Hip Resurfacing

Hip resurfacing provides a more conservative and less traumatic alternative to total hip replacement surgery providing the younger more active patient unmatched quality of life.

Hip resurfacing (HRS) implants have been cleverly engineered to resurface the bone in the hip joint. The head of the femur is resurfaced with a metal dome and the socket is resurfaced with a metal cap. There is no need for the bone to be cut and removed as in a standard hip replacement.

It is particularly relevant to young, active people, people who want to return to high-level activities. There is a much lower rate of wear, and potentially much greater durability.

  1. What is Hip Resurfacing?
  2. Who is suitable for Hip resurfacing surgery?
  3. What are the advantages of Hip resurfacing surgery?
  4. How is the condition diagnosed?
  5. What is involved in the procedure?
  6. What happens after surgery?
  7. What post-operative exercises should I do?
  8. What complications & risks are there?
  9. Estimate of Fees

1What is Hip Resurfacing?

Hip Resurfacing is an artificial joint replacement used for the treatment of severe arthritis as an alternative to conventional Total Hip Replacement.

In hip resurfacing, the femoral head is not removed, but is instead trimmed and capped with a smooth metal covering.

The damaged bone and cartilage within the socket is removed and replaced with a metal shell, just as in a traditional total hip replacement.

2Who is suitable for Hip resurfacing?

Patients who exhibit osteoarthritis on x-ray may not need a total hip replacement to relieve pain and restore function of the hip. The alternative option is hip resurfacing surgery (HRS).

Hip resurfacing has been designed to address patients with mild to moderate osteoarthritis before extensive bone destruction has occurred.

There is a high probability that the pain due to the arthritis itself, the worn bone surfaces, will resolve with a partial hip replacement procedure.

It is important to understand that pain due to other causes such as referred from the back, poor circulation or damaged nerves, other types of information, etc, may continue. At times, it is necessary to understand that only an incremental improvement can be achieved.

In some instances, low-grade, mild pain may persist for a prolonged period of time after joint resurfacing and therefore, this type of joint surgery should be considered only if:

  • Other methods of treatment have been tried, and have failed to help
  • You have debilitating and severe pain with loss of function and loss of quality of life
  • You are emotionally and psychologically prepared for surgery
  • You have understood thoroughly and comprehensively what the operation involves, and that the potential risks to you are outweighed by the potential benefits

3What are the advantages of Hip resurfacing surgery?

With the development of hip surgery many advantages exist compared to the traditional full hip replacement procedures:

    • Ease of Revision

Hip resurfacing removes less bone from the femur than a total hip replacement which means it is usually easier to exchange implants if they fail.

      • Smaller Device

The device is chrome cobalt and molybdenum combination. It is smaller than a traditional total hip device so less of the bone needs to be operated on providing the patient with a rapid, postoperative mobilisation program.

        • Minimal Bone Removal

Hip resurfacing literally means retreading the bone with a metal prosthesis. Therefore, there is a significant decrease in the amount of bone removed. Only a small amount of bone needs to be removed.

          • Decrease in Complication Rates

Hip resurfacing greatly reduces the disruption of the joint therefore providing a shorter recovery period and a decrease in complications. A dramatic reduction of dislocation rates and a reduction to the problem of leg lengthening or shortening.

            • Shorter Recovery Time

Most hip patients are walking 4 hours after surgery. Total time spent in hospital is approximately 1-2 days. Within 2 -3 weeks most patients are back driving, resuming most of their normal activities. Hip resurfacing dramatically improves quality of life.

4How is the condition diagnosed?

The most common and very effective method of diagnosing a hip problem is an X-ray. The X-ray should be performed while you are standing. Most hip problems are worse when you weight bear in the joint, therefore a weight bearing x-ray is an effective diagnostic tool.

The X-ray must show loss of cartilage or deformity of the head of the femur and in the acetabulum for you to be considered for this surgical technique. Next you need a specific and clear description of your pain.

Historically, arthritic pain is dull and annoying and primarily in the joint. It hurts when you are standing and usually goes when you are sitting. Arthritic pain in the hip sometimes migrates into the groin. It also can run down your thigh and into your knee.

5What is involved in the procedure?

Hip resurfacing surgery or retread surgery requires the removal of the worn bone surface only. This means, the bone removed is minimised to 4-5mm from the head of the femur and approx 4-5mm from the acetabulum. The bone surface is then replaced with a metal cover.

Hip resurfacing surgery may be performed as an overnight procedure. This means the nursing/physiotherapy staff on the ward will have you out of bed and walking within 4 hours after the surgery.

