Endoprosthetics of the hip joint

The hip joint is the largest joint in the human body. This system connects the pelvic skeleton to the femur in such a way that the lower limb is movable in different planes.

While walking, it is affected by the pressure of the entire upper body, that is, the joint is subjected to significant loads every day. Like any systemic complex formation in the human body, the hip joint apparatus can undergo various injuries and pathologies during a person’s life: they can be associated with congenital developmental anomalies, with unsuccessful mechanical effects or the presence of inflammatory processes and some diseases.

What is the essence of the arthroplasty procedure, why is it prescribed

Various degenerative-dystrophic lesions of the articular apparatus can form in a person at any stage of his life. Their main danger is that, firstly, they only progress over time, and secondly, if medical assistance is not provided in time, a person may completely lose the ability to move independently and become bedridden. Diseases and pathologies of the hip joint can be the cause of the disability of the affected person.

Especially common is deforming arthrosis, in which a progressive pathological process gradually changes the shape of the articular elements, deforming them, as a result of which a person loses limb mobility and constantly feels pain.

Conservative treatment in such cases is usually ineffective – it can only slow down the process, and only in the early stages. If the disease is advanced, the attending physician decides on arthroplasty.

What is a hip arthroplasty? During the operation, the surgeon physically removes the affected elements of the articular apparatus, and replaces them with artificial prostheses. The procedure is carried out to achieve several goals – to eliminate pain in the joint, improve its mobility, return the patient to his usual way of life, restore his ability to walk and move.

Indications and contraindications for surgery

In order to determine the need for surgery, the attending physician must first determine whether the patient has indications for it. Not every diagnosis, not every pathology and injury necessarily requires arthroplasty. Usually doctors are of the opinion that where the patient can be helped conservatively, it is better to start with conservative therapy. In addition, the operation for endoprosthesis replacement is complex and expensive, and for its implementation it is necessary to specially prepare not only the affected person, but also the surgeon himself.

Indications for arthroplasty are:

• aseptic necrosis of the articular head;
• comminuted fractures of the femoral head;
• osteoarthritis of the joints, reaching 3-4 degrees;
• new fractures of the femoral neck in patients over the age of 65;
• false joints and ununited fractures of the femoral neck;
• joint damage caused by connective tissue diseases (Bekhterev’s disease, rheumatoid arthritis, systemic lupus erythematosus);
• tumors found in the neck and head of the femur.

What are the contraindications for the operation?

Despite its obvious value and benefit, the replacement of damaged joint elements is not possible in every case, and sometimes it can even cause harm to the patient. Endoprosthetics is not prescribed in the presence of tuberculosis, neuropsychiatric diseases, pathologies of the cardiovascular system, acute and chronic osteomyelitis.

Types of endoprosthetics: in what ways the surgeon can help the patient

Depending on the extent of the planned operation, the patient may be prescribed:

• total;
• unipolar replacement of articular elements.

Total arthroplasty means the complete replacement of all elements of the system with artificial prostheses.

Hemiarthroplasty, or unipolar replacement, is the replacement of only the head of the joint, while the native acetabulum remains in place. During such an operation, only the endoprosthesis stem is implanted. Its unipolar head and acetabulum form a new joint.

In this case, the leg of the prosthesis is fixed in the bone with special bone cement or with the use of a dense nozzle. If a patient has a weakening of the bone against the background of osteoprorosis, the method of strengthening the head of the prosthesis with cement is more appropriate.

Another differentiation involves the division of endoprosthetics operations into the following types:

• primary;
• revision.

The first type means that the replacement of the joint occurs for the first time. In the second case, there is a need to eliminate the problems associated with the operation of a previously installed artificial joint or parts thereof.

Implants for primary and revision surgery are slightly different in design and functionality.

Another, stand-alone type of arthroplasty is the replacement of articular surfaces. This type of surgery is increasingly used in relation to young patients. Surface arthroplasty makes it possible to preserve the native bone structure as much as possible, especially in the proximal femur.

How is the patient prepared for surgery?

Preparations for this complex operation begin weeks before the scheduled date. Before admission to the hospital, the patient must undergo a thorough examination, namely:

• visit a therapist
• make x-rays and MRI of the joint;
• take a series of tests (blood, urine, etc.).

The results obtained are relevant not only for the surgeon, but also for the anesthesiologist, who, on their basis, will select the appropriate drug to introduce the patient into a state of drug-induced sleep.

The patient needs to obtain permission for the operation from the therapist – for this it is necessary to assess the condition and stages of all concomitant diseases in acute and chronic forms.

For example, the presence of hypertension in the affected person can become a serious obstacle to arthroplasty. In this case, before a planned operation, the affected person needs to adjust the course of treatment in such a way as to stabilize blood pressure as much as possible within the normal range.

Under the supervision of a doctor, the patient begins to do a set of exercises for the muscles of the whole body in advance – this is necessary to achieve a normal muscular shape during the operation. In addition, after the operation, the patient will need to get used to the use of crutches, walkers, canes, which will require certain physical efforts and a level of training from his arms and torso.

It is advisable to choose crutches and walkers for yourself in advance, so that during the recovery period you will be able to move more or less independently. You can even practice walking on crutches beforehand.

Excess weight in a patient creates additional loads on the endoprosthesis – this must be taken into account when prescribing endoprosthesis. If the operation is scheduled for a distant date, an overweight patient should, as far as possible, deal with the issue of losing weight, at least putting his diet in order.

