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.
Hip Osteotomy
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 weightbearing 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 nonweightbearing..
Options For Avascular Necrosis
(Osteonecrosis)
Numerous operations have been described for
treating avascular necrosis. Various rates of success
have been reported for each, and these success rates
vary widely. Ultimately, most joint replacement
surgeons use hip replacement or resurfacing when the
femoral head is sufficiently diseased, and the majority
of patients do very well.
Most of the operations other than hip replacement
or resurfacing are designed to try to prevent
progression of the dying bone. A common technique
involves core decompression. This essentially means
drilling a hole from the side of the hip up into the ball
of the femoral head, with the goal of restarting normal
bone formation. This is a very quick operation
(typically less than half an hour) that usually leaves only
a half inch incision. Success depends on how far along
the disease is, but sometimes it can stop or even reverse
the process of bone death. Most joint surgeons believe
that this success rate is probably only about 50% at best, although some claim success rates of 80% with
this operation. The rate of success appears to be at
least somewhat dependent on the stage of the disease
and how much of the bone is involved.
The major downside to the procedure is that it
requires prolonged nonweightbearing (or minimal
weightbearing), usually 6 weeks or so, with crutches or
a walker. This is not usually an option for patients who
have both hips affected. Additionally, there is some
risk of a fracture because of the long tunnel drilled
through the upper femur.
Another variant of a core decompression involves
drilling the hole and then placing something inside that
hole to support the bone while it heals. Some surgeons
have advocated harvesting a 6 inch segment of the
fibula from the leg, and placing it into the drilled out
hole in the hip. This is called a free fibula grafting, and
it usually requires two surgical teams and a surgical
microscope to re-attach the arteries to the bone graft.
Most joint surgeons are not advocates of this
procedure because the results are not as predictable as
joint replacements, it is a long surgery with potential
complications, and many patients have chronic
problems with swelling and pain in the leg where the
fibula has been harvested from.
Still another variant of this surgery involves placing
a cylindrical core of trabecular metal (very porous
metal) into the drilled hole. There is not much data or
surgical experience with this yet, however.
Other procedures have been described over the
years that directly place bone graft into the area of
dying bone in the femoral head. These procedures are
sometimes called “light bulb” or “trapdoor” grafting
procedures, based on how the femoral head is scraped
out and packed with graft (either from below or above,
respectively). These surgeries also are typically more involved than hip replacement or resurfacing and often
do not have as predictable results or outcomes.
In our practice, we may on occasion recommend
trying a core decompression procedure for a young or
otherwise very active patient who only has avascular
necrosis in one hip, with the understanding that the
chances for success may be 50% or less. More often,
however, we will perform total hip replacement or hip
resurfacing with good results.
Hip Arthroscopy
It is possible to insert a camera and small instruments into the hip joint and have a look around, possibly removing bone fragments or pieces of torn cartilage. This is not a good operation for a patient with significant arthritis, but may on occasion be useful for a patient with bone or tissue fragments (e.g., labral tears) that are causing locking or other mechanical problems in an otherwise healthy joint.
Although this only involves very small incisions to place the camera and instruments through, there are some risks. Nerve injury can occur both from the placement of the instruments as well as (more commonly) from the pressure of the post placed between the legs for counter-traction as the leg is distracted to open up the hip joint. This can cause numbness or loss of sensation in the genital region, which can be problematic and may not return.
If surgery for these types of problems is needed, in our practice we may often recommend an arthrotomy instead, which involves making a small incision over the hip joint and opening the joint in order to fully visualize structures. It is not as minimally invasive, but the incision is still quite small and offers better visualization and less risk to nerves from positioning. Additionally, arthrotomy is significantly faster than hip arthroscopy, and the surgery can often be accomplished in less time than it takes to complete the complex traction set-up required for hip arthroscopy.
Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.
