Hip resurfacing- about the procedure

Dr.A.K.Venkatachalam
Consultant Orthopedic surgeon
www.hipsurgery.in

Have you been advised a hip replacement?

If yes, please read the following information on facts about the operation and more
advanced bone preserving hip replacement options called Proxima hip replacement
and hip resurfacing.
The hip joint may need to be replaced with an artificial joint when it is irreversibly
damaged and cannot be salvaged by alternate surgery. The patient with hip arthritis
complains of pain and restriction of movement. The pain may often be referred to the
knee or felt in the knee alone and no hip symptoms. Occasionally the pain may be
felt more in the buttock area rather than in front of the groin.

Who needs a hip replacement?

In India, many young patients with ankylosing spondylitis, avascular necrosis, post
septic arthritis, post injury suffer from hip arthritis and are advised a hip replacement
for disabling pain. Thus many hip replacement operations are performed in younger
patients. The surgery should cater to the enhanced demands on an artificial joint by
younger and more active patients. Naturally an operation designed for Western
elderly patients is not suitable for younger patients.

What is a total hip replacement?

In this operation the ball shaped upper end of the thigh bone (femur) and the socket
(acetabulum) are replaced. The ball is replaced with a long metal stem that is fixed
into the upper end if the thigh bone. Its upper spherical end articulates with a cup
shaped polyethylene socket that is cemented into the pelvis. Conventional hip
replacements sacrifice a great deal of normal bone as the head, neck, and upper part
of the thigh bone is removed for implantation of the prosthesis. Moreover wear debris
from the polythetheylene liner lead to osteolysis and bone loss. When this first hip is
to be changed or revised after its lifespan more bone loss occurs. Conventional hips
have a small ball to reduce friction and wear, but the ill effect of this is an increased
risk of dislocation. An average dislocation rate of 3- 4 % has been reported. These
implants do not last very longer than 20 years and revision rates of 50% at 20 years
have been reported. Survival rates are less satisfactory for the relatively younger
active patients. Thus a total hip replacement is not an ideal implant for younger
patients less than fifty years old who need a new hip.

Problems with conventional total hip replacement:

(1) Excessive bone sacrifice and loss
(2) Increased risk of dislocation
(3) Patients cannot squat or sit cross legged on the floor with out the risk of
dislocation.
(4) Range of movement is less
(5) Patients cannot involve in sports
(6) Poor survival in young and active patients they require earlier revision.
(7) Revision surgery is difficult
(8) The hip feels less like a normal hip
(9) The cup wears with time and plastic from it harms bone
(10) Change in length of the leg after surgery leading to leg length discrepancy.

Why remove normal bone when only the surface of the ball is bad?
This is the logic behind hip resurfacings. This bone preserving hip resurfacing
involves replacing only the diseased bony surfaces of the head of femur and
acetabulum. This involves sculpting the head of the femur and covering it with a
metal cap and fixing an uncemented socket into the acetabulum to receive the head.
Hip Resurfacing- A bone preserving hip replacement!
Preservation of bone and less stress shielding makes it easy to revise this hip if
needed. The large head size provides a very stable joint and recreates the sensation
of a normal hip joint. Patients have gone back to playing Judo and Squash after this
operation. Advances metallurgy makes the metal on metal articulation likely to
survive longer in the young and active patient. With less metal inside the bone and
less invasion of the medullary cavity of the femur, the risk of infection is reduced.
Rehabilitation is faster and better.

Advantages of hip resurfacing:

(1) Allows the patient to squat and sit cross legged on the floor safely
(2) Allows a normal range of movement
(3) Sacrifices only the surface diseased bone and preserves normal bone
(4) Imparts a more normal sensation
(5) The joint is likely to last longer even in younger and active patients.
(6) Earlier and faster rehabilitation
(7) less risk of dislocation
(8) Easier to revise if needed.
(9) No leg length discrepancy

some drawbacks of hip resurfacing are

• Inability to increase leg length in shorter limbs
• Inadvisable when there is advanced bone destruction in the head of more than 50%
• Propensity for femoral fracture in 2% of patients
• Metal on metal debris may be a concern in metal allergy and carcinogenicity.

Proxima Hip replacement, Best of both worlds- large diameter head and
stemless stem.

Proxima hip replacement This is the latest addition to the armamentarium of the
hip surgeon in India. It is bone preserving hip replacement. In this operation, the
entire diseased head of the femur is removed. The lining of the hip socket is
resurfaced with a metal cup. A tiny uncemented hip with a short stem called the
Proxima hip is impacted into the upper end of the femur or thigh bone. The size of
the implant matches the natural one and hence the risk of dislocation is almost
eliminated. It is recommended when the bony destruction is advanced and hence
unsuitable for resurfacing and a total hip replacement would be overkill.