A TOTAL HIP REPLACEMENT MANUAL

FOR THE PATIENTS OF

JOHN R. MORELAND, M. D.

2001 SANTA MONICA BOULEVARDSUITE 1280W

SANTA MONICA, CALIFORNIAPHONE (310) 453-1911

FAX (310) 453-6902

This booklet is the original work of John R. Moreland, M.D. Dr. Moreland requests that his material not be reproduced without his written permission. Additional booklets can be obtained by calling or writing his office. January 2008.

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WHERE AND WHAT IS THE HIP?..................................................................................6

WHAT MAKES A HIP HURT?.........................................................................................6

WHAT IS ARTHRITIS?....................................................................................................7

WHAT IS OSTEONECROSIS?........................................................................................8

WHAT IS OSTEOPOROSIS?..........................................................................................9

WHERE WILL I FEEL HIP PAIN?...................................................................................9

WHAT ARE THE NON-OPERATIVE TREATMENTS OF HIP ARTHRITIS?................10

WHAT MEDICATIONS ARE USED FOR HIP ARTHRITIS?........................................10

WHAT ABOUT NARCOTICS FOR HIP PAIN?.............................................................12

WHAT ABOUT EXERCISE FOR PEOPLE WITH HIP ARTHRITIS?............................12

WHAT ABOUT STEROID HIP INJECTIONS?..............................................................13

WHAT CAUSES MY LIMP?..........................................................................................13

WHEN SHOULD A CANE BE USED?..........................................................................13

SHOULD I LOSE WEIGHT?..........................................................................................14

WHAT ABOUT OTHER TREATMENTS?.....................................................................14

WHEN SHOULD I HAVE MY HIP REPLACED?...........................................................14

CAN I PUT OFF SURGERY?........................................................................................15

ARE THERE OTHER SURGICAL TREATMENT ALTERNATIVES?...........................16

WHAT IS THE HISTORY OF HIP REPLACEMENT SURGERY?.................................16

WHY IS IT CALLED A TOTAL HIP REPLACEMENT?.................................................17

WHAT ARE THE PROBLEMS WITH CEMENTED HIP REPLACEMENT?..................18

ARE THERE MORE DURABLE ALTERNATIVES?......................................................18

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WHAT ARE THE PROBLEMS WITH CEMENTLESS HIP REPLACEMENTS?...........19

WHAT DETERMINES CHOICE OF TYPE OF FIXATION?...........................................20

WHAT ABOUT THE HYBRID HIP REPLACEMENT?..................................................21

SHOULD THE PATIENT DECIDE IMPLANT TYPE?...................................................22

WHAT ABOUT SURFACE REPLACEMENT?..............................................................22

WHAT ABOUT OTHER NEW TECHNIQUES?.............................................................23

WHAT ARE THE SOME COMPLICATIONS OF HIP REPLACEMENT?......................25

IS WEAR A PROBLEM?...............................................................................................25

WHAT ABOUT HIP DISLOCATION AND SURGICAL APPROACH?.........................27

WHAT ABOUT OTHER POSSIBLE COMPLICATIONS?.............................................28

WHAT ABOUT WRONG SIDE SURGERY?.................................................................30

DOES DR. MORELAND USE THE NEW MINMALLY INVASIVE TECHNIQUES?......30

WHEN WILL FULL WEIGHT BEARING BE ALLOWED?............................................31

WHAT ARE THE SURGICAL APPROACH OPTIONS? 32

WHAT ABOUT BILATERAL SIMULTANEOUS HIP REPLACEMENT?......................34

WILL DR. MORELAND DO THE SURGERY?..............................................................34

INITIAL CONSULTATION WITH DR. MORELAND......................................................35

SURGICAL SCHEDULING............................................................................................35

AUTOLOGOUS BLOOD DONATION...........................................................................35

WHAT SHOULD I AVOID PRIOR TO SURGERY?.......................................................36

THE PREOPERATIVE VISIT.........................................................................................37

WHAT DO I BRING TO THE HOSPITAL?....................................................................37

WHAT HAPPENS THE DAY OF SURGERY?..............................................................38

WHAT ABOUT THE NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES? ....38

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THE HOSPITAL STAY..................................................................................................39

DISCHARGE FROM THE HOSPITAL...........................................................................42

WHAT ABOUT FOLLOW-UP APPOINTMENTS?........................................................43

HOW CAN I PREPARE MY HOME?.............................................................................44

Dr. Moreland's Hip operation Data.................................................................................46

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WHERE AND WHAT IS THE HIP?

In everyday language the buttock area is usually called the hip. In anatomical terms used by physicians, however, the hip is actually the ball and socket joint where the femur (thigh bone) meets the pelvis. The top end of the femur is shaped as a round ball (femoral head) which normally rotates in a shallow cup or socket (acetabulum) formed by the pelvic bones. In a healthy hip, the head of the femur is covered with a layer of a smooth and slippery white substance about one-eighth of an inch thick called articular cartilage. The acetabulum is also lined with this same type of articular cartilage. When the hip joint moves, the cartilage-covered femoral head rotates in the cartilage-lined acetabulum. Articular cartilage has no nerve endings to transmit signals to the brain and thus we are not aware of movement between the two cartilage layers. Little friction is generated and no discomfort is felt. Since cartilage does not stop x-rays and thus does not show up on x-ray film, an x-ray of the hip will normally show about a one-quarter inch space between the bony edge of the femoral head and the bony edge of the socket.

WHAT MAKES A HIP HURT?

In almost all types of hip disease, the articular cartilage has deteriorated and is partially or completely absent. Without the articular cartilage layer, the bone of the femoral head will rub on the acetabular bone of the pelvis. X-rays will then show the femoral bone touching the acetabular bone, since the cartilage layers are absent. This bone-on-bone contact usually causes pain. Early in the course of hip arthritis the cartilage space will narrow and patients usually have mild pain. As the disease process progresses, the bones will gradually move closer together on the x-ray as the cartilage layer is lost. As the bones touch over larger areas, the pain usually will gradually worsen. A hip replacement is just a complicated replacement for the missing cartilage.

The cartilage-covered femoral head can be compared to a man’s head covered with hair. During the process of balding, the man first gets a thinned area of hair, and then the thin area gradually progresses to a small bald spot. Later, the bald spot enlarges. Cartilage loss from the femoral head is similar. At surgery the femoral head usually has large areas devoid of cartilage, but may still have some peripheral cartilage even though the patient has severe symptoms.

Many people are surprised to hear that bones are alive and can hurt. Inside the calcium crystalline structure of bone are nerve cells, which can transmit pain signals to the brain when the bones touch. In addition, this bone-on-bone touching often flattens the femoral head by grinding away some of the bone surface and releasing bone and cartilage fragments to the joint cavity. These released fragments irritate the lining of the joint (synovium) and cause a painful inflammation of the joint lining (synovitis).

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At times patients can even hear a creaking noise (crepitation) coming from the hip caused by the bone-on-bone contact. The bone surfaces often become highly polished and harder from this repetitive rubbing. The body often attempts to heal the diseased joint by forming extra bone at the edges of the joint. These extra bone formations can be seen on the x-ray and are called spurs, or more scientifically, osteophytes.

As the cartilage layer wears out, normal hip flexibility is often decreased by various mechanisms (pain, high friction, lack of head roundness, osteophyte formation and muscle stiffness). This lack of normal hip flexibility can make it difficult to position the legs when bending over for tasks such as tying shoes or cutting toenails. Many patients with hip stiffness cannot separate their legs very well, making sexual intercourse difficult for women. Horseback riding also is commonly uncomfortable, if not impossible. Stiffness can even be so severe as to interfere with personal hygiene.

The hip stiffness can make standing up straight difficult and this stiffness may aggravate back problems, since extra back movement is needed to compensate for the lack of hip flexibility. Hip stiffness can cause an exaggerated curvature in the lower back called (hyperlordosis) and can cause spinal curvature (scoliosis). Hip stiffness also can cause the pelvis to be held in a tilted position, resulting in extra stress on the lumbar spine and making the leg lengths functionally unequal.

WHAT IS ARTHRITIS?

Joint pain is called arthritis (arthr means joint and itis means inflammation). Thus, patients with arthritis simply have at least one joint causing pain. There are many types of hip arthritis. The most common type is called primary osteoarthritis, which results from wearing out the articular cartilage of the joint for no identifiable reason. Secondary osteoarthritis is that due to an identifiable cause. Secondary osteoarthritis can be due to an old hip injury, to conditions with which one is born, such as developmental dysplasia of the hip (DDH: a problem of shallow sockets, usually in women), to conditions that develop during childhood such as slipped capital femoral epiphysis (SCFE-usually in boys ages 10-13) and Legg-Calve-Perthes disease (LCP: usually in boys ages 3-9), or to arthrocatydesis (Otto pelvis: a condition usually in young women with extra-deep sockets and usually causing more hip stiffness than pain). The tendency for the hips to wear out during a patient’s lifetime runs in families.

Rheumatoid arthritis (RA) is another frequent cause of hip deterioration. The inflammation of rheumatoid arthritis is a generalized rather than a localized condition, usually affecting many joints in the body as well as causing a general ill feeling. The severity of rheumatoid arthritis is variable and most RA patients are under the regular care of a rheumatologist (an internal medicine doctor specially trained in diseases which cause joint problems but who does not do surgery). Rheumatologists and orthopedists often work together in the care of patients with RA. Certain powerful drugs such as gold, methotrexate, penicillamine and prednisone are often used by the rheumatologist to control the joint pain and swelling. Patients, who take the steroid drug, prednisone, need extra amounts of steroid during the surgical period. All these powerful drugs have the potential for significant side effects and require regular follow-up with the rheumatologist. Over the last several years, some new and quite effective drugs to combat rheumatoid arthritis have come on the market.

RA is probably an autoimmune disease (a disorder of the immune system in which the patient’s tissues come under attack by the patient’s own immune system). Patients with RA

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sometimes develop deterioration of the neck bones causing spinal instability and have an increased risk of spinal cord damage during any general anesthesia. Neck stability x-rays before surgery and special anesthesia techniques may be necessary. Patients with RA also sometimes have arthritis of the jaw joint (temporomandibular joint) causing difficulty in opening the mouth wide enough for the usual anesthesia techniques. Special anesthesia equipment and techniques may be needed for such patients.

Children can get a variation of RA called juvenile rheumatoid arthritis (JRA). These children suffer joint inflammation and resultant damage during childhood and may need hip replacement even as a child but more commonly when they become adults.

Ankylosing spondylitis (AS) is another type of inflammatory arthritis that can damage the hips. Ankylosing spondylitis usually affects men. Patients suffer stiffening of the back and neck, making it difficult sometimes to see straight ahead. The neck stiffness of AS can make the job of the anesthesiologist difficult and special anesthetic techniques and instrumentation may be necessary.

Other inflammatory conditions such as systemic lupus erythematosis (SLE or lupus), psoriatic arthritis, and inflammatory bowel arthritis can also cause hip disease.

WHAT IS OSTEONECROSIS?

Osteonecrosis is a condition in which parts of the femoral head die (osteo means bone and necrosis means death). If extensive, the dead bone cannot stand up to the stress of walking and the femoral head loses its roundness, resulting in pain. The most common causes of osteonecrosis (also called aseptic necrosis and ischemic necrosis) are oral steroid intake (such as prednisone), excessive alcohol intake and trauma. Other causes are hyperuricemia, systemic lupus erythematosis (SLE), sickle cell syndrome, Gaucher’s disease, pancreatitis, pregnancy, liver disease, the bends, caisson disease, polycythemia, diabetes, obesity, and hyperlipidemia. Sometimes, no reason can be found for osteonecrosis (idiopathic osteonecrosis).

It is helpful to understand osteonecrosis by using the analogy of a building. Buildings are dead but the people inside are alive and maintain the building. Window breakage is repaired and roof leaks are fixed as these problems occur. Without such maintenance, buildings will decay and eventually fall down. The calcium crystal structure of the femoral head is not alive but the tiny bone cells in the bone are. These bone cells maintain the bones just as humans maintain buildings. When a portion of a bone dies, what really happens is bone cell death. Without bone maintenance the bone structure usually deteriorates in a year or two. Thus, there is usually a delay between bone death and the onset of symptoms.

Very early in the problem of osteonecrosis when the femoral head is still round, a procedure called core decompression is sometimes performed in which a hole is drilled up into the femoral head to decrease an abnormally elevated pressure in the femoral head. This treatment may relieve pain as well as allow blood supply to return to the femoral head. Core decompression is controversial and is not universally accepted by orthopedic surgeons as a valid treatment.

When the femoral head loses its roundness from osteonecrosis, the usual treatment is hip replacement, if the symptoms are sufficiently severe. Rarely, surgery is performed in which the

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bones are purposely broken (osteotomy) and their position rearranged to take advantage of those portions of the femoral ball which are still intact.

Bone grafting is also sometimes used for osteonecrosis. Bone from cadavers or from other parts of the patient’s body (usually the fibula) is placed in the femoral head through a hole drilled into the femoral head. This highly complex, technically difficult, and long (six to eight hours) surgical technique is rarely performed. It involves placing a piece of the fibula with its blood vessels into the femoral head with the blood vessels then connected to hip area blood vessels. This procedure, developed at Duke University, is not generally accepted by the orthopedic community and is considered unproven and experimental.

WHAT IS OSTEOPOROSIS?

The terms osteoporosis (literally “porous bone”) and osteoarthritis are often confused. Osteoarthritis, as explained above, is a problem with a joint. Osteoporosis is a condition of soft bones. Osteoarthritis involves pain coming from the joints. Osteoporosis does not hurt unless the softened bones fracture, as they frequently do if the osteoporosis becomes severe.

WHERE WILL I FEEL HIP PAIN?

Pain from the hip joint is usually felt in the groin (in the front of the body where the thigh joins the torso). The pain often radiates down the front of the thigh to the knee and sometimes to the mid-shin. Pain, which is perceived in areas of the body remote from the actual problem, is termed referred pain. You may be aware that referred pain from the heart is usually felt in the left side of the neck and in the left arm, and referred pain from the diaphragm is felt in the shoulder. The referred pain of the hip to the anterior thigh and knee occurs because the nerve root supply to the hip and the anterior thigh and knee are the same. In some cases, the referred pain to the knee area is so prominent that the patient, and sometimes even the physician, thinks the knee itself is diseased, when really the hip is the problem.

Lower back pain is often confused with hip disease. Pain from the spine is usually felt across the low back, in the buttock, down the back of the thigh, and often down to the foot. Pain radiating in these areas from the spine is called sciatica. Sciatica is often accompanied by numbness and tingling, whereas hip pain is not. Most pain felt in the back of the body in the buttock area is coming from the spine. Most pain felt in the front of the body in the groin and in the front part of the thigh is coming from the hip. Patients often expect the hip to cause pain in the buttock, but buttock pain is usually coming from the low back or the sacroiliac joint. The buttock is not the anatomical hip, although the buttock is usually referred to as the hip in everyday language. Patients with hip problems also often have lower back pain since the accompanying hip stiffness puts extra stress on the spine and since back pain, even without hip arthritis, is very common.

