Transcription:
Surgical Approaches Used for Hip Surgery

Prakash:    Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest.

This episode is sponsored by the University of Maryland Joint Network. UM Joint Network surgeons are experts in total hip and knee replacements. Held to the highest standards of care, UM Joint Network surgeons produce better outcomes for patients compared to national averages, including lower infection rates and faster recovery times. The UM Joint Network, home to Maryland's leading joint replacement surgeons.

Today's topic is surgical approaches used for hip surgery. My name is Prakash Chandran. And my guest today is Dr. Kevin McCoy. He's currently an orthopedic surgeon at the Orthopedic Center, a partner of UM Shore Regional Health, where he specializes in joint replacement of the hip and knee as well as general orthopedics.

Dr. McCoy, thank you so much for joining me today. You know, I know that total hip replacement is one of the most successful surgeries currently performed, but in general, what should patients know about how successful it's been and some of the benefits of getting a hip replacement?

Dr Kevin McCoy: You're absolutely right. Total hip replacement is currently one of the most successful surgeries that we perform as a whole medical system. It's got a very low complication rate about 1% to 2%. And I think it very successfully improves patient's pain and quality of life. So you take somebody that has debilitating hip arthritis that has trouble playing on the ground with their grandchildren and give them that quality of life and decrease pain back and patients are typically very happy with the outcome.

Prakash: Okay. So going into the patients themselves, who typically needs a hip replacement to begin with?

Dr Kevin McCoy: Yeah. The most common indication for a hip replacement is good old-fashioned hip osteoarthritis, where the cartilage or padding between the ball and socket is worn out. There are some other causes such as rheumatoid arthritis or osteonecrosis where the ball of the ball and socket loses its blood supply. There's also some childhood diseases of the hip or injuries that will go on to lead to a similar picture to arthritis in the future.

Prakash: Okay. Understood. And so how do you actually know that you need a hip replacement? Does it typically happen after an event like a fall or do symptoms slowly start exhibiting themselves?

Dr Kevin McCoy: So typically, hip joint disease causes pain in the groin or the front part of the thigh. So I think the first step would be to go to an orthopedist and have the hip evaluated typically with an x-ray. There are some conditions that cause pain in the "hip" that aren't actually joint-specific conditions. So it may be something such as bursitis, which we commonly see in our office that will be treated without a hip replacement.

Prakash: Okay. So I want to understand a little bit more around what is involved when you get a hip replacement. What does the procedure look like?

Dr Kevin McCoy: The hip replacement involves an incision over the hip and what we ended up doing is going down and replacing the ball and socket of the joint. So typically, we put a metal half-sphere that goes up into the socket or the acetabulum. There's a plastic liner that snaps into that. And then we put a femoral stem down the top of the thigh bone, that goes about 10 centimeters down the shaft of the bone. On the end of that stem is typically a metal or ceramic ball. So the patient ends up with typically a metal or ceramic-on-plastic articulation instead of bone-on-bone.

Prakash: Okay. I see. And just for a lay person, typically the mechanics of how a hip works is there's kind of like a socket and a ball that moves around and it allows you to kind of, I guess, move and be mobile with your hip, you're replacing that piece with metal and I guess an artificial socket. Did I get that right?

Dr Kevin McCoy: Yes, that's exactly correct. And our goal during a hip replacement is to recreate that natural articulation with metal or ceramic on plastic as you described. And the advantage to this is there is no nerves in that hip joint. So instead of the bone-on-bone that is quite debilitating and painful, you end up with a functioning hip joint that does not have pain.

Prakash: Okay. That makes sense. So, you know, as people listen to this and they hear the dynamics around how the procedure works, they might be a little apprehensive around getting surgery to replace their hip. So are there alternatives or things that you can do prior to getting hip replacement to treat the problem?

Dr Kevin McCoy: Yeah. Typically, hip or knee arthritis, it's more of an inflammation problem. That's what causes the pain and stiffness and sometimes swelling, which is easier to see in the knee than it is in the hip. But typically, the non-operative treatments are based upon relieving that inflammation. So I like to tell people that anti-inflammatories are good for short periods of time. And I think sometimes having people take Aleve or ibuprofen, or even a prescription-strength anti-inflammatory for 10 to 14 days can often help settle down that inflammation and their pain.

