HIP ARTHRITIS AND TREATMENT
The popularity of the anterior approach for hip replacement has grown exponentially because of its advantages and superior outcomes. The joint is replaced without detaching any muscles from the hip or pelvis and the implants are placed with enhanced precision using image-guided “navigation” techniques. The dislocation risk is markedly reduced, leg length restoration is more accurate, and post-operative pain is substantially less than after traditional hip replacement techniques. Patients are allowed full motion, without any restrictions, immediately after surgery and return to limitless activities sooner.
Dr. Ferguson is a technical master and academic thought leader with anterior approach THA surgery (aTHA). She has published more than twenty scholarly articles, book chapters and online lectures advancing the techniques and understandings of hip and pelvis surgery. She is a founding member of the Anterior Hip Foundation. Dr. Ferguson has been instrumental in the education of residents and surgeons around the world, teaching this technique since 2005. Her research and educational successes have been pivotal in the expansion of the aTHA in the United States.
What is Total Hip Replacement (THA)?
Hip arthritis is a disease that involves the degeneration and loss of the cartilage surface leading to bone-on-bone contact between the femoral head and acetabulum. The treatment for hip arthritis is a Total Hip Replacement. This is a surgery in which the patient’s hip joint is replaced with an artificial hip prosthesis.
Why The Anterior Approach Total Hip Replacement (aTHA)?
Anterior Approach THA (aTHA) has measured advantages and superior outcomes compared to traditional methods of hip replacement surgery.
The hip is replaced through naturally occurring intervals between the muscles without cutting through or detaching any muscles from the hip or pelvis. The intact muscular envelope preserves the dynamic stability of the hip after surgery, contributing to the low dislocation rate. Also, post-surgical pain is minimized due to the lack of muscle injury.
The aTHA technique allows the surgeon to use image-guided navigational techniques to precisely place the hip components and accurately restore the patient’s leg lengths during surgery.
There are no limitations on motion or activity after aTHA. Patients are encouraged to walk and move their hip freely right away without any restrictions, simplifying rehabilitation and accelerating recovery.
After aTHA, patients are able to walk within hours of surgery and require no IV pain medications or medical interventions. 80% percent of Dr. Ferguson’s patients are able to leave the hospital on the day of surgery, reaping the benefits of recovering at home.
The muscle preserving approach greatly decreases post-surgical pain. Utilizing a highly coordinated “multi-modal” pain management program, many of Dr. Ferguson’s patients require no opioid/narcotic-based medications after discharge.
aTHA: Muscle Sparing Surgery
The “anterior approach” indicates that the hip joint is exposed from the front of the body “anterior,” rather than from the side “lateral” or back “posterior.” This is facilitated by the use of the orthopaedic table (HANA table-pictured below).
The HANA® Table (Mizuho OSI)
Other surgical approaches for hip replacement (the lateral and posterior approaches) require detachment of the hip stabilizing muscles from the femur during surgery. Not surprisingly, hip dislocation is an important concern after these techniques and the most common cause of revision surgery in the US.
In the anterior approach, by contrast, the hip is approached and replaced through natural intervals between the muscles. The muscles for hip function and stability are left intact, the hip is more stable, and the reported dislocation rate is 10 times lower than after traditional hip replacement techniques.
By leaving the important hip muscles intact, the hip is more stable and less likely to dislocate than after lateral and posterior approaches.
Because the muscles are left intact, the risk of sustained abductor weakness and limp are minimized.
The lack of muscle injury greatly decreases post-operative pain after aTHA compared to other techniques, minimizing the need for pain medicines after surgery. Many patients recover without any opioid-based medications.
After traditional hip replacement, the patient is commonly told not to bend at the hip or rotate the leg for a period of time to prevent the positions associated with dislocation. Patients require therapy and education to learn these “precautions”. After aTHA, there are NO PRECAUTIONS or limitations on position or movement, simplifying recovery and accelerating the return to normal function.
The accelerated rehabilitation, shorter hospital stays, and impressive return to limitless functional activities associated with aTHA surgery have been attributed largely to the muscle sparing nature of the exposure.
aTHA: Precise Hip Implant Positioning
One of the biggest reasons for the surge in popularity of the aTHA in the United States is that it allows for reliably well positioned components and accurate leg length restoration. A common problem with other “minimally invasive” techniques of hip replacement is in positioning the implants. With limited visualization through small incisions, surgeons have difficulty getting the cup orientation and leg lengths correct. Inaccurately placed implants increase the risk of dislocation, weakness/limping, and leg lengths that are too short or long.
