August 24, 2023 • 51 mins
Ever wondered how advances in orthopaedic surgery, particularly hip replacement, have revolutionized patient care in the last few decades? Join us for an enlightening conversation with Dr. Gerald Andah, a fellowship-trained orthopaedic joint replacement surgeon at the Kayal Orthopaedic Center, as we dissect the intricacies of revision hip replacement surgery. Immerse yourself in the realities of the surgical world as we talk about the durability of hip replacement implants and the remarkable strides made in this field.
Warning signs post-surgery are not to be taken lightly. A major aspect of our discussion involves the significance of post-operative follow-up care, and how to interpret symptoms that might indicate complications such as implant failure or infection. Take note as we discuss practical ways to reduce pre-surgical bacterial levels and the importance of maintaining optimal health and nutritional status. We'll also delve into the potential consequences of ignoring persistent pain after a total hip replacement – a situation that demands immediate medical intervention.
We round off our conversation by discussing possible complications that could arise from hip replacement surgery, such as implant failure due to wear and tear, osteolysis, instability, and leg length inequality. Hear Dr. Andah explain the techniques adopted in revision hip replacement surgeries, including the use of modular implants that provide a customized approach for each patient. Don't miss out on the valuable advice on maintaining open and regular communication with your orthopaedic surgeon and why follow-up visits are crucial in ensuring the success of the surgery.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the K Lortho podcast.
Today is August 23, 2023, andtoday's special guest is our
very own Dr Gerald Anda.
Dr Anda is a fellowship trainedorthopedic surgeon with an
expertise in hip and kneeprimary and revision joint
replacement surgery.
Welcome to the podcast, dr Anda.
(00:22):
Thank you so happy to have youwith us today.
Thank you for having me here.
So today's topic is revisiontotal hip arthroplasty.
Why don't we take thisopportunity, dr Anda, to
introduce yourself to ourlistening and viewing audience
before we start this podcast?
Gerald Andah, MD (00:36):
Yeah, absolutely so.
My name is Dr Anda.
I'm from Ghana originally.
I went to school at Penn inPhilly for about 13 years, did
the first half of my trainingthere and finished up with a
fellowship in adultreconstruction, which is
basically hip and kneereplacements, at Montefiore in
New York City.
Robert A. Kayal, MD, FAAOS (00:56):
Okay .
So it's so good to have youwith us, dr Anda.
Why don't we just take thisopportunity first of all to just
inform our viewing andlistening audience about hip
replacement surgery and revisionhip replacement surgery in
particular?
Gerald Andah, MD (01:09):
Right, absolutely so.
Most people know about primaryhip replacements, which is
having your hip done the firsttime around, but sometimes there
are situations in which you'regoing to need to have it redone,
which is what we call revisiontotal hip arthroplasty.
Robert A. Kayal, MD, FAAOS (01:26):
Okay , great.
So what are some of the reasonsthat people would sometimes
have to encounter the need forrevision?
Hip replacement.
Gerald Andah, MD (01:35):
Right.
So actually, if you couldbelieve it, the most common
reason for needing to have arevision total hip arthroplasty
is not having it done by myselfor any of the other surgeons
that care orthopedics.
Okay, no, but on a more seriousnote, the most common reason is
loosening, and that can be fortwo different reasons.
It could either be aseptic orseptic.
(01:57):
All that means is that onecould be without an infection
and one could be with aninfection.
Some of the other reasons forneeding a revision hip
replacement are instability, andso, as you know you know, hip
replacement has a ball in thesocket, and so sometimes that
ball can pop out of the socket,and so that's another reason,
(02:18):
and that can happen for multiplereasons, but that's another
reason why you might need arevision hip replacement.
Robert A. Kayal, MD, FAAOS (02:24):
Yeah , so how long are these primary
hip replacements supposed tolast in?
Gerald Andah, MD (02:28):
general.
So, while the longevity ofthese implants the literature
tells us is about 80 to 90%, ofthem are still good at about 20
to 30 years.
Robert A. Kayal, MD, FAAOS (02:38):
It's incredible.
They've made some significantstrides over the years,
absolutely, and in hipreplacement and knee replacement
surgery in particular.
And what are some of thosethings that affect the longevity
of implants?
Gerald Andah, MD (02:51):
So some of the things that affect the
longevity of the implants is thedurability of the materials
that are used for the total hipreplacements.
There have been so manyadvancements in the last you
know, 10, 20 years that makethese implants so much more
durable that you know theliterature itself hasn't even
caught up to how long they last.
To be honest, the liners thatwe use, which is the sort of
(03:14):
cushion in between the two partsof the implant, is so durable
now that we're not seeing thesame problems that we were
seeing, you know, 10, 20 yearsago as frequently.
And then the materials that theactual hip implants are made of
are titanium, and so they'revery durable and they you know
they last a very long time.
Robert A. Kayal, MD, FAAOS (03:36):
Yeah , and I don't think we want to
talk about today the basicfundamentals of hip replacement
surgery because, as you know, wealready discussed primary hip
replacement surgery with DrVictor Ortiz when we focused on
the direct anterior hipreplacement.
But I think it's important forour listening audience and our
viewing audience to at least geta nice visual of some of the
(03:59):
implants that we're talkingabout when we're talking about
hip replacement surgery.
So can we first demonstrate toour patients the components
involved in hip replacementsurgery, so that they can get a
better understanding when wetalk about why and when some of
these implants fail, what needsto be done to fix it Absolutely.
Gerald Andah, MD (04:21):
So we're going to start out with the
acetabulum, which you can thinkof as the socket component for
your hip replacement.
So, as you can see here, it's ahemispherical shape, okay, and
it has these holes in case youneed to put screws in it to
increase the stability orfixation.
The other part of thiscomponent is this liner in the
(04:44):
center of it, and this is what Iwas talking about as the
cushion that you know.
It provides a buffer betweenthis and the other aspects of
the total hip replacement.
So this liner is what has had,you know, so many changes happen
over the last few years to makeit so durable that these are
lasting even longer than the 20,30 years that we're accustomed
(05:06):
to having it last.
Robert A. Kayal, MD, FAAO (05:07):
Right .
So, just so the patients areclear, the first thing we do
when we do a hip replacement iswe dislocate the hip right.
The hip replacements aretraditionally done for hip
arthritis, when there's a boneon bone, arthritic, painful
condition, right.
So we have to provide thepatients with a new what we call
a bearing surface right and inthe hip it's a ball and socket
(05:29):
joint, just like in the shoulderit's a ball and socket joint.
So what you're holding up inyour hand is the socket of the
ball and socket joint, right.
So the first thing we do, as DrOrtiz and I have discussed in
the past, is we first preparethe acetabulum.
So we ream the acetabulum withinstruments to prepare a
(05:53):
hemispherical socket to allow usto install that shell right,
what we call the shell.
Once that shell is seated intothe bone, it's a nice press fit
fixation.
Typically, sometimes we'll haveto augment that with screws to
supplement that fixation.
But then the new ball you putin has to articulate with
(06:15):
something, and that's somethingis that plastic liner that you
described.
So so far we've talked aboutthe shell and we've talked about
the polyethylene liner or theplastic liner.
Now that liner could be made upof different materials, but
most commonly we're using, in2023, a plastic or polyethylene
(06:35):
liner, right.
So let's talk about the stemnow.
Gerald Andah, MD (06:38):
So for the stem, this is an example of a
primary hip replacement stemwhere you can see that it has
the bulk of its shape in the inthe proximal or top part of the
implant.
This fits in the proximal partof your bone, that's called the
metaphysis and this fits in theactual canal of your femur.
(07:01):
So this is the stem portion ofyour hip replacement.
You can see that it has somequoting around the implant here
and that helps bone to grow andattach to the implant to
increase the stability.
Robert A. Kayal, MD, FAAO (07:15):
Right , and some of the innovations in
orthopedics, especially jointreplacement surgery, have
largely been made in theimplants themselves.
It's not just the way thatsurgeons are performing the hip
replacement, but the vendorshave contributed significantly
in the technologicaladvancements of total hip
replacement surgery too, byproviding us with better
(07:37):
products, better implants,absolutely, and we'll talk about
that more in detail in thefuture.
Gerald Andah, MD (07:42):
Yeah absolutely so.
One of the things that haschanged over the years is the
shapes of these implants.
Right, they have all sorts oftapers and they have different
shapes and sizes that allow itto fit into the bone more
specifically, yeah, and thematerials as well.
Robert A. Kayal, MD, FAAOS (08:01):
Some of them used to be very stiff
and rigid, and now the stiffnessassociated with these implants,
especially these titaniumimplants, is much more
bone-friendly, where theseimplants will now become more
load sharing devices as opposedto load bearing devices, which
has significant impact on thelongevity of the total hip
(08:25):
construct correct, yeah, and sothe materials that they're using
for these implants now match alot more closely the stiffness
of our bone, and that allows itto distribute force more evenly
throughout the bone.
Right.
So, dr Andow, why don't youdescribe what I'm holding in my
hand right now and you can showour viewing audience how a total
(08:47):
hip replacement construct isput back together during?
Gerald Andah, MD (08:50):
surgery, absolutely.
So what we're looking at here ishalf of your pelvis right here,
and then this is the top partof your femur right, and so when
we're doing a hip replacement,you can see that this socket is
prepared for this implant to fitin in a press fit way, which
(09:14):
sort of means that we're usingthe friction of the implant to
hold it in place and the bonegrows into it over time.
This is that liner that we'vespoken about that provides a
cushion between the other partof the implant that I'm about to
show you and this socketimplant.
So this is the proximal or toppart of your femur right, your
(09:37):
thigh bone, your thigh bone,where the stem of the implant is
going to sit, and it literallyfits in there like that.
It's just like that, especiallywhen we're in surgery too, and
then we relocate the hip, so youhave the ball fit into the
(09:58):
socket, just like that, okay,and then eventually, I'm just
gonna take this apart, actually,and show you guys, this is how
you move your hip after hipreplacement.
See how it looks perfect andbeautiful.
Robert A. Kayal, MD, FAAOS (10:14):
So that's what we call the bearing
surface.
Now, in this model inparticular, we're seeing this
purplish color, lavender colorball, and that is an example of
what we call a ceramic head.
Ceramic heads are very commonlyused in primary and revision
total hip arthroplasty thesedays and in this particular
(10:36):
model, this ceramic ball isarticulating with a plastic
polyethylene liner that'sinserted into a titanium shell
that is also inserted into thenative acetabulum and in the
femur or the thigh bone.
You saw Dr Anda place atitanium stem, and this is what
(10:59):
we call a total hip replacement.
So, as we've discussed, totalhip replacement surgery is an
operation that is incrediblysuccessful.
