- February 13, 2018
We’re going to start out the day talking about hip replacements and hip arthritis and some of the new things we do for hip arthritis. So advances in hip arthritis and hip fractures. So conservative care you come to the office and you have hip pain. Hip pain when I think about hip pain is three different things. So you can have a groin pain and groin pain is truly your joint. That’s the ball and socket join you get to have lateral pain going down the side of your leg. That could be coming from the joint or coming from your back. And then you could have buttocks or posterior hip pain and that’s usually from the back or from muscle spasms. So three different places you call you have hip pain could be any of those three and then we’ll sort them out when we see in the office. If it’s truly arthritis or truly groin pain or lateral pain then there’s a few things we can do for it.
We can start out pretty easy. We start out with cortisone what we can do called PRP which is a platelet rich plasma. That’s taking your blood spinning it down and put it back in. We can do the new injections called Stem Cells. And we can do it’s called Viscosupplementation. Physical supplementation is the chicken shots you hear about the chicken shots are approved for the knee they’re not approved for the hip yet.
We can do them but the insurance company may make you guys pay for them. We can do therapy. We can do a range of motion to maintain the motion you have if you’re losing motion because of arthritis you can gain some back as we teach you what to do for it we can do strengthening so if you’re getting weak and you may need a hip replacement down the road we do it’s called prehab. And Paul is out here from our therapy department, he could tell you about prefab getting your quads stronger your hamstrings stronger, your hip flexor stronger before you actually get into surgery. And a lot of times if you guys get stronger and you have arthritis you can deal with arthritis because your strength comes back so it buys you some time actually and then there’s modalities that therapy can do the modalities or they can either do ultrasound they can do medicine they can do what’s called iontophoresis and this takes away the inflammation that’s in there.
So instead of doing a shot if you guys are afraid of shots like I am you can do these things really for the medicine on the outside and then use the machines to get it to go through the skin. If you’re not afraid of shots it makes it a little easier. And then lastly we have Nsaids or what we call anti inflammatories. Anti inflammatory is could be pills, you taking my mouth. Or nowadays we have also rub on anti inflammatory so they have creams and liquids that you can rub into the area and It’ll seep through your skin. So a lot of things we can do before we actually get the surgery.
When we do have surgery there’s types of hip surgery that we can do so we can do it’s called an arthroscopy we put a camera in there we look around just like we do knee and we do shoulder your ankle we can also do hip arthroscopy we can put a shaver in there we can clean it out and we find a tear we can repair it. So a lot of things you can do before actually get a replacement if it’s one side of the joint that’s bad. We can do a partial hip replacement. So if the Balls dying but the socket is good and you don’t want a full hip replacement. You have a lot of tennis or pick a ball or bowling that you do and you’re worried that you might be in weird positions that you might this dislocate we can just do a partial hip replacement. We can do what’s called a hip resurfacing.
So you’re really not collapsed. It’s not a horrible hip is not bone on bone but there’s arthritis all around the head.
We can take the ball from the ball and socket and we can basically Rotor the top of it and put a little cap on it. And that cap resurfaces and then we can put a cup on the other side. And then you have a new joint but you don’t have any big cuts taking a lot of bone away.
And then lastly we can do the actual hip replacement then the hip replacement comes in multiple different types so we can do an anterior hip replacement depending on your body habits and depending on your bone stock. So you have osteopenia or osteoporosis. It’s not really good for anterior hips because it could break the bone the way we put it in. If you have really big body habits and a big belly makes it hard to do the anterior approach because it’s right there when you sit up the front part of the belly will sit on the incision. And it gets sweaty and moist and get infected so that’s dangerous. We have done a couple where people asked us to do that. We took a binder and we put a binder on them just to keep that belly off for a couple of weeks so that the incision would heal and then they can go on for the hip replacement part. And now you’ll see as we get down the road the person that wants the injured hip replacement is really an active gung ho person. It might be the right leg.
They might be home alone and they have the drive and you can do all of your activities faster with an anterior hip replacement especially with your right leg which can drive faster. But there are some risks too it’s not the gold standard yet. The gold standard is still anterio-lateral or posterior. So the anterio-lateral or posterior approaches are where make the incision, we peel the muscles off, and then we put the prostheses in and we put the muscles back. Whereas the anterior approach we just separate the muscles and drop the prostheses through that and we’ll go over.
