Transcription:
Anterior Approach To Hip Replacement: Less Pain and Shorter Recovery Times

Melanie Cole (Host): With people living longer than ever, arthritis of the hip is becoming more common. When severe pain or joint damage limits your daily activities, it might be time to consider a joint replacement. My guest is Dr. Kenneth Rauschenbach. He's a board certified orthopedic surgeon with expertise in sports medicine, hip and knee replacement, and trauma at St. Luke's Cornwall Hospital. Dr. Rauschenbach, what types of conditions that you see cause the hip joint to break down? What do you see every day?

Dr. Kenneth Rauschenbach, DO (Guest): Typically the most common condition that we're treating with this is arthritis. There's a number of different types of arthritis. The most common is osteoarthritis, which is kind of wear and tear on the joints. Every one of us will get it to a certain degree over time, and these are the conditions that most likely will necessitate intervention.

Melanie: When somebody comes to you as an orthopedic surgeon with this type of hip pain, you've got to diagnose it. So how do you go about diagnosing, and once you've figured out what's going on, what's your first line of defense before the discussion of replacement comes into play?

Dr. Rauschenbach: Well the most important thing is the description, tell me what your pain is like, and then a physical examination. After figuring out what's going on and what areas are affected, then we will use alternative studies like x-rays to get a better idea of what's going on. The first line of defense is always conservative measures, and those include activity modification, weight loss, and anti-inflammatory medications. Once those fail or do not provide adequate relief, then we get a little more invasive and we can attempt injections, and when everything else fails, at some point we discuss joint replacement.

Melanie: Tell us about the different types of hip replacements that you perform. And I mean what's changed now versus ten or fifteen years ago as far as hip replacements?

Dr. Rauschenbach: Well the good news is hip replacement is the number one surgery in all of medicine, about a 95% good to excellent rate. The longevity of the hips are lasting a lot longer. Typically over the last ten years, we went from fifteen to twenty years to twenty to twenty-five years. This is due to the higher quality prosthetics.

There's also a number of different ways to approach the hip replacement. There are multiple approaches. The most common or classic approach is a posterior approach which I've been performing for about twenty-five years. It does have some limitations and require some precautions after the joint replacement. Over the last few years I've learned a second approach which is the anterior approach total hip, and this provides us with excellent visualization, really great results, and with the added bonus of having no precautions due to the way we approach the hip joint.

Melanie: So tell us about the procedure itself, and what can patients expect as far as recovery and benefits? What are we seeing now?

Dr. Rauschenbach: Well both approaches work very, very well. Typically a hip replacement is performed in about a one hour time period. The patient is usually admitted to the hospital for about forty-eight hours, and that's to get their pain under control, get them up and ambulating. The approach- the classic approach, the posterior approach, we approach the hip from the back, there would be a curved incision on the buttock, and essentially we go in, detach the muscles to get access to the joint. By detaching those muscles, it leaves a little bit of weakness back there, and that's what we worry about, and have to take those precautions into play.

The anterior approach, the advantage there is that it's a muscle sparing approach, meaning instead of taking the muscles down off the bone, we're able to kind of weave in between them and do the approach without taking any of the muscle off. This allows us to have better stability around the joint, and it gives us good access to where we need to be, and have shown excellent results.

Melanie: And how soon after a replacement can the patient get back to their normal activities? And what should they be looking out for as far as red flags for any complications?

Dr. Rauschenbach: Well typically the patient has the procedure in the morning, we have them up at St. Luke's with the physical therapy staff walking that afternoon. The following day they're doing stairs and usually getting ready to go home that next day once they've accomplished their goals in therapy and are deemed to be safe.

In the post-operative period, the things we worry about are blood clots, so each and every person will be put on some sort of what we call DVT prophylaxis. It's usually a medication, typically aspirin twice a day for the first six weeks after surgery. We always look for problems with the wound, drainage, redness, swelling, fever or chills. This could be early indications of infection which can be a devastating complication. Fortunately it's very, very rare and we do everything possible to prevent it.