This confusion of hip problems with back and knee problems often obscures and delays the diagnosis of hip disease. Sometimes back or knee operations are tragically done by mistake for patients when the real problem is the hip.

Another disease entity often confused with hip arthritis is greater trochanteric bursitis. This is an inflammation of the soft tissues just superficial to the greater trochanter (the bump of bone in the area of your hip on which you lie when you are on your side). Patients notice pain (often burning in character) and tenderness over the greater trochanter. Pain can radiate down the

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outside of the thigh. Patients can develop a painful and sometimes audible snap or pop over the greater trochanter with certain movements. Trochanteric bursitis is seen most frequently in young adult women. Treatment is usually with NSAIDS, steroid injections and education. Patients often see several physicians before this problem is correctly diagnosed.

It is, of course, possible to be bothered by back pain, hip arthritis pain, and trochanteric bursitis pain all at the same time, and deciding which is the main problem can be difficult. Fixing an arthritic hip with a total hip replacement often helps the commonly accompanying back pain. Back surgery, on the other hand, will not help an arthritic hip and, in fact, the failure rate of back surgery (already higher than hip surgery) is increased further for patients who also have an arthritic hip. Thus, patients with an arthritic hip and a bad back are almost always better off having the hip replaced before having back surgery. In many instances, the best way to relieve back pain in a patient with hip arthritis is to replace the hip.

WHAT ARE THE NON-OPERATIVE TREATMENTS OF HIP ARTHRITIS?

The hip is the most important joint of the body for walking and thus, a person with hip pain has a very serious disability. The more a patient with hip arthritis walks, the more the hip will usually hurt. Often the first one or two steps after prolonged sitting or lying down may be particularly painful. We call this start-up pain. Patients can minimize hip pain by simply decreasing life’s activities: the elevator can be used rather than walking stairs, lifting can be minimized, the patient can allow the car driver to let him or her out at the front of destinations and all long walks can be avoided. Running and playing vigorous sports such as tennis will almost always significantly increase the discomfort.

All exercise involving an arthritic hip joint can increase hip inflammation and consequently, aggravate hip pain. Remember that exercise strengthens muscles but at the same time puts increased stress on the joints. Many people assume incorrectly that the more exercise the better. Exercise may help if you have significant muscle weakness, but the more exercise the better is actually not good advice for an arthritic hip. Actually, rest is the most dramatic way of decreasing hip pain, since rest will decrease the hip inflammation and thus give pain relief. You may have noticed that if you are not active for a few days, the hip pain is a lot less and if you become very active for a period of time, you may have pain at the end of the vigorous activity or increased pain for the next few days. A sedentary life, besides being inconvenient, can lead to a decrease in muscle and bone strength as well as depress your morale, which sometimes results in a significant loss of interest in life’s activities.

As you probably know, the State of California provides special handicapped parking for people with difficulty walking. Ask our office personnel if you qualify and we will help you submit the proper forms for this.

WHAT MEDICATIONS ARE USED FOR HIP ARTHRITIS?

A large group of drugs called non-steroidal anti-inflammatory drugs (NSAIDS) can decrease the inflammation that develops around an arthritic hip and lessen the pain. These drugs do not slow the progression of hip arthritis (nothing really does). No particular one of these NSAIDS has been proven to give better pain relief than the others, but individuals sometimes respond

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better to a certain NSAID. Hence, your physician may try you on several of these NSAIDS in an effort to find the one that suits you best. Periodically, new NSAIDS are introduced to the market, often with a great fanfare of publicity. So far, none of these drugs have demonstrated definite superiority. Some, such as Vioxx and Bextra, have been withdrawn from the market when unforeseen serious side effects occurred with widespread use. It is probably better to avoid new drugs until safety and effectiveness are well established.

The three most common NSAIDS are (Advil, Nuprin, and Motrin) and naproxen. They have the advantage of being inexpensive and available without prescription (over-the-counter drugs). Aspirin and ibuprofen both require frequent dosing. Naproxen (Aleve) has the advantage of less frequent dosing.

Most prescription NSAIDS also have the advantage of less frequent dosing but the disadvantage of increased cost and, of course, require a prescription. All of the NSAIDS commonly cause stomach upset and have potential for other side effects such as kidney, liver, heart, and bone marrow damage. The best-tolerated form of aspirin is probably Ecotrin (a coated aspirin tablet which protects the stomach by dissolving in the small intestine). All NSAIDS should be taken with food. Cytotec, Zantac, Tagamet, Pepcid, Nexium, Prevacid and Prilosec are sometimes given with NSAIDS to help the stomach tolerate the NSAIDS. These drugs decrease the amount of acid produced by the stomach.

When used in large doses for long periods, NSAIDS require periodic blood tests to detect possible side effects. If you take NSAIDS this way, your internist or family physician should monitor your NSAID intake with periodic blood tests. The side effects of NSAIDS are usually reversible if the problem is detected and the medication stopped in time. Your internist or family physician should always be notified if you are regularly taking moderate or large doses of NSAIDS. NSAIDS can interact negatively with multiple other medications that you may also be taking, so always first clear NSAIDS intake with your medical physician.

NSAIDS are not narcotics and are not habit forming, nor do patients develop a tolerance for these drugs, which would make them less effective with time. Still, patients often report decreased effectiveness of their NSAID with time. The reason for this is that the disease process has progressed causing greater pain rather than that the patient has developed drug tolerance.

Side effects of NSAIDS depend mostly on the daily dosage. Higher doses are more likely to be effective but also are more likely to cause problems such as stomach upset and kidney damage. In the elderly, side effects are more frequent. For these reasons Dr. Moreland rarely recommends NSAIDS in the usual prescription doses. He prefers low dose NSAIDS and usually recommends the over-the-counter doses of ibuprofen (Advil: up to six tablets per day) and naproxen (Aleve: up to two per day) since these low doses are effective as well as safer and more economical.

The newest NSAIDS are Celebrex (celecoxib), Bextra (valdecoxib), and Vioxx (rifecoxib). They are from a new class of NSAIDS called COX-2 inhibitors. These new drugs were supposed to have fewer side effects than regular NSAIDS, but did not claim to give better pain relief. Vioxx and Bextra have been taken off the market because of associated heart problems. Those who cannot tolerate the other NSAIDS may be able to tolerate Celebrex. It is more expensive than older NSAIDS and may cause heart problems also. Unlike the older NSAIDS, Celebrex does not cause increased bleeding and, thus, does not have to be stopped during the surgical

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period. In some situations the Celebrex can be used to help with immediate postoperative pain. Recently, the FDA has warned that all NSAIDS may cause heart problems.

Acetaminophen (Tylenol) is not an NSAID. It is a pain reliever but not an anti-inflammatory. It does not share with the NSAIDS their possible side effects. Pain can often be helped significantly with Tylenol and patients may usually safely take six or eight a day. Large doses of acetaminophen have occasionally been associated with liver toxicity, particularly in patients who drink large amounts of alcohol. Acetaminophen can be used to supplement the pain relief of the NSAIDS (acetaminophen and NSAIDS can be taken at the same time). A good over-the-counter regimen for arthritis pain is two Tylenol and two Advil with each meal.

WHAT ABOUT NARCOTICS FOR HIP PAIN?

Patients with sleep-disturbing hip pain can sometimes benefit from low doses of mild narcotics such as Tylenol (acetaminophen) with codeine (Tylenol #3), Vicodin (hydrocodone with acetaminophen), Darvocet (propoxyphene with acetaminophen), Darvon compound (propoxyphene with aspirin) and plain Darvon (propoxyphene). These drugs are habit forming, have the potential for physical and psychological dependence and, like all narcotics, lose their effectiveness when used regularly. Thus, patients should carefully limit their intake of such drugs to no more than one or two a day to maintain the effectiveness and to decrease the risk of addiction. All narcotics tend to cause constipation and stool softeners can help prevent this problem. Low dose narcotic use at night, when sleep is disturbed by hip pain, is relatively safe. Day use is less desirable, since mental alertness is decreased. Operating machinery or driving a car under the influence of a narcotic should not be done.

The stronger narcotics such as Percodan (oxycodone with aspirin), Percocet (oxycodone with acetaminophen), Dilaudid (hydromorphone), Oxycontin (a long acting and very highly addictive narcotic), Demerol (meperidine) and morphine are almost never indicated for chronic hip pain because of their strong potential for addiction. All narcotics become gradually less effective when taken for long periods and thus higher and higher doses will be gradually required in order to continue to get pain relief. The patient then will develop another problem: narcotic addiction. If the narcotics are stopped or decreased in addicted patients, unpleasant withdrawal symptoms will develop. In most hip pain circumstances it is better to have hip replacement rather than to become addicted to large doses of narcotics. Dr. Moreland believes that some “Pain” physicians today seem too quick to give patients high doses of powerful narcotics for hip arthritis pain and thus create unnecessary and unpleasant addiction in their patients. The management of postoperative pain in heavily addicted patients is complicated, since such patients do not get pain relief with ordinary narcotic doses.

WHAT ABOUT EXERCISE FOR PEOPLE WITH HIP ARTHRITIS?

Patients with hip disease, like everyone, need to exercise for general cardiovascular fitness. Jogging and other exercises resulting in impact loading of the hip will probably cause an increase in the hip pain and are usually best avoided. The best exercise to maintain cardiovascular fitness for people with hip disease is swimming, since the buoyancy of the water minimizes the stress on the hip. Bicycling (road bikes or stationary bikes), the elliptical machine, and gym stair climbers are also better tolerated than running. The treadmill is

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intermediate in stressing the hip and many people can tolerate this since there are usually handrails, but again, the exercise bicycle will probably give more cardiovascular exercise with less hip pain. After experimentation each patient usually becomes the best judge of what can be done with an acceptable level of discomfort.

Activity is unlikely to cause deterioration of the hip to a degree that the damage cannot be fixed later by hip replacement, so remain as active as your hip allows. Think of activity as irritating your hip, not as damaging your hip. Inactivity can damage the rest of your body since activity is needed to properly maintain your muscles and bones, your cardiovascular system and your mental health.

WHAT ABOUT STEROID HIP INJECTIONS?

Occasionally, physicians inject steroids (cortisone) directly into the hip joint to decrease the inflammation and thus the pain. It is difficult, however, to get the drug always in the hip joint cavity since the joint is deep and the capsule is tight. The process of injecting this medicine can be uncomfortable for the patient and there is a small risk of introducing an infection. Steroid injections do not really treat the cause of the pain. They simply make the hip hurt less. Steroids do not always help the pain and the improvement is always only temporary. Because of these problems, Dr. Moreland does not encourage this treatment for the hip.

When the patient must have temporary pain relief and surgery cannot be done for some reason, steroid injections can have a place. To insure correct placement of the steroid with maximum safety and minimum discomfort, Dr. Moreland will arrange for a radiologist to do the injection under x-ray control.

WHAT CAUSES MY LIMP?

Most patients with significant hip disease have a limp and it is common for the patient to think that the reason for the limp is shortness of the extremity. Sometimes, the extremity actually is short, but the limp is usually due to the pain. In fact, when patients limp from a painful hip they are usually limping because it lessens the pain. The reason it hurts less is that the limping way of walking allows the patient to contract the hip muscles with less force. This results in less hip pain but causes an awkward and inefficient gait. Many patients with early hip disease recognize this and note that they can walk without a limp; but that doing so causes more pain and that it is easier and more comfortable to limp. With time and the lack of use of certain hip muscles, weakness results and the limp is then due to the weakness as well as the pain.

Sometimes with hip disease, leg shortening occurs from the bones getting closer together as the cartilage wears out. This slight shortening is actually helpful for the patient, since it is easier to walk with a painful hip if that extremity is a little shorter. One way of thinking about this is to realize that the short leg is walking downhill all the time and the long leg is walking uphill. The short leg, therefore, has to put out less effort. If the short leg is the painful leg, the patient is better off leaving the painful leg short and not using a shoe lift. If the painful leg happens to be the long leg, then shoe lifts can take some of the pressure off the painful extremity. Dr. Moreland can advise you on the usage of lifts during your examination.

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WHEN SHOULD A CANE BE USED?

When the symptoms worsen to a significant degree, a cane is usually very helpful to patients with hip problems. The cane should usually be carried in the hand opposite the side that has the hip disease. Special platform canes may be useful for people whose hand problems limit their ability to push on a cane. Patients with rheumatoid arthritis often have this problem. The Horton and Converse pharmacy on the first floor of our building has a wide selection of canes. There are foldable canes that will fit in a large purse or a briefcase. The cane then can be readily available if unexpected long distance walking is required. The cane should be the right height (usually such that the elbow is bent about 20 degrees) and, thus, an adjustable cane is convenient. We can help you adjust your cane length and instruct you in its use. Most patients find the cane useful when going outdoors and for long walks (such as shopping malls, airports, amusement parks and foreign travel). Since the cane gives tremendous mechanical advantage when used in the opposite hand, just a little hand pressure will relieve a lot of hip pain and control the limp.

SHOULD I LOSE WEIGHT?

Extra weight will aggravate hip pain. Weight loss will make you more comfortable, but is unlikely to relieve the pain completely. One pound of weight loss decreases hip stress by three pounds, since the muscles then have to contract with less force and it is the muscle contraction that contributes to most of the hip stress. Obesity also makes surgical treatment technically more difficult for the surgeon and increases the risk of surgical complications for the patient. It is more difficult with the extra weight for patients to walk on crutches during the healing period and to move around in bed. This increased risk is rarely of a degree to make replacement not possible. While weight loss is desirable, we rarely insist upon weight loss before surgery, recognizing the well-known difficulty of weight loss, particularly when compounded by the enforced sedentary lifestyle resulting from the hip pain.

WHAT ABOUT OTHER TREATMENTS?

Massage, acupuncture, acupressure, ultrasound, diet, vitamins, minerals, magnets, Chinese herbs, copper bracelets, hypnosis, TENS unit, special physical therapy techniques, water therapy and many other treatment methods are occasionally used. At times some of these can alleviate the pain but cannot correct the basic arthritic condition. Hip pain is often episodic. A lot of activity will often cause a delayed increase in pain from the inflammation stirred up by the activity. With rest, NSAIDS, and inactivity the pain may completely resolve for a while with or without other treatment. This episodic nature of hip pain often confuses patients when they try to evaluate the effectiveness of various activities and treatments.

Health food stores have marketed shark cartilage for arthritis. There are no scientific studies supporting shark cartilage use for arthritis. Dr. Moreland has seen many patients who have taken shark cartilage. Few have reported any benefit and Dr. Moreland does not recommend shark cartilage.

By far the most popular health food store supplements for arthritis recently have been glucosamine and chondroitin sulfate, which are usually taken together. Occasionally, patients have reported some symptomatic relief but most patients report no effect. Definitely, we have not seen any repair of arthritis damage or slowing of arthritis progression with use of these

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preparations and there is no good scientific evidence of such benefits. Dr. Moreland does not recommend these health food store supplements or any others. On the other hand, worrisome side effects have not been reported with glucosamine and chondroitin sulfate.

