Hip Replacement & Resurfacing Alternatives
The vast majority of patients reading this book to learn about hip surgery will be considering either total hip replacement or hip resurfacing. However, there are some other surgical alternatives that exist. Most of these options were developed in the years before joint replacement or resurfacing was widely available, but some are still performed today in very select cases.
Hip Fusion (Arthrodesis)
In the years before hip replacement, a common surgery for a severely arthritic hip was to fuse the femur to the pelvis with a large plate and screws, effectively eliminating the joint and creating a single bone from the pelvis to the knee.
This surgery persisted even after the development of hip replacements, primarily as an option for young patients (such as laborers) who would otherwise wear out an artificial joint very quickly. Modern designs and materials have mostly made this surgery obsolete, however, and it is very rarely considered today. Few patients in the U.S. would be willing to accept the limitations of a fused hip in the modern era of hip replacement and resurfacing surgeries.
The principal disadvantage of a fusion is that there is no longer any motion at the hip, given that the bones are fused together. This leads to an awkward gait pattern. Sitting and walking are severely affected. Also, the back and the knee typically begin to develop arthritis from "double duty" trying to accommodate the lost motion. The patient needs to have a normal opposite hip and good knees to consider hip fusion.
However, once the two bones have fully grown together, a fusion will rarely need any further medical treatment. There is no implant to wear out, break, or become infected. It is also much cheaper than using a hip replacement prosthesis. For this reason, this surgery is still used in poorer parts of the world where hip replacement is not an option for patients.
Hip Excisional Arthroplasty (Girdlestone Procedure)
If there is a severe problem with the hip joint, such as arthritis or infection, another surgery developed in the early days of orthopaedics was to simply remove the femoral head (or ball). This was called a Girdlestone procedure, and it is still used today for last- ditch efforts at fixing complex problems, typically infection.
Patients can still walk without the femoral head. The weight is borne on the remaining femur, which usually rides against the rim of the socket (acetabulum). It usually does require wearing a substantial shoe lift, however, to make up for the loss of the ball, which can frequently be several inches or more. It is also an uncomfortable gait compared to hips that have had replacement or resurfacing surgeries.
This procedure is used most commonly today for a hip replacement that has had severe complications and cannot be reconstructed or reimplanted. This might be recommended for an elderly or very ill patient who would not do well with a complex revision surgery. Another scenario is a total hip replacement that has become infected, and the infection cannot be cleared by other, less drastic means.
A similar scenario is the patient with a history of intravenous drug abuse (such as heroin). These patients have a high likelihood of infecting the hip replacement if they continue to use I.V. drugs, and many surgeons would opt for a Girdlestone procedure in treating a hip replacement that has become infected in this way.
An osteotomy means cutting the bone and realigning it to heal in a different position or angle. Several types of osteotomies have been used over the last 100 years for the treatment of arthritis and other hip problems.
One particular application that is still used is pelvic and/or femoral osteotomies for young patients with hip dysplasia. If the bone has not formed correctly, it is sometimes possible to cut it and re-align it, such as changing the angle of the hip socket (acetabulum) for a very shallow hip, so that it does not dislocate. This is still commonly used for pediatric patients instead of hip replacement.
Another application for osteotomy is to cut the femur to rotate the femoral head (or ball) so that the worn out or arthritic portion is not in contact as much, and a healthier area of cartilage is used for the weight-bearing portion instead. Most osteotomies take a long time (months) to heal because they are surgically created fractures, typically with a long period of limited or non weight-bearing..
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