Does risk of dislocation depend upon surgical approach?

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RSC

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I was diagnosed with Stage IV osteoarthritis in the left hip in 2007, but have managed pretty well until the last couple of months, when my hip suddenly deteriorated. It is very clear to me that I am now ready for THR. Surgery is scheduled for November 7.

My surgeon has a very good reputation and has done over 3000 knees and hips. He's conveniently located close to home and I think he's a good choice.

My main misgiving is the restrictions on movement (such as internal rotation of the femur) to avoid dislocation. I can see myself accidentally violating the restrictions, say by facing left while keeping the feet pointed straight ahead.

My surgeon is pretty firm on never violating the restrictions. He told me that he had one patient experience a dislocation six years after surgery. However, my neighbor across the street had THR this year at the VA, and they told him to go home and do whatever he wanted to do. He didn't know what kind of surgery he had, but he showed me the scar and it looked like he had a posterior approach. My surgeon is doing a posterior approach in which the gluteus maximus is split (not cut). There are two small muscles that are cut and sewn back. He has done anterior, but doesn't see any real advantage in the end result.

Is this just a question of some surgeons being more conservative than others? Would an anterior approach reduce the risk of dislocation? Would I then have to avoid external rotation? This would be much more difficult for me than avoiding internal rotation.

Thanks,
Ray
 
Hi Ray. Here are some articles from our library about dislocation.
Dislocation: incidence of dislocation after THR
Dislocation risk and 90 degree rule
Dislocations: what are the risks?

My own sense is that we are at very low risk of dislocation from our own actions....unless we are at a higher risk for some other reason. From my reading here, other reasons could be....something about your own bone structure and placement of bones that may make insertion of the cup or the ball harder to keep in place.... or the surgeon's skill perhaps, but that's always an easy bandwagon to jump on and a hard one to prove. But it behooves us to find the best surgeon available to us. I have an acquaintance who dislocated two weeks out with just a slight movement breaking the rules. It wasn't because she bent over too far though...it's because the cup was the wrong size for her body. (Maybe that speaks to surgical skill too.) She had a quick revision with a new cup and all has been well for a good five years now.

I had posterior for both my hips. I was breaking rules before the six weeks were up....not on purpose, but because I would forget and my body was letting me. Yes, many surgeons are conservative. It's how they were trained to be, and it has generally worked out well for them. They see no need to change that.

I can't speak to an anterior approach. I know there are fewer restrictions, but I don't know the science of why that is. We have lots of people here who have been very happy with that approach...but we have others who have had some problems. There are pros and cons to each approach. Still best to find the most skilled surgeon you can, and then trust him to use the approach that works for him, I think.

Sharon
 
My main misgiving is the restrictions on movement (such as internal rotation of the femur) to avoid dislocation. I can see myself accidentally violating the restrictions, say by facing left while keeping the feet pointed straight ahead. My surgeon is pretty firm on never violating the restrictions. He told me that he had one patient experience a dislocation six years after surgery. However, my neighbor across the street had THR this year at the VA, and they told him to go home and do whatever he wanted to do.
@ray, so glad you asked this question, as I've been troubled by the same concern re: restrictions. I cross my legs all of the time and am certain I will do so unconsciously postop. (My surgery is only a week away.) I'm sure there are other movements I make as well without thinking that will be part of "restrictions." Similar to you, I've encountered discrepant information: allusion to "restrictions" with surgeon whom I've ended up with vs. "no restrictions" at another facility where I was unable to schedule due to repeated cancellations on part of surgical practice and no help from them in getting hooked up with another doctor. It makes no sense to me that restrictions both would and would not be necessary; you would think that something like this, if important, would be evidence-based and therefore drawn from a collective body of data, not varying markedly from one facility or surgeon to the next.

It's my understanding, as well, that an anterior approach doesn't eliminate the risk of dislocation.
 
There does not seem to be a "generalized" protocol on restricted or allowed movements. The recommendations even differ within the same approach depending on the OS or hospital or PT. Some stay very conservative and emphasize use of walking aids and restrict movements for months post-OP, others are like "do what you can". So in my opinion and few weeks experience with my THR it is best to stay sensible within some restrictions but listen to your body and not to some guy with others.

