Interventions

Total Hip Arthroplasty

Hip wear is often associated with a reduction in joint range of motion (stiffness) and, most importantly, pain. Clinically, this manifests as limping, difficulty putting on shoes, and challenges with personal hygiene. 

Hallux Rigidus

Hallux rigidus is the name given to primary osteoarthritis of the first metatarsophalangeal joint, as well as between the head of the first metatarsal and its sesamoids.

Hallux Valgus

The most common deformity is HALLUX VALGUS (commonly called the "bunion"). It affects the first ray of the foot, where the phalanges are deviated outward and the first metatarsal (the long bone on the inner edge of the foot) is deviated inward.

Hip

Hip wear is often accompanied by reduced joint amplitude (stiffness) and, above all, pain.

Knee

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Total Hip Arthroplasty

In Brief

Hip surgery consists in replacing the worn joint with a total prosthesis, thereby relieving the pain associated with coxarthrosis and restoring normal mobility.

Causes

Natural wear and tear of the joint (osteoarthritis), trauma or congenital anomalies can lead to significant stiffness and pain, necessitating surgical intervention.

Intervention

The procedure is performed under anaesthetic, and the prosthesis replaces the femoral and acetabular parts of the hip. The choice of prosthesis depends on the quality of the bone and the degree of wear.

Recovery

From the day of the operation, you will be able to walk with canes. Full recovery takes a few months, with a gradual return to normal life and a resumption of sporting activities after 3 months.

3 Hip

What's it all about?

Your hip has a deformity or wear (called coxarthrosis) that requires replacement. The hip is replaced in its entirety, i.e. both the femoral and acetabular parts (the part of the pelvis that articulates with the femur).

Hip wear is often accompanied by reduced joint amplitude (stiffness) and, above all, pain. Clinically, this manifests itself as limping, difficulty putting on shoes and toileting. It is sometimes necessary to use a cane to relieve the pain and maintain walking autonomy.

In the case of so-called infra-radiological wear, i.e. wear that is not visible or only slightly visible on X-rays, surgery may be indicated after the failure of various medical treatments, such as the test of time, painkillers or infiltrations. An MRI or CT scan then confirms the diagnosis of osteoarthritis.

The aim of the operation is to stop stiffening and deformation, and even to restore the knee's functional axis. Reducing or even eliminating pain is often the patient's main motivation for undergoing surgery.

Intervention

The procedure is carried out in hospital, in the operating theatre, under general anaesthetic or spinal anaesthetic, i.e. with a shot in the back that puts only the lower limbs to sleep. The advantage of spinal anesthesia is that the patient remains conscious, and is therefore less affected by the consequences of general anesthesia, which can sometimes cause nausea, vomiting or a slowdown in higher functions lasting a few hours. The disadvantage of spinal anaesthesia is the need for passive participation in the procedure, which may appear noisy to some.

You are positioned on the side opposite the operated hip. An anterolateral incision is made, allowing access to the hip joint. Using tools to expose the operated joint, the femoral head is resected and the inside of the bone is prepared to give it the shape of the prosthesis. The acetabulum, for its part, is prepared using motorized circular burs, enabling the natural sphericity of this very special bone to be maintained.

The principle of the procedure is to cut away the worn cartilage covering the femoral and acetabular bone and replace it with solid surfaces, while respecting the local anatomy.

There are cemented, cementless or mixed prostheses, the choice of which is guided by the quality of your bone, its shape and the level of wear. Friction torque (what moves in the prosthesis) also varies according to the surgeon's habits, but also to the evolution of scientific knowledge. To sum up, there are so-called hard-hard couples (metal against metal, abandoned or ceramic against ceramic) or hard-soft couples (metal or ceramic against polyethylene).

The soft tissues - i.e. the vessels, nerves, ligaments, muscles and tendons surrounding the hip joint - are preserved throughout the operation, and only the joint is changed.

At the end of the procedure, an anesthetic is injected into the synovial and capsular tissues to optimize immediate post-operative pain relief. The skin is closed with staples and a pressure dressing is applied for 24 hours.