2-3 weeks before the operation, it is necessary to stop taking certain medications – this issue must be agreed with the attending physician, anesthetist and surgeon. All medications, including over-the-counter medications, that the affected person is taking must be reported to the doctor in advance.

Preparation also includes a moral aspect, because in the period after the operation at home, the patient will most likely need the help and care of another person, he may feel pain and inconvenience due to the need for significant restrictions on the rehabilitation time.

The home environment will also need to be prepared for the discharge of the patient after prosthetics:

• all frequently used items should be placed at hand level;
• if there is no radiotelephone at home, it is better to purchase one;
• patients living in private homes with several floors should minimize the need to move around the floors, for example, moving their own bedroom to the ground floor;
• furniture should be rearranged so that it leaves enough space for movement on walkers and crutches;
• all rugs should be removed, and electrical wires, if they pass through walking areas, should be hidden;
• for small necessary items, it is better to buy a small soft bag;
• if there are animals at home that can get under your feet, it is better to transfer them to relatives or friends for the first few weeks after the operation.

The Day Before Surgery: What to Expect

For endoprosthetics, the patient must be placed in a hospital clinic or hospital. After hospitalization, he is again examined by a therapist, a surgeon, an anesthesiologist talks to him.

Do not drink alcohol on the day before the operation. Eating during the day should be light, excluding foods that promote gas formation in the intestines.

For 10-12 hours before the start, it is forbidden to eat food and liquid. In the evening, you can make a cleansing enema and take a laxative.

It is possible that the surgeon will require the removal of hair from the site of the surgical field, as well as the removal of varnish or gel coatings from the nail plates.

Endoprosthetics: intervention algorithm

Before sending the patient on a gurney to the surgical ward, he will be offered to put on a compression stocking on the opposite leg, or bandage it up to the knee with an elastic bandage – this will prevent the formation of blood clots.

Next, the operated person is given anesthesia – general or regional. Both types imply that the patient is in a state of drug-induced sleep, however, patients’ reviews of regional anesthesia are more optimistic – it is easier to wake up after it, in addition, even after waking up, anesthesia works for some time.

When the patient is asleep, a catheter is inserted into his bladder.

The entire duration of the operation is usually 1-2 hours. In the process, the surgeon separates the damaged elements of the joint, and installs artificial parts of the prosthesis in their place. To remove the accumulated blood, a silicone drainage tube and a special “accordion” are installed in the wound to take fluid from the postoperative wound.

After completing all the manipulations, the surgeon sutures the incisions, treats the wound and applies a certain type of dressing.

After surgery: the patient’s condition

When the surgical procedures are completed, the patient is transferred to the ward under the supervision of a doctor. At first, he was prescribed antibacterial therapy with antibiotics, and anti-inflammatory drugs. On the first day after the operation, the patient can already move in bed, but not too actively.

On the second day, it is allowed to sit down in bed, do breathing exercises and a certain type of physical therapy exercises – a therapeutic physical education complex.

A dosed load in the form of walking with support (crutches, walkers or an arena) begins on the third day.

Within a few days after prosthetics, the catheter is removed from the bladder. The normal condition after the intervention will be swelling of the leg, pain in the groin and in the joint itself, radiating to the limb. The patient may be given pain medication.

The treatment of a postoperative wound consists in the daily replacement of a sterile dressing, as well as cleansing its surface with aseptic solutions. The stitches can be removed 10-14 days after the operation. Then the patient is discharged from the hospital home. Ahead of him is the process of rehabilitation.

Postoperative period and return to normal life

The first thing that the operated person should learn is the simple rules for handling a new joint. To prevent dislocation, it must not be bent at an angle of more than 90 degrees. Crossing legs and squatting are also prohibited.

Already in the first days after the intervention, the patient needs to gradually begin to perform simple exercises – a foot pump, rotation in the ankle joint, knee flexion with heel support, buttock contractions.

The wound at the site of surgical penetration should be kept dry for 7-10 days after discharge. Edema after surgery is normal for the first months of recovery. The patient will need to master the technique of moving with crutches, a new way of moving up stairs, as well as doing more and more complex exercises over time.

The main rules of postoperative rehabilitation are to limit the load on the joint, the constant position of the foot with the foot forward, avoiding the deviation of the leg to the side in the sitting position. Do not bend over more than 90 degrees, lift weights, cross your legs, or lean forward while sitting or lying down.

After arthroplasty, a sick leave is opened for a person for up to 3 months – its duration is determined individually, according to the patient’s well-being.

Usually after three months, the operated person can return to their usual activities – sports, active walking, cycling. It should be remembered that lifting more than 18 kilograms, playing basketball or weightlifting is not recommended for a person with an endoprosthesis even at the end of the rehabilitation process, especially after a total endoprosthesis.

It will be useful for the operated person to visit a rehabilitation center or rest in a sanatorium in the process of recovery after surgery.

Operations for hip arthroplasty are complex surgical interventions, primarily due to the fact that the joint itself is a complex structural connection. However, if the surgeon is experienced enough and the patient is conscientious about the preparation and recovery requirements, the risk of postoperative complications is minimized.

Endoprosthetics gives a chance to walk and move again for people with extensive and deep lesions of the articular apparatus, when conservative therapy is powerless.