WHEN SHOULD I HAVE MY HIP REPLACED?

The decision to have a hip replacement is up to the patient. Hip replacement can commonly be avoided as long as the patient is willing to put up with the pain and the disability. In fact, most patients, if determined, can put up with one bad hip indefinitely, since the good side can do most of the work. Patients with deterioration of both hips often are under more pressure for surgery, since such patients literally do not have a good leg to stand on. Since hip replacement surgery involves some risk, expense, several months of recovery and a temporary increase in pain from the surgical procedure and may still not be a permanent solution, surgery should not be undertaken unless the symptoms are significant and persistent. If your hip disease is so bad that you cannot get around without a wheelchair or two crutches or are even bedridden, then most orthopedists would urge hip replacement, assuming you are physically fit enough to undertake the surgery. If you can walk without a cane or crutch for long distances with minimal limp or pain and do not have any sleep disturbance, your symptoms are probably not severe enough to proceed with replacement.

Most patients have their hip replaced when they experience significant and persistent pain, need a cane at least part of the time, are having sleep disturbance, and are regularly taking non-steroidal anti-inflammatory medications (NSAIDS), assuming such drugs can be tolerated. If your hip is making life miserable, a replacement is usually a reasonable alternative to putting up with the pain and disability. If the hip problem is only a minor and occasional bother, non-operative treatments are probably more reasonable than surgery. The decision to have surgery should be based on information acquired from the orthopedist, the family physician, and possibly second opinions. The final decision is always the patient’s. Most patients have hip replacement when the thought of having hip replacement surgery sounds better than putting up with the pain and disability of the arthritic hip. We hope this hip booklet will give patients the information needed about hip replacement to make that decision. There is almost never any urgency for replacement of the hip unless the pain is severe.

Patients who have only one painful and stiff hip can usually get by with a sedentary lifestyle by avoiding airports, amusement parks, malls, and travel. The desire to have a more active lifestyle can force surgery at an earlier stage. Many patients find that just at retirement age when they finally have the time to travel and enjoy the world, an arthritic hip can make these activities difficult, if not impossible. With a hip replacement the patient’s world can be expanded and the retirement years can be more active.

Since introduced in the United States about 1969, hip replacement has gradually been improved. In the early years there were problems with short term complications, long term durability, and a long and uncomfortable recovery period. On all three issues there has been tremendous progress. Today in the hands of an expert surgeon operating in a good hospital with competent medical personnel, patients should expect extremely high short term success rates as well as a shorter and more comfortable recovery period. Modern prostheses promise durability that probably will exceed most patients’ life span. Durability has been so increased that patients now are given almost no activity limitations. Patients with modern hip

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replacements can do many very vigorous activities such as tennis, skiing, volleyball, handball, racquetball, etc. with little increased risk to the longevity of their hip replacements. Hip replacement today is truly a medical miracle.

CAN I PUT OFF SURGERY?

There are some advantages to putting off surgery. Progress in hip replacement surgery continues. Thus, if you wait five to ten years, the technology available should be better than what we have currently. If you wait, you will get older and thus need the replaced hip for a shorter period of time. This is important since the major problem with hip replacements has been durability, since loosening and wear occur occasionally. That said, the technology of hip replacement today is so advanced that there is little reason to wait for further improvements. Hip replacement is one of the best, if not the best, elective operations surgeons have to offer.

The disadvantages of waiting are the discomfort and disability, the possible loss of muscle and bone strength from inactivity and the decreased mental and physical vigor from the disease-enforced low activity lifestyle.

Do not worry that the hip deterioration will get so bad that it cannot be fixed or the chances of surgical success will be less later. Such deterioration rarely occurs. Do not worry that you will damage the other surrounding joints (such as your back, knees, or other hip). While the extra stress on these joints may irritate these areas, it is unlikely damage will occur. Also do not worry you will get too old or too sick to have surgery later. It is very rare for a patient who needs surgery to be too old or too sick to have it done. If you are too sick, usually you are so inactive that surgery is not needed. The only valid reason to have hip replacement is a hip that is giving you persistent and significant pain and disability resulting in a miserable lifestyle.

ARE THERE OTHER SURGICAL TREATMENT ALTERNATIVES?

Hip disease can be treated by other surgical methods besides hip replacement. One alternative is hip fusion (arthrodesis). This is a procedure in which the femoral bone is made to attach to the pelvic bone resulting in permanent and complete stiffness of the hip joint. The lost mobility of the fused extremity is partially compensated for by the mobility of the spine and the knee. Arthrodesis is rarely performed today because most patients will not accept this hip stiffness. It makes both sitting and standing awkward, and activities involving reaching down to the foot are quite difficult. Occasionally, hip fusion is recommended for young people who need to do vigorous labor. Because a stiff hip puts extra stress on the spine and the knee, it is common for patients to develop pain and arthritis in these joints as the result of a stiff hip. One concept is to eventually do a hip replacement for a fused hip when the patient is older. This problem of extra stress on the spine and the knee requires the patient to have a normal spine, normal knees and a normal hip on the other side for a hip fusion to be seriously considered. Hip fusion is very rarely done today.

Another alternative is termed osteotomy of the pelvic or femoral bone. An osteotomy is a procedure in which the bone of the femur or the pelvis, or both, is cut, and the bones are then placed in a new and different position and then the bones are allowed to heal in this new position. This results in a redirection of the hip forces in a new and, it is hoped, less painful and more durable direction. Osteotomies of the hip are much more popular in Europe than in

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America. Osteotomies require longer recuperation and the results are less predictable than hip replacement. Patients with shallow sockets from DDH (developmental dysplasia of the hip) are often candidates for this operation but the improved reliability of hip replacement today has decreased the need for this operation.

WHAT IS THE HISTORY OF HIP REPLACEMENT SURGERY?

In 1962 Sir John Charnley, an English orthopedist who was knighted by the Queen of England for his hip replacement contributions, put together the key ingredients of the modern hip replacement. Charnley’s operation involves removal of the bony femoral head and replacing this with a smaller metal ball which is attached to a stem which fits into the femur (the thigh bone). The femur is basically hollow in its mid-portion and ordinarily there is some bone marrow in this area. This hollow area is where the stem of the prosthesis is placed. The bone marrow that is removed from that area is not needed. The prosthesis itself must be fixed to the femur, since movement between the prosthesis and the bone causes pain. In Charnley’s operation it is fixed with plastic cement called methylmethacrylate, which is the same chemical compound as Plexiglass and was first developed for human use by dentists. The bony socket surface is also replaced by a plastic socket fixed into place in the bony socket, also with the methylmethacrylate cement. This cement acts as a grout similar to tile grout and should not be considered glue. Cement comes unmixed with powder and liquid components which are mixed together until a dough-like consistency is reached. This dough is then pressed into the bone and the prosthesis is pressed into the dough. The cement then hardens over ten to fifteen minutes into a stone-like consistency. After the hip replacement is assembled, the metal ball will move around in the plastic socket and transmit the force across the hip joint. Since the femoral bone is no longer rubbing on the pelvic bone, the patient gets pain relief. The plastic socket is made of ultra-high molecular weight polyethylene, which has little frictional resistance against the metal ball.

Wear of hip replacements has always been a problem. In the 1950’s Charnley used Teflon as the plastic in his hip replacements and had great short term success, only to be disappointed when many operations failed because of rapid wear of the Teflon. The modern era of hip replacement dates to 1962 when Charnley started using ultra-high molecular weight polyethylene which has a dramatically lower wear rate than Teflon. See the section entitled “IS WEAR A PROBLEM?” on page 25 for more information on wear.

Charnley-type total hip replacements were introduced in the United States about 1969. Hip replacement operations have become routine (over 300,000 hip replacements are done in the U.S. annually) and are considered successful a very high percentage of the time.

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WHY IS IT CALLED A TOTAL HIP REPLACEMENT?

The term total hip replacement is commonly used by orthopedists but is actually not a good name for the procedure, since it sounds more radical than the actual operation. A joint is an area of the body where two bones come together. Orthopedists refer to each bone as being a separate side of the joint. Thus, the hip joint has the acetabular side and the femoral head side. Surgery done on only one of the two bones, leaving the other bone unchanged, is called a hemiarthroplasty. Hemi means half and arthroplasty means an operation to make a joint

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better. Hemiarthroplasties of the hip are commonly done for patients with fractures of the hip. The hip usually breaks just below the ball or head of the femur in the narrowed area of the bone called the neck of the femur. Since fractures of that area commonly disrupt the blood supply to the femoral ball, surgeons often replace the bony ball with a large metal ball that is attached to a stem fixed inside the femoral canal often with cement. The acetabular bone is actually not changed in this operation. The big metal ball is large enough and of the appropriate size to fit in the original bony acetabulum.

When hip replacements began to be done and both bones were operated on, the term total hip replacement was coined and has come into common usage in the United States. In fact, Charnley referred to his operation as the low friction arthroplasty and in England a hip replacement is still referred to as a low friction arthroplasty. Charnley liked this term, since it was his original concept that hip replacements should have low friction. He felt, and was probably right, that a small ball rubbing around in a polyethylene socket gave low frictional resistance and that this was critically important for the hip to do well.

Since hip fractures are very common, many thousands of hemiarthroplasties are performed for hip fractures. The hemiarthroplasty operation takes less time than a total hip replacement and has less blood loss. Patients with a broken hip have extreme pain but with a hemiarthroplasty are usually able to get out of bed and resume their daily functions. On the other hand, the pain relief from hemiarthroplasties is often less complete and less consistent than one gets with a total hip replacement. Patients with pain from a hemiarthroplasty usually have pain in the groin associated with activity. If patients have persistent and significant pain, some may require conversion to a total hip replacement.

WHAT ARE THE PROBLEMS WITH CEMENTED HIP REPLACEMENT?

The major long-term problem with the Charnley type cemented hip replacement is the potential for development of loosening of the attachment of the plastic cement to the bone. With loosening, the prosthesis then moves in a gradually increasing degree with respect to the bone. This movement causes irritation to the bone, can cause bone loss, and results in a pain similar to pain with an arthritic hip. Pain from an arthritic hip is caused by the bone-on-bone contact. What a hip replacement does is keep the bones from touching, with the movement occurring only between the two pieces of the hip replacement: the ball moving around in the socket. The key to making a hip replacement painless is no movement of the hip replacement components with respect to the bone. The components themselves must be securely fixed to the bone. If there is movement between the component and the bone, irritation of the bone will occur with resultant pain.

If the pain or bone loss from loosening is severe, a second surgery may be necessary, usually referred to as revision surgery. The precipitating reason to proceed with revision surgery of a loose hip replacement is almost always a degree of pain and disability sufficient that the patient and the surgeon think that revisional surgery is indicated. Many patients have minor degrees of loosening determined by various findings on their radiographs but have minimal symptomatology and thus do not need a revisional surgery. As the prosthesis loosens, there is commonly damage to the bone. We are very protective of the bone in the area of a hip since the bone quality is a strong determinant affecting the surgeon’s ability to place a new hip replacement if necessary. If the bones are of poor quality, the surgeon may have difficulty

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getting a new prosthesis fixed to the bone and in rare cases it is not possible to do so. Some patients have x-ray changes of severe bone loss but few symptoms. Occasionally, we advise revisional surgery for such situations, particularly in active patients with long life expectancies.

ARE THERE MORE DURABLE ALTERNATIVES?

Surgeons have continually tried to develop techniques which will lower the loosening rate and also give the same excellent pain relief and function of a Charnley type (cemented) hip replacement. A well proven alternative now is to use a prosthesis which has a surface into which or onto which bone can attach and permanently bond the prosthesis to the bone. For this technique the methylmethacrylate cement is not used. This is called a cementless hip replacement. The first cementless hip replacements allowing bone attachment had porous surfaces or are referred to as porous hip replacements. The innovators of this cementless concept began using porous prostheses in the United States about 1978. Several researchers in France such as Judet and Lord began even before that. Today there are multiple types of cementless hip replacements available in the United States. The oldest one in continuous usage in the United States is the AML hip replacement manufactured by DePuy in Warsaw, Indiana. This device was first used by its innovators in 1978 and is a porous total hip that has been used by Dr. Moreland for many years. About 1983, as the concept of cementless replacement became popular with surgeons and patients, many other types of porous hip replacements were introduced in the United States. Some of these have stood the test of time and some have not. The reported results of various types of porous hip replacements have varied greatly depending upon the particular device used, the skill of the surgeons, and the patient population treated. Many designs have been discontinued or greatly modified. Some (such as the AML) have stood the test of time and are still widely used.

There are now also many successful hip replacements with surfaces that allow bone attachment but do not have a porous surface. Some just have a surface roughness that allows consistent bone attachment. Some are covered with a material similar to bone called hydroxyapatite which further promotes bone attachment.

WHAT ARE THE PROBLEMS WITH CEMENTLESS HIP REPLACEMENTS?

First of all, we should recognize that there is a great difference in the design of the various cementless hip replacements. There is also a great difference in the design of the various cemented hip replacements. Today, the original Charnley hip prosthesis is used relatively infrequently in the United States, although it is still considered a well-designed prosthesis.

Many other designs of cemented prostheses have been introduced to the U.S. market since the Charnley replacement came into wide use almost thirty-five years ago. Many of these newer cemented hip replacements have proven with time to have higher rates of loosening and other problems compared to the original Charnley prosthesis. As these prostheses have been proven to have inferior results compared to the Charnley, their use has been abandoned. As mentioned, a similar situation exists with cementless replacements. The AML is a cementless prosthesis that has stood the test of time but there are now other good cementless hip replacements on the market. The AML has one of the longest track records with good

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results. There are many cemented hip replacements also with good track records and in common use in the United States.

Problems with the cementless hip replacements have been the occasional lack of bony attachment, fracture of the bone on insertion and incomplete pain relief. When most cementless hip series are compared to the best cemented hip series, the cementless hips have shown a slightly higher rate of pain. On the other hand, if you compare some cementless hip replacement results against some of the cemented stems of inferior designs, the cementless replacements look better. The important thing is to compare well done (since the results of surgery varies greatly with respect to the quality of the initial surgery) cemented hip replacement with a good prosthesis with well done cementless hip replacements with prosthesis of a recognized good design. Such direct comparisons are not readily available because of many difficult to control variables. Still, it is Dr. Moreland’s assessment that if you compare a large group of well done cemented hip replacements with a good prosthesis to a large group of well done cementless hip replacements using a good prosthesis, the pain relief on average, particularly in the first one to two years, would be slightly less complete and less consistent with the cementless prosthesis. There would be some patients in the cemented group with some aches and pains but more patients in the cementless group with aches and pains. By about one to two years after surgery the pain relief for the two groups is very similar. The rationale behind the cementless replacement being utilized despite this slightly inferior early pain relief is that a more vigorous lifestyle is possible since the cementless bond to the bone is sturdier than the bond of the cement to the bone. There is much less apprehension and fear of failure for a patient to do such things as playing tennis and snow skiing and other vigorous activities than there is with a cemented implant.