It's really changed the livesof millions and millions of
people across the world over theyears.
It is considered to be one ofthe most successful orthopedic
operations performed.
(11:19):
But, that being said, ultimatelysome patients require a
revision.
Dr Anda already discussed someof the common reasons for
revision total hip replacement,including, but not limited to,
loosening, instability andinfection.
Those are probably the threemost common reasons for failure
(11:40):
of total hip arthroplasty andneed for revision surgery.
So let's try to focus on thisvery complicated topic but
communicated to you in layman'sterms so it's fairly simple to
understand when something mightbe wrong with your hip
replacement and when you need toconsult an orthopedic
specialist like Dr Anda to getyour total hip replacement
(12:02):
evaluated.
So, dr Anda, let's first talkabout when we perform primary
total hip arthroplasty what istypical for routine follow up
for a hip replacement?
Gerald Andah, MD (12:14):
So for follow up after a total hip replacement
, first time we see the patientsat two weeks, next time is six
weeks, three months, six monthsone year and then each year we
see them at least once afterthat, and the reason that we do
that is to make sure that we'renot missing anything that could
be happening down the line thatcould be potentially causing the
(12:36):
patient an issue or pain.
Robert A. Kayal, MD, FAAOS (12:38):
Yeah , I agree with that fully,
because certainly when implantsfail for whatever reason and
they can, we wanna pick up onthat early right.
Earlier diagnosis is better.
We have a tendency to nipthings in the bud and address
small problems with smallsolutions as opposed to big
problems with big solutions,right.
So that's very important toemphasize and I agree with that.
(12:59):
Once a year after the firstyear, at least follow up and see
your doctor again for a followup visit.
Let the doctor take some x-rays, check the wound, make sure
there are no concerning issues.
So many times after this verysuccessful operation, patients
think that they're done afterthe first year and we won't see
them again for five years or 10years, for whatever reason, for
(13:20):
a different problem, becausethey think everything's great
and I'm glad things are great.
But the thing is they forgetwhen I tell them you need to
come back once a year for anx-ray because they're feeling so
good.
But it is important toemphasize once a year routine
follow up with your orthopedicsurgeon so that he or she can
assess you and make sure thex-rays look good and there are
(13:41):
no concerning findings.
Yeah, absolutely so.
That being said, dr Andrew,what are some of the concerning
complaints that patients mayreport and maybe some of the
concerning findings on physicalexam and x-ray that makes us
suspicious that maybe somethingmight be beginning to fail?
Gerald Andah, MD (13:59):
Yeah, so your discussion with the patient is
probably the most importantthing, because the patient knows
their body really well andthey're gonna tell you when
something isn't necessarilyright.
So pain is probably the numberone factor that leads us to
think that there might besomething going on persistent
pain.
And then sometimes patients cancomplain of instability in the
(14:22):
sense of feeling like somethingis shifting or moving.
That might be one reason tosort of pause and assess and see
if something's going on.
And then there's one thingcalled startup pain.
Sometimes patients get what'scalled startup pain and to sort
of explain that, that means thatwhen you first get up from a
(14:44):
seated position and you startwalking, you might have some
pain.
As the implant starts to settleinto a better region or a
better location, that pain easesup.
So that indicates that theimplant might be loose.
Robert A. Kayal, MD, FAAOS (15:00):
Yeah , when they start to weight bear
, when they get up out of bed orget up out of a chair and start
to weight bear, theyimmediately get that stiffness.
Very often they complain ofstiffness more than anything and
that's that microscopicsubsidence of the implant into a
stable configuration.
And if that is something thatyou're experiencing, you
(15:20):
definitely need to see yourorthopedic surgeon or one of us
to get that assessed, becauseit's very, very important not to
miss loosening of an implant.
Absolutely so.
That startup pain is a classiccomplaint and it's often
associated, even more than pain,with stiffness.
(15:42):
Patients say I'm stiff, I can'treally walk immediately.
I have to sort of stand up andhold on to something for a few
seconds until I can get mybearings, and then they start
walking and they're better.
And, surprisingly, the morethey walk on a loose implant,
the better they feel, because,as they're continuing to walk
(16:02):
through it and put their bodyweight through that construct,
it is stabilizing the implant inthe bone and, although that
implant is loose, they feelbetter when they're walking on
it.
But that is something that youhave to see your doctor about
quickly.
Yep, absolutely so.
You mentioned startup pain,stiffness we talked about.
(16:23):
What other signs and symptomsmight they be concerned about if
they have, for instance, aninfection?
Gerald Andah, MD (16:31):
Right, so things that you want to look for
if you have an infection isredness around the incision area
.
If you have drainage after yourtotal hip replacements, two
weeks after surgery, that issomething that's concerning and
should be evaluated by yourdoctor, and so any sort of
drainage after the two week markis something that you should
(16:52):
bring to the attention of yourphysician.
Robert A. Kayal, MD, FAAOS (16:53):
Yeah , at the most two weeks.
Some people even are gettingconcerned at five to seven days
after surgery.
So we don't like drainage froma wound after surgery.
If a wound is draining you needto see your doctor to get that
assessed to make sure there's noevidence of infection.
But let's assume that this hipreplacement was done six months
(17:13):
ago.
What are some of the concerningfindings regarding infection at
that?
Gerald Andah, MD (17:18):
time.
So redness pain is one of thebig things, and so persistent
pain at six months after a totalhip replacement is something
that should be worked up by yourphysician to make sure that you
don't have an infection, and wecan talk about how that's done
a little bit later.
Robert A. Kayal, MD, FAAOS (17:34):
So look, it's one of the most
rewarding operations.
I've already alluded to that.
Patients should only continueto get better after this
operation, right?
If patients start experiencingpain that's out of proportion to
the surgery that was performedand if it does not seem to be
dissipating or if it's headingin the wrong direction?
(17:54):
Our training is that we alwaysthink of infection in our
differential diagnosis.
Right?
Infection is called the greatmimicar.
It can present like anything.
You don't have to have theclassic signs of infection where
the wound is opening up anddraining pus or you're suffering
with a fever and chills andpersistent drainage from the
(18:17):
wound.
That always happened.
When somebody is notprogressing well after hip
replacement surgery and the painpersists and they're just
continuing to complain, it isincumbent upon us as physicians
to work that patient up forinfection and assume that it's
infected until proven otherwise.
So the work up for infection iscritical in a joint that's not
(18:41):
performing well.
What else we talked aboutinfection?
We talked about startup painand loosening.
What about instability?
How will patients present ifthey feel unstable?
Gerald Andah, MD (18:53):
So patients that feel unstable usually
present by saying that whenthey're either getting up from a
seated position or doinganything that involves bending
their hip, they feel like theirhip is shifting.
They feel a sensation of eitherthe ball actually shifting or
just coming out of the socket alittle bit.
That's what presents the mostas instability.
Robert A. Kayal, MD, FAAOS (19:17):
Yeah , and instability can be
catastrophic for the patient.
Instability can cause literallythe joint to dislocate.
When patients dislocate,they're miserable.
The hip, the construct justcompletely dislocates.
The ball falls out of thesocket.
The patients endure asignificant deformity.
Sometimes their sciatic nervescan be irritated or stretched
(19:40):
during that traumatic event.
Only the patients cannot weightbear on a hip construct that is
unstable and dislocated.
So instability can happen for amyriad of different reasons.
What are some of those reasonsthat a hip can be?
Gerald Andah, MD (19:55):
unstable.
Probably one of the primaryreasons that a hip can be
unstable is if the tension inthe muscles around the hip has
not been adequately restored.
There are different ways thatyou can restore the tension, but
we have muscles around our hip,several different kinds of
muscles.
If the tendons that areattached to those muscles are
(20:15):
not stretched out appropriately,that might allow the ball to
pop out of the socket at somepoint after your hip replacement
, exactly.
Robert A. Kayal, MD, FAA (20:23):
That's critical to restore what we
call the offset right.
When we do total hipreplacement surgery, our goal is
to restore the proper offset ortension of the muscles and
tendons that keep the hip stable.
And again, the onus is on us tomake sure that we restore that
offset properly.
And nowadays, especially at theKale Orthopedic Center, when we
(20:45):
employ the latest and greatesttechnologies with respect to
designing patient-specificcustomized total hip replacement
surgery using proprietarysoftware and CAT scan technology
where we do a virtual hipreplacement on a computer, and
then robotic technology to makesure we put it in accurately and
(21:05):
precisely we're able toproperly restore the patient's
offset exactly how we want torestore that, so that the
patients are stable andcomfortable and their leg
lengths are proper, and all thatis very, very important to
ensure a successful outcome forthe patients after this
procedure.
(21:27):
So those are some of the mostcommon reasons for need for hip
replacement revision surgery, solet's talk about them a little
bit in more detail.
First and foremost, let's talkabout infection.
Okay, so we talked a little bitabout the fact that patients
can get infections early on andeven later, right?
(21:49):
What are some of the reasonsfor acute infections, infections
that are occurring right after?
Gerald Andah, MD (21:56):
surgery, for instance.
So right after surgery,sometimes what we talked about
drainage, because if there isfluid coming out of the wound,
that means that there's apotential for bacteria to get
into the wound.
So that's probably one of themore common reasons for getting
an infection in the acute periodwhich is soon after your
surgery.
Robert A. Kayal, MD, FAAOS (22:14):
So that drainage can come from the
surgery itself.
It can come from blood thinnerstoo, right it's?
You know patients can get bloodclots after joint replacement
surgery or any orthopedicsurgery or any surgery in
general.
But certainly joint replacementsurgery does put patients at
risk and some patients are at ahigher risk than other patients
Absolutely, and we have to putthose patients on blood thinners
(22:35):
.
So it's sort of a catch-22, butwe have to do it because we
don't want our patients to getblood clots and pulmonary emboli
.
But if they do get placed on anaggressive blood thinner and
they end up bleeding a littlebit, that some of that blood can
continue to drain out of thewound and that is something that
can potentially predispose ourpatients and other patients for
(22:57):
infection correct.
So what other risk factors canincrease the patient's risk?
Gerald Andah, MD (23:03):
of infection.
So sometimes some comorbiditiesthat patients have, including
diabetes, rheumatoid arthritis,things like that might put you
at increased risk for getting aninfection, and the reason that
that happens is that when youhave those conditions, it really
decreases your body's abilityto fight off bacteria and puts
you at higher risk for gettingan infection, and some of the
(23:25):
risks that have a higher bodymass index are also at risk for
getting an infection for thesame reasons, certainly, and
smokers too.
Robert A. Kayal, MD, FAAO (23:33):
Right , and smokers, yeah, People that
smoke.
It definitely deleteriouslyaffects your circulation and
increases the risk of infection.
