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Hip

Posted in Orthopedic Specialties.

Minimally Invasive Total Hip Replacement

Total hip replacement (also known as hip arthroplasty) is a common orthopaedic procedure and, as the population ages, it is expected to become even more common. Replacing the hip joint with an implant or "prosthesis" relieves pain and improves mobility so that you are able to resume your normal, everyday activities.

The traditional surgical approach to total hip replacement uses a single, long incision to view and access the hip joint. A variation of this approach is a minimally invasive procedure in which one or two shorter incisions are used. The goal of using shorter incisions is to reduce pain and speed recovery. Unlike traditional total hip replacement, the minimally invasive technique is not suitable for all patients. Your orthopaedic surgeon will discuss different surgical options with you.

Description

During any hip replacement surgery, the damaged bone is cut and removed, along with some soft tissues. In minimally invasive surgery, a smaller surgical incision is used and fewer muscles around the hip are cut or detached. Despite this difference, however, both traditional hip replacement surgery and minimally invasive surgery are technically demanding and have better outcomes if the surgeon and operating team have considerable experience.

Traditional Hip Replacement

To perform a traditional hip replacement:

  • A 10- to 12-inch incision is made on the side of the hip. The muscles are split or detached from the hip, allowing the hip to be dislocated and fully viewed by the surgical team.
  • The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur, then a metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed.
  • The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place.
  • A plastic, ceramic or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface.

hipreplacement

(Left) The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.

Minimally Invasive Hip Replacement

In minimally invasive total hip replacement, the surgical procedure is similar, but there is less cutting of the tissue surrounding the hip. The artificial implants used are the same as those used for traditional hip replacement. However, specially designed surgical instruments are needed to prepare the socket and femur and to place the implants properly.

Minimally invasive total hip replacement can be performed with either one or two small incisions. Smaller incisions allow for less tissue disturbance.

Single-incision surgery. In this type of minimally invasive hip replacement, the surgeon makes a single incision that usually measures from 3 to 6 inches. The length of the incision depends on the size of the patient and the difficulty of the procedure.

The incision is usually placed over the outside of the hip. The muscles and tendons are split or detached from the hip, but to a lesser extent than in traditional hip replacement surgery. They are routinely repaired after the surgeon places the implants. This encourages healing and helps prevent dislocation of the hip.

Two-incision surgery. In this type of minimally invasive hip replacement, the surgeon makes two small incisions:

  • A 2- to 3-inch incision over the groin for placement of the socket, and
  • A 1- to 2-inch incision over the buttock for placement of the femoral stem.

To perform the two-incision procedure, the surgeon may need guidance from x-rays. It may take longer to perform the two-incision surgery than it does to perform traditional hip replacement surgery.

The hospital stay after minimally invasive surgery is similar in length to the stay after traditional hip replacement surgery--ranging from 1 to 4 days. Physical rehabilitation is a critical component of recovery. Your surgeon or a physical therapist will provide you with specific exercises to help increase your range of motion and restore your strength.

Hip Resurfacing

Patients with advanced arthritis of the hip may be candidates for either traditional total hip replacement (arthroplasty) or hip resurfacing (hip resurfacing arthroplasty). Each of these procedures is a type of hip replacement, but there are important differences. Your orthopaedic surgeon will talk with you about the different procedures and which operation would be best for you.

Description

hipresurfacing

The hip is a ball-and-socket joint. In a healthy hip, the bones are covered with smooth cartilage that enables the femoral head and acetabulum to glide painlessly against each other.

In a traditional total hip replacement, the head of the thighbone (femoral head) and the damaged socket (acetabulum) are both removed and replaced with metal, plastic, or ceramic components.

In hip resurfacing, the femoral head is notremoved, but is instead trimmed and capped with a smooth metal covering. The damaged bone and cartilage within the socket is removed and replaced with a metal shell, just as in a traditional total hip replacement.

Advantages of Hip Resurfacing

The advantages of hip resurfacing over traditional total hip replacements is an area of controversy among orthopaedic surgeons. A great deal of research is currently being done on this topic.

