What is Bikini Hip Replacement?

It is a true minimally invasive muscle sparing (inter-muscular and inter-nervous ) approach which preserves the muscles and tendons without cutting them. The scar is hidden in the groin crease as opposed to a standard longitudinal incision on the front of the thigh.


Dr. Ikram Nizam’s Enhanced Recovery Bikini Hip Replacement Program.

Our Staff at Ozorthopaedics and the relevant hospital you are meant to have surgery will make every effort to ensure you have a safe and smooth journey in having a joint replacement.

The reason for your surgery would have already been explained by Dr. Nizam in simple language.

The aim of this surgery is to enable you to have a pain free quality of life with improved function and activity.

It is important to Understand the following:
  • Why you are having surgery.
  • Preparing yourself for your Surgery.
  • What happens in hospital – before, during and after surgery.
  • Nizam’s expectations of you and what you should expect after surgery.
  • Where and when you would be discharged

Total hip is a safe and reliable procedure in modern times enabling patients to mobilize well than when they did when suffering from arthritis


Diagnosis of Hip Arthritis

Involves a complete history followed by physical examination. A painful hip that has constant pain, restricting mobility (walking) with sleep disturbance, diminished quality of life not much relief from pain medications, may be a strong indication for surgery after a trial of non-operative measures like :
activity modifications, weight loss, use of walking aids, physiotherapy in some cases.


Physical Examination

: We would look at walking, assessment of pain and stiffness, any leg length discrepancies, or fixed deformities (like flexed hip due to arthritis). We need to address these during Surgery.


Other Investigations:

  • X-ray; needs to be taken to determine the extent of the degeneration in the joint – ***Please Bring PRINTED Copy On day of surgery****
  • Blood test - To check blood count and any other electrolyte imbalance.
  • ECG (Heart Tracing).

Bone Mineral Density to determine bone density (in cases of hip resurfacing )

Hip surgery is recommended only after careful diagnosis of a hip problem, including the degree of pain and lack of mobility.

Hip Prostheses.

Each prosthesis is made up of two parts.

  1. Femoral Component Or the stem.
  2. The Cup: or acetabular component.

Both these are usually made of metallic or titanium alloys but it is the Bearing Surface that Matters.

In Almost All instances it is usually Ceramic / Oxinium on Polyethelene (Extra High Molecular weight). We DO NOT use metal on metal bearings.

Only in cases of Hip resurfacings do we use metal on metal.


Anaesthesia :Usually discussed by the anaesthetist.
Majority of our patients have spinal anaesthesia and sedation to enable quicker recovery with less nausea.
Anaesthesia these days are usually very safe.

However, it needs to be kept in mind that, while the risks are very low, they are not zero.

The procedure is performed in hospital as an inpatient. This means that the hospital stay is usually overnight, but maybe longer, depending on individual circumstances. Some patients living alone may go to Rehab before going home.
You Will Walk 3-6 hours after surgery either with a Physiotherapist or Nurse.

The incision is made over the groin (Outer Groin Crease).

Tendons and Muscles are preserved, so patients can walk a few hours

after surgery! we want you to walk on your hip!, unless otherwise advised – as often as comfortable.
At the site of the operation, the tissues may not be completely flat, immediately after surgery, because of some swelling. However usually settles down after a few weeks.

It is essential that patients see the anaesthetist, in preparation for the operation (Preoperative Assessment).
Make sure your spouse, partner, or significant other person in your life, comes to the consultation as well.

Preparation for Surgery

You will be given education and guidance to help you prepare.

Our Website www.ozorthopaedics.com.aualso has plenty of information on this.

It is important to feel like you have enough information and education on the operation and after care before you have surgery.

Do not hesitate to ask any questions at any point in time before or after surgery.

Blood transfusion may be required under certain rare circumstances although this is not common practice.