Smokers commonly occur fromprimarily a few different
sources.
Right, One of those sources canbe our own body.
Right, Because our skin is abarrier to infection and there
(23:56):
are a lot of organisms that liveon our skin.
Right, so some of those mostcommon infections are staff
right and our bodies have staffepidermis, for instance, all
over it.
Staff aureus is a very commoninfection.
People can get infections fromother infections in other areas
of their body.
If they have an upperrespiratory tract infection or a
(24:18):
urinary tract infection, adental infection, these bacteria
can get into the bloodstreamand then ultimately circulate to
the joint and infect yourimplant as well.
Gerald Andah, MD (24:29):
Yeah, and you know, one of the other things
I'm glad you brought that up isbecause we have a lot of
bacteria, like you said, on ourskin, in our gut and also in our
mouth, right and so it isimportant that you let your
physician know after you have atotal hip or a total near
placement when you're gettingdental work done, because you're
going to need to haveantibiotics before you get the
(24:51):
dental work, so that whateverbacteria is in your mouth does
not spread through your blood toyour implant.
Robert A. Kayal, MD, FAAO (24:57):
Right .
So infection is a devastatingcomplication and you know the
onus is on us, but also thepatient, to take measures to
minimize the risk of infection.
First of all, with respect tous, what can we do besides
sending our patients to thedentist, if necessary,
addressing their dental carriesbefore surgery, making sure that
(25:20):
they don't have any otheractive infections in their body
when we do the joint replacement, like dental infections or
urinary tract infections orothers?
We can also do things to theskin right to decolonize our
patients, right?
Yeah, speak about that for usif you can.
Gerald Andah, MD (25:38):
So some of our pre-surgery routine involves
reducing the amount of bacteriathat you have on your skin and
in other parts of your body.
So we routinely have patientsget a what's called a hibiclens
wipe, which is a special kind ofsolution that kills bacteria,
and we have patients wipe thesurgical site for five days
(26:00):
prior to surgery, whether you'regetting a hip or knee
replacement.
We also have patients use anointment that kills bacteria
that can live inside your nose.
It's actually pretty harmfulbacteria for the same amount of
time prior to surgery to helpreduce that risk of that
bacteria getting to the implantthat we put in.
Robert A. Kayal, MD, FAA (26:17):
That's the back to the band or the
mute person ointment correct?
Yeah, so we take some measuresto optimize our patients for
surgery, but I think it'simportant for the patients also
to take some responsibility,because we're doing this
operation together.
Absolutely, we strongly believethat we're going to live up to
our expectations and takeresponsibility.
(26:38):
But it's important for patientsto participate in their care as
well, which means to optimizetheir medical health and
nutrition status and weightprior to their joint replacement
surgery.
Absolutely, some patientssuffer from diabetes mellitus
and their hemoglobin A1C is high.
It's poorly controlled.
We recognize that through bloodwork et cetera.
(27:00):
But then we want the patientsto participate to minimize the
risk of infection by gettingtheir diabetes under control.
Yeah, or we ask them to stopsmoking.
Or if they're an autoimmunepatient that happens to be on
some medications that canincrease the risk of infection,
we ask them to consult with therheumatologist or their primary
(27:22):
care doctor to minimize theusage of certain medications
like steroids, before thesurgery which can compromise
wound healing after surgery.
So I think it's important tomention all those things because
we can work as a team with ourpatients to really decrease that
risk of periproestheticinfection.
(27:43):
As far as the other commonsource of revision hip
replacement loosening.
We discussed loosening and thenwe talked about two different
types of loosening.
For the most part there isaseptic loosening and septic
loosening.
Well, septic loosening would besecondary to that infection
where the bacteria invade andstart to eat away the bone and
(28:06):
loosen the construct, and that'sa devastating complication,
clearly.
But let's talk a little bitabout aseptic loosening, or
loosening that can occur withoutinfection Right.
Gerald Andah, MD (28:18):
So loosening that can occur without infection
can happen for a couple reasons.
Probably one of the more simplereasons is if the implant
that's put in at the time ofsurgery is too small.
Sometimes that has the abilityto loosen because it doesn't
grab the bone as well.
One of the other reasons thatyou can get loosening in your
implant is sometimes there aresmall particles that are
(28:40):
released from the materialsitself in the hip over time that
the body starts to try to fightand in your body's attempt to
fight these particles it can eataway at some of the healthy
bone.
Sometimes, when that happens,that allows the implants to
loosen over time.
So those are probably the two,I would say, most common reasons
(29:01):
why you get aseptic orloosening from no infection.
Robert A. Kayal, MD, FAAOS (29:06):
Yeah , and just to further elaborate
on what Dr Ando was mentioning,there's the concept of
particulate debris that we'retalking about here, where
there's debris that's formed dueto repetitive microscopic
motion between parts of theimplant.
You can see, based on thevisual that we presented to you
(29:27):
earlier, that these total hipconstructs are modular
constructs.
They're not what we callmonoblocks, they're modular.
The pieces are interchangeable.
You have different stem sizes,you have different ball sizes,
you have different cup sizes,you have different polyethylene
liner sizes, and when you snapon one piece to another, there
(29:52):
tends to be some type of lock ortape or fit that secures that
implant in place for life,hopefully.
But over the years, afterloading this implant, millions
and millions and millions ofcycles, there can be some
microscopic wear between thebearing surfaces and between the
(30:16):
articulations between thesemodular components, and some of
that wear can be plastic wearand some of the wear can be
metal articulating with metalwear.
But what Dr Ando was mentioningwas that this wear, this part
what we call particulate debrisincites some type of autoimmune
inflammatory response where ourbody's immune system attacks
(30:41):
that debris and, unfortunately,in its efforts to rid ourselves
of that debris, it often cancause what we call osteolysis
and loosening of the implant.
It can erode and eat up some ofthe bone and cause implants to
fail.
It causes some types ofreactions sometimes, especially
(31:03):
the metal on metal types ofarticulations can cause some
adverse soft tissue reactionswhich can cause very, very
devastating effects to the softtissues, which can cause
loosening and instability andfailure of the construct.
So that is another potentialsource of failure of total hip
(31:26):
replacement.
If these things are not pickedup.
And this really reinforces myrecommendation to make sure that
you see a doctor at least oncea year after your hip
replacement to make sure thatthere are no signs on physical
exam or on radiographs thatwould suggest potentially that
(31:49):
any of these things is occurringAbsolutely.
Also, we talked about anothersource of failure which, besides
loosening, besides infection,we talked about instability as
well.
But how about leg lengthinequality?
Is that potentially a problemafter hip replacement?
Gerald Andah, MD (32:07):
surgery as well 100%, and so one of the
other reasons that patients getinstability is when they don't
have their leg lengths restoredto its natural anatomy, and what
that does is that goes back tothe point that we made earlier,
where it doesn't restore thecorrect amount of tension to the
muscles that are attached toyour hip, and so it makes your
(32:29):
hip loose in a sense.
So if your leg is short by afew millimeters, that reduces
the amount of tension that themuscles or tendons around your
hip have and it reduces theirability to hold the ball in the
socket, and then that's when youcan dislocate, which is a very
traumatic event that we sort ofspoke about.
Robert A. Kayal, MD, FAAOS (32:51):
Yeah , and we're talking about all
these complications only becausewe're talking about the topic
of revision hip replacementsurgery.
But I think it's important toemphasize that, like I said
earlier in the podcast, totalhip replacement surgery is
probably the most successfuloperation performed in our field
, absolutely.
There are incredible,incredible outcomes and
(33:13):
long-term outcomes.
That is as well, and thesecomplications that we're
discussing are incrediblyuncommon.
They can occur, but they'reexceedingly uncommon.
But I think it's important totalk about it, just so the
patients know that these thingsexist and, if they're suffering
from any of these complications,that we do have solutions for
(33:35):
these problems.
And that's what we're here fortoday To bring this information
to you so that you can find hope, if you're suffering from some
of these complications, that wehave solutions at the Kale
Orthopedic Center.
So let's talk about some ofthese solutions, because I know
you gave us a beautifuldemonstration of how a primary
(33:55):
total hip replacement getsperformed.
But when these things happen,there has to be a solution to
restore that patient's qualityof life and function.
So let's talk about themspecifically.
If there is an infection andthat implant is now infected,
let's make believe that thatsurgery was done recently.
(34:16):
The patient's still drainingtwo weeks after total hip
replacement surgery, maybe threeweeks at the most.
Hopefully he didn't wait thatlong.
Just had the operation.
The wound is still draining.
Gerald Andah, MD (34:30):
What are you going to do so?
First thing we do is work up aninfection.
We do some of the ways that wedo that, obviously with imaging
and lab work.
So blood tests there arespecific blood tests that assess
your body's level ofinflammation, which is a sign of
infection.
If those markers are high, thenwe depending on how recent your
(34:51):
surgery was, we eitherautomatically take you back to
the operating room or we takesome fluid out of the joint If
we're talking about hips rightnow so out of the hip joint and
send that to the lab to see ifit grows bacteria or has certain
markers that indicate aninfection.
Once that's done, if you've hadyour surgery in the acute period
(35:12):
, which is within a few weeks,then you can go back to the
operating room and take out thereplaceable parts of the hip.
So there are some parts of yourhip the socket part and the
stem that take a lot more workto replace.
There are parts like the balland the liner that can be
replaced pretty easily.
(35:32):
So in those situations whereyou have an acute spread of an
infection that came from dentalwork or a UTI or an upper
respiratory tract infection orsomething of that sort, the key
is to be really aggressive andattack it really quickly.
So we want to take thosepatients back to the operating
room as soon as possible to tryto save the implant, and so the
(35:52):
real key in a situation likethat is getting them to the
operating room as soon aspossible to get that treated.
Robert A. Kayal, MD, FAAOS (35:58):
Yeah .
So I think it's so importantfor patients to understand.
If you have a total hipreplacement that was just done
and is still draining to sevento 10 days after surgery two
weeks after surgery more thanlikely you're going to have to
get that hip washed out, cleanedup and that hip will more than
(36:18):
likely be able to be salvagedwith that simple little washout.
If you have a hip replacementthat was functioning well for
many, many, many years and thenall of a sudden you get an
infection in your body somewhereor have a dental procedure or
have an abscess in your mouth orhave a urinary tract infection,
an ear infection, upperrespiratory tract infection, and
(36:39):
then suddenly, a couple weekslater, your previously well
functioning hip all of a suddenstarts bothering you
tremendously, there is a concernthat maybe some of the
infection got into the blood andthen subsequently infected your
well functioning total hip.
In that particular case, again,you're going to have to get
that hip washed out quickly.
(37:01):
Time is of the essence.
See your doctor, let themassess you and you may need to
get that hip washed out.
