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Basic Hip Replacement Information    Additional Links



FAQs



Are redo surgeries more difficult?

Jim Cissel: So you talked about it a little bit, what about a redo. I mean does that ever happen to you?

Dr. Firestone: Oh sure, sure.

Jim Cissel: Is it more difficult then or is it just get it over because of some complications.

Dr. Firestone: As a general answer, yes, redoes are always more difficult than the first time around. Now, there are two types of situations where you are doing redoes or the technical term is revision, revisions surgery. One, early on if something has gone wrong, for example if the hip has dislocated, if the ball has come out of the socket and the positioning of the implants is off and that’s why the hip is dislocated. That’s going to require a surgery sometimes within a few months maybe even less after the initial surgery. Long term, plastic wearing out, the stem loosening, we used to use cement and that used to be… have a finite lifespan of fixation. So we would have to go in and revise that. But those are the ones that are done fifteen, twenty, twenty-five, thirty years after the initial surgery. So long story made short, yes revision surgery is more difficult. Obviously, it depends on what you are doing, what you are revising. But it can be done. I’ve had a small percentage of patients that I have had to go back in on an anterior approach.  I used the same incision and I fixed the problem from the front. Typically, that was a dislocation, and I had one case where the stem loosened and I had to go back in and I put a stem in from the front. I have done over six hundred anterior hip replacements and I had to re-operate on about six, so it’s about one percent. Which is pretty much, you know I think that’s what you are looking at. If you can give it a one percent for reoperation, that’s very good.

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Is there much blood loss?

Jim Cissel: In the operating room there’s quite a bit of blood flying around to me, to an outside observer. What about blood loss during the surgery. Are transfusions required? Is that ever a danger to the patient?

Dr. Firestone: Well first of all let’s qualify. You are not in many situations where you see a lot blood flying around. I mean even in the NFL you know you don’t see a lot of blood flying around and I don’t think it was flying around. I think the anterior hip maybe criticized that maybe there's a little bit more blood loss with anterior opposed to posterior and having done a lot of both surgeries I would probably say that’s true. And I think it is most likely due to the fact that the anterior supine - you know the patient on the back and with the leg completely straight - the blood vessels are not being kinked at all, so there is constant blood flow. But I don’t have my patients donate blood, and I can’t remember the last time I had to transfuse anybody. So we keep our blood loss, three…four…five hundred cc’s. I use the aquamantys - that was that bipolar sealer. I think that is a great instrument for anterior approach. And I use tranexamic acid that stops the fibrinolysis in the clotting mechanism so it also helps things clot but it doesn’t affect our blood clot rate. So I think that the, yes compared to most situations where you are watching that the, you don’t see a lot of blood a hip replacement is a little bit more that type of procedure. But I think that we do it pretty safely and I have not seen that much of a problem with the need for post up transfusion. 

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How is the risk for infection decreased?

Jim Cisssel: Are there any techniques that you can use to decrease the risk of infection?

Dr. Firestone: There are a lot of factors that go into preventing infection. A designated operating room, like you saw with the laminar floor. Having a designated team, people who are familiar, nurses who are familiar with joint replacement procedures. You can see the team I have. They have been with me on thousands of replacements. Giving the antibiotics before the procedure, using irrigation, and not taking too long in the operating room, the appropriate amount of time spend on the procedure, minimizing the muscle damage. All these things go into keeping the infection rate at a low level. I will compare my infection rate at Scottsdale Shea Hospital with anyone in the country. But you know we’re hoping that it can always be much less than one percent. Because like I said that’s a really bad complication.

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What is Dr. Firestone’s approach to the surgery?

Jim Cissel: So watching you in the operating room and the intensity of that operation, the teamwork required from all the assistants in the room and immediate teamwork. The stress, the stakes that are on the table so to speak there has anybody ever said that you're difficult to work with?

Dr. Firestone: No, never. Well you know basically my philosophy has been I try to take care of patients like a family member you know. We are constantly being told that we have to do things a certain way and abide to this and you can't do that but then again you know the doctors that I that I respect and that I see out there working hard try to take care of patients like family members and it's challenging. So am I difficult to work with? Yeah, probably but I think all those people in the operating room with me they wanted to be there I wasn't twisting anybody's arm.