Hospital Admission Forms will be emailed or posted. Please Fill and send to the appropriate hospital.
Blood Tests have to be done atleast 2 weeks before surgery

On the day of surgery you will be expected to arrive at the hospital 2 hours prior to your scheduled surgery time.
The operation time is an estimate, it can be adjusted for various reasons, and the staff will inform you if the time is changed.
We recommend that you wear loose fitting slacks (or shorts in the warmer weather) to the hospital. It is much easier for you after surgery. Your family is welcome to visit and stay with you prior to surgery.
You will be checked in by Pre-Admission Staff at Hospital
They will do all the paperwork necessary and prepare you

You will also be given Pre-medication and a pain patch applied. We target pain even before you go to sleep so that after surgery you recover comfortably with much less discomfort

After surgery, you will wake up in the recovery room.
Thigh High TED stockings and intermittent Calf compressors will be applied there to reduce risk of Blood Clots.
ICE will be applied over the surgical site to reduce swelling/inflammation – this reduces pain.
You will then be taken to the ward within 45 mins – 2 hours after depending on how you perform.


POST OPERATIVE CARE

When you arrive in the room, you will have:
  1. Compression Dressing around the operation site to apply pressure there. This has to be removed 24 hrs after surgery.
  2. A pain catheter which will be removed before discharge. We inject local anaesthetic through this to maintain the pain relief – there will be upto 3 lots of infiltration after surgery through this.
  3. Ted Stockings (Thigh high white stockings) must be worn for 2 weeks after surgery.
  4. Calf Compressors can be disconnected before ambulation.
  5. Drip, this will provide hydration and blood if you need it.
  6. You Will Walk 3-6 hours after surgery either with a Physio or Nurse

REMEMBER – ***DO NOT SHOWER***FOR 2 WEEKS (KEEP Dressing DRY)


Enhanced Recovery (Rapid Recovery) Programme

To minimise the pain, we adopt several pathways.

  1. We establish an effective local anaesthetic block at the time of the operation, which actually starts even before the operation.
  2. We numb all the parts which have been operated on, and which may generate pain.
  3. The second pathway involves oral medications to control pain. Injections available, if required.
  4. A pain controlling skin patch will be applied, which also contains a slow release analgesic.

The incision is usually closed with dissolving sutures.

If patients develop increased redness, oozing from the cut, or fever, please call the office asap


Preventing Blood Clots

After surgery patients have an increased risk of blood clots. We make every effort to reduce this risk. We provide Thigh High TED stockings which you should wear upto 2 weeks after surgery. We also put on pneumatic calf compressors until you walk just after surgery enhancing your circulation. We also give you aspirin to thin your blood slightly and Most importantly, We get you walking few hours after surgery and This is the Single Most important factor reducing Blood clotsEarly Mobilization. Some patients may receive clexane (blood thinner) for a period of time.
We generally use Aspirin to think your blood.
- Drink plenty of Water / fluids so you are well Hydrated after surgery.
- Keep moving your feet and ankle (up and down) and exercises that keep your circulation going every hour (daytime)
- Keep mobile and walk as much as you feel comfortable – avoid laying down for too long or laying still.
- Always have the TED stockings on at night for the 3-4 weeks after surgery.

Medication after discharge from hospital.  Our Physicians/Anaesthetists will guide you with this.

EXPECTATIONS

Each individual has his/her own set of expectations. Each individual is different. Each patient is treated as an individual with general health, age and attitude considered.

  • Remember You ARE NOT SICK!!!. You have a problem with your hip that needs to be fixed, so it is important to consider yourself as not sick. Therefore getting back on your feet after surgery is the most important goal: Motion is Lotion”.
  • Remember Hospitals are BAD places and we like you to go home soon to recover in the comfort of your own home reducing risks of infections and blood clots.
  • Medications for Pain: Make sure you take the regular medications before you get the pain. You will need to take regular panadol and non steroidal (the anaesthetist will advice if there are issues). You will have a Pain Patch (on Skin) which you can change after a week (Anaesthetist will advice). Other stronger medications will also be given like Tramadol, Endone or Targin (Please check with anaesthetist).

Before you go home Make sure you know how much pain killers to take and how frequently.


What do we expect of you?

