Total Hip Replacement
When is a Total Hip Replacement Required
Total Hip Replacements are the final stage in treatment of osteoarthritis of the hip. Pre-operative measures that may be used prior to the decision to proceed with surgery include basic pain management, walking aids and activity modification. By the time patients attend an Orthopaedic Surgeon, they have often exhausted all of the non operative options. The initial pain management options include anti-inflammatory medications (Prescribed, over the counter or natural).
What approach does Dr Liew use for total hip replacement
To perform a Total Hip Replacement, there are a multitude of techniques. This includes a selection of approaches to gain access to the hip for replacement, as well as a selection of types of implants and how to fix the implants in the bone. In general, most approaches to the hip involve removing and reattaching muscle. A tried and tested technique allows total hip replacements to be performed using a direct anterior approach.
“When performing total hip arthroplasty, the surgeon aims at reconstructing the joint. In the majority of cases, they are several possible approaches. The approach we describe has been introduced by Robert Judet and derived from the Hueter approach. It requires, most often, use of an orthopaedic table. It is highly anatomical because it preserves the periarticular muscles and appears to be the preferred approach for a prosthetic implantation according to a minimally invasive protocol” – The minimally invasive trend in total hip arthroplasty through the anterior approach – Lesur, Laude. Encyclopedie Medico-Chirugicale 44-667-B (2004)
The Direct Anterior Approach to the hip is an internervous and intermuscular approach, meaning that muscles are not cut from bone and the interval to gain access to the hip runs between muscles supplied by different nerves. Only one other approach utilises an approach which does not cut muscle (Watson Jones approach), but it runs between two muscles which are supplied by the same nerve. This can put the nerve at risk and cause damage to nerves that supply muscles. Using a truly internervous and intermuscular plane, the nerves which supply muscles are at at much lower risk of being injured than with comparable approaches.
The Direct Anterior Approach is a unique approach that has been used for over 20 years for inserting total hip replacements. It is commonplace in other countries such as in France and Switzerland, and is one of the fastest growing approaches in the USA and Australia. Its success is mainly attributed to the benefits that some surgeons see in their patients, especially with early rehabilitation and for the first few years. After this time, a well performing total hip replacement via any approach is relatively equal, except for the lack of post operative movement restrictions with most direct anterior approach total hip replacements. After a direct anterior approach, there are no restrictions to sitting in a normal chair, toilet seat or car, early in the rehabilitation timeline. After a direct anterior approach total hip replacement, putting your leg far behind you and rotating your body at the same time is not advisable as this is the position it is most unstable.
The total hip replacement via direct anterior approach uses a 5-10cm cut on the front of the leg. The muscles are moved to one side as the deeper layers are split. Once down onto the hip joint capsule, the capsule is opened in a specific way, in order to allow the hip joint to be accessed. A saw is used to cut the neck at a predetermined level based on preoperative X-rays. The femoral head is then removed, and the cup side (acetabulum) is prepared using special instruments, specifically designed to make this approach easier. Once the acetabulum and femur have been prepared, a trial prosthesis is inserted. Dr Chien-Wen Liew uses X-rays to confirm accurate placement of the implants and as a tool to verify leg length measurements. A combination of visual inspection of the implant orientation and Xray check provides additional countermeasures against incorrect positioning. Once accepted, the real implants are inserted, and the layers are closed. A benefit of this approach is the minimal muscle damage as they are not detached, and therefore, do not need to be reattached. It is thought that this plays a large role in the very rapid recovery seen in most patients who undergo total hip replacements in this way. (Ref: Total hip arthroplasty through an anterior hurter minimally invasive approach, Laude, Moreau, Vie – Maitrise Orthopedique ISSN 1148 2362)
Dr Liew also performs other approaches. For example, he routinely still uses the posterior approach for revision surgery and some primary cases. In addition, he uses the lateral approach at the Royal Adelaide Hospital for many cases of hip fracture as the protocol dictates. All approaches have risks and benefits. In general, the best approach is one that a surgeon is familiar with, and trained in. For different circumstances, each approach can be the better option.
After your operation
After the operation, patients are often kept in a recovery room for 1-2 hours and then transferred to the high dependency unit where they start to mobilise if they have regained feeling in their legs, or are awake enough to try. All total hip replacements are sent to the high dependency unit post operatively to ensure closer monitoring during the hours after major joint surgery. A physiotherapist may come and help you stand and take a few steps a few hours after your surgery. Generally you will have a drain placed under the skin that will restrict how far away from your bed you can walk on the night of surgery. The drain is generally removed the next day, and you can start to walk further with physiotherapy. After a total hip replacement performed via a direct anterior approach you will not require a pillow to be strapped to you after the operation, and there are no movement restrictions, within reason, after (Except forced extension and external rotation – an uncommon movement). This means that you can sit in a normal chair, use a normal toilet seat, get in and out of a car, and do your normal activities once you are comfortable to do so. Dr Liew allows his patients to drive a vehicle when they are comfortable, mobilising with minimal aids, and feel that they can reasonably control a car. Often this achievable at approximately 2 weeks post surgery.
What is the usual pain relief regimen
For pain relief, there are various options available. In general, most patients require only tablets for pain relief after the operation, rather than injectable agents. Once you are comfortable, you will be discharged home. This can be between 2-5 days after your surgery depending on how you feel. There is no rush to go home after your total hip replacement, but you are encouraged to do so once you are safe mobilising with physiotherapy and your pain is under control. Your dressing will remain on for 2 weeks after which Dr Liew will remove the dressing himself at your first post operative appointment.
When do I need to see Dr Liew for review
Dr Chien-Wen Liew believes in monitoring his total hip replacements long term. This means that you will present regularly for an Xray at 2 weeks, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years after your operation, and then every 5 years after this. This will enable early detection of any changes in your bony structure, or implant. It is very unusual for a problem to arise, however its early detection will enable an easy solution to anything that may arise. As a hip joint is a bearing surface, it will wear out in time and will require monitoring to ensure it continues to perform well. Dr Chien-Wen Liew will decide what is most appropriate for your total hip replacement bearing surface when you see him. In general, there are options to use metal, ceramic, polyethylene (plastics) and other bearing combinations. There are benefits of each however in general patients receive a combined ceramic and polyethylene coupling.
To discuss your specific situation, please contact (08) 7099 0188 for a more personal discussion.
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Frequently Asked Questions prior to Anterior Approach Hip replacement Surgery