The bond in the cemented hip replacement is at its maximum shortly after the operation is done. The bond of the cementless prosthesis to the bone initially is only via a press-fit in which the prosthesis is simply driven into the bone as a nail is into a piece of wood with an interference fit. Over the next one to two years the bone attaches itself to the prosthesis. The femur itself must gradually accommodate and change in response to the different stresses that are now being applied to the inside of the bone. During this time some patients have some aches and pains usually manifested by feelings of discomfort in the thigh. An occasional patient has significant problems. These problems, however, are almost always transitory and of a relatively minor nature and resolve with time as the bone changes in response to the prosthesis.

Just as cemented prostheses can get loose, a cementless prosthesis that does not get bony ingrowth may also get loose as the initial interference fit is gradually overcome by the forces placed on the prosthesis. This lack of bone fixation to the implant rarely occurs in first time hip replacements and occurs more often in patients with poor bone quality. Most of the patients who do not achieve bone attachment have more aches and pains than patients who do achieve bone attachment but most still have less pain than before surgery and are happy enough with the pain relief not to need additional surgery. In fact, Dr. Moreland has been performing the AML type cementless hip replacement since 1984 and has done over 3,400 of these replacements for patients with hip arthritis. Only 15 (0.4%) patients so far have had to have a revisional surgery for a component that did not achieve bony ingrowth in first time hip replacement. With some other implants, surgeons have reported higher rates of the prostheses not achieving bone ingrowth and requiring further surgery. No documented cases of loss of the bony ingrowth have been found, once the AML prosthesis has become ingrown.

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The cemented hip replacement’s main advantage is consistent, complete and early pain relief but with problems with late loosening. The cementless hip replacement’s main advantage is increased durability to vigorous activities but with the possibility of more aches and pains, particularly in the early postoperative period. One should not label cemented and cementless replacements as good or bad. In reality, both types of fixation of the prosthesis to the bone work very well in the hands of a good surgeon and with a well-designed prosthesis. Bad prosthetic designs of both types, particularly in the hands of less skilled surgeons, will give high failure rates.

Surgeons have learned over several decades of hip replacement that different patients have different demands, and hence, both cemented and cementless hip replacements are being used with the cementless technique increasingly dominating the market. In fact, cemented replacements now have a small part of the U.S. market and even that portion is declining. Dr. Moreland almost always uses cementless hip replacements

WHAT DETERMINES CHOICE OF TYPE OF FIXATION?

The most important determining factors with respect to choice of type of replacement are the quality of the bone, the patient’s life expectancy, and the patient’s expected activity level. Many patients develop osteoporosis for various reasons. Bone is not a solid structure, but instead has small holes in it similar to a sponge. The more holes there are and the larger the holes, the more porotic the bone and the less strong the bone. As we grow older, all of us have skeletons which are becoming more porotic or osteoporotic. Patients with low activity levels do not stimulate their skeleton to be strong and often develop osteoporosis. People with low calcium and vitamin D intake and other metabolic deficiencies will develop osteoporosis. Lighter skinned people have a greater tendency to develop osteoporosis than darker skinned people do. Women as a group have a higher propensity to osteoporosis, which seems to accelerate after menopause. Thus, lighter skinned women after menopause are at particular risk for osteoporosis.

Osteoporosis can be treated in various ways but treatments are mainly directed against minimizing further bone loss. All of us should have an adequate calcium intake in our diet and if you do not, calcium supplements should be taken. Some women after menopause take estrogen for a variety of reasons, one of which is to maintain bone strength. One can detect osteoporosis by a variety of techniques but usually a reasonable assessment of the quality of the bones can be made simply by a review of the hip x-rays. Dr. Moreland can tell you whether you have significant osteoporosis and if so, further consultation and treatment for this with the appropriate specialist can be arranged.

Cementless implants do not work as well for patients with severe osteoporosis as for those with strong bones. Older patients, patients with severely osteoporotic bones, and patients with a limited life expectancy may be well served by a cemented implant. Sometimes the pros and cons of the two different types of replacements sum up to a situation where patient and surgeon can simply choose either operation and achieve a similar high degree of success. Many surgeons believe that patients with severe osteoporosis do better with a cemented femoral implant, but the failure rate of cemented hip replacement is also higher in patients with severe osteoporosis. Even in patients with significant osteoporosis, Dr. Moreland usually prefers cementless hip replacements.

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Patients with a very active lifestyle, such as those who play tennis and snow ski and do other vigorous activities are much better served by a cementless replacement, which has a better chance of standing up to such activities than would a cemented hip replacement. There are many patients in their seventies and even eighties still doing very vigorous activities, such as playing tennis, and who usually have excellent bones. These patients are certainly better served with a cementless implant. Young patients are almost always advised to have a porous hip replacement, since they will likely benefit from the increased durability.

WHAT ABOUT THE HYBRID HIP REPLACEMENT?

Hybrid hip replacement is the term used to describe a hip replacement in which one component is fixed with cement and the other is not. Currently, surgeons almost always use porous (cementless) acetabular (socket) components since it is generally agreed that they are more durable and give the same pain relief. The controversy is mainly over cement versus cementless for the femoral stem component. Patients receiving a cemented femoral component with a cementless acetabular component are said to have had a hybrid hip replacement. This hybrid concept was more popular 5 to 10 years ago than now. Today completely cementless hip replacements are much more popular than the hybrid hip replacements.

SHOULD THE PATIENT DECIDE IMPLANT TYPE?

How well a patient does with a hip replacement depends upon a variety of factors. One factor is prosthetic choice, but the choice of the surgeon and the hospital with its support personnel and facilities are very important factors. In fact, the most important factor is how well the surgery is technically done. The skill of the surgeon is overwhelmingly the most important factor as to how well the patient does. While it is interesting and important to discuss types of prostheses used and various surgical techniques, patients really should concentrate more on making sure that they have selected a good surgeon and allow that surgeon to do the operation in a way with which the surgeon is most confident and familiar. When arranging piano music for a party, you would probably spend more time evaluating the pianist than selecting the piano. A good pianist can get music from a bad piano and a poor pianist cannot get music from the world’s best piano. Surgery is similar. There are many surgeons with excellent skills and experience with hip replacement and Dr. Moreland would be happy to help you locate a good surgeon in your area, if travel to our area is a problem or for any other reason.

WHAT ABOUT SURFACE REPLACEMENT?

Before Charnley’s hip replacement was first used in the U.S. around 1969, the most common operation for hip arthritis was the cup arthroplasty. In this relatively simple operation, a thin metal cup was placed over the femoral head after some bone shaping. The metal cup covered head was simply placed back in the bony socket (acetabulum). No cement was used to anchor the cup to the femur. When Charnley’s operation proved its dramatic superiority, the cup arthroplasty operation was quickly discarded with the approval of cement by the Food and

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Drug Administration (FDA) around 1970. Later, when loosening developed in some patients with Charnley’s operation (particularly in the young, big and active patients), several centers worldwide began using an operation which combined elements of the old cup arthroplasty with elements of Charnley’s operation. The centers were UCLA (Amstutz), Indianapolis (Capello), Michigan (Townley), England (Freeman), Germany (Wagner), Japan, and Italy. In the late 1970’s this operation (termed surface replacement in the U.S.) was used widely around the world. Similar to the cup arthroplasty, the femoral head was maintained rather than being removed as in a Charnley type replacement. A metal shell was placed over the femoral head, as in the cup arthroplasty, but in this operation it was cemented in place with the same methylmethacrylate cement used in the Charnley operation. A thin plastic socket made out of polyethylene was also cemented in the bony socket. Since both sides of the hip were replaced, this was considered a type of total hip replacement. Surgeons worldwide were hopeful surface replacement would be more durable than Charnley’s operation. By the early 1980’s multiple centers reported results, not better than the Charnley operation, but much worse. Surface replacement of the hip was then rarely used for many years.

Some investigators continued to work on experimental variations of operations in which the femoral head is maintained instead of being removed (an intuitively attractive concept) but unacceptable rates of failure continued for several surgical variations of surface replacement. Most authorities believe that the inherent thinness of the polyethylene in surface replacement (thin polyethylene has a high wear rate) was the Achilles heel of surface replacement.

Metal-on-metal (no polyethylene at all) surface replacements are now being used in the United States. This operation has received FDA approval but is not covered by all insurance plans. A recent report in the orthopedic journal “The Journal of Bone and Joint Surgery” (JBJS) documented a worrisome early failure rate from femoral loosening and femoral neck fracture in patients given experimental metal-on-metal surface replacements. This article was published in January, 2004 in volume 86-A. In that series of 400 metal-on-metal surface replacements done between November, 1996 and November, 2000, 17 hips (4.3%) had already required reoperations, mostly for femoral loosening or fracture of the femoral neck and another patient had known failure when last seen. Dr. Moreland has reviewed his patients having cementless total hips during that same November, 1996 to November, 2000 time frame. There were 859 cementless total hips done during that period with only 8 hips (0.9%) requiring reoperations so far. Please see more detailed hip replacement data on pages 46 and 47 of this booklet.

Metal-on-metal surface replacements produce huge numbers of submicroscopic metal particles. Some of the metal goes into solution and high levels of metal ions in the blood and urine have been measured in patients with metal-on-metal surface replacements. There is concern that these metal ions could cause cancer or other metabolic abnormalities. There is particular concern about the safety of metal-on-metal hip replacements in women who may later have children, since the fetus would be exposed to these metal ions, and in patients with renal disease, since some of the metal ions are excreted by the kidneys. There have also been reports from Europe with metal-on-metal hip replacements of pain from metal allergy requiring revision to metal on plastic in order to relieve the pain.

Surface replacement of the hip has been heavily promoted on the internet. Young, athletic people with hip arthritis have been attracted to the metal-on-metal surface replacement concept. As stated, it is intuitively attractive and there have been claims by some that metal-on-metal surface replacements allow a higher level of function for these high activity

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individuals. There is no scientific support for this claim. Once a cementless stem type hip replacement has fully healed, Dr. Moreland places no activity restrictions on the patient. Patients with successful cementless stem type hip replacements can be just as active as those patients with surface replacements. Surface hip replacements have a known risk of femoral neck fracture. Dr. Moreland believes there is more risk of failure with vigorous activities with the surface replacement than with a stem type replacement because of concern about femoral neck fracture. Well-controlled and long-term studies are needed to determine what is best but most reports available so far show a higher rate of failure with the surface replacement.

WHAT ABOUT OTHER NEW TECHNIQUES?

Periodically, new implants and surgical techniques are introduced to the orthopedic and lay community with great fanfare and claims of superiority to older techniques. In hip replacement surgery we already have well-established techniques (e.g. Charnley’s operation) that quite consistently and reliably give excellent pain relief and function. What has been lacking is an ability to give all patients (especially the young, big and active patient) a hip replacement which will reliably last the rest of the patient’s life. Thus, any new technique or implant can add to the state of the art of hip replacement only by proving to be more durable. Durability can only be tested by human implantation and long-term observation. Thus, all new techniques and implants do not automatically represent improvements. The words “new and improved” go hand in hand in most new product introductions such as cars, cell phones, computers, etc. and we almost treat the words “new and improved” as synonyms. In hip replacement “new” and “improved” are definitely not synonyms but instead “new” really equals unproved, or even harsher, experimental. Remember that Charnley did the first modern hip replacement only in 1962 and we began hip replacement in the United States only in about 1969. If a patient’s life expectancy is many decades, most types of hip replacement for that patient should be considered experimental procedures for that patient, since virtually all hip prostheses in common use today have usage history less than the life expectancy of such a patient.

The media, in an effort to increase viewership and thus revenue, often report various new health developments in an exaggerated way and, thus, often falsely and cruelly raise the hopes of patients. Some hospitals and some surgeons pay the media to report their supposed dramatic advances in hip replacement surgery in a shameless attempt to attract more patients. The media seems at times to try purposefully to disguise advertising copy as a scientific report, making it difficult to differentiate reports of real scientific advances from simple advertising.

Many promising new techniques, such as surface replacement (described above), custom hip replacements, the Mittelmeir hip (the original ceramic-on-ceramic hip developed in Austria and introduced many years ago and later taken off the market because of a high failure rate), custom hip prostheses made during surgery, “improved” polyethylene formulations and the threaded acetabular component have with time proved to be big steps backward and not steps forward.

Hip replacement using a robot and hip replacement with computer guided navigational systems have received media attention. Neither the necessity nor practicality of these experimental techniques has been proven and cannot be proven for many years despite the glowingly positive media reports propagated by their enthusiasts.

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Hip arthroscopy (similar to the widely used knee arthroscopy) has little place in the treatment of hip arthritis. Some surgeons use the lure of a “simple” hip arthroscopy in a “bait-and-switch” way to attract patients. Hip arthroscopy is not a simple procedure like knee arthroscopy and has a significant risk of complications. As opposed to the knee, the hip is a deep structure and does not have a spacious joint cavity into which an arthroscope can be easily inserted. The leg must be pulled forcibly to distract the femur away from the acetabulum so that the arthroscope can be inserted. Damage to the hip articular cartilage can be done by the arthroscope itself in this process. Also importantly, there is actually very little that an arthroscopist can do to help a patient with hip arthritis.

Be wary of self-proclaimed “Institutes or Centers of Excellence in Hip Replacement” without well-established community recognized expertise. There are, unfortunately, no requirements for the use of the terms “institute” and “center”. Many institutes are truly substantial, but some consist only of glossy brochures, an advertising agency, and a phone answering service relaying referrals to physicians without particular extra expertise.

Dr. Moreland has prepared a report of the results of his primary hip replacements on pages 46 and 47 of this booklet. This data may be useful to patients seeking to compare the results of one surgeon with another. When making comparisons, it is not enough only to know incision lengths, predictions of rapid recovery and early discharge, and undocumented claims of being “better”. Patients should also compare surgeon hip replacement volume, infection rates, dislocation rates, loosening rates, reoperation rates, perioperative death rates, nerve (femoral, peroneal, posterior tibial, and anterior femoral cutaneous) damage rates, femoral fracture rates, blood clot rates, leg length discrepancy rates, vascular damage rates and heterotopic bone formation rates.

WHAT ARE THE SOME COMPLICATIONS OF HIP REPLACEMENT?