Physical therapy can also be helpful. Using an assistive device such as a cane or a walker for a period of time can help offload that joint. Another option are intraarticular steroid injections. In the hip, we typically apply these under imaging, such as ultrasound or CT scan or x-ray. But this can relieve the symptoms for a temporary period of time.

Prakash: I see what you're saying. So a lot of these things are temporary fixes, but in order to really get to the root of the problem, typically the hip replacement is required. And because the success rate is so high, it's probably something that you recommend quite often, wouldn't you say?

Dr Kevin McCoy: Yeah, absolutely. And hip replacement surgery is nothing that I push people into, but I like to tell people when you've tried all these conservative options and you still have debilitating pain that keeps you from doing things in life, it may be time to consider having the hip replaced.

Prakash: Okay. So let's go into the different types of hip replacements and how they work.

Dr Kevin McCoy: In terms of the surgical approaches to the hip, there's really three main ones that we're going to talk about. And they're named in reference to how we approach the hip joint relative to the greater trochanter or that bone on the outside of the hip.

Prakash: Right. And the three that we're covering today are the posterior, the anterior and the lateral. Is that correct?

Dr Kevin McCoy: Yes, that's correct.

Prakash: And just one more clarification before we go into the details. Anterior means front, posterior means back and lateral means side, right?

Dr Kevin McCoy: Yes exactly. That's correct.

Prakash: Okay. So let's start with the posterior hip replacement. Talk a little bit about what it is.

Dr Kevin McCoy: The posterior approach is really the tried and true traditional approach. It's certainly been done that way the longest. And basically what we do for the posterior approach is make an incision that's centered over that bump on the outside of the hip. We then split the fascia or the connective tissue that overlies the muscles there and we approach that greater trochanter from the posterior or back part of it. So we end up taking down what's called the short external rotator muscles as well as the joint capsule that surrounds the joint off of the back of that greater trochanter.

Prakash: Okay. So let's talk about some of the advantages of this tried and true posterior hip replacement.

Dr Kevin McCoy: It's certainly a very reliable, relatively easy way to approach the joint. It reproducibly gives a surgeon great visualization. It's also easily extensile, meaning if I have to go up or down to get better visualization, this is very easy to do through this approach. This makes it very useful during revision or redo total joint replacements.

Prakash: And are there any disadvantages that people should know about?

Dr Kevin McCoy: Really, the historical disadvantage to the posterior approach is again debatable. Traditionally, it had a slightly higher dislocation rate. There's certainly some recent evidence that surgeons who repair that joint capsule and those short external rotator muscles can have a very low dislocation rate. In some series, it's been shown to be 0%.

Prakash: Okay. So let's move on to the direct anterior hip replacement. How is it different from the posterior hip replacement? And what are some of the advantages and disadvantages?

Dr Kevin McCoy: The direct anterior approach certainly over the past decade has gained more and more enthusiasm. Some people see it as the "latest and greatest." But it's actually interesting, it was described by a German surgeon all the way back in 1881. It's really become more popular over the past decade due to advances in instrumentation and implants that have made it a much more viable approach.

This approach is centered over the front of the hip. And what we do is on the way down, we split two muscles called the TFL and the sartorius on the way down to the hip joint. The advantages, with any approach, it's very debatable. Some papers have shown that there's less pain very early on within the first two weeks of surgery. By six weeks, this has really been shown to be the same, no matter which way you do the surgery. Most literature would point to a lower dislocation rate using the direct anterior approach. I think that one of the great advantages of it is we can easily use interoperative fluoroscopy or x-ray, so the surgeon can actually see the sizing and positioning of the components as an advantage to this approach.

In terms of disadvantages to the anterior approach, it sometimes can be a little bit of a difficult exposure, particularly when you need to gain access to the femur or the thighbone. This has been shown in some series to have a higher proximal femur fracture rate as compared to other approaches. There's also been shown in some studies to have a little bit higher risk of wound problems such as drainage or infection, just because that skin over this area is thin, and it's near the groin crease.

Prakash: Okay. Understood. And then finally, let's talk about the lateral surgical approach. Talk a little bit about the differences and then the advantages and disadvantages.

