A TOTAL HIP REPLACEMENT MANUAL
FOR THE PATIENTS OF
JOHN R. MORELAND, M. D.
2001 SANTA MONICA BOULEVARD
SUITE 1280W
SANTA MONICA, CALIFORNIA
PHONE (310) 453-1911
FAX (310) 453-6902
This booklet is the original work of John R. Moreland, M.D. Dr.
Moreland requests that his material not be reproduced without his
written permission. Additional booklets can be obtained by calling
or writing his office.
July 2013
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WHERE AND WHAT IS THE HIP? ................................................................................. 6
WHAT MAKES A HIP HURT? ........................................................................................ 6
WHAT IS ARTHRITIS? ................................................................................................... 7
OSTEONECROSIS OF THE HIP .................................................................................... 8
OSTEOPOROSIS ........................................................................................................... 9
WHERE WILL I FEEL HIP PAIN? .................................................................................. 9
ACTIVITY AND HIP ARTHRITIS .................................................................................. 11
MEDICATIONS USED FOR HIP ARTHRITIS .............................................................. 11
WHAT ABOUT NARCOTICS FOR HIP PAIN? ............................................................. 13
EXERCISE FOR PEOPLE WITH HIP ARTHRITIS ....................................................... 13
STEROID HIP INJECTIONS ......................................................................................... 14
WHAT CAUSES MY LIMP? .......................................................................................... 14
WHEN SHOULD A CANE BE USED?.......................................................................... 14
SHOULD I LOSE WEIGHT? ......................................................................................... 15
OTHER NONOPERATIVE TREATMENTS .................................................................. 15
WHEN SHOULD I HAVE MY HIP REPLACED? .......................................................... 15
CAN I PUT OFF SURGERY? ....................................................................................... 16
OTHER SURGICAL TREATMENT ALTERNATIVES ................................................... 17
HISTORY OF HIP REPLACEMENT SURGERY........................................................... 17
WHY IS IT CALLED A TOTAL HIP REPLACEMENT? ................................................ 18
PROBLEMS WITH CEMENTED HIP REPLACEMENT ................................................ 19
ARE THERE MORE DURABLE ALTERNATIVES? ..................................................... 20
PROBLEMS WITH CEMENTLESS HIP REPLACEMENT ........................................... 20
WHAT DETERMINES CHOICE OF TYPE OF FIXATION? .......................................... 21
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HYBRID HIP REPLACEMENT ..................................................................................... 21
SHOULD THE PATIENT DECIDE IMPLANT TYPE? ................................................... 22
SURFACE REPLACEMENT ......................................................................................... 22
OTHER NEW TECHNIQUES ........................................................................................ 24
COMPLICATIONS OF HIP REPLACEMENT ............................................................... 25
WEAR ........................................................................................................................... 26
HIP DISLOCATION AND SURGICAL APPROACH .................................................... 28
OTHER POSSIBLE COMPLICATIONS ........................................................................ 29
WRONG SIDE SURGERY ............................................................................................ 31
MINMALLY INVASIVE HIP REPLACEMENT ............................................................... 31
WHEN WILL FULL WEIGHT BEARING BE ALLOWED?............................................ 32
SURGICAL APPROACH OPTIONS ............................................................................. 33
BILATERAL SIMULTANEOUS HIP REPLACEMENT.................................................. 35
WILL DR. MORELAND DO THE SURGERY? ............................................................. 35
INITIAL CONSULTATION WITH DR. MORELAND ...................................................... 36
SURGICAL SCHEDULING ........................................................................................... 36
AUTOLOGOUS BLOOD DONATION ........................................................................... 36
OTHER PREOPERATIVE CONSIDERATIONS ........................................................... 37
THE PREOPERATIVE VISIT ........................................................................................ 38
WHAT DO I BRING TO THE HOSPITAL? ................................................................... 38
THE DAY OF SURGERY .............................................................................................. 39
NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES ........................................ 40
THE HOSPITAL STAY.................................................................................................. 41
DISCHARGE FROM THE HOSPITAL .......................................................................... 43
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FOLLOW-UP APPOINTMENTS ................................................................................... 44
HOW CAN I PREPARE MY HOME? ............................................................................ 45
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WHERE AND WHAT IS THE HIP?
In everyday language the buttock area is usually called the hip. In anatomical terms used by
physicians, however, the hip is actually the ball and socket joint where the femur (thigh bone)
meets the pelvis. The top end of the femur is shaped as a round ball (femoral head) which
normally rotates in a shallow cup or socket (acetabulum) formed by the pelvic bones. In a
healthy hip, the head of the femur is covered with a layer of a smooth and slippery white
substance about one-eighth of an inch thick called articular cartilage. The acetabulum is also
lined with this same articular cartilage. When the hip joint moves, the cartilage-covered femoral
head rotates in the cartilage-lined acetabulum.
Articular cartilage has no nerve endings to transmit signals to the brain and thus we are not
aware of movement between the two cartilage layers. Little friction is generated and no
discomfort is felt. Since cartilage does not stop x-rays and thus does not show up on x-ray film,
an x-ray of the hip will normally show about a one-quarter inch space between the bony edge of
the femoral head and the bony edge of the socket.
WHAT MAKES A HIP HURT?
In almost all types of hip disease, the articular cartilage has deteriorated and is partially or
completely absent. Without the articular cartilage layer, the bone of the femoral head will rub
on the acetabular bone of the pelvis. Radiographs will then show the femoral bone touching
the acetabular bone, since the cartilage layers are absent. Bone, as opposed to cartilage, does
have nerve endings and this bone-on-bone contact usually causes pain.
Early in the course of hip arthritis the cartilage space will narrow and patients usually have mild
pain. As the disease process progresses, the bones will gradually move closer together on the
radiograph as the cartilage layers are lost. As the bones gradually touch over larger areas, the
pain usually will worsen. A hip replacement is simply a mechanical replacement for the missing
cartilage, so that the bones do not rub together and cause pain.
The cartilage-covered femoral head can be compared to a man’s head covered with hair.
During the process of balding, the man first gets a thinned area of hair, and then the thin area
gradually progresses to a small bald spot. Later, the bald spot enlarges. Cartilage loss from
the femoral head is similar. At the time of hip replacement surgery the femoral head usually is
found to have large areas devoid of cartilage, but may still have some peripheral cartilage left
even though the patient has severe symptoms.
Many people are surprised to hear that bones are alive and can hurt. As stated, cartilage does
not have nerve ending and thus when cartilage rubs on cartilage there is no feeling. But inside
the calcium crystalline structure of bone there are nerve endings, which can transmit pain
signals to the brain when the bones touch. In addition, this bone-on-bone touching can flatten
the femoral head by grinding away some of the bone surface and releasing bone and cartilage
fragments to the joint cavity. These released fragments irritate the lining of the joint (synovium)
and cause a painful inflammation of the joint lining (synovitis).
At times patients can even hear a creaking noise (crepitation) coming from the hip caused by
the bone-on-bone contact. The bone surfaces often become highly polished and denser and
harder from this repetitive rubbing. The body usually attempts to heal the diseased joint by
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forming extra bone at the edges of the joint. These extra bone formations can be seen on the
radiograph and are often called spurs but more correctly should be called osteophytes.
As the cartilage layer wears out, normal hip flexibility is often decreased by various mechanisms
(pain, high friction, lack of head roundness, osteophyte formation and muscle stiffness). This
lack of normal hip flexibility can make it difficult to position the legs when bending over for tasks
such as tying shoes or cutting toenails. Many patients with hip stiffness cannot separate their
legs very well, making sexual intercourse difficult for women. Horseback riding also is
commonly uncomfortable, if not impossible. Stiffness can even be so severe as to interfere
with personal hygiene.
The hip stiffness can make standing up straight difficult and this stiffness may aggravate back
problems, since extra back movement is needed to compensate for the lack of hip flexibility.
Hip stiffness can cause an exaggerated curvature in the lower back called (hyperlordosis) and
can cause spinal curvature (scoliosis). Hip stiffness also can cause the pelvis to be held in a
tilted position, resulting in extra stress on the lumbar spine and making the leg lengths
functionally unequal.
WHAT IS ARTHRITIS?
Joint pain is called arthritis (arthr means joint and itis means inflammation). Thus, patients with
arthritis simply have at least one joint causing pain. There are many types of hip arthritis. The
most common type is called primary osteoarthritis, which results from wearing out the articular
cartilage of the joint for no identifiable reason. Secondary osteoarthritis is that due to an
identifiable cause.
Secondary osteoarthritis can be due to an old hip injury, to conditions with which one is born,
such as developmental dysplasia of the hip (DDH: a problem of shallow sockets, usually in
women), to conditions that develop during childhood such as slipped capital femoral epiphysis
(SCFE-usually in boys ages 10-13) and Legg-Calve-Perthes disease (LCP: usually in boys
ages 3-9), or to arthrocatydesis (Otto pelvis: a condition usually in young women with extradeep sockets and usually causing more hip stiffness than pain). The tendency for the hips to
wear out during a patient’s lifetime runs in families.
Rheumatoid arthritis (RA) is another frequent cause of hip deterioration. The inflammation of
rheumatoid arthritis is a generalized rather than a localized condition, usually affecting many
joints in the body as well as causing a general ill feeling. The severity of rheumatoid arthritis is
variable and most RA patients are under the regular care of a rheumatologist (an internal
medicine doctor specially trained in diseases which cause joint problems but who does not do
surgery). Rheumatologists and orthopedists often work together in the care of patients with RA.
Certain powerful drugs such as gold, methotrexate, penicillamine and prednisone have long
been used by rheumatologists to control the joint pain and swelling. Patients, who chronically
take the steroid drug, prednisone, need usually extra amounts of steroid during the surgical
period, because of adrenal suppression.
Some quite effective drugs to combat rheumatoid arthritis are now available. These medicines
are called disease-modifying antirheumatic drugs (DMARDs) and can slow or sometimes
prevent joint destruction. Starting treatment early with DMARDs can reduce the severity of the
disease. DMARDs are also called immunosuppressive drugs or slow-acting antirheumatic drugs
(SAARDs). Common ones are Humira, Enbrel, and Remicade. These medicines work best
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when taken over a long period to help control the disease. These powerful drugs have the
potential for significant side effects and require regular follow-up with a rheumatologist.
RA is probably an autoimmune disease (a disorder of the immune system in which the patient’s
tissues come under attack by the patient’s own immune system). Patients with RA sometimes
develop deterioration of the neck bones causing spinal instability and have an increased risk of
spinal cord damage during general anesthesia. Neck stability x-rays before surgery and special
anesthesia techniques may be necessary. Patients with RA also sometimes have arthritis of the
jaw joint (temporomandibular joint) causing difficulty in opening the mouth wide enough for the
usual anesthesia techniques. Special anesthesia equipment and techniques may be needed
for such patients.
Children can get a variation of RA called juvenile rheumatoid arthritis (JRA). These children
suffer joint inflammation with resultant damage during childhood and may need hip replacement
even as a child but more commonly when they become young adults.
Ankylosing spondylitis (AS) is another type of inflammatory arthritis that can damage the hips.
Ankylosing spondylitis usually affects men. Patients suffer stiffening of the back and neck,
making it difficult sometimes to see straight ahead. The neck stiffness of AS can make the job
of the anesthesiologist difficult and special anesthetic techniques and instrumentation may be
necessary.
Other inflammatory conditions such as systemic lupus erythematosis (SLE or lupus), psoriatic
arthritis, and inflammatory bowel arthritis can also cause hip disease.
OSTEONECROSIS OF THE HIP
Hip osteonecrosis is a condition in which parts of the femoral head die (osteo means bone and
necrosis means death). If affected area of bone is extensive, the dead bone sometimes cannot
support the forces on the femoral head and the head surface may fracture, lose its roundness
and generate pain. The most common causes of osteonecrosis (also called aseptic necrosis
and ischemic necrosis) are oral steroid intake (such as prednisone), excessive alcohol intake
and trauma. Other causes are hyperuricemia, systemic lupus erythematosis (SLE), sickle cell
syndrome, Gaucher’s disease, pancreatitis, pregnancy, liver disease, the bends, caisson
disease, polycythemia, diabetes, obesity, and hyperlipidemia. Sometimes, no reason can be
found for osteonecrosis (termed idiopathic osteonecrosis).
It is helpful to understand osteonecrosis by using the analogy of a building. Buildings are dead
but the people inside are alive and maintain the building. Window breakage is repaired and
roof leaks are fixed as these problems occur. Without such maintenance, buildings will decay
and eventually fall down. The calcium crystal structure of the femoral head is not alive but the
tiny bone cells in the bone are. These bone cells maintain the bones just as humans maintain
buildings. When a portion of a bone dies, what really happens is the bone cells die. Without
bone maintenance by the bone cells the bone structure usually deteriorates in a year or two.
Thus, there is usually a delay between bone death and the onset of symptoms.
Very early in the problem of osteonecrosis when the femoral head is still round, a procedure
called core decompression is sometimes performed in which a hole is drilled up into the femoral
head to decrease the usually abnormally elevated pressure in the femoral head. This treatment
may relieve pain as well as allow blood supply to return to the femoral head. Core
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decompression is controversial and is not universally accepted by orthopedic surgeons as a
valid treatment.
When the femoral head loses its roundness from osteonecrosis, the usual treatment is hip
replacement, if the symptoms are sufficiently severe. Rarely, surgery is performed in which the
bones are purposely broken (osteotomy) and their position rearranged to take advantage of
those portions of the femoral ball which are still intact.
Bone grafting is also sometimes used for osteonecrosis. Bone from cadavers or from other
parts of the patient’s body (usually the fibula) is placed in the femoral head through a hole
drilled into the femoral head. This highly complex, technically difficult, and long (six to eight
hours) surgical technique is rarely performed. It involves placing a piece of the fibula with its
blood vessels into the femoral head with the blood vessels then connected to hip area blood
vessels. This procedure, developed at Duke University, is not generally accepted by the
orthopedic community and is considered unproven and experimental.
OSTEOPOROSIS
The terms osteoporosis (literally “porous bone”) and osteoarthritis are often confused.
Osteoarthritis, as explained above, is a problem with a joint. Osteoporosis is a condition of soft
bones. Osteoarthritis involves pain coming from the joints. Osteoporosis does not hurt unless
the softened bones fracture, as they frequently do if the osteoporosis becomes severe.
Bone is not a solid structure, but instead has small holes in it similar to a sponge or to bread.
The more holes there are and the larger the holes, the more osteoporotic the bone and the less
strong the bone.
Patients develop osteoporosis for various reasons. As we grow older, all of us have skeletons
which are becoming more porotic or osteoporotic. Patients with low activity levels do not
stimulate their skeleton to be strong and often develop osteoporosis. People with low calcium
and vitamin D intake and other metabolic deficiencies will develop osteoporosis. Lighter
skinned people have a greater tendency to develop osteoporosis than darker skinned people
do. Women as a group have a higher propensity to osteoporosis, which seems to accelerate
after menopause. Thus, lighter skinned women after menopause are at particular risk for
osteoporosis.