Actually pain is a very good meter for what's the limit of what you can do or shouldn't. Exercise for example. In the first few weeks post-OP exercise is not really necessary (so I was told by OS and PT). That's the time for healing. Training comes afterwards. So actually painkillers are also an ambivalent choice after the initial pain of surgery has been coped with. They help you through the day, but make moving more "dangerous" because the body's alarm for unsensible behaviour is turned off.

I had an anterior approach and was kept on the restriction "do all movements you can do by yourself, if the muscles allow it, but do not force the body or leg into positions while going over or ignoring pain". And pain for me includes everything exceeding a level 3 of 10. That kept my leg more or less not rotating and not bending over 90° for three weeks. Then the tissue around the incision (swelling) started softening, I was off painkillers and started with a bit rotating or bending over to where it started to hurt a bit - and stopped there. Not as an exercise - just to get a feeling of what I can or cannot do yet or just by moving around in daily activities like putting on socks or cleaning the cats litterbox or getting in and out of the car.

The PT in my clininc told me she only had 2 dislocations while mobilizing hundreds of THR patients. One was bad luck during transport, the second due to very unsensible behaviour at home shortly after OP.
 
@RSC I had posterior for my left hip and lateral for my right. I was no 90 degree restrictions for 6 weeks post LTHR and had no restrictions post RTHR. The only life time restrictions I have are no bungee jumping or parachuting.

For the first few weeks post op the hip just does not want to move past any restricted area. As mopster says, listen to your body and easy does it. When you are ready your hip will let you cross your legs or rotate internally.

Many surgeons are very conservative. Bottom line, I can't see anyone post THR having lifetime restrictions on normal daily activities. And no, anterior approach does not reduce the risk of dislocation just post op.
 
My surgeon does anterior app, mainly because it's a quicker recovery initially and with less pain. He says nowadays the risk of dislocation is very low whatever the approach. I was also concerned about the leg-crossing and 90 degree restrictions so was happy to find a surgeon who has been doing anterior for 10 years. My surgery is in 3 hours time so by this afternoon I should be walking!


Sent from my iPhone using BoneSmart Forum
 
mainly because it's a quicker recovery initially and with less pain.
Don't want to "rain on your parade" but I am afraid this is all marketing hype. Anterior approach does not necessarily result in a quicker recover with less pain. The recovery time and pain levels vary with every patient. Most of it is down the the surgeon's expertise and how the patient reacts to major surgery.
 
Anterior approach does not necessarily result in a quicker recover with less pain.

I agree (having at least experience with one anterior approach). I think I am recovering well and quickly, but not "super speedy" and after surgery I was mostly flat on my back for at least three weeks. "My" anterior "AMIS" method is sometimes sold as "hop off the table after surgery", which is complete rubbish.

The risk of dislocation is nevertheless there, but it's a risk, not a certain danger. It is caused by the necessary luxation of the leg and resulting damage to muscle tone. If your muscles take it well, the muscle tone returns a bit faster and dislocation risk diminishes. If your muscles take it badly, or the procedure is performed poorly - recovery takes longer. So it's different with each person's muscular disposition combined with the skill of the surgeon.

I'm glad my OS actually didn't "sell" the surgery, but put it in perspective for me and, knowing my case and having the experience, he predicted my recovery and explained the risks and restrictions during that time fairly well. Of course he pointed out, that there are some people who recuperate really, really fast, but that's an exception and not my motivation. I am glad to be in a range of smoothly running and thoroughly average recoveries.
 
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Thanks to everyone for all the replies so far. This seems to be a very helpful and supportive place.

I didn't state everything that I should have in my original post. My concerns are not really with restrictions or recovery for the first few months. A few extra weeks, what's the difference - it's going to be winter anyway. As long as I can be hiking and backpacking by summer. My surgeon told me that the restrictions on crossing my legs or internal rotation would be for the rest of my life.