Doctors and patients must work together to ensure the best possible outcome. We have an experienced team, and offer the following guidelines for our patients:

  1. We expect that you will Read The Bikini Hip Replacement BOOKLET, research and investigate your condition, using resources such as friends, the Internet, the library, and others.
  2. We expect that you will follow up on instructions asking you to obtain medical, dental, and other specialty medical consultations before surgery, and that you will take the time to understand the instructions given to you and contained in this booklet.
  3. We expect that you will educate and familiarize yourself with the planned procedure, its attendant risks and benefits, and the full complement of potential outcomes, and that you will make your decision accordingly.
  4. We expect you to visit our Web site ozorthopaedics.com.auif accessible and carefully review the information contained at that location, and to ask us to clarify or elaborate on anything that is not entirely clear to you. AlternativelyPlease read this booklet thoroughly.
  5. We expect you to take care of your health, by practicing sound personal hygiene, avoiding smoking and excess alcohol use, and maintaining a reasonable body weight and activity level after surgery.
  6. We expect you to investigate your surgeon and his team, and to establish a relationship with us only if you are entirely convinced that we are compatible and that our relationship will benefit your health.
  7. We expect you to respect the constraints that we must work within health care in terms of scheduling surgery, planning discharges, and accommodating changes, and unexpected deviations in planning.
  8. We expect you to treat our team with professional courtesy and respect, and to expect compassion, attention, care, and professionalism from us in turn.
  9. We expect you to understand that the decision to proceed with joint replacement surgery is a major and irreversible undertaking, and that there is nothing casual about this surgery no matter what the media may have led you to believe, and that life with an artificial joint in place is not the same as life with your own joint in your body.

We expect that you understand the value of a relationship based on mutual respect, regard, trust, integrity, and the value of such a relationship in optimizing the service that we can provide you, and to realize and accept that we are here to do our best for you.

  1. Swelling: from your thigh down into your foot is common. generally occurs in the first few days after the operation. The swelling gradually decreases with time, but may take some months to restore the shape of a limb to normal. Muscle movement such as in walking, and exercising will help to diminish the swelling more quickly. This is encouraged.
  1. Bruising: in some patients marked bruising can be found. This can extend from your thigh down into your foot. It will gradually resolved, and while it may look dramatic, it does not alter the progress of the healing
  1. Muscle soreness, your muscles can feel stiff and soreto touch. Many manipulations of the lower limb are undertaken during the
operation

Similarly, backache can result from the impaction of the components into place.

. Modified activity level
  • For the first 2 weeks after surgery, your activity level is usually limited, however, you will be able to walk independently, use the bathroom and perform normal activities of daily living. Remember, this operation is done from the front. As a result, hip bending will not be limited.
  • NOTE:Be wary of advice from other sources, in relation to activities which you will undertake. Other well-meaning people may advise you in relation to a toilet seat , bending of the hip, pillow in bed, etc. While this advice may be relevant to other types of operation, it is not in the case of this operation.If in doubt, please ask us!
  • After 1-2 weeks you will be able to engage in moderate activities, such as driving a car and climbing stairs.
  • Within 4-6 weeks you will have resumed most of your normal activities. Complete surgical healing takes 6 – 12 weeks.
  • During this time some swelling and discomfort is normal, and should be manageable with the prescribed medication.

It Is important to have a positive attitude.

Replacing your hip can relieve your pain and stiffness and return you to most of your activities you enjoy.
With the anterior approach total hip replacement you can look forward to getting back into the swing of things and enjoying life as it was before you were in pain.

Frequently Asked Questions After Surgery:

Pain and Swelling

The pain usually decreases rapidly during the first few weeks, but  pain usually continues to improve for 12 months or even longer. Walking helps.  Exercise, stockings and elevation also help.

Exercising:

Mild to moderate exercise is helpful, over-exercise is painful and can be harmful.

Driving?

Some people regain their co-ordination quicker than others. Following hip surgery, avoid driving for 1week and longer if still taking pain medications. Some people have driven after a few days after stopping pain medications – that can make you drowsy.

Stair Climbing?

The Physiotherapists usually show you how to do stairs the day of the surgery or the day after.

Shoes:

Avoid High Heels for 3-4 months.

Medications after surgery?