Osteoporosis can be treated in various ways but treatments are mainly directed against
minimizing further bone loss. All of us should have an adequate calcium intake in our diet and
if you do not, calcium supplements should be taken. In the past many women after menopause
took estrogen for a variety of reasons, one of which was to maintain bone strength. One can
detect osteoporosis by a variety of techniques but usually a reasonable assessment of the
quality of the bones can be made simply by a review of the hip radiographs. Dr. Moreland can
tell you whether you have significant osteoporosis and if so, further consultation and treatment
for this with the appropriate specialist can be arranged.
WHERE WILL I FEEL HIP PAIN?
Pain from the hip joint is usually felt in the groin (in the front of the body where the thigh joins
the torso). The pain often radiates down the front of the thigh to the knee and sometimes to the
mid-shin. Pain, which is perceived in areas of the body remote from the actual problem, is
termed referred pain. You may be aware that referred pain from the heart is usually felt in the
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left side of the neck and in the left arm, and referred pain from the diaphragm is felt in the
shoulder. The referred pain of the hip to the anterior thigh and knee occurs because the nerve
root supply to the hip and the anterior thigh and knee are the same. In some cases, the
referred pain to the knee area is so prominent that the patient, and sometimes even the
physician, thinks the knee itself is diseased, when really the hip is the problem.
Lower back pain is often confused with hip disease. Pain from the spine is usually felt across
the low back, in the buttock, down the back of the thigh, and often down to the foot. Pain
radiating in these areas from the spine is called sciatica. Sciatica is often accompanied by
numbness and tingling, whereas hip pain is not. Most pain felt in the back of the body in the
buttock area is coming from the spine. Most pain felt in the front of the body in the groin and in
the front part of the thigh is coming from the hip. Patients often expect the hip to cause pain in
the buttock, but buttock pain is usually coming from the low back or the sacroiliac joint. The
buttock is not the anatomical hip, although the buttock is usually referred to as the hip in
everyday language. Patients with hip problems also often have lower back pain since the
accompanying hip stiffness puts extra stress on the spine and since back pain, even without hip
arthritis, is very common.
This confusion of hip problems with back and knee problems often obscures and delays the
diagnosis of hip disease. Sometimes back or knee operations are tragically done by mistake
for patients when the real problem is the hip.
Another disease entity often confused with hip arthritis is greater trochanteric bursitis. This is
an inflammation of the soft tissues just superficial to the greater trochanter (the bump of bone in
the area of your hip on which you lie when you are on your side). Patients notice pain (often
burning in character) and tenderness over the greater trochanter. Pain can radiate down the
outside of the thigh. Patients can develop a painful and sometimes audible snap or pop over
the greater trochanter with certain movements. Trochanteric bursitis is seen most frequently in
young adult women. Treatment is usually with NSAIDS, steroid injections and education.
Patients often see several physicians before this problem is correctly diagnosed.
There is a second condition which also can cause pain over the greater trochanter. Muscles
attach to the greater trochanter and the attachment of these muscles can rupture causing
trochanteric pain and hip weakness and sometimes even a limp. The gluteus minimus and
gluteus medius are the muscles usually involved. The diagnosis of this problem can usually be
made with an MRI of the hip. These muscle ruptures are most commonly seen in elderly female
patients.
It is, of course, possible to be bothered by back pain, hip arthritis pain, and trochanteric bursitis
pain all at the same time, and deciding which is the main problem can be difficult. Treating an
arthritic hip with a total hip replacement often helps the commonly accompanying back pain.
Back surgery, on the other hand, will not help an arthritic hip and, in fact, the failure rate of back
surgery (already much higher than hip replacement) is increased further for patients who also
have an arthritic hip. Thus, patients with an arthritic hip and a bad back are almost always
better off having the hip replaced before having back surgery. In many instances, the best way
to relieve back pain in a patient with hip arthritis is to replace the hip.
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ACTIVITY AND HIP ARTHRITIS
The hip is the most important joint of the body for walking and thus, a person with hip pain has
a very serious disability. The more a patient with hip arthritis walks, the more the hip will usually
hurt. Often the first one or two steps after prolonged sitting or lying down may be particularly
painful. We call this start-up pain. Patients can minimize hip pain by simply decreasing life’s
activities: the elevator can be used rather than walking stairs, lifting can be minimized, the
patient can allow the car driver to let him or her out at the front of destinations and all long
walks can be avoided. Long distance walking, running and playing vigorous sports such as
tennis will almost always significantly increase hip discomfort.
In fact, all exercise involving an arthritic hip joint can increase hip inflammation and
consequently, aggravate hip pain. Remember that exercise strengthens muscles but at the
same time puts increased stress on the joints. Many people assume incorrectly that the more
exercise the better. Exercise may help if you have significant muscle weakness, but the more
exercise the better is actually not good advice for an arthritic hip. Actually, rest is the most
dramatic way of decreasing hip pain, since rest will decrease the hip inflammation and thus give
pain relief. You may have noticed that if you are not active for a few days, the hip pain is a lot
less and if you become very active for a period of time, you may have pain at the end of the
vigorous activity or increased pain for the next few days. A sedentary life, besides being
inconvenient, can lead to a decrease in muscle and bone strength as well as depress your
morale, which sometimes results in a significant loss of interest in life’s activities.
As you probably know, the State of California provides special handicapped parking for people
with difficulty walking. Ask our office personnel if you qualify and we will help you submit the
proper forms for this.
MEDICATIONS USED FOR HIP ARTHRITIS
A large group of drugs called non-steroidal anti-inflammatory drugs (NSAIDS) can decrease the
inflammation that develops around an arthritic hip and lessen the pain. These drugs do not
slow the progression of hip arthritis (nothing really does). No particular one of these NSAIDS
has been proven to give better pain relief than the others, but individuals sometimes respond
better to a certain NSAID. Hence, your physician may try you on several of these NSAIDS in an
effort to find the one that suits you best. Periodically, new NSAIDS are introduced to the
market, often with a great fanfare of publicity. So far, none of these drugs have demonstrated
definite superiority. Some, such as Vioxx and Bextra, have been withdrawn from the market
when unforeseen serious side effects occurred with widespread use. It is probably better to
avoid new drugs until safety and effectiveness are well established.
The three most common NSAIDS are aspirin, ibuprofen (Advil, Nuprin, and Motrin) and
naproxen(Aleve). They all have the advantage of being inexpensive and available without
prescription (over-the-counter drugs). Aspirin and ibuprofen both require dosing every three or
four hours. Naproxen (Aleve) has the advantage of less frequent dosing (usually taken only
twice a day) and some studies have shown it to be safer for the heart than the other NSAIDS.
Dr. Moreland often recommends Aleve for patients with hip pain.
Most prescription NSAIDS have the advantage of once daily dosing but have the disadvantage
of increased cost and, of course, require a prescription. All of the NSAIDS commonly cause
stomach upset and have the potential for other side effects such as kidney, liver, heart, and
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bone marrow damage. The best-tolerated form of aspirin is probably Ecotrin (a coated aspirin
tablet which protects the stomach by dissolving in the small intestine). All NSAIDS should be
taken with food. Cytotec, Zantac, Tagamet, Pepcid, Nexium, Prevacid and Prilosec are
sometimes given with NSAIDS to help the stomach tolerate the NSAIDS. These drugs
decrease the amount of acid produced by the stomach.
When used in large doses for long periods, NSAIDS require periodic blood tests to detect
possible side effects. If you take NSAIDS this way, your internist or family physician should
monitor your NSAID intake with periodic blood tests. The side effects of NSAIDS are usually
reversible if the problem is detected and the medication stopped in time. Your internist or family
physician should always be notified if you are regularly taking moderate or large doses of
NSAIDS. NSAIDS can interact negatively with multiple other medications that you may also be
taking, so always first clear NSAIDS intake with your medical physician.
NSAIDS are not narcotics and are not habit forming, nor do patients develop a tolerance for
these drugs, which would make them less effective with time. Still, patients often report
decreased effectiveness of their NSAID with time. The reason for this is usually that the
disease process has progressed causing greater pain rather than that the patient has
developed drug tolerance.
Side effects of NSAIDS depend mostly on the daily dosage. Higher doses are more likely to be
effective but also are more likely to cause problems such as stomach upset and kidney
damage. Elderly patients are particularly susceptible to suffering complications from taking
NSAIDS. For these reasons Dr. Moreland rarely recommends NSAIDS in the usual prescription
doses. He prefers low dose NSAIDS and usually recommends the over-the-counter doses of
ibuprofen (Advil: up to six tablets per day) and naproxen (Aleve: up to two per day) since these
low doses are still effective but safer.
Celebrex (celecoxib), Bextra (valdecoxib), and Vioxx (rifecoxib) are from a class of NSAIDS
called COX-2 inhibitors. These drugs were originally marketed as having fewer side effects than
regular NSAIDS, but claims were never made of better pain relief. Vioxx and Bextra have been
taken off the market because of associated heart problems. The FDA now has warned that all
NSAIDS can cause heart problems.
Those who cannot tolerate the other NSAIDS may be able to tolerate Celebrex, which remains
available. It is more expensive than older NSAIDS and may also cause heart problems. Unlike
the older NSAIDS, Celebrex does not cause increased bleeding and, thus, does not have to be
stopped during the surgical period. Celebrex seems to be particularly useful to relieve
immediate postoperative pain.
Acetaminophen (Tylenol) is not an NSAID. It is a pain reliever but not an anti-inflammatory. It
does not share with the NSAIDS their possible side effects. Pain can often be helped
significantly with acetaminophen and patients may usually safely take six pills a day. Large
doses of acetaminophen have been associated with liver toxicity, particularly in patients who
drink large amounts of alcohol. Acetaminophen can be used to supplement the pain relief of
the NSAIDS (acetaminophen and NSAIDS can be taken at the same time). A good over-thecounter regimen for arthritis pain is two Tylenol and one Aleve twice a day.
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NARCOTICS FOR HIP PAIN
Patients with sleep-disturbing hip pain can sometimes benefit from low doses of mild narcotics
such as Tylenol #3 (acetaminophen with codeine ), Vicodin (hydrocodone with acetaminophen),
and Tramadol. The once commonly used pain relievers Darvocet, Darvon compound, and plain
Darvon have all been taken off the market. All narcotics are habit forming, have the potential
for physical and psychological dependence and lose their effectiveness when used regularly.
Thus, patients should carefully limit their intake of such drugs to no more than one or two a day
to maintain the effectiveness and to decrease the risk of addiction. All narcotics tend to cause
constipation and stool softeners can help prevent this problem. Low dose narcotic use at night,
when sleep is disturbed by hip pain, is relatively safe. Day use is less desirable, since mental
alertness is decreased. Operating machinery or driving a car under the influence of a narcotic
should not be done.
The stronger narcotics such as Percodan (oxycodone with aspirin), Percocet (oxycodone with
acetaminophen), Percolone (oxycodone alone), Dilaudid (hydromorphone), Oxycontin (a long
acting and highly addictive preparation of oxycodone), Opana (oxymorphone), Demerol
(meperidine, now off the market) and morphine are almost never indicated for chronic hip pain
because of their strong potential for addiction. All narcotics become gradually less effective
when taken for long periods and thus higher and higher doses will be gradually required in
order to continue to get pain relief. The patient then will develop another problem: narcotic
addiction. If the narcotics are stopped or decreased in addicted patients, unpleasant withdrawal
symptoms will develop.
In most hip pain circumstances it is better to have hip replacement rather than to become
addicted to large doses of narcotics. Dr. Moreland believes that some “Pain” physicians today
seem too quick to give patients high doses of powerful narcotics for hip arthritis pain and thus
create unnecessary and unpleasant addiction in their patients.
The management of
postoperative pain in heavily addicted patients is more difficult, since such patients do not get
pain relief with ordinary narcotic doses.
EXERCISE FOR PEOPLE WITH HIP ARTHRITIS
Patients with hip disease, like everyone, need to exercise for general cardiovascular fitness.
Jogging and other exercises resulting in impact loading of the hip will probably cause an
increase in the hip pain and are usually best avoided. The best exercise to maintain
cardiovascular fitness for people with hip disease is swimming, since the buoyancy of the water
minimizes the stress on the hip. Bicycling (road bikes or stationary bikes), the elliptical
machine, and gym stair climbers are also better tolerated than running. Patients with back
problems often find the recumbent exercise bicycle more comfortable than the upright bicycle.
The treadmill is intermediate in stressing the hip and is best avoided but many people can
tolerate this since there are usually handrails, but again, the exercise bicycle will probably give
more cardiovascular exercise with less hip pain. After experimentation each patient usually
becomes the best judge of what can be done with an acceptable level of discomfort.
Activity is unlikely to cause deterioration of the hip to a degree that the damage cannot be fixed
later by hip replacement, so remain as active as your hip allows. Think of activity as irritating
your hip, not as damaging your hip. Inactivity can damage the rest of your body since activity is
13
needed to properly maintain your muscles and bones, your cardiovascular system and your
mental health.
STEROID HIP INJECTIONS
Occasionally, physicians inject steroids (cortisone) directly into the hip joint to decrease the
inflammation and thus the pain. It is difficult, however, to get the drug always in the hip joint
cavity since the joint is deep and the capsule is tight. The process of injecting this medicine
can be uncomfortable for the patient and there is a small risk of introducing an infection. Steroid
injections do not really treat the cause of the pain. They simply make the hip hurt less.
Steroids do not always help the pain and the improvement is always only temporary. Because
of these problems, Dr. Moreland does not encourage this treatment routinely for the hip.
When the patient must have temporary pain relief and surgery cannot be done for some
reason, steroid injections can have a place. To insure correct placement of the steroid with
maximum safety and minimum discomfort, Dr. Moreland will arrange for a radiologist to do the
injection under radiographic control.
WHAT CAUSES MY LIMP?
Most patients with significant hip disease have a limp and it is common for the patient to think
that the reason for the limp is shortness of the extremity. Sometimes, the extremity actually is
short, but the limp is usually due to the pain. In fact, when patients limp from a painful hip they
are usually limping because it lessens the pain. The reason it hurts less is that the limping way
of walking allows the patient to contract the hip muscles with less force. This results in less hip
pain but causes an awkward and inefficient gait. Many patients with early hip disease
recognize this and note that they can walk without a limp; but that doing so causes more pain
and that it is easier and more comfortable to limp. With time and the lack of use of some hip
muscles, weakness results and the limp is then due to the weakness as well as the pain.
Sometimes with hip disease, leg shortening occurs from the bones getting closer together as
the cartilage wears out. This slight shortening is actually helpful for the patient, since it is easier
to walk with a painful hip if that extremity is a little shorter. One way of thinking about this is to
realize that the short leg is walking downhill all the time and the long leg is walking uphill. The
short leg, therefore, has to put out less effort. If the short leg is the painful leg, the patient is
better off leaving the painful leg short and not using a shoe lift. If the painful leg happens to be
the long leg, then shoe lifts can take some of the pressure off the painful extremity. Dr.