If it is determined that yousuffered from what's called an
acute hematogenous spread to awell functioning hip replacement
, then there's the patient thathad a hip replacement that was
never, ever, ever satisfiedafter their hip replacement
(37:24):
continuing to deteriorate, neversatisfied, persistent pain,
maybe startup pain, maybeevidence of loosening osteolysis
.
On x-ray More than likely thatpatient was suffering from a
chronic infection all the waydating back to the beginning and
that's a chronic infection.
(37:45):
That implant cannot be saved.
If it is determined that thatpatient is suffering from a
chronic infection of thatimplant, that patient is going
to have to have that implanttaken out, an antibiotic
impregnated spacer put in.
That patient will need to betreated with antibiotics for a
(38:05):
minimum of six weeks IV and thenonly after that chronic
infection is cleaned up fullycan your surgeon go back and
reinstall a new total hipreplacement.
Is there anything else you wantto add to that?
Gerald Andah, MD (38:19):
Yeah, you know , the reason that we distinguish
between having an acuteinfection and having a chronic
infection is because of howbacteria behave.
So I'm not going to get intotoo much detail.
But the bacteria create alittle cover around the implant
if you give them enough time.
So the reason we try to get tothese acute infections quickly
(38:41):
is so that we don't allow thebacteria to do that.
But if you have a chronicinfection, like you were just
saying, if this has been goingon for months and months or it
never felt right, then mostlikely the bacteria has already
created that cover, that film,that antibiotics cannot
penetrate.
Robert A. Kayal, MD, FAAOS (38:56):
I think that's a great point and
I'm so glad you brought that upbecause it's so important to
emphasize that.
What he's talking about is thiscover or lining that we call a
glycocalyx.
It's an impenetrable sheatharound the infection that is
often impenetrable to IVantibiotics and it definitely
(39:18):
requires a very, very aggressivedebris month to get rid of
those bacterial infections andsometimes removal of the implant
itself.
So time is always of theessence with infection, because
some literature says that, youknow, these bacteria can form
these impenetrable glycocalyxieswithin a day or so hours after
(39:43):
infections.
So it's so important whenyou're experiencing symptoms of
infection pain, persistent painheading in the wrong direction,
loosening, instability see yourdoctor and let us make sure that
you're not suffering from acomplication.
So now that we've talked aboutloosening an infection and
instability, leg length,inequality and certainly other
(40:04):
things can go wrong too.
Right, if somebody has a hipreplacement, someone can fall
and suffer a serious fracturearound a hip replacement.
You could break your thigh bone, your femur, even without a hip
replacement.
But if you break it around ahip replacement, that would
require sometimes a revision,total hip replacement.
So in all of these scenariosthat we've outlined, where
(40:26):
there's loosening, infection,instability, leg length,
inequality and certainlyfracture and infection.
Sometimes these patients haveto undergo a revision total hip
replacement.
So we've demonstrated earlierin this podcast how a primary
total hip replacement getsperformed.
But now you're dealing with arevision and in a revision
(40:50):
scenario you're already missingbone In a primary total joint.
All the bone is there, so it'scertainly much more easy to
perform a primary total hipreplacement.
What do you do with a revisionwhen there's bone loss?
How do you do a hip replacementif you're missing bone?
Gerald Andah, MD (41:09):
It's actually really interesting.
This right here is a primarytotal hip replacement stem.
So you can see how it's wide atthe top and gets really skinny
down here, because it gets mostof its fixation in the top part
of the bone.
This because there's good bonethere.
Exactly, this is a revisionstem and you can see how it's
(41:29):
much longer in the primary stembecause this gets its fixation
lower down in the bone.
And that happens because whenyou're in the situation where
you have to do a revision totalhip replacement, the top part of
the bone is compromised and thequality of the bone is usually
not that good, and so now youhave to go a level lower to get
good fixation.
(41:50):
So that's why these revisionimplants look so long, because
they get their fixation in thebottom half of the bone.
Robert A. Kayal, MD, FAAOS (41:56):
Yeah , the bottom half of the bone we
call the diaphysis, or theshaft of the bone right.
The top part of the bone wecall the metaphysis, and in the
primary hip replacement wetypically get what's called
metaphysial fixation becausethere's good bone there.
But in the revision scenarioit's very much compromised for
the reasons we talked about.
It can be infected, it could behorrible bone, it can be an
(42:18):
area of what we call osteolysisfor many different reasons where
the bone gets eaten up anddestroyed and you can't rely on
fixing a revision hipreplacement most of the time in
the metaphysis Right so we haveto obtain what's called
diaphysial fixation and if youcan just show us those stems
again, with diaphysial fixationwe're dealing typically with
(42:42):
those tapered, fluted stemsright so, and they're coated
circumferentially.
So let's show all that comparedto the primary hip replacement
that is coated approximately inthe metaphysis, as you can see
here in Dr Ando's left hand yousee that primary total hip
coated strictly in themetaphysis.
(43:03):
That's where the bone in growthand fixation takes place.
It's what's called a taperedstem and you get great fixation
in that metaphysial region inthe virgin native femur.
But in the revised femur in hisright hand there's no good bone
approximately.
So he's demonstrating this longtapered fluted stem that's
(43:26):
coated circumferentially.
Gerald Andah, MD (43:28):
That will allow bone to grow into all of
that circumferentially, and thefluted stem will also provide a
lot of rotational stability aswell, yeah, and so you can see
how the primary stem is thick atthe top right and thin at the
bottom Because, again, we'refocusing most of our fixation at
the top.
But you can see in the revisionstem it's pretty cylindrical
(43:53):
all the way down and it's muchthicker at the bottom half than
you have in a primary stem.
Robert A. Kayal, MD, FAAOS (43:59):
So the way these implants get
installed.
We have to prepare the canalsright With the primary total hip
.
We tend to use broaches andthen get a nice tight fit and in
the revision scenario we'lloften ream right.
We'll ream the canal to acertain diameter a tapered
reamer and really get a reallynice purchase in that diaphysis
(44:22):
and we get a well fixeddiaphysial engagement stem.
Now let's focus our attentionin the revision scenario now on
the cup.
What can happen in the cup andhow do we address these issues
with bone loss in the acetabulum?
Gerald Andah, MD (44:40):
So this is your acetabulum.
Normally, in a revisionsituation, there is some amount
of bone loss around theacetabulum.
What we rely on for fixation ina primary hip replacement is
these columns.
So if there is a revisionsituation in which either the
infection has eaten up the boneor there is osteolysis from
(45:02):
where particles for some otherreason, sometimes there's no
longer this support and so youneed there are different.
There are a few different kindsof implants that you can use.
Most of them are geared towardsgetting some sort of alternate
stability in instead of gettingthat press fit fixation between
these two columns.
So that can involve usingscrews.
(45:23):
That can involve usingconstructs called a cup cage.
That can involve using customimplants that are actually made
specific per patient based onthe amount of bone that's lost,
called custom triflinges, andthey're all geared towards
getting screws and fixation indifferent parts of the bone
other than the bone that's lostRight.
Robert A. Kayal, MD (45:44):
Fortunately though, however, most of the
time patients can just get awaywith the doctor performing a
revision of the cup right byjust putting in a bigger cup,
you know, just reaming theacetabulum a little bit more and
putting a bigger cup, and it'sprobably the most common
technique employed in thefailure of the acetabulum a
(46:06):
revision, total hip arthroplastythat affects the acetabulum.
But you know what about withinstability?
When there's instability, whattypes of things can be done to
address that, whether it's, youknow, changing the ball or
changing offset stems, what canbe done if a patient is just
feeling unstable?
Gerald Andah, MD (46:26):
Yeah, so there are two things that really
affect your stability.
That's one we've talked aboutoffset a couple of times already
, and your leg lengths, and sousually if your hip is unstable,
one of those two things needsto be addressed.
So at the time of the revisionsurgery, you can go in and
increase the ball size, which isgoing to increase your leg
(46:49):
length, or increase the amountof offset that you have, which
is increasing the tension onthat, on those muscles and
structures around the hip, sothat you're putting in the hip
tighter so it doesn't pop outRight.
Robert A. Kayal, MD, FAAOS (47:03):
Well , fortunately, because these are
modular hip replacements, aslong as your surgeon can
identify what the problem is andvery often we can based on
x-rays alone, but sometimeswe'll employ MRI imaging
technology or CAT scan imagingtechnology.
Fortunately, because there aremodular implants, we have so
(47:23):
many different options toaddress each patient's concern
on a case-by-case basis.
Sometimes that will entail usrevising all components in the
total hip replacement and veryoften we can get away with just
changing one component or twocomponents, like the size of the
head or the plastic liner.
Sometimes we have to change thestem, sometimes we have to
(47:47):
change the cup, but it reallydepends on what the patient's
problem is, and that's oftenvery easily identified and we
treat each patient as anindividual and on a case-by-case
basis, we address them that way.
Correct, absolutely.
So sometimes even revisions canbe performed in a very minimally
invasive manner, 100%, yeah, sothis is probably, I think we
(48:12):
nailed, the most commonimportant issues to talk about
with patients when it comes toimplants that have failed and
require revisions.
And, by the way, when we say afailed total hip, it doesn't
necessarily mean that yoursurgeon did anything wrong.
These are just mechanicalconstructs that can fail over
time or certain things are outof surgeon's control, like
(48:35):
infection and patientcomorbidities, but in general we
call it a failed total hip,when a total hip replacement has
failed over time for whateverreason.
And what would you say is theimportant take-home message to
our viewing audience and ourlisteners that they should just
remember after this podcast ifthey're suffering from some
(48:58):
issues pertaining to their totalhip replacement.
Gerald Andah, MD (49:01):
I would say the most important message is to
communicate with your physician, right?
I would say the most importantmessage is to let them know how
you're feeling, so that ifsomething is actually wrong, it
can be worked up.
Robert A. Kayal, MD, FAAOS (49:12):
Yeah , I mean because common things
are common and uncommon thingsare uncommon, and certainly when
you say those buzzwords to us,we immediately start thinking of
things in a differentialdiagnosis, because we know what
complaints are concerning andwhich ones are normal.
So I think it's very importantto communicate exactly how
you're feeling to your doctor,and the only other thing I'd
(49:36):
like to add to that is thatregular follow-up is so
important, regardless of how youfeel, because an orthopedic
surgeon can look at an x-ray anda million things can go through
our minds.
Based on the results of anx-ray, we know if something
looks perfect or if something'sbeginning to suggest that
(49:57):
there's early wear, earlyloosening or a problem that's
developing.
And certainly just by talkingto us, just by talking to us we
can start tabulating adifferential diagnosis in our
mind based on some of thebuzzwords that you may or may
not be saying to us.
