- Need a new hip? Someday you may grow your own.
- 'Fix-me itis' fueling boom in joint surgeries
- Risk Assessment Tool for Osteoarthritis
- Wall Street Journal: Pushing Limits of New Knees
- New York Times: Getting a New Knee or Hip? Do It Right the First Time
- Dr. Bal in the News...
TestimonialsDr. Bal's Patients Tell Their Stories
"I am very satisfied with the outcome of my surgery and the improved quality of life I am now enjoying..."
Shamsy Kazemi-Bardool, Iran
"I am looking forward to being able to boat and golf this summer, without having to endure the pain and limitations of prior years..."
Greg Voreis, Mo.
"Just 9 ½ weeks following my surgery knee replacements, I traveled to Hawaii and went scuba diving..."
David Booker, Mo.
"Dr. Bal did great a job explaining the procedure through conversation and with his hip surgery book. He changed my life..."
Dennis Disselhoff, Mo.
"It is so important to have a physician who you trust, and who will listen to you. That's critical. I have never seen a doctor who cares so much for each and every patient..."
Faye Bleigh, Mo.
"I am glad to have come to Dr. Bal; his office staff was great to work with; the hospital experience was very good, and the outcome of surgery was all I had hoped for..."
Craig Jacobson, Ne.
"I feel so free now. Last weekend I rode my bike to Cooper's Landing and enjoyed a great meal as I watched the Missouri River roll by and listened to the bluegrass music..."
Marilyn McCreary, Mo.
"The staff at Capitol Region were very gracious, attentive and thorough. I would go back there anytime. They made sure I was comfortable..."
Bob Smith, Mo.
"It has been a real pleasure to meet and get to know Dr. Bal. He is caring, thorough in his explanations, and a great friend...."
Richard Wallace, Mo.
5. Hip Replacment Surgery Basics
Information for Hip Patients
1. Anatomy of the Hip
2. Arthritis of the Hip
3. Treatment Options
4. Surgery Options
5. Hip Replacement Surgery Basics
6. Artificial Hip Components
7. Preparing for Hip Replacement Surgery
8. Recovery from Hip Replacement Surgery
9. Managing Pain or Discomfort
10. Life with an Artificial Hip
Exercise Guide for Hip Patients
(click to download PDF)
What is a total hip arthroplasty?
Surgeons use the word “arthroplasty” to mean replacement. The word “total” means that both the ball and socket part of the hip are replaced. “Total hip arthroplasty” means the same thing as total hip replacement.
Is there a partial hip replacement?
Yes. In some cases of hip fracture in elderly patients who have no arthritis in the joint, surgeons may elect to replace only the ball. This means a metal ball moves inside the patient’s own socket. In low-demand patients, this is a reasonable option, although a total hip replacement is usually more durable and offers more predictable pain relief.
When should hip replacement be considered?
The ideal time for surgery is when other measures, such as medicines, exercise, weight loss, and alternative therapies no longer work. If hip pain causes a limp, affects your lifestyle, interferes with work or recreation, and negatively impacts your body image, then surgery is a reasonable option.
Will a new hip joint be a perfect substitute for my own hip?
Metal and plastic cannot fully replicate the complexity, intricate engineering, and healing ability of the human body. Hip replacement components are products of modern science and engineering that come close but cannot duplicate the natural hip joint.
However, a prosthetic hip provides dramatic pain relief and improves movement, function, and lifestyle. Many patients experience complete resolution of their pre-surgery pain and discomfort.
How does the artificial hip joint get lubricated?
The replaced hip develops a lining around it and the cells secrete synovial fluid, or a biological lubricant, into the synthetic joint. This fluid provides lubrication so that the artificial bearing is never dry.
Synovial fluid is recycled by the cells. No external lubrication of the new hip joint is ever needed. Injections into an artificial hip joint are not beneficial and will increase the risk of infection.
About how long does a hip replacement take?
Our surgical time is about 25 to 30 minutes. However, patient preparation for surgery, safe positioning, safety checks, and anesthesia add considerably to this time. Individual patient and anatomic variations may also alter surgical times. Each person is unique and surgery is never an assembly-line procedure.
Is it possible to replace both hip joints at the same time?
Yes. We do these routinely in patients who need both hips replaced and are in good health otherwise. Rehabilitation time is perhaps slightly longer than for one hip replacement, but not noticeably so.