Hospitalization

On the day of the operation, which usually takes place in the morning, you will be able to get up for the first time in the afternoon. Most of the time, you will be able to walk under your own power, with the help of a pair of walking sticks, accompanied by a caregiver.

On the first day, general analgesia (via the veins) and local analgesia (anaesthetic injected into the hip at the end of the operation) enable you to spend the first 24 hours in almost complete indolence. After that, post-operative haematoma gradually sets in, and tension in the operated lower limb contributes to pain, which should however remain moderate. Pain control is one of the criteria for discharge.

The day after the operation, your independence will be assessed by the department's physiotherapist and nurses. Various criteria will be used to validate your return home. Pain and bleeding control, autonomy in washing and dressing, and ability to climb stairs are the main criteria. You may be discharged home on the 1st post-operative day, but this takes an average of 48 hours. You can stay longer if you don't feel ready to go home. The length of your hospital stay is discussed on a case-by-case basis between you and your surgeon, but it has been shown that the shorter your stay, the lower your risk of complications.

The entire duration of your hospital stay is governed by a Rapid Recovery protocol established within the department, the aim of which is to enable you to return to your autonomy in a participatory manner. This recovery is based on motivation, starting in the pre-operative phase, to enable voluntary, uncomplicated recovery. Indeed, immediate post-operative standing reduces the complications associated with bed rest, such as digestive, urinary, appetite and sleep disorders, as well as the risk of phlebitis. It has been demonstrated that a rapid return to daily life leads to a statistically proven reduction in medical complications, particularly those linked to phlebitis and therefore to the occurrence of pulmonary embolism, the most dreaded complication after any surgery on the lower limbs.

Returning home is essential to reduce the rate of complications. It has been shown that the older the patient, the earlier they can return home. Post-operative hospitalization as a cure is becoming the exception rather than the rule, and should only be proposed in situations where autonomy was already very low prior to surgery, in a person living alone, with little support, and with associated defects or illnesses.

After hospitalization

When you return home, you will be taught to change the dressing yourself. The dressing is watertight, so you can wash yourself without additional protection. The staples are removed on the 18th post-operative day by a home care nurse or your GP. Post-operative haematomas become permanent around the 8th post-operative day. It can sometimes be impressive, causing the skin tissues to become extremely taut and, in extreme cases, leading to the appearance of phlyctenes (large blisters) on the skin. This hematoma is nothing to worry about; it's normal and necessary for healing. As long as it is not accompanied by unbearable pain, despite painkillers, or paralysis of the limb, self-education and walking should be continued. If this is not the case, you should contact your surgeon or attending physician to discuss your concerns.

You will be entitled to full support immediately, under cover of a pair of canes for the first month. Daily tasks must be able to be carried out as soon as you return home. It is possible to leave your home.

It is recommended not to drive for the first month, as explained above.

Medical treatments must be taken as prescribed on the discharge prescriptions. The first post-operative check-up takes place between the second and third month, but will be adapted on a case-by-case basis.

A return to leisure activities is possible between the 2nd and 3rd month, and to sporting activities after the 3rd month, although this resumption must be gradual and the preoperative level is not immediately recovered.

The return to work takes between 1 and 4 months, depending on whether the work is sedentary, requiring few car journeys, or physical, intense, standing work.

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Long-term development

In the ideal situation, a total hip prosthesis can be fitted without the need for further surgery.

The life of the prosthesis can be that of the patient, if the hip is used rationally. These are wearing parts, as in mechanical engineering. Consequently, being overweight (obesity), carrying heavy loads or engaging in strenuous sporting activity can reduce the implant's lifespan. It is generally accepted that the average lifespan is 15 years. However, this average increases if the complications mentioned above do not occur.

A healthy lifestyle is essential to the longevity of implants.

Your surgeon will provide radioclinical monitoring, initially on an annual basis and then more frequently. Outside these scheduled periods, you should consult your surgeon if you notice any change in the way your hip feels or functions.

