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Total Hip Arthroplasty

Patients can best make decisions about their health care when they are fully informed. “Informed consent” describes the process through which patients give health care providers written permission to provide health care services, after being fully informed about those services. In order to give informed consent before total hip arthroplasty, you must be fully educated about your diagnosis, your treatment options, the details surrounding the procedure, the expected post-operative recovery time, the important risks of surgery, typical benefits of surgery, and any available alternatives to surgical treatment. I will discuss each of these points with you in the office. Since there is an abundance of information to digest, however, this comprehensive written summary is provided for your convenience.

Diagnosis

Total hip arthroplasty is used to treat a variety of hip disorders. The one central feature that links all of these disorders, however, is damaged cartilage. The vast majority of patients undergoing total hip arthroplasty will have one of the following conditions:

Osteoarthritis: Osteoarthritis (OA) is the most common form of arthritis affecting the hip. Also called degenerative joint disease, or degenerative arthritis, OA is characterized by progressive deterioration and thinning of the cartilage inside your hip. Cartilage is the smooth coating over the ends of the bones where two bones meet to form a joint. Like Teflon on a frying pan, cartilage provides an ultra-smooth coating over the bone to allow smooth gliding of the joint. Normal cartilage is about a quarter of an inch thick. In OA, the cartilage becomes progressively thinner until the underlying bone becomes exposed (“bone-on-bone” arthritis). This ultimately leads to joint stiffness, roughness of motion (called “crepitance”) and pain. An additional important source of pain is from reaction of the lining membrane of the hip (“synovial tissue”), which becomes inflamed like a blood-shot eye in response to the arthritis. This membrane produces fluid when it is inflamed, which causes hip swelling.

The cause of OA of the hip is unknown, although increased wear-and-tear, biochemical factors, and genetic factors are thought to play a role. OA may arise without known cause (Primary OA), or it may result from a variety of childhood hip disorders (Secondary OA), including slipped capital femoral epiphysis (SCFE), Legg-Perthes disease, and hip dysplasia. Primary OA may affect one or multiple joints, but often involves the hands, spine, hips, and knees.

Avascular Necrosis: Avascular necrosis, or osteonecrosis, results when the blood supply to the head of the femur (the “ball” of the ball-in-socket hip joint) is disrupted. This leads to death of a portion of the bone in this part of the hip. The size or extent of dead bone varies, and the seriousness of the prognosis is directly related to the extent of bone death. Over time the dead bone collapses which leads to further deterioration of the overlying cartilage. In the latter stages of the disease, arthritis develops in the hip. Osteonecrosis occurs without known cause in 30% of patients. There are many associated conditions, including long-term steroid dependency, heavy alcohol use, Gaucher’ disease, and others.

Rheumatoid Arthritis: Rheumatoid arthritis (RA) is one of several forms of “inflammatory” arthritis. In RA, the synovial tissue becomes severely inflamed and enlarged, producing enzymes and other factors in the joint fluid that ultimately begins to destroy the cartilage. RA is usually treated by a rheumatologist using a variety of strong medications to control the inflammation. If the disease cannot be well-controlled over the long term, cartilage damage and joint destruction may follow, necessitating total joint replacement. Because of improved medical treatment of this disease, fewer patients with RA are coming to total joint replacement.

Post-Traumatic Arthritis: Occurs after trauma to the hip joint usually resulting in fracture of the hip. After the fracture has healed, a certain percentage of patients will develop deterioration of the cartilage and arthritis. Some patients will also develop avascular necrosis, when the femoral head blood supply is disrupted because of the break in the bone.

Alternative Treatments

Once you have exhausted conservative treatment measures, including medications, joint injections, and physical therapy, AND if it has been determined that you are an appropriate candidate for total hip arthroplasty, then the only alternative to surgery is to continue living with the arthritis as you are doing.  In general it is advisable to wait as long as you can before proceeding with THA, for two important reason:

1. although serious complications are rare, THA is associated with important risks; and
2. the older you are when you have a THA, the better the chance that it may last you your lifetime and eliminate the need for revision surgery, which is riskier and is associated with poorer results.