Total hip replacement is by far the best solution to most problems involving severe arthritis of the hip. But occasionally in certain circumstances other alternatives may be more appropriate. These alternatives include hip fusion, hip osteotomy, and rarely resection of the hip joint. This article will describe the surgical alternatives to a total hip replacement based on the patient’s age (please note that these are general age ranges, not absolutes).
Age Less than 40 Years
In patients who are under 40 who have a problem with only one hip joint and are otherwise healthy, consideration may be given to arthrodesis, or fusion, of the hip. When the hip is fused (i.e. the femur bone grows to the pelvis bone) no motion occurs at the hip. This completely relieves pain and provides a stable leg for walking. There are two main advantages: one, that there are no total hip implants that can come loose or fail, and; two, a hip fusion provides a durable long lasting result. The surgery is performed in only a small number of patients, and in our practice we consider this surgery for someone who performs a job involving heavy lifting, such as a manual laborer.
Age 40 to 60 Years
Developmental Dysplasia of the Hip
In the 40 to 60 age group or in patients with certain diseases such as developmental dysplasia of the hip, an osteotomy of the hip may be the best operative procedure. To perform an osteotomy the upper end of the femur near the hip joint is cut and the hip joint rotated into a new position. This procedure requires that some portion of the hip have functioning cartilage in it, and that the hip retain a large amount of rotation. Therefore, it is not indicated when the hip cartilage is completely destroyed. A hip that is stiff with minimal side movement or rotation are not good candidates for this procedure. This procedure has approximately a 70% success rate and success is defined here as improvement of symptoms rather than complete freedom of pain. It is, however, a conservative operation that preserves the hip joint and can allow future conversion to a total hip replacement.
Femuro-Acetabular Impingement (FAI)
In FAI, although the cartilage in the joint is well preserved, the patient complains of groin or buttock pain, loss of motion, at times clicking or locking of the hip, and severe pain with certain motions of the hip. While we understand how to diagnose FAI with clinical and radiographic tests, we still are not sure why this occurs. Treatment options vary, depending on whether the FAI is due to bony changes, soft tissue injury, changes in how the acetabulum (socket) and femoral head are positioned, or often a combination of the above. In the appropriately selected patient treatment options include hip arthroscopy versus an open surgery (a hip dislocation) to address the problem. This condition requires a careful decision as to the true underlying pathology leading to the FAI, and a careful decision about whether surgery is warranted. At this time a cautious estimate would be that 70% of patients will be improved by surgery, although this may be for a short time. Given these results, if we see moderate loss of cartilage in the hip joint, combined with the findings suggestive of FAI, we generally recommend a total hip replacement.
A (Rare) Possibility at Any Age
A final alternative, which is considered a “salvage procedure”, is a resection arthroplasty of the hip. This was developed by a man by the name of Girdlestone and is frequently referred to as the "Girdlestone Procedure". In this case a severely arthritic hip is improved by removing the entire ball portion of the upper end of the femur. This essentially removes the hip joint and allows the femur to shorten. Scar tissue develops between the upper end of the femur and the pelvis bone and allows motion with minimal pain. The leg, however, is quite short and weak and usually patients require at least a cane and often two crutches to walk. The older the patient, the more difficult it is to walk with after a resection arthroplasty. This procedure is usually reserved as a salvage for failed hip replacements that for some reason cannot be revised. In this instance when the hip replacement is removed, what is left is essentially a "Girdlestone". The success rate of this procedure is in the 50-70% range and success again does not imply total relief of pain, but rather an improvement as compared to the situation before the operation.
While we recognize that most of our patients are being seen to consider if they are a candidate for hip replacement surgery, each patient is different. Depending upon your age, the amount of arthritis in your hip, the cause of the arthritis, and the amount of cartilage left in the joint, one of these alternatives may apply to you. If indicated your surgeon will discuss one of these alternative surgeries.