Jim Cissel: You know you're a perfectionist.

Dr. Firestone: You know I don't think there's any such thing as perfection but that's what we're striving for because if you come a little bit short of perfection it's going to be pretty good and you know I think the anterior approach allows me to be more accurate. I would never have thought that I would want to use x-ray and gown up in a lead-shield in the operating room to do a surgery. You know it makes sense, the technique makes sense to me. When I first saw it, I said Dr. Gorab in Orange County invited me to the OR. He had just come back from Dr. Matta’s and he called me on the phone. We shared ideas for 20 years. He's about my age and he said you got to come out and you're not going to believe this anterior approach and I had heard about it this is 5 years ago and I like said Dr. Matta’s had been promoting this for more than 10 pretty much. So I went out there and I watched him do the first surgery. I watched him put that hook in and I said I am never going to do that. But you know I saw how the patients did after the surgery. I stayed a day and I saw how the patients recovered the next day and I said Bob I think you're right. I think this is the way to go and fortunately I spent more time with him, and then you know we've been in courses together. So it takes a dedication to learn the technique like anything new though.

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Can muscle damage occur even with the anterior approach?

Jim Cissel: We pointed out the difference in the posterior that muscles have to be cut whereas when we come in with the anterior approach they're spread. Can that spreading of the muscle cause tissue damage that might have lasting effects?

Dr. Firestone: Anytime you cut you make a skin incision and then go deep to a skin incision muscle can be damaged I mean you have to be careful. Now with the posterior approach the tendon the tendons are taken off the back of the proximal femur and they're repaired. So I don't want you to think that the muscles are being cut. They're not and they're not being treated improperly. They're not being reattached, but they are being taken off the bone and then put back on the bone. Now you remember when we did the anterior approach I spread the two muscles and I was looking right at the capsule. The capsules not a muscle it's a ligament-type tissue that holds all the synovial fluid in the joint. And that's what I cut. What I cut actually - I cut out some of the capsule. So you can spread things too hard, to answer your question, but all you need is the appropriate exposure by spreading the muscles the way we did it in the operating room and there was no trauma. But you have to be careful of managing the muscles. You also have to be careful where you're replacing those retractors. One of the other things that I think stops a lot of surgeons from looking into the anterior approach is that there's some major nerves and arteries in the front of the hip and you have to be very careful. I had one patient with a temporary nerve palsy. Fortunately, it completely resolved by six months. She was walking fine. She left the hospital the day after surgery, but had weakness extending her knee. So now I use a slightly different technique in terms of where I put the retractors in. But you know there's nerve injury with a posterior approach, too. The approach, the way you get in, doesn't make anything foolproof. You have to be really careful when you go in to do a hip replacement because you know you're an inch away from things that have Latin names that if you injure them can harm the patient and definitely cause you some sleepless nights.

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Is it important to preserve the capsule?

Jim Cissel: Well I hear surgeons talking about the importance of preserving the capsule. Can you explain what that means and what it means for the patient?

Dr. Firestone: Well it's very important to preserve the capsule if you are going to do a posterior approach because what we are talking about is preventing dislocation. With the anterior approach, preserving the capsule is not as important because it's more of the dynamic musculature that is keeping the hip joint in. The risk of dislocation was always one of the concerns with the posterior approach. Because the hip naturally rotates when you sit, that's what made the hip susceptible for dislocation. Now, the surgeons who use the posterior approach have solved that problem, ninety-nine percent of the time. There is still dislocation risk for both approaches. Both - they solved that problem by using bigger balls. So we can use bigger head sizes in the liner, so we have the bigger range of motion and less chance of dislocation and also repairing the capsule in the back of the joint. So I think that the capsule issue is probably more of a posterior hip replacement matter than the anterior.

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Any concerns about radiation exposure?

Jim Cissel: Some surgeons question whether the use of x-rays is endangering the patients. Comment on that.

Dr. Firestone: Well the amount of x-ray that is given off with let's say thirty seconds of fluoroscopy is about - I think it's the equivalent of a chest x-ray. That's what doctor Owens, the head of our radiology department has told me. My average fluoro time is about fourteen seconds, so I don't think that is a major factor. We do a pretty quick hit, as you were in there, a pretty quick shot. And for the added accuracy, it's worth it.

