ALTERNATIVE HIP OPERATIONS
CONTENT:
Fusion (arthrodesis) of the hip
Some alternative operations for avascular hip necrosis
Resection arthroplasty - Girdlestone
WHY?
Not all damaged hip joints need just a total hip replacement operation. Sometimes a more simple operation or an operation with a special device is all what is needed.
These "alternative" operations are, however, best suited for younger patients.
"When there is minus 70 degrees in Alaska, you have only one chance" wrote Jack London.
When you are 70, you may also have only one chance - your body may tolerate just one major hip joint surgery. Then the total hip joint surgery is the operation of choice because its is an operation with predictable success.
The alternative operations have less predictable success rates. Your body might not tolerate a second major hip surgery if the alternative operation fails.
(0) Arthroscopy
| For whom:
young patients with mild hip disease (osteoarthritis), for extraction of loose bodies, for treatment of joint capsule damage Aftertreatment: on crutches some days until the pain disappears Results: during ten years after the hip arthroscopy, 67% of the patients were operated on with a total hip, |
Arthroscopy is a key-hole operation of the hip joint, is not an easy operation. The hip joint lies deep, large nerves and arteries pass close to it, the joint capsule is strong. When you eventually come into the joint space with the arthroscope, there is very little space for movement of the instrument. The progress of the arthroscope into the hip joint is guided by X-ray, which is connected with risks for higher doses of X-rays for women in fertile age.
(Arhroscope is a tube about 6 millimeters in diameter, that contains the optical system to look into the joints, lenses, light system, and fiber optic together. The system is coupled with a TV screen).
Not so long ago, one leading orthopedic surgeon characterized hip arthroscopy as "technically difficult, fraught with some danger, which should be attempted only by the most experienced arthroscopic surgeon".( Griffin 1999).
How is it done
The operation is done in general anesthesia usually, the patient may be prone or on the side, the traction is applied on the leg. Most complications after arthroscopy are actually caused by this traction which is quite forceful. Traction, however, is necessary to put hip joint surfaces away from each other to provide space for the arthroscope.
After the operation, the patient usually stays overnight in the hospital and is on crutches until the pain in the hip and groin disappears.
Why is it done
(1) Diagnostic method to evaluate the damages in the thick part of the hip joint capsule (so called "labral tears"), and the damages of the joint cartilage not demonstrated on the X-ray pictures.
(2) Treatment such as
extracting of loose bodies from the hip joint
removal of the damaged joint cartilage and flush the joint from the small fragments of the cartilage in patients with mild osteoarthritis of the hip joint.
The results
About one third of the patients with hip osteoarthritis rated the result of hip arthroscopy as excellent, one third was slightly improved, and one third had another hip operation within 18 months after the arthroscopy, among them 10% have had a total hip operation..
Only young patients and patients with lesser damages to the hip joint cartilage benefited from this procedure.
Yet, after ten years 67%of all arthroscopied patients have had total hip replacement surgery.
The complication of this operation method is mainly the transient nerve palsy, which occurred in 1,6% of all patients. The nerve palsy disappeared successively (weeks to months) in all patients.
Other methods to replace hip arthroscopy
The surgeons still discuss whether MRI may replace the arthroscopy of the hip joint as a pain-free diagnostic method with no complications.
(1) Osteotomy
| For whom: young patients
(<55 years) with not much damaged hip joints and good range of motion in the hip
joint (flexion from 0 to 90 degrees) Aftertreatment: on non weight / partial weight bearing regime until the osteotomy heals, which may take 6 - 12 weeks Results:
|
Osteotomy means " division of the bone". There are two main purposes for osteotomy operation:
(1) correction of bone deformity in the hip joint and realignment to the "normal" position of the hip joint. By the realigning the hip joint to the normal position, the peak body weight stresses on the hip joint will be distributed more evenly and diminished.
