Clinician-to-Clinician Update Clinician-to-Clinician Update

Comprehensive Approach Helps Hip Replacement Patients Reclaim Mobility

December 2016

In contemporary orthopaedic practice, a number of surgical procedures are available to address damaged hip joints. Patients and surgeons may opt to repair joint capsules or to pursue total hip arthroplasty through one of a variety of surgical approaches. Among candidates for hip replacement, there has been a surge of interest in anterior hip arthroplasty as an alternative to the more commonly employed posterior approach and a perception that the procedure might lead to faster recovery times.1 Research suggests, however, that other factors, in particular a comprehensive treatment program, may be more significant contributors to positive patient outcomes than surgical approach alone.2, 3

Total hip replacement procedures can be broadly categorized by the direction at which the orthopaedic surgeon approaches the joint: via the posterior, anterior, or lateral approach.2 Patients who underwent anterior hip arthroplasty have been shown to walk without aid sooner than those who received posterior hip arthroplasty. At 90-days postsurgery, however, patient mobility is similar across the 2 groups.2 No clinically significant difference has been found between the 2 procedures in implant alignment or general health outcomes at 6-weeks postsurgery4, and overall outcomes for each group at 90-days postprocedure have been reported to be similar.2, 5

Adult-Spec-Dec-2016-Feature-Article-Main-Image-Stock iStock 000010147084 Medium
— A comprehensive care approach has been found to be a predictor of good outcomes in hip replacement. Image ©iStock.

A comprehensive treatment approach has been found to be a better predictor of good patient outcomes, regardless of the surgical approach.6, 7, 8 Patient education and the use of rapid rehabilitation and pain management protocols have been identified as important components of effective care.3, 7, 8 A comprehensive approach includes:

  • Accurate evaluation. Pain secondary to osteoarthritis of the spine or another joint can be identified through imaging and physician consultation with spine surgeons and immunologists.6, 7
  • Targeted intervention. Partial replacement or joint resurfacing, rather than total hip arthroplasty, may be possible in some instances.7
  • Patient education. Hip arthroplasty can be physically and psychologically demanding for patients. Practices that apprise patients of the risk of complications and counsel them in preparation for rehabilitation and recovery regimens are associated with better patient outcomes.7, 8
  • Modern surgical techniques. Surgeons employ tranexamic acid to minimize blood loss, smaller incisions, and larger artificial hip head sizes. They may also pursue repair, rather than replacement, of the joint capsule.7
  • Pain management. Effective peri-operative pain management is an important component to improved outcomes and rapid recovery.7, 8
  • Rapid rehabilitation. Physical and occupational therapists, nursing staff, anesthesia, and sports medicine physicians are key members of the team, and rehabilitation begins the same day after hip replacement.8

References

  1. Jaret, P. A new approach to hip surgery. The New York Times. http://well.blogs.nytimes.com/2013/03/18/faster-recovery-from-hip-surgery/. March 18, 2013. Accessed October 20, 2016.
  2. Petis S, Howard JL, Lanting BL, et al. Surgical approach in primary total hip arthroplasty: anatomy, technique, and clinical outcomes. Can J Surg. 2015;58(2):128-139.
  3. L’Hommedieu CE, Gera JJ, Rupp G, et al. Impact of anterior vs. posterior approach for total hip arthroplasty on post-acute care service utilization. J Arthroplasty. 2016 Sep;31(9 Suppl):73-7. doi: 10.1016/j.arth.2016.06.057.
  4. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res. 2014 Feb;472(2):455-63. doi: 10.1007/s11999-013-3231-0.
  5. Watts CD, Houdek MT, Wyles CC, et al. Direct anterior versus posterior simultaneous bilateral total hip arthroplasties: no major differences at 90 Days. Am J Orthop. 2016;Sep/Oct;45(6):E373-E378.
  6. Higgins BT, Barlow DR, Heagerty NE, et al. Anterior vs. posterior approach for total hip arthroplasty, a systemic review and meta-analysis. J Arthroplasty. 2015;30(3):419-434.
  7. Ibrahim MS, Khan MA, Nizam I. Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Medicine. 2013;11(37).
  8. Raphael M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth. 2011;58(10):902-910.

When to refer

Through University of Minnesota Health, orthopaedic patients of all ages have access to comprehensive care for shoulder conditions, sports injuries, hip and knee replacement, spinal pathology, orthopaedic oncology, and hand and upper extremity surgery. Each patient is carefully screened for pain secondary to a degenerative condition in another joint. If the affected joint can be saved, our orthopaedic surgeons perform joint resurfacing, osteotomy, and partial arthroscopy. Our surgeons are highly skilled at all joint replacement and resurfacing procedures, including anterior, lateral, and posterior hip replacement.

Multidisciplinary, Collaborative Care

A multidisciplinary approach to treatment lays the foundation for successful outcomes for patients. University of Minnesota Health orthopaedic specialists collaborate closely with referring physicians throughout their patients’ treatment. In treating patients found to have joint pain secondary to a spine condition, we maintain strong relationships with spinal surgeons, and we work closely with rheumatologists in assisting patients suffering from degenerative joint conditions such as rheumatoid arthritis. Our anesthesiologist partners can perform non-narcotic and regional anesthesia techniques to minimize side effects and maximize recovery. Orthopaedic nurses counsel patients before and after surgery to keep them informed of what to expect from treatment and rehabilitation. Our sports medicine physicians and physical therapists are central to preparing the patient for surgery and rehabilitation. Our approach to treatment is designed to return each orthopaedic patient to full mobility with minimal pain.

To find current clinical trials available through M Health providers: studyfinder.umn.edu

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