We want to know that you'redoing well, we want to know that
(50:17):
there are no problems, but ifthere are problems, we want to
know about it.
The sooner the better.
Right, absolutely All right.
So thank you so much forspending some time with me, dr
Andan, to help us communicate toour patients about hip
replacements and problems thatcan occur with hip replacements
and the need to see a specialistlike Dr Anda, who's always
(50:39):
readily available and happy tosee you at any time.
So feel free to reach out.
Thanks so much, dr Andan.
Gerald Andah, MD (50:45):
It was a pleasure.
Thank you for having me.
Thanks for your time.
Robert A. Kayal, MD, FAAOS (50:47):
All right.
Hello and welcome to another edition
of the K Lortho podcast.
Today is August 23, 2023, andtoday's special guest is our
very own Dr Gerald Anda.
Dr Anda is a fellowship trainedorthopedic surgeon with an
expertise in hip and kneeprimary and revision joint
replacement surgery.
Welcome to the podcast, dr Anda.
(00:22):
Thank you so happy to have youwith us today.
Thank you for having me here.
So today's topic is revisiontotal hip arthroplasty.
Why don't we take thisopportunity, dr Anda, to
introduce yourself to ourlistening and viewing audience
before we start this podcast?
Gerald Andah, MD (00:36):
Yeah, absolutely so.
My name is Dr Anda.
I'm from Ghana originally.
I went to school at Penn inPhilly for about 13 years, did
the first half of my trainingthere and finished up with a
fellowship in adultreconstruction, which is
basically hip and kneereplacements, at Montefiore in
New York City.
Robert A. Kayal, MD, FAAOS (00:56):
Okay .
So it's so good to have youwith us, dr Anda.
Why don't we just take thisopportunity first of all to just
inform our viewing andlistening audience about hip
replacement surgery and revisionhip replacement surgery in
particular?
Gerald Andah, MD (01:09):
Right, absolutely so.
Most people know about primaryhip replacements, which is
having your hip done the firsttime around, but sometimes there
are situations in which you'regoing to need to have it redone,
which is what we call revisiontotal hip arthroplasty.
Robert A. Kayal, MD, FAAOS (01:26):
Okay , great.
So what are some of the reasonsthat people would sometimes
have to encounter the need forrevision?
Hip replacement.
Gerald Andah, MD (01:35):
Right.
So actually, if you couldbelieve it, the most common
reason for needing to have arevision total hip arthroplasty
is not having it done by myselfor any of the other surgeons
that care orthopedics.
Okay, no, but on a more seriousnote, the most common reason is
loosening, and that can be fortwo different reasons.
It could either be aseptic orseptic.
(01:57):
All that means is that onecould be without an infection
and one could be with aninfection.
Some of the other reasons forneeding a revision hip
replacement are instability, andso, as you know you know, hip
replacement has a ball in thesocket, and so sometimes that
ball can pop out of the socket,and so that's another reason,
(02:18):
and that can happen for multiplereasons, but that's another
reason why you might need arevision hip replacement.
Robert A. Kayal, MD, FAAOS (02:24):
Yeah , so how long are these primary
hip replacements supposed tolast in?
Gerald Andah, MD (02:28):
general.
So, while the longevity ofthese implants the literature
tells us is about 80 to 90%, ofthem are still good at about 20
to 30 years.
Robert A. Kayal, MD, FAAOS (02:38):
It's incredible.
They've made some significantstrides over the years,
absolutely, and in hipreplacement and knee replacement
surgery in particular.
And what are some of thosethings that affect the longevity
of implants?
Gerald Andah, MD (02:51):
So some of the things that affect the
longevity of the implants is thedurability of the materials
that are used for the total hipreplacements.
There have been so manyadvancements in the last you
know, 10, 20 years that makethese implants so much more
durable that you know theliterature itself hasn't even
caught up to how long they last.
To be honest, the liners thatwe use, which is the sort of
(03:14):
cushion in between the two partsof the implant, is so durable
now that we're not seeing thesame problems that we were
seeing, you know, 10, 20 yearsago as frequently.
And then the materials that theactual hip implants are made of
are titanium, and so they'revery durable and they you know
they last a very long time.
Robert A. Kayal, MD, FAAOS (03:36):
Yeah , and I don't think we want to
talk about today the basicfundamentals of hip replacement
surgery because, as you know, wealready discussed primary hip
replacement surgery with DrVictor Ortiz when we focused on
the direct anterior hipreplacement.
But I think it's important forour listening audience and our
viewing audience to at least geta nice visual of some of the
(03:59):
implants that we're talkingabout when we're talking about
hip replacement surgery.
So can we first demonstrate toour patients the components
involved in hip replacementsurgery, so that they can get a
better understanding when wetalk about why and when some of
these implants fail, what needsto be done to fix it Absolutely.
Gerald Andah, MD (04:21):
So we're going to start out with the
acetabulum, which you can thinkof as the socket component for
your hip replacement.
So, as you can see here, it's ahemispherical shape, okay, and
it has these holes in case youneed to put screws in it to
increase the stability orfixation.
The other part of thiscomponent is this liner in the
(04:44):
center of it, and this is what Iwas talking about as the
cushion that you know.
It provides a buffer betweenthis and the other aspects of
the total hip replacement.
So this liner is what has had,you know, so many changes happen
over the last few years to makeit so durable that these are
lasting even longer than the 20,30 years that we're accustomed
(05:06):
to having it last.
Robert A. Kayal, MD, FAAO (05:07):
Right .
So, just so the patients areclear, the first thing we do
when we do a hip replacement iswe dislocate the hip right.
The hip replacements aretraditionally done for hip
arthritis, when there's a boneon bone, arthritic, painful
condition, right.
So we have to provide thepatients with a new what we call
a bearing surface right and inthe hip it's a ball and socket
(05:29):
joint, just like in the shoulderit's a ball and socket joint.
So what you're holding up inyour hand is the socket of the
ball and socket joint, right.
So the first thing we do, as DrOrtiz and I have discussed in
the past, is we first preparethe acetabulum.
So we ream the acetabulum withinstruments to prepare a
(05:53):
hemispherical socket to allow usto install that shell right,
what we call the shell.
Once that shell is seated intothe bone, it's a nice press fit
fixation.
Typically, sometimes we'll haveto augment that with screws to
supplement that fixation.
But then the new ball you putin has to articulate with
(06:15):
something, and that's somethingis that plastic liner that you
described.
So so far we've talked aboutthe shell and we've talked about
the polyethylene liner or theplastic liner.
Now that liner could be made upof different materials, but
most commonly we're using, in2023, a plastic or polyethylene
(06:35):
liner, right.
So let's talk about the stemnow.
Gerald Andah, MD (06:38):
So for the stem, this is an example of a
primary hip replacement stemwhere you can see that it has
the bulk of its shape in the inthe proximal or top part of the
implant.
This fits in the proximal partof your bone, that's called the
metaphysis and this fits in theactual canal of your femur.
(07:01):
So this is the stem portion ofyour hip replacement.
You can see that it has somequoting around the implant here
and that helps bone to grow andattach to the implant to
increase the stability.
Robert A. Kayal, MD, FAAO (07:15):
Right , and some of the innovations in
orthopedics, especially jointreplacement surgery, have
largely been made in theimplants themselves.
It's not just the way thatsurgeons are performing the hip
replacement, but the vendorshave contributed significantly
in the technologicaladvancements of total hip
replacement surgery too, byproviding us with better
(07:37):
products, better implants,absolutely, and we'll talk about
that more in detail in thefuture.
Gerald Andah, MD (07:42):
Yeah absolutely so.
One of the things that haschanged over the years is the
shapes of these implants.
Right, they have all sorts oftapers and they have different
shapes and sizes that allow itto fit into the bone more
specifically, yeah, and thematerials as well.
Robert A. Kayal, MD, FAAOS (08:01):
Some of them used to be very stiff
and rigid, and now the stiffnessassociated with these implants,
especially these titaniumimplants, is much more
bone-friendly, where theseimplants will now become more
load sharing devices as opposedto load bearing devices, which
has significant impact on thelongevity of the total hip
(08:25):
construct correct, yeah, and sothe materials that they're using
for these implants now match alot more closely the stiffness
of our bone, and that allows itto distribute force more evenly
throughout the bone.
Right.
So, dr Andow, why don't youdescribe what I'm holding in my
hand right now and you can showour viewing audience how a total
(08:47):
hip replacement construct isput back together during?
Gerald Andah, MD (08:50):
surgery, absolutely.
So what we're looking at here ishalf of your pelvis right here,
and then this is the top partof your femur right, and so when
we're doing a hip replacement,you can see that this socket is
prepared for this implant to fitin in a press fit way, which
(09:14):
sort of means that we're usingthe friction of the implant to
hold it in place and the bonegrows into it over time.
This is that liner that we'vespoken about that provides a
cushion between the other partof the implant that I'm about to
show you and this socketimplant.
So this is the proximal or toppart of your femur right, your
(09:37):
thigh bone, your thigh bone,where the stem of the implant is
going to sit, and it literallyfits in there like that.
It's just like that, especiallywhen we're in surgery too, and
then we relocate the hip, so youhave the ball fit into the
(09:58):
socket, just like that, okay,and then eventually, I'm just
gonna take this apart, actually,and show you guys, this is how
you move your hip after hipreplacement.
See how it looks perfect andbeautiful.
Robert A. Kayal, MD, FAAOS (10:14):
So that's what we call the bearing
surface.
Now, in this model inparticular, we're seeing this
purplish color, lavender colorball, and that is an example of
what we call a ceramic head.
Ceramic heads are very commonlyused in primary and revision
total hip arthroplasty thesedays and in this particular
(10:36):
model, this ceramic ball isarticulating with a plastic
polyethylene liner that'sinserted into a titanium shell
that is also inserted into thenative acetabulum and in the
femur or the thigh bone.
You saw Dr Anda place atitanium stem, and this is what
(10:59):
we call a total hip replacement.
So, as we've discussed, totalhip replacement surgery is an
operation that is incrediblysuccessful.
It's really changed the livesof millions and millions of
people across the world over theyears.
It is considered to be one ofthe most successful orthopedic
operations performed.
(11:19):
But, that being said, ultimatelysome patients require a
revision.
Dr Anda already discussed someof the common reasons for
revision total hip replacement,including, but not limited to,
loosening, instability andinfection.
Those are probably the threemost common reasons for failure
(11:40):
of total hip arthroplasty andneed for revision surgery.
So let's try to focus on thisvery complicated topic but
communicated to you in layman'sterms so it's fairly simple to
understand when something mightbe wrong with your hip
replacement and when you need toconsult an orthopedic
specialist like Dr Anda to getyour total hip replacement
(12:02):
evaluated.