Moreland can advise you on the usage of lifts during your examination.
WHEN SHOULD A CANE BE USED?
When the symptoms worsen to a significant degree, a cane is usually very helpful to patients
with hip problems. The cane should usually be carried in the hand opposite the side that has
the hip disease. Special platform canes may be useful for people whose hand problems limit
their ability to push on a cane. Patients with rheumatoid arthritis often have this problem. The
Horton and Converse pharmacy on the first floor of our building has a wide selection of canes.
There are foldable canes that will fit in a large purse or a briefcase. The cane then can be
readily available if unexpected long distance walking is required. The cane should be the right
height (usually such that the elbow is bent about 20 degrees) and, thus, an adjustable cane is
14
convenient. We can help you adjust your cane length and instruct you in its use. Most patients
find the cane useful when going outdoors and for long walks (such as shopping malls, airports,
amusement parks and foreign travel). Since the cane gives tremendous mechanical advantage
when used in the opposite hand, just a little hand pressure will relieve a lot of hip pain and
control the limp.
SHOULD I LOSE WEIGHT?
Extra weight will aggravate hip pain. Weight loss will make you more comfortable, but is
unlikely to relieve the pain completely. One pound of weight loss decreases hip stress by three
pounds, since the muscles then have to contract with less force and it is the muscle contraction
that contributes to most of the hip stress. Obesity also makes surgical treatment technically
more difficult for the surgeon and increases the risk of surgical complications for the patient. It
is more difficult with the extra weight for patients to walk during the healing period and to move
around in bed. This increased risk with obesity is rarely of a degree to make replacement
unreasonable. While weight loss is desirable, we rarely insist upon weight loss before surgery,
recognizing the well-known difficulty of weight loss, particularly when compounded by the
enforced sedentary lifestyle resulting from the hip pain.
OTHER TREATMENTS
Massage, acupuncture, acupressure, ultrasound, diet, vitamins, minerals, magnets, Chinese
herbs, shark cartilage, copper bracelets, hypnosis, TENS unit, special physical therapy
techniques, water therapy and many other treatment methods are occasionally used. At times
some of these can alleviate the pain but cannot correct the basic arthritic condition. Hip pain is
often episodic. A lot of activity will often cause a delayed increase in pain from the inflammation
stirred up by the activity. With rest, NSAIDS, and inactivity the pain may completely resolve for
a while with or without other treatment. This episodic nature of hip pain often confuses patients
when they try to evaluate the effectiveness of various activities and treatments.
Haluronate preparations for joint injection (Hyalgan, Synvisc, Euflexa) have been approved by
the FDA for use in the knee. Such have not been approved by the FDA for use in the hip,
although some physicians give it to patients in what is termed "off-label" use. There is not good
data to support its use in the hip and Dr. Moreland does not recommend it for his patients.
By far the most popular health food store supplements for arthritis have been glucosamine and
chondroitin sulfate, which are usually taken together. Occasionally, patients have reported
some symptomatic relief but most patients report no effect. Definitely, we have not seen any
repair of arthritis damage or slowing of arthritis progression with use of these preparations and
there is no good scientific evidence of such benefits. Dr. Moreland does not recommend these
health food store supplements or any others. On the other hand, worrisome side effects have
not been reported with glucosamine and chondroitin sulfate.
WHEN SHOULD I HAVE MY HIP REPLACED?
The decision to have a hip replacement is usually up to the patient. Hip replacement can
commonly be avoided as long as the patient is willing to put up with the pain and the disability.
In fact, most patients, if determined, can put up with one bad hip indefinitely, since the good
side can do most of the work. Patients with deterioration of both hips often are under more
15
pressure for surgery, since such patients literally do not have a good leg to stand on. Since hip
replacement surgery involves some risk, expense, several months of recovery and a temporary
increase in pain from the surgical procedure and may still not be a permanent solution, surgery
should not be undertaken unless the symptoms are significant and persistent. If your hip
disease is so bad that you cannot get around without a wheelchair or two crutches or are even
bedridden, then most orthopedists would urge hip replacement, assuming you are physically fit
enough to undertake the surgery. If you can walk without a cane or crutch for long distances
with minimal limp or pain and do not have any sleep disturbance, your symptoms are probably
not severe enough to proceed with replacement.
Most patients have their hip replaced when they experience significant and persistent pain,
need a cane at least part of the time, find walking short distances painful, are having sleep
disturbance, and are regularly taking non-steroidal anti-inflammatory medications (NSAIDS),
assuming such drugs can be tolerated. If your hip is making your life miserable, a replacement
is usually a reasonable alternative to putting up with the pain and disability. If the hip problem is
only a minor and occasional bother, non-operative treatments are probably more reasonable
than surgery.
The decision to have surgery should be based on information acquired from the orthopedist, the
family physician, and possibly second opinions. The final decision is always the patient’s. Most
patients have hip replacement when the thought of having hip replacement surgery sounds
better than putting up with the pain and disability of the arthritic hip. We hope this hip booklet
will give patients the information needed about hip replacement to make that decision. There is
almost never any urgency for replacement of the hip unless the pain is severe.
Patients who have only one painful and stiff hip can, if desired, usually get by with a sedentary
lifestyle by avoiding airports, amusement parks, malls, and travel. The desire to have a more
active lifestyle can force surgery at an earlier stage. Many patients find that just at retirement
age when they finally have the time to travel and enjoy the world, an arthritic hip can make
these activities difficult, if not impossible. With a hip replacement the patient’s world can be
expanded and the retirement years can be more active.
Since introduced in the United States about 1969, hip replacement has gradually been
improved. In the early years there were problems with short term complications, long term
durability, and a long and uncomfortable recovery period. On all three issues there has been
tremendous progress. Today in the hands of an expert surgeon operating in a good hospital
with competent medical personnel, patients should expect extremely high short term success
rates as well as a shorter and more comfortable recovery period than in the past. Modern
prostheses promise durability that probably will exceed most patients’ life span. Durability has
been so increased that patients now are given almost no activity limitations. Patients with
modern hip replacements can do many very vigorous activities such as tennis, skiing, volleyball,
handball, racquetball, etc. with little increased risk to the longevity of their hip replacements.
Hip replacement today is truly a medical miracle.
CAN I PUT OFF SURGERY?
There are some advantages to putting off surgery. Progress in hip replacement surgery
continues. Thus, if you wait five to ten years, the technology available should be better than
what we have currently. If you wait, you will get older and thus need the replaced hip for a
shorter period of time. This is important since the major problem with hip replacements has
been durability, since loosening and wear occur occasionally. That said, the technology of hip
16
replacement today is so advanced that there is little reason to wait for further improvements.
Hip replacement is one of the best, if not the best, elective operations surgeons have to offer.
The disadvantages of waiting are the discomfort and the disability, the possible loss of muscle
and bone strength from inactivity and the decreased mental and physical vigor from the
disease-enforced low activity lifestyle.
Do not worry that the hip deterioration will get so bad that it cannot be fixed or the chances of
surgical success will be less later. Such deterioration rarely occurs. Do not worry that you will
damage the other surrounding joints (such as your back, knees, or other hip). While the extra
stress on these joints may irritate these areas, it is unlikely damage will occur. Also do not
worry you will get too old or too sick to have surgery later. It is very rare for a patient, who
needs surgery, to be too old or too sick to have it done. If you are too sick, usually you are so
inactive that surgery is not needed. The only valid reason to have hip replacement is a hip that
is giving you persistent and significant pain and disability resulting in a miserable lifestyle.
OTHER SURGICAL TREATMENT ALTERNATIVES
Hip disease can be treated by other surgical methods besides hip replacement. One alternative
is hip fusion (arthrodesis). This is a procedure in which the femoral bone is made to attach to
the pelvic bone resulting in permanent and complete stiffness of the hip joint. The lost mobility
of the fused extremity is partially compensated for by the mobility of the spine and the knee.
Arthrodesis is rarely performed today because most patients will not accept this hip stiffness
and hip replacement works so well.
Hip fusion makes both sitting and standing awkward, and activities involving reaching down to
the foot are quite difficult. Hip fusion occasionally is recommended for young people who need
to do vigorous labor. Because a stiff hip puts extra stress on the spine and the knee, it is
common for patients to develop pain and arthritis in these joints as the result of a stiff hip. One
concept is to eventually do a hip replacement for a fused hip when the patient is older. This
problem of extra stress on the spine and the knee requires the patient to have a normal spine,
normal knees and a normal hip on the other side for a hip fusion to be seriously considered.
Hip fusion is very rarely done today.
Another alternative to hip replacement is termed osteotomy of the pelvic or femoral bone. An
osteotomy is a procedure in which the bone of the femur or the pelvis, or both, is cut, and the
bones are then placed in a new and different position and then the bones are allowed to heal in
this new position. This results in a redirection of the hip forces in a new and, it is hoped, less
painful and more durable direction. Osteotomies of the hip have been much more popular in
Europe than in America. Osteotomies require long recuperation and the results are less
predictable than hip replacement. Patients with shallow sockets from DDH (developmental
dysplasia of the hip) are often candidates for this operation but the improved reliability of hip
replacement today has decreased the need for this operation. Osteotomies are usually
reserved only for patients less than 40 years of age.
HISTORY OF HIP REPLACEMENT SURGERY
In 1962 Sir John Charnley, an English orthopedist who was later knighted by the Queen of
England for his hip replacement contributions, finally after years of work put together the key
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ingredients of the modern hip replacement. Charnley’s operation involves removal of the bony
femoral head and replacing this with a smaller metal ball which is attached to a stem which fits
into the femur (the thigh bone). The femur is basically hollow in its mid-portion and ordinarily
there is some bone marrow in this area. This hollow area is where the stem of the prosthesis is
placed. The bone marrow that is removed from that area is not needed. The prosthesis itself
must be fixed to the femur, since movement between the prosthesis and the bone causes pain.
In Charnley’s operation it is fixed with plastic cement called methylmethacrylate, which is the
same chemical compound as Plexiglass and was first developed for human use by dentists.
The bony socket surface is also replaced by a plastic (polyethylene) socket fixed into place in
the bony socket, also with the methylmethacrylate cement. This cement acts as a grout similar
to tile grout and should not be considered glue. Cement comes unmixed with powder and liquid
components which are mixed together until a dough-like consistency is reached. This dough is
then pressed into the bone and the prosthesis is pressed into the dough. The cement then
hardens over ten to fifteen minutes into a stone-like consistency. After the hip replacement is
assembled, the metal ball will move around in the plastic socket and transmit the force across
the hip joint. Since the femoral bone is no longer rubbing on the pelvic bone, the patient gets
pain relief. The plastic socket is made of ultra-high molecular weight polyethylene, which has
little frictional resistance against the metal ball.
Wear of hip replacements has always been a problem. In the 1950’s Charnley used Teflon as
the plastic in his hip replacements and had great short term success, only to be disappointed
when many operations failed because of rapid wear of the Teflon. The modern era of hip
replacement dates to 1962 when Charnley started using ultra-high molecular weight
polyethylene which has a dramatically lower wear rate than Teflon. See the below section
entitled “WEAR ” on page 26 for more information on wear.
Charnley-type total hip replacements were introduced in the United States about 1969. Hip
replacement operations today have become routine (over 400,000 hip replacements are done in
the U.S. annually) and are considered successful a high percentage of the time.
.
WHY IS IT CALLED A TOTAL HIP REPLACEMENT?
The term total hip replacement is commonly used by orthopedists but is actually not a good
name for the procedure, since it sounds more radical than the actual operation. A joint is an
area of the body where two bones come together. Orthopedists refer to each bone as being a
separate side of the joint. Thus, the hip joint has the acetabular side and the femoral head
side. Surgery done on only one of the two bones, leaving the other bone unchanged, is called
a hemiarthroplasty. Hemi means half and arthroplasty means an operation to make a joint
better.
Hemiarthroplasty of the hip is most commonly done for patients with fractures of the neck of the
femur. The femur usually breaks just below the ball or head of the femur in the narrowed area
of the bone called the neck of the femur. These fractures are called femoral neck fractures.
Since fractures of that area commonly disrupt the blood supply to the femoral ball, surgeons
often replace the bony ball with a large metal ball that is attached to a stem fixed inside the
femoral canal often with cement. The acetabular bone is actually not changed in this operation.
The big metal ball is large enough and of the appropriate size to fit in the original bony
acetabulum.
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A second type of hip fracture a little lower on the femur does not interrupt the blood supply to
the femoral head and is rarely treated by femoral head replacement. Such fractures are usually
fixed with metal plates and screws.
When hip replacements began to be done and both bones were operated on, the term total hip
replacement (also called total hip arthroplasty) was coined and has come into common usage in
the United States. In fact, Charnley referred to his operation as the low friction arthroplasty and
in England a hip replacement is still referred to as a low friction arthroplasty. Charnley liked this
term, since it was his original concept that hip replacements should have low friction. He felt,
and was probably right, that a small ball rubbing around in a polyethylene socket gave low
frictional resistance and that this was critically important for the hip to do well.
Since fractures of the femoral neck are very common, many thousands of hemiarthroplasties
have been performed for such fractures. The hemiarthroplasty operation takes less time than a
total hip replacement and has less blood loss. Patients with a broken hip have extreme pain
but with a hemiarthroplasty are usually able to get out of bed and resume their daily functions.
On the other hand, the pain relief from hemiarthroplasties is often less complete and less
consistent than one gets with a total hip replacement.
Patients with pain from a
hemiarthroplasty usually have pain in the groin associated with activity. If patients have
persistent and significant pain, some may require conversion to a total hip replacement. It is
increasingly common today for femoral neck fractures to be treated with total hip replacement
rather than hemiarthroplasty.
PROBLEMS WITH CEMENTED HIP REPLACEMENT
The major long-term problem with the Charnley type cemented hip replacement is the potential
for development of loosening of the attachment of the plastic cement to the bone.
With
loosening, the prosthesis then moves in a gradually increasing degree with respect to the bone.
This movement causes irritation to the bone, can cause bone loss, and results in a pain similar
to pain with an arthritic hip. Pain from an arthritic hip is caused by the bone-on-bone contact.
What a hip replacement does is keep the bones from touching, with the movement occurring
only between the two pieces of the hip replacement: the ball moving around in the socket. The
key to making a hip replacement painless is no movement of the hip replacement components
with respect to the bone. The components themselves must be securely fixed to the bone. If
there is movement between the component and the bone, irritation of the bone will occur with
resultant pain.
If the pain or bone loss from loosening is severe, a second surgery may be necessary, usually
referred to as revision surgery. The precipitating reason to proceed with revision surgery of a
loose hip replacement is almost always a degree of pain and disability sufficient that the patient
and the surgeon think that revisional surgery is indicated. Many patients have minor degrees of
loosening determined by various findings on their radiographs but have minimal
symptomatology and thus do not need a revisional surgery. As the prosthesis loosens, there is
commonly damage to the bone. We are very protective of the bone in the area of a hip since
the bone quality is a strong determinant affecting the surgeon’s ability to place a new hip
replacement if necessary. If the bones are of poor quality, the surgeon may have difficulty
getting a new prosthesis fixed to the bone and in rare cases it is not possible to do so. Some
patients have x-ray changes of severe bone loss but few symptoms. Occasionally, we advise
revisional surgery for such situations, particularly in active patients with long life expectancies.