Hip replacement is very successful and complications are uncommon. There is easily a greater than 95% chance that the replacement can be accomplished without serious complications. The most devastating complication is infection. The chances of an infection in a first time operation are one out of several hundred. Infection can be introduced into the hip joint at the time of surgery when the wound is open, since there are always bacteria in the air and on the patient’s skin. Precautions are taken against this occurring by using special operating rooms with extra clean air (laminar flow rooms) and by giving prophylactic antibiotics. Infection also can be introduced into the hip by way of the bloodstream at any time after the surgery. Although unlikely, infections in other parts of the body can spread to the hip replacement. Dental work also can release bacteria into the bloodstream which then can travel to a hip replacement and cause an infection. Thus, patients with hip replacements may need to take prophylactic antibiotics by mouth shortly before and after some dental work and before other medical procedures which can cause bacteria in the bloodstream. Before any medical or dental procedures, a patient with a hip replacement should always remind the treating physician or dentist that the patient has a hip replacement. Responsibility for giving prophylactic antibiotics is that of the physician or dentist performing the medical procedure. Hip replacement patients should have any bacterial infections, other than those of the hip replacement itself, treated promptly by their primary care physician. Viral infections, such as colds, and fungal infections of the skin or nails are not a threat to a hip replacement.

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Loosening of the fixation of the prosthesis to the bone, as has already been mentioned, is a major long-term problem with cemented hip replacements. The durability of a cemented hip replacement is determined by three factors. The skill of the surgeon is the first and most important factor. If the surgery is done well, it will last much longer than if it is done poorly. The second factor is the stress the prosthesis will have to withstand. This is dictated by the patient’s activity level. Vigorous activities such as running and heavy lifting cause stress to be delivered to the prosthesis and can cause it to become loose. Thus, patients with cemented hip replacements should avoid stressful activities. Cemented hip replacement patients can participate in golf, swimming and bicycle riding but should avoid other more stressful activities. The third factor affecting the rate of loosening is the condition of the individual patient’s bones since some bones are formed in a way that makes it difficult to get the replacement well fixed. In contrast, once bony ingrowth has been achieved, cementless porous-coated hip replacements have an almost zero chance of loosening, even with the most stressful activities.

IS WEAR A PROBLEM?

Wear of the ultra-high molecular weight polyethylene socket had been considered for a long time a minimal problem. In the 1950’s Charnley experimented with Teflon as the plastic for his socket and was disappointed to find high rates of failure because of wear. With his introduction of the ultra-high molecular weight polyethylene beginning in 1962, wear became much less of a problem and during the 1970’s and 1980’s attention was focused on ways to improve fixation of the implant. With the improved fixation of an ingrown porous hip replacement and increased activity levels of the patients, surgeons found that the durability of the prosthetic fixation often exceeded the wear potential of the polyethylene. There is some evidence to suggest that wear of the plastic is increased with the cementless devices but there are many other factors possibly affecting wear (activity level, plastic quality, ball quality, ball size, cup design, stem design, and the type of metal).

Cobalt-chrome alloy balls create much less wear on the plastic than titanium alloy balls which are no longer used. Ceramic balls also can be used to articulate against the polyethylene. Ceramic has the advantage of being very hard and thus very difficult to scratch and can be polished to a high degree. Ceramic has the disadvantages of possible fracture (extremely rare with modern designs) and increased cost.

Wear is a problem from two standpoints. The ball can wear its way all the way through the plastic and start to hit the metal shell and cause catastrophic problems. This actually rarely occurs with today’s modern designs but did occur occasionally with some earlier designs which had a thin layer of polyethylene. The problem today is bone loss which can occur from the wear particles themselves. The body’s tissues can react to the tiny microscopic wear particles in a way that destroys bone. Most likely the body confuses these tiny wear particles with bacteria and in an effort to clear these particles from the hip, the body’s tissues reabsorb some of the bone. Patients will not necessarily have symptoms from wear until very late in the wear process. Thus, patients should be followed by their orthopedist with x-rays every two or three years to look for evidence of wear and possible bone destruction from the wear particles. The plastic lining of the cup and the ball of the stem can usually be relatively easily changed without disturbing the cemented or bone ingrown surfaces of the implant. A reoperation for wear is usually a much easier one than a reoperation for loosening.

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Wear has been the most frequent cause of reoperations at most hip replacement centers in recent years. Fortunately, significant progress in wear reduction has been made. Several researchers working in different centers have developed a new manufacturing process for the polyethylene which increases the cross-linking of the long chain polyethylene molecule and lowers the laboratory wear rate of the plastic to practically zero. Dr. Moreland has been using this highly cross-linked polyethylene formulation routinely since September 1999 and so far virtually no wear has been found in these patients. Thus, the clinical results are corroborating the wear testing in the laboratory. Even in young patients, we now have the potential for life-long hip replacement durability. It is a gratifying time for both hip replacement candidates and hip replacement surgeons.

Metal-on-metal hip replacements are also being used but have the disadvantage of metal ion release into the blood. Metal-on-metal hip replacements produce huge numbers of submicroscopic metal particles. Some of the metal goes into solution and high levels of metal ions in the blood and urine have been measured in patients with metal-on-metal hip replacements. There is concern that these metal ions could cause cancer or other metabolic abnormalities. There is particular concern about the safety of metal-on-metal hip replacements in women who may later have children, since the fetus would be exposed to these metal ions, and in patients with renal disease, since some of the metal ions are excreted by the kidneys. There have also been reports from Europe with metal-on-metal hip replacements of pain from metal allergy requiring revision to metal on plastic in order to relieve the pain.

Ceramic-on-ceramic hip replacements have been reintroduced in the U.S. with a lot of advertising by some manufacturers, one of which has used the golfer, Jack Nicklaus, as a paid spokesman. Jack probably would be a good source for advice about putters, but his advice about prosthetic choice in hip replacement is suspect. An earlier version ceramic-on-ceramic hip replacement introduced with similar great fanfare about 15 years ago (the Mittelmeir) was taken off the market completely a few years later because of a high failure rate. A serious but infrequent problem with ceramic-on-ceramic hip replacement is fracture of the ceramic itself. This weak material can and has fractured. In addition, there are now frequent reports of bothersome squeaking sounds coming from ceramic-on-ceramic hip replacements.

Today we have three relatively new developments in hip replacement to address the wear problem: highly cross-linked polyethylene, metal-on-metal articulations, and ceramic-on-ceramic articulations. All look quite good since short term data and laboratory testing show much less wear than earlier technology. All three have their advocates but there is actually no data to prove that one of these three is to be preferred.

WHAT ABOUT HIP REPLACEMENT DISLOCATION AND SURGICAL APPROACH?

Dislocation of hip replacements (the metal ball coming out of the plastic socket) occurs infrequently. The metal ball is held into the plastic socket by muscle tension and, after the hip maturely heals, by scar tissue. Thus, patients with poor muscles are more likely to suffer dislocation. During the first few weeks after surgery, before scar forms around the metal ball and before muscle strength returns, the hip is more likely to dislocate. During this time avoidance of certain positions may help to decrease the rate of dislocation. The physical therapist can teach you the positions to avoid and how to use your hip replacement safely in the first few weeks after surgery. If the hip does dislocate, it is usually a relatively simple

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matter after sedation in the emergency room for the surgeon to pull on the extremity and the hip will pop back into place. Dislocations most commonly occur in the first few weeks after surgery, but occasionally patients develop repetitive dislocations requiring corrective surgery.

The postoperative dislocation rate varies with the skill of the surgeon, the surgical approach chosen by the surgeon, the size of the ball used and the patient population served. The usual dislocation rate reported in the literature in first time (primary) hip replacement is about 3%. Dr. Moreland’s primary dislocation rate is around 0.4% or about one-eighth of the usual rate. Dislocation is a significant complication, since a dislocation is painful and causes the patient to lose faith in the replacement which can be a significant psychological burden.

Several different surgical approaches can be used to obtain the exposure needed to put in a hip replacement. Hip replacements are done with a variety of approaches. Surgical approaches can be broadly divided as to whether the hip joint is entered by going anterior (in front of) or posterior (behind) the top end of the femur (thigh bone).. The hip replacement literature has repetitively documented a much lower dislocation rate for the anterior approaches compared to the rate with the posterior approaches. Dr. Moreland has used an anterior approach since 1992 because of the low dislocation rate.

Sir John Charnley strongly advocated the transtrochanteric approach. This approach involves the temporary removal of the greater trochanter with it being replaced at the end of the surgery. This approach gives the best view of the hip but is very rarely used today because it requires the use of wires and has the risk of wire breakage and lack of trochanteric bone healing. Rarely (less than one case out of a hundred) Dr. Moreland uses the original trochanteric removal approach in difficult and complex cases because of its better exposure. Dr. Moreland stopped using this approach routinely many years ago, as did almost all other surgeons, because its disadvantages outweighed its advantages in the usual primary replacement.

Anterior approaches can be subdivided into two types. The two differ as to whether the hip is approached anterior (Smith Peterson approach) or posterior (Watson Jones approach) to the tensor fascia lata muscle. These are both old approaches having been described by two famous early 20th century English surgeons. The Watson Jones approach (a version of which Dr. Moreland has used for 15 years) has been until recently practically the only type of anterior approach used in the United States. The Smith Peterson type of anterior approach has been advocated by several surgeons in recent years. Both of these anterior approaches have low dislocation rates.

As mentioned, the head size of the femoral component affects dislocation rates. Larger heads are less likely to dislocate and thus Dr. Moreland today uses heads as large as is practical, limited by technical considerations of prosthetic design.

WHAT ABOUT OTHER POSSIBLE COMPLICATIONS?

Nerve damage occurs less than 0.1% of the time with a hip replacement. The nerve most commonly damaged is the nerve to the muscles which bring the foot up toward the face. Damage to this nerve causes drop foot. Usually if this nerve is damaged, it will slowly recover over many months but not always. Nerve damage occurs most commonly in association with

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the need for significant leg lengthening with the hip replacement, particularly with developmental hip dysplasia patients.

Less than 1% of the time, patients develop extra bone formation around the hip joint which causes the hip to be significantly stiffer than desired. This is more likely to occur in men with osteoarthritis. Formation of small amounts of extra bone called heterotopic bone occurs commonly around hip replacements and does not cause a problem. A large amount of extra bone causing severe stiffness rarely occurs and can be treated later by surgical removal of the bone after it has matured. Radiation therapy or medications, such as Indocin, are sometimes used to try to prevent bone formation when the surgeon believes the patient is likely to develop this extra bone.

Rarely, the femur will fracture during a hip replacement or from later trauma. Sometimes these fractures can be treated without surgery but sometimes surgery is required to fix the fracture fragments. Healing can almost always be obtained.

The prosthesis itself can break. The stem of the component is under very large stresses and is loaded repetitively and may fracture via a mechanism called fatigue fracture. Smaller prostheses are more likely to fracture. Bigger sizes with large diameters are extremely unlikely to fracture. Manufacturers are very aware of this problem and today produce devices which are less likely to fracture compared to prostheses used in the past. We are aware of only two stem fractures in over 5,700 hip replacements done by Dr. Moreland in his career.

One should not expect a hip replacement to be as good as a normal hip, although many patients seem virtually normal. The completeness of pain relief and the degree of mobility is partially determined by the individual patient’s type of problem. Rarely, patients have pain after surgery which cannot be explained and does not resolve.

The length of the leg can be changed to some degree by the hip replacement surgery. Getting the leg lengths exactly equal is difficult and is not always the object of the operation. Some differences in leg lengths after surgery cannot be avoided and shoe lifts may be necessary after surgery. Sometimes, some lengthening cannot be avoided because of dislocation problems.

The most common medical complication in hip replacement is blood clots (deep venous thrombosis or DVT) which may develop in the legs and the pelvic area after surgery. As long as the blood clots do not move up to the heart, the only effect is swelling in the leg, sometimes with calf or thigh pain. Occasionally, the blood clots may move up through the heart to the lungs causing the patient to be short of breath and have chest pain (pulmonary emboli or P.E.). Dr. Moreland’s replacement patients are given Coumadin (warfarin) which thins (anticoagulates) the blood and helps prevent clots after surgery. Very rarely death can occur from large clots moving to the heart and lungs. Dr. Moreland, fortunately, has not had a patient die of this problem. Other measures such as compressive support hose (TEDS), bed exercises, and early walking also help prevent blood clots.

A fat embolism is another potential complication of hip replacement. There is fat in the cavity of the bone where the femoral prosthesis is placed. Apparently, if this fat is pressurized, some of it can be driven into the veins which then can carry the fat back up to the heart, then to the lungs and somehow also to the brain. This can cause the patient to have difficulty breathing and to develop neurological problems. Evidence now suggests that evacuating the fat out of the femur before the prosthesis is placed probably prevents this complication. Patients will

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usually recover from a fat embolism problem, if measures are taken to support the patient’s breathing while the tissues are recovering from the insult of the fat.

Anesthetic complications can occur and very rarely the patient can die. Your anesthesiologist will see you before surgery and should explain the risk of anesthesia and your anesthetic choices. There are two broad types of anesthesia which are used for hip replacement: general and regional. In general anesthesia you are completely asleep and thus totally unaware during the operation. In this technique an IV is first started in your arm. The anesthesiologist next puts multiple monitoring devices on you (EKG, stethoscope, pulse oximeter, blood pressure cuff), lets you breath pure oxygen for a few minutes, and then puts you to sleep by injecting a sedative through your IV. Your next awareness is usually when you are waking up in the recovery room.

In the regional anesthetic, an IV is also started and the same monitoring devices are placed. Then, while on your side on the operating room table, the anesthesiologist injects medicine in your back next to your spinal nerves. You will then gradually lose feeling from about your waist down. There are two types of regional anesthetic: the spinal and the epidural (often given to women in labor). The spinal rarely can cause postoperative headaches. You can be entirely awake with a regional but the anesthesiologist almost always sedates you so that you are completely unaware of the operation. The final decision as to type of anesthesia is the anesthesiologist’s after consultation with the patient and the surgeon. With the advanced anesthetic monitoring techniques available today, anesthesia is safer than ever before. Dr. Moreland strongly prefers the spinal anesthetic since it is associated with less bleeding, a lower rate of blood clots, and patients seem to have less postoperative pain.

Blood transfusions carry risk. We use many measures to limit the usage of banked blood. Many patients store their own blood before surgery (autologous blood) and with today’s techniques for testing the blood and screening donors, the blood supply today is safer than in the past.

Other complications can occur, but you should keep in mind that the chances of any significant complication occurring is small. As with many things we do in life, major surgery cannot be done without risk. We will do everything we can to minimize the risk you undertake. Keep in mind that the worse your preoperative symptoms are, the more reasonable it is that you take the risks inherent in having hip replacement surgery.

WHAT ABOUT WRONG SIDE SURGERY?

Publicity about patients tragically having surgery on the wrong side of the body has made many patients very anxious about this possibility. Dr. Moreland has done over 5,700 hip replacements and over 2,600 knee replacements and has never operated on the wrong side. There are many preventative mechanisms in place and you may get tired of being asked which side is the correct one. Dr. Moreland during your preoperative office visit usually the day before the surgery will personally mark his initials on the operative site. This is a requirement of a government agency overseeing hospitals.

DOES DR. MORELAND USE

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THE NEW MINIMALLY INVASIVE HIP REPLACEMENT TECHNIQUES?