(2) for hips affected by osteonecrosis, the major goal of surgery is to move the necrotic segment (in the femoral head) away from the weight bearing area and restore the blood supply to the necrotic zone
Osteotomy for correction of skeletal deformity
In patients with sequels after Congenital Hip Displacement, or after a fracture in the hip area, the skeleton around the hip joint may not be aligned right. The load on the joint surfaces is eccentric and this leads to the destruction of join cartilage and development of secondary osteoarthritis.
for both types of osteotomy operation are young patients, <55 years, with mild osteoarthritic changes in their hip joints. Old patients are not good candidates for hip osteotomy as the following Table showsThe surgeon may restore the alignment of the skeleton by an osteotomy operation. Depending on the type of deformity, the surgeon may restore the alignment of the thigh bone (femoral osteotomy) or of the hip socket (pelvic osteotomy). Very seldom the surgeon may realign both thighbone and pelvis in one surgery - a very bloody operation. Whichever type of the osteotomy the surgeon would carry out depends on the motion in the hip joint and the state of the joint cartilage.
Types of osteotomy:
Femoral osteotomy Pelvic osteotomy Osteotomy through thighbone Osteotomy through pelvic bones Reconstructive Osteotomy
Salvage Osteotomy
For more information visit also the chapter Young age and total hip operation
Good candidates for hip osteotomy:Age: Patients under 30 years of age are excellent candidates for osteotomy and poor candidates for total hip replacement. Even patients < 50 years of age are still good candidates for osteotomy and less good candidates for total hip replacement
Activity: Very active patients with still small damges of the hip joint surfaces are excellent candidates for osteotomy and poor candidates for total hip surgery.
Poor candidates for hip osteotomy:
Old age. Usually patients over 55 years of age are considered bad candidates for osteotomy. But this age limit is not absolute.
Patients with inflammatory hip joint disease. The osteotomy operation will not arrest progression of the inflammatory joint disease and continuous destruction of the hip joint.
Severe damage of the hip joint with bad range of motion. These patients do not improve their bad joint motion and might become completely stiff in their hip joint after any osteotomy operation. Such patients are better treated by total hip replacement or, in very special cases, by hip fusion.
Techniques of hip osteotomy:
FEMORAL OSTEOTOMY
PELVIC OSTEOTOMY
This operation is carried out on patients with good hip socket (acetabulum), preoperative x-ray study should demonstrate that the femoral head would have good coverage within the socket (acetabulum) after the osteotomy. Good range of motion is another prerequisite for this type of osteotomy. In this patient the angle between the shaft of the femur (thigh bone) and the neck has been too large.
A part of femoral head was outside the socket so that the body weight was concentrated only on a small area of the head that was in contact with the socket.
The load on the femoral head was asymmetric.
In this schematic picture, you see that after the femoral osteotomy, the femoral head is well centralized inside the socket and is well covered by it.
How was it done?
The surgeon first removed a bone wedge at the junction between the neck and shaft.
Then the surgeon readapted the cut bone ends and fastened them together with a plate and screws in the new position.
The angle between the neck and shaft is now smaller and the whole femoral head is in contact with the socket.
The loads on the femoral head are now symmetrical.
Thanks to strong screw and plates, the patient does not need any brace, but weight bearing is restricted for the 6 - 12 postoperative weeks
There are two types of pelvic osteotmy: The first type reconstructs the good shape of the hip joint (reconstructive osteotomy)
the second type of osteotomy helps only to cover the femoral head with pelvic skeleton (paliative osteotomy)
Reconstructive osteotomy
Picture A (upper)
This patient is a candidate for reconstructive osteotomy:
X-ray picture shows that the femoral head is well rounded and congruent with the socket and the joint line is well retained. Other examinations demonstrated that the patient has good motion in the hip joint.
How is it done?
The the surgeon divided the socket of the hip joint its attachment to the pelvic bones, and then rotated it so that the socket now covers the whole femoral head. The good shape of hip joint is now reconstructed. In this new position rotated socket is fixed with screws. This reconstruction will last long because a healthy joint cartilage in the socket now covers whole femoral head.
Salvage osteotomy (Chiari Osteotomy): Technique
Picture B (lower)
This patient is a not a candidate for reconstructive osteotomy.