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Mainly because of loosening problems cemented hip replacements today are done infrequently
in the United States.
ARE THERE MORE DURABLE ALTERNATIVES?
Surgeons have continually tried to develop techniques which will lower the loosening rate and
also give the same excellent pain relief and function of a Charnley type (cemented) hip
replacement. A now well proven alternative is to use a prosthesis which has a surface into
which or onto which bone can attach and permanently bond the prosthesis to the bone. For this
technique the methylmethacrylate cement is not used and this operation is termed a
cementless hip replacement. The first cementless hip replacements allowing bone attachment
had porous surfaces and are referred to as porous hip replacements. The innovators of this
cementless concept began using porous prostheses in the United States about 1978. Several
researchers in France such as Judet and Lord began even before that. Today there are
multiple types of cementless hip replacements available in the United States. One of the oldest
in continuous usage in the United States is the AML hip replacement manufactured by DePuy in
Warsaw, Indiana. This device was first used by its innovators in 1978 and was a porous total
hip that was used successfully by Dr. Moreland for many years.
About 1983, as the concept of cementless replacement became popular with surgeons and
patients, many new types of cementless hip replacements were introduced in the United States.
Some of these have stood the test of time and some have not. The reported results of various
types of cementless hip replacements have varied greatly depending upon the particular device
used, the skill of the surgeons, and the patient population treated. Many designs have been
discontinued or greatly modified. Some (such as the AML) have stood the test of time and are
still used, but the AML, like the Charnley hip replacement, is today much less popular with
surgeons and is no longer used by Dr. Moreland.
There are now also many successful hip replacements with surfaces that allow bone
attachment but do not have a porous surface. Some just have a surface roughness that allows
consistent bone attachment. Some are covered with a material similar to bone called
hydroxyapatite which further promotes bone attachment.
Cementless hip replacements now are the standard in the United States.
PROBLEMS WITH CEMENTLESS HIP REPLACEMENT
First of all, we should recognize that there is a great difference in the design of the various
cementless hip replacements. There is also a great difference in the design of the various
cemented hip replacements. Today, the original Charnley hip prosthesis is used relatively
infrequently in the United States, although it is still considered a well-designed prosthesis.
Many other designs of cemented prostheses have been introduced to the U.S. market since the
Charnley replacement came into wide use almost thirty-five years ago. Many of these newer
cemented hip replacements have proved with time to have higher rates of loosening and other
problems compared to the original Charnley prosthesis. As these prostheses have been
proven to have inferior results compared to the Charnley, their use has been abandoned. As
mentioned, a similar situation existed with cementless replacements. The AML is a cementless
20
prosthesis that has stood the test of time but there are now many other good cementless hip
replacements on the market. The AML has one of the longest track records with good results.
Problems with the cementless hip replacements have included occasional lack of bony
attachment, fracture of the femur on prosthesis insertion and incomplete pain relief.
Cementless hip replacements allow a more vigorous lifestyle since the cementless bond to the
bone is sturdier than the bond of the cement to the bone. There is little apprehension and fear
of failure for a patient to do such things as playing tennis and snow skiing and other vigorous
activities with a cementless bonded hip implant as opposed to a cemented implant.
The bond in the cemented hip replacement is at its maximum shortly just after the operation is
done. The bond of the cementless prosthesis to the bone initially is only via a press-fit in which
the prosthesis is simply driven into the bone as a nail is into a piece of wood with an
interference fit. Over the next one to two years the bone attaches itself maturely to the
prosthesis. The femur itself gradually accommodates and changes in response to the different
stresses that are now being applied to the inside of the bone
Just as cemented prostheses can get loose, a cementless prosthesis that does not get bony
ingrowth may also get loose as the initial interference fit is gradually overcome by the forces
placed on the prosthesis. This lack of bone fixation to the implant occurs infrequently in first
time hip replacements and if fixation fails to occur, the problem can be usually fixed with a
second operation. Once cementless prostheses have bonded with the bone, loosening is
extremely rare.
Both cemented and cementless hip replacements are currently being used with the cementless
technique strongly dominating the market. In fact, cemented hip replacements now have a very
small part of the U.S. market and even that portion is declining. Dr. Moreland virtually always
uses cementless hip replacements
WHAT DETERMINES CHOICE OF TYPE OF FIXATION?
Patients with a very active lifestyle, such as those who play tennis and snow ski and do other
vigorous activities are clearly much better served by a cementless replacement, which has a
better chance of standing up to such activities than would a cemented hip replacement. There
are many patients in their seventies and even eighties still doing very vigorous activities, such
as playing tennis, and who usually have excellent bones. These patients are certainly better
served with a cementless implant. Young patients are almost always advised to have a
cementless hip replacement, since they will likely benefit from the increased durability.
Initially many surgeons felt no need to use cementless implants in the elderly inactive patient
and also thought that cementless implants did not work as well as cemented replacements for
patients with severe osteoporosis. Even in patients with significant osteoporosis and very
advanced age, Dr. Moreland and most hip surgeons today prefer cementless hip replacements.
HYBRID HIP REPLACEMENT
Hybrid hip replacement is a term used to describe a hip replacement in which one component is
fixed with cement and the other is not. Cementless acetabular fixation became the standard
before cementless femoral fixation became the standard and for a time surgeons would often
21
use a cementless acetabular component with a cemented femoral component. Patients
receiving such a combination were said to have had a hybrid hip replacement. This hybrid
concept was popular 25 years ago. Today completely cementless hip replacements are the
standard and dominate the market and hybrid hip replacements are rarely performed.
SHOULD THE PATIENT DECIDE IMPLANT TYPE ?
How well a patient does with a hip replacement depends upon a variety of factors. One factor
is prosthetic choice, but the choice of the surgeon and the hospital with its support personnel
and facilities are actually more important factors. In fact, the most important factor is how well
the surgery is technically done with the skill of the surgeon overwhelmingly the most important
factor as to how well the replacement performs. While it is interesting and important to discuss
types of prostheses used and various surgical techniques, patients really should concentrate
more on making sure that they have selected a good surgeon and allow that surgeon to do the
operation in a way with which the surgeon is most confident and familiar. When arranging
piano music for a party, you would probably spend more time evaluating the pianist than
selecting the piano. A good pianist can get music from a bad piano and a poor pianist cannot
get music from the world’s best piano. Surgery is similar. There are many surgeons with
excellent skills and experience with hip replacement and Dr. Moreland would be happy to help
you locate a good surgeon in your area, if travel to our area is a problem or for any other
reason.
SURFACE REPLACEMENT
Before Charnley’s hip replacement was first used in the U.S. around 1969, the most common
operation for hip arthritis was the cup arthroplasty. In this relatively simple operation, a thin
metal cup was placed over the femoral head after some bone shaping. The metal cup covered
head was simply placed back in the bony socket (acetabulum). No cement was used to anchor
the cup to the femur. When Charnley’s operation proved its dramatic superiority, the cup
arthroplasty operation was quickly discarded with the approval of cement by the Food and Drug
Administration (FDA) around 1970.
Later, when loosening developed in some patients with Charnley’s operation (particularly in the
young, big and active patients), several centers worldwide began using an operation which
combined elements of the old cup arthroplasty with elements of Charnley’s operation. The
centers were UCLA (Amstutz), Indianapolis (Capello), Michigan (Townley), England (Freeman),
Germany (Wagner), Japan, and Italy. In the late 1970’s this operation (termed surface
replacement in the U.S.) was used widely around the world.
Similar to the cup arthroplasty, the femoral head was maintained rather than being removed as
in a Charnley type replacement. A metal shell was placed over the femoral head, as in the cup
arthroplasty, but in this operation it was cemented in place with the same methylmethacrylate
cement used in the Charnley operation. A thin plastic socket made out of polyethylene was
also cemented in the bony socket. Since both sides of the hip were replaced, this was
considered a type of total hip replacement.
Surgeons worldwide were hopeful surface replacement would be more durable than Charnley’s
operation. By the early 1980’s multiple centers reported results, not better than the Charnley
22
operation, but much worse. Surface replacement of the hip was then rarely used for many
years.
Some investigators continued to work on experimental variations of operations in which the
femoral head is maintained instead of being removed (an intuitively attractive concept) but
unacceptable rates of failure continued for several surgical variations of surface replacement.
Most authorities believe that the inherent thinness of the polyethylene in surface replacement
(thin polyethylene has a high wear rate) was the Achilles heel of surface replacement.
The FDA approval in 2006 of a metal-on-metal (no polyethylene at all) surface replacement led
to an increase again in the usage of surface replacement worldwide. Still, an article already
published at that time in January, 2004 in volume 86-A of the orthopedic journal “The Journal of
Bone and Joint Surgery” (JBJS) documented a worrisome early failure rate from femoral
loosening and femoral neck fracture in patients given metal-on-metal surface replacements. In
that series of 400 metal-on-metal surface replacements done between November, 1996 and
November, 2000, 17 hips (4.3%) had already required reoperations, mostly for femoral
loosening or fracture of the femoral neck and another patient had known failure when last seen.
Dr. Moreland reviewed his patients having cementless total hips during that same November,
1996 to November, 2000 time frame. There were 859 cementless total hips done during that
period with only 8 hips (0.9%) requiring reoperations at that time. Since Dr. Moreland's results
were better than the surface replacement report, Dr. Moreland decided not to use these new
metal-on-metal surface replacements. This has turned out to be a good decision for Dr.
Moreland's patients.
Metal-on-metal surface replacement of the hip was heavily promoted, particularly on the
internet. Young, athletic people with hip arthritis were especially attracted to the metal-on-metal
surface replacement concept. As stated, it is intuitively attractive and there were claims by
some that metal-on-metal surface replacements allowed a higher level of function for these high
activity individuals. There is no scientific support for this claim.
Once a cementless stem type hip replacement has fully healed, Dr. Moreland places no activity
restrictions on the patient. Patients with successful cementless stem type hip replacements can
be just as active as those patients with surface replacements. Surface hip replacements have a
known risk of femoral neck fracture. Dr. Moreland believes there is more risk of failure with
vigorous activities with the surface replacement than with a stem type replacement because of
concern about femoral neck fracture and loosening.
Metal-on-metal surface replacements produce high numbers of submicroscopic metal particles.
Some of the metal goes into solution and high levels of metal ions in the blood and urine have
been routinely found in patients with metal-on-metal surface replacements. There was initial
concern that these metal ions could cause cancer but such has not been found. There was also
initially concern that the metal ions could cause metabolic abnormalities and now we know such
does occur when the metal ion levels are very high and such metabolic abnormalities may be
occurring in some currently undetectable way in patients with lower metal ion levels.
There is particular concern about the safety of metal-on-metal hip replacements in women who
may later have children, since the fetus would be exposed to these metal ions, and in patients
with renal disease, since some of the metal ions are excreted by the kidneys. There have also
been reports with metal-on-metal hip replacements of pain from metal allergy requiring revision
to metal on plastic in order to relieve the pain.
23
We now know that some metal-on-metal surface replacements produce metal ion levels
sufficient to be toxic to the tissues around the hip, causing tissue death and failure of the
arthroplasty and in very high levels can result in toxicity to other body organs and systems.
Several surface replacement designs have been taken off the market and there today is much
medical legal activity surrounding metal-on-metal surface replacements. Surface replacement
has lost popularity with surgeons and patients and surface replacement is once again being
done very infrequently.
OTHER NEW TECHNIQUES
Periodically, new implants and surgical techniques are introduced to the orthopedic and lay
community with great fanfare and claims of superiority to older techniques. In hip replacement
surgery we already have well-established techniques (e.g. Charnley’s operation) that quite
consistently and reliably give excellent pain relief and function. What has been lacking is an
ability to give all patients (especially the young, big and active patient) a hip replacement which
will reliably last the rest of the patient’s life. Thus, any new technique or implant can add to the
state of the art of hip replacement only by proving to be more durable. Durability can only be
tested by human implantation and long-term observation.
All new techniques and implants do not automatically represent improvement. The words “new
and improved” go hand in hand in most new product introductions such as cars, cell phones,
computers, etc. and we almost treat the words “new" and "improved” as synonyms. In hip
replacement “new” and “improved” are definitely not synonyms but instead “new” really equals
unproved, or even harsher, experimental. Remember that Charnley did the first modern hip
replacement only in 1962 and we began hip replacement in the United States only in about
1969. If a patient’s life expectancy is many decades, most types of hip replacement for that
patient should be considered experimental procedures for that patient, since virtually all hip
prostheses in common use today have usage history less than the life expectancy of such a
patient.
The media, in an effort to increase viewership and thus revenue, often report various new
health developments in an exaggerated way and, thus, often falsely and cruelly raise the hopes
of patients. Some hospitals and some surgeons pay the media to report their supposed
dramatic advances in hip replacement surgery in a shameless attempt to attract more patients.
The media seems at times to try purposefully to disguise advertising copy as a scientific report,
making it difficult to differentiate reports of real scientific advances from simple advertising.
Many promising new techniques, such as surface replacement (described above), custom hip
replacements, the Mittelmeir hip (the original ceramic-on-ceramic hip developed in Austria and
introduced many years ago and later taken off the market because of a high failure rate),
custom hip prostheses made during surgery, “improved” polyethylene formulations and the
threaded acetabular component have with time proved to be big steps backward and not steps
forward. More recently modular necks for femoral components were introduced and are causing
major problems with breakage and metal debris and some are already off the market.
Hip replacement using a robot and hip replacement with computer guided navigational systems
has received media attention. Neither the necessity nor practicality of these experimental
techniques has been proven and cannot be proven for many years despite the glowingly
positive media reports propagated by their enthusiasts.
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Hip arthroscopy (similar to the widely used knee arthroscopy) has little place in the treatment of
hip arthritis. Some surgeons use the lure of a “simple” hip arthroscopy in a bait-and-switch way
to attract patients. Hip arthroscopy is not a simple procedure like knee arthroscopy and has a
significant risk of complications. As opposed to the knee, the hip is a deep structure and does
not have a spacious joint cavity into which an arthroscope can be easily inserted. The leg must
be pulled forcibly to distract the femur away from the acetabulum so that the arthroscope can
be inserted. Damage to the hip articular cartilage can be done by the arthroscope itself in this
process and other complications can occur. Also importantly, there is actually very little that an
arthroscopist can do to help a patient with hip arthritis.
Be wary of self-proclaimed “Institutes or Centers of Excellence in Hip Replacement” without
well-established community recognized expertise. There are, unfortunately, no requirements
for the use of the terms “institute” and “center”. Many institutes are truly substantial, but some
consist only of glossy brochures, an advertising agency, and a phone answering service
relaying referrals to physicians without particular extra expertise.
When making comparisons between surgeons, it is not enough only to know incision lengths,
predictions of rapid recovery and early discharge, and undocumented claims of being “better”.