We used the “anterior” surgical approach to hip replacement in our practice, which means that the patient is on his or her back, and muscles are spread, rather than cut. The anterior surgical approach, used in our practice for all hip replacements, makes surgery on both sides much simpler, safer, and faster.
What is the optimal age for hip replacement?
Hip replacement is usually done in patients in their 50s through their 80s, although the operation is also done in patients who are older or younger than this age range. With modern implants and bearings, young age is not a contraindication to successful surgery. In the past, hip replacement was reserved for the elderly, because the implants and synthetic bearings were not as durable as they are today.
Should I wait, or get my hip replaced now?
New technology, streamlined surgical methods, and improved implants should not affect your decision to have a hip replacement. Non-surgical methods of relieving pain should be tried first; sometimes they can help postpone surgery for many years.
Will waiting to get a hip replacement make things worse?
No. Waiting is safe. Even if the hip joint gets becomes more deformed, the surgery is just as easy. The only downside to waiting is that muscles might get weaker, thereby making recovery a bit longer. This can be offset by maintaining a reasonable body weight and following a program of light exercise to keep your muscles in shape.
One exception applies to revision hip implant surgery. If your joint was replaced many years ago, and the wear particles are starting to dissolve bone, we may advise you to have surgery sooner rather than later.
Another exception applies to joints that have been replaced, and are suspected of having a deep infection of the prosthetic device. In those cases, corrective surgery is recommended early, so that the infection does not penetrate the bone.
Surgical Techniques for Hip Replacement
What is a surgical approach?
The anatomic pathway used to reach the bones of the hip joint is also referred to as the "surgical approach." Each surgical approach is a different technique to gain access to the joint itself, and expose the anatomy for a hip replacement or hip resurfacing.
The most common hip joint surgical approach used by U.S. surgeons is called the posterior (from the back) approach. Patients who have had a posterior approach typically have a curved scar on the outside of the thigh with a top part of the scar curving into the buttock. This approach is very popular, easy to learn, predictable, and cuts through a limited amount of muscle and tendon, resulting in good recovery.
Even in the hands of very good surgeons, the posterior approach is associated with a small risk of the hip popping out after surgery. Newer techniques and implants have reduced this risk somewhat, but a small possibility of hip dislocation remains associated with the posterior approach.
Another common surgical approach to hip replacement is the lateral (from the side) approach. The lateral approach also involves a scar on the side of the thigh, but instead of being curved, the scar is usually a straight line. The advantage of this approach over the posterior approach described above is a lower risk of dislocation.
The lateral approach nearly eliminates the risk of dislocation, but the approach involves cutting through more muscle tissue on the way to the hip joint. As a result, patients will usually have a slight limp after surgery, which generally disappears 6 to 12 months following surgery.
The approach we use is called the anterior (from the front) approach. This method is still new in the U.S., with more surgeons using it every year. Very few surgeons in the United States use this approach routinely for all hip replacements.
Why do you prefer the anterior approach?
One advantage of the anterior approach relates to easier and safer patient positioning for surgery. The patient is on the back, which is a more natural position than placing the patient on the side, which is required in the posterior and lateral approaches.
Another advantage is that leg length checks are easier when the patient is on his or her back. Both legs can be easily assessed relative to each other.
Finally, the anterior approach does not cut through any muscle. The muscles are separated along their natural planes, and the entire joint can be replaced through a much shorter incision, with true sparing of muscle.
Muscle-sparing is beneficial in another way. The risk of dislocation (the hip ball popping out of the socket unexpectedly) is nearly zero with the anterior approach. With other methods of hip replacement, patients must follow certain precautions for a lifetime. For example, patients are usually advised to not bend too far, tie shoes, or cross the legs for fear of the hip popping out of socket. These precautions and worries do not apply to hips replaced using our anterior approach.
How did you adopt the anterior approach for hip surgery?
Around 2003, a "two-incision" hip surgical approach was developed by surgeons in Chicago as the first truly minimally invasive hip replacement. We adopted that technique, published our results in peer-reviewed literature, and refined the method to make it safe and predictable in our patients.
The present-day anterior approach is an evolution of that work; instead of two incisions, the anterior approach allows us to perform the entire hip replacement through one short skin incision placed toward the front of the thigh.
Our experience and that of other surgeons in the country shows that patient recovery and function are better with the anterior approach, when compared to conventional techniques. That is why we routinely use this approach for all hip replacement and resurfacing surgeries.
What are the disadvantages to the anterior approach?