The surgery is approximately 2-3 hours of operating time. There is approximately 1 hour in the recovery room after surgery.

The incision is approximately 20 – 30cm in length and it runs over the outer edge of your hip joint. The scar line may not be completely flat immediately after surgery. This will settle down a few weeks after surgery. The operation itself is performed with the patient on their side.

The surgical cut is closed with sutures and at the skin with staples. The staples need to be removed 10-14 days after surgery while the sutures will dissolve. The dressing is designed for compression. This particular dressing stays in place for 48hrs.

Click on the animation below for a step by step guide on the procedure:

6What happens after surgery?

Immediately after surgery, you will wake up in the recovery room. You may feel a bit groggy. Professor Kohan and his staff will monitor you, checking your blood pressure, temperature and pulse. Dr Kerr will also assess your pain level. Post-operative x-rays will be performed in recovery.

After 45 minutes – 1 hour you will then be transferred back to your room on the ward.

When you arrive to your room, you will have:

  • A compression garment around the operation site to apply pressure there. This is removed 24 hrs after surgery.
  • A pain catheter which will be removed before discharge. We inject local anaesthetic through this to maintain the pain relief.
  • TED Stockings (knee high white stockings) on your legs which must be worn for 2 weeks post procedure.
  • A drip in your arm. This will provide hydration and blood if you need it

In the first week following surgery you may experience:

      • Swelling – From your thigh down into your foot is common. This at times may be quite marked. The swelling will increase for the first few days after surgery and will gradually diminish. Some swelling can be present for 12 months or so. The swelling may be diminished by walking as the muscle function will push the fluid away. When you stop walking, the limb should be elevated above the level of the hip.
      • Bruising – Marked bruising can be found in some patients. This can be found from your thigh down into your foot. At times the bruising can be quite dramatic but it will resolve. It is the result of some residual bleeding making its way to the surface. The body will eventually remove the bruising. It is also the result of the blood thinning tablets you will be taking.The blood thinning tablets will tend to make the bleeding after surgery a little more marked because the blood clotting is impaired. This is however preferable to developing a blood clot.
      • Blistering – On occasions blisters will develop near the operation and possibly above it. The blistering is due to surface fluid. It looks dramatic but it is of no consequence and always resolves. One cause may be the bandage rubbing on the skin. Sometimes, when the blood dries in the bandage it can be like cardboard and rub on the skin producing these blisters. We change the bandage after about a week but would prefer not to interfere with that earlier because of the risk of infection. After about a week the wound is sealed enough to be a reasonable barrier against infection. Another cause for the blistering is tissue swelling. This is associated with the bruising and is a result of fluid leaking into the skin. These blisters always go away. They may burst and leak fluid and again the appearance may be dramatic. Sometimes if they are large we may burst them. This is so that the dressings sit more comfortably.
      • Muscle soreness – Your muscles can feel stiff and sore to touch. During the operation some stretching and pulling of the muscles occurs. This may result in some pain like a corked thigh. Occasionally you may feel cramps and spasms. The discomfort however will resolve and activity such as walking, stretching, physiotherapy, etc, will help to speed the improvement.
      • Heat – The operated site may feel hot and the heat may last for 12 months. As part of the healing process the operation site requires more blood supply from the body and it is this extra blood supply which is the cause of the local heat.

For the first 2 weeks after surgery, your activity level is usually limited. However, you will be able to walk independently, use the bathroom and perform normal activities of daily living

After 3 weeks or so you will be able to engage in moderate activities, i.e. driving a car and climbing stairs

Within 6 weeks Hip flexion must still be limited to 90 degrees however you will have resumed most of your normal activities.

Complete surgical healing takes 6 – 8 weeks. During this time some swelling and discomfort is normal, and should be manageable with the prescribed medication.The most important thing is to have a positive attitude.

Restrictions still need to be observed for the first six months after surgery. This is to allow the bone to strengthen around the new hip components and to minimise the risk of hip fracture through excessive loading and activity in this early, vulnerable period.

You should not run or jump in this period, and should not carry more than 10Kg.

Apart from these restrictions you should be able to return to the activities you were able to manage the week before the operation.

PRECAUTIONS

The major precaution following Hip Resurfacing surgery is limiting hip bending for the first 2 – 6 weeks to 90 degrees.

There are four rules of thumb to remember to keep your hip in position:

                • When sitting, keep your knees below your hips (Sitting on a small pillow helps)
                • Avoid crossing your legs while lying down or sitting
                • Avoid bending over at the waist
                • Sit with your knees 10 – 20cm apart

Incision care

The incision is usually closed with skin staples. These need to be removed 10 days after surgery. Sometimes, dissolvable stitches are used, which do not require removal. A decision is made on the basis of local circumstances at the time of the operation.