X-ray picture shows that the femoral head is deformed, the joint line is narrower - evidence that joint cartilage has been destructed at least partially. The body weight is concentrated on a small area of the femoral head. The reconstructive osteotomy cannot prevent further development of osteoarthritis because the joint cartilage has already been damaged. The cartilage damage would spread in spite of reconstructive osteotomy and the such operation will fail.
If the patient has good range of motion he / she is a candidate for salvage osteotomy;
that operation may provide a coverage of the whole femoral head and provide at least a temporary relief of pain.
Compared with reconstructive osteotomy, salvage osteotomy is a relatively simple operation. Often used is the method of the Austrian surgeon professor Chiari. The pelvis is osteotomized (divided) just above the origin of the hip joint capsule. The inferior segment of the pelvis together with the femoral head is then displaced medially (to the middle), the upper segment of the pelvis (shelf) together with joint capsule covers the head. Joint capsule forms initially a soft cover of the femoral head. This capsular tissue undergoes change into connective tissue cartilage and a well covered hip joint forms.
Originally, the patient was put in a brace after the surgery untill the osteotomy healed. Today the surgeons use screws and plates to fix the fragments in place.
Candidates
| AGE at femoral osteotomy | % Converted to total hip during 10 years |
| mean 30 years | 15 % |
| > 55 years | 90 % |
Osteotomy relieves pain but it does not improve movement in the hip joint. Thus, candidates for osteotomy operation should have at least 90 degrees bending in their hips.
Postoperative treatment:
the patients are put on non-weight bearing or partial weight bearing regime with two crutches / walker until the osteotomy heals. In young patients this takes between 6 to 12 weeks.
Results:
about 75 to 85 % of all patients have had very good and good pain relief in their hips initially. Successively, however, the pain might return and the range of modtion diminish. The published results show that during the ten years after the pelvic osteotomy about 30 - 40% of all osteotomied patients have their osteotomied hip changed to total hip replacement.
In every case, these patients postponed the total hip replacement into more "mature" age, with less activity, these patients "gained time".
Total hip replacement of a previously osteotomied hip may be a more difficult operation if the osteotomy changed the skeleton too much. Moreover, the surgeon must remove first the screws and plates that once fixated the ostotomy which prolongs the surgery.
The possible complications:
non healing of the osteotomy site and pain from the plate and screws, both complications occur in 5 -15 % of all osteotomy operations.
Osteotomy to put away the body weight pressure on the femoral head in avascular necrosis of the hip
The purpose of this osteotomy is to rotate the femoral head so that it will be outside the main body weight pressure.
Click on the icon for a full size image Upper picture: the necrotic area (the black spot) in the femoral head is directly loaded by the body weight (Black arrow = direction of the resulting body weight).
The surgeon divides the femoral bone close to the femoral neck and then rotates the neck with the head so that the dead bone area comes away from the main body weight pressure. This operation is possible to carry out only if the area of the dead bone is still small.
The surgeon may rotate the neck & head in different directions, upwards, downwards, or around the longitudinal axis.
In this picture the surgeon rotated the femoral head and neck downwards. The black spot of the dead bone is no longer under the direct pressure of body weight.
The surgeon then fixes the divided bone ends together with a plate and screws (not shown in the picture).
These are delicate operations because the blood supply to the femoral head goes along the neck and close to the site where the surgeon divides the thigh bone.
If the vessels for the femoral head have been damaged during the operation, the bone necrosis damage may increase instead of to heal. "Osteotomies are not widely accepted as a standard method of treatment of osteonecrosis of femoral head " (Lieberman 2002)
The possible candidates: Young patients with early stages of avascular necrosis of the hip, without collapse (deformation) of the femoral head. But if your surgeon recommends this operation discuss it with him/ her carefully.
Aftertreatment
is by non-weight bearing regime until the osteotomy heals, which takes between 6 - 12 weeks.