Patients should also compare surgeon hip replacement volume, infection rates, dislocation
rates, loosening rates, reoperation rates, perioperative death rates, nerve (femoral, peroneal,
posterior tibial, and anterior femoral cutaneous) damage rates, femoral fracture rates, blood clot
rates, leg length discrepancy rates, vascular damage rates and heterotopic bone formation
rates.
COMPLICATIONS OF HIP REPLACEMENT
Hip replacement is very successful and complications are uncommon. There is easily a greater
than 95% chance that the replacement can be accomplished without serious complications.
The most devastating complication is infection. The chances of an infection in a first time
operation are one out of several hundred. Infection can be introduced into the hip joint at the
time of surgery when the wound is open, since there are always bacteria in the air and on the
patient’s skin. Precautions are taken against this occurring by using special operating rooms
with extra clean air (laminar flow rooms) and by giving prophylactic antibiotics. Infection also
can be introduced into the hip by way of the bloodstream at any time after the surgery.
Although unlikely, infections in other parts of the body can spread to the hip replacement.
Dental work also can release bacteria into the bloodstream which then can travel to a hip
replacement and can very rarely cause an infection.
Thus, some authorities have
recommended that patients with hip replacements take prophylactic antibiotics by mouth shortly
before and after some dental work and other medical procedures which can cause bacteria in
the bloodstream. There is no data to support this practice. Before any medical or dental
procedures, a patient with a hip replacement should always remind the treating physician or
dentist that the patient has a hip replacement. Responsibility for giving prophylactic antibiotics
is that of the physician or dentist performing the medical procedure. Hip replacement patients
should have any bacterial infections, other than those of the hip replacement itself, treated
promptly by their primary care physician. Viral infections, such as colds, and fungal infections
of the skin or nails are not a threat to a hip replacement.
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Loosening of the fixation of the prosthesis to the bone, as has already been mentioned, is a
major long-term problem with cemented hip replacements. The durability of a cemented hip
replacement is determined by three factors. The skill of the surgeon is the first and most
important factor. If the surgery is done well, it will last much longer than if it is done poorly.
The second factor is the stress the prosthesis will have to withstand. This is dictated by the
patient’s activity level. Vigorous activities such as running and heavy lifting cause stress to be
delivered to the prosthesis and can cause it to become loose. Thus, patients with cemented hip
replacements should avoid stressful activities. Cemented hip replacement patients can
participate in golf, swimming and bicycle riding but should avoid other more stressful activities.
The third factor affecting the rate of loosening is the condition of the individual patient’s bones
since some bones are formed in a way that makes it difficult to get the replacement well fixed.
In striking contrast, once bony attachment (osseointegration) has been achieved to the implant
surface, cementless hip replacements have an almost zero chance of loosening, even with the
most stressful activities.
WEAR
In the 1950’s Charnley experimented with Teflon as the plastic for his socket and was
disappointed to find high rates of failure because of wear. With his use of the ultra-high
molecular weight polyethylene beginning in 1962, wear became much less of a problem and
during the 1970’s and 1980’s attention was focused mainly on ways to improve fixation of the
implant. With the improved fixation of cementless hip replacements and increased activity
levels of patients, surgeons found that the durability of the prosthetic fixation often exceeded
the wear potential of the polyethylene.
Wear is a problem from two standpoints. The ball can wear its way all the way through the
plastic and start to hit the metal shell and cause catastrophic problems. This actually rarely
occurs with today’s modern designs but did occur occasionally with some earlier designs which
had thinner layers of polyethylene.
The main problem with wear today is bone loss which can occur from the wear particles
themselves. The body’s tissues can react to the tiny microscopic wear particles in a way that
destroys bone. Most likely the body confuses these tiny wear particles with bacteria and in an
effort to clear these particles from the hip, the body’s tissues become inflamed and reabsorb
some of the bone.
Patients will not necessarily have symptoms from wear until very late in the wear process.
Thus, patients should be followed by their orthopedist with radiographs every two or three years
to look for evidence of wear and possible bone destruction from the wear particles. The plastic
lining of the cup and the ball of the stem can usually be relatively easily changed without
disturbing the cemented or bone ingrown surfaces of the implant. A reoperation for wear is
usually a much easier one than a reoperation for loosening.
Wear has been the most frequent cause of reoperations at most hip replacement centers in
recent years. Fortunately, significant progress in wear reduction has been made. Several
researchers working in different centers have developed a new manufacturing process for the
polyethylene which increases the cross-linking of the long chain polyethylene molecule and
lowers the laboratory wear rate of the plastic to practically zero. Dr. Moreland has been using
this highly cross-linked polyethylene formulation routinely since September 1999 and so far
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virtually no wear has been found in any of these patients. Thus, the clinical results are
corroborating the wear testing in the laboratory. Even in young patients, we now have the
potential for life-long hip replacement durability. It is a gratifying time for both hip replacement
candidates and hip replacement surgeons.
The type of femoral head on the prosthesis also affects the rate of wear of a hip replacement.
Hip replacement has always mainly been done with metal heads. Heads of stainless steel,
cobalt-chrome alloy and titanium have all been used. Titanium is today never used as a head,
since it was found to produce too much wear of the polyethylene. Charnley’s original stem was
a one solid piece of stainless steel and thus had a stainless steel head. Stainless steel stems
fell out favor because some of the stainless stems fractured. Modern hip replacements all have
modular heads and there are no stainless steel modular heads. So today all metal heads are
made out of the alloy cobalt-chrome. Cobalt-chrome heads rubbing against highly cross-linked
polyethylene works extremely well.
Ceramic heads also can be used to articulate against the polyethylene. Ceramic has the
advantage of being very hard and thus very difficult to scratch and can be polished to a high
degree. These properties result in lower wear rates for ceramic heads compared to cobaltchrome heads. Ceramic has the disadvantages of possible fracture (extremely rare with modern
designs) and increased cost.
Metal-on-metal stem type hip replacements have also been used but, similar to the problem of
metal-on–metal surface replacements, have the disadvantage of metal ion release into the
blood. Both metal-on-metal surface replacements and metal-on-metal stem type hip
replacements produce high numbers of submicroscopic metal particles. Some of the metal
goes into solution and high levels of metal ions in the blood and urine have been routinely found
in patients with metal-on-metal replacements. There was initial concern that these metal ions
could cause cancer but such has not been found. There was also initially concern that the metal
ions could cause metabolic abnormalities and now we know such does occur when the metal
ion levels are very high and such metabolic abnormalities may be occurring in some currently
undetectable way in patients with lower metal ion levels.
There is particular concern about the safety of metal-on-metal hip replacements in women who
may later have children, since the fetus would be exposed to these metal ions, and in patients
with renal disease, since some of the metal ions are excreted by the kidneys. There have also
been reports with metal-on-metal hip replacements of pain from metal allergy requiring revision
to metal on plastic in order to relieve the pain.
We now know that some metal-on-metal hip replacements produce metal ion levels sufficient to
be toxic to the tissues around the hip, causing tissue death and failure of the arthroplasty and in
very high levels can result in toxicity to other body organs and systems. Several metal-on–metal
hip replacement designs have been taken off the market and there today is much medical legal
activity surrounding metal-on-metal hip replacements. Both metal-on-metal surface and metalon-metal stem type hip replacement have dramatically lost popularity with surgeons and
patients. Dr. Moreland has never performed either type of metal-on-metal hip replacement.
Ceramic-on-ceramic hip replacements have been reintroduced in the U.S. with a lot of
advertising by some manufacturers, one of which has used the golfer, Jack Nicklaus, as a paid
spokesman. Jack probably would be a good source for advice about putters, but his advice
about prosthetic choice in hip replacement is suspect. An earlier version ceramic-on-ceramic
hip replacement introduced with similar great fanfare about 25 years ago (the Mittelmeir) was
taken off the market completely a few years later because of a high failure rate. A serious but
27
infrequent problem with ceramic-on-ceramic hip replacement is fracture of the ceramic itself. In
addition, there are now frequent reports of bothersome squeaking sounds coming from
ceramic-on-ceramic hip replacements and such devices are not popular today.
When a cobalt-chrome modular head is placed on either a cobalt-chrome or titanium stem, the
interface between the two metals can produce cobalt and chromium ions. Since this problem
was identified a few years ago as significant in some situations, Dr. Moreland has routinely
used a ceramic head. The prosthesis he now routinely uses consists of a titanium stem, a
titanium socket, a ceramic head and a highly cross-linked polyethylene insert. There is no
cobalt-chrome at all and so no potentially toxic cobalt or chromium ions can be produced.
In the 2008 edition of this booklet Dr. Moreland wrote, “Today we have three relatively new
developments in hip replacement to address the wear problem: highly cross-linked
polyethylene, metal-on-metal articulations, and ceramic-on-ceramic articulations. All look quite
good since short term data and laboratory testing show much less wear than earlier technology.
All three have their advocates but there are actually no data to prove that one of these three is
to be preferred.” Dr. Moreland decided not to use either the metal-on-metal or the ceramic-onceramic articulations and this seems to have been a wise choice, since today there are very few
of these devices still being used.
HIP REPLACEMENT DISLOCATION AND SURGICAL APPROACH
Dislocation of hip replacements (the metal ball coming out of the plastic socket) occurs
infrequently. The femoral head is held into the plastic socket by muscle tension and, after the
hip maturely heals, by scar tissue. Thus, patients with poor muscles are more likely to suffer
dislocation. During the first few weeks after surgery, before scar forms around the head and
before muscle strength returns, the hip is more likely to dislocate. During this time avoidance of
certain positions may help to decrease the rate of dislocation. The physical therapist can teach
you the positions to avoid and how to use your hip replacement safely in the first few weeks
after surgery. If the hip does dislocate, it is usually a relatively simple matter after sedation in
the emergency room for the surgeon to pull on the extremity and the hip will pop back into
place. Dislocations most commonly occur in the first few weeks after surgery, but occasionally
patients develop repetitive dislocations requiring corrective surgery.
The postoperative dislocation rate varies with the skill of the surgeon, the surgical approach
chosen by the surgeon, the size of the head used and the patient population served. The usual
dislocation rate reported in the literature in first time (primary) hip replacement is about 3%. Dr.
Moreland’s primary dislocation rate is around 0.4% or about one-eighth of the usual rate.
Dislocation is a significant complication, since a dislocation is painful and causes the patient to
lose faith in the replacement which can be a significant psychological burden.
Several different surgical approaches can be used to obtain the exposure needed to put in a hip
replacement. Surgical approaches can be broadly divided as to whether the hip joint is entered
by going anterior (in front of) or posterior (behind) to the top end of the femur (thigh bone)..
The hip replacement literature has repetitively documented a much lower dislocation rate for the
anterior approaches compared to the rate with the posterior approaches. Dr. Moreland has
used an anterior approach since 1992 because of the low dislocation rate.
Sir John Charnley strongly advocated the transtrochanteric approach. This approach involves
the temporary removal of the greater trochanter with it being replaced at the end of the surgery.
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This approach gives the best view of the hip but is very rarely used today because it requires
the use of wires and has the risk of wire breakage and lack of trochanteric bone healing. Dr.
Moreland uses very rarely the original trochanteric removal approach in difficult and complex
cases because of its better exposure. Dr. Moreland stopped using this approach routinely
many years ago, as did almost all other surgeons, because its disadvantages outweighed its
advantages in the usual primary replacement.
Anterior approaches can be subdivided into two types. The two differ as to whether the hip is
approached medial (Smith Peterson approach) or lateral (Watson Jones approach) to the
tensor fascia lata muscle. These are both old approaches having been described by two
famous early 20th century English surgeons. The Watson Jones approach (a version of which
Dr. Moreland has used for over 20 years) has been until recently practically the only type of
anterior approach used in the United States. The Smith Peterson type of anterior approach has
been advocated by several surgeons in recent years. Both of these anterior approaches have
low dislocation rates.
As mentioned, the head size of the femoral component affects dislocation rates. Larger heads
are less likely to dislocate and thus Dr. Moreland today uses heads as large as is practical,
limited by technical considerations of prosthetic design. Very large cobalt-chrome heads have
particularly been associated with cobalt and chromium ion production at the head-stem
interface and are used only in special circumstances, such as when dislocation is very likely.
OTHER POSSIBLE COMPLICATIONS
Nerve damage occurs less than 0.1% of the time with a hip replacement. The nerve most
commonly damaged is the nerve to the muscles which bring the foot up toward the face.
Damage to this nerve causes drop foot. Usually if this nerve is damaged, it will slowly recover
over many months but not always. Nerve damage occurs most commonly in association with
the need for significant leg lengthening with the hip replacement, particularly with
developmental hip dysplasia patients.
Less than 1% of the time, patients develop extra bone formation around the hip joint which
causes the hip to be significantly stiffer than desired. This is more likely to occur in men with
osteoarthritis. Formation of small amounts of extra bone called heterotopic bone occurs
commonly around hip replacements and does not cause a problem. A large amount of extra
bone causing severe stiffness rarely occurs and can be treated later by surgical removal of the
bone after it has matured. Radiation therapy or medications, such as Indocin, are sometimes
used to try to prevent bone formation when the surgeon believes the patient is likely to develop
this extra bone.
Rarely, the femur will fracture during a hip replacement or from later trauma. Sometimes these
fractures can be treated without surgery but sometimes surgery is required to fix the fracture
fragments. Healing can almost always be obtained.
The prosthesis itself can break. The stem of the component is under very high stress and is
loaded repetitively and may fracture via a mechanism called fatigue fracture. Smaller
prostheses are more likely to fracture. Bigger sizes with large diameters are extremely unlikely
to fracture. Manufacturers are very aware of this problem and today produce devices which are
less likely to fracture compared to prostheses used in the past. We are aware of only two stem
fractures in over 6,500 hip replacements done by Dr. Moreland in his career.
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One should not expect a hip replacement to be as good as a normal hip, although many
patients seem virtually normal. The completeness of pain relief and the degree of mobility is
partially determined by the individual patient’s type of problem. Rarely, patients have pain after
surgery which cannot be explained and does not resolve.
The length of the leg can be changed to some degree by the hip replacement surgery. Getting
the leg lengths exactly equal is difficult and is not always the object of the operation. Some
differences in leg lengths after surgery cannot be avoided and shoe lifts may be necessary after
surgery. Sometimes, some lengthening cannot be avoided because of dislocation problems.
The most common medical complication in hip replacement is blood clots (deep venous
thrombosis or DVT) which may develop in the legs and the pelvic area after surgery. As long
as the blood clots do not move up to the heart, the only effect is swelling in the leg, sometimes
with calf or thigh pain. Occasionally, the blood clots may move up through the heart to the
lungs causing the patient to be short of breath and have chest pain (pulmonary emboli or P.E.).
Dr. Moreland’s replacement patients are given usually Coumadin (warfarin) postoperatively
which thins (anticoagulates) the blood and helps prevent clots after surgery. Very rarely death
can occur from large clots moving to the heart and lungs. Dr. Moreland, fortunately, has not
had a patient die of this problem. Other measures such as compressive support hose (TEDS),
bed exercises, and early walking also help prevent blood clots.
