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Minimally Invasive Posterior Approach Total Hip Replacement

The posterior approach to total hip replacement is a minimally invasive surgical technique where the replacement of the damaged hip joint is made through the side of the hip, along the outer buttock area, and is the most commonly used approach. The normal incision is about five inches but may vary according to a patient's body size. Though small incisions are often considered desirable by patients, it should be kept in mind that the degree and type of tissue disturbance beneath the skin is a more important factor. The hip joint is exposed by splitting the gluteus maximus muscle in line with its fibers. The piriformis and superior gemeli muscles, which are two of the four external rotators of the hip, are detached and later reattached to allow implantation. . The benefits of minimally invasive hip replacement include less damage to soft tissues, leading to a quicker, less painful recovery and more rapid return to normal activities. While the surgical process in a minimally invasive hip replacement is similar to the traditional approach, there is significantly less damage to the tissue surrounding the hip joint as the splitting of the muscles is greatly reduced and repaired after implantation of the prosthetics to prevent dislocation of the hip. Rehabilitation is accelerated and hospital time decreased because of the smaller incisions as well as less interference with the soft tissues. The rapid hip pathway employed by Orthopedic + Fracture Specialists surgeons allows for healthy patients to be done on an outpatient basis regardless of surgical approach. Larger femoral heads and smaller incision surgery has brought the dislocation rate to between .5-1%. The posterior approach can be extended for revision surgery with little difficulty. Possible complications of minimally invasive hip replacement include infection, injury to nerves or blood vessels, fractures, hip dislocation and the need for revision surgery.

Not everyone is a candidate for the minimally invasive posterior approach to total hip replacement; therefore it is important to extensively discuss the advantages and disadvantages of this approach with the physician. The physician will help decide the best approach based on the individual's characteristics and conditions.

Overview

The hip is one of the largest joints in the human body and is a ball-and-socket joint. The ball is the femoral head, which is the upper end of the femur (thighbone). The socket is formed by the acetabulum, which is part of the large pelvis bone. The bone surfaces of the ball and socket are covered with articular cartilage, a smooth, white connective tissue that enables the bones of a joint to easily glide over one another with very little friction allowing easy movement. The remaining surfaces of the hip joint are covered by the synovial membrane, which is a thin tissue lining that releases fluid that lubricates the cartilage, reducing the friction within the hip joint. Large ligaments (tough bands of tissues) connect the ball and the socket in order to stabilize the joint by preventing excessive movement.

When an individual has arthritis of the hip, the underlying bone develops spurs and irregularities which can cause severe pain and loss of motion. A total hip replacement (also referred to as total hip arthroplasty) has the ability to relieve pain and restore normal function in patients whose hip joint has been significantly damaged by overuse or trauma. In this type of surgery, the damaged hip ball-and-socket of the femur is replaced by man-made, prosthetic implants. Total hip replacement surgery has been done routinely for the past 50+ years with the main objective being to restore the natural, pain-free movement of the hip joint and allowing patients to return to their desired level of activity. Of all the joints currently replaced in the human body, total hip replacement has had the most success, is the most durable (lasting upwards of 30 years), and has the quickest recovery period.

Symptoms

Individuals who require a total hip replacement surgery typically experience these symptoms:

  • Persistent pain in the hip region that worsens with walking or bending
  • Persistent pain in the hip region that interferes with rest and sleep
  • Limited or restricted range of motion making going up or down stairs or rising from a seated position difficult

Severe hip pain should not be ignored. Paying a visit to a physician is highly recommended if an individual experiences the symptoms mentioned above despite the use of pain medication.

Diagnosis

Arthritis of the hip can be diagnosed with a combination of physical examination as well as imaging studies. After gathering information about the individual's general health and the extent of his or her hip pain and how it affects their ability to perform day-to-day activities, the physician may examine the hip to assess the motion, stability, strength, and overall alignment of the hip joint. The physician may order X-rays to assess the extent of deformity or damage in the hip joint or an MRI scan to determine the condition of the tissues and bones of the hip and identify the type of arthritis. The physician will educate you on the benefits from this surgery as well as what to expect post-operatively.

Arthritis is the most common cause of chronic hip pain and disability. Although there are many types of arthritis that cause pain, the most common that often lead to a total hip replacement are the following:

  • Osteoarthritis - Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage on the ends of your bones wears down over time. It's often called a degenerative joint disease where the cartilage experiences a significant amount of wear and tear over a long period of time, generally occurring in individuals over the age of 50.
  • Rheumatoid Arthritis (RA) - Rheumatoid arthritis is quite possibly the most serious form of arthritis as it is a major crippling disorder. Unlike osteoarthritis, rheumatoid arthritis affects the synovial membrane (lining of the joints), causing a painful swelling, resulting in joint deformity and bone erosion. Rheumatoid arthritis is three to four times more likely to occur in women and may affect various systems of the body such as eyes, heart, lungs, skin, and the nervous system.
  • Post-Traumatic Arthritis - Traumatic arthritis is caused by repeated trauma to the articular cartilage. This is most common among individuals who were/are athletic or active. Injuries to joints such as a fracture or sprain can cause major damage to the articular cartilage, which leads to arthritic changes in the joint over time.

Avascular Necrosis - Avascular necrosis occurs when the blood supplied to the femoral head is limited due to an injury such as a dislocation or fracture to the hip. The lack of blood can cause the surface of the bone to breakdown, resulting in arthritis.

Treatment

A total hip replacement entails the removal of the damaged bone and cartilage of the hip ball-and-socket and replacement with man-made prosthetic components. A total hip replacement procedure takes anywhere between one to two hours to complete and occurs in the following order:

  • Entering the Joint - An incision is made near the side of the hip and the muscles, tendons, and other tissues are moved away from the joint to expose the femoral head (ball) and acetabulum (socket). The hip is then positioned to expose or open up the joint.
  • Removal of Femoral Head - During this step, the head and neck of the femoral head is removed and the acetabulum is cleaned out in preparation for the replacement components.
  • Femoral Canal Preparation - Once the acetabulum is cleaned out, an acetabular metal shell component is fit into the space along with a plastic liner to surround the prosthetic femoral head to allow or a smooth gliding surface. The femur is then hollowed out in preparation for the femoral stem insertion.
  • Femoral Placement - The femoral stem may be secured with the use of cement or be "press-fit" into the hollow center of the femur. A carefully fitted metal or ceramic ball is then secured to the top of the femoral stem.
  • Rejoining the Hip Joint - The hip joint is then rejoined and all the surrounding muscle and tissues are repaired back to position and the procedure is completed.

Recovery

Recovery after a total hip replacement will depend heavily on how well the individual follows home care and precautions after the surgery. After a total hip replacement surgery, there will be some pain, but the medical team will provide the proper medication to make the patient as comfortable as possible. Walking and hip movement will being soon after the surgery where a physical therapist will provide instructions on the specific exercises to strengthen the leg and restore hip movement to allow for walking and other activities post operatively. Major part of the recovery process will occur at home where proper care must be taken in terms of wound care, diet, and activity as prescribed by the physician and physical therapist. Patients who have undergone total hip replacement surgery generally resume normal activities three to six weeks post operatively. Each patient is unique, so the recovery period will vary depending on the level of activity the individual hopes to return to; this should be discussed with the physician as well as the physical therapist.

Disclaimer

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