Results
vary in different reports and depend on the size of the necrotic core. The results are better in patients with small areas of necrotic bone and in patients with the early stages of the avascular hip necrosis. Still, even for patients with small area of necrotic bone, the osteotomy was successful in only about 50% of all cases. Moreover, about 50% of all patients experienced some form of complication such as delayed healing of the divided bone ends, pain from the screws and plates, and infection around the osteotomy.(Schneider,2002, Lieberman 2002).
The revision of the failed osteotomized hip to a total hip replacement is usually difficult, the screws and plates must be removed first which adds to the difficulty of the operation.
See also the chapter Hip diseases / Avascular necrosis
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References: Schneider et al J Bone Joint Surg-Br,2002;84-B:817- 824
Lieberman et al : J Bone Joint Surg-Am,2002;84-A:834- 853
(2) Surface replacement
For whom: mainly young active patients (<55) with advanced hip disease Aftertreatment: in cemented: weight bearing "as tolerated" 2-3 days after the surgery
in cementless: restricted weight bearing 6-12 weeks
Results: 86 to 99% of surface replaced hips still in function five years after the surgery
Some surgeons believe that it is unnecessary to remove the whole femoral head in young patients who should have a hip replacement operation. They carry out a surface replacement operation instead.
Some surgeons regard the surface replacement surgery as a "buy time operation". The surgeons who carry out the surface hip replacement operation believe that the surface replacement will fail after some 10 -25 years of service life. The patient will then be 10 -25 years older and less mobile. Then it is time to exchange the failed surface replacement by a total hip prosthesis. At this exchange operation the patient became older so that the total hip will last during the patient's resting life.
For more details visit , please, the chapter Surface hip replacement
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References:
Hemi-surface replacement
| Candidates: young patients with osteonecrosis of the hip joint, with intact acetabular joint cartilage Aftertreatment: partial weight bearing 6 -12 weeks Results: excellent for the first five years in 90% patients, only 60% after ten years. Conversion to total hip replacement successful >90% of all patients 10 years after revision to total hip surgery. |
In young patients with avascular necrosis of the femoral head and intact acetabulum (socket) of the hip joint it is also possible to carry out a surface replacement of only the femoral head . Such operation is called hemi- surface replacement.
The advantage of this operation is a minor surgical trauma. The femoral component is a thin metallic shell that articulates direct with intact joint cartilage of the acetabulum.
Successively, however, the acetabulm cartilage will be worn out and the hemi-surface replacement will be painful. Then the hemisurface will be revised to a total hip replacement.
The results of this operation are initially excellent, but the results deteriorate successively. As the originally intact cartilage in the hip socket will be worn out by contact with the metallic femoral component the patient will successively get more pain and the hemiarthroplasty will be converted into total hip replacement.
Studies demonstrate that the total hip replacement that followed the hemi-surface arthroplasty has lasting results. Ten years after the revision total hip replacement, 91% of all patients have satisfied results.
Candidates
for this operation are young patients with avascular necrosis limited to the femoral head, without damage of the hip socket (acetabulum).
Aftertreatment: Non-weight bearing 6 -12 weeks.
Results:
The results are excellent during the first five years after the operation (80 to 90% of patients have excellent pain relief), then the percentage of excellent results drops down, so that ten years after the hemi-surface replacement only 60 -70% of all patients still have excellent to good pain relief. (Lieberman 2002 )
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Reference:
Lieberman et al : J Bone Joint Surg-Am,2002;84-A:834- 853
(3) Hip fusion / arthrodesis
| For whom:
exceptional, young patients with healthy spine and no changes in other joints may be also attempted for patients with failed total hip joints Aftertreatment: bandage, partial weight bearing >12 weeks Results: pain-free fused hip in > 70 % of all operated patients. |
Arthrodesis is the fusion of the femur (thighbone) to the pelvis.
This operation is carried out only exceptionally nowadays. In this operation, the surgeon removes all hip joint surfaces up to the raw bone and then presses and fixes the denuded joint surfaces together with special plates and screws. Healing of the arthrodesis - solidifying of the bone tissue and obliteration of the previous joint space - takes about 12 weeks.