You may not get the incision wet until the staples are removed; a sponge bathe for 10 days after surgery instead of a shower is recommended.

You may shower 2 days after the sutures are removed, but may not bathe or swim until 2 weeks from surgery.

You may apply Vitamin E or some moisturizing lotion to the incision after the staples, or dressings are removed.

Some swelling and warmth is expected after surgery however if you develop increased redness, oozing from the cut, or fever, please call the office immediately.

Walking

You will be out of bed and walking within 4 hours after surgery. Upon discharge from hospital you will be walking with crutches. You may discontinue using crutches after being assessed by Professor Kohan 1 – 2 weeks after surgery. After this time you may use a cane, or if you feel confident you may discontinue using any walking aids.

You may go up and down stairs as needed, but only straight legged for the first 2 weeks.

After this time there should be enough flexibility and repair in the muscles around your hip.

Expectations

Each individual has his/her own set of expectations. Each patient is treated as an individual with general health, age and attitude considered.

One of the important things to remember is that you are not ‘sick’ but have a problem with your hip that needs to be fixed. Getting back on your feet after surgery is the most important goal: “Motion is Lotion”.

Resurfacing the bones in your hip can relieve your pain and stiffness and return you to most of your activities you enjoy

7What post-operative exercises should I do?

The following exercises should be started on the day following surgery:

Exercises when lying down

1. Move feet up and down in circles 20 times.

2. Pull your feet towards you, and tighten the muscles around the knee.
Hold 5 secs.
Repeat 20 times.
You should feel the backs of your knees pressing against the bed.

3. Tighten your buttock muscles together.
Hold 5 secs.
Repeat 20 times.

4. Place a pillow under your knee, straighten the knee by lifting your foot off the bed.
Hold 5 sec, then slowly lower the foot back to the bed.
Repeat 20 times.
Keep the knee resting on the pillow at all times.

5. Place a slide board or plastic bag under the heel. Lying on your back, slide the heel of the operated leg towards your buttocks, then straighten the leg slowly.
Repeat 20 times.

6. Slide the operated leg out to the side, keep the knee straight and your toes facing the ceiling.
Repeat 20 times.

Exercises when standing up

Begin these exercises as soon as you are able to safely stand holding onto a steady support, such as the back of a chair.

7. Take the operated leg out to the side, keep your toes facing forwards.
Hold 5 secs
Repeat 20 times

8. Bend the hip and knee of the operated leg, hold 5 secs then slowly lower foot back to the floor. Keep your back straight, and avoid leaning backwards.
Repeat 20 times.

9. Keeping the operated hip still, bend your knee so that the heel moves towards the buttocks.
Hold 5 secs.
Repeat 20 times.

10. Lie on your non-operated side with a pillow between the knees. Lift operated leg 2-3 inches and hold 5 secs.
Repeat 20 times.
Make sure the toes do not rotate up or down.

These exercises can be done in groups of 15 repetitions 2 to 3 times per day.

Regular walking is one of the best forms of exercise for your new hip. Walk for as long as you can tolerate.

Follow our advice on using crutches or a cane for balance and support as the hip heals. Since your balance may be off, for the first couple of weeks, use handrails and wear low shoes for your safety. Whether you use crutches, a walking stick, or not, depends on how confident and stable you are.

The most important thing is not to fall. If you feel that you need some extra stability, do continue to use a walking stick or a crutch.

8What complications & risks are there?

As with all surgery there are certain risks and potential complications. Although the incidence of these risk factors is low each patient needs to be informed of the possible complications prior to surgery.

Infection

Infection is uncommon occurring in less than two percent of operations. It is usual for each patient to be given intravenous antibiotics at the time of their joint surgery however, this cannot possibly cover all types of infection which may be encountered. Infection in the postoperative period in most patients is treatable. It may require longer hospitalisation, treatment with antibiotics for a longer period than normal and washout of the joint. In some cases, the implant will be removed to treat the infection before reimplanting a new joint. In rare cases when the infection cannot be treated successfully, a patient may need to have the artificial joint removed permanently. Infection is uncommon and we take precautions to avoid this problem.

Delayed infection has been reported years after joint replacement and appears to be related to the ability of the implants in general, to harbor bacteria transported by the blood stream from other sites of the body. Bladder or kidney infections can be a source but dental abscesses, infected ingrown toe nails, or skin infections may also be a significant danger to a joint implant. Please call the office, or contact your family doctor if infection is suspected in any area.