Blood thinning medications (Aspirin) should be taken for 6 weeks.  All pain medications may be taken as directed for pain.
If you have any questions about your medications, please ask.

Sleeping Problems?

Sleeping trouble is the most common question.
may be slightly uncomfortable for this time. Taking prescribed medication and ice can help.
Getting out of bed and moving around also helps.

Surgical Risks:

All Risks and Complications are discussed before surgery and this is documented at the time of consultation so the patient is well informed before surgery.

INTRODUCTION:

Total Hip Arthroplasty (THA) has become a preferred treatment option for end stage arthrosis helping patients to regain independence and achieve a good quality of life. The number of THAs performed are expected to increase over the coming year with many requiring a contralateral hip arthroplasty after the index procedure [1].

There is no clear clinical consensus in the literature on which is better, between one-stage bilateral versus staged bilateral THA procedures. Some studies indicate higher incidence of complications after one-stage bilateral THA [2]. Heterotopic ossification, blood loss, higher prevalence of deep vein thrombosis, and greater risk of pulmonary complications are amongst the main reported complications post one-stage bilateral THA [3,4]. These results have been reported to be much better with improved anaesthetic and surgical techniques and postoperative care. Some of the benefits of bilateral one stage THA include more efficient use of resources, reduced hospitalization and shorter rehabilitation [4]. Further, the improvements in various elements of walking are reportedly higher in patients with bilateral THA than in those with unilateral staged replacement.

There are various surgical approaches used for THA, the most common being the posterior approach. However, with modern advancements and innovations, studies show that anterior hip arthroplasty claims to have less damage to muscles and hence quicker recovery with less pain, early return to routine activities and early mobilisation with improved gait [4-6].

We present two patients and report their recovery after bilateral THA for end stage arthritis, in which one-stage bilateral Anterior Hip Arthroplasties were done.

CASE 1

In October 2016, A 54-year-old male presented with bilateral crippling hip pain in the groin on both sides radiating to the front of the thigh with reduced mobility for almost 3 years and progressive worsenin of symptome. He had developed a significant limp preventing him from walking and performing routine activities independently with disturbed sleep.

On examination, he had a bilateral stiff hip, antalgic gait with a BMI of 34.1. Both hips had very limited range of motion (Table 1). He had a poor Harris Hip Score of 34.2 for the left hip and 34.3 for the right hip. Anteroposterior X-ray of the pelvis with both hip joints showed bone on bone arthritis (Figure 1) in both the hip joints. He elected to undergo simultaneous bilateral soft tissue sparing bikini anterior hip replacements described previously by the senior surgeon [7]. The left hip was operated first followed by right with a surgical time of 135 minutes total.

Post-operatively, mechanical thromboprohpylaxis was used for 24 hours followed by oral aspirin 300mg with nexium for 6 weeks. He was mobilized within few hours after surgery as part of our enhanced recovery programme. He started walking on the same day with the aid of a walking frame and even managed a dozen steps unaided the same day. He was discharged on the 2nd post-operative day. He started on his exercise bike Day 5 post op and resumed driving on the sixth day onwards as he was very mobile with a single crutch mainly for safety and not on any narcotic analgesia. He felt very confident and comfortable and had no issues in driving.

On day 9 post-op, he was back at work doing light duties and clerical activities. He reported that he was mobile, had pain free hip movements and there was no mechanical dysfunction at all. At the 6 weeks mark he had a well healed surgical scar with no swelling and walked in without a limp. He was followed up regularly at 3 months and 1 year post-operatively. His last follow up was one-year post-surgery by which time he was having no issues in either hip joints and was able to do all his day to day activities, with a highly improved quality of life. His X-Rays (Figure 1) were showing well aligned Acetabular & Femoral Prosthesis insitu on both sides. His post-operative Harris Hip score was Excellent, for both hips being 100.

CASE 2

In October 2017, a 59-year-old female presented with severe pain in both her hips over the preceding 3 years. Most of her pain was localized to her groin, right being worse than the left. Over the preceding few months her pain increased to a level where she couldn’t perform her normal daily activities with disturbed sleep at night. Along with this pain, she started developing a noticeable limp over 12 months. She used two crutches to support herself with a walking distance of only 30-50m. Her quality of life was severely compromised and taking strong analgesics including opiods.