I'm not in the Bay Area, the Central Valley, or anyplace where there is a great selection of local surgeons, but if getting the anterior approach means freedom from restrictions for the rest of my life, I suppose this is worth traveling out of the area and looking into. But maybe there's no big difference and the surgeon is just being extra cautious.
 
but if getting the anterior approach means freedom from restrictions for the rest of my life,
But that's exactly what we are saying. The approach does not dictate any restrictions. Your surgeon dictates them. I had lateral for my RTHR and have no lifetime restrictions.
the surgeon is just being extra cautious.
Yes, this is exactly the case. Some surgeons give life long restrictions. But these days more and more surgeons don't. In the end it is really up to you.

If you trust your surgeon - go for it. In the end the decision to never cross your legs or internally rotate is yours. But I can tell you I have had both hips replaced and don't ever have a problem doing either of these activities.
 
@Jaycey, thanks for clearing that up. It probably won't be too much of a problem following the restrictions most of the time, since haven't been able to move that way for some time anyway and I'm used to it. I'm just having some pre-op anxiety and concerns about making the correct decision, since I don't get a do-over.
 
Of course you are nervous. But this says it all:
My surgeon has a very good reputation and has done over 3000 knees and hips. He's conveniently located close to home and I think he's a good choice.
If you trust your surgeon and he has the experience you are doing the right thing.

It's a tough decision. No one like major surgery. But I can confirm the pre-op is the hardest part. Once it's all done and dusted you will wonder why you waited.
 
Lifetime restrictions on leg-crossing?! First time I've heard that. If that was really necessary, I wouldn't have the surgery at all. That is draconian. I think that surgeon must fall into the 0.1% who would say such a thing is necessary. The idea of the surgery is to regain some mobility, not to sacrifice a large chunk of it. (I consider leg-crossing a necessary part of my mobility.)
 
@FraidyCat, I think that I'm allowed to cross my legs as long as my knees are wide apart. I know that my primary care nurse practitioner said that. I think that the surgeon said that too, but I'll have to check with him. Right now I have almost zero mobility in the hip and almost anything would be an improvement. That's my main motivation for the surgery.
 
My surgeon told me that the restrictions on crossing my legs or internal rotation would be for the rest of my life. But maybe there's no big difference and the surgeon is just being extra cautious.
Exactly so! Mostly surgeons say this to cover themselves just in case you have a dislocation and then he can say "I told you not to do that"! His 'get out of jail free' card and protection against litigation. As it happens, the incidence of dislocation is very small, whatever the approach.

You might find this chart of interest
dislocation risk small.jpg
 
I think that I'm allowed to cross my legs as long as my knees are wide apart.
Eh? How do you accomplish that? I think all of these cautionary restrictions are so much hooey! I bet you anything that by the time you are 12-18 months out, you'll have forgotten all about it and do whatever you want to!
 
Eh? How do you accomplish that?

@Josephine, by that I mean if sitting in a chair, the ankle is resting on the knee, rather than thigh over thigh. Or if sitting on the floor, padmasana/lotus would be OK. Not that I've ever been able to get there, but my primary care person said that this would actually be a good thing.
 
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I went to the county health fair today, and as luck would have it the Stryker rep was there in the bone density screening booth.

I asked about the direct superior approach, which sounds good to me and is an approach featured on the Stryker website. I've been considering this approach the last couple of days, although it would require me to travel. He didn't think it had been in use long enough to get a lot of data on long-term dislocation results and didn't seem to think it was a big deal, at least for someone like me who wasn't concerned about short-term recovery. He pretty much echoed the advice I've been given here and told my that my prospective surgeon seemed to be good.

My bone density T-score was 1.1 and hemoglobin 16.7, so I should be good and ready for the surgery. (I've been taking iron for the last month.)
 
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, the ankle is resting on the knee, rather than thigh over thigh.
I would say this position is not a good one for a hip replacement whatever the approach. You'd be grossly externally rotating and abducting the leg which is so far from a good idea it makes me shudder!

leg on knee.jpg


Or if sitting on the floor, padmasana/lotus would be OK.
You mean like this? I wouldn't recommend it until at least 6 months out

BarbaraR THR at 6 months.jpg
 
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