Recent minimally invasive hip replace ment surgery/Anesthesia Issues?

Question

Have received 25 rounds of anesthesia in my lifetime/no problems, this time major problems. Surgery was 5/23/08; am 49, 18 year history/very complex mental health/auto immune disorders(very high functioning bipolar, CFS, mild Fibro), sleep apnea. Am overweight but 5'11''/ lg frame. Maternal history of multiple chemical sensitivities. Been in and out of an altered state of consciousness, amnesia or aware but memory/motor skills slow as molasses. Saw family Dr./full blood work done 7/21; everything is at theraputic levels, kidney/liver function is fine. Psychiatrist appt this afternoon. Hip replacement total success but what the H is going on with me? Articles to help me back this up would be helpful. Prefer medical professionals or someone who went through similar thing. Surgeon was aware of vulnerabilities, dropped ball in aftercare/won't speak with me. Documenting everthing to keep track, not stable enough to drive, friends checking in on me. Two more hospitalizations, some PTSD.

Answer 1

It is usually reasonable to try a number of non-operative interventions before considering hip replacement surgery for arthritis. Prior to surgery, an orthopaedic surgeon may offer pills (either non-steroidal anti-inflammatory medications or analgesics like acetaminophen, also known as Tylenol), knee injections, or exercises. Your surgeon may talk to you about activity modification, weight loss, or use of a cane.

The decision to undergo a hip replacement is a “quality of life” choice. Patients typically have the procedure when they find themselves avoiding activities that they used to enjoy because of hip pain. When basic activities of daily life--like walking, shopping, or reasonable recreational pastimes--are inhibited or prevented by the hip pain, it may be reasonable to consider the surgery.

Very rarely, the arthritis can cause a destructive pattern of bone loss. In this instance, a surgeon might recommend the surgery in order to prevent a type of pelvic fracture (called protrusio acetabuli), even if your symptoms are otherwise manageable non-surgically. But again, this is quite uncommon. In almost all instances, the decision and timing of hip replacement surgery for arthritis are a personal decision to be made by the patient, not by the surgeon. The decision should be made in consultation with a trusted surgeon who can help educate the patient as to risks, benefits, alternatives, and issues related to recovery from surgery. If a surgeon says you “need” a hip replacement for arthritis, without discussing alternatives or asking you about quality-of-life issues, it might be worth considering getting a second opinion.

What happens without surgery?

Arthritis is often progressive, and symptoms typically worsen over time. In other patients, the symptoms wax and wane, causing “good days and bad days.” Hip arthritis does not usually improve on its own. Sometimes, if the hip becomes quite stiff, this can result in increased stresses to the lower back with low back pain being the result. As mentioned, in very rare cases, the arthritis can cause a pattern of bone loss in the pelvis (protrusio acetabuli) that can predispose patients to fracture of the hip socket.

Surgical options

“Traditional” or “minimally-invasive” hip replacement?

This topic, more than any other, is on the minds of patients who come to the office to discuss hip replacements today.

Traditional hip replacement--using an incision that varies proportionally with the size of the patient, and may be between 5 and 8 inches long--has been done, with a few modifications of surgical technique, for over 40 years. The results of this approach have been published by literally thousands of surgeon-scientists, from hundreds of medical centers, in dozens of countries. There is a known success rate from this surgery, and it is above 90% with more than 10 years of follow-up after the operation. It is predictable, and considered one of the great surgical innovations of the 20th century. It would appear from this that we ought to set the bar fairly high before trying something radically new or experimental.

In contrast, “minimally-invasive” hip replacement is a new surgical approach; few surgeons have even been doing it for two years. “Minimally-invasive” means different things to different surgeons. There is no accepted definition--it can be the same operation done through a slightly smaller incision than the surgeon used to use (say 5 inches rather than 6 or 8 inches), a much shorter incision (an approach calling for a 3 inch incision is popular in some places), or even two 1.5-inch incisions using an x-ray machine to find the bones and put the components in the right place.

Surgeons who perform these approaches often say that the shorter incision results in a number of benefits: shorter recovery time, less blood loss, less post-operative pain, or fewer days in the hospital.

The problem with these claims is that, to date, they have not been proved in a single scientific study. And even if one or two studies come out on the topic, most scientists agree that before advertising that something in surgery is true, it should be validated by different surgeons in different medical centers--to make sure that the claims are in fact true and that the results can be reproduced by others. As of now, this has not been done.

One might reasonably ask “What could be wrong with a shorter incision--if anything, the results would be the same, but the scar would be more attractive, right?” The answer is, not necessarily. If the shorter incision causes the surgeon difficulty seeing the hip socket or the thigh bone (femur) clearly, or if it impedes his/her ability to work in the tighter surgical field, the result could be badly positioned hip replacement components. That could cause surgical complications like fractures or nerve injuries, hip dislocations (where the ball painfully comes out of the socket after the surgery), and premature wear of the artificial bearing surface.

This is in contrast to minimally-invasive partial knee replacement, which has been around only a few years longer than the hip technique, but already has a number of studies proving patients recover faster, and that surgeons are able to get the components properly positioned through the smaller incision.

It is particularly telling that the Journal of Arthroplasty, which is the main research journal for joint replacement surgeons, recently wrote an editorial criticizing surgeons who have advertised the “minimally-invasive” hip technique to the public before any reasonable scientific analysis has been performed on it.

On the other hand, innovation and new approaches are essential to the improvement of techniques in all areas of medicine. It seems very possible that some, if not all, of the benefits of “minimally-invasive” hip replacement may be realized. It is quite likely that we will learn much more about this technique in the near future. At this point, it is reasonable for patients who are attracted to the idea of a more cosmetic appearance of the shorter incision, and who are not troubled by the as-yet-unanswered questions about this approach, to consider “minimally-invasive” hip replacement. Others might consider going with a traditional surgical approach.

Like so much else in medicine and surgery, this is a personal choice that is best made in view of all the facts.

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