Hip Replacement Surgery
with James Stiehl, M.D.
This month's Medical Moment spotlights a number of different joint replacements, but the oldest type of replacement, and still the most common, is the artificial hip.
Hip replacement began in 1960 in Britain, using a metal ball and plastic socket to replace the damaged joint and a special cement to hold the artificial pieces in place.
Today the procedure is much the same but non-cemented designs are also available. These allow the surgery to be done on younger people.
Candidates for surgery
Those who suffer from osteoarthritis (a form of arthritis characterized by gradual loss of cartilage of the joints, usually affecting people after middle age) comprise the vast majority of hip replacement patients. Other candidates include those who have some abnormalities in their joints or suffer from rheumatoid arthritis, a condition that may destroy the cartilage (tough elastic tissue) in the joint.
Surgeons prefer to operate on people 60 and older. This is because artificial joints tend to wear out over time and a person who has the surgery at too young an age may live beyond the life of the joint.
"I can operate on anyone who can survive the surgery and make a big difference in their lives. But the ideal patient would be between seventy and seventy-seven and in great health. First, because they won't wear out the device. Second, there won't be any big issues with the surgery itself," said Dr. Stiehl, a joint replacement specialist with Columbia St. Mary's.
"Surgery is indicated if patients show a lack of response to medication that we use for arthritis," Dr. Stiehl said. Such prescribed medications include over-the-counter anti-inflammatories, prescription drugs like Celebrex or experimental alternative supplements containing glucosamine sulfate. Although not approved by the FDA for the cure or prevention of disease, Dr. Stiehl said, "Glucosamine is one of the few things that has come out of the natural medical area that really seems to work."
Glucosamine sulfate, an amino sugar found in the body, is thought to play a role in cartilage formation and repair. Caution is advised, however, because various formulations of the dietary supplement are available on the market and they may not have the same effect on severe osteoarthritis. People should consult with their physician about using glucosamine sulfate.
A poor candidate for total joint replacement would be someone who isn't fit or who had an infection in the hip, even years ago, according to Dr. Stiehl. Young patients also are poor candidates.
"You know their surgery won't last a lifetime. However, if a patient is young and has no other options, I'll give it a go. If I do the surgery, I know I'll have the option to re-do it later, if necessary," the doctor said.
Cemented vs. "press fit" replacements
Cemented replacements are still done on most older hip replacement patients. Cement creates a firm, almost immediate bond that allows patients to be up and walking very quickly after surgery.
In elderly patients, the cement also provides some added strength to the femur (thigh bone). However, the process does not easily allow a second replacement surgery, which makes cemented replacements a poor choice for younger patients who may wear out the artificial joint. For them, "press fit" replacements are usually a better choice.
Press fit replacements have irregular surfaces on the metal part of the non-cemented implants. "We know that bone grows into an irregular surface and that there are certain chemicals that are biologically active in bones. We use these to coat the implants and the bone just grows right into it," Dr. Stiehl explained.
Since bone growth takes time, the recovery period is longer with press fit replacements and less weight-bearing activity is allowed on the joint in the weeks following surgery.
The surgery
Hip replacements are always inpatient surgery, typically with a five- to seven-day hospital stay. If the new joint was cemented, patients are usually up and walking the second day.
Over the next few days, hospital physical therapists work with patients on self-help skills. Stair climbing is the last skill mastered. They are then released to go home or to a rehabilitation center until they are strong enough to be on their own.
Dr. Stiehl said approximately 70% of his patients go home and 30% go to a rehabilitation center, usually for an additional five to seven days.
Patients who go to a rehabilitation center often do so because they have no one at home to care for them. "What do you do if you are seventy-five and have no family at home? Are you going to be able to take care of yourself? That's the patient who ends up in rehab," Dr. Stiehl explained.
Post-op physical therapy…and life with a new joint
Physical therapy following a hip replacement consists of simple exercises to restore strength to the hip and leg muscles. Patients do these at home, usually two or three times a day.
Patients with office jobs may return to work after three to six weeks, while those with physically demanding professions may not return to work for up to three months after surgery. Most patients are fully recovered at three months.
Precautions still need to be taken, Dr. Stiehl advises. The new artificial joint in place functions somewhat differently from the natural one.
"With hips I worry about stairs and chairs. Going up and down stairs provides a real high torsion to the joint, so patients should always use elevators. I also tell patients they need to always sit in chairs with arms and get up by pushing themselves up."
Why Columbia St. Mary's
"Columbia St. Mary's has the longest history of joint replacement of any hospital in the state. We focus on this type of care. I have used a lot of hospitals in the area, but by far the services at Columbia St. Mary's are the best," Dr. Stiehl said. He added that the Joint Camp has been a huge help in the successful recovery of joint replacement patients.
