence of steps involving particle residual formation, precise movement of the prosthetic joint, and phagocytosis-induced osteolysis.⁽⁴⁾

Wound Infections: The spectrum of wound complications after total hip replacement ranges from superficial surgical infections such as cellulitis and/or delayed wound healing to deep infections leading to full thickness necrosis, and deep infections requiring return to the operating room for debridement and drainage.⁽⁴⁾

Joint infections: Infections of the artificial hip joint after total hip replacement occur in approximately 1-2% as reported in the medical literature.⁽⁴⁾

Venous thromboembolism: Pulmonary embolism and deep vein thrombosis, together referred to as venous thromboembolism, are the most serious complications after total hip replacement, with an in-hospital incidence of 0.6%.⁽⁴⁾

Hematoma: Bleeding (hematoma) may occur in the muscles around the joint during a total hip replacement, and this may require going to the operating room to drain the excess blood that has accumulated under the skin.⁽⁵⁾

Other Complications and Considerations

• Sciatic nerve palsy
• Leg Length Discrepancy (LLD)
• Iliopsoas impingement
• Heterotopic ossification
• vascular injury ⁽⁴⁾

Expectations and outcome after total hip replacement

The life expectancy of a total hip replacement (new joint) is affected by the amount of stress placed on the joint. Controlling body weight and adhering to activity recommendations increases joint life. In general, more than 90% prostheses should last at least 15 years.⁽⁵⁾

People who have had a total hip replacement can expect to regain pain-free movement and overcome limitations in their daily and occupational activities. Total hip replacement is a highly successful treatment as over 80% patients are satisfied with the outcome after the replacement surgery. In a survey of 806 patients 94% returned to their usual function after replacement surgery, and the number of patients with hip-related functional limitations decreased from 20% before surgery to only 3% after replacement surgery.⁽¹⁾

The long-term clinical outcome of total hip replacement surgery is determined by the materials and components used by the surgeon and the patient himself. Permanent solutions with total hip replacement can only be achieved if the surgeon can reconstruct the hip joint in a way that enables it to function properly, and if it can It is possible to achieve stable fixation of all components of the artificial joint.⁽¹⁾

Hip replacement cost in Türkiye

The cost of hip replacement surgery in Turkey varies according to the type of joint used, the competence of the surgeon, and the quality of the hospital in which the operation will be performed.

The cost of installing the best type of single hip joint in Turkey starts with quality ZIMMER This includes performing the operation under the supervision of a professor specializing in joint surgery in Turkey and with modern techniques that require only a simple incision that does not cause muscle rupture.

The price of the operation may vary depending on the patient's condition, the technique used, and the quality of the artificial joint. Note that the procedure for replacing both knee joints for the patient is about 9.5 thousand US dollars.

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Sources:

1. Holzwarth U, Cotogno G. Total Hip Arthroplasty. Publications Office of the European Union, 2012.
2. UMPIERRES et al. Rehabilitation after hip arthroplasty: randomized trial. JRRD 2014;51(10):1567–1578.
3. Krastanova MS, Ilieva EM, Valcheva DE. Rehabilitation of patients with hip joint arthroplasty. Folia Medica 2017;59(2):217-221.
4. Varacallo M, Luo TD, Johanson NA. Total Hip Arthroplasty Techniques. StatPearls Publishing 2022.
5. Outpatient Hip and Hip Replacement Information Manual. Winnipeg Regional Health Authority 2020.
6. Soffin E. M, YaDeau JT Enhanced recovery after surgery for primary hip and hip arthroplasty: a review of the evidence. British Journal of Anesthesia 2016; 117:62–72.