While certainly not among the first surgeons to adopt the new minimally invasive hip replacement techniques, he now routinely uses a minimally invasive prosthesis and a surgical approach that allow and facilitate immediate full weight bearing as tolerated and result in quicker recovery than in the past.

The term “minimally invasive surgery” in the last few years has acquired a special magic. The term “laser surgery” had a similar appeal in the past. The reason for the excitement about this term “minimally invasive surgery” is that several surgical techniques with this name have been developed which have revolutionized some operations. The interior of various body cavities can now be easily viewed by a miniaturized camera attached to a small tubular telescope (endoscope) with the image displayed on a monitor. Surgery can then be performed using long thin surgical instruments inserted through small incisions, or through natural body openings, with the instruments’ movements seen on the monitor. The resultant smaller surgical insult to the surrounding tissues allows the patient to recover quicker and with less pain in most situations. In orthopedics, arthroscopy of the knee, and later many other joints, has allowed surgeons to see certain areas of joints better and to do surgeries through small incisions. In general surgery, laparoscopic cholecystectomy (removal of the gall bladder) has been a dramatic advance using minimally invasive surgical techniques. There are many other surgical examples. These procedures as a group have become known as minimally invasive surgery and almost all involve the use of these small telescopes and cameras and very small incisions. There is no wonder about the magic this term has today with patients, since these revolutionary techniques have received appropriate and deserved wide publicity.

Today, however, the term “minimally invasive surgery” is being applied somewhat inappropriately to some total hip replacement techniques, since the small telescopes and cameras of the usual minimally invasive surgical techniques are not used in these new hip techniques. In addition, minimally invasive surgical techniques typically involve incisions less than one-half inch in length. Since all hip replacements require the insertion of prostheses of a significant size, the minimal incision length to allow the prosthesis itself to go through the skin needs to be at least two inches and even this length requires skin stretching, which can lead to delayed skin healing. Still, we should not quibble too much with semantics and definitions, particularly since minimally invasive hip replacements techniques seem to represent an advance over previously available techniques. While it certainly has not been shown conclusively in the standard scientific way whether minimally invasive hip replacement techniques represent an advance or not, there is no doubt that the concept is an extremely effective marketing tool that has been aggressively and successfully used by surgeons and hospitals to recruit more patients.

Hip replacement prostheses have been dramatically improved since introduced in the United States in 1969. Prostheses available today have a dramatically lower potential for loosening, wear, dislocation, and stem fracture and, as stated above, have a probable durability exceeding the life span of the typical patient. Interestingly, Dr. Moreland’s medical career almost exactly coincides with hip replacement in the U.S., since he started medical school in 1968 and thus he has seen and participated in the gradual improvement of total hip replacement surgery. The chances of short term complications such as infection, dislocation, nerve damage, blood clots, femoral fracture, extra bone formation and the resultant stiffness, and leg length discrepancy have been dramatically decreased. Compared to 30 years ago,

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when Dr. Moreland first became involved with hip replacement as an orthopedic resident at UCLA, the average length of surgery and the amount of blood loss are much less today. Hip replacement then took three to four hours and often involved several units of blood loss (one unit is about one pint). Today Dr. Moreland routinely does hip replacements in about an hour and blood loss averages less than a unit. The minimally invasive technique that Dr. Moreland now uses takes longer to do than previous techniques.

Dr. Moreland had already gradually decreased the length of his hip incisions and before the publicity a few years ago about minimally invasive hip replacements his incisions were about five or six inches long. Now with the emphasis on incision length his incisions are about four or five inches. Any shorter is unnecessary and compromises his ability to do a good hip replacement in a timely manner. What Dr. Moreland does now is a minimally invasive technique, although he has not marketed his practice this way.

Other surgeons also have gradually decreased their incision lengths and there are a few reports in the literature which document no increased complication rates in the hands of certain expert surgeons. It is not clear that all surgeons can get such results with small incisions. Most surgeons who market their hip surgery as minimally invasive simply have decreased the incision length to varying degrees. The results and complication rates of such surgeons both before and after the incisions were shortened are usually not available. An article entitled “Comparison of Primary Total Hip Replacements Performed with a Standard Incision or a Mini-Incision” in the prestigious orthopedic journal, “The Journal of Bone and Joint Surgery,” Volume 86-A, July 2004, page 1353, showed no advantages of the minimally invasive approach but did document a worrisome higher rate of complications compared to standard approaches.

Marketing for minimally invasive hip replacement emphasizes a quicker recovery as well as shorter incision length. Recovery is hard to quantify and cannot be measured simply by the length of the hospital stay or when weight bearing is allowed. Certainly patients today recover much faster than 30 years ago but whether one surgeon’s patients recover faster than another’s is difficult to document.

When the term minimally invasive hip replacement first was used, most of the emphasis was on incision length. Now more of the emphasis is appropriately on its capacity to allow immediate weight bearing and quicker recovery which are actually more important than incision length.

WHEN WILL FULL WEIGHT BEARING BE ALLOWED?

The operative technique that Dr. Moreland now uses includes immediate weight bearing as tolerated. Of course, the surgical trauma causes some discomfort and patients at first need walking aids, but there are no restrictions placed on weight bearing on the new hip. When patients get out of bed the morning after surgery, two crutches or a walker are usually needed. As the operative pain decreases, patients can progress to a cane as soon as the patient is able.

When cementless hip replacement was popularized in the early 1980’s, virtually all experts recommended that patients postoperatively use crutches or a walker with minimal weight bearing on the operated extremity, thinking that this would facilitate bone attachment to the implants. As surgeons became more experienced with cementless hip replacement and saw that patients who ignored this minimal weight bearing advice usually did well anyway, many

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began to allow patients to weight bear as tolerated right after surgery. It is still not clear whether immediate weight bearing or delayed weight bearing is better for bone attachment, but it is very clear that if there is a difference, it is small. Conservative patients, who are not in a rush to weight bear immediately, still may choose to go slowly with weight bearing.

A second reason to limit early weight bearing is to facilitate soft tissue healing, particularly if muscles have been detached or damaged during the surgical approach. The AML prosthesis because of its design and relatively long length is more difficult to insert without a larger incision and some muscle damage than other stem designs. Dr. Moreland’s long term extremely successful experience with the AML made him reluctant to change to a different implant. His surgeon competitors used the fact that he was not allowing immediate weight bearing to convince patients that their surgical technique was better. Obviously if the same good result can be obtained quicker with immediate weight bearing, patients will prefer that technique.

Since patients today clearly do prefer immediate weight bearing and the quickest possible recovery, as well as a good long term result, Dr. Moreland has changed to a different shorter prosthesis which facilitates an operative approach compatible with immediate weight bearing as tolerated. He has chosen the Corail stem. This prosthesis was developed in France and has been in use since 1986. Excellent results have been reported from multiple centers and this stem has stood the test of extensive use and close scrutiny. It has a special rough surface and is coated with hydroxyapatite and is ideal for inserting with a minimally invasive approach. Dr. Moreland’s initial experience with it has been excellent. It is manufactured by the Depuy orthopedic company which is owned by Johnson and Johnson.

WHAT ARE THE SURGICAL APPROACH OPTIONS?

The era of emphasis on minimally invasive hip replacements was ushered in almost single-handedly several years ago by the Chicago orthopedic surgeon, Dr. Richard Berger. He, in alliance with the orthopedic company, Zimmer, developed and aggressively promoted a truly new hip replacement surgical approach. This approach, actually invented by another surgeon but popularized by Dr. Berger, is usually referred to by orthopedic surgeons as the “two incision approach”. In this approach two one and a half to two inch incisions are made. Some of the control of the instruments’ and implants’ positions is guided by the image intensifier (an x-ray device like the fluoroscope). Patients thus get extra exposure to x-ray radiation with this technique. These surgeries take, even with Dr. Berger, a longer time to do than more standard approaches. At the February, 2004 meeting of The Hip Society, Dr. Berger reported his very promising results. It is important to note that Dr. Berger uses this two incision approach only on a carefully chosen minority of his patients. He mostly uses a type of anterior approach called the Watson Jones approach after an early 20th century English orthopedist who first described that approach.

Dr. Berger also trumpeted very early discharge for his patients. This, by itself, does not validate his technique, since he is operating on selected, highly-motivated patients who go to Chicago for the surgery and who in some instances have a vested interest in validating this technique. Time of discharge is heavily dependent on patient motivation, health, and home support systems. Most patients in Dr. Moreland’s practice with minimally invasive hip

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replacement stay in the hospital for three days and when home need little nursing care, but do need others at first to help with cooking, cleaning, and shopping.

Zimmer has sponsored training courses to teach this technique to other orthopedic surgeons. Records have been kept of the results the trained surgeons achieved after returning home and trying this new technique on their patients. The results showed worrisome complication rates and were generally much worse than those reported by Dr. Berger. Femoral fracture was a significant problem. There are reports that most surgeons who attend the training courses do not later adopt this technique as a standard part of their practice. This approach has not gained popularity with surgeons after an initial wave of publicity and usage and today is used by few surgeons.

Dr. Berger gained so much publicity and so many new patients with his minimally invasive hip replacement technique that other surgeons were spurred to devise minimally invasive hip replacement techniques also. Most surgeons simply modified the techniques they had been using to accommodate a shorter incision and then marketed themselves as minimally invasive hip replacement surgeons.

Before the era of emphasis on minimally invasive hip replacements, there were basically two approaches with multiple variations being used in the United States. These approaches can be divided into those that access the femoral head and the socket (acetabulum) by going behind (posterior) or in front of (anterior) the femur.

The most popular approach then and now is to go posterior to the femur. The posterior approach is also called the posterolateral approach. Surgeons using this approach today have shortened their incisions and call their technique minimally invasive. This approach always involves cutting muscle attachments. The piriformis muscle and the obturator internis muscle with the inferior and superior gemelli muscles are routinely cut from their attachments to the femur. The posterior approach can not be done without cutting these muscles. An attempt at repair of the cut muscles is made as the hip is being closed but these muscles probably do not heal back properly.

The main criticism of the posterior approach in comparison to anterior approaches is a much higher rate of postoperative dislocation, probably related to the muscle weakness caused by the muscle cutting. Posterior approach advocates today emphasize efforts to securely repair all cut structures including the released muscles and the posterior capsule and now report lower dislocation rates than previously. Surgeons using the posterior approach routinely require that patients avoid bending over for several weeks after surgery to prevent dislocations. Such positional precautions are not needed after anterior approaches.

As mentioned above, Dr. Berger usually uses the Watson Jones approach. This approach with multiple variations around the country was the other popular hip approach before the era of emphasis on minimally invasive hip replacements. Dr. Moreland used a variation of the Watson Jones approach for many years. It can be done with or without cutting muscle attachments. The cutting of some muscle attachments allows the surgeon better visualization and allows easy insertion or all prosthetic designs. If muscles are not detached and only retracted (pushed out of the way), then a shorter and more easily inserted prosthesis is needed. Both Dr. Berger and Dr. Moreland now retract only the muscles and use minimally invasive friendly stems.

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The Watson Jones variation of anterior approaches has several advantages over the posterior approach. First, anterior approaches can be done without cutting or releasing muscles and the posterior approach cannot. Second the dislocation rates are lower with anterior approaches and thus, patients do not have the inconvenience of avoiding certain positions after surgery.

Since the advent of the era of minimally invasive hip replacement, another type of anterior approach has been popularized. This is actually a variation of another old approach described by another early 20th century English orthopedist named Smith Peterson. It is referred to as the Smith Peterson approach. The Watson Jones approach and the Smith Peterson approach are in a very similar location and differ only as to whether the muscle interval used to get to the hip is in front of or behind the tensor fascia lata muscle.

Most surgeons using the Smith Peterson approach use a special fracture table. In the fracture table technique the feet are strapped tightly in boots and in order to get proper hip exposure the leg is twisted with significant force and ankle fractures have occurred. A type of x-ray imaging called image intensification is used throughout the surgery. Taking a single x-ray is similar to taking a single photo. The x-ray technique of image intensification is analogous to taking a movie but with x-rays and involves more radiation exposure. All people close to the x-rays receive radiation exposure. The surgeons and other operating room personnel remain next to the patient during image intensification. These people wear protective lead gear but are still partially exposed to radiation. The patient is not shielded with lead at all and since the hip and the gonads are in the same area radiation sensitive gonads unfortunately are radiated. Many patients of child bearing age are receiving hip replacement today. Since minimally invasive hip replacement can be done without this radiation exposure, Dr. Moreland prefers not to use this fracture table and image intensification technique.

WHAT ABOUT BILATERAL SIMULTANEOUS HIP REPLACEMENT?

While it is possible to do replacement of both hips during the same surgical procedure, and some surgeons advocate this, Dr. Moreland does not recommend this except in rare circumstances. He believes that the increased magnitude of the surgical insult in doing two hip replacements at once is such that the rate of serious complications (e.g. death) is increased. This increased risk, however slight, seems not worth taking. Many well regarded and prestigious surgeons commonly, however, do perform replacement of both hips simultaneously. It is a controversial issue. Dr. Moreland’s practice is to wait a minimum of two months or, preferably, four to six months between hip replacements. This delay allows full recovery from the first surgery and increases the safety of the second.

WILL DR. MORELAND DO THE SURGERY?

Some surgeons employ other surgeons to do parts of the hip replacement such as the opening or closing of the wound and sometimes even the entire operation. Dr. Moreland personally does all of the operation. He does the patient positioning for the surgery making sure that the patient is properly placed and padded to prevent injury during the surgery. He makes the incision and does all of the operation, including skin closure, as well as the placement of the wound dressing. He also visits his hospitalized patients at least six and sometimes seven days a week except when he is out of town. He also takes his own emergency calls six, and

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sometimes seven, days a week when in town. Thus, if you have an emergency after your surgery, you usually will have direct access to him instead of someone not familiar with your situation. When he is not available, his calls are usually taken by Jack Purdy M.D., an experienced, board certified orthopedic surgeon. Dr. Purdy has been assisting Dr. Moreland at surgery since 1985 and they have done thousands of hip replacements together. Dr. Purdy will often be familiar with your particular situation since he probably assisted at your surgery. Dr. Moreland does not use surgeons in training, such as residents or fellows, as surgical assistants nor do such physicians help with your postoperative care.

INITIAL CONSULTATION WITH DR. MORELAND

The initial office visit for patients who are considering hip replacement surgery involves a discussion and examination with Dr. Moreland lasting thirty to forty-five minutes. Before your visit you will be asked to fill out a questionnaire concerning the history of your hip problem. An x-ray evaluation is always needed and if you have had previous films taken elsewhere, it is useful to bring those films with you. We have an x-ray facility in our office and we can take additional views as necessary. It would be helpful if you bring a list of medications that you take with the dosages. We welcome spouses and other family members or important friends to participate in the discussion of treatment. We routinely call and/or write your physicians telling them of the situation and we will be happy to write anyone else that you wish to have a copy of your consultation. We will send you a copy of your consultation also. Please feel free to ask as many questions as you like. We believe strongly that an informed patient is a better patient with a much higher chance of success with medical and surgical treatment.