This technique is still relatively new and not widely used in the United States, since it involves new learning, and is difficult to master. Very few surgeons use it routinely in all patients, given the technical challenges in learning it and getting comfortable with the technique.
Another reason is that with the scar in the front there is the risk of skin numbness over the side and front of the thigh as the result of microscopic skin nerves that are cut in during surgery. These nerves will heal over time, and thigh sensation is restored a few months after surgery. The nerves do not affect any muscles; subjective numbness is the only symptom.
In our experience with more than 1,000 patients, thigh numbness has not been a significant issue other than a transient symptom that resolves. It is generally agreed that the temporary numbness is more than balanced out by the substantially improved recovery, reduced pain, absence of a limp, faster return to function, and virtual elimination of the risk of hip dislocation.
What surgical approach do you use in complex total hip replacement?
In very difficult hip reconstructions, such as those in which the hip has been replaced many times previously, or the pelvis has to be repaired with plates and screws before placing a metal socket, or where extensive repair of the femur needed, the surgical method that spares the muscles while permitting the best exposure is called a trochanteric osteotomy.
A trochanteric osteotomy involves cutting a piece of bone near the top of the femur. This bone is called the trochanter, and is the bump you can feel on the side of the thigh. The major hip muscles involved in walking all attach to the trochanter.
Cutting the trochanter with all the muscles still attached is the oldest of hip approaches. Once the trochanter is cut, it can be moved aside along with the attached muscles, thereby facilitating entry into the hip joint. The resulting visualization of the hip is excellent for any type of hip replacement, no matter how complicated or difficult.
Metal cables are used to reattach the trochanter to the femur. The trochanter can be attached farther down the femur if tightening of the muscles is desired. This method gives the surgeon the freedom and flexibility to adjust leg lengths and tissue tension, independent of each other.
For first-time hip replacements, and even many repeat hip replacements, a trochanteric osteotomy, despite its above advantages, is rarely needed. We use this method when dictated by complex, difficult, and unusual hip replacement cases.
Do you use computer navigation during hip replacement surgery?
Precise alignment of the bones and components is essential to the long-term success of both hip replacement and hip resurfacing. Computer and robotic technology can help in alignment of bones and reduce the possibility of error.
We continue to investigate these technologies as they evolve; however, so far there is no substitute for the skill, judgment, experience, hands, and eyes of a high-volume surgeon.
What is the role of computer guidance in hip replacement?
At present, computer-assisted technology is most effective for low-volume surgeons. It helps such surgeons reduce the likelihood of error in implantation of the hip components. For some surgeons and hospitals, the greatest advantage of this technology is in marketing.
Do you perform minimally invasive hip replacement that I read about?
We have extensive experience in all types of minimally invasive hip surgery described in professional literature. Bear in mind, though, that all surgery is invasive to the mind, body, and psyche. Surgery is a very different experience for the patient than it is for the surgeon, hospital, or implant manufacturer. Hip surgery is much easier today when compared to the past, but complications, pain, discomfort, and recovery still apply. Each patient's expectations and physical, emotional, personal, and spiritual attributes are different and affect recovery profoundly.
For example, some patients can leave the hospital the same day or the day after hip replacement. But this is not true of all patients. Unfortunately, some health-care professionals use words like minimally invasive surgery, computer-driven surgery, custom-built implants, and same-day operation as business-driving tools. This type of marketing can be misleading and can create unrealistic expectations.
How long will my scar be?
The scar is about 3 to 5 inches long, and placed in front of the thigh. The length of the scar can vary, and will depend upon patient body size, the severity of arthritis, the condition of the soft tissues, and the deformity of the joint.
While the length of the scar has little to do with how fast you heal, everyone prefers to have the shortest scar. We aim for the smallest possible incision that allows safe and efficient surgery, with accurate implant placement.
Independent of the scar length, hip replacement surgery with our anterior approach avoids muscle damage. By spreading muscles apart, the recovery is much faster and easier.
How many joints can one have replaced?
It is possible to have multiple joints replaced safely. For patients with other serious health conditions, it may be best to get these done one at a time, starting with the worst one first.
Some of our patients have had more than a single hip or knee replacement, and there are several people with artificial joints in both hips, knees, shoulders, and more.
What if my previous hip replacement surgery did not work out?
Hip surgery can be complicated by deep infection, implant mal-positioning, nerve injury, leg length discrepancy, and other unhappy outcomes. A second opinion is worth exploring even if a surgeon tells you nothing can be done.