  • Hip resurfacings may be easier to revise. Because the components (called implants) used in hip replacements and hip resurfacings are mechanical parts, they can — and do — wear out or loosen over time. This typically occurs between 10 and 20 years after the procedure, although implants may last longer or shorter periods of time.
  • If an implant fails, an additional operation may be necessary. This second procedure is called a revision and it can be more complicated than the initial operation. Because hip resurfacing removes less bone from the femur (thighbone) than a traditional hip replacement, many surgeons believe it is easier to exchange implants that fail after hip resurfacing.
  • Decreased risk of hip dislocation. In hip resurfacing, the size of the ball is larger than in a traditional hip replacement, and it is closer to the size of the natural ball of your hip. Because of this, it may be harder to dislocate. This stance is controversial because several factors can affect the risk of dislocation, such as surgical approach, and the type and size of the implants used.
  • More normal walking pattern. Several studies have shown that walking patterns are more natural following hip resurfacing compared to traditional hip replacement. These differences in walking are quite subtle, however, and special instruments are needed to measure them.
  • Greater hip range of motion. Hip resurfacing patients are usually able to move their hips in a greater range of motion than total hip patients. However, certain total hip implants can achieve the same range of motion as hip resurfacings.

Hip Arthroscopy

Arthroscopy is a surgical procedure that gives doctors a clear view of the inside of a joint. This helps them diagnose and treat joint problems

During hip arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your hip joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Hip arthroscopy has been performed for many years, but is not as common as knee or shoulder arthroscopy.

hiparthroscopy

During arthroscopy, your surgeon can see the structures of your hip in great detail. (Right) Small instruments are used to repair a labral tear.

Anatomy

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

A slippery tissue called articular cartilage covers the surface of the ball and the socket. It creates a smooth, frictionless surface that helps the bones glide easily across each other.

The acetabulum is ringed by strong fibrocartilage called the labrum. The labrum forms a gasket around the socket.

The joint is surrounded by bands of tissue called ligaments. They form a capsule that holds the joint together. The undersurface of the capsule is lined by a thin membrane called the synovium. It produces synovial fluid that lubricates the hip joint.

hiparthroscopy2

In a healthy hip, the femoral head fits perfectly into the acetabulum.

Total Hip Replacement

Whether you have just begun exploring treatment options or have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. This article describes how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery, and what exercises and activities will help restore your mobility and strength, and enable you to return to everyday activities.

If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting.

If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.

First performed in 1960, hip replacement surgery is one of the most successful operations in all of medicine. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 285,000 total hip replacements are performed each year in the United States.

Anatomy

The hip is one of the body's largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.

A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.

hipreplacement2

Normal hip anatomy.

Common Causes of Hip Pain

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

  • Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older and often in individuals with a family history of arthritis. The cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by subtle irregularities in how the hip developed in childhood.
  • Rheumatoid arthritis. This is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage the cartilage, leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed "inflammatory arthritis."
  • Post-traumatic arthritis. This can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
  • Avascular necrosis. An injury to the hip, such as a dislocation or fracture, may limit the blood supply to the femoral head. This is called avascular necrosis. The lack of blood may cause the surface of the bone to collapse, and arthritis will result. Some diseases can also cause avascular necrosis.
  • Childhood hip disease. Some infants and children have hip problems. Even though the problems are successfully treated during childhood, they may still cause arthritis later on in life. This happens because the hip may not grow normally, and the joint surfaces are affected.

hipreplacement3

A hip with osteoarthritis.

Knee Arthroscopy

Posted in Orthopedic Specialties.

Arthroscopy is a common surgical procedure in which a joint (arthro-) is viewed (-scopy) using a small camera. Arthroscopy gives doctors a clear view of the inside of the knee. This helps them diagnose and treat knee problems.

Technologiccal advances have led to high definition monitors and high resolution cameras. These and other improvements have made arthroscopy a very effective tool for treating knee problems. According to the American Orthopaedic Society for Sports Medicine, more than 4 million knee arthroscopies are performed worldwide each year.

Description

arthro1

Arthroscopy is done through small incisions. During the procedure, your orthopaedic surgeon inserts the arthroscope (a small camera instrument about the size of a pencil) into your knee joint. The arthroscope sends the image to a television monitor. On the monitor, your surgeon can see the structures of the knee in great detail.

Your surgeon can use arthroscopy to feel, repair or remove damaged tissue. To do this, small surgical instruments are inserted through other incisions around your knee.


Preparing for Surgery

arthro2

If you decide to have knee arthroscopy, you may need a complete physical examination with your family physician before surgery. He or she will assess your health and identify any problems that could interfere with your surgery.

Before surgery, tell your orthopaedic surgeon about any medications or supplements that you take. He or she will tell you which medicines you must stop taking before surgery.

To help plan your procedure, your orthopaedic surgeon may order pre-operative tests. These may include blood counts or an EKG (electrocardiogram).


Surgery

Almost all arthroscopic knee surgery is done on an outpatient basis.

