Mr Samsani was trained in minimally invasive joint replacement surgery at Austin Health Centre, Melbourne Australia under supervision of world renowned Hip and Knee Surgeon Dr Neil Bergman. Mr Samsani has, since his appointment as substantive Consultant Orthopaedic Surgeon at Medway NHS Foundation Trust in 2006, performed hundreds of minimally invasive hip replacement operations. He performs this operation through “NICE” (National Institute of Clinical Excellence England) recommended single scar (Mini-Posterior approach) of around 7 to 12 cm, which is provided only by a limited number of experienced surgeons in the England. Recognising his contribution and expertise in the field of Enhanced Recovery and Minimally Invasive Hip Surgery, Medway NHS Foundation Hospital has awarded him Clinical Excellence awards.
The hip is one of the largest joints in the body. It is a ball and socket type of joint. The ball is formed by head of femur, the upper end of the femur (thigh bone) and the socket is formed by the acetabulum, a part of hip bone. The surface of the joint is covered with a special tissue called articular cartilage which enables the hip to move smoothly. The hip joint is lined by a thin layer of tissue called synovial membrane that makes the lubricating fluid for the hip joint to move without friction. The ball and socket of the hip joint is also bound together by strong ligaments and joint capsule.
Total hip replacement is a very successful operation for treatment of arthritis and other painful hip conditions. Hip replacement is traditionally performed through larger skin cuts (incisions) measuring about 20 to 25 centimetres. This may cause significant pain, increased blood loss and require longer recovery time after the operation. With the improvements in surgical techniques and surgical instrumentation, it is now possible to perform the total hip replacement surgery through a smaller skin cut (incision).
Minimally invasive total hip replacement involves less surgical dissection and less muscle cutting. Special surgical techniques and instrumentation allow the surgeon to safely perform the operation through a small incision.
Minimally invasive hip replacement is part of “enhanced recovery” to facilitate rapid recovery after total hip replacement.
The main advantages of minimally invasive total hip replacement are:
- Less pain after surgery
- Small and more cosmetic scar
- Less muscle damage
- Less blood loss
- Shorter hospital stay
- Rapid functional recovery
Minimally Invasive Hip Replacement is a technically demanding procedure and requires proper training and considerable experience to perform this surgery safely.
Who can have a Minimally Invasive Total Hip Replacement?
Patients suitable for minimally invasive hip replacement are usually thinner, healthier and more motivated to have rapid recovery after operation.
Common indications for minimally invasive hip replacement are:
- Avascular necrosis
- Rheumatoid arthritis and other inflammatory arthropathies
- Uncomplicated post-traumatic arthritis
- Some cases of hip fractures.
Orthopaedic examination: You will be evaluated by the Orthopaedic Surgeon to confirm the diagnosis and assess the severity of disability. Orthopaedic Surgeon will ask you questions about your hip problem, disability and your medical health. He will obtain x-rays of your hips to assess the severity of arthritis. Sometimes special scans such as MRI (magnetic resonance imaging) are performed to assess soft tissues around the hip joint.
Preoperative assessment and preparation for surgery: The main aim of the preoperative assessment procedure is to make sure that you are fit for hip replacement surgery and recover well after operation. As a part of this you may have a general medical examination and undergo few tests
Medical examination: You may be reviewed by a medical specialist to make sure your general health is in satisfactory condition to undergo hip replacement and complete recovery after the operation. You may also be seen by a specialist medical doctor such as a
Cardiologist or Nephrologist if you have chronic medical problems such as angina, kidney problems.
Tests: Routine blood and urine tests and an ECG may be carried out. A chest x-ray may be needed.
Medication: Inform Mr Samsani or his team about all the medicines you are taking.Please carry a list of your medicines with you including the name, dosage, and how often you take it. Mr Samsani or his team will advise you which medicine you should stop or can continue taking before surgery.
Preparing your skin: Presence of an infection in the body at the time of operation markedly increases the risk of wound infection. Make sure that you do not have any infection either on the leg or anywhere else on your body before surgery. Contact Mr Samsani or his team if you notice any infection and get it treated before the operation.
Dental evaluation: If you suffer from any dental problems or diseases, you should get it treated before hip replacement operation. Dental procedures (dental extractions, periodontal work) release bacteria into the blood steam which increases the risk of wound infection. Routine cleaning of teeth should be delayed for few weeks after hip replacement.
