Hip Replacement: An Overview
Guest: Dr. Harry Demos – Orthopedic Surgery
Host: Dr. Linda Austin – Psychiatry
Linda Austin: I’m Dr. Linda Austin. I’m talking today with Dr. Harry Demos who is
an orthopedist and Assistant Professor of Orthopedics here at the Medical
University of South Carolina. Dr. Demos,
you’re an expert in artificial hip replacement.
Harry Demos: Correct.
Linda Austin: Let’s talk about
that. Who is a good candidate for that
Harry Demos: It used to be that the
ideal candidate for hip replacement was an older sedentary patient, basically,
a retired patient who wanted to be able to remain ambulatory and couldn’t
because of lifestyle-limiting pain.
We’re now finding that there are more and more younger patients that are
good candidates for hip replacement surgery, the young active patient, the
mother or father with young children at home who still wants to be able to keep
up with their children or still wants to be able to lead a productive life in
the workforce, rather than just retired or sedentary patients.
are two issues that have caused that.
One is that people seem to be getting arthritis at younger ages because
of more wear-and-tear on their joints, working harder, playing harder, and
other conditions that lead to arthritis.
The other is that joint replacement wasn’t always an option for those
patients. Joint replacement would fail
in the younger patient. The results of
joint replacement in younger patients were no where near as good as they were
in older patients. And for that reason,
many people avoided doing joint replacements in younger patients, whereas now
we’re finding that we can do it in younger patients and keep them active.
Linda Austin: I would guess that, in the
case of, let’s say, post-auto accident, you might end up doing replacements in
very young patients. But let’s say, the
arthritic patient, what’s the youngest age at which folks may start to need to
think about a joint replacement?
Harry Demos: The only reason to think
about a joint replacement is if the pain becomes so severe that you can’t do
what you want to do in life. And that
can be from a number of different causes, not just degenerative arthritis, but
childhood abnormalities that are manifesting themselves later on in life, the
dysplastic hip or the child who had perthes that is now developing arthritis at
a relatively young age, several other childhood conditions that lead to early
hip arthritis. The majority of the ones
that we see in this part of the country are usually from avascular necrosis,
which happens for a variety of reasons, including prednisone use.
Linda Austin: Steroid use?
Harry Demos: Right, correct, steroid
use, or alcohol, or even post-traumatic.
There are many different causes.
It’s also seen very commonly in patients that have lupus or other
inflammatory-type autoimmune conditions.
Linda Austin: Now, just to explain a
little bit more, avascular, of course, means that there is not good blood
Harry Demos: Correct.
Linda Austin: And necrosis means that
the joint starts to actually die as a result?
Harry Demos: Correct. The ball of the femur, the femoral head,
loses its blood supply and then collapses, so it’s not a round ball in a round
socket anymore. And that leads to
arthritis in the joint because of the weight-bearing forces, the concentrated
forces, that are going across it. So, it
becomes very painful. Avascular necrosis
itself is painful. But, once it
collapses and you develop arthritis, it is a painful condition. And it’s one that is not going to get better
on its own.
thought on that is, for the young active patient who wants to remain in the
workforce, to tell that patient, you’re too young for a joint replacement, come
back when you’re 70, and is really not a good option anymore. We want those patients to continue to do what
they want to do.
Linda Austin: So, are you doing them,
sometimes, for patients in their, say, 30s?
Harry Demos: Usually, it starts off in
about the 40s. That’s when we really see
people starting to have problems from things that started off earlier. I have operated on patients in their teens
with joint replacement surgery. And
that’s usually for inflammatory conditions, like rheumatoid arthritis.
majority of the degenerative processes start to happen in the early 40s,
usually not in the 30s. And, obviously,
if there’s anything we can do preserve the hip joint, if we can do a correction
of whatever problem to preserve it before arthritis starts, we can do that as
Linda Austin: Now, if someone is in
their 40’s and otherwise they’re pretty healthy and pretty active, how long can
a hip replacement last?
Harry Demos: That’s a good question and
it’s one that we really don’t know, entirely, the answer to. If we look back at hip replacement from 30
years ago, we knew that hip replacement in the young, under 50, population had
about 50 percent survival at 15 to 20 years.
Only about 50 percent of those joints were still good for 15 to 20
years. But there have been a lot of
advances in bearing surfaces. There have
been a lot of advances in bony end-growth of the implants, to the point where,
now, even looking back at ones we were doing 15 years ago, we’ve got about
95 to 99 percent survival of the
implants at 15 years.
problem with joint replacement is it takes a long time to know how good what
we’re putting in now is going to last because the latest and greatest thing on
the market is not always the best. It
takes 15, 20 years before we know whether that’s better than what we’ve been
doing before. So, we can simulate things
in the lab, but it’s hard to know how that transfers from the lab to actual
patient survival of the implant.
Linda Austin: What are some of the
debates now in the field? I know
surgeons often are kind of a contentious group and everybody wants to figure
out the best way. So, what are some of
the debates going on in the field about hip surgery?
Harry Demos: There are always a lot of
debates about hip surgery. And, even
within a group of surgeons, you’ll find debates of some surgeons who do it
through an anterior approach, some who do hip replacement through a posterior
approach, some who do it through two incisions.
There are multiple ways of doing things.
I’d say the biggest debates now are the minimally invasive controversies
that came out from several years ago, about the two-incision technique with
minimally invasive surgery and the complications associated with that. There are some improved outcomes by being
less invasive but we really did find a lot of complication from people trying
to alter the technique too much. So,
that’s one of the big debates that’s going on now.
second is still the ongoing debate about bearing surfaces. We have several different bearing surfaces
that we can do in young active people, whether it’s cross-linked polyethylene,
ceramic bearing surfaces, or metal-on-metal bearing surfaces. There are some surgeons who use all
three. There are some surgeons who stick
with just one. And it’s very
controversial as to which one is the best.
I think that all three are much better than what we were doing 20 years
ago, and it’s what’s really taken us to the next level of being able to offer
this to younger patients.
Linda Austin: How long does the
Harry Demos: The procedure itself takes
between one and two hours in the operating room. The actual OR (operating room) time is a
little bit longer than that by the time you get positioned and catheters and
lines and anesthesia, and everything else, and then wake up and get turned back
onto your bed with your dressing and everything. But the procedure itself can usually be done
in just a little bit over an hour. We
generally keep people in the hospital for about three nights. That’s our average length of stay, about
three nights in the hospital afterwards.
have been some studies looking at outpatient total hip replacement and some
where people just stay overnight. But,
most complications, if they occur, occur on the second postoperative day. We feel it’s safer just to keep people in the
hospital for three days, just to make sure they’re doing what they should be
doing with therapy and make sure there aren’t going to be any complications.
Linda Austin: How long before they can
start walking again?
Harry Demos: We have people walking the
day after surgery. Most patients are
full weight-bearing on their joint as soon as they start to recover. By the end of the third day, by the time they
go home on the third day, we usually have people walking down the hall and
going up and down stairs. So, they’re
pretty independent by the time they go home.
I usually tell people, it takes about six weeks to get to the point
where they’re ready to go back to work, ready to go shopping, and ready to go
to church, those kinds of things, drive a car, all that, is about a six-week
recovery period. That’s a little
conservative for some people, but for other people who are more debilitated,
they make take a little bit longer than that.
Linda Austin: Dr. Demos, thanks so much
for talking with us today.
Harry Demos: Thank you.
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