The anterior approach allows the patient to be operated while lying on their back on the radiolucent HANA table (see above). This facilitates the use of x-ray in surgery (the portable x-ray is called fluoroscopy). By using the anterior approach and fluoroscopy to guide the surgeon, the final product of a well-positioned hip can be reliably achieved and implant positioning is absolutely precise.
Image guided ("Navigated") implant placement allows the most accurate restoration of leg lengths and component positioning.
Why does this matter?
1. The Acetabular Component: Hip dislocation rate is closely associated with inaccurate positioning of the acetabular component (socket). With aTHA surgery, fluoroscopic visualization allows placement of the acetabular component with absolute precision.
Fluoroscopic Navigation of the Acetabular Component:
A). Dr. Ferguson uses x-ray imaging to modify the orientation of the acetabulum preparation based on the fluoroscopy imaging.
B). The acetabular component can then be placed in exactly the position Dr. Ferguson desires. C). Final component position is precisely determined by this technique which is associated with the lowest dislocation rate reported in the orthopaedic literature for hip replacement surgery.
2. The Femoral Component: Leg Length and Offset: With hip replacement surgery, the surgeon has to choose between various prosthesis sizes and geometries. The goal is to restore and optimize each individual’s hip mechanics and leg lengths. Utilizing fluoroscopic navigation during surgery, the surgeon can image various implant option sizes and compare each to the intact extremity. Changes can be made based on the direct visualization of imperfections, allowing the surgeon to precisely restore the hip angles, offsets and leg lengths.
Fluoroscopic navigation of the Femoral Geometry:
A). Dr. Ferguson can obtain an image of the unaffected "good hip" as well as the operative hip with "trial" hip components placed. These images are compared visually to see if the trial sizes restore the leg lengths and mechanical angles appropriately.
B). After marking the landmarks of the pelvis (unchanged by surgery), and the femur (which change as a result of the prosthetic component sizes), the images are overlapped to see if the components restore the leg lengths or make the operated leg too long or too short. Additionally, the mechanical angles are evaluated to see if the trialed components have restored the hip mechanics to the pre-arthritic condition appropriately. This optomizes muscular control of the hip and minimizes weakness and limping after surgery.
Dr. Ferguson uses a computer navigation system called JointPoint to take the component placement level of accuracy within two degrees of error. This computer program evaluates the exact orientation of the acetabular component and Dr. Ferguson can then make fine adjustments (within two degrees of precision) before finalizing the implantation. Similarly, JointPoint is able to evaluate exactly how many millimeters of leg lengthing or offset change has occurred with the trial implants based on the fluoroscopic images. This allows Dr. Ferguson to make millimeter based changes in the prosthesis. JointPoint is the most accurate method of hip replacement positioning in contemporary medicine. Dr. Ferguson has incorporated this technology to her aTHA program to optimize the accuracy of her patients’ component placements, enhancing outcomes and minimizing the risk of dislocation and leg length imperfections.
aTHA: Accelerated, Simplified Recovery
NO RESTRICTIONS, NO PRECAUTIONS AFTER aTHA!
Because the aTHA is performed without detaching any muscles and the component placement so accurate, the hip is inherently stable. The risk of dislocation is very low, so there is no reason to limit the patient’s motion after surgery. Unlike other approaches, there are no “precautions” or restrictions on the leg’s position starting immediately after surgery.
Furthermore, as there has been very little trauma to the muscles with aTHA, patients have less pain after surgery than with other surgical approaches. Patients generally begin walking and practicing on stairs within 4 hours of surgery and most patients are able to go home the day of their operation.
The anatomic reconstruction and muscle sparing techniques allow patients to return to their daily lives and activities, their work, and even high level athletics early in the postoperative course. Patients are encouraged to start walking as their primary form of “therapy” after surgery. Many patients simply start walking, then walking on inclines then gradually return to the activities they enjoyed before hip arthritis limited their function. Those patients that feel that a therapist could help accelerate their functional return are encouraged to make an appointment with the team therapists at any time.
Pre-Op X-Ray before bilateral aTHA
Post-Op X-Ray after Fast Track bilateral multimodal aTHA
Patient is walking well wearing bilateral Game Ready ice sleeves shortly after surgery! He used no IV pain medications and felt “sore." He said, “I woke up, and my hip pain is just gone!”