Urinary problems: People with history of urinary infections may require urological assessment to rule out any ongoing urinary infection before surgery. Severe prostate conditions may have to be treated before hip replacement surgery.
Weight loss: Being overweight may increase the risk of complications during surgery. It may also reduce the lifespan of the total hip replacement prosthesis. Therefore Mr Samsani or his team may advise you to lose some weight before the operation to reduce the risk of complications.
Blood donations: Some blood loss can occur during hip replacement surgery and you may need blood transfusion to after the operation. Therefore Mr Samsani or his team may ask you to donate your own blood before operation. This will be stored in the blood bank in case you need it after surgery.
Help from family and friends:After hip replacement surgery you will be walking with the help of crutches or a frame. However you will benefit from some help for several weeks with day to day activities such as cooking, bathing, shopping and laundry.
Home planning: Some home modifications are required to make your home return easier during your recovery from hip replacement surgery. Following are the list of home modifications that can make your home easier to navigate after surgery.
- Secure handrails along stairways.
- Safety bars or handrails in your shower or bath
- A stable high chair with two arms and a firm seat cushion that allows your knees to remain below the level of hips in sitting position
- A raised toilet seat
- Stable bench or chair for bathing
- A long handled sponge for bath
- Sock aid, long-handled shoe horn
- A reacher to pick up objects from the floor without excessive bending of your hips
- A firm pillow for your chairs, sofas, and car that enable you sit with your knees at a lower level than hips.
Patient is usually admitted on the same day or day before the operation.
Special anaesthetic techniques are used for this operation to allow safe and rapid recovery from anaesthesia.
Specially designed instruments may be required to perform the surgical procedure. Computer assisted surgery may be used to improve the precision of prosthesis positioning.
Usually a small single incision measuring 7 to 12 centimetres placed on outside of hip is used. Less amount of muscle and tendon dissection or detachment is performed when compared to the traditional hip replacement surgery. They are usually reattached to the bone at the end of the procedure to prevent the risk of hip dislocation.
The implants used in minimally invasive hip replacement surgery are the same as those used in the traditional hip replacement procedure.
A mixture of local anaesthetic drug and anti-inflammatory medications is injected in to the wound for post-operative pain relief.
Mr Samsani uses NICE (National institute of Clinical Excellence UK) recommended single incision minimally invasive posterior approach to perform this procedure.
After the operation you will be transferred to recovery which is very close to the operation theatre. You will be closely monitored in recovery whilst you are recovering from anaesthesia. Once you are recovered from anaesthesia and the vital parameters are stable, you will then be moved to a ward where the rest of the post-operative recovery takes place. Sometimes patients who have complex medical problems, may be transferred to a high dependence ward (HDU) or intensive care unit (ICU) for intense monitoring before transferring to the ward. Patients will have the following in the recovery room and early.
- Intra-venous drip attached to a vein of the arm to give fluids, medications and sometimes blood.
- A blood pressure cuff around the arm to measure blood pressure regularly.
- A pulse-oximetre attached to a toe or finger to measure pulse rate and oxygen levels in the blood.
- A sterile dressing over the operated hip to cover the wound.
- A special pillow will be placed between the legs to restrict the movement of operated leg until they are mobile.
- IV antibiotics are administered through a cannula to minimise the risk of wound infection
- Injections or oral medicine are given to reduce the risk of blood clot formation.
You are allowed to drink and eat as soon as you feel better. You will be encouraged to drink plenty of fluids to prevent dehydration and also to flush out the various medications from your body. Nausea and vomiting are common after the operation and usually settles down with time but sometimes medicines are given to control these symptoms.
Adequate pain relief is essential for early mobilisation and physiotherapy after minimally invasive total hip replacement. Pain killers are given either through a vein or by mouth to make you as comfortable as possible. Pain killers should be taken at regular intervals to prevent any breakthrough pain.
After the operation you will have few blood tests to make sure that your
haemoglobin and electrolytes in blood are within satisfactory limits. You
will also undergo an x-ray of the operated hip to make sure position of
the prosthesis is satisfactory. If your haemoglobin is found to be low and
having symptoms related to low haemoglobin, you may then require a blood transfusion.