So, dr Anda, let's first talkabout when we perform primary
total hip arthroplasty what istypical for routine follow up
for a hip replacement?
Gerald Andah, MD (12:14):
So for follow up after a total hip replacement
, first time we see the patientsat two weeks, next time is six
weeks, three months, six monthsone year and then each year we
see them at least once afterthat, and the reason that we do
that is to make sure that we'renot missing anything that could
be happening down the line thatcould be potentially causing the
(12:36):
patient an issue or pain.
Robert A. Kayal, MD, FAAOS (12:38):
Yeah , I agree with that fully,
because certainly when implantsfail for whatever reason and
they can, we wanna pick up onthat early right.
Earlier diagnosis is better.
We have a tendency to nipthings in the bud and address
small problems with smallsolutions as opposed to big
problems with big solutions,right.
So that's very important toemphasize and I agree with that.
(12:59):
Once a year after the firstyear, at least follow up and see
your doctor again for a followup visit.
Let the doctor take some x-rays, check the wound, make sure
there are no concerning issues.
So many times after this verysuccessful operation, patients
think that they're done afterthe first year and we won't see
them again for five years or 10years, for whatever reason, for
(13:20):
a different problem, becausethey think everything's great
and I'm glad things are great.
But the thing is they forgetwhen I tell them you need to
come back once a year for anx-ray because they're feeling so
good.
But it is important toemphasize once a year routine
follow up with your orthopedicsurgeon so that he or she can
assess you and make sure thex-rays look good and there are
(13:41):
no concerning findings.
Yeah, absolutely so.
That being said, dr Andrew,what are some of the concerning
complaints that patients mayreport and maybe some of the
concerning findings on physicalexam and x-ray that makes us
suspicious that maybe somethingmight be beginning to fail?
Gerald Andah, MD (13:59):
Yeah, so your discussion with the patient is
probably the most importantthing, because the patient knows
their body really well andthey're gonna tell you when
something isn't necessarilyright.
So pain is probably the numberone factor that leads us to
think that there might besomething going on persistent
pain.
And then sometimes patients cancomplain of instability in the
(14:22):
sense of feeling like somethingis shifting or moving.
That might be one reason tosort of pause and assess and see
if something's going on.
And then there's one thingcalled startup pain.
Sometimes patients get what'scalled startup pain and to sort
of explain that, that means thatwhen you first get up from a
(14:44):
seated position and you startwalking, you might have some
pain.
As the implant starts to settleinto a better region or a
better location, that pain easesup.
So that indicates that theimplant might be loose.
Robert A. Kayal, MD, FAAOS (15:00):
Yeah , when they start to weight bear
, when they get up out of bed orget up out of a chair and start
to weight bear, theyimmediately get that stiffness.
Very often they complain ofstiffness more than anything and
that's that microscopicsubsidence of the implant into a
stable configuration.
And if that is something thatyou're experiencing, you
(15:20):
definitely need to see yourorthopedic surgeon or one of us
to get that assessed, becauseit's very, very important not to
miss loosening of an implant.
Absolutely so.
That startup pain is a classiccomplaint and it's often
associated, even more than pain,with stiffness.
(15:42):
Patients say I'm stiff, I can'treally walk immediately.
I have to sort of stand up andhold on to something for a few
seconds until I can get mybearings, and then they start
walking and they're better.
And, surprisingly, the morethey walk on a loose implant,
the better they feel, because,as they're continuing to walk
(16:02):
through it and put their bodyweight through that construct,
it is stabilizing the implant inthe bone and, although that
implant is loose, they feelbetter when they're walking on
it.
But that is something that youhave to see your doctor about
quickly.
Yep, absolutely so.
You mentioned startup pain,stiffness we talked about.
(16:23):
What other signs and symptomsmight they be concerned about if
they have, for instance, aninfection?
Gerald Andah, MD (16:31):
Right, so things that you want to look for
if you have an infection isredness around the incision area
.
If you have drainage after yourtotal hip replacements, two
weeks after surgery, that issomething that's concerning and
should be evaluated by yourdoctor, and so any sort of
drainage after the two week markis something that you should
(16:52):
bring to the attention of yourphysician.
Robert A. Kayal, MD, FAAOS (16:53):
Yeah , at the most two weeks.
Some people even are gettingconcerned at five to seven days
after surgery.
So we don't like drainage froma wound after surgery.
If a wound is draining you needto see your doctor to get that
assessed to make sure there's noevidence of infection.
But let's assume that this hipreplacement was done six months
(17:13):
ago.
What are some of the concerningfindings regarding infection at
that?
Gerald Andah, MD (17:18):
time.
So redness pain is one of thebig things, and so persistent
pain at six months after a totalhip replacement is something
that should be worked up by yourphysician to make sure that you
don't have an infection, and wecan talk about how that's done
a little bit later.
Robert A. Kayal, MD, FAAOS (17:34):
So look, it's one of the most
rewarding operations.
I've already alluded to that.
Patients should only continueto get better after this
operation, right?
If patients start experiencingpain that's out of proportion to
the surgery that was performedand if it does not seem to be
dissipating or if it's headingin the wrong direction?
(17:54):
Our training is that we alwaysthink of infection in our
differential diagnosis.
Right?
Infection is called the greatmimicar.
It can present like anything.
You don't have to have theclassic signs of infection where
the wound is opening up anddraining pus or you're suffering
with a fever and chills andpersistent drainage from the
(18:17):
wound.
That always happened.
When somebody is notprogressing well after hip
replacement surgery and the painpersists and they're just
continuing to complain, it isincumbent upon us as physicians
to work that patient up forinfection and assume that it's
infected until proven otherwise.
So the work up for infection iscritical in a joint that's not
(18:41):
performing well.
What else we talked aboutinfection?
We talked about startup painand loosening.
What about instability?
How will patients present ifthey feel unstable?
Gerald Andah, MD (18:53):
So patients that feel unstable usually
present by saying that whenthey're either getting up from a
seated position or doinganything that involves bending
their hip, they feel like theirhip is shifting.
They feel a sensation of eitherthe ball actually shifting or
just coming out of the socket alittle bit.
That's what presents the mostas instability.
Robert A. Kayal, MD, FAAOS (19:17):
Yeah , and instability can be
catastrophic for the patient.
Instability can cause literallythe joint to dislocate.
When patients dislocate,they're miserable.
The hip, the construct justcompletely dislocates.
The ball falls out of thesocket.
The patients endure asignificant deformity.
Sometimes their sciatic nervescan be irritated or stretched
(19:40):
during that traumatic event.
Only the patients cannot weightbear on a hip construct that is
unstable and dislocated.
So instability can happen for amyriad of different reasons.
What are some of those reasonsthat a hip can be?
Gerald Andah, MD (19:55):
unstable.
Probably one of the primaryreasons that a hip can be
unstable is if the tension inthe muscles around the hip has
not been adequately restored.
There are different ways thatyou can restore the tension, but
we have muscles around our hip,several different kinds of
muscles.
If the tendons that areattached to those muscles are
(20:15):
not stretched out appropriately,that might allow the ball to
pop out of the socket at somepoint after your hip replacement
, exactly.
Robert A. Kayal, MD, FAA (20:23):
That's critical to restore what we
call the offset right.
When we do total hipreplacement surgery, our goal is
to restore the proper offset ortension of the muscles and
tendons that keep the hip stable.
And again, the onus is on us tomake sure that we restore that
offset properly.
And nowadays, especially at theKale Orthopedic Center, when we
(20:45):
employ the latest and greatesttechnologies with respect to
designing patient-specificcustomized total hip replacement
surgery using proprietarysoftware and CAT scan technology
where we do a virtual hipreplacement on a computer, and
then robotic technology to makesure we put it in accurately and
(21:05):
precisely we're able toproperly restore the patient's
offset exactly how we want torestore that, so that the
patients are stable andcomfortable and their leg
lengths are proper, and all thatis very, very important to
ensure a successful outcome forthe patients after this
procedure.
(21:27):
So those are some of the mostcommon reasons for need for hip
replacement revision surgery, solet's talk about them a little
bit in more detail.
First and foremost, let's talkabout infection.
Okay, so we talked a little bitabout the fact that patients
can get infections early on andeven later, right?
(21:49):
What are some of the reasonsfor acute infections, infections
that are occurring right after?
Gerald Andah, MD (21:56):
surgery, for instance.
So right after surgery,sometimes what we talked about
drainage, because if there isfluid coming out of the wound,
that means that there's apotential for bacteria to get
into the wound.
So that's probably one of themore common reasons for getting
an infection in the acute periodwhich is soon after your
surgery.
Robert A. Kayal, MD, FAAOS (22:14):
So that drainage can come from the
surgery itself.
It can come from blood thinnerstoo, right it's?
You know patients can get bloodclots after joint replacement
surgery or any orthopedicsurgery or any surgery in
general.
But certainly joint replacementsurgery does put patients at
risk and some patients are at ahigher risk than other patients
Absolutely, and we have to putthose patients on blood thinners
(22:35):
.
So it's sort of a catch-22, butwe have to do it because we
don't want our patients to getblood clots and pulmonary emboli
.
But if they do get placed on anaggressive blood thinner and
they end up bleeding a littlebit, that some of that blood can
continue to drain out of thewound and that is something that
can potentially predispose ourpatients and other patients for
(22:57):
infection correct.
So what other risk factors canincrease the patient's risk?
Gerald Andah, MD (23:03):
of infection.
So sometimes some comorbiditiesthat patients have, including
diabetes, rheumatoid arthritis,things like that might put you
at increased risk for getting aninfection, and the reason that
that happens is that when youhave those conditions, it really
decreases your body's abilityto fight off bacteria and puts
you at higher risk for gettingan infection, and some of the
(23:25):
risks that have a higher bodymass index are also at risk for
getting an infection for thesame reasons, certainly, and
smokers too.
Robert A. Kayal, MD, FAAO (23:33):
Right , and smokers, yeah, People that
smoke.
It definitely deleteriouslyaffects your circulation and
increases the risk of infection.
Smokers commonly occur fromprimarily a few different
sources.
Right, One of those sources canbe our own body.
Right, Because our skin is abarrier to infection and there
(23:56):
are a lot of organisms that liveon our skin.
Right, so some of those mostcommon infections are staff
right and our bodies have staffepidermis, for instance, all
over it.
Staff aureus is a very commoninfection.
People can get infections fromother infections in other areas
of their body.
If they have an upperrespiratory tract infection or a
(24:18):
urinary tract infection, adental infection, these bacteria
can get into the bloodstreamand then ultimately circulate to
the joint and infect yourimplant as well.