Arrival

Your hospital or surgery center will contact you with specific details about your appointment. You will likely be asked to arrive at the hospital an hour or two before your surgery. Do not eat or drink anything after midnight the night before your surgery.

Anesthesia

When you first arrive for surgery, a member of the anesthesia team will talk with you. Arthroscopy can be performed under local, regional, or general anesthesia.

  • Local anesthesia numbs just your knee
  • Regional anesthesia numbs you below your waist
  • General anesthesia puts you to sleep

The anesthesiologist will help you decide which method would be best for you.

If you have local or regional anesthesia, you may be able to watch the procedure on a television monitor.

Procedure

The orthopaedic surgeon will make a few small incisions in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid. This helps your orthopaedic surgeon see your knee clearly and in great detail.

arthro3

arthro4

Your surgeon's first task is to properly diagnose your problem. He or she will insert the arthroscope and use the image projected on the screen to guide it. If surgical treatment is needed, your surgeon will insert tiny instruments through another small incision. These instruments might be scissors, motorized shavers, or lasers.

This part of the procedure usually lasts 30 minutes to over an hour. How long it takes depends upon the findings and the treatment necessary.

Arthroscopy for the knee is most commonly used for:

  • Removal or repair of torn meniscal cartilage
  • Reconstruction of a torn anterior cruciate ligament
  • Trimming of torn pieces of articular cartilage
  • Removal of loose fragments of bone or cartilage
  • Removal of inflamed synovial tissue

Your surgeon may close your incisions with a stitch or steri-strips (small bandaids) and cover them with a soft bandage.

You will be moved to the recovery room and should be able to go home within 1 or 2 hours. Be sure to have someone with you to drive you home.


Recovery

Recovery from knee arthroscopy is much faster than recovery from traditional open knee surgery. Still, it is important to follow your orthopaedic surgeon's instructions carefully after you return home. You should ask someone to check on you the first evening you are home.

Swelling

arthro5

Keep your leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by your doctor to relieve swelling and pain.

Dressing Care

You will leave the hospital with a dressing covering your knee. Keep your incisions clean and dry. Your surgeon will tell you when you can shower or bathe, and when you should change the dressing.

Your surgeon will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.

Bearing Weight

Most patients need crutches or other assistance after arthroscopic surgery. Your surgeon will tell you when it is safe to put weight on your foot and leg. If you have any questions about bearing weight, call your surgeon.

Driving

Your doctor will discuss with you when you may drive. This decision is based on a number of factors, including:

  • The knee involved
  • Whether you drive an automatic or stick shift
  • The nature of the procedure
  • Your level of pain
  • Whether you are using narcotic pain medications
  • How well you can control your knee.

Typically, patients are able to drive from 1 to 3 weeks after the procedure.

Medications

Your doctor will prescribe pain medication to help relieve discomfort following your surgery. He or she may also recommend medication such as aspirin to lessen the risk of blood clots.

Exercises to Strengthen Your Knee

arthro6

You should exercise your knee regularly for several weeks after surgery. This will restore motion and strengthen the muscles of your leg and knee.

Therapeutic exercise will play an important role in how well you recover. A formal physical therapy program may improve your final result.

Treatment for Arthritis

Posted in Orthopedic Specialties.

Although there is no cure for osteoarthritis of the knee, there are many treatment options available. The primary goals of treatment are to relieve pain and restore function.

In its early stages, arthritis of the knee is treated with nonsurgical methods. Some of the more common options include changes in activity level, pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, as well as physical therapy, and corticosteroid injections.

Another treatment option is a procedure called viscosupplementation. In this procedure, a gel-like fluid called hyaluronic acid is injected into the knee joint. Hyaluronic acid is a naturally occurring substance found in the synovial (joint) fluid. It acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads.

People with osteoarthritis ("wear-and-tear" arthritis) have a lower-than-normal concentration of hyaluronic acid in their joints. Viscosupplementation may be a therapeutic option for individuals with osteoarthritis of the knee.

Effects of Viscosupplementation

Viscosupplementation has been shown to relieve pain in many patients who have not responded to other nonsurgical methods. The technique was first used in Europe and Asia, and was approved by the U.S. Food and Drug Administration in 1997. Several preparations of hyaluronic acid are now commercially available.