Please Note: If dental surgery, bladder surgery, bowel surgery or rectal surgery is planned, the physician or dentist should be informed that you have had a joint replacement.

Blood Clots (The medical term for this is Deep Venous Thrombosis)

Another potential risk is the occurrence of blood clot or thrombosis after a joint replacement. Because our patients are mobilised very soon after surgery, this potential risk is small. In addition to early mobilisation patients are treated with calf compressors to prevent Thromboembolic disease (the development of clots in the lower extremities) during surgery. Post surgery TED stockings and low doses of aspirin or other anticoagulation (blood thinners) medications are prescribed depending on the patient’s medical history. In patients without any history of thromboembolic problems we advise taking aspirin, 300 mg per day, for a period of six weeks.

These measures are in place to reduce the risk of forming a clot. In the event the patient is diagnosed with a blood clot intravenous or subcutaneous anticoagulation therapy may be required. Some clots are small and of no clinical significance and so do not require any specific treatment other than the aspirin. This needs to be assessed on a case-by-case basis. If full anticoagulation is required this may mean a longer stay in hospital for the patient.

There is no perfect treatment and while trying to decrease the significant risk of deep vein thrombosis and the possibility of more serious complications such as pulmonary embolism (blood clots breaking off and traveling to the lungs), other potential side effects (such as bleeding) can occur with the drugs used to decrease this complication. These medications require extreme care in their use.

Dislocation

Dislocation of components is a potential risk of joint replacement. Less than 1% of hips however dislocate in the immediate postoperative period. In the vast majority of these cases treatment of this problem requires manipulation of the joint. If unsuccessful in relocating the prosthesis, a second open surgical procedure may be necessary to correct the situation.

Limb length Inequality

Although in standard hip replacements it is possible for the limb length to be altered to a significant extent this is not the case with hip resurfacing. In hip resurfacing only a few millimeters of bone are machined to allow for the seating of the component and so, the potential for limb length inequality is minimal. Almost invariably however, you may feel that the operated limb is several centimetres longer than the preoperative state. This is the result of pelvic tilting and scarring around the hip joint related to the arthritic process. This feeling the limb length inequality gradually diminishes with time and requires no specific treatment.

On occasions the femoral head (the ball of the joint) is deformed and flattened. Restoring it to a round configurations does add to the limb length but only to the extent that the length is restored to the pre-arthritic length.

Nerve Damage

Nerve damage is another potential risk factor when considering joint replacement surgery. The nerves can be traumatised at the time of the operation through stretching and occasionally due to postoperative swelling. Precautions are in place to protect the nerves via superior surgical technique but the risk nevertheless exists for these potential complications to occur. These risk factors are small and are dependant on the age and prior medical condition of the patient.

If nerve damage occurs rest and further examination of the nerve will be required and possible further surgery.

Diabetes, smoking and peripheral vascular disease are also risk factors, as is the presence of previous back problems.

Fracture

Fracture is a potential complication of hip resurfacing. A fracture may occur at the level of the neck of the femur, below the femoral component. The fracture may occur during the operation when the femoral head is being prepared to receive the component or it may occur later, as a result of excessive loading in the postoperative period. We try and minimise the impact of this complication by assessing the strength of the bone before the operation with a bone mineral density investigation and by trying to limit the activity postoperatively.

During the first six months after hip resurfacing we have advised that activities which involve running and jumping be avoided and that any carrying of loads is limited to less than 10 kg. The fractures which have occurred in our patient population have occurred within the first six months.

In looking back over our patient population we have noted that with this treatment program there were no fractures in patients under 65 years of age and in patients over 65 years of age who underwent resurfacing the fracture incidence was about 8%. Some 92% of the patients in this age group went on to recover satisfactorily, and did not fracture.

The type of fracture which is being considered as a complication here is the fracture which occurs spontaneously without any significant trauma having been experienced. Clearly, a situation which involves something like a fall from a roof, a motor vehicle accident or a significant sporting injury (skiing) is another matter. This type injury can cause a fracture at any time, not necessarily in association with a hip resurfacing procedure.

Loosening

Loosening or wearing of the components (plastic, metal and cement fatigue) is another complication of joint surgery. Loosening can occur in one or all components. This may increase in rate with inappropriate use of the prosthesis. Running and jumping should be avoided in the early postoperative period and care taken to avoid carrying heavy loads. The potential risk is approximately 1%. This means it is a gradual process characterised by increasing discomfort. In most cases if the components become loose it can be corrected by another surgical procedure replacing the worn or loose component.