Many factors can compromise the results of hip replacement, even though the X-rays look fine. A stepwise approach to identifying the reason for an unsatisfactory outcome, and addressing it can help patients who have had a poor outcome.
Hips can be replaced more than once. Modern technology allows replacement of deficient bone, even if the entire femur bone is lost.
If both hips are replaced, can you add height to my body?
Yes. If both hips are replaced, it is possible to increase the leg length on one side and increase it by the same amount on the other side. But, any gain in height is about an inch or less. The limiting factor includes the muscles, tendons, and nerves, which only have so much stretch before there is injury or damage.
Will my leg be longer or shorter after hip replacement surgery?
This is an important topic, and should be understood before you embark on any hip replacement, no matter where you have the hip replacement done.
Hip resurfacing is an operation that is similar to replacement. During resurfacing, the arthritic ball is capped with metal, and an artificial socket is placed in the pelvis. Any bone removed is replaced with an equivalent thickness of metal in hip resurfacing, so there is no noticeable gain or loss in leg length during hip resurfacing.
In contrast to hip resurfacing, during hip replacement, the arthritic ball is removed and replaced with a new ball. Since the artificial ball comes in different neck lengths, the surgeon is able to adjust muscle tension, leg length, and ball-socket stability during the hip replacement. These adjustments reflect complex decision-making and trade-offs during surgery.
Rarely, because of anatomic constraints or other patient-specific reasons, slight leg lengthening may occur. If this is totally unacceptable, you should not consider hip replacement surgery.
In the overwhelming majority of cases, there is no change in leg length after hip replacement. In most cases where the patient feels a change in leg lengths, that perception will disappear over several months as the muscle and tissues stretch. In some cases, however rare, there is a permanent change in leg length.
Can leg length be changed during hip replacement surgery?
Yes. An example would be a patient with a leg that was shortened from injuries after a motor vehicle accident, who now needs a new hip. In such cases, it is possible to restore the original leg length during surgery. The decision-making is complex, requires professional judgment, and is specific to each situation.
Likewise, if the patient has too long a leg before surgery, it is possible to shorten it during hip replacement, using specific surgical techniques that keep muscle tension within safe limits. Again, the exact steps taken and the decision-making are specific to each patient; we can discuss whether this is applicable to you.
My leg ended up too long after a hip replacement. Can anything be done?
In most cases, with exercise, stretching, and healing over 6 to 12 months, the perception of a leg length difference will disappear on its own. During this time, to avoid a limp and facilitate walking, a shoe-lift built into the shoe can help.
The reason for waiting is that the majority of leg-length discrepancy after hip replacement is not a true difference in skeletal lengths.
Rather, the discrepancy is from pelvic tilt, tight muscles, altered biomechanics, and even spinal arthritis that can lead to a curvature in the back. With muscles stretching, exercises, and time, such discrepancy will likely resolve in a few months.
If leg length discrepancy is permanent, additional surgery may be an option. During such surgery, the femoral stem component is removed, and the bone at the top of the femur is removed to equalize the leg lengths. Then, a new femoral stem is implanted.
While this sounds easy, additional steps must be taken to avoid improper muscle tensioning and to reduce the risk of creating hip instability and a limp. Recovery from this type of surgery is about 6 to 12 weeks.
How can we know if my leg is truly longer after a hip replacement?
Special X-ray studies can help determine if the perceived difference in leg lengths is really in the bone or arising from some other source, such as a tilted pelvis, a curvature in the back, or tight muscles. These X-rays, called scanograms, involve imaging the entire length of both legs with a measuring ruler that leaves no doubt about the actual length of each leg, from the top of the pelvis to the ankle.
Where else can I learn about hip surgery?
To learn more about the anterior hip replacement technique specifically, visit the following sites: http://www.hipandpelvis.com/
patient_education/totalhip/index.html and www.newhipnews.com.
Another useful source is www.bonesmart.org, which even has a patient dialogue forum.
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Summary of main points for successful hip surgery:
Inform yourself about outcomes and risks of surgery.
Get recommended medical, dental, and other checks to ensure safety.
Exercise muscles before surgery, whether upper or lower body.
Understand discharge instructions when you leave the hospital.
Communicate with us often, especially if you have questions.
Avoid smoking and excess alcohol use during recovery.
Maintain good hygiene and reasonable body weight.
Participate in scheduling, planning, discharge, and related processes.
Select a surgeon in whom you have confidence and trust.
Do not make the decision to have surgery without taking the time for careful thinking and deliberation.