A fat embolism is another potential complication of hip replacement. There is fat in the cavity of
the bone where the femoral prosthesis is placed. Apparently, if this fat is pressurized, some of
it can be driven into the veins which then can carry the fat back up to the heart, then to the
lungs and somehow also to the brain. This can cause the patient to have difficulty breathing and
to develop neurological problems. Evidence now suggests that evacuating the fat out of the
femur before the prosthesis is placed probably prevents this complication. Patients will usually
recover from a fat embolism problem, if measures are taken to support the patient’s breathing
while the tissues are recovering from the insult of the fat.
Anesthetic complications can occur and very rarely the patient can die. Your anesthesiologist
will see you before surgery and should explain the risk of anesthesia and your anesthetic
choices. There are two broad types of anesthesia which are used for hip replacement: general
and regional. In general anesthesia you are completely asleep and thus totally unaware during
the operation. In this technique an IV is first started in your arm. The anesthesiologist next
puts multiple monitoring devices on you (EKG, stethoscope, pulse oximeter, blood pressure cuff
and other monitors), lets you breath high levels of oxygen for a few minutes, and then puts you
to sleep by injecting a sedative through your IV. Your next awareness is usually when you are
waking up in the recovery room.
In the regional anesthetic, an IV is also started and the same monitoring devices are placed.
Then, while on your side or sitting on the operating room table, the anesthesiologist injects
medicine in your back next to your spinal nerves. You will then gradually lose feeling from
about your waist down.
There are two types of regional anesthetic: the spinal and the epidural (often given to women in
labor). The spinal rarely can cause postoperative headaches. You can be entirely awake with
a regional but the anesthesiologist almost always sedates you so that you are completely
unaware of the operation.
The final decision as to type of anesthesia is the anesthesiologist’s after consultation with the
patient and the surgeon. With the advanced anesthetic monitoring techniques available today,
30
anesthesia is safer than ever before. Dr. Moreland strongly prefers the spinal anesthetic since
it is associated with less bleeding, a lower rate of blood clots, and patients seem to have less
postoperative pain.
Blood transfusions carry risk. We use many measures to limit the usage of banked blood. In
the past many patients stored their own blood before surgery (autologous blood). Today experts
recommend against autologous blood donation. With today’s techniques for testing the blood
and screening donors, the blood supply today is much safer than in the past.
Other complications can occur, but you should keep in mind that the chances of any significant
complication occurring is small. As with many things we do in life, major surgery cannot be
done without risk. We will do everything we can to minimize the risk you undertake. Keep in
mind that the worse your preoperative symptoms are, the more reasonable it is that you take
the risks inherent in having hip replacement surgery.
WRONG SIDE SURGERY
Publicity about patients tragically having surgery on the wrong side of the body has made many
patients very anxious about this possibility.
Dr. Moreland has done over 6,500 hip
replacements and over 3,500 knee replacements and has never operated on the wrong side.
There are many preventative mechanisms in place and you may get tired of being asked which
side is the correct one. Dr. Moreland during your preoperative office visit, usually the day
before the surgery, will personally mark his initials and the word "yes" on the operative site.
You can still shower but do not scrub the writing off before surgery.
MINIMALLY INVASIVE HIP REPLACEMENT
Minimally invasive hip replacement techniques are now standard for almost all hip replacement
surgeons. Dr. Moreland has been routinely doing minimally invasive hip replacement for many
years. Surgeons perform minimally invasive hip replacement in many different ways but the
common surgical goal is to do minimal damage to the soft tissues so that patients will have less
postoperative pain and disability and quicker recovery
The term “minimally invasive surgery” has acquired a special magic. The term “laser surgery”
has had a similar appeal to prospective surgical patients. The reason for the excitement about
minimally invasive surgery is that several surgical techniques with this name have been
developed which have revolutionized some operations. The interior of various body cavities can
now be easily viewed by a miniaturized camera attached to a small tubular telescope
(endoscope) with the image displayed on a monitor. Surgery can then be performed using long
thin surgical instruments inserted through small incisions, or through natural body openings,
with the instruments’ movements seen on the monitor. The resultant smaller surgical insult to
the surrounding tissues allows the patient to recover quicker and with less pain in most
situations.
In general surgery, laparoscopic cholecystectomy (removal of the gall bladder) has been a
dramatic advance using minimally invasive surgical techniques. Good examples in orthopedics
are arthroscopy of the knee, and later many other joints, which have allowed surgeons to see
the interior of joints better and to do surgeries through small incisions. There are many other
surgical examples. These procedures as a group have become known as minimally invasive
surgery and almost all involve the use of these small telescopes and cameras and very small
31
incisions. There is no wonder about the magic this term has today with patients, since these
revolutionary techniques have received appropriate and deserved wide publicity.
Today, however, the term "minimally invasive surgery" is being applied somewhat
inappropriately to total hip replacement techniques, since the small telescopes and cameras of
the usual minimally invasive surgical techniques are not used in these new hip techniques. In
addition, minimally invasive surgical techniques typically involve incisions less than one-half
inch in length. Since all hip replacements require the insertion of prostheses of a significant
size, the minimal incision length to allow the prosthesis itself to go through the skin needs to be
at least two or three inches and even this length requires skin stretching, which can lead to
delayed skin healing. Still, we should not quibble too much with semantics and definitions,
particularly since minimally invasive hip replacement techniques represent a dramatic advance
over previously available techniques.
Hip replacement prostheses have been gradually improved since introduced in the United
States in 1969. Prostheses available today have a dramatically lower potential for loosening,
wear, dislocation, and stem fracture and, as stated above, have a probable durability exceeding
the life span of the typical patient. Interestingly, Dr. Moreland’s medical career almost exactly
coincides with hip replacement in the U.S., since he started medical school in 1968 and thus he
has seen and participated in the gradual improvement of total hip replacement surgery. The
chances of short term complications such as infection, dislocation, nerve damage, blood clots,
femoral fracture, extra bone formation and the resultant stiffness, and leg length discrepancy
have all been greatly decreased.
Compared to 30 years ago, when Dr. Moreland first became involved with hip replacement as
an orthopedic resident at UCLA, the average length of surgery and the amount of blood loss
are significantly less today. Hip replacement then took three to four hours and often involved
several units of blood loss. Today Dr. Moreland routinely does hip replacements in about 90
minutes and blood loss averages less than a unit and transfusion is rare. The minimally
invasive surgery that Dr. Moreland now uses usually takes a little longer than the techniques he
used just before adoption of minimally invasive surgery. A few more minutes in the operating
room is a good tradeoff for the usual quicker and less painful recovery.
When minimally invasive hip replacement first was popularized, most of the emphasis was on
incision length. Now most of the emphasis is appropriately on its capacity to allow immediate
weight bearing with quicker recovery and less postoperative pain.
Dr. Moreland had gradually decreased the length of his hip incisions even before adoption of
minimally invasive hip replacement and his incisions then were about five or six inches long.
Now his incisions are about four or five inches. Any shorter is unnecessary and compromises
his ability to do a good hip replacement in a timely manner.
WHEN WILL FULL WEIGHT BEARING BE ALLOWED?
The minimally invasive technique that Dr. Moreland uses allows immediate weight bearing as
tolerated. Of course, the surgical trauma causes some discomfort and patients at first need
walking aids, but there are no restrictions placed on weight bearing on the new hip. When
patients get out of bed the morning after surgery, two crutches or a walker are usually needed.
As the operative pain decreases, patients can progress to a cane as soon as the patient is able.
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When cementless hip replacement was popularized in the early 1980’s, virtually all experts
recommended that patients postoperatively use crutches or a walker with minimal weight
bearing on the operated extremity for several weeks, thinking that this would facilitate bone
attachment to the implants. As surgeons became more experienced with cementless hip
replacement and saw that patients who ignored this minimal weight bearing advice usually did
well anyway, many began to allow patients to weight bear as tolerated right after surgery. It is
still not clear whether immediate weight bearing or delayed weight bearing is better for bone
attachment, but it is very clear that if there is a difference, it is small. Conservative patients,
who are not in a rush to weight bear immediately, still may choose to go slowly with weight
bearing.
A second reason to limit early weight bearing is to facilitate soft tissue healing, particularly if
muscles have been detached or damaged during the surgical approach. The AML prosthesis
because of its design with a relatively long length is more difficult to insert without a larger
incision and more muscle damage than other stem designs. With this prosthesis and the
surgical approach Dr. Moreland used at that time for insertion a period of limited weigh bearing
was needed. Dr. Moreland’s long term extremely successful experience with the AML made him
initially reluctant to change to a different implant.
Since patients today clearly do prefer immediate weight bearing and the quickest possible and
minimally painful recovery, as well as a good long term result, Dr. Moreland changed to a
different shorter prosthesis to facilitate a minimally invasive operative approach with immediate
weight bearing. He chose the Corail stem. This prosthesis was developed in France and has
been in use since 1986. Excellent results have been reported from multiple centers and this
stem has stood the test of extensive use and close scrutiny. It has a special rough surface and
is coated with hydroxyapatite and is ideal for inserting with a minimally invasive approach. Dr.
Moreland’s experience with it and minimally invasive hip replacement has been excellent. The
Corail stem is manufactured by the Depuy orthopedic company which is owned by Johnson and
Johnson.
SURGICAL APPROACH OPTIONS
The era of emphasis on minimally invasive hip replacements was ushered in almost singlehandedly several years ago by the Chicago orthopedic surgeon, Dr. Richard Berger. He, in
alliance with the orthopedic company, Zimmer, developed and aggressively promoted a truly
new hip replacement surgical approach. This approach, actually invented by another surgeon
but popularized by Dr. Berger, is usually referred to by orthopedic surgeons as the “two incision
approach”. In this approach two one and a half to two inch incisions are made. Some of the
control of the instruments’ and implants’ positions is guided by the image intensifier (an x-ray
device like the fluoroscope). Patients thus get extra exposure to x-ray radiation with this
technique. These surgeries take, even with Dr. Berger, a longer time to do than more standard
approaches.
Dr. Berger not only promised quicker and easier recovery but also trumpeted very early
discharge for his patients. Time of discharge is heavily dependent on patient motivation, health,
and home support systems. Most patients in Dr. Moreland’s practice with minimally invasive hip
replacement stay in the hospital for two or three nights and when home, need little nursing care,
but do need others at first to help with cooking, cleaning, and shopping.
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Zimmer sponsored training courses to teach Dr. Berger's technique to other orthopedic
surgeons. Records were kept of the results the trained surgeons achieved after returning home
and trying this new technique on their patients. The results showed worrisome complication
rates and were generally much worse than those reported by Dr. Berger. Femoral fracture was
a significant problem. Most surgeons who attended the training courses did not adopt this
technique as a standard part of their practice. This approach did not gain popularity with
surgeons after an initial wave of publicity and usage and today is rarely used, even by Dr.
Berger.
Dr. Berger gained so much publicity and so many new patients with his minimally invasive hip
replacement technique that other surgeons were spurred to devise minimally invasive hip
replacement techniques also. Most surgeons simply modified the techniques they had been
using to accommodate a shorter incision with less damage to the tissues and then marketed
themselves as minimally invasive hip replacement surgeons.
Before the era of emphasis on minimally invasive hip replacements, there were being used in
the United States basically two types of approaches with multiple variations. These approaches
can be divided into types that access the femoral head and the socket (acetabulum) by going
behind (posterior) the femur or in front of (anterior) the femur.
The most popular approach then and now is to go posterior to the femur. The posterior
approach is sometimes called the posterolateral approach. Surgeons using this approach
today have shortened their incisions and call their technique minimally invasive. This approach
always involves cutting muscle attachments. The piriformis muscle and often the obturator
internis muscle with the inferior and superior gemelli muscles are routinely cut from their
attachments to the femur. The posterior approach can not be done without cutting some
muscles. A repair of the cut muscles is usually made as the hip is being closed but these
muscles probably do not heal back anatomically.
The main criticism of the posterior approach in comparison to anterior approaches has always
been a much higher rate of postoperative dislocation, probably related to the muscle weakness
caused by the muscle cutting. Posterior approach advocates today emphasize efforts to
securely repair all cut structures including the released muscles and the posterior capsule and
now report lower dislocation rates than previously. Surgeons using the posterior approach
usually require that patients avoid bending over for several weeks after surgery to prevent
dislocation.
Dr. Berger now usually uses the Watson Jones approach. This approach with multiple
variations around the country was the other popular hip approach before the era of emphasis
on minimally invasive hip replacements. Dr. Moreland has also used a variation of the Watson
Jones approach for many years. It can be done with or without cutting muscle attachments.
The cutting of some muscle attachments allows the surgeon better visualization and allows
easy insertion of all prosthetic designs. If muscles are not detached and only retracted (pushed
out of the way), then a shorter and more easily inserted prosthesis is needed. Both Dr. Berger
and Dr. Moreland now only retract the muscles and use minimally invasive friendly stems.
Anterior approaches have several advantages over posterior approaches. First, anterior
approaches can be done without cutting or releasing some muscles and the posterior approach
cannot. Second the dislocation rates are lower with anterior approaches and thus, patients do
not have the inconvenience of avoiding certain positions after surgery.
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Since the advent of the era of minimally invasive hip replacement, another type of anterior
approach has been popularized. This is actually a variation of another old approach described
by another early 20th century English orthopedist named Smith Peterson. It is referred to as the
Smith Peterson approach. The Watson Jones approach and the Smith Peterson approach are
in a very similar location and differ only as to whether the muscle interval used to get to the hip
is medial or lateral to the tensor fascia lata muscle.
Many surgeons using the Smith Peterson approach use a special fracture table. In the fracture
table technique the feet are strapped in boots and in order to get proper hip exposure, the leg is
twisted with significant force and ankle fractures have rarely occurred, mainly during the
development of this technique. A type of x-ray imaging called image intensification is used
throughout the surgery. All people close to the x-rays receive radiation exposure. The surgeons
and other operating room personnel usually remain close to the patient during image
intensification and these people wear protective lead gear but are still partially exposed to
radiation. The patient is not shielded with lead at all and since the hip and the gonads are in
the same area radiation sensitive gonads unfortunately are radiated. Many patients of child
bearing age are receiving hip replacement today. Since minimally invasive hip replacement can
be done without this extra radiation exposure, Dr. Moreland prefers not to use this fracture table
and the image intensification technique.
BILATERAL SIMULTANEOUS HIP REPLACEMENT
While it is possible to do replacement of both hips during the same surgical procedure, and
some surgeons advocate this, Dr. Moreland does not recommend this except in rare
circumstances. He believes that the increased magnitude of the surgical insult in doing two hip
replacements at once is such that the rate of serious complications (e.g. death) is increased.
This increased risk, however slight, seems not worth taking. Many well regarded and
prestigious surgeons commonly, however, do perform replacement of both hips simultaneously.
It is a controversial issue. Dr. Moreland’s practice is to wait a minimum of two months or,
preferably, four to six months between hip replacements. This delay allows full recovery from
the first surgery and increases the safety of the second.
