Are You A Candidate For Total Hip Surgery?
October 27, 2023
WHO MAKES THE DECISION?
Who decides whether you will have a total hip replacement operation? Curiously enough, you are the boss who decides!
- Your surgery depends principally on your willingness to comply with the long, demanding post-operative physical therapy and rehabilitation program that follow the surgery.
- All other considerations (your age, disease character, etc.) are secondary.
- The decision to have the operation of an arthritic joint is a highly personal matter, and only you can make that decision, together with your surgeon.
PAIN - THE CARDINAL SIGN
The surest guide to determine the need for a total hip replacement is the severity of the pain in your hip joint. Although you suffer severe pain, you may still be unable to describe the pain, not even pinpoint its location.
"I have been suffering from acute pain for a few years. I never could pin point where that pain was coming from. Time and time again I have went to my family doctor and was receiving x-rays on my knee and thigh area but nothing was found, although I still felt constant pain. Finally, I went to an orthopedic surgeon and demanded having a x-ray of my whole body. But just getting x-ray of my hip was all that was needed. Now, I have had my left hip replaced and my pain is gone".
Most patients with hip disease feel groin or buttock pain, but other patients may experience pain in the lover back, on the inside or backside of the thigh or in their knee entirely.
You must, however, be aware that not all pain that you feel in your hip, groin, buttock, and thigh area is provoked by a hip joint disease.
The pain in this area may be caused by
low back problems, spinal stenos, and prolapsed intervertebral disc
encroachment of some of the nerves around the hip joint
inflammation in tendons and bursa ( sacs with fluid lying between tendons and bone) around the hip joint
pain in the hip and thigh area may be a projection from vascular disease (abdominal aorta aneurysm, intermittent claudicatio)
The character of the hip pain depends on the type of the hip disease. It is related to the patient activity in osteoarthritis, it varies with the disease activity in the rheumatoid arthritis, and it is constant in the avascular necrosis of the femoral head or in a tumor.
THR - AN OPERATION TO RELIEVE YOUR PAIN
Total hip replacement operation is most successful in just relieving pain. Therefore, the more pain you have the greater are the chances that the operation will be a success.
You suffer severe pain that impairs not only your work and recreation, but also ordinary activities of daily living
The pain does not disappear after a longer period of rest
You notice disturbing pain also when sitting or standing still
Pain in your hip is so severe that it impairs you sleep
The pain killing medicines do not work or work only for a short time
Together with pain you also notice increasing painful stiffness in the hip joint, that further impairs your ordinary activities of daily living
Several months treatment (anti-inflammatory medicines, physiotherapy, and like) did not change the pain
If your pain is like this and the X-ray pictures demonstrate impairment of your hip joint, then you are a candidate for total hip replacement and you should seriously consider the surgery.
"I researched the prospects of a total hip surgery and I spoke with people in the know and I have decided to postpone my surgery until I am in more pain. I still can get a good night sleep and although I still have problem getting my sock and shoe on, I can have a good walk with a stock. Hearing some of these crazy stories I now understand that a lot of weird things can go wrong after surgery. I'm uncomfortable with my hip, but I can put up with a whole lot more if necessary."
Remember that the total hip replacement is no good to treat minor pain and occasional discomfort in your hip. Moreover, total hip operation is a major surgery and as such always associated with certain risks. Therefore, ask yourself these questions:
Do you experience pain in the hip only after long periods of strenuous activity, for example after playing soccer or after cross-country jogging?
Does this pain disappear after a shorter period of rest (30 minutes or so)?
Is the pain bothersome, but not severe enough to require pain killers?
Is the pain bothersome but you can always relieve it by pain killers or NSAIDs?
Do you notice the pain only during and shortly after physical activity, but never during rest or sleep?
Do the X-ray pictures of your hip show only minor impairment?
If you answered yes to these six questions, the chances are that you don’t need surgery - at least not for the time being.
In the meantime, you should modify your activities to ease the stress that you put on the painful hip joint. Shorten the walk, or try bicycling, stationary or mobile. The best all-round exercise is swimming. A physiotherapist can prescribe an exercise program for you.
Why should you wait?
Patients operated on for minor hip problems are more often dissatisfied with the results of their total hip operation
Total hip replacement is major surgery and entails certain risks. Thus, it should not be undertaken unless there are compelling reasons for it.
Will the operation be more difficult if you wait?
Usually not, especially if you are suffering from idiopathic osteoarthritis of the hip joint (wearing out disease of the hip joint). But there are certain diseases that may destroy the hip joint too much if you wait too long (rheumatoid arthritis, e.g.). So ask always your surgeon whether the operation will be more difficult if you postpone it.