Loss of Motion (Stiffness)

A decrease in motion of a joint is also a potential risk. The joint condition prior to surgery will have some bearing on the movement post surgery. On occasions, excessive bone can form postoperatively that can limit the range of movement. This excessive bone formation cannot be totally predictable but, if it has happened at another joint replacement site the risk is increased.

The risk is also greater in men, and over the age of 70.
Physiotherapy and exercise are encouraged prior to surgery. Post surgery, if the joint remains stiff physiotherapy or manipulation can improve the range of motion in the joint.

Other Complications

Other complications that can occur include; instrument failure and breakage, muscle wasting, artery or vein trauma, drug reactions, implant breakage and loss of income, through prolonged hospitalisation, and a longer than anticipated recovery. These complications are not common however it is important to be aware of potential complications when considering joint surgery.

Metal Ion Release

The metal that is currently used in Australia has been used for over 30 years and worldwide for some 40 years. These implants (prostheses) have been thought to offer a good solution to the problem of arthritis and pain. There has been no problem associated with the use of this metal in patients despite them probably having high ion levels associated with the watery environment of the body (some metal dissolves in the salt water environment of the body). This is an area of some concern and is currently being evaluated more scientifically.

At the present time it is not possible to manufacture a resurfacing prosthesis out of ceramics because the ceramic material is likely to break if manufactured in a thin, bone conserving way. High-density polyethylene (plastic) has been used and wears excessively and does not provide a durable option. At this time metal on metal resurfacing using this particular metal (stainless steel) can be made in a thin and conforming manner with high precision manufacture and appear to be the best that are available for use.

These increased ion levels do not occur in everyone, and do not appear to cause any problems. It is worthwhile to note that people who take vitamins also have elevated serum ions, without any deleterious effect having been documented. It is suggested however, that if you do take vitamins, you take those vitamins which do not provide extra chromium and cobalt. An extensive discussion of this matter, can be found at http://www.activejoints.com/resurfacing.html under the heading of “Proposed Metal Defense Protocol”.

If you have any concerns, which we have not addressed, please bring these up for discussion in consultation with Professor Kohan.

Medical

Medical risks are varied. They can range from minor to more serious complications. These may include cardiovascular, (Heart attack), respiratory, gastrointestinal, neurological (stroke) and genitourinary systems in the body. If a medical complication occurs, it is addressed on an individual basis.

While Orthopaedic surgery carries with it certain risks, it would be safe to say that these risks can be encountered with any surgical procedure. Careful pre-surgical screening and education, a superior surgical technique and a closely monitored postoperative period all add up to minimising the occurrence of any of these complications. It is our conscientious effort to adhere to these criteria whenever a patient is under our care. With this in mind, the potential for a complication to occur is reduced.

9Estimate of Fees?

Generally our ‘Estimate of Fees’ is accurate however, on occasion unforeseen circumstances can arise during the operation which may require additional medical services or a different, more costly prosthetic device to be used. If this happens there may be additional costs to you that are not covered by the estimate.

This will be fully explained to you after the operation should it occur.

Estimate of Fees

          • Aftercare Consultation Fees

There will be 2 ‘no charge’ consultations after your Total Hip Replacement procedure.

Follow-Up Appointments

Aftercare appointments with Professor Kohan following your procedure include:

      • 7 Days Post Surgery – This appointment is in order to check the skin cut & for Professor Kohan to asses your overall recovery.
      • 14 Days Post Surgery – At this appointment the skin clips will be removed. An ultrasound will also be done by our radiographer in the rooms in order for Professor Kohan to check for blood clots.
      • 6 Weeks Post Surgery – At this appointment Professor Kohan will asses the X-ray and monitor your overall recovery.

Consultations after this time attract a fee which is reimbursed in part from Medicare.

      • Professor Kohan’s Surgical Fees

Medical Item No: 49318

      • Surgical Assistant Fees

The surgical assistant fees will either be billed to you directly or Professor Kohan will bill you on his behalf. A Medicare rebate applies:

Medical Item No: 51303

      • Anesthetic Fees

You will meet with Dr Kerr, the anesthetist before your operation so that you can obtain an estimate of his fees. These will be billed to you directly. A Medicare rebate applies:

Medical Item No’s : 17620, 17690, 21214, 23111, 22045, 18225

      • Hospital Fees

These fees should be discussed with the hospital directly. Please be sure to check with your health fund regarding a gap or out of pocket expenses.

      • Prosthetic Fees

If you are privately insured the prosthesis used in a Total Hip Replacement procedure is usually fully covered by your Health fund.

      • Ultrasound Fees

These fees are payable directly to the sonographer.