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Total Hip Replacement Surgery -Types, Approach & Articulations

Updated: Oct 4, 2023

Hip replacement surgery is a prevalent procedure in India, particularly for individuals experiencing persistent and debilitating hip pain that cannot be relieved through non-surgical methods. If you find yourself in this situation, it may be recommended to undergo hip replacement surgery. However, it is crucial to have a clear understanding of what to expect from the surgery, as it can help individuals be better prepared and informed about the process.


In this comprehensive blog, we will explore the various types of hip replacements available and the different types of articulations used and provide detailed information to help you better understand the procedure. By familiarising yourself with the intricacies of hip replacement surgery, you can approach it with a sense of knowledge and confidence.


It is important to remember that if you have any doubts or concerns regarding total hip replacement surgery, it is always recommended to communicate openly with your doctor. They are the best source of information and can address any specific queries or fears you may have, ensuring that you are well-informed and comfortable throughout your surgical journey.

 
 

What is total hip replacement surgery?


What is total hip replacement surgery?

Total hip replacement surgery, often referred to as total hip arthroplasty, is a surgical procedure involving removing damaged bone and cartilage in the hip joint and replacing them with prosthetic components. The surgery begins with removing the damaged femoral head, the upper part of the thigh bone (femur). Subsequently, a metal stem is carefully inserted into the hollow centre of the femur, providing stability to the new joint. Depending on the case, the stem may be secured using cement or a press-fit technique.


To replicate the natural movement and function of the hip joint, a metal or ceramic ball is precisely positioned on the upper part of the inserted stem, effectively replacing the previously damaged femoral head. In conjunction with this, the damaged cartilage surface of the socket, known as the acetabulum, is removed and substituted with a metal socket. In certain instances, screws or cement may be utilised to secure the socket in its proper place. Finally, to ensure smooth gliding and minimise friction within the joint, a spacer OR LINER made of polyethylene, ceramic, or metal is carefully inserted between the new ball and socket.



Types of total hip replacement surgery


1. Uncemented total hip replacement surgery


Uncemented total hip replacement surgery

Uncemented total hip replacement is a widely used approach involving specialised artificial components designed to achieve bone-to-implant fixation. In this technique, the femoral component is typically coated with a porous surface on its Outer surface This porous surface is applied using a spray technique and is characterised by microscopic contoured troughs and ridges. The unique feature of the porous surface allows for natural bone growth both on and within it, forming a solid interlocking bone between the implant and the bone. This phenomenon, often referred to as osseointegration, creates a gridlock effect that firmly binds the implant to the surrounding bone. As a result, uncemented fixation has become the most prevalent method utilised in total hip replacement surgeries.


Uncemented total hip replacement is an effective and widely accepted technique for achieving long-lasting implant stability. The utilisation of porous coatings and osseointegration promotes bone ingrowth, enhances implant longevity, and minimises the risk of any complications.



2. Cemented total hip replacement surgery


Cemented total hip replacement surgery

Cemented total hip replacement is a technique that involves using polymethylmethacrylate (PMMA) bone cement to secure the implant surface to the bone. Unlike simply "glueing" the implant to the bone, this technique creates an interlocking connection between the implant and the bone, promoting stability and long-term fixation. The PMMA bone cement is typically prepared by combining powder and liquid components, creating a dense material that can be applied during the surgical procedure.


The cement acts as an intermediary layer, filling the void between the implant surface and the bone. It provides immediate fixation and stability by forming a mechanical bond with the surrounding bone. The PMMA bone cement hardens quickly, creating a solid, durable interface that allows for weight-bearing and functional joint movement.



In some cases Hybrid hip replacements can be opted by combining a cemented femoral stem with an uncemented acetabular cup. The cemented femoral stem provides immediate stability and fixation by utilising bone cement, ensuring a solid connection between the stem and the femur. In contrast, the uncemented acetabular cup is inserted into the hip socket without using bone cement. The cup is designed with a porous coating that encourages natural bone growth and integration, allowing the patient's own bone to bond with the implant. This promotes long-term stability and reduces the likelihood of the acetabular cup loosening or dislocation.


By combining the cemented femoral stem with the uncemented acetabular cup, hybrid hip replacements provide the benefits of both techniques, and most importantly its a cost effective solution.



Approach


During a total hip replacement surgery, the surgeon has the option to access the hip joint from either the front or the back, and they are categorised into two,


1. Posterior hip replacement approach


The posterior approach involves accessing the hip joint from the backside of the patient. With this technique, the surgeon makes an incision just behind the femur. The posterior approach does not require cutting through major muscles. Instead, the surgeon carefully works between the muscles, which allows for the preservation of muscle integrity and potentially faster recovery. By minimising muscle disruption, patients undergoing a posterior approach may experience less pain and a shorter rehabilitation period.


2. Anterior hip replacement approach


On the other hand, the anterior approach involves accessing the hip joint from the front side of the hip. In this technique, the surgeon makes an incision in the front of the hip. The anterior approach is often referred to as a "muscle-sparing" approach because it aims to minimise damage to the surrounding muscles and tendons. By avoiding major muscle detachments or cuts, the anterior approach may lead to less post-operative pain, reduced risk of dislocation, and potentially faster recovery. It offers the advantage of preserving the natural stability of the hip joint and maintaining normal muscle function.


3. Lateral hip replacement approach


The lateral approach is a surgical technique wherein the surgeon makes an incision on the side of the hip to access the hip joint. This approach provides good visibility of the joint and allows for removing and replacing the damaged hip joint components. The surgeon works through the muscles and soft tissues on the side of the hip to reach the joint.