Gerald Andah, MD (24:29):
Yeah, and you know, one of the other things
I'm glad you brought that up isbecause we have a lot of
bacteria, like you said, on ourskin, in our gut and also in our
mouth, right and so it isimportant that you let your
physician know after you have atotal hip or a total near
placement when you're gettingdental work done, because you're
going to need to haveantibiotics before you get the
(24:51):
dental work, so that whateverbacteria is in your mouth does
not spread through your blood toyour implant.
Robert A. Kayal, MD, FAAO (24:57):
Right .
So infection is a devastatingcomplication and you know the
onus is on us, but also thepatient, to take measures to
minimize the risk of infection.
First of all, with respect tous, what can we do besides
sending our patients to thedentist, if necessary,
addressing their dental carriesbefore surgery, making sure that
(25:20):
they don't have any otheractive infections in their body
when we do the joint replacement, like dental infections or
urinary tract infections orothers?
We can also do things to theskin right to decolonize our
patients, right?
Yeah, speak about that for usif you can.
Gerald Andah, MD (25:38):
So some of our pre-surgery routine involves
reducing the amount of bacteriathat you have on your skin and
in other parts of your body.
So we routinely have patientsget a what's called a hibiclens
wipe, which is a special kind ofsolution that kills bacteria,
and we have patients wipe thesurgical site for five days
(26:00):
prior to surgery, whether you'regetting a hip or knee
replacement.
We also have patients use anointment that kills bacteria
that can live inside your nose.
It's actually pretty harmfulbacteria for the same amount of
time prior to surgery to helpreduce that risk of that
bacteria getting to the implantthat we put in.
Robert A. Kayal, MD, FAA (26:17):
That's the back to the band or the
mute person ointment correct?
Yeah, so we take some measuresto optimize our patients for
surgery, but I think it'simportant for the patients also
to take some responsibility,because we're doing this
operation together.
Absolutely, we strongly believethat we're going to live up to
our expectations and takeresponsibility.
(26:38):
But it's important for patientsto participate in their care as
well, which means to optimizetheir medical health and
nutrition status and weightprior to their joint replacement
surgery.
Absolutely, some patientssuffer from diabetes mellitus
and their hemoglobin A1C is high.
It's poorly controlled.
We recognize that through bloodwork et cetera.
(27:00):
But then we want the patientsto participate to minimize the
risk of infection by gettingtheir diabetes under control.
Yeah, or we ask them to stopsmoking.
Or if they're an autoimmunepatient that happens to be on
some medications that canincrease the risk of infection,
we ask them to consult with therheumatologist or their primary
(27:22):
care doctor to minimize theusage of certain medications
like steroids, before thesurgery which can compromise
wound healing after surgery.
So I think it's important tomention all those things because
we can work as a team with ourpatients to really decrease that
risk of periproestheticinfection.
(27:43):
As far as the other commonsource of revision hip
replacement loosening.
We discussed loosening and thenwe talked about two different
types of loosening.
For the most part there isaseptic loosening and septic
loosening.
Well, septic loosening would besecondary to that infection
where the bacteria invade andstart to eat away the bone and
(28:06):
loosen the construct, and that'sa devastating complication,
clearly.
But let's talk a little bitabout aseptic loosening, or
loosening that can occur withoutinfection Right.
Gerald Andah, MD (28:18):
So loosening that can occur without infection
can happen for a couple reasons.
Probably one of the more simplereasons is if the implant
that's put in at the time ofsurgery is too small.
Sometimes that has the abilityto loosen because it doesn't
grab the bone as well.
One of the other reasons thatyou can get loosening in your
implant is sometimes there aresmall particles that are
(28:40):
released from the materialsitself in the hip over time that
the body starts to try to fightand in your body's attempt to
fight these particles it can eataway at some of the healthy
bone.
Sometimes, when that happens,that allows the implants to
loosen over time.
So those are probably the two,I would say, most common reasons
(29:01):
why you get aseptic orloosening from no infection.
Robert A. Kayal, MD, FAAOS (29:06):
Yeah , and just to further elaborate
on what Dr Ando was mentioning,there's the concept of
particulate debris that we'retalking about here, where
there's debris that's formed dueto repetitive microscopic
motion between parts of theimplant.
You can see, based on thevisual that we presented to you
(29:27):
earlier, that these total hipconstructs are modular
constructs.
They're not what we callmonoblocks, they're modular.
The pieces are interchangeable.
You have different stem sizes,you have different ball sizes,
you have different cup sizes,you have different polyethylene
liner sizes, and when you snapon one piece to another, there
(29:52):
tends to be some type of lock ortape or fit that secures that
implant in place for life,hopefully.
But over the years, afterloading this implant, millions
and millions and millions ofcycles, there can be some
microscopic wear between thebearing surfaces and between the
(30:16):
articulations between thesemodular components, and some of
that wear can be plastic wearand some of the wear can be
metal articulating with metalwear.
But what Dr Ando was mentioningwas that this wear, this part
what we call particulate debrisincites some type of autoimmune
inflammatory response where ourbody's immune system attacks
(30:41):
that debris and, unfortunately,in its efforts to rid ourselves
of that debris, it often cancause what we call osteolysis
and loosening of the implant.
It can erode and eat up some ofthe bone and cause implants to
fail.
It causes some types ofreactions sometimes, especially
(31:03):
the metal on metal types ofarticulations can cause some
adverse soft tissue reactionswhich can cause very, very
devastating effects to the softtissues, which can cause
loosening and instability andfailure of the construct.
So that is another potentialsource of failure of total hip
(31:26):
replacement.
If these things are not pickedup.
And this really reinforces myrecommendation to make sure that
you see a doctor at least oncea year after your hip
replacement to make sure thatthere are no signs on physical
exam or on radiographs thatwould suggest potentially that
(31:49):
any of these things is occurringAbsolutely.
Also, we talked about anothersource of failure which, besides
loosening, besides infection,we talked about instability as
well.
But how about leg lengthinequality?
Is that potentially a problemafter hip replacement?
Gerald Andah, MD (32:07):
surgery as well 100%, and so one of the
other reasons that patients getinstability is when they don't
have their leg lengths restoredto its natural anatomy, and what
that does is that goes back tothe point that we made earlier,
where it doesn't restore thecorrect amount of tension to the
muscles that are attached toyour hip, and so it makes your
(32:29):
hip loose in a sense.
So if your leg is short by afew millimeters, that reduces
the amount of tension that themuscles or tendons around your
hip have and it reduces theirability to hold the ball in the
socket, and then that's when youcan dislocate, which is a very
traumatic event that we sort ofspoke about.
Robert A. Kayal, MD, FAAOS (32:51):
Yeah , and we're talking about all
these complications only becausewe're talking about the topic
of revision hip replacementsurgery.
But I think it's important toemphasize that, like I said
earlier in the podcast, totalhip replacement surgery is
probably the most successfuloperation performed in our field
, absolutely.
There are incredible,incredible outcomes and
(33:13):
long-term outcomes.
That is as well, and thesecomplications that we're
discussing are incrediblyuncommon.
They can occur, but they'reexceedingly uncommon.
But I think it's important totalk about it, just so the
patients know that these thingsexist and, if they're suffering
from any of these complications,that we do have solutions for
(33:35):
these problems.
And that's what we're here fortoday To bring this information
to you so that you can find hope, if you're suffering from some
of these complications, that wehave solutions at the Kale
Orthopedic Center.
So let's talk about some ofthese solutions, because I know
you gave us a beautifuldemonstration of how a primary
(33:55):
total hip replacement getsperformed.
But when these things happen,there has to be a solution to
restore that patient's qualityof life and function.
So let's talk about themspecifically.
If there is an infection andthat implant is now infected,
let's make believe that thatsurgery was done recently.
(34:16):
The patient's still drainingtwo weeks after total hip
replacement surgery, maybe threeweeks at the most.
Hopefully he didn't wait thatlong.
Just had the operation.
The wound is still draining.
Gerald Andah, MD (34:30):
What are you going to do so?
First thing we do is work up aninfection.
We do some of the ways that wedo that, obviously with imaging
and lab work.
So blood tests there arespecific blood tests that assess
your body's level ofinflammation, which is a sign of
infection.
If those markers are high, thenwe depending on how recent your
(34:51):
surgery was, we eitherautomatically take you back to
the operating room or we takesome fluid out of the joint If
we're talking about hips rightnow so out of the hip joint and
send that to the lab to see ifit grows bacteria or has certain
markers that indicate aninfection.
Once that's done, if you've hadyour surgery in the acute period
(35:12):
, which is within a few weeks,then you can go back to the
operating room and take out thereplaceable parts of the hip.
So there are some parts of yourhip the socket part and the
stem that take a lot more workto replace.
There are parts like the balland the liner that can be
replaced pretty easily.
(35:32):
So in those situations whereyou have an acute spread of an
infection that came from dentalwork or a UTI or an upper
respiratory tract infection orsomething of that sort, the key
is to be really aggressive andattack it really quickly.
So we want to take thosepatients back to the operating
room as soon as possible to tryto save the implant, and so the
(35:52):
real key in a situation likethat is getting them to the
operating room as soon aspossible to get that treated.
Robert A. Kayal, MD, FAAOS (35:58):
Yeah .
So I think it's so importantfor patients to understand.
If you have a total hipreplacement that was just done
and is still draining to sevento 10 days after surgery two
weeks after surgery more thanlikely you're going to have to
get that hip washed out, cleanedup and that hip will more than
(36:18):
likely be able to be salvagedwith that simple little washout.
If you have a hip replacementthat was functioning well for
many, many, many years and thenall of a sudden you get an
infection in your body somewhereor have a dental procedure or
have an abscess in your mouth orhave a urinary tract infection,
an ear infection, upperrespiratory tract infection, and
(36:39):
then suddenly, a couple weekslater, your previously well
functioning hip all of a suddenstarts bothering you
tremendously, there is a concernthat maybe some of the
infection got into the blood andthen subsequently infected your
well functioning total hip.
In that particular case, again,you're going to have to get
that hip washed out quickly.
(37:01):
Time is of the essence.
See your doctor, let themassess you and you may need to
get that hip washed out.
If it is determined that yousuffered from what's called an
acute hematogenous spread to awell functioning hip replacement
, then there's the patient thathad a hip replacement that was
never, ever, ever satisfiedafter their hip replacement
(37:24):
continuing to deteriorate, neversatisfied, persistent pain,
maybe startup pain, maybeevidence of loosening osteolysis
.
On x-ray More than likely thatpatient was suffering from a
chronic infection all the waydating back to the beginning and
that's a chronic infection.
(37:45):
That implant cannot be saved.
If it is determined that thatpatient is suffering from a
chronic infection of thatimplant, that patient is going
to have to have that implanttaken out, an antibiotic
impregnated spacer put in.