After that, the most important thing is getting up and going, getting to the physical therapist early on, and that gives us the best chance to get the best result.

Melanie: What about things like driving a car? Do they need a walker right away? Is that something that takes just a little bit longer?

Dr. Rauschenbach: Everyone will be started out with a walker. Typically at two weeks when most of my patients come back to have their wound checked and their stitches or staples removed, most are on a cane or nothing, to be honest with you at this point. Again, some of that has to do with how they came in. The sixty-year-old versus the eighty-five-year-old will progress a little bit quicker. Driving a car, once the patients is off their narcotics and not using an assisted device, and typically around two weeks most people can start driving.

Melanie: Are all doctors doing this anterior approach, Dr. Rauschenbach? And is there a learning curve? Is it more difficult for you surgeons?

Dr. Rauschenbach: There's definitely a learning curve. Even though I know this approach, I do not do it on every single person because of the way we access the joint, that heavily muscled men and people with larger body habitus are not a candidate in my hands for that type of procedure. So not everyone does it. The most important thing is whoever your surgeon is, whatever they feel comfortable with, that should be the way that you go for it.

There are some people- there's probably eight or nine different approaches for hip replacement being done across the country, and the most important thing is the surgeon's experience, that he feels confident in doing it. So there's no right or wrong way, it's just the best way for that particular doctor to get you the best possible result.

Melanie: Well the question that I'm sure you get quite often is about the implants themselves, how long do they last? Do they set off the metal detectors in airports? Will they have to have this redone?

Dr. Rauschenbach: Well all of those are great questions and we go through them with each and every patient. It definitely can set off the metal detectors. We give you a card, but at this day in age with the way the world is, usually you'll get wanded. The joint replacements can last up into thirty to forty years. The typical is about twenty to twenty-five years. At that point, because of the bearing surfaces we use, there can be some micro wear. That wear can loosen the components which may cause some pain. If that pain occurs, that's when we have to do what we call a revision, and go back in there, and possibly redo the hip. Every single person is different. The amount of activity plays a role, injuries to that hip afterwards play a role, but the typical scenario is about twenty years.

Melanie: Wrap it up for us, Doctor, with your best advice about keeping healthy hips and what you want patients to ask you when the discussion turns to a hip replacement.

Dr. Rauschenbach: Well the biggest thing is when to have this hip. The most important thing going forward is A) take care of your body. Keep your weight down. Your hip is a weight bearing joint and the more you beat it up, the more it's going to wear. Once that wears out, make sure you do all those conservative options. Again, lose weight, try the anti-inflammatories. There's no certain age you have to be to have a hip replacement, but it comes down to quality of life. When the pain is there to the point where it's interfering with your activities of daily living, when you can't walk four or five blocks without stopping, and getting through the supermarket is a chore, then it's time to consider hip replacement.

The important questions to ask when you come into my office are, "Am I ready for this procedure? Have I done everything in my power to get myself ready by losing weight, doing all the conservative options, being in good shape?" Because these all play a role in your ultimate outcome. When the pain has affected your activities of daily living, when you can't get through the supermarket without having to lay on the couch for an hour, walking four or five blocks is a chore, then joint replacement is an excellent option for you.

Again, each person has to be evaluated and checked individually by the surgeon, they will review the requirements for the joint replacement, the risks and possible complications of the surgery, and the you'll be seen by your medical doctor, and then the surgery will be performed. And very, very good results from these hip replacements.

Melanie: Thank you so much, Dr. Rauschenbach, for sharing your expertise in this topic. So many people suffer from hip pain. Thank you so much for coming on and clearing so much of this up for us. This is Doc Talk presented by St. Luke's Cornwall Hospital. For more information please visit www.StLukesCornwallHospital.org. That's www.StLukesCornwallHospital.org. I'm Melanie Cole, thanks so much for listening.