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What is robotic hip replacement surgery?

Jim Cissel: What about quote-unquote robotic surgery, such as makoplasty?

Dr. Firestone: Robots doing surgery? I’m going to go out on a limb and I’m going to say that in 10 years a surgeon is still going to be doing a hip replacement with his hands and his eyes. We might have some other things to help like x-ray or this or that, but in terms of the robot actually putting the implants in – yeah, I don’t see the value in that. I think that we’ll have better ways of navigating our way through the body with smaller incisions or what have you - even less muscle being moved about. But you know I don’t see the value in robots actually taking over our ability to put the implants in because you were in the operating room with me you saw how I was able to shape the bone to fit the implants step by step. It really isn’t - that really isn’t the area where we really need a lot of help. Where we need help for the future where the hip replacement is going to get better is definitely with our ability to have a better bearing surface so we can let patients do whatever they want. Maybe even add what they talk about smart implants that will notify us if there’s something wrong with them or if there is an infection. We’ll be able to have some kind of sensor in them that can get feedback because there are some times when a patient comes back with pain and we don’t know why they have pain. You know the x-ray looks good you know there’s no markers the blood tests are all normal. So we don’t know. So maybe I see that as a potential area of future improvements. But the robot putting the implant in I’m going to go out on a limb and say I don’t think that’s going to be the big thing in the future.

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What is the superior approach?

Jim Cissel: I heard of a new procedure or a procedure that is called the superior approach where they actually place the patient in the operating table in a fetal position. Will that be the new latest procedure?

Dr. Firestone: Well, you will never know. I think that there is - there's always new ways of doing things, and I think that you have to be careful because you can't experiment on patient. All these approaches were tried and learned on cadavers. If there is a way that's better to get into the hip joint without cutting muscle, and a surgeon is comfortable with doing it, then by all means. I am not recommending the anterior approach is the end all way for all surgeons to do hip replacement. I did thousands of hip replacements in a posterior approach and patients are doing fantastic. And I think that you can't criticize surgeons who want to continue to do posterior approach because it is more time tested, and it is in some hospitals where you don't have the table and you don't have a choice. In terms of minimally invasive approaches, or whatever term you want to use least invasive approaches. I have some patients that come in and say, do you have to make an incision to put the hip replacement in. And I wonder, I don't think that's going to be the future, but who knows. We are certainly not doing it athroscopically, and right now we have to make an incision, but it's what's done under that skin incision that's most important. You know patients come to me and they say, well should I have the anterior approach or the posterior approach. You know, this is what I find is the best way for me to do a hip replacement. Personally it's the way I would have my hip replacement done. But my advice to them is find a surgeon that you trust that has done maybe surgery on your friends or relative, and do what they think is best for you. Because that's in the end is you know the most important, surgeon comfort level and patient comfort level.

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What happens to the implant as it wears?

Jim Cissel: The hip replacement with the elements we have now can last forty years. Eventually the will wear out. What happens with the ground out polyethylene liner, does it enter the body? Does it cause complications?

Dr. Firestone: Well we have a lot of experience with that since we have been using polyethylene for so long. There are billions of particles that are generated over the years. A year of walking is a million cycles. So polyethylene particles degrade. Now, what we have done with the improvements of polyethylene are the rate of wear has decreased to less than point one millimeter per year. So if you add that up for ten years that's a millimeter. Now hopefully it would be better than that, but let's say that is what it is. We don't want to use an implant any thinner than six millimeter.

Jim Cissel: Sixty years

Dr. Firestone: So you know that should give us thirty, or forty, or fifty years. Now, we tried to use different barring surfaces. Metal on metal generates metal ions. We have seen some problems with that. There are some surgeons still using metal on metal. Most surgeons have gone away from metal on metal. I think that the future in the United States is going to see more ceramic on ceramic. The FDA has been a little bit slow in improving some of the implant designs that have been around Europe for years. I think that is what we are going to see over the next five years. I think we will see more ceramic being introduced because it is a harder barring surface than metal and there is much less wear generated. But polyethylene is tried and true and we know the complications that occur over the years. It is called particle disease. It is called Osteolysis. So the particles get into the areas of the bone and create almost an autoimmune reaction. So the bone the inflammatory cells the osteoclast try to take out the plastic and at the same time clean up the plastic particles and at the same time they eat away some of the bone. So anytime you are doing revision procedure I talk about earlier for the wear and losing over twenty or twenty-five years you are going to have a situation where the bone has been eaten away a little bit. Then you are going to have to use some kind of substitute some metal substitute or bone craft substitute.