So the anterior approach is a straight anterior.It’s right in front of the groin right now on your thigh. It’s muscle sparing meaning we take the muscles away and then let them come back. We don’t cut any of them and it’s a smaller prostheses. So that smaller prosthesis has to sit in really good bone. We’ve tried it in the past where we put their prostheses in and if you have a little osteopenia a little osteoporosis as you’re walking that prostheses can subside a little. If it subsides a half a centimeter it’s not so bad. We can do a little shoe edge but if it subsides centimeter or two centimeters it’s really low. We’d have to put a bigger prosthesis in or put a cable around that the entire lateral approach comes off the entire side of your thigh down the lateral side of your thigh and then the post here comes around into your buttocks.
So we do an anterior approach and this is what we have to talk about. We talk about are we going to do it on a regular table. And some of the docs will do it on the left which is a regular table and some of us will do it on a special table which I do on the right. This is called the Hana table and this Hana table allows us to take your leg and put it in positions that you don’t want to see but you’re asleep so you don’t have to. And by doing that we’re able to get that smaller prostheses in we’re able to get the ball and socket in and then drop the muscles back and not actually have to do a big surgery on your muscles or on your bone. The problem is if you have weak bone and we’re talking your leg all around we could actually break your femur.
So it’s important to talk about in the office more trying to decide once you’re ready for the surgery which type of surgery we will do. On the left. You have to have a lot of help. And those people manipulate the leg into all those different positions just like the table does. So when we talk about this we get that far in the office. We talk about the hand a table that’s the table that’s the anterior hip table. And why a special table. We talked a little about it but this is the model showing you what you can do. So we can keep this leg up. We can really hyper extend this leg and get all the way down the shaft. We can do traction down here we can pull on it as much as we need to. We can do rotation internal and external with this little button.
And we can do Ab duction and Ad duction where we take it to your body or away from your body. We fluoroscopy and x ray machines. We bring the x ray machine right in and look at your hip because of the special table. So we should be able to get the leg length nearly exact to the millimeter and the offset meaning from the pelvis to the outside of the hip, nearly exact to the millimeter as well because we’re doing it looking at the hip and with x ray. Whereas the anterio-latera or posterior we’re just doing it from clinical. We’re looking at it and getting it as close as we can. We can also do this for fractures. So this person had a hip fracture and we wanted to do a replacement for the fracture. We can do it on this table.
So why not why sometimes don’t some doctors use it or some hospitals do it it’s really expensive table. So once you have it is good but it’s hard to get it budgeted. So if you go to a hospital and you want your doctor to do an anterior hip they don’t have the table that maybe the reason. Setup time is a little longer. You need someone to run the tables in the first couple of cases the rep will comment I’ll run the table for us but then once he gets his check we never see him again. So then we have to teach somebody from our program or from the hospital’s program how to run the table to an extra person to do that. You don’t really have a feel for the hip when we’re trialling, when we take the fake implants and put them in to see how they fit before we put the real implants in. We’re taking your leg when we’re not using a special table and we’re manipulating it all around lifting it up pulling it pushing it make sure it’s as stable as we can get it so that you do not dislocate. Because if you dislocate then you had to come to the E.R. and we gotta pop it .back in you can’t really feel that on the table but that’s what the x ray machines for the X-ray machine shows us all of that to make up the difference.
And then you can perform the surgery wherever they have the table. So that makes it easy once we do get the table. So I think personally once we get the table it’s actually cost effective because there’s all these different things we’ve learned how to do on it now so we can do that total hip. We can fix your femur we can fix your tibia. We can fix your hip fracture. If you were before all this and you need a hip arthroscopy we could actually do that on the same table now. Which is really nice. So what are the indications and contra indications if you need a hip replacement. So if you have end stage hip arthritis meaning of the bone on bone, the X ratio collapse, or the MRI shows a vast going across as meaning the ball is dead, You have a groin pain or groin pain and lateral pain, you can’t walk, You can’t put weight on it, you can’t internally externally rotate, It’s time for hip replacement. And it’s a big surgery if any of you guys in this audience have had one or any. Not yet. OK. So it’s a big surgery. You’re in the hospital for a couple of days. It’s about a two month rehab and you know you lose some blood you’re under anesthesia for an hour and a half. So it is a big decision.
If you have a femoral neck fracture and that’s what this is showing right here. And an active person with a displaced neck fracture with arthritis right here in this area. We take the ball out and then we put a total hip in. And that can be done on the anterior approach with that table or a regular approach. And then obviously if there’s no histories of DVt, no chronic use of coumadin or xeralto, If you’re on blood thinners it’s a big surgery. We have to wait until we get you off those blood thinner switch you tolovenox then stop the lovenox the day before and then we can do the surgery. So we’ll talk about all that at the time of hospital or time of surgery. So this is what we do we make our little anterior incision and we put this little plastic ring in there and I protect your skin.
And then we have these metal retractors. These metal detractors have little hands on it by my assistant. And then we’re able to see right inside your hip so you don’t need that big lateral incision or big post your incision anymore. We can do it like this if you’re a good candidate. It’s obviously less invasive. It’s muscle sparing. Your butt muscles your gluteus maximus and medius are preserved. We’re not back. They’re cutting them or stretching on them. You’ll see people come in after hip replacement and their hip feels great their groins are awesome but they have a little limp. And that limp could be because those muscles back they’re never recuperated from the surgery. We call that a trendelenburg gait. So we can try a shoe lift. We can try therapy but some people don’t get rid of that limp. They still have a little limp.
And your iliotibial band, you’re big muscle down the side your leg is preserved. You have a faster recovery. And the best thing for therapists and Paul and his group is there’s no precautions. So when you have an anterior hip approach soon as you leave the hospital you can do whatever you can tolerate. Because of the way the ball goes in and the way the cut in the socket are built, It’s nearly impossible unless you’re doing tricks on the trapeze or ballerina stuff to get that ball out. Whereas if you cut through the muscle the muscles a little bit weaker and it can’t do all the things it used to do and then there’s a chance for getting down to get your ball out of the hole playing golf or if you’re pivoting the wrong way and going down to get something off the floor you can pop that ball out.
So that is one of the advantages. It’s called the Smith-Peterson approach. The approach has been around for years and years and years and it’s muscle sparing. These are the muscles that we go through but don’t cut and then there’s a couple of there’s an artery in two veins that we like it or we tie off so that it doesn’t bleed and those go to the balls since we’re replacing the ball anyway. You don’t need those. So they’re extra once we take the ball out. We do cut the capsule and then we cut the neck of the femur and the head off and put the new metal one in. So there is a little bit of cutting but not as much as the other way. So we call it the direct anterior total hip approach and there’s a lot of data. And studies out for the last 10 years now. So it’s getting more and more widely used but it’s still not the gold standard.
Had a nice study in the North East. It’s a prospective study meaning he did it right from the beginning said all right we’re going to look at this and then they did the patients and the study. They didn’t do the patients and then come back and do the study afterwards. That would be called a retrospective study. So the average age was fifty nine and he did him as young as 17 and as old as 91. So if you’re ninety one you have hip arthritis but you have good bone you can still get an anterior approach. BMI meaning the weight that you carry to your body habitus was twenty nine average. Sixteen to fifty eight. Now with the new Medicare studies and with our outcomes at FOI, we try and keep it under 40 so if you’re over 40 BMI we want to get under 40 where we want to see that you have at least about a 10 percent weight loss going in so that we know there’s going to be a little safer for you.
Infection rates higher, your dislocation rates higher, the length the surgery’s higher for the higher BMI. So we try and keep it under 40. Patients or immediate weight bearing there’s no toe touch no lift in your leg in the air with a walker your immediate weight bearing with a walker or crutches or a cane you don’t have to protect it at all there’s no hip precautions you can do whatever you can tolerate the pain feels good enough. You can drive. You can take your car your golf cart whatever you want. They had three groups. The operative time decreased from each group. So the first group was about two hours and 10 minutes. Then the second group was ninety nine minutes of the learning curve was getting less and less. The third group was seventy four.
So a standard total is about an hour to an hour and a half. So now they have the anterior approach down with the first 300 back down to about an hour and 10 minutes.
So in summary. The anterior total hip is safe. There’s rare instability or dislocations. The alignment is better with the fluoroscopy. The learning curve better with time obviously and the patients and therapists are much happier. This is pretty cool I found this little bottle online it’s a little bottle of wine with Infante on it. I haven’t tried it yet but I found it.
And then this is what it looks like. So this is the cup. This is the neck. This is the stem. And then the ball is inside of the cup. That’s us doing the special table. And then this is how they do it on the regular table. It’s pretty similar and we have all of these assistance with you.
This is the little stem going in to see how it’s got a little hook to it so it comes in and it slides up the femur and that’s so that we don’t go straight down and through the femur. If you go straight down and through the femur that we have to take that out and cable it and then we don’t let you guys waver. On it so ideally we don’t do that. It can happen. We try not to. This is what the ball looks like right before we pop it in.
And this is the final product so cup, screw, ball, stem. And that’s a complete hip replacement.
And then you can get out if you do it early enough in the morning we’re up to about 1 o’clock you can get up that same day with therapy and walk if it’s later in the day like 4 or 5 o’clock then we get you up the next day.
So wait very immediately no precautions.
1 to 3 days in the hospital instead of 3 to 5 days. To wake up the next morning and your bloodwork is good and you walk with therapy and you want to go home, you can go home the next day now. If you have somebody at home with you if you make sure you can get around and get up from your chair to your bed your kitchen and your bathroom you’re ready to roll.
So we can use the special table the regular order table we prefer the special table the patients the therapist and the nurses are all very happy without the help precautions nowadays actually if I do a regular hip replacement then Paul from therapy or Heather from therapy will call me up and give me crap why I did it and I have to explain to them why did it’s kind of have an extra wife.
So we try to do anterior approach if we can. All right so hip fractures.
As we get older and older and older we’re gonna fall and we’re gonna get hip fractures or some people think that we get hip fractures and then fall. So if you have osteoporosis or osteopenia and you’re walking and you have a stress area in your femur it can crack. And you can fall. So we’ll see people in the hospital on the say Doc I was walking fine I swear. This broke before I hit the ground. And it’s very possible it happens a lot and it can happen in different areas it can happen in the subcapital which is right below the ball. You can have in mid neck where this one is where it can happen down here in the trochanteric region which is intertrochantear tear. And there’s different things that we do for those hip fractures and most of those things are new nowadays in the last ten years. Those are different types of fractures there are no tests you don’t have to learn those.
So femoral neck it’s intracapsular, meaning the blood supply is cut off. So we either have to fix those right away or we have to replace them if you have arthritis. This is different areas and the different angles that they happen. And these are all the different ones that we’ve seen. If it’s down low like this we typically fix this with a rod and with screws. If it’s this area intertrochanteric region, again it gets a rod and screws. This one is more stable so the rod is short This one is unstable so the rod is long. You get to the E.R. and you have groin pain or thigh pain and you can’t walk like you used to. You tell them you think you broke your hip it’s not coming from anywhere else. They do all these other tests and then they send you home. And then when you’re home that hip fracture can get worse it can move and it can displace and then you can’t walk at all.
And then we have to do a bigger surgery. So I try to teach them it’s not a zebra it’s gonna be a horse if you hear hooves. Always think hip fracture in this population. If it’s not a hip fracture. Fine. You got to get a CAT scan you getting an MRI. You got to make sure it’s not a hip fracture. Don’t send them home.
So we get the X-rays. We don’t see anything we say. OK. Something weird is going on they have groin pain they don’t feel right we get the MRI. Boom Big crack right through the neck. The MRI is so much more sensitive nowadays than an X-ray. So we have to check that in the E.R. for you. We can get a C.T. scan if you have stance.
If you have a pacemaker, if you have some metal fragments in your head and they’re afraid the MRI is going to pull those metal fragments out or your eyes then we can get a C.T. scan the C.T. scan isn’t as good as the MRI.
The MRI is the most sensitive and you see the cracks really well.
This is what we see in the E.R. if you break it. And then we give you some sedation and we pull traction on it to see what it’s going to look like when it lines up.
Sometimes we do this in the E.R. if you guys already on the floor we don’t like the pull on your broken femur. If we don’t have to.
Physical exam. So if you come to the E.R. you see this at home you’re one leg is up with a little bit of rotation and your other leg is out with a lot of external rotation.
That’s a hip fracture until somebody else tells you differently. OK. So either get a ride to the hospital or call nine one one and get there because when you externally rotate like this the ball and the femur aren’t intact anymore.
So what to do. We can reduce it and fix it if we get it quick enough or if it’s non displaced. If it’s displaced.
And have our yes we can actually do a hip replacement just like we talked about before. Totals can be the anterior approach just like we talked about.
And if it’s your right leg you’re driving almost immediately with an anterior approach. 4 weeks typically for the posterior where the anterio-lateral approach so you’ll save about four weeks of driving time especially if you own.
Well we remember that as we get older and older and you get into your 80s you can’t really hop. It’s really hard to hop as an octogenarian. So kids can hop. The octogenarians can’t. So we try to fix everything and make you weight bearing. If you’re trying to hop and you’re training as a walker chances are you’re going to fall again and you’re going to break something else you’re gonna hurt your head. And if you’re on blood thinners Coumadin or Lovenox or Xarelto and something’s in a bleed. So we try not to do this. If somebody tells you Oh no you’re non weight bearing on that question it. Say why am I not a weight bearing, who said I’m that weight bearing maybe the order is incorrect. You should be weight bearing on all of these. Thank you very much.