One of the advantages of the lateral approach is that it preserves the posterior soft tissues, such as the gluteal muscles, which play an essential role in hip stability. This can lead to faster recovery and improved postoperative function. However, it is vital to note that the lateral approach may have a longer incision and potentially damage the abductor muscles during the surgical process.


4. Anterior hip replacement approach


The direct anterior approach is the one where the surgeon makes an incision at the front of the hip to access the hip joint. The main advantage of this approach is that it allows the surgeon to work between the muscles without detaching or cutting any muscles or tendons.

Several potential benefits of this approach include less muscle damage and a faster recovery time than traditional approaches. It may also lead to improved joint stability and reduced risk of dislocation. However, this approach requires specialized training and expertise due to the proximity of essential structures, such as nerves and blood vessels.


The choice of approach is typically determined by the surgeon's expertise, patient-specific factors, and the goals of the surgery. Both the posterior and anterior approaches have their own benefits and considerations. It is important for patients to discuss with their surgeon to determine the most suitable approach for their individual case. Factors such as the patient's anatomy, age, activity level, and pre-existing conditions will be taken into account to optimise the surgical outcome and facilitate a successful recovery.



Different articulations


When it comes to total hip replacement surgery, there are 3 primary types of articulations or bearing options available. These options determine the materials used for the prosthetic components that create the joint surfaces


So there are three types of bearing options and the type of articulation scenarios


1. Polyethylene


Polyethylene articulations involve using a plastic material called polyethylene for the bearing surfaces. Polyethylene is known for its durability and ability to withstand wear and tear. It provides a smooth gliding surface between the femoral ball and the acetabular socket. Polyethylene articulations have been widely used for many years and have proven to be effective in restoring mobility and reducing pain for hip replacement patients.


2. Ceramic


Ceramic articulations utilise ceramic materials, such as alumina or zirconia, for the joint surfaces. Ceramic is a very hard and smooth material, which allows for minimal friction and wear. Ceramic articulations offer excellent resistance to scratching and corrosion, making them a desirable option for active individuals who may put more stress on their hip joints. These articulations can provide long-term durability and can potentially last longer than other options.


3. Metal


Metal articulations involve using metal materials, such as cobalt-chromium alloys, for the bearing surfaces. Metal articulations can provide good stability and range of motion but require careful monitoring for any signs of metal ion release or adverse reactions.


4. Ceramic On Ceramic (CoC)


Ceramic-on-ceramic (CoC) bearings in total hip arthroplasty offer exceptional durability and wear resistance. Made from alumina/zirconia composite ceramics, they have a low friction coefficient, superior lubrication, and minimal wear. CoC bearings are ideal for young, active THA patients. While there is a small risk of ceramic fracture, new composite ceramics have reduced this risk. CoC articulations use ceramics for both the femoral head and acetabular socket, providing a smooth, low-friction surface that minimises wear. With excellent biocompatibility and durability, CoC articulations are suitable for long-lasting, wear-resistant implants. They have shown promising outcomes in reducing implant wear and preventing osteolysis.


5. Ceramic On Polyethylene(CoP)


Ceramic-on-polyethylene articulations involve pairing a ceramic femoral head with a polyethylene socket. This combination takes advantage of the low friction and wear characteristics of ceramics while utilising the excellent load-bearing and shock-absorbing properties of polyethylene. CoP articulations provide a good balance between durability and reduced wear, making them a suitable option for many patients. The use of polyethylene as the socket material allows for easy and secure fixation to the bone.


6. Metal On Polyethylene(MoP)


Metal-on-polyethylene articulations involve using a metal femoral head with a polyethylene socket. This combination is a more traditional and commonly used option.


Metal-on-polyethylene articulations provide good stability and function, with the metal femoral head offering strength and durability while the polyethylene socket provides a smooth bearing surface. This type of articulation has a long clinical history and has shown reliable outcomes in terms of functional improvement and pain reduction.


Final takeaway,

Now that you deeply understand total hip replacement surgery, its types, approaches, and articulations, you are equipped with valuable knowledge to make informed decisions about your hip health. Whether you require a cemented or uncemented procedure, a posterior or anterior approach, or a specific type of bearing such as ceramic-on-ceramic, your understanding of these options will enable you to have meaningful discussions with your healthcare provider. Remember, each individual's case is unique, and the choice of surgical technique and components should be tailored to your specific needs. With this knowledge, you can confidently embark on your journey towards improved mobility, reduced pain, and an enhanced quality of life through total hip replacement surgery.


Polaris Healthcare offers one of the most affordable and high-quality hip replacement surgeries in Pune with a state-of-the-art facility, a team of top orthopaedic surgeons, and an excellent physiotherapy department. Our exceptional pre and post-surgical guidance ensures that our patients receive excellent care, enabling them to resume their activities and improve their quality of life.


 
About The Author: Dr. Surendra Patil

Dr. Surendra Patil, MBBS, Diploma in Orthopaedics, DNB - Orthopedics Surgery, is a dynamic surgeon with skilled hands well versed in various surgical procedures in orthopedics and exceptionally well-read in his chosen expertise. He is proficient in Arthroscopic Surgeries, Adult Joint Reconstruction Surgery, Accidents & Emergencies, Joint Replacement, Healthcare Management, and Healthcare in general. He is an experienced Medical Professional with a demonstrated history of working in the hospital & healthcare industry.

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