If non-surgical treatment is chosen, you may be given prescriptions for arthritis medications, walking aids or physical therapy, as well as advice about living with your hip arthritis.

SURGICAL SCHEDULING

If surgical treatment is elected, our office staff will normally arrange the surgery at Saint John’s Health Center (1328 22nd Street in Santa Monica). Since this is major surgery, a medical evaluation is usually indicated. Your internist or family practitioner will do this evaluation. If you do not have such, we will assist you in making an appointment (seven to ten days before surgery) to see a physician who can do a medical evaluation and preoperative laboratory work. If you have a cardiologist or pulmonologist because of significant heart or lung problems, then you should see that doctor also for a preoperative evaluation. If you are taking blood thinners such as Coumadin or Plavix, these drugs will need to be stopped temporarily before the surgery and this will need to be coordinated with your medical physicians.

AUTOLOGOUS BLOOD DONATION

The patient may choose to donate blood to be saved and given back at the time of surgery if needed. This type of blood donation is called autologous blood donation and is safer for patients than donor blood, which has a very small chance of transmitting infectious diseases such as hepatitis and AIDS, and can also cause transfusion reactions.

For a patient having a hip replacement for the first time, banking one unit of blood is reasonable but not mandatory, since the chance of a patient with a normal blood count

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needing a blood transfusion is only five to ten percent. The usual blood loss for a first time uncomplicated hip replacement is less than a unit and the surgery usually takes less than an hour. Small patients (less than 100 pounds) and anemic patients may not be able to donate. The shelf life of unfrozen blood is about six weeks. The blood can be frozen if patients must collect blood slowly, or for other reasons. Frozen blood has several years of shelf life, but about 30% of the red cells are lost in the freezing and thawing process. Freezing the blood also increases the cost, and thus we try to use liquid blood.

It is better to allow at least two or three weeks between donation and surgery so that the body can replace the donated blood. Both autologous and blood bank transfusions involve a remote chance of getting the wrong unit of blood and both have a remote risk of bacterial contamination.

Patients may also have friends and relatives donate blood. Compatible units can be specifically reserved for the patient. This type of donation is called directed donor blood donation. Blood banking experts do not believe directed donor blood is safer than bank blood, since directed donor blood involves some potential for coercion in collection, however minimal. The blood bank offers directed donor blood as a service to patients, since many patients are more comfortable getting blood from friends and relatives. It usually takes 48 hours or longer to process directed donor blood. Thus, trying to arrange directed donor blood postoperatively is usually impractical. The blood bank will not first test the directed donor for compatibility with the patient, so there is no assurance that you will be compatible with all your directed donors.

Rarely, if you are unable to donate blood or for other reasons, Dr. Moreland will use the Cellsaver. This is a device that can salvage and clean the blood cells from the blood collected from the surgical wound. This clean blood (mostly only the red cells) can then be retransfused. It is possible to collect and reuse about half of the blood cells lost during surgery. The Cellsaver can be brought into use during surgery if blood loss is unusually high but Dr. Moreland cannot remember the last time this was necessary.

It is rare to need blood transfusion for the usual patient having first time hip replacement. Most patients can get by without any blood transfusion. Dr. Moreland estimates that for the usual uncomplicated hip replacement in a patient without preoperative anemia and with no autologous blood the risk of needing a bank unit is five to ten percent. With one unit of autologous blood the chances of needing an additional bank unit is less than five percent. The risk of needing bank blood cannot be reduced to absolute zero. Autologous blood can be given at the hospital where surgery is planned or at a Red Cross facility. Other hospitals rarely, if ever, will allow patients to give autologous blood at their facility for surgery elsewhere.

WHAT SHOULD I AVOID PRIOR TO SURGERY?

If you are currently taking any nonsteroidal anti-inflammatory medications (NSAIDS), you should stop taking these three days prior to surgery; since all NSAIDS can cause increased bleeding during surgery (NSAIDS inhibit platelet function). Aspirin (an NSAID) particularly can cause bleeding, and if you are taking aspirin, or aspirin containing drugs such as Darvon compound, Percodan, Ecotrin, Excedrin or Anacin, you should stop taking these at least seven days prior to surgery. For pain before surgery you may take Tylenol, Darvocet, Darvon plain, Tylenol with codeine, Percocet, Vicodin and other drugs not containing aspirin or any other

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NSAIDS. The COX-2 inhibitor, Celebrex, can be continued right up until surgery, since it does not affect bleeding.

Smoking increases operative risk, and should be stopped or at least decreased in the period before surgery. Smoking also increases the chance that the new hip replacement will not get fixed to the bones. Patients should not smoke for at least two months. Smoking is strongly associated with slow healing. All hospitals are now non-smoking facilities. Obesity also increases operative risk and weight loss before surgery, if indicated, is desirable but not essential.

THE PREOPERATIVE VISIT

We will usually ask you to come back for a final preoperative visit a day or two before surgery to check that surgical arrangements are complete. At that time we will give final instructions and we will again discuss the surgical arrangements and the potential complications and risks. Sometimes, a preoperative visit to the hospital is also made that same day, and your blood is drawn again for usage by the blood bank and for a final blood count.

Patients are not admitted to the hospital until the morning of surgery. This practice of admission the day of surgery, rather than the day before surgery, began in about 1986 when most insurance companies began insisting that patients not be admitted the day before surgery because of the expense of that extra day. This procedure has now become standard across the country. If your surgery is the first one of the day, check-in time at the hospital is 5:00 a.m. If your surgery is later, you will check in at a later appropriate time.

In the Santa Monica area there are many hotels which are conveniently located near Saint John’s. The Gateway Hotel (a Best Western Hotel) offers discounted prices for patients who are entering Saint John’s. It is located at the corner of 20 th Street and Santa Monica Boulevard and can be reached by calling (310)829-9100. Loews Santa Monica Beach Hotel at (310)458-6700, Shutters on the Beach at (310)458-0030, and the Sheraton Miramar Hotel at (310)576-7777 are all located close to the beach in Santa Monica and many rooms have views of the ocean.

WHAT DO I BRING TO THE HOSPITAL?

In general, the items you bring to the hospital should be limited. You should not wear valuable jewelry or bring expensive music devices, computers, or cell phones. A small amount of cash (less than ten dollars) may be useful. It is helpful to bring a telephone calling card or to know your numerical code for long distance calling if you are planning any calls from the hospital.

Orthopedic patients now fortunately are usually hospitalized on the Orthopedic Unit on the third floor of the new St. John’s North Pavilion. All of the rooms there are private without additional charge and have 42 inch plasma televisions and other modern amenities.

Personal hygiene items, such as cosmetics, lip balm, toothbrush and toothpaste, should be brought with you to the hospital. You may bring an electric shaver. Hair washing is difficult at the hospital, as you will not be ready to shower; however, a beautician can assist you with this.

You may bring clothing to wear instead of a hospital gown. The day of surgery you will have to be in a hospital gown; however, the next day you may wear your own pajamas, nightgown or loose fitting, comfortable clothing. Some patients are sensitive to the detergent the hospital

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uses to clean bed linens and gowns. Wearing your own nightgowns, pajamas or T-shirt will protect your skin and help prevent skin problems. You may bring underwear and something to cover yourself while walking in the hallways. Bathrobes and gowns should not be so long as to make walking difficult or dangerous. You will need comfortable and safe shoes such as tennis shoes or sturdy slippers.

WHAT HAPPENS THE DAY OF SURGERY?

The night or morning before surgery, you should take a shower or bath. This will decrease the bacterial population on your skin and decrease the chance of infection. The night before surgery, you should not have anything to eat or to drink after midnight. Food in the stomach can cause anesthetic complications. Sometimes the internist or the anesthesiologist will tell you to take your usual morning medications with a sip of water on the morning of surgery. Patients who usually take blood pressure medications in the morning should also do so the morning of surgery with a small sip of water.

On arrival at Saint John’s Hospital on the day of surgery, you will go to the preoperative area on 1 West. During your preoperative visit to the hospital, directions to 1 West will be given to you. The visitors’ waiting area for surgery is directly adjacent to the preoperative area and your family and friends can remain there while you are in surgery. The volunteer at the desk in the surgery waiting room should be told that your family is there so that Dr. Moreland can call them and tell them when surgery is completed. The surgery area is on the first floor at Saint John’s.

The anesthesiologist may come to see you before you go to the operating area to discuss the anesthesia, but sometimes this discussion will occur in the surgical area after you leave your family. Usually the anesthesiologist will call you the night before surgery to exchange information and to discuss the anesthetic risks.

You will ultimately be taken to the operating room suite where you sometimes see Dr. Moreland before you are sedated, and the surgery will commence after you are given your anesthetic. A catheter is placed in your bladder after you are given your anesthetic. First time, uncomplicated hip replacements take less than one hour of actual operating time (not including preparation). You are usually in the operating room itself for one to two hours. Revisional surgeries can take anywhere from one to three hours of operating room time or, rarely, even more in particularly difficult situations.

Friends and relatives should wait in the surgical waiting area at Saint John’s (first floor). Patients are usually in the recovery room from one to two hours. Patients cannot be visited in the recovery room but can be visited in the patient’s room after leaving the recovery room. Joint replacement patients are usually hospitalized on the Orthopedic Unit on the third floor of the new St. John’s North Pavilion. Patients do not go routinely to the ICU (intensive care unit), but rarely, patients are placed in the ICU for closer monitoring after surgery.

WHAT ABOUT THE NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES?

Over the last few years there has been dramatic progress in preventing and treating postoperative pain. In the past postoperative pain was simply treated with narcotics until the patient was more comfortable. There are a lot of problems with this approach. Patients need

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widely varying amounts of narcotics for pain control. Since too large a dose of narcotics can cause the patient to stop breathing and even die, physicians must first use lower doses for safety and then increase doses, if initial doses are not sufficient. Patents thus can be in a lot of pain before an adequate dose of narcotics is determined. Narcotics are not really that good at controlling pain. Some authorities say narcotics do not make pain go away and that they make the patient not care about the pain. Narcotics have a lot of side effects. Narcotics sedate patients and decrease their mental alertness. Elderly patients particularly can become confused. Some patients can hallucinate. The respiratory depression can cause other problems such as pneumonia. Narcotics depress the smooth muscles of the gastrointestinal tract and cause nausea, vomiting and constipation. Patients sometimes put off needed surgery from the appropriate fear and dread of postoperative pain. A new approach was greatly needed.

It has now been shown that if a patient feels a lot of pain, his brain gets sensitized to pain such that the patient will feel later pain more intensely. It is important than this extra pain sensitivity not be allowed to develop.

Today we prevent postoperative pain by treating even before it occurs and use other medications for pain. Narcotics are still used but in smaller doses. The morning of surgery you will be given Celebrex (if not allergic). Celebrex is great for postoperative pain and will be given after surgery also. You will also be given a dose of acetaminophen (Tylenol). We also will give you a dose of Oxycontin which is long acting, well tolerated, and effective narcotic.

A spinal anesthetic is strongly recommended rather than a general anesthetic. With a general anesthetic your brain still knows that you are having an operation and your brain is being sensitized to postoperative pain. With a spinal the brain receives no pain impulses from the operative site and is not being sensitized to postoperative pain. Patients are sedated and are completely unaware during the operation. Spinal anesthetics also have the advantage of less bleeding and fewer postoperative problems with blood clots.

A small dose of narcotics is injected with the local anesthetic of the spinal anesthetic. This can give pain relief for 12 hours or more. Your gastrointestinal tract does not see this narcotic dose and GI side effects are minimized.

At the end of the operation before wound closure the wound is injected with a long acting local anesthetic similar to the Novocain used by the dentist. The pain relieving effects of this may last 12 hours or more.

Postoperatively you will receive more Celebrex for a few days, Torodal ( a great NSAID) for one day, and oral doses of the long acting narcotic Oxycontin every 12 hours for two days.

THE HOSPITAL STAY

After surgery most patients experience little or no pain, particularly right after the surgery when so many things have been given already for pain. In addition the minimally invasive hip replacement techniques produce less pain than earlier techniques. Break through pain medication will be ordered for you. To get pain medication call your nurse and tell her that you are having pain and she will then give you medication. For milder pain take pain pills. If you are experiencing a lot of pain, you can take a pain shot. The pain shots are usually ordered no more frequently than every two hours.

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You routinely without asking will be given through your IV drugs to prevent nausea. There are also drugs ordered for sleep.

Almost all patients develop postoperative constipation due to the narcotics and need to take a mild laxative, typically a rectal suppository, on the second day after surgery. Prolonged urinary catheter use can cause urinary infections, which rarely can spread to the hip replacement. Thus, we usually remove urinary catheters two days after surgery. After a urinary catheter is removed, we give one dose of urinary antibiotics to prevent urinary infection. All patients are given intravenous antibiotics to prevent hip infection just before the operation and then usually two doses after surgery to minimize infection risk.

Suction drains are usually placed in the wound to remove any blood which collects after surgery. Dr. Moreland usually removes these suction drains the day after surgery. Your blood count will be monitored at least daily for two days. We normally do not give iron supplementation in the hospital due to the stomach upset it can cause. Transfusions of directed donor or blood bank blood are minimized to avoid the risks of disease transmission and transfusion reactions.

Most patients stay in bed until the morning after surgery at which time the physical therapist will get you up and help you walk. In addition to walking, there are some gentle exercises which the therapist will teach you to prevent blood clots from forming in your legs. You will also wear special stockings to prevent blood clots. After surgery the leg is suspended in two slings which make the leg more comfortable. These slings are designed to unweight the leg and to hold the leg in the proper position to prevent dislocation, not actually to elevate the extremity. Some surgeons use a special firm pillow, called a Charnley pillow or abduction pillow between the legs while in bed. Dr. Moreland does not use these pillows as they are uncomfortable. Do not force your thigh up to your chest for several weeks after surgery to prevent dislocation. The therapist will go over these things with you in detail during hospitalization. Most patients, by the second day after surgery, no longer have an IV, are eating normally, are not taking antibiotics, need only pain pills for pain relief, have no monitoring devices or any tubes, and are feeling quite well.

To prevent blood clots, patients are given Coumadin (warfarin) which is a blood thinner (anticoagulant). The level of blood thinning must be monitored on a daily basis requiring your blood to be drawn each morning. Dr. Moreland will order a dose of Coumadin each evening depending on how thin your blood was that morning. It is important that your blood not be too thin since this can cause bleeding. After discharge most patients are instructed to take one aspirin a day (if able to tolerate) to prevent blood clots and the Coumadin is stopped. Patients with a history of blood clots may need Coumadin for two or three months after surgery.

We have noticed that some of our patients report feelings of depression around the third or fourth postoperative day. These feelings are usually transient, lasting a day or so. We theorize that the excitement of surgery is over, but the patient realizes that the recovery is far from complete and gets depressed. Soon, however, the plan for going home progresses and the depressed feeling is relieved. So, if you experience these feelings, do not worry since they will probably be transient and other patients have similar experiences.

