Types of Procedures
What is a hip resection or Girdlestone procedure?
The diseased hip ball joint can be removed in limited cases in which an artificial hip is simply not feasible. In the past, this was commonly done for severe tuberculosis-induced destruction of the hip joint. The infected bone would be removed, and the hip cavity would be left empty. Over time, this cavity fills with scar tissue. The femur bone rides upward, and the patient's leg shortens. People in this situation are able to walk very limited distances, using a walker and a shoe lift. While the results are not as good as having an artificial hip joint, the operation can be converted to a total hip replacement in many cases. Alternatively, the patient may choose to have no further hip operations following a hip resection. The hip resection procedure, also called a Girdlestone procedure, is rarely performed now. We reserve it for serious infections that cannot be eliminated, or for severe bone destruction from multiple failed surgeries, or other causes.
In very difficult repeat surgeries, it has been necessary to do a resection surgery, at least temporarily in very limited cases. These are cases that are tedious, long and very difficult technically. If bone destruction is severe, we may be able to do a part of the reconstruction, including major bone grafting. It may be necessary in some such cases to leave the hip out, so that the patient cannot load it, while the bone graft is healing. In six months or more, depending on the individual case, we go operate again on such hips, and finish the rest of the procedure, with the bone graft giving us additional support. Therefore, the resection procedure is useful in the interim in such cases.
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What is a hip fusion?
The arthritic hip joint in the very young patient can be treated by fusing the hip. This involves making the ball joint continous with the pelvic bone so that the joint does not exist as a site of movement. Hip movement is then taken up, in part, by the knee and the back. Hip fusions are almost obsolete now, given the success of hip replacement surgery, but still worth thinking about. Even though some activities such as driving, sitting and sexual activities may require modifications after a hip fusion, the operation has a long-term, scientifically validated good track record. Pain coming from the diseased hip joint is eliminated, and the result is very durable for many decades. If the fusion is done properly, and the muscles are preserved, it is even possible to take the fusion down at a later date, and insert a total hip, when the patient is older and more suitable for a total hip. The strength of this operation is the long-term success in relieving pain. The drawbacks are the obvious lack of motion of the hip and the need to compensate for this. Also, over many decades, the knee below a fused hip will develop arthritis, as will the back, since these organs take up the movement missing from the fused hip, and get progressively overloaded. Still, in limited situations, a hip fusion is worth considering.
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I read about the sports procedure for hip and knee replacement where people go home the same day. Do you do this?
As part of a teaching institution and as surgeons who is always keen to keep learning and developing all that we do, rest assured that if a procedure pertaining to hip or knee replacement is done elsewhere by a reputable surgeon, then we also offer it. For example, we have among the largest series of consecutively performed MIS-2-incision total hip replacements, and we have refined and improved on this procedure over time. We perform the quadriceps-sparing total knee replacement, the computer-navigation-guided knee replacement procedure, and all types of so-called minimally-invasive surgery related to the hip or knee joint.
Keep in mind however, that the term "minimally invasive surgery" is misleading. Often it is a term used by surgeons to promote or market themselves. In truth, all surgery, no matter how small the cut, is inherently invasive. Complications, pain, discomfort, regaining and rebuilding strength and stamina, rehabilitation, compliance with post-operative programs, and precautions are a part of every surgical procedure, no matter how minimally invasive it is touted to be. Beware of surgeons giving seminars describing their own expertise at performing certain procedures. Beware of being the first to undergo any new procedure that just was introduced to your community. Beware of the upbeat newspaper article, Web site, or television report promoting a new, quick surgical procedure that does so much better at recovery. Even though we perform all the latest operations for hip and knee replacement, surgery is still invasive and must be approached prudently, cautiously, and modestly, with realistic expectations by both the patient and the surgeon.
Another related concern is the concept of early discharge. Each patient, in our experience, is different and recovery times are very individual. If you can go home quickly, that is desirable. But, as a matter of principle, we will not be an agent of the insurance company, nor that of any other agency, pushing you out of the hospital in order to save money. It is your health, and your health insurance premium dollars. It is desirable to take your time, recover properly, ensure your safety, make sure your questions are answered, and be reassured that all is going well, rather than have your surgeon trying to get you discharged. Your time in the hospital is our chance to show you our concern, and our professionalism, and the things that make our profession worthwhile and something to be proud of. We do not believe in shortening this process just because because a surgical procedure is touted as being a quick, in-and-out deal. Experience shows that surgery is never that way.
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What is a “partial” or unicompartmental knee replacement?
In some cases of knee arthritis, either the inside or the outside of the knee is diseased exclusively. This occurs rarely, and it is far more common for arthritis to be throughout the knee joint. Fewer than 5 percent of our knee surgery patients qualify for a partial knee replacement. The procedure is simpler, less traumatic, and the recovery is much faster than a complete knee replacement. The cruciate ligaments are left alone; whereas in a total knee replacement, both ligaments are typically removed. As a result, a partial knee replacement feels much more natural, and patients do not have to learn to walk again.
The downside is that patient selection is critical. Beware of any surgeon advertising partial knee replacements, and as a patient, you should avoid insisting on this procedure if the surgeon advises you that you are not a candidate for it. Done properly, and in the appropriate patients, the partial knee replacement has longevity similar to that of a total knee replacement. When it is necessary to convert a partial replacement to a full replacement, usually this can be done using the same type of implants that would have been used for a first-time knee replacement. The reason is that a partial replacement replaces only very thin slivers of diseases cartilage and bone; thereby preserving most of the bone for future surgery, if it should become necessary.
For a front-to-back x-ray view of what a partial replacement looks like when performed on the inside (or the medial side) of a patient who had a slight varus (bow-legged) deformity, please click here. For a similar x-ray of a knee that had the identical procedure done on the outside compartment for a slight valgus (knock-knee) deformity, with the surgical staples still in place on this x-ray, please click here. In either case, the implants used look like this. In very unusual cases, only the knee cap may be arthritic, in which case a patellofemoral arthroplasty (which replaces the underside of the kneecap and part of the femur bone) may be possible. Keep in mind that these specialized procedures are rarely indicated.
Specifically, if you have any type of rheumatoid arthritis, or other inflammatory arthritis, or advanced osteoarthritis, or have pain on stair-climbing or stooping, or if you have a large deformity of the knee joint, then partial replacements of any sort will not help. In such cases, a complete knee replacement is usually the preferred option.
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