During your hospital stay a Physiotherapist will visit you regularly to help you with early mobilisation and commence your exercises. Standing and walking usually begins on the same day of operation. The Physiotherapist will help you walk with a walking frame initially. Once you are walking confidently with the frame, you will then progress to crutches and later on to a walking stick. The Physiotherapist will also teach you the exercises to help strengthen the muscles around the hip and the leg.
Rehabilitation techniques used after minimally invasive hip replacement surgery tends to be more aggressive to facilitate rapid recovery after surgery.
Due to the effects of anaesthesia, pain medication and lying in the bed, patients tend have shallow breathing in the early postoperative periods. This shallow breathing can lead to lung
collapse and chest infection. Breathing exercises (deep and frequent breaths and frequent coughing) will help you reduce the risk of lung collapse and lung infection. A special breathing apparatus (spirometer) may be used to encourage deep breathing.
It is important mobilise as soon as possible after surgery to minimise the risk of complications such as blood clots, chest infection etc. Depending on complexity of surgery and surgeons preference you will either fully or partially weight bear after the operation. You will also be shown positions of the leg you should avoid to prevent the risk of dislocation.
The Occupational therapist will also visit you to assess your home environment and furniture is suitable
When performed by an experienced surgeon in minimally invasive hip replacement the possible risks of minimally invasive hip replacement surgery are the same as that of any traditional total hip replacement.
There is always a small risk associated with administration of general or regional (spinal or epidural) anaesthesia. The risk is increased if the patient is older and has multiple medical conditions which may have affected the functions of vital organs such as heart, lung, liver and kidneys. A complete pre anaesthetic assessment will be carried out before surgery to optimise the medical condition and to minimise the risks associated with anaesthesia and surgery.
Total Hip Replacement Surgery Risks:
• Major bleeding:Very rare and blood transfusion(s) may be required when this happens.
• Infection:Incidence of infection after total hip replacement is less than 1%. The risk of infection is reduced by administration of prophylactic antibiotics in the perioperative period. Superficial infections are usually treated with antibiotics and the deep infections may require washout of wound in addition to administration of antibiotics. Rarely the deep infection may not respond to the antibiotics alone and may require implant removal and reinsertion of implant after some time as a two stage procedure.
• Deep Venous Thrombosis and Pulmonary Embolism:Blood clots can occur after any type of hip surgery including hip replacement. This risk is reduced by administration blood thinning Injections or tablets after surgery. Other measures such as TED stockings and calf compression devises are also used to reduce the risk of blood clots. Early mobilisation after surgery also reduces this risk. Rarely, if not detected and treated properly, a portion of the blood clot can break off and migrate to lungs causing pulmonary embolism ( about 0.4%), a serious and life threatening condition.
• Leg length inequality: It is not uncommon to see a leg length discrepancy up to 1cm following total hip replacement. In most of the cases it is easily tolerated. Other cases may require shoe rise on the shorter side to correct leg length inequality. One of the reasons for discrepancy may be the result of adjusting an adequate tension in the artificial hip joint to prevent dislocation. Initially the leg may sometimes appear to be long but this is often due to muscle contractures which over time will loosen up and leg lengths will even out.
• Hip Dislocation:Artificial joints may dislocate occasionally. The risk of dislocation is generally around 1%. Provided the components are placed in correct position and the appropriate hip precautions are followed in the postoperative period, it is unlikely that the hip joint will dislocate.
• Fracture of Femur and Pelvis bone:fracture of thigh bone or hip bone can occur during the surgery but is very rare. The fractures that occur during surgery are usually treated immediately with wiring or plating. It is very rare to see these fractures after the surgery unless you have been involved in a bad accident.
• Loosening of prosthesis: The majority of the artificial hips may not last forever and they can wear out or become loose during an individual’s life time. Loosening will happen when the prosthesis is not fixed to bone due to lack of bone in-growth in to the prosthesis or if the bearing surface wear out to produce areas of bone loss around the prosthesis leading to loosening. If the prosthesis becomes loose it needs to be revised. Alternatively if only the bearing surface wears out and the prosthesis is stable, then usually only bearing surface requires revision which is a smaller operation.
• Damage to nerves and vessels: Damage to major nerves (sciatic and femoral nerves) around the hip joint is very rare. Sometimes these nerves get stretched during the operation and may result in temporary paralysis of the affected nerves. Permanent damage to these nerves is very rare. Damage to major vessels is again very rare.