After this operation, the patients are completely free from pain in the hip joint but their hip joint is also completely stiff. Their operated extremity is very stable, so that patients with hip arthrodesis may do also a heavy work. After some time, however, many of them develop pain in their backs, knees, and the other hip.
The hip fusion is better tolerated by male than by female patients.
The results depend on the position in which the hip has been fused. Too much bent position in the thigh and the adducted thigh (thigh drawn to the midline) cause soon pain in the spine.
Only about two thirds of all fusion hip operations heal with fused hip, in one third of the patients the fusion does not succeed according to the X-ray pictures. Yet the patients may be still pan-free and the hip completely stiff
This operation may be also a last rescue for a failed total hip replacement where for some reason it would be impossible to implant a new total hip prosthesis. To achieve a fusion under these circumstances, with severe deficit of the skeleton around the once hip joint is extremely difficult.
For more information visit also the chapter Young age and total hip operation
Some alternative operations for avascular hip necrosis
(4) Core decompression & bone grafting.
| For whom
: young patients with initial stages of osteonecrosis of the hip, before the head
collapses Aftertreatment: on crutches 6 to 24 weeks Results: depend on the size of the osteonecrosis. In small size damages up to 80% successful results, in advanced stages <30% successful results |
This is the most widespread operation used to treat the osteonecrosis of the hip. It is called "decompression operation" because the operations is based on the idea that the blood pressure in the bone tissue around the death bone focus is increased.
Opening the area of the dead bone from outside will attain three objectives:
lower - decompress the blood pressure
restore the blood circulation to the dead bone tissue
relieve pain
The surgeon hopes that a new, healthy bone tissue will grow into the necrotic (dead) bone and rebuild it successively
To help the replacement process, the surgeon may remove the dead bone and replace it with healthy bone chips taken from the patient's skeleton.
Click on the icon for a full size picture
The operation is carried out under fluoroscopic (X-ray) guidance.
The surgeon puts first a guide wire through the neck of the femoral bone from the outside of the hip joint (trochanter) into the area of dead bone. (There are other ways how to access the necrotic bone area in the femoral head that are more difficult). On this wire the surgeon then puts a drill head that makes a canal through the femoral neck and open the area of the necrotic bone.
After opening ( "decompressing") the necrotic bone area, the surgeon may stop there.
Many surgeons, however, remove with special instruments the dead bone tissue and replace it with patient's own small "fresh" bone chips. The cells in the "fresh" crushed bone tissue are of course dead but the "fresh" bone tissue contains hormones (bone morphogenetic protein hormones) that entice formation of the new healthy bone tissue that successively rebuilds the inlaid bone chips.
On this theory, there are experiments ongoing which place genetically engineered bone morphogenetic hormones into areas after necrotic bone removal to entice formation of new bone there.
Who is the candidate: Patients with early stages of osteonecrosis of the hip
Aftertreatment: protective weight bearing at least 6 weeks, longer if the the decompression canal was larger
Results: depend on the stage of the disease. In early stages, before the femoral head collapses, there were up to 80 % of successful results, with healed necrosis. In later stages of the disease, when the surface femoral head already was damaged, there were less than 30% successful results.
Core decompression vs. non-weight bearing regime.
Studies show that core decompression is more effective than simple non-weight bearing treatment (possibly supplemented by medicines, electromagnetic fields, etc.).
Table summarizes the results of 47 studies:
Treatment % "satisfactory" results Core decompression 64 % Non-operative treatment 23 % (Lieberman 2002 ).
(4B) Vascularized free bone (fibular) graft
For whom : young patients with still retained form of the femoral head Aftertreatment: Crutches or walker up to 24 weeks
Results: up to 80% satisfactory results
the goal of this operation is to prevent the eventual collapse of the femoral head over the area of necrotic bone and to enhance the rebuilding of the dead bone area.
In this operation the surgeon decompress the femoral head as in core decompression operation but then continues with removal of the dead bone focus, replaces it with with patient's own fresh bone chips, places a viable piece of fibular bone (smaller lower leg bone) to support the bone chips.