Immediate Effects

  • Hyaluronic acid does not have an immediate pain-relieving effect.
  • For the first 48 hours after the shot, you should avoid excessive weight bearing on the leg, such as standing for long periods, jogging or heavy lifting.
  • You may notice a local reaction, such as pain, warmth, and slight swelling immediately after the shot. These symptoms generally do not last long. You may want to apply an ice pack to help ease them.
  • Rarely, patients may develop a local allergy-like reaction in the knee. In these cases, the knee may become full of fluid, red, warm, and painful. If this occurs, contact your doctor immediately.
  • Infection and bleeding are also very rare complications of this procedure.

Longer Term Effects

  • Over the course of the injections, you may notice that you have less pain in your knee.
  • Hyaluronic acid does seem to have anti-inflammatory and pain-relieving properties.
  • Effects may last for several months.
  • Viscosupplementation may be effective in relieving the symptoms of arthritis, but has never been shown to reverse the arthritic process or re-grow cartilage.

 

Total Knee Replacement

Posted in Orthopedic Specialties.

If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.

If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.

Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States.

Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy

Normal knee

The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.

The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily.

The menisci are located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.

All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.

Cause

The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

  • Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another, causing knee pain and stiffness.
  • Rheumatoid arthritis. This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed "inflammatory arthritis."
  • Post-traumatic arthritis. This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.

Osteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of arthritis.

Ubchondroplasty

Posted in Orthopedic Specialties.

Knee osteoarthritis (OA) is a common form of arthritis that causes joint pain and stiffness. It is a progressive disease in which the joint cartilage gradually wears away and may lead to disability.

Bone marrow lesions or BMLs are strong predictors of osteoarthritic cartilage damage. Bone marrow lesions are visible on an MRI but not in a regular X-ray. BMLs are sites of chronic inflammation of subchondral bone. They lie below the bone surface within the marrow and are accompanied by swelling and fluid collection (edema). BMLs are associated with subchondral defects, insufficiency fractures and stress fractures.

Conservative treatments for BMLs include pain medications, knee braces, crutches, and physical therapy. However, long lasting (chronic) BMLs that do not heal by themselves will require treatment. Patients with chronic BMLs have faster cartilage destruction and are more likely to require a total knee replacement, earlier.

Subchondroplasty is a minimally invasive procedure that is performed to specifically repair chronic BMLs by filling them with a bone substitute material. The bone substitute is then slowly resorbed and replaced with healthy bone repairing the bone defect. Subchondroplasty also resolves the associated edema. Subchondroplasty may be performed alone or along with other arthroscopic procedures.

Ideal candidate

Patients diagnosed with BMLs as the primary source of pain in the knee may benefit from the procedure. However, subchondroplasty is contraindicated in patients with BMI more than 40 or those with severe malalignment of the knee joint.

Procedure

  • The whole subchondroplasty procedure is performed under fluoroscopy to accurately target the chronic BMLs. Fluoroscopy provides the surgeon with intraoperative real time X-ray images of the surgical area to guide the surgeon. Before the procedure the BMLs are first diagnosed on a T2 Fat Suppressed MRI.
  • For subchondroplasty, first, the patient is administered general anaesthesia.
  • A semi-circular reference frame is placed relative to the individual patient’s tibia or shin bone. The semi-circular frame allows the surgeon to target the internal subchondral location of BML from a range of trajectories. A pin is inserted through the skin to the bone under fluoroscopic imaging using this semi-circular frame.
  • A cannulated drill is then used to advance the pin to the desired depth in the bone.
  • The semi-circular guide is then removed leaving only the pin.
  • A cannula is placed over the pin and is slid into the bone until it is firmly in place.
  • The luer lock of the delivery syringe filled with the bone substitute is attached to the back of the cannula.
  • The bone substitute is then injected into the bone by applying steady pressure. The delivery syringe is then detached. If more bone substitute is required an additional filled syringe may be attached to the same cannula and injected until the desired volume is reached.
  • A trocar is inserted into the delivery cannula to push the left behind bone substitute into the bone.
  • The cannula is then removed.
  • Finally, proper placing of the bone substitute is confirmed using the fluoroscopic imaging and the incision is closed.

After the procedure

Some pain and discomfort in the operated area is usually experienced for 1-2 days after the procedure. Pain medications will be prescribed to manage it. Crutches will be recommended for 1-2 weeks after the surgery to reduce weight bearing on the operated leg. Physical therapy will also be recommended to rregain strength and mobility in the knee.

Advantages of Subchondroplasty

Subchondroplasty is a minimally invasive procedure with the following advantages:

  • It is an outpatient procedure. The patient is usually discharged on the same day as the surgery.
  • It leads to faster recovery and quicker return to normal activities.
  • It does not hinder total knee replacement if required in the future.