WILL DR. MORELAND DO THE SURGERY?
Some surgeons employ other surgeons to do parts of the hip replacement such as the opening
or closing of the wound and sometimes even the entire operation. Dr. Moreland personally
does all of the operation. He does the patient positioning for the surgery making sure that the
patient is properly placed and padded to prevent injury during the surgery. He makes the
incision and does all of the operation, including skin closure, as well as the placement of the
wound dressing. He also visits his hospitalized patients at least six and sometimes seven days
a week except when he is out of town. He also takes his own emergency calls six, and
sometimes seven, days a week when in town. Thus, if you have an emergency after your
surgery, you usually will have direct access to him instead of someone not familiar with your
situation. When he is not available, his calls are usually taken by Jack Purdy M.D., an
experienced, board certified orthopedic surgeon. Dr. Purdy has been assisting Dr. Moreland at
surgery since 1986 and they have done thousands of hip replacements together. Dr. Purdy will
often be familiar with your particular situation since he probably assisted at your surgery. Dr.
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Moreland does not use surgeons in training, such as residents or fellows, as surgical assistants
nor do such physicians help with your postoperative care.
INITIAL CONSULTATION WITH DR. MORELAND
The initial office visit for patients who are considering hip replacement surgery involves a
discussion and examination with Dr. Moreland lasting thirty to forty-five minutes. Before your
visit you will be asked to fill out a questionnaire concerning the history of your hip problem. An
radiographic evaluation is always needed and if you have had previous films taken elsewhere, it
is useful to bring those films with you. We have a radiographic facility in our office and we can
take additional views as necessary. It would be helpful if you bring a list of medications that you
take with the dosages. We welcome spouses and other family members or important friends to
participate in the discussion of treatment. We routinely call and/or write your physicians telling
them of the situation and we will be happy to write anyone else that you wish to have a copy of
your consultation. We will send you a copy of your consultation also. Please feel free to ask as
many questions as you like. We believe strongly that an informed patient is a better patient
with a much higher chance of success with medical and surgical treatment.
If non-surgical treatment is chosen, you may be given prescriptions for arthritis medications,
walking aids or physical therapy, as well as advice about living with your hip arthritis.
SURGICAL SCHEDULING
If surgical treatment is elected, our office staff will normally arrange the surgery at Saint John’s
Health Center (1328 22nd Street in Santa Monica). Since this is major surgery, a medical
evaluation is usually indicated. Your internist or family practitioner will usually do this
evaluation. If you do not have such, we will assist you in making an appointment (seven to ten
days before surgery) to see a physician who can do a medical evaluation and preoperative
laboratory work. If you have a cardiologist or pulmonologist because of significant heart or
lung problems, then you should see that doctor also for a preoperative evaluation. If you are
taking blood thinners such as Coumadin, Plavix or Xarelto, these drugs will need to be stopped
temporarily before the surgery and this will need to be coordinated with your medical
physicians.
AUTOLOGOUS BLOOD DONATION
Autologous blood donation is a technique in which the patient donates blood which is then
stored and can be given back later to the patient. Autologous blood donation was very popular
for hip replacement patients before effective screening programs for the AIDS virus and
hepatitis C were developed. Experts now recommend against autologous blood storage for hip
replacement patients because analysis has shown that today the risks of an autologous blood
program itself outweigh the benefits.
All units of blood, including autologous units, have the risk of being given to the wrong patient
despite precautionary systems to prevent this tragedy and have a remote risk of bacterial
contamination. All units of blood are stored for some period of time before transfusion and the
blood deteriorates while in the refrigerator and then creates negative reactions in the recipient.
The usual blood loss for a first time uncomplicated hip replacement is around a unit and most
patients can tolerate the usual blood loss of a hip replacement without a transfusion.
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Patients may also have friends and relatives donate blood. Compatible units can be specifically
reserved for the patient. This type of donation is called directed donor blood donation. Blood
banking experts do not believe directed donor blood is safer than bank blood, since directed
donor blood involves some potential for coercion in collection, however minimal. The blood
bank offers directed donor blood as a service to patients, since many patients are more
comfortable getting blood from friends and relatives. It usually takes 48 hours or longer to
process directed donor blood. Thus, trying to arrange directed donor blood postoperatively is
usually impractical. The blood bank will not first test the directed donor for compatibility with the
patient, so there is no assurance that you will be compatible with all your directed donors.
Rarely, Dr. Moreland will use the Cellsaver. This is a device that can salvage and clean the
blood cells from the blood collected from the surgical wound. This cleaned blood (mostly only
the red cells) can then be retransfused. It is possible to collect and reuse about half of the
blood cells lost during surgery. The Cellsaver can be brought into use during surgery if blood
loss is unusually high but Dr. Moreland cannot remember the last time this was necessary.
It is rare to need blood transfusion for the usual patient having first time hip replacement. Most
patients can get by without any blood transfusion. Patients with preoperative anemia are the
most likely patients to need a transfusion. Dr. Moreland estimates that for the usual
uncomplicated hip replacement in a patient without preoperative anemia the risk of needing a
bank unit is less than five percent.
OTHER PREOPERATIVE CONSIDERATIONS
If you are currently taking any nonsteroidal anti-inflammatory medications (NSAIDS), you
should stop taking these three days prior to surgery; since all NSAIDS except Celebrex can
cause increased bleeding during surgery (NSAIDS inhibit platelet function). Aspirin (an NSAID)
particularly can cause bleeding, and if you are taking aspirin, or aspirin containing drugs such
as Percodan, Ecotrin, Excedrin or Anacin, you should stop taking these at least seven days
prior to surgery. For pain before surgery you may take Tylenol, Tylenol with codeine, Tramadol,
Percocet, Vicodin and other drugs not containing aspirin or any other NSAIDS. The COX-2
inhibitor, Celebrex, can be continued right up until surgery, since it does not affect bleeding.
Smoking increases operative risk, and should be stopped or hopefully at least decreased in the
period before surgery. Smoking also increases the chance that the new hip replacement will
not get fixed to the bones. Patients should not smoke for at least two months. Smoking is
strongly associated with slow healing. All hospitals are now non-smoking facilities. Obesity also
increases operative risk and weight loss before surgery, if indicated, is desirable but not
essential.
To reduce the risk of postoperative wound infection dermatological experts recommend:
1. Avoiding washing your skin with sponges or loofah as these may harbor staph bacteria.
2. Avoiding hot tubs one week before and three weeks after surgery as these may harbor
pseudomonas bacteria.
3. Applying prescription mupirocin skin ointment twice daily inside each nostril for three days
before surgery and one week after surgery.
4. Showering with Hibiclens wash (as a soap) applied to chest, back and thighs once daily for
three days before surgery
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To improve wound healing and to minimize risk of a raised or spread scar dermatological
experts also recommend:
1. Enhancing collagen formation by taking zinc gluconate 50 mg once daily for 2 weeks before
surgery and taking vitamin C 500 mg twice daily for two weeks before and after surgery.
2. Avoiding scratching the wound area.
3. Applying BioCorneum topical suspension to the scar. You may start this three weeks after
surgery. Rub onto scar twice daily for three months. This is available on Amazon.
4. Avoiding sun exposure on the scar (the sun's rays can darken the healing tissues). Zinc
based sunscreens provide good protection. Vanicream SPF 50-60 OR Elta MD sport are good
choices.
THE PREOPERATIVE VISIT
We will usually ask you to come back for a final preoperative visit the day before surgery to
check that surgical arrangements are complete. At that time we will give you final instructions
and we will again discuss the surgical arrangements and the potential complications and risks.
Sometimes, a preoperative visit to the hospital is also made that same day, and your blood is
drawn again for usage by the blood bank and for a final blood count. Of course, your questions
will also be answered.
Patients are not admitted to the hospital until the morning of surgery. This practice of
admission the day of surgery, rather than the day before surgery, began in about 1986 when
most insurance companies began insisting that patients not be admitted the day before surgery
because of the expense of that extra day. This procedure has now become standard across
the country. If your surgery is the first one of the day, check-in time at the hospital is 5:00 a.m.
If your surgery is later, you will check in at a later appropriate time.
In the Santa Monica area there are many hotels which are conveniently located near Saint
John’s. The Gateway Hotel (a Best Western Hotel) offers discounted prices for patients who
are entering Saint John’s. It is located at the corner of 20th Street and Santa Monica Boulevard
and can be reached by calling (310)829-9100. Loews Santa Monica Beach Hotel at (310)4586700, Shutters on the Beach at (310)458-0030, and the Fairmont Miramar Hotel at (310)5767777 are all located close to the beach in Santa Monica and many rooms have views of the
ocean.
WHAT DO I BRING TO THE HOSPITAL?
In general, the items you bring to the hospital should be limited. You should not wear valuable
jewelry or bring expensive music devices, computers, or cell phones. A small amount of cash
(less than ten dollars) may be useful. It is helpful to bring a telephone calling card or to know
your numerical code for long distance calling if you are planning any calls from the hospital.
Orthopedic patients are usually hospitalized on the Orthopedic Unit on the third floor of the new
St. John’s North Pavilion. All of the rooms there are private without additional charge and have
42 inch plasma televisions and other modern amenities.
Personal hygiene items, such as cosmetics, lip balm, toothbrush and toothpaste, should be
brought with you to the hospital. You may bring an electric shaver. Hair washing is difficult at
the hospital, as you will not be ready to shower.
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You may bring clothing to wear instead of a hospital gown. The day of surgery you will have to
be in a hospital gown; however, the next day you may wear your own pajamas, nightgown or
loose fitting, comfortable clothing. Some patients are sensitive to the detergent the hospital
uses to clean bed linens and gowns. Wearing your own nightgowns, pajamas or T-shirt will
protect your skin and help prevent skin problems. You may bring underwear and something to
cover yourself while walking in the hallways. Bathrobes and gowns should not be so long as to
make walking difficult or dangerous. You will need comfortable and safe shoes such as tennis
shoes or sturdy slippers.
THE DAY OF SURGERY
The night or morning before surgery, you should take a shower or bath. This will decrease the
bacterial population on your skin and decrease the chance of infection. The night before
surgery, you should not have anything to eat or to drink after midnight. Food in the stomach
can cause anesthetic complications. Sometimes the primary care physician or the
anesthesiologist or Dr. Moreland will tell you to take all or some of your usual morning
medications with a small sip of water the morning of surgery. Patients who usually take blood
pressure medications in the morning should almost always take these the morning of surgery
with a small sip of water.
On arrival at Saint John’s Hospital the day of surgery, you should report to the preoperative
suite on the second floor. During your preoperative visit to Dr. Moreland’s office, directions and
maps to the preoperative suite will be given to you. There is a visitors’ waiting area for surgery
patients on the second floor directly adjacent to the PACU (recovery room) and your family and
friends can remain there while you are in surgery. The volunteer at the desk in the surgery
waiting area should be told that your family is there so that Dr. Moreland can update them after
surgery.
The anesthesiologist will usually call you the night before surgery to discuss the anesthesia.
The anesthesiologist will also to see you in the preoperative suite before you go to the
operating room.
You will ultimately be taken to the operating room suite where you sometimes see Dr. Moreland
before you are sedated, and the surgery will commence after you are given your anesthetic. A
catheter is placed in your bladder after you are given your anesthetic. First time, uncomplicated
hip replacements usually take one to one and a half hours of actual operating time (not
including preparation). You are usually in the operating room itself for two to three hours.
Revisional surgeries can take anywhere from one to three hours of operating room time or,
rarely, even more in particularly difficult situations.
Friends and relatives should wait in the surgical waiting area at Saint John’s (second floor).
Patients are usually in the PACU (recovery room) from one to two hours. Patients usually
cannot be visited in the recovery room but can be visited in the patient’s room after leaving the
recovery room. Joint replacement patients are usually hospitalized on the Orthopedic Unit on
the third floor of St. John’s North Pavilion. Patients do not go routinely to the ICU (intensive
care unit).
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NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES
Over the last decade there has been dramatic progress in preventing and treating postoperative
pain. These revolutionary postoperative pain control techniques were introduced about the
same time as minimally invasive hip replacement and many authorities believe the current more
rapid and less painful recovery period after hip replacement is related more to these pain
control techniques than to the minimally invasive hip replacement surgery itself.
In the past postoperative pain was simply treated with narcotics until the patient was more
comfortable. There were many problems with this approach. Patients need widely varying
amounts of narcotics for pain control. Since too large a dose of narcotics can cause the patient
to stop breathing and even die, physicians must first use lower doses for safety and then
increase doses, if initial doses are not sufficient. Patents thus can be in a lot of pain before an
adequate dose of narcotics is determined.
Narcotics are not really that good at controlling pain. Some authorities say narcotics do not
make pain go away but that they make the patient not care about the pain. Narcotics have a lot
of side effects. Narcotics sedate patients and decrease their mental alertness. Elderly patients
particularly can become confused. Some patients can hallucinate. The respiratory depression
can cause other problems such as pneumonia. Narcotics depress the smooth muscles of the
gastrointestinal tract and cause nausea, vomiting and constipation.
Patients sometimes put off needed hip surgery from fear and dread of postoperative pain. A
new approach was greatly needed.
It has now recognized that if a patient feels a lot of pain, the brain gets sensitized to pain such
that the patient will feel later pain more intensely. It is important than this extra pain sensitivity
not be allowed to develop.
Today we prevent postoperative pain by treating pain even before it occurs and use several
types of medications for pain. Narcotics are still used but in smaller doses. The morning of
surgery you will be given the NSAID, Celebrex (if not allergic). Celebrex is great for
postoperative pain and will be given both before and after surgery. You will also be given a
dose of the pain medications Tramadol and acetaminophen (Tylenol). We also will give you a
dose of Oxycontin which is long acting, well tolerated, and effective preparation of the narcotic,
oxycodone.
A spinal anesthetic is strongly recommended rather than a general anesthetic. With a general
anesthetic your brain still knows that you are having an operation and your brain is being
sensitized to postoperative pain. With a spinal the brain receives no pain impulses from the
operative site and is not being sensitized to postoperative pain. Patients are sedated and are
completely unaware during the operation. Spinal anesthetics also have the advantage of less
bleeding and fewer postoperative problems with blood clots.
A small dose of narcotic is injected with the local anesthetic of the spinal anesthetic. This can
give pain relief for 12 hours or more, but sometimes causes itching. Your gastrointestinal tract
does not see this narcotic dose and GI side effects are minimized.
At the end of the operation before wound closure the wound is injected with a long acting local
anesthetic similar to the Novocain used by the dentist. The pain relieving effects of this may
last 12 hours or more.
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Postoperatively you will usually receive more Celebrex for two days and oral doses of the long
acting narcotic Oxycontin every 12 hours for two days. It has been found that patients do better
with oral narcotics than those given by IV or by injection.
THE HOSPITAL STAY
After surgery most patients today experience little or no pain, particularly right after the surgery
when so many things have been given already for pain. In addition, the minimally invasive hip
replacement techniques produce less pain than earlier techniques. Break through pain is pain
not controlled by the medicines given without a request from the patient. If you are having
break through pain, call your nurse and additional pain medication will be given to you.