• Haematoma:occasionally persistent bleeding following surgery in the tissues around hip joint can result in formation of haematoma. This may sometimes require surgical drainage.
• Scarring:Scar tends to be thicker in some patients than others and usually does not cause any major problem.
• Leg swelling:Slight swelling of operated leg and foot is common after the hip operation. It resolves usually with elevation, exercises and time.
• New bone formation in muscles around Hip Joint:Sometimes new bone is formed in the muscles around hip joint after hip replacement (heterotopic ossification). It does not cause any problems in majority of the cases and does not need any treatment.
• Trochanteric bursitis:After hip replacement you may experience some discomfort at the side of the hip joint due to inflammation. This usually settles down with pain killers, physiotherapy and rarely steroid injections.
Successful outcome following minimally invasive hip replacement depends mainly on how well you follow various instructions given by the surgeon in the first 4 to 6 weeks after hip replacement.
Wound care: After completion of operation your wound may be closed with sutures or stitches or staples (metal clips). Stitches and sutures are usually removed at 12 to 14 days. Make sure that the wound is kept dry until it is completely healed. Contact Mr Samsani or his team immediately if you see any signs of infection such as redness, swelling, wound discharge with or without fever.
Food and Eating: No special diet is required after hip replacement surgery. Patients will be encouraged to have a balanced diet and drink plenty of non-alcoholic fluids. You may sometimes be advised to take iron supplements for a limited period.
Exercises and activities at home: It is very important for you to continue with the physiotherapy and other exercises at home to achieve successful outcome after hip replacement operation. You will be able to perform most of light day to day activities in 4 to 6 weeks after surgery. Some amount of discomfort after activity is common up to 4 to 6 weeks after surgery. The physiotherapy programme is aimed at:
- Improving the ability to walk gradually, initially inside your home and later outside.
- Resuming activities such as sitting and standing as well as stair climbing.
- Strengthening leg exercises and improving hip movements.
- Avoiding certain positions of leg to avoid dislocation of artificial hip joint.
Dislocation is a recognised complication of hip replacement and it tends to happen commonly in the first 6 to 12 weeks after surgery. Special precautions should be taken, as mentioned below, to reduce the risk dislocation.
- Do not bend the operated hip more than 90 degrees (do not bring your knee up higher than your hip). Do not reach forward when sitting, to reach any thing! Use aides of daily living to accomplish these tasks
- Avoid sitting on low chairs, stools, toilets or car seats where your knees are at a higher level than hips
- Avoid crossing your legs or putting your operated leg across the midline of your body
- Avoid lying or sleeping on the operated leg for 3 months. You may be able to sleep or lie on the non-operated side with pillow between legs
- Do not kneel on the knee on the un-operated leg.
- Avoid driving
- Avoid twisting or crossing of legs
- Avoid lifting heavy weights
- Avoid heavy house work
- Avoid reaching towards your feet to dry them or put on foot wear such as socks. Use aides of daily living to accomplish these tasks
Prevention of infection: Infection after minimally invasive total hip replacement is rare. However, presence of an active focus of infection in the body can result in spread of bacteria through the blood steam. These bacteria then can lodge at the hip replacement site and result in infection. Common causes of such infection are urinary tract infections and skin and nail bed infections and must be treated with antibiotics immediately. You must also take prophylactic antibiotics too before any dental procedure to prevent spread of bacteria through blood stream.
You must contact Mr Samsani or his team immediately if you develop any of the following signs of possible infection in the hip replacement:
• High fever
• Redness, swelling and tenderness of hip wound
• Discharge from hip wound
• Severe pain in the operated hip at rest and night
Prevention of Blood clot: Blood clots can occur in the legs after hip replacement surgery. Early mobilisation and continuation of exercises after operation combined with administration of blood thinning medicines reduces the risk of blood clots in legs.
You must contact Dr Samsani or his team immediately if you develop any of the following signs of possible blood clots in your legs:
• Increasing pain in your calf and thigh
• Increasing swelling in your thigh, calf, foot and ankle.
• Tenderness in thigh and calf
Very rarely the blood clot can dislodge from legs and migrate to lungs resulting pulmonary embolism. The following are warning signs of pulmonary embolism:
• Sudden onset of chest pain
• Sudden onset of breathlessness
• Cough with chest pain
You must go to a nearest Emergency Department or see a qualified doctor immediately if you have any signs of pulmