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Hip prosthesis

Complaints that may be associated with a worn-out hip ("hip osteoarthritis") are:

- Groin pain

- Pain in the thigh or knee

- Bilge pain

- Night pain

- Starting pain

- Morning stiffness

- Difficulty putting on socks and shoes

- Limited walking distance

Conservative path

If osteoarthritis of the hip is diagnosed, a conservative course can always be started first, i.e. non-operative treatments are tried for at least a few months. These include painkillers, physiotherapy, losing weight and adjusting the load on the hip.

Operative route

If the conservative course does not sufficiently alleviate the symptoms, surgical replacement of the hip joint can be considered: placing a new head and a new socket, the so-called hip prosthesis.

But how many complaints should someone have before deciding on a hip prosthesis? Unfortunately, there is no simple answer to this question. The conditions that are often used are:

1. Osteoarthritis on the radiograph, grade 3 or 4 according to the Kellgren-Lawrence classification.

2. Night pain

3. Pain that cannot be adequately suppressed with painkillers

4. Pain-free walking distance of up to 500 metres

5. Difficulty putting on socks and shoes

6. Not too many risk factors in the patient, such as Body Mass Index (BMI) over 35, smoking, COPD, heart failure, diabetes.

Of course, these conditions are not rigid and will be discussed during the consultation.

The hip prosthesis

The prosthesis we use, the Accolade 2 stem with 32 mm ceramic head and Trident bowl, is made by the Stryker company and has proven itself worldwide. The expected life span of this prosthesis is about 20-30 years. This titanium prosthesis is provided with a hydroxyapatite layer so that it will fuse with the own bone. The advantage of the Accolade 2 stem is that it is a relatively short stem, leaving enough bone for a new, longer stem to be fixed in the bone during a possible recovery operation.

Only if the bone quality is poor due to osteoporosis can a "cemented" hip prosthesis be chosen, in which case it is glued to the bone.

The operation - preparation

Before the operation, the anaesthetist will carry out a pre-operation examination. You will first complete an extensive online questionnaire about your health and medication. Then you will discuss whether you want a spinal anaesthetic with sedation or a general anaesthetic. The first option is chosen in more than 90% of cases because of the faster recovery in the first hours after surgery. If you are taking anticoagulants ('blood thinners'), the anaesthetist will discuss with you whether you should temporarily stop taking them around the time of the operation.

The operation - in the holding area

On the day of surgery, you will be admitted to the holding area, the preparation room before you go to the operating theatre. There, you will receive an infusion and antibiotic prophylaxis will be started to minimise the risk of a wound infection.

The operation - in the operating theatre

First, a checklist is carried out with the entire operating team (Time Out Procedure). You will be connected to the anaesthesia machine to monitor all your vital functions during the operation. You will then be given spinal anaesthesia or general anaesthesia. The anaesthetist will remain at the head end of the operation to monitor you. The skin is disinfected and the operation area is covered with sterile drapes. You will also receive Tranexamic Acid to reduce the amount of blood lost during surgery.

The operation - the approach

The hip joint can be approached from three sides: from the back (posterolateral), from the side (lateral) or from the front (anterior).

The anterior approach is also called Direct Anterior Approach (DAA).

This approach is now the gold standard for us because of the following advantages:

- use of a natural muscle interval that does not loosen muscles

- more stable hip and therefore less chance of luxation (0.5% versus 3-4% with the posterolateral approach)

- smoother recovery

- supine position, which makes it easier to control leg length, less chance of a leg length discrepancy postoperatively

- better positioning of the cup due to the supine position, the patient is more stable than in the lateral position

The disadvantages of the DAA are:

- Longer learning curve to get used to this method

- temporary loss of a small cutaneous nerve in 1-2 % of operations (cutaneous femoral nerve, thigh deafness)

The operation - placement of prostheses

First the femoral head is removed, then the own socket is rounded off and the cup component is inserted. This cup is clamped in the hip socket and takes 4-6 weeks to fuse with the bone. In the next step, the thigh bone is opened and the right stem size is determined with a progressive rasp. With the final rasp, the hip is put back in place and tested for function and stability. Now the rasp is replaced by the real component. This femoral stem will also fuse with the bone in 4-6 weeks. Finally the ceramic head is placed on the stem and reduced in the cup. Because of the DAA approach no muscles need to be attached and the wound can be closed in 2 layers. The skin is closed with soluble sutures or a ZIP line suture.

The wound is covered with a shower plaster. The scar will be between 10-15 cm in size. At the end of the operation, another checklist is taken with the whole team (Sign Out Procedure).

The operation takes about 60 minutes and the average blood loss is 250cc. A control X-ray is always taken after the operation.

The operation - in the recovery room

After the operation, you will be taken to the recovery room and your vital signs will be monitored extra, such as blood pressure, breathing, pain and blood loss. If you are stable, you may return to the ward.

In the post-operative department

Once the spinal anaesthesia or general anaesthesia has worn off, you can immediately start to put 100% weight on your body under the supervision of the physiotherapist. First with a walker, later with 2 crutches. You will quickly learn how to walk to the bathroom and toilet on your own. The next day you will learn to climb stairs. Once the pain is under control and the wound is dry, you may go home.

At home

The shower plaster can be left in place for 10-14 days, only to be replaced if it leaks through. Physiotherapy will help you to increase the load. Inside the house you will soon be able to walk with 1 crutch, outside with 1 crutch only after 2 weeks. You should not drive a car until you can walk outside with one crutch, usually after 3-4 weeks. Only after 6 weeks should you swing your leg far back and resume sports such as golf, swimming, dancing, tennis and outdoor cycling.

Possible complications after a hip prosthesis

- Temporary numbness of the upper leg, 1-2% chance

- Wound infection, chance 1.0 %

- Leg length discrepancy after surgery >1 cm, chance 1.0%

- Luxation of the hip (dislocation), probability 0.5%.

• Trombose, kans <0,5%

Temporary numbness in thigh

The Nervus Femoralis Cutaneus Lateralis can be slightly damaged by traction during the operation or by swelling after the operation. Patients then temporarily have a numb spot on the upper leg of about 10-15 cm. In most cases, the sensation returns completely within 4-6 months.

Wound infection

You are always given antibiotics around the operation, but sometimes you may be unlucky if the wound does not heal properly and continues to leak. If the leakage continues for more than 2 weeks, the operation wound must be flushed in the operating theatre. This is to prevent the bacteria from settling on the prosthesis and becoming difficult to remove. After the flushing operation (also called DAIR: Debridement, Antibiotics and Implant Retention), you will be given an antibiotic for a minimum of 6 weeks, first for 1-2 weeks via infusion, then as tablets. In more than 90% of patients, this is how the infection is controlled.

Leg length difference after surgery >1 cm

During the operation, the leg length is determined in combination with the stability of the hip. If the hip shows some laxity, which makes it easier to dislocate, the leg can be lengthened a little. Up to a difference of 1 cm in leg length, you do not need to put insoles in your shoes, because you usually get used to them. The advantage of Direct Anterior Approach (DAA) is that the muscles are not loosened, the hip is already more stable and lengthening the leg is almost never necessary.

Luxation of the hip (dislocation)

The first 6 weeks with the DAA method you should not swing the leg all the way back together with turning the foot outwards ('exorotation'). This is because the capsule at the front of the hip has been opened and needs about 6 weeks to heal completely. Because all the muscles have remained intact, the risk of luxation is very small. If it should happen unexpectedly, the hip can be re-inserted in the emergency room. You will then have to take it easy for another six weeks. In case of permanent instability the cup can be extended or a special cup can be placed ('double mobility cup'), but fortunately this is rare.

Thrombosis prophylaxis

To reduce the risk of thrombosis, patients are given Heparin injections for 4 weeks, to be injected once a day into the abdominal fat or upper leg. You will be taught how to do this during your hospital stay.