On examination, she walked with a bilateral stiff hip antalgic gait with a BMI of 24.1 Both her hips had very limited range of motion (Table 1). She had a poor Harris Hip Score of 19.5 for the left hip and 19.4 for the right hip. Her X-rays revealed, severe bone on bone osteoarthritic changes Bilaterally (Figure 2). She underwent one stage bilateral anterior hip replacement.

The same post-operative recovery protocol was followed as in the first case. She went to rehab on day 3 as she lived alone. At her 2-week post-operative visit, she was doing excellent and hardly experienced any pain. She had a well healed scar with hip flexion beyond 90o in both hips (Figure 3). She commenced driving within 2 weeks. On her 6-week post-operative visit, her Harris Hip Score was 100 for both hips.

REFERENCES:

  1. Alfaro-Adrian J, Bayona F, Rech JA, Murray DW: One- or two-stage bilateral total hip replacement. J Arthroplasty 1999, 14(4):439-445.
  2. Berend ME, Ritter MA, Harty LD, Keating EM, Meding JB, Thong AE. Simultaneous bilateral versus unilateral total hip arthroplasty an outcomes analysis. J Arthroplasty. 2005; 20(4):421-426.
  3. Parvizi J, Tarity TD, Sheikh E. Bilateral total hip arthroplasty: one-stage versus two-stage procedures. Clin Orthop Relat Res. 2006; 453:137–141.
  4. Bhan S, Pankaj A, Malhotra R: One- or two-stage bilateral total hip arthroplasty: a prospective, randomised, controlled study in an Asian population. J Bone Joint Surg (Br). 2006; 88(3):298-303.
  5. Taunton MJ, Mason JB, Odum SM, Springer BD (2014) Direct anterior total hip arthroplasty yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty 29: 169-172.
  6. Martin CT, Pugely AJ, Gao Y, Clark CR (2013) A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty 28: 849-854.
  7. Nizam I. The Bikini Hip Replacement - Surgical Technique Preserving Vessels and Deep Soft Tissues in Direct Anterior Approach Hip Replacement. J Orthop Res Physiother 2015;1:007.
  8. Power FR, Cawley DT, Curtin PD (2017) Simultaneous bilateral total hip arthroplasties in nonagenarians Ir J Med Sci.186(4):947-951.
  9. Rolfson O, Digas G, Herberts P, Karrholm J, Borgstrom F et al (2014) One-Stage Bilateral Total Hip Replacement is Cost-Saving. Orthop Muscul Syst 3: 175. doi: 10.4172/2161-0533.1000175.

Pre-operative AP X-Ray Pelvis with both Hip Joints (Case 1) showing grade IV OA both hip joints and One year Follow-up Post-Operative X-ray after bilateral Uncemented Bikini Hip Replacement showing well aligned Acetabular & Femoral Prosthesis insitu. (Case 1).

Pre-operative AP X-Ray Pelvis with both Hip Joints (Case 2) showing grade IV OA both hip joints and Post-Operative X-ray after bilateral Uncemented Bikini Hip Replacement showing well aligned Acetabular & Femoral Prosthesis insitu. (Case 2).

 

Post-operative hip flexions and Scars healing for Right and Left Hip joints at 2 weeks (Case 2)

 
 

Range of Movements preoperative and postoperative for both hip for both case one and case two

 

Particulars Patient 1 Patient 2
(Male, 54yrs) (Female, 59yrs)
Left Hip Right Hip Left Hip Right Hip
Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative
RANGE OF MOVEMENTS
Fixed Flexion Deformity 20° 10° 25° 20°
Flexion 80° 120° 90° 120° 90° 120° 90° 120°
Abduction 25° 30° 25° 30° 20° 30° 15° 30°
Adduction 10° 25° 10° 25° 10° 30° 30°
Internal Rotation <10° 30° 30° 30° 30°
External Rotation 25° 30° 20° 30° 10° 30° 10° 30°
HARRIS HIP SCORE 34.2 100 34.3 100 19.5 100 19.4 100