Dr Kevin McCoy: The lateral approach, the incision is very similar to the posterior approach. It's centered over that greater trochanter or bump on the outside of the hip. The fascia is split very similarly to the posterior approach. Instead of going to the backside of that trochanter, the hip is really approached from the side. And typically, that involves splitting at least some of what we call the abductor muscles or the muscles that bring that leg out to the side.

The advantage of this is it's traditionally a very low dislocation rate. Similar to the posterior approach,. it's a very nice exposure and it is extensile, similar to the posterior approach as well. The main disadvantage is really concern for healing of that musculature that you take off of that greater trochanter. And there is some concern that that may lead to weakness in the hip afterwards, although, again, this is very debatable depending on what papers you're looking at.

Prakash: Okay. So, in evaluating these three different approaches, you've highlighted some advantages and disadvantages. I'm wondering how you decide along with the patient, which one is right for them.

Dr Kevin McCoy: You know, that's a very good question. Typically, my go-to is the direct anterior approach. And there's many reasons for that. Typically, in a primary total joint setting, I think it helps get them up and get them moving quicker and certainly gets them home a little bit quicker with that early pain relief.

There are certain instances where I would recommend a posterior or a lateral approach, and most of these are based upon previous surgery. So in somebody with a current joint replacement that is either loose or has another issue such as an infection, I would recommend either a posterior or a lateral approach based on what they had done prior. This will give me more ability to extend the incision one way or another and get much greater exposure if I need to do revision type of work.

Prakash: Understood. And you know, we've talked about these three approaches and the one that you like to use most commonly, but are there other alternative surgical approaches that we should be aware about?

Dr Kevin McCoy: You know, there are other approaches that are described. For the most part, most of these are small variations on the big three that we just talked about.

Prakash: And also in considering all of these things, what is one piece of advice or one thing that you wish more patients understood before coming to get hip replacement surgery?

Dr Kevin McCoy: I think the big take home is that this is a major surgery. Although it's very successful with a 1% to 2% complication rate, it is quite a recovery. Some people come into this thinking that they're just going to be better overnight. And honestly, it is about a two to three-month recovery until everything heals and you're back to normal.

Prakash: Got it. So let's talk a little bit about that recovery. So you said it's about two to three months. So let's talk about maybe the first couple of weeks after you undergo the surgery. Is that really involved with like you're not really mobile and someone has to take care of you? And then talk a little bit about how you heal over time.

Dr Kevin McCoy: For the most part, we do these surgeries in the hospital, although there are a fair amount of patients that qualify for an outpatient setting where you go home the same day. We do the surgery and that takes a little bit over an hour to do. And in the majority of patients, we get you up the same day and let you put full weight on this hip. Typically, I do recommend a walker for at least a couple of weeks, mostly to prevent falls and allow you to mobilize better.

Most people that are done in the hospital are going home the next day and this is something that the implants are designed such that the bone actually grows into these implants. And that is about a two to three month process. So I tell the patient to be careful, avoid impact activities and certainly falls for the first two to three months afterwards.

I don't require that everybody goes to physical therapy, although some patients do feel that they'd benefit from it. My main concern is just letting this hip joint heal and the bone to ingrow appropriately to provide long-term stability and happiness for the patient.

Prakash: Right. So after that recovery period, I'm wondering is there any further work or maintenance that needs to be done to ensure that their hip replacement parts are working properly? Or do they just perform the surgery or the replacement and it's one and done?

Dr Kevin McCoy: So overall, this is a very successful surgery. And in terms of redo surgery, this surgery has about a 1% failure rate per year. So that means 20 years down the line, there's a 20% chance that you'll need to have this hip redone for one reason or another. It's possible that that could just be changing out some of the plastic parts or it's possible that we may need to redo either the femoral or acetabular component.

Prakash: So just as we close here, Dr. McCoy, is there any other information that you want to provide our audience regarding hip replacement?

Dr Kevin McCoy: You know, I think if you're having hip pain, especially if it's been going on for quite some time, I think it's definitely in your best interest to head to your orthopedic office and get an x-ray and see if you can see exactly what's going on. Because again, there are people that have hip pain that don't necessarily need a hip replacement. A lot of times, even if it is hip arthritis, it can be treated with conservative methods, and you may or may not need to consider a hip replacement anytime soon.

Prakash: Well, Dr. McCoy, thank you so much for your time today. I really appreciate it.

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