Possible complications

Infection

Its risk is statistically estimated at 2 %, but is increased in the case of associated diseases, the most frequent of which are obesity and diabetes, as well as poor quality of the venous network or skin. Smoking and alcohol consumption are also risk factors. On the other hand, if you are free of defects, have regular physical activity before the operation and eat a balanced diet, the risk of complication is lower than the statistical data. In the event of infection, secondary surgery may be required, in conjunction with antibiotic treatment.

Phlebitis

Related to bed rest and reduced mobility, in association with post-operative hematoma, it occurs as a result of poor circulation. A history of phlebitis increases this complication. You will be given a preventive anticoagulant treatment, the dosage and duration of which will be adapted to your history. Phlebitis manifests itself as pain, most often in the calf, of secondary origin, which should always be suspected and investigated by a venous ultrasound scan of the lower limbs.

Untreated phlebitis can lead to pulmonary embolism, i.e. the migration of blood clots from the veins into the lungs, which in exceptional cases can be fatal.

Fracture

After the operation, the bone is weakened, firstly by under-use of the limb due to pre-operative osteoarthritis, and secondly by the operation itself. As a result, in the event of a fall, the impact on the operated bone may lead to a fracture around the prosthesis, or even loosening of the prosthesis (detachment of the prosthesis from the bone). It may then be necessary to intervene again to repair the bone, or even replace the prosthesis.

For the first month after surgery, there is a risk of the implant sinking into the bone. You will be asked to keep your pair of walking sticks on during this first month in order to control this risk. The canes should be used as a safety device in the event of a stumble or near-fall, similar to the small wheels on a child's bicycle.

Luxation

In the first two months, post-operative hematoma and muscular sideration can lead to dislocation of the prosthesis. If this happens, you can no longer walk, and the pain usually leads to a visit to the emergency room. You then have to fall asleep to put the prosthesis back in place.

This risk is of the order of 1 %, but to keep it as close to zero as possible, you will be taught to avoid or adapt certain everyday movements. You are also asked not to drive during the first month, as a dislocation at the wheel can lead to an accident. You can, however, travel in the car as a passenger, but you should sit upright and avoid journeys of more than an hour without a break.

unequal limbs

Limb inequality can occur after surgery. Adjusting the height of the prosthesis takes into account limb length, and in some cases even allows limb length to be regained if there was a preoperative inequality. However, the stability of the implants in relation to each other or in the bone is more important than the identical length of the limbs. The surgeon therefore does not always control this parameter, giving priority to prosthetic stability. An inequality of up to 2 cm is not usually perceptible, but may be visible on X-rays. If necessary, you can be offered compensation with a sole or heel cup.

Joint stiffness

Joint stiffness may be a consequence of preoperative stiffness. Indeed, when the wear is long-standing and the hip has not had its natural range of motion for several years, it is sometimes difficult, if not impossible, to regain full mobility. In such cases, you will have to accept a certain amount of sequelae stiffness.

Except in special cases, no physiotherapy will be prescribed after your discharge. You will be given a series of exercises to do yourself. Walking makes the hip more flexible.

Other

The post-operative course may be marked by disturbances that are not considered complications, but rather post-operative incidents. These include edema of the operated lower limb, which can last up to a year, and joint effusion (fluid in the hip), which can last several years as a result of local inflammatory reactions.

Some background pain may persist, but it will be less than it was preoperatively, without any malfunction or complication. This pain is assessed with the surgeon and treated according to its intensity. If it is poorly tolerated, this may lead, in extreme cases, to re-operation, if abnormalities are found that could explain it.

In the shorter term, scarring incidents with delayed healing, or even scar disunion, can mar recovery, although in the absence of infectious syndrome, healing is eventually achieved.

Finally, any anesthetic procedure can theoretically lead to a massive allergic reaction called anaphylactic shock, with cardio-respiratory arrest and death. However, you will be under constant surveillance by monitors and caregivers during and even after the procedure, so this fatal risk remains purely theoretical and has become extremely rare.

But don't let these complications frighten you. They do exist and you should be aware of them, but they are rare, and your surgeon will be happy to discuss them with you, reassure you and support you should they arise.

Consultation

Make an appointment with
Dr. Paul MIELCAREK

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