By Alexander S. McLawhorn, MD, MBA
A recent study in the National Institutes of Health found that nearly 15 percent of adults 60 years of age and older reported significant hip pain. At Hospital for Special Surgery (HSS), multidisciplinary teams meet weekly to discuss cases, innovative ideas, new technologies and the latest research to provide patients with world-class surgical and non-operative treatments of varying hip conditions.
Some of the more common problems we treat are degenerative conditions such as osteoarthritis; trauma to the hip that can damage cartilage; developmental abnormalities of the hip joint such as hip dysplasia; and acquired conditions that can lead to abnormal shape of the bones comprising the hip joint that can cause impaired motion and cartilage damage over time.
Treatment for these various conditions depends on the severity of symptoms and the relative preservation or degradation of joint cartilage. For those with cartilage thinning around the hip that limits their physical activity, we can temporize symptoms with non-surgical management before hip replacement. These treatments, ranked by importance, are weight loss, if medically necessary; a targeted physical therapy regimen; the use of non-steroidal anti-inflammatory drugs; and administering various joint injections.
Joint Replacement Checklist
For many patients, hip replacement surgery is the best solution to improve their physical condition in a meaningful way. There are several criteria patients need to satisfy before we determine that hip replacement is appropriate.
First, they must be experiencing significant hip pain which is limiting their quality of life. Second, they have attempted methods of non-surgical management. And third, their imaging demonstrates degeneration of the hip joint and the need for joint replacement surgery.
Direct Anterior Approach
The vast majority of hip surgeries that I perform are total hip replacements using a direct anterior (frontal) approach in which the hip ball and socket are removed and replaced with prosthetic components. With the anterior approach, I follow an intramuscular plane by entering the hip joint between muscles, not through them. This avoids damaging not only the muscles around the hip but also nerves supplying power to those muscles. Patients undergoing this approach report less pain and quicker surgical recovery compared to other approaches to the hip joint. We’re preserving more of the tendons and soft tissues around the hip which reduces the chances for hip dislocations after hip replacement. HSS’s extensive research finds that the hip dislocation risk can be up to 80 percent less with anterior hip replacement versus using a posterior approach.
For patients concerned about the cosmetics of the hip replacement scar, an inguinal crease or “bikini” style incision may be used. This scar runs parallel to the natural groin crease and is more discrete than the traditional anterior approach scar, which is vertically oriented.
More Convenient Recovery
There are other potential benefits to anterior replacement over alternative surgical approaches. In the first six weeks after surgery, anterior patients experience a somewhat faster functional recovery, reporting less pain and greater ease with everyday activities, such as rising from sitting and bending over. Even though this healing advantage disappears later in their recovery, a more rapid early recovery helps patients return to their daily work and personal lives more readily. HSS shared its own research on this topic at this year’s American Academy of Orthopedic Surgeons (AAOS) annual meeting.
It should be noted that the fundamental biology of healing after surgery is not different based on surgical approach; it takes the same amount of time for the bone and implants to fuse together and for the soft tissues to heal. However, with reduced dislocation risk, anterior patients regain range of motion sooner for simple tasks like getting their shoes and socks on, going out to dinner, and returning to work. Our goal is to lessen the downtime for patients post-surgery.
Technology Leadership
HSS is leading the way in technology to individualize care across the patient experience. At the center of this effort is using machine learning and artificial intelligence (AI) to delve into our huge repository of patient data, including patient-reported outcomes measures (PROMs), imaging and other outcomes, to come up with predictive systems to guide patient care for optimal results.
Prior to a patient’s initial consult with an HSS surgeon for hip replacement, PROMs are collected, which give the surgeon a summary of an individual patient’s hip health. We are fairly unique in collecting and using PROMs from our patients at the point-of-care. Our electronic medical records system enables us to collect comprehensive patient information which helps us assess the potential benefits of surgery with greater accuracy and insight. After surgery, we continue to use PROMs to assess a patient’s joint health. Our goal is to connect the patient with the right treatment for their disease state at the right time and then monitor that treatment over time.
The clarity of our high-quality imaging and the expertise of our radiologists allow us to be more precise in our diagnoses and for surgical planning. For example, HSS has pioneered imaging-based methods to optimize positioning for total hip replacement, to maximize the longevity of implanted parts and minimize chances for dislocation. We customize the placement of the implanted joint to achieve an ideal outcome for each patient.
Additionally, we’re excelling in the use of robotics, which allows for creating a 3D preoperative plan with a CT scan to virtually run through the surgery ahead of time. Robotics provides the advanced tools to execute that plan with unsurpassed exactness during surgery.
While most of the surgery is performed without robotic assistance, we apply the technology at critical points of the procedure. First, robotics lets us precisely control the position of the hip socket, where it sits in the pelvis. Second, it carefully tracks changes in leg length throughout the procedure. The technology allows us to hit our targets with 95 percent or greater accuracy, augmenting a surgeon’s precision. By getting these parts of the procedure right, our research has shown that robotics significantly reduces the risks for dislocation and leg length inequality after hip replacement.
Alexander S. McLawhorn, MD, MBA, is an orthopedic surgeon at HSS Orthopedics with Stamford Health, specializing in joint replacement of the hip and knee.