Fast Track: Ambulatory "Same-Day-Discharge" Hip Replacement
Eighty-five percent of our patients qualify for the FAST TRACK program, in which we safely get you out of the hospital and AWAY from hospital acquired infections the day of the surgery! Patients are able to be discharged home the day of surgery.
BENEFITS OF FAST TRACK "SAME-DAY-DISCHARGE" aTHA:
Lower risk of hospital-acquired infections
Significantly decreased amount of opioids and other medications administered
Far lower narcotic-related complications
Lower cost for both patients and providers
Higher overall patient satisfaction: outpatient joint replacement recipients report being more satisfied with the care they’ve received
Our FAST TRACK “Outpatient Total Joint Replacement” program was started by Dr. Ferguson in 2013 in response to one patient’s desire to go home rather than stay in the hospital after her surgery. She was a physical therapist at the hospital, as was her husband. They developed a PREOPERATIVE therapy program for patients and their designated “Care Partner.” The program included patient instruction on how to move around with the walker, navigate stairs and cars, and learn and “what to expect” after hip surgery BEFORE the patient actually had surgery. This preoperative “Prep School” eliminated the need to do post-operative education in the hospital AFTER the operation.
A cardiac surgery anesthesiologist was recruited to determine the best anesthesia to allow patients to start walking within one hour of surgery. Dr. Ferguson, the anesthesiologist and the pain management team developed an opioid free pain management program; minimizing narcotic administration to optimize recovery immediately after surgery and eliminating the use of IV pain medications. With this highly choreographed program, patients were soon able to safely and predictably go home the day of surgery. Now more than 50% of our patients choose Dr. Ferguson’s FAST TRACK program; even when traveling from out of town!
The fact is, aTHA is an atraumatic surgery that tends to require less pain medication than even an arthroscopic surgery! With contemporary anesthesia, therapy, and medical advances, most patients are able to walk without any IV pain medication within 4 hours of surgery.
PREPARATION IS THE KEY TO SUCCESS! MOST OF THE WORK IS DONE BEFORE SURGERY SO THAT THE POST-OPERATIVE PERIOD IS SMOOTH SAILING!
aTHA: Opioid Free Recovery
The Opioid crisis is real and avoidable. Furthermore, opioid or “narcotic based” medications are responsible for the majority of post-operative complications requiring hospitalizations after hip replacement.
Working with other THA surgeons, anesthesiologists and pain management specialists, Dr. Ferguson has developed a “Multimodal” Pain Management Program that virtually eliminates the need for IV narcotic pain medication (most patients don’t even require oral pain medications).
Dr. Ferguson’s non-narcotic, multimodal pathway is the foundation of her patients’ early mobilization and ability to get walking within hours of the operation. It is the mainstay of our FAST TRACK program’s success!
DR. FERGUSON'S MULTIMODAL PAIN MANAGEMENT PROGRAM:
Pre-operative “cocktail” taken the morning of surgery blocks pain perception pathways
Spinal anesthesia during surgery minimizes medication overload
Atraumatic surgical technique: no muscle damage = less pain!
Periarticular anesthetic block: numbs the surgical area for 2-3 days after surgery
Movement is the most effective method of decreasing surgical pain
Cryotherapy with the GAME READY cold compression device: “It is a Game Changer!”
aTHA: Dr. Ferguson's Role in the US
Dr. Ferguson was among the first American surgeons to adopt the anterior approach THA as an exclusive technique for primary hip replacement surgery in 2004. She was one of the earliest surgeons to practice this technique at a university center (training residents and fellows) and has been intimately involved in the development of surgeon educational programs worldwide to spread the techniques of the anterior approach THA across the globe.
Her research and innovative techniques utilizing the anterior approach THA for acute fractures of the hip and pelvis has extended this beneficial technique to patients requiring hip replacements for injuries and accidents. Her efforts have been integral to the increasing popularity of the anterior approach as the safe, high-quality, and preferred technique for THA in the United States.
Dr. Ferguson has devoted a career of research, education and practice to optimize your entire experience with hip replacement surgery; no detail is left unconsidered. Her experience combined with the comprehensive team approach at the Nashville Hip Institute allows patients to return to limitless activities – even competitive athletics. Our program has changed the lives of patients from all avenues of life and from all of over the country. From the school teacher trying to get back to the classroom to the grandparent wanting to play with her grandkids to the performance athlete wanting to return to high level competition, our goal is to help you get your life back; whatever that means to you!