Because the surgeon uses a living bone strut with vessels anastomosed to the vessels in the hip area, the transplanted strut is alive and offers a full support to the femoral head.
This is a difficult operation carried out by two teams of surgeons. One team makes core decompression operation in the hip area, the second team removes the middle third of the fibula bone (the smaller lower leg bone) with attached vessels. (The diameter of these vessels is only 1 -2 millimeters!). This is a vascularized fibula graft.
Click on the icon for a full size picture
The fibula graft is placed into the core canal as a duvet. Then follows hooking (anastomosis) of the very small vessels from the fibular graft to the vessels in the hip area. With the size of the vessels this is a painstaking work, done under operation microscope and taking several hours.
Healing and complete filling of the defect takes about 6 months, during which time the patient must be on crutches.
The hospital stay is 2 - 4 days, the non-weight bearing for six weeks and restricted weight bearing up to 24 weeks follows.
Although the vascularized fibular graft is successful, there are several potential disadvantages:
Pain in the lower leg, weakness of the muscles in the lower leg in 16 % of all operations as a results of taking vascularized fibula graft from the outside of the lower leg.
Fracture of the femoral neck in 2,5% resulting from too much weight bearing.
Potential difficulties later if the procedure fails and the patient will need conversion to the total hip prosthesis.
For whom: young patients (<50 years) with still well retained surface of the femoral head and no damage to the joint cartilage. Patients with incipient osteoarthritis in the hip joint have usually worse results.
Aftertreatment: totally 24 weeks on crutches
Results: In published studies the success rate of vascularized fibular graft operations was 80%.
( 5) Hemiarthroplasty
Hemi-arthroplasty means a half replacement joint operation. The surgeon replaces only the femoral head and lefts the acetabulum (hip socket) intact.
Candidates for this operation are patients with traumatic damage of the femoral head, such as patients who have had dislocated fracture of the femoral neck or dislocation of the hip joint. In these patients the circulation to the femoral head is damaged and the femoral head dies and collapses. The other side of the hip joint, the hip socket (acetabulum) still has a healthy cartilage cover.
Thus it is possible to remove and replace the femoral head only and replace it with an artificial ball the same size as the removed head.
This operation produces much less operation trauma, need not blood transfusion, and the patient may be mobilized quickly.
The surgeon removes only the diseased (dead) femoral head and replace it with an artificial ball of the same dimensions. The artificial head then articulates with the healthy cartilage in the socket (acetabulum) of the hip joint.The ball may be attached firmly to the prosthetic shaft (monopolar prosthesis), or the prosthetic ball may be mobile on the shaft through an articulation (bipolar prosthesis). In old infirm patients the surgeon usually cements the shaft of the prosthesis.
Candidates:
usually old infirm patients with fracture of the neck of the femoral bone
Aftertreatment:
mobilization with two crutches as soon as possible. Weight bearing as tolerated from the beginning in cemented prostheses.
Results:
good in older patients, the majority of the hemiarthroplasty prostheses survive the old infirm patients.
The results of a total hip arthroplasty are. however, superior to those of the hemiarthroplasty in well mobile, socially independent older patients. Table.
RESULTS Hemiarthroplasty Total hip Failure 38 % 0 % *) Patients walking > 1 mile 27 % 77 % Excellent / good results 12 % 86 %
(6% of total hips dislocated!) (Squires 1999)
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References
Squires , Bannister: Injury, 1999;30: 345-8
(6) Resection arthroplasty -Girdlestone
In patients with repeated failed revision operations of the total hip prosthesis the skeleton around the hip joints is more and more thin. Eventually, there is not enough bone stock left to which the surgeon might attach the total joint prosthesis.
In these patients the surgeon is forced to stop further surgery and to let the patients live without a hip joint.
Yes, it is possible to live without a hip joint, but it is difficult. This condition has a name: Girdlestone’s plastic - an embellishing term for a difficult terminal state after failed total hip replacement.
For more details see also the chapter Treatment of total hip infections
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