How important are X-ray pictures?
How much importance should you put on the X-ray pictures for your decision to be operated on? This depends on the character of your hip joint disease. Remember that a X-ray picture is a meager shadow of reality. The X-ray picture cannot tell how much pain and other discomfort you really have. In some very painful hip joint diseases (avascular necrosis, e.g.), the conventional X-ray picture cannot even discover any disease in the hip joint initially.
Statistics even show that about 40 % of all patients with signs of osteoarthritis of the hip joint on their X-ray pictures do not need any hip operation.
Should you wait for development of better artificial hip joints?
If you hope that the technology of artificial joint replacement will improve with time then it is good to know that the rate of progress in this area is uncertain. Although there is a steady stream of "new" total hip prostheses entering loudly the market, equally many are silently withdrawn.
The "old" models of total hip prostheses introduced 20 - 30 years ago are still in use today and perform very well (Charnley, Stanmore). By the way, this is a big paradox of the artificial joint science - can you think of 30 years old pacemakers, artificial eye lenses, etc. still to be used by today doctors?
If your pain and disability are severe, than there is no point in waiting for progress of the technique.
Should you wait for bio-engineered hips?
The bio - engineering science makes certainly a very good progress in preparing living cartilage tissues - at least as heralded in the media. Should you wait until these bio-engineered cartilage cells be available to be implanted into your worn out hip joint?
You should know two facts. First, as yet the bio -engineered cartilage cells failed to heal badly worn joints. Second, only about 20 % of all results in this field have been published. Much of the development in this field is financed by private for-profit companies that often decide which results should be published.
Can osteoarthritis of your hip improve without operation?
This is possible, but the progress of osteoarthritis is not predictable, it varies greatly from person to person. The pain may become unbearable within six months for one person, yet drag on at a tolerable level for several years in another person who has the same degree of arthritis on X-ray pictures.
SPECIFIC HIP CONDITIONS
Patients with fused hip joints
can they have a functioning total hip replacement?
It is possible, but it is a difficult operation, best carried out by the surgeon who is experienced in the technique.
The fusion of a destructed hip joint was treatment of choice up to 1970's. Many of these patients have excellent function in the limb with totally stiff hip, if the fusion placed the thigh in right position.
Patients with a hip fused in faulty position developed soon pain in low back, opposite hip and knee.
Many hips fused spontaneously after a bacterial hip infection, and these usually have fused in a bad position. Sometimes, the patients are unknowing of this fact.
Usually, the young patients wish to convert their fused hip to the total hip replacement. This put another important aspect into the decision: the total hip should last very long time.
For the success of the operation one factor is important: preserved buttock (abductor )muscles. (The muscles that put the limb to the side from the middle line). Testing the muscles before the operation is impossible, so that the surgeon usually asses the state of abductor muscles directly during the operation.
If the surgeon finds that the abductor muscles are missing, scared or damaged in another way, he/ she may decide not to continue with a total hip replacement.
This possibility must be discussed with the patient before the operation.
Studies show that the conversion of the fused hip into the total hip replacement is fraught with following risks:
The operated length may remain too short (it is usually short already before the surgery)
The lengthening of the leg by total hip surgery may cause damage to the limb nerves (specifically to n. ischiadicus)
The weak hip musculature may limit the ability to walk without support
The total hip may dislocate
The quiet infection may flare up after the total hip surgery
The patient should discuss all these risks with his / her surgeon before the operation
A recent large study followed up 45 patients who have conversion of fused hips to total hip replacement.. Their hip joints had been fused 36 years (mean)! After a mean 9 years, only 3 % of the total hip replacement failed. These patients could bent the hip up to 90 degrees. Their walking ability depended on the function of their buttock muscles. One patient developed nerve damage and one patient had a flare up of a tuberculous infection in the hip. (Hamadouche 2001).
(Note: other, previous studies showed worse results).
WHO CANNOT HAVE A TOTAL HIP SURGERY
- Patients with recent ( arbitrary < 9 months) heart infarct and stroke
- Patients with uncontrolled diabetes, lung, kidney, or other systemic disease
- Patients with ongoing or recent infection in the hip joint area
- Patients with severe paralysis of muscles around the hip
- Patients with severe circulation problems (painful claudicatio) in the extremity
Other reasons why surgeons may abstain from operation
Many surgeons will hesitate to carry out total hip replacement in
- overweight patients ( > 100 kg)
- persons with alcohol abuse
- people with dementia
(Mancuso et al 1997)
Other important factors may influence your decision to have a total hip replacement and your satisfaction with the operation.
These factors include
your age - you are never too old but you may be too young (in the eyes of your surgeon) for a THR surgery
the character of your hip disease