Most patients develop a low-grade fever in the first few days after surgery. The temperature is usually up in the evening and down in the morning. The patient will commonly have fever up to 101 degrees or even 102 degrees for the first few days. This is a normal reaction to the

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surgery and does not mean infection. As the fever goes up, the patient may feel a chill and as it goes down, the patient may have a sweat.

Some wounds drain a light yellow fluid for several days after surgery. This, too, is a commonly seen reaction to the surgery and does not mean infection and usually resolves in a few days.

The social worker and the physical therapist will talk to you about supplies you will need when you go home. All patients should get some type of bedside commode apparatus or a raised toilet seat, which sits up higher than a normal toilet seat. This is because sitting on normal low toilet seats can cause dislocations. It is also easier to get up from a raised toilet seat during the postoperative period.

The physical therapist will get you up the morning after surgery. You will be allowed to weight bear as tolerated on your new hip replacement. You will have some soreness and at first you will need to use crutches or a walker. The therapist will help you decide which is best for you, and the social worker will help you obtain them. Exercise before surgery to increase the strength of your triceps muscles will make postoperative crutch or walker use easier. Crutches are more convenient in tight areas and for climbing stairs, but do require more strength and balance than a walker. A walker is easier to learn to use, requires less strength and balance and is generally used by the older patients. Some patients like to have both types of devices available for differing situations.

By the time of discharge (usually three days after surgery) most patients can without assistance get in and out of bed, go to the bathroom, and take short walks comfortably. Older patients and some patients with other musculoskeletal problems may take longer to reach these recovery milestones. It is best to be able to go to a home after discharge in which there are other people around for portions of the day to assist you with shopping, meal preparation, etc. Constant nursing care is rarely needed. Once home, most patients stay there for one or two weeks while strength is returning. By two to three weeks after surgery most patients are feeling well and begin to go out to eat and shop. Some also return to work at that time if they have a sedentary occupation which will allow walking aids. You can start using a cane held in the opposite side from the new hip when you fell comfortable. There certainly is no reason to rush to using a cane.

Patients often wonder about the need for a hospital type bed for home use. Features such as adjustable height, adjustable head and a trapeze can be useful but are rarely essential. It is very unusual for an insurance policy to cover the cost of such a bed for a patient with a recent hip replacement. Dr. Moreland’s ordering the bed for a patient does not mean that it will be covered by insurance policies. The insurance companies are very restrictive about paying for equipment which is not required for the patient’s care. Patients can still rent a bed, if needed or desired, and assume the financial obligation personally.

If you do not have a satisfactory home situation and you need extended care facilities, such can be arranged with the discharge planner at the hospital in consultation with your family. Our office has a list of local extended care facilities and you may visit them or speak with them.

Many patients are apprehensive about the drive home. Virtually all patients can go home via private car, assuming usual car size and configuration. Occasionally, patients go home via ambulance in situations where the patient cannot easily negotiate serious obstacles such as long, high, or narrow stairs. The physical therapist can help with planning and practicing maneuvers for the trip home.

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Most patients who have a hip replacement need instruction from the physical therapist in the hospital, but after they go home, physical therapy visits are usually unnecessary. Only gentle exercises are needed for the first few weeks after surgery. These exercises are not designed to build muscle strength, but are designed to prevent blood clots during the healing period. We wait until several weeks after the hip replacement to start building muscle strength seriously. Some hip replacement surgeons emphasize muscle strengthening and rehabilitation sooner than Dr. Moreland’s outlined program. All hip replacement surgery involves at least some bruising of soft tissues to gain exposure to place the prosthesis. Dr. Moreland believes some healing of these bruised tissues before vigorous exercise is undertaken will lead to fewer complications and a stronger hip. Most patients later receive physical therapy to build muscle strength, but most patients do quite well with simple walking, the exercise bicycle or the treadmill.

The first office visit after hospital discharge is usually four weeks after surgery. Until then, the patient should generally take it easy and not overdo. Resist showing off how much you can already do to friends.

Frequently, patients develop swelling of the foot and ankle after surgery. If this occurs, you should elevate your foot and be sure to wear the white compressive stockings (TED hose) that you received in the hospital. Severe swelling can be due to inflammation or clots in the veins (DVT) and Dr. Moreland’s office should be notified if this occurs, especially if considerable swelling is associated with pain in the calf or thigh. There is a simple non-painful, non-invasive test (Doppler) to detect blood clots (DVT). If a DVT is found, the patient is usually readmitted to the hospital for a few days of treatment with heparin (another blood thinner), followed by a few months of Coumadin as an outpatient.

DISCHARGE FROM THE HOSPITAL

Just before discharge from the hospital, new steristrips and a new wound covering will be placed over the wound. Until two weeks after surgery, it is best to keep the wound dry and not shower or bathe, other than a sponge bath. After two weeks you can remove the plastic dressing and the tapes and bathe or shower normally. We recommend avoiding a bath tub for several weeks after surgery, because of the difficulty of climbing in and out of the tub and the awkward position that one commonly assumes when taking a bath in a small tub. It is usually safer to shower rather than trying to get in and out of tubs.

After the hospital discharge, any wound drainage should be reported to Dr. Moreland’s office. The wound should gradually become more comfortable. If you notice increased swelling, warmth, and redness over the hip wound, our office should be notified and in most instances, you will need to come in and let us examine the wound. If you begin to run a significant fever (greater than 101 degrees), we also need to know about this. In general, your hip should be gradually getting better but if you think you are getting worse, please give us a call.

You may sleep on the operated side when it is comfortable. For at least the first four weeks after surgery, when you lie on either side, you should put one or two fluffy pillows between your knees. This is to make you more comfortable.

Postoperative dislocations are very rare. If you suffer dislocation, you will usually have severe pain and be unable to walk. Call Dr. Moreland and he will meet you in the emergency room

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and relocate the hip. If you are unable to get in the car with the assistance of friends and relatives, you will need to have an ambulance bring you to the emergency room.

It is best to avoid driving for several weeks after surgery, particularly if the right hip has been replaced, since most driving is with the right foot. The main issue is whether the patient can control the car rather than injuring the new hip replacement. Some patients, however, may need to do so sooner and this can be discussed with Dr. Moreland. It is good to continue to wear the special white stockings for about four weeks after surgery. If, however, you are not having any swelling and you find these stockings uncomfortable, they can be discontinued before this.

WHAT ABOUT FOLLOW-UP APPOINTMENTS?

Office visits after the four week visit are usually at six months and two years after surgery, then every two or three years thereafter. Regular visits to have an x-ray and to have your hip examined are essential for monitoring the result of the surgery and giving you periodic advice for the care of your hip replacement.

We believe the cementless replacements will withstand more vigorous activities than the cemented replacements. We do know that the major failure of cemented joint replacements is loosening. With time and stress, fixation of the cement to the bone can fail and movement can occur between the cement and the bone. This movement can cause pain and if the pain becomes severe, a revisional operation may be necessary. The longevity of your cemented hip replacement can be increased by avoiding stressful activities such as all types of impact sports including: running, jogging, tennis, snow and water skiing, racquet ball, badminton, football, baseball, bowling, and horseback riding. Heavy lifting, weight lifting, jumping from a height, falls, and some exercise machines for the legs are dangerous for you. It is important that you not become overweight, since excess weight increases the stress on the hip replacement and can cause loosening.

Cementless replacements, once ingrown, can withstand the most vigorous activities. We have many patients who ski, play tennis and other racquet sports, beach volleyball, and other such very vigorous activities. With the cross-linked polyethylene now used, wear is also much less of a worry.

Another concern about your hip replacement is the possibility of infection occurring around the replacement. If you develop an infection elsewhere in your body, it can travel via the bloodstream to the replacement. Infections likely to do this are urinary tract infections, as well as skin and toenail infections. If you develop any of these, you should consult your family physician or internist and be treated promptly. Dental work can push bacteria into the bloodstream and cause an infection in your joint replacement. Your dentist may recommend that you take antibiotics with your dental work. You should always notify any treating physician that you have a joint replacement since other medical procedures, tests, and surgeries can involve infection risks to the replacement. The physician or the dentist doing the procedure should give the appropriate antibiotic coverage for the procedure. Since there really is no proof as to what the best antibiotic to give is and exactly how it should be given, Dr. Moreland is satisfied with whatever antibiotic treatment your physician or dentist wants to give you. It is more convenient and appropriate for that physician or dentist to prescribe the antibiotics, than for Dr. Moreland since he doesn’t know exactly what procedure you are having.

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Patients with a hip replacement usually trigger the airport metal detection devices. We can give you a card attesting to the presence of your hip replacement.

Finally, it is important to see us at least every two or three years for an x-ray and examination, so that we can advise you as to how your joint replacement is doing and recommend possible activities. This serial x-ray record of your hip replacement often is helpful in the evaluation of any possible future problems. Wear of the polyethylene plastic in your hip replacement can be a problem, and the patient does not always feel symptoms from the wear until the damage is extensive. With the cross-linked polyethylene now used, wear is also much less of a worry. The best way to look for wear is to take a radiograph every two or three years.

HOW CAN I PREPARE MY HOME?

Most patients need to make a few modifications to their home environment prior to undergoing joint replacement surgery. Planning your postoperative needs will help you to more easily adapt to the transition from hospital environment to home. The hospital has an advantage over home in that it is a smaller room with all the necessities delivered right to you and a nurse to assist you with such needs as eating and toileting.

Prior to discharge, most patients are able to independently get out of bed safely and walk a functional distance, maintaining minimal weight bearing using a walker or crutches. You do not need to purchase a walker or crutches prior to admission to the hospital as these will be supplied to you there. If you have already obtained a walker or crutches, you should bring these with you to the hospital so that the physiotherapist can adjust them to your size and check them for safety. Borrowing another person’s used equipment is an acceptable way to reduce costs as long as the equipment is in good shape and adaptable to your size.

You will be taught, prior to leaving the hospital, how to get dressed, including shoes and socks. Initially, upon returning home, you will probably be most comfortable in loose-fitting clothing which is easy to get on and off. Your shoes should be safe (non-skid soles) and comfortable to walk in for use in the hospital and at home.

If you live alone at home or if you think you will need additional help, there are nursing agencies that can provide people to take care of such necessities as changing and washing the bed linens, shopping, and meal preparation. They can also assist you with watering plants and the maintenance of pets. Our office can supply you with names of agencies and phone numbers to call and make arrangements to meet the people prior to your surgery. Most insurance companies, including Medicare, do not cover the cost of homemaker/chore persons. The fees, however, are usually reasonable and professional home help can allow you to enjoy the comforts of your own home rather than having the inconveniences of an institution.

You will not be able to take a shower or a tub bath until two weeks after your hip replacement. Until the wound is completely healed, bacteria could enter the wound with the bath water. In the hospital the nurses will assist you with bathing utilizing a basin of water and soap. Until such time as you are allowed to shower, you should follow this same procedure at home. A stall shower is the safest way of showering. The commode chair, which you will be using as a raised toilet seat, may be placed in the shower so you can sit safely while you are showering. Many people find that the hand-held shower nozzles are very convenient to shower with in the postoperative period. If you only have a bathtub, special arrangements and assistance will be

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needed in order for you to bathe safely. You should discuss this with the therapists in the hospital.

If your bedroom is located upstairs or is too far away for you to get to the bathroom or kitchen conveniently, you may want to set up another room in your house as your temporary bedroom. Most patients do not need a hospital bed. The bed you use, however, should not be excessively low as some platform beds are. If you have concerns about your sleeping arrangements, you can contact our office to discuss the situation.

You will need a comfortable chair with arms at home. Look around your house for a chair with arms and a firm seat which is not too low. The arms will help you to get in and out of the chair. You may want to consider such items as baskets that you can attach to walkers to carry things, or attachments you can place on crutches to allow for movement while carrying something to drink. Remember that your hands will be used for the walker or crutches so, in order to carry an item with you from one room to another, you must be able to put it in something. Pockets, preferably large ones, are a very convenient way to carry things which won’t spill. Some patients like to utilize small backpacks or fanny packs.

Talking to other patients who have experienced hip replacement surgery about your specific needs at home can be very helpful. Our office would be happy to supply you with a list of patients to contact.

We are pleased to be able to present this manual to you and we hope it helps you in understanding your condition and the possible treatments which are available. Please feel free to ask additional questions. We look forward to taking good care of you!

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DR. MORELAND’S HIP OPERATION DATA

The most common hip operation performed by Dr. Moreland is primary hip replacement using cementless techniques. For many years he consistently used the anterolateral approach and implanted one type of cementless femoral component, the Prodigy (an advanced type of AML), paired with two types of cementless acetabular components (the Duralock and the Pinnacle). All of these prostheses are manufactured by Depuy, which is owned by Johnson and Johnson. Between 10/1/1992 and 10/1/2002, a period of ten years, he performed 1,926 total hip replacements using this combination. This does not represent all of the operations he performed during that period, since he also performed some primary hip replacements using other techniques, as well as revision hip replacements and total knee replacements. On the next pages are the statistics for these 1,926 primary cementless hip replacements using the Prodigy femoral component with the anterolateral approach.

John R. Moreland, M.D.Hip Operations Summary

August, 2004

Dates of Surgery Number Operation Type

7/1979 to 7/2004 5,159 all hip operations

7/1979 to 7/2004 3,586 primary hip replacements

10/1983 to 7/2004 3,037 primary cementless hip replacements

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3/1992 to 7/2004 2,406 primary cementless hip replacementsusing the Prodigy femoral component

10/1992 to 10/2002 1,926 primary cementless hip replacementsusing the Prodigy femoral component

with the anterolateral approach

Statistics for 1,926 Primary Cementless Hip Replacements Using the Prodigy Femoral Component

with the Anterolateral Approach

ReoperationsReoperations for femoral fixation problems…………........ 5 (0.3%)

Reoperations for acetabular fixation problems……...….…0 (0.0%)

Reoperations for dislocation……………………..………….. 6 (0.3%)

Reoperations for wear………………………………………….5 (0.3%)

Reoperations for leg length problems....................…......... 2 (0.1%)

Reoperations for bursitis ……………………….…….……….1 (0.1%)

Total reoperations...…………………………………………….19 (1.0%)

Complications Perioperative deaths……………………………………...........0 (0.0%)

Infections………………………………………….….…………..0 (0.0%)

Femoral fracture ……………………………………………….. 0 (0.0%)

Nerve damage (any nerve)…………………………………….. 0

(0.0%)

Vascular injury …………………………………………………. 0 (0.0%)

Severe heterotopic bone formation………………………….0 (0.0%)

Dislocations……………………………………...……………… 9 (0.47%)

Deep venous thrombosis………………………….…………...31 (1.6%)

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Pulmonary emboli……………………………………………….5 (0.3%)

StatisticsAverage operative time……………………………………….…50 minutes

Average blood loss during surgery…………………….…….350 cc’s

Usual incision length…………………. ………………………. 5 inches

Usual hospital stay……………………………………………... 4 days

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