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For someone who wants the procedure, what should they ask for and make sure of?

Jim Cissel: Suppose someone decides they're tired of living with the pain that they have and they wanted to have the surgery done what should they look out for what do they need to make sure that they're receiving?

Dr. Firestone: Well you know patients come in and they say do I need a hip replacement and I basically say no. You're a candidate for a hip replacement, and then we go about making the decision of whether they are going to get a hip replacement. But it's an elective operation in most cases so they're patients who choose to use a walker instead of having the surgery. So everything's a risk benefit ratio but I think people have a lot of confidence now in our ability to replace the hip and we have great techniques and great reliability. I know you see those midnight commercials about: you know have you had this done - have you had this done. Those problems with implants represent such a small, small percentage of hip replacements it gets blown out of proportion. I would have no problem having a hip replacement if I had pain every day, if I couldn't play golf or walk or hike, couldn't sleep at night but everybody has their own level of pain tolerance. Taking drugs is not a good option for putting up with a hip replacement. So everybody has to be - I think everyone has their own way of determining when it's time and I think that's the way it should be. What we offer with anterior approach is an easier recovery in my opinion, and but it's still a big operation and it still has to be taken seriously.

Jim Cissel: And with the improved materials maybe people don't have to put it off as long you know.

Dr. Firestone: We have definitely expanded the age range for patients undergoing a hip replacement. You mentioned in your opening about 300,000 to be performed in the United States this year a lot of those patients are 40, 50 years old and that numbers growing. So we have to get better at getting long term results because we don't want to be redoing these in 10, 15 years. Now, there are patients who will go out there and they run marathons and they're jogging and you're not going to stop them. There hasn't been any scientific data that shows that they're going to wear out their hip any faster than patients who are just doing the regular walking, hiking, golfing, tennis kind of thing - time will tell. We're constantly looking for a better bearing surface, and it just makes you realize how great the one we're born with really is that it lasts for as long as it does in majority of cases. But this won't heal itself when this wears out, it's worn out. But the quest for the perfect bearing surface has not ended.

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Basic Hip Replacement Information

Dr. Ted Firestone utilizes medical illustrations in The Latest Procedure: Anterior Total Hip Replacement to show anatomy and surgical entry approaches. Those images, along with his explanation for each, are provided here as an additional resource. The caption information is from the television program.

Medical Illustrations: Mike Austin

Arthritis of the hip is where the ball and the socket wear out. Cartilage, the smooth covering, wears out and that's what causes all the problems. If you look at this illustration, you can see that there's some spurs that have formed at the hip joint.

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With a hip replacement, we remove that arthritic femoral head.  We then prepare the pelvis for the acetabular component. Then we go back to the femur side.  We place a stem into the canal. Then we place a femoral head ball on to the stem and put it all back together.  That's the replacement.

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Approaches to Access the Hip Joint Surgically

There are three basic ways:

Posterior Approach
The posterior approach is based on an incision more toward the back of the hip, closer to the buttock region.  

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Lateral Approach
There's a lateral incision, which is based right over the side.

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Anterior Approach
And there's an anterior incision, which is based where your front pocket would be.

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Posterior Approach

Step 1
This is what we would access with a posterior incision.  The big muscle is the gluteus maximus.  

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Step 2
With the posterior approach, we make an incision into the muscle, cutting it in line with the fibers.

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Step 3
Then you get down to the tendons in the back of the joint and you take them down off the femur to the hip joint.

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Anterior Approach

Step 1
When we do the anterior, you can see the muscles in the front of the thigh.  We go in between the tensor and the rectus.  That's called an internervous interval because those muscles are innervated by two different nerves.

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Step 2
We identify those muscles and then spread them apart.

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Step 3
Now we are looking at the hip capsule.

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Step 4
Underneath the capsule is the hip joint.

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