That patient will need to betreated with antibiotics for a
(38:05):
minimum of six weeks IV and thenonly after that chronic
infection is cleaned up fullycan your surgeon go back and
reinstall a new total hipreplacement.
Is there anything else you wantto add to that?
Gerald Andah, MD (38:19):
Yeah, you know , the reason that we distinguish
between having an acuteinfection and having a chronic
infection is because of howbacteria behave.
So I'm not going to get intotoo much detail.
But the bacteria create alittle cover around the implant
if you give them enough time.
So the reason we try to get tothese acute infections quickly
(38:41):
is so that we don't allow thebacteria to do that.
But if you have a chronicinfection, like you were just
saying, if this has been goingon for months and months or it
never felt right, then mostlikely the bacteria has already
created that cover, that film,that antibiotics cannot
penetrate.
Robert A. Kayal, MD, FAAOS (38:56):
I think that's a great point and
I'm so glad you brought that upbecause it's so important to
emphasize that.
What he's talking about is thiscover or lining that we call a
glycocalyx.
It's an impenetrable sheatharound the infection that is
often impenetrable to IVantibiotics and it definitely
(39:18):
requires a very, very aggressivedebris month to get rid of
those bacterial infections andsometimes removal of the implant
itself.
So time is always of theessence with infection, because
some literature says that, youknow, these bacteria can form
these impenetrable glycocalyxieswithin a day or so hours after
(39:43):
infections.
So it's so important whenyou're experiencing symptoms of
infection pain, persistent painheading in the wrong direction,
loosening, instability see yourdoctor and let us make sure that
you're not suffering from acomplication.
So now that we've talked aboutloosening an infection and
instability, leg length,inequality and certainly other
(40:04):
things can go wrong too.
Right, if somebody has a hipreplacement, someone can fall
and suffer a serious fracturearound a hip replacement.
You could break your thigh bone, your femur, even without a hip
replacement.
But if you break it around ahip replacement, that would
require sometimes a revision,total hip replacement.
So in all of these scenariosthat we've outlined, where
(40:26):
there's loosening, infection,instability, leg length,
inequality and certainlyfracture and infection.
Sometimes these patients haveto undergo a revision total hip
replacement.
So we've demonstrated earlierin this podcast how a primary
total hip replacement getsperformed.
But now you're dealing with arevision and in a revision
(40:50):
scenario you're already missingbone In a primary total joint.
All the bone is there, so it'scertainly much more easy to
perform a primary total hipreplacement.
What do you do with a revisionwhen there's bone loss?
How do you do a hip replacementif you're missing bone?
Gerald Andah, MD (41:09):
It's actually really interesting.
This right here is a primarytotal hip replacement stem.
So you can see how it's wide atthe top and gets really skinny
down here, because it gets mostof its fixation in the top part
of the bone.
This because there's good bonethere.
Exactly, this is a revisionstem and you can see how it's
(41:29):
much longer in the primary stembecause this gets its fixation
lower down in the bone.
And that happens because whenyou're in the situation where
you have to do a revision totalhip replacement, the top part of
the bone is compromised and thequality of the bone is usually
not that good, and so now youhave to go a level lower to get
good fixation.
(41:50):
So that's why these revisionimplants look so long, because
they get their fixation in thebottom half of the bone.
Robert A. Kayal, MD, FAAOS (41:56):
Yeah , the bottom half of the bone we
call the diaphysis, or theshaft of the bone right.
The top part of the bone wecall the metaphysis, and in the
primary hip replacement wetypically get what's called
metaphysial fixation becausethere's good bone there.
But in the revision scenarioit's very much compromised for
the reasons we talked about.
It can be infected, it could behorrible bone, it can be an
(42:18):
area of what we call osteolysisfor many different reasons where
the bone gets eaten up anddestroyed and you can't rely on
fixing a revision hipreplacement most of the time in
the metaphysis Right so we haveto obtain what's called
diaphysial fixation and if youcan just show us those stems
again, with diaphysial fixationwe're dealing typically with
(42:42):
those tapered, fluted stemsright so, and they're coated
circumferentially.
So let's show all that comparedto the primary hip replacement
that is coated approximately inthe metaphysis, as you can see
here in Dr Ando's left hand yousee that primary total hip
coated strictly in themetaphysis.
(43:03):
That's where the bone in growthand fixation takes place.
It's what's called a taperedstem and you get great fixation
in that metaphysial region inthe virgin native femur.
But in the revised femur in hisright hand there's no good bone
approximately.
So he's demonstrating this longtapered fluted stem that's
(43:26):
coated circumferentially.
Gerald Andah, MD (43:28):
That will allow bone to grow into all of
that circumferentially, and thefluted stem will also provide a
lot of rotational stability aswell, yeah, and so you can see
how the primary stem is thick atthe top right and thin at the
bottom Because, again, we'refocusing most of our fixation at
the top.
But you can see in the revisionstem it's pretty cylindrical
(43:53):
all the way down and it's muchthicker at the bottom half than
you have in a primary stem.
Robert A. Kayal, MD, FAAOS (43:59):
So the way these implants get
installed.
We have to prepare the canalsright With the primary total hip
.
We tend to use broaches andthen get a nice tight fit and in
the revision scenario we'lloften ream right.
We'll ream the canal to acertain diameter a tapered
reamer and really get a reallynice purchase in that diaphysis
(44:22):
and we get a well fixeddiaphysial engagement stem.
Now let's focus our attentionin the revision scenario now on
the cup.
What can happen in the cup andhow do we address these issues
with bone loss in the acetabulum?
Gerald Andah, MD (44:40):
So this is your acetabulum.
Normally, in a revisionsituation, there is some amount
of bone loss around theacetabulum.
What we rely on for fixation ina primary hip replacement is
these columns.
So if there is a revisionsituation in which either the
infection has eaten up the boneor there is osteolysis from
(45:02):
where particles for some otherreason, sometimes there's no
longer this support and so youneed there are different.
There are a few different kindsof implants that you can use.
Most of them are geared towardsgetting some sort of alternate
stability in instead of gettingthat press fit fixation between
these two columns.
So that can involve usingscrews.
(45:23):
That can involve usingconstructs called a cup cage.
That can involve using customimplants that are actually made
specific per patient based onthe amount of bone that's lost,
called custom triflinges, andthey're all geared towards
getting screws and fixation indifferent parts of the bone
other than the bone that's lostRight.
Robert A. Kayal, MD (45:44):
Fortunately though, however, most of the
time patients can just get awaywith the doctor performing a
revision of the cup right byjust putting in a bigger cup,
you know, just reaming theacetabulum a little bit more and
putting a bigger cup, and it'sprobably the most common
technique employed in thefailure of the acetabulum a
(46:06):
revision, total hip arthroplastythat affects the acetabulum.
But you know what about withinstability?
When there's instability, whattypes of things can be done to
address that, whether it's, youknow, changing the ball or
changing offset stems, what canbe done if a patient is just
feeling unstable?
Gerald Andah, MD (46:26):
Yeah, so there are two things that really
affect your stability.
That's one we've talked aboutoffset a couple of times already
, and your leg lengths, and sousually if your hip is unstable,
one of those two things needsto be addressed.
So at the time of the revisionsurgery, you can go in and
increase the ball size, which isgoing to increase your leg
(46:49):
length, or increase the amountof offset that you have, which
is increasing the tension onthat, on those muscles and
structures around the hip, sothat you're putting in the hip
tighter so it doesn't pop outRight.
Robert A. Kayal, MD, FAAOS (47:03):
Well , fortunately, because these are
modular hip replacements, aslong as your surgeon can
identify what the problem is andvery often we can based on
x-rays alone, but sometimeswe'll employ MRI imaging
technology or CAT scan imagingtechnology.
Fortunately, because there aremodular implants, we have so
(47:23):
many different options toaddress each patient's concern
on a case-by-case basis.
Sometimes that will entail usrevising all components in the
total hip replacement and veryoften we can get away with just
changing one component or twocomponents, like the size of the
head or the plastic liner.
Sometimes we have to change thestem, sometimes we have to
(47:47):
change the cup, but it reallydepends on what the patient's
problem is, and that's oftenvery easily identified and we
treat each patient as anindividual and on a case-by-case
basis, we address them that way.
Correct, absolutely.
So sometimes even revisions canbe performed in a very minimally
invasive manner, 100%, yeah, sothis is probably, I think we
(48:12):
nailed, the most commonimportant issues to talk about
with patients when it comes toimplants that have failed and
require revisions.
And, by the way, when we say afailed total hip, it doesn't
necessarily mean that yoursurgeon did anything wrong.
These are just mechanicalconstructs that can fail over
time or certain things are outof surgeon's control, like
(48:35):
infection and patientcomorbidities, but in general we
call it a failed total hip,when a total hip replacement has
failed over time for whateverreason.
And what would you say is theimportant take-home message to
our viewing audience and ourlisteners that they should just
remember after this podcast ifthey're suffering from some
(48:58):
issues pertaining to their totalhip replacement.
Gerald Andah, MD (49:01):
I would say the most important message is to
communicate with your physician, right?
I would say the most importantmessage is to let them know how
you're feeling, so that ifsomething is actually wrong, it
can be worked up.
Robert A. Kayal, MD, FAAOS (49:12):
Yeah , I mean because common things
are common and uncommon thingsare uncommon, and certainly when
you say those buzzwords to us,we immediately start thinking of
things in a differentialdiagnosis, because we know what
complaints are concerning andwhich ones are normal.
So I think it's very importantto communicate exactly how
you're feeling to your doctor,and the only other thing I'd
(49:36):
like to add to that is thatregular follow-up is so
important, regardless of how youfeel, because an orthopedic
surgeon can look at an x-ray anda million things can go through
our minds.
Based on the results of anx-ray, we know if something
looks perfect or if something'sbeginning to suggest that
(49:57):
there's early wear, earlyloosening or a problem that's
developing.
And certainly just by talkingto us, just by talking to us we
can start tabulating adifferential diagnosis in our
mind based on some of thebuzzwords that you may or may
not be saying to us.
We want to know that you'redoing well, we want to know that
(50:17):
there are no problems, but ifthere are problems, we want to
know about it.
The sooner the better.
Right, absolutely All right.
So thank you so much forspending some time with me, dr
Andan, to help us communicate toour patients about hip
replacements and problems thatcan occur with hip replacements
and the need to see a specialistlike Dr Anda, who's always
(50:39):
readily available and happy tosee you at any time.
So feel free to reach out.
Thanks so much, dr Andan.
Gerald Andah, MD (50:45):
It was a pleasure.
Thank you for having me.
Thanks for your time.
Robert A. Kayal, MD, FAAOS (50:47):
All right.
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