Almost all patients develop postoperative constipation due to the narcotics and need to take a
mild laxative, typically a rectal suppository, on the second day after surgery. Prolonged urinary
catheter use can cause urinary infections, which rarely can spread to the hip replacement.
Thus, we usually remove urinary catheters two days after surgery. All patients are given
intravenous antibiotics to prevent hip infection just before the operation and then usually only
two doses after surgery.
A suction drain is usually placed in the wound to remove any blood which collects after surgery
in the wound. Dr. Moreland usually removes these suction drains the morning after surgery.
Your blood count will be monitored at least daily for two days. We normally do not give iron
supplementation in the hospital due to the stomach upset it can cause. Transfusions of all
types of blood are always minimized to avoid the risks of disease transmission and transfusion
reactions.
Most patients stay in bed until the morning after surgery at which time the physical therapist will
get you up and help you walk. In addition to walking, there are some gentle exercises which
the therapist will teach you to prevent blood clots from forming in your legs. You will also wear
special stockings to prevent blood clots. After surgery the leg is suspended in two slings which
make the leg more comfortable. These slings are designed to unweight the leg and not to
elevate the extremity. Some surgeons use a special firm pillow, called a Charnley pillow or
abduction pillow between the legs while in bed. Dr. Moreland does not use these pillows as
they are uncomfortable. Most patients, by the second day after surgery, no longer have an IV,
are eating normally, are not taking antibiotics, need only pain pills for pain relief, have no
monitoring devices or any tubes, and are feeling quite well.
To prevent blood clots, patients are given Coumadin (warfarin) which is a blood thinner
(anticoagulant). The level of blood thinning must be monitored on a daily basis requiring your
blood to be drawn each morning. Dr. Moreland will order a dose of Coumadin each evening
depending on how thin your blood was that morning. It is important that your blood not be too
thin since this can cause bleeding. After discharge most patients are instructed to take one
aspirin a day (if able to tolerate) to prevent blood clots and the Coumadin is stopped. Patients
with a history of blood clots may need Coumadin for six weeks or longer after surgery.
We have noticed that some of our patients report feelings of depression postoperatively. These
feelings are usually transient, lasting a day or so. We theorize that the excitement of surgery is
over, but the patient realizes that the recovery is not complete and gets depressed. Soon,
however, the plan for going home progresses and the depressed feeling is relieved. So, if you
experience these feelings, do not worry since they will probably be transient and other patients
have had similar experiences.
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Some patients develop a low-grade fever in the first few days after surgery. The temperature is
usually up in the evening and down in the morning. The patient will sometimes have fever up to
101 degrees for the first few days. This is a normal reaction to the surgery and does not mean
infection. As the fever goes up, the patient may feel a chill and as it goes down, the patient
may have a sweat. Some wounds occasionally drain a light yellow fluid for several days after
surgery. This does not mean infection and usually resolves in a few days.
The discharge planner and the physical therapist will talk to you about supplies you will need
when you go home. Patients usually get a bedside commode which sits up higher than a
normal toilet seat. It is easier to get up from a raised toilet seat during the postoperative period.
The physical therapist will get you up the morning after surgery. You will be allowed to weight
bear as tolerated on your new hip replacement. You will have some soreness and at first you
will need to use crutches or a walker. The therapist will help you decide which is best for you,
and the discharge planner will help you obtain them. Exercise before surgery to increase the
strength of your triceps muscles will make postoperative crutch or walker use easier. Crutches
are more convenient in tight areas and for climbing stairs, but do require more strength and
balance than a walker. A walker is easier to learn to use, requires less strength and balance
and is generally used by the older patients. Some patients like to have both types of devices
available for differing situations.
By the time of discharge (usually after two or three nights after surgery) most patients can
without assistance get in and out of bed, go to the bathroom, and take short walks comfortably.
Older patients and some patients with other musculoskeletal problems may take longer to reach
these recovery milestones. It is best to be able to go to a home after discharge in which there
are other people around for portions of the day to assist you with shopping, meal preparation,
etc. Constant nursing care is rarely needed. Once home, most patients stay there for one or
two weeks while strength is returning. By two to three weeks after surgery most patients are
feeling well and begin to go out to eat and shop. Some also return to work at that time if they
have a sedentary occupation which will allow walking aids. You can start using a cane held in
the opposite side from the new hip when you feel comfortable. There certainly is no reason to
rush to using a cane.
Patients often wonder about the need for a hospital type bed for home use. Features such as
adjustable height, adjustable head and a trapeze can be useful but are rarely essential. It is
very unusual for an insurance policy to cover the cost of such a bed for a patient with a recent
hip replacement. Dr. Moreland’s ordering the bed for a patient does not mean that it will be
covered by insurance policies. The insurance companies are very restrictive about paying for
equipment which is not required for the patient’s care. Patients can still rent a bed, if needed or
desired, and assume the financial obligation personally.
If you do not have a satisfactory home situation and you need extended care facilities, such can
be arranged with the discharge planner at the hospital in consultation with your family. Our
office has a list of local extended care facilities and you may visit them or speak with them.
Many patients are apprehensive about the drive home. Virtually all patients can go home via
private car, assuming usual car size and configuration. Occasionally, patients go home via
ambulance in situations where the patient cannot easily negotiate serious obstacles such as
long, high, or narrow stairs. The physical therapist can help with planning and practicing
maneuvers for the trip home.
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Most patients who have a hip replacement need instruction from the physical therapist in the
hospital, but after they go home, physical therapy visits are usually unnecessary. Only gentle
exercises are needed for the first few weeks after surgery. These exercises are not designed
to build muscle strength, but are designed to prevent blood clots during the healing period. We
wait until several weeks after the hip replacement to start seriously building muscle strength.
Some hip replacement surgeons emphasize muscle strengthening and rehabilitation sooner
than Dr. Moreland’s outlined program. All hip replacement surgery involves at least some
bruising of soft tissues to gain exposure to place the prosthesis. Dr. Moreland believes some
healing of these bruised tissues before vigorous exercise is undertaken will lead to fewer
complications and a stronger hip. Most patients later receive physical therapy to build muscle
strength, but most patients do quite well with simple walking, the exercise bicycle or the
treadmill.
The first office visit after hospital discharge is usually four weeks after surgery. Until then, the
patient should generally take it easy and not overdo. Resist showing off how much you can
already do to friends.
Frequently, patients develop swelling of the foot and ankle after surgery. If this occurs, you
should elevate your foot and be sure to wear the white compressive stockings (TED hose) that
you received in the hospital. Severe swelling can be due to inflammation or clots in the veins
(DVT) and Dr. Moreland’s office should be notified if this occurs, especially if considerable
swelling is associated with pain in the calf or thigh. There is a simple non-painful, non-invasive
test (Doppler) to detect blood clots (DVT). If a DVT is found, the patient is usually readmitted to
the hospital for a few days of treatment with heparin (another blood thinner), followed by a few
months of Coumadin as an outpatient.
DISCHARGE FROM THE HOSPITAL
Before discharge from the hospital a new occlusive wound covering will be placed over the
wound. Until two weeks after surgery, it is best to keep the wound dry. If there is a good seal
with the occlusive dressing, you can shower when you return home but try to keep the water
away from the dressing. Alternatively you can just do a sponge bath. After two weeks you can
remove the plastic dressing and the tapes and shower normally. We recommend avoiding a
bath tub for several weeks after surgery, because of the difficulty of climbing in and out of the
tub and the awkward position that one commonly assumes when taking a bath in a small tub. It
is usually safer to shower rather than trying to get in and out of tubs.
After the hospital discharge, any wound drainage should be reported to Dr. Moreland’s office.
The wound should gradually become more comfortable. If you notice increased swelling,
warmth, and redness over the hip wound, our office should be notified and in most instances,
you will need to come in and let us examine the wound. If you begin to run a significant fever
(greater than 101 degrees), we also need to know about this. In general, your hip should be
gradually getting better but if you think you are getting worse, please give us a call.
You may sleep on the operated side when it is comfortable. For at least the first four weeks
after surgery, when you lie on either side, you should put one or two fluffy pillows between your
knees. This is to make you more comfortable.
Postoperative dislocations are very rare. If you suffer dislocation, you will usually have severe
pain and be unable to walk. Call Dr. Moreland and he will meet you in the emergency room and
43
relocate the hip. If you are unable to get in the car with the assistance of friends and relatives,
you will need to have an ambulance bring you to the emergency room.
It is best to avoid driving for at least four weeks after surgery, particularly if the right hip has
been replaced, since most driving is with the right foot. The main issue is whether the patient
can control the car, rather than injuring the new hip replacement. Some patients, however, may
need to drive sooner and this can be discussed with Dr. Moreland. It is good to continue to
wear the special white stockings for about four weeks after surgery. If, however, you are not
having any swelling and you find these stockings uncomfortable, they can be discontinued
before this.
FOLLOW-UP APPOINTMENTS
The first visit to Dr. Moreland’s office after discharge is usually four weeks after surgery. Office
visits after the four week visit are usually at six months and two years after surgery, then every
three years thereafter. Regular visits to have an x-ray and to have your hip examined are
essential for monitoring the result of the surgery and giving you periodic advice for the care of
your hip replacement.
Cementless replacements will withstand more vigorous activities than cemented replacements.
The major mode of failure of cemented hip replacements is loosening. With time and stress,
fixation of the cement to the bone can fail and movement can occur between the cement and
the bone. This movement can cause pain and if the pain becomes severe, a revisional
operation may be necessary. The longevity of a cemented hip replacement can be increased
by avoiding stressful activities such as all types of impact sports including: running, jogging,
tennis, snow and water skiing, racquet ball, badminton, football, baseball, bowling, and
horseback riding. Heavy lifting, weight lifting, jumping from a height, falls, and some exercise
machines for the legs are dangerous for you. It is important that such patients not become
overweight, since excess weight increases the stress on the hip replacement and can cause
loosening.
Cementless replacements, once ingrown, can withstand the most vigorous activities. We have
many patients who ski, play tennis and other racquet sports, beach volleyball, and other such
very vigorous activities. With the cross-linked polyethylene now used, wear is also much less of
a worry.
There is concern about the possibility of infection developing later in a hip replacement. If you
develop an infection elsewhere in your body, it can travel via the bloodstream to the
replacement. Infections likely to do this are kidney infections, as well as skin and toenail
infections. If you develop any of these, you should consult your family physician or internist and
be treated promptly.
Dental work can push bacteria into the bloodstream and can cause very rarely an infection in
your joint replacement. Your dentist may recommend that you take antibiotics with your dental
work. You should always notify any treating physician that you have a joint replacement since
other medical procedures, tests, and surgeries can involve infection risks to the replacement.
The physician or the dentist doing the procedure should give the appropriate antibiotic coverage
for the procedure. Since there really is no proof as to what the best antibiotic to give is and
exactly how it should be given, Dr. Moreland is satisfied with whatever antibiotic treatment your
physician or dentist wants to give you. It is more convenient and appropriate for that physician
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or dentist to prescribe the antibiotics, than for Dr. Moreland since he doesn’t know exactly what
procedure you are having.
Patients with a hip replacement usually trigger the airport metal detection devices. We can give
you a card attesting to the presence of your hip replacement. Unfortunately our card has no
official status.
Finally, it is important to see us at least every two or three years for an x-ray and examination,
so that we can advise you as to how your joint replacement is doing and recommend possible
activities. This serial x-ray record of your hip replacement often is helpful in the evaluation of
any possible future problems. Wear of the polyethylene plastic in your hip replacement can be
a problem, and the patient does not always feel symptoms from the wear until the damage is
extensive. With the cross-linked polyethylene now used, wear is also much less of a worry. The
best way to look for wear is to take a radiograph every two or three years.
HOW CAN I PREPARE MY HOME?
Most patients need to make a few modifications to their home environment prior to undergoing
joint replacement surgery. Planning your postoperative needs will help you to more easily
adapt to the transition from hospital environment to home. The hospital has an advantage over
home in that it is a smaller room with all the necessities delivered right to you and a nurse to
assist you with such needs as eating and toileting.
Prior to discharge, most patients are able to independently get out of bed safely and walk a
functional distance using a walker or crutches. You do not need to purchase a walker or
crutches prior to admission to the hospital as these will be supplied to you there. If you have
already obtained a walker or crutches, you should bring these with you to the hospital so that
the physical therapist can adjust them to your size and check them for safety.
You will be taught, prior to leaving the hospital, how to get dressed, including shoes and socks.
Initially, upon returning home, you will probably be most comfortable in loose-fitting clothing
which is easy to get on and off. Your shoes should be safe (non-skid soles) and comfortable to
walk in for use in the hospital and at home.
If you live alone at home or if you think you will need additional help, there are nursing agencies
that can provide people to take care of such necessities as changing and washing the bed
linens, shopping, and meal preparation. They can also assist you with watering plants and the
maintenance of pets. Our office can supply you with names of agencies and phone numbers to
call and make arrangements to meet the people prior to your surgery. Most insurance
companies, including Medicare, do not cover the cost of homemaker/chore persons. The fees,
however, are usually reasonable and professional home help can allow you to enjoy the
comforts of your own home rather than having the inconveniences of an institution.
You will not be able to take a tub bath until two weeks after your hip replacement. Until the
wound is completely healed, bacteria could enter the wound with the bath water. In the hospital
the nurses will assist you with bathing utilizing a basin of water and soap. You can follow this
same procedure at home, but if you have a good seal with the occlusive dressing, you can
shower. A stall shower is the safest way of showering. The commode chair, which you will be
using as a raised toilet seat, may be placed in the shower so you can sit safely while you are
showering. Many people find that the hand-held shower nozzles are very convenient to shower
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with in the postoperative period. If you only have a bathtub, special arrangements and
assistance will be needed in order for you to bathe safely. You should discuss this with the
therapists in the hospital.
If your bedroom is located upstairs or is too far away for you to get to the bathroom or kitchen
conveniently, you may want to set up another room in your house as your temporary bedroom.
Patients rarely need a hospital bed. If you have concerns about your sleeping arrangements,
you can contact our office to discuss the situation.
You will need a comfortable chair with arms at home. Look around your house for a chair with
arms and a firm seat which is not too low. The arms will help you to get in and out of the chair.
You may want to consider such items as baskets that you can attach to walkers to carry things,
or attachments you can place on crutches to allow for movement while carrying something to
drink. Remember that your hands will be used for the walker or crutches so, in order to carry
an item with you from one room to another, you must be able to put it in something. Pockets,
preferably large ones, are a very convenient way to carry things which won’t spill. Some
patients like to utilize small backpacks or fanny packs.
Talking to other patients who have experienced hip replacement surgery about your specific
needs at home can be very helpful. Our office would be happy to supply you with a list of
patients to contact.
We are pleased to be able to present this manual to you and we hope it helps you in
understanding your condition and the possible treatments which are available. Please feel free
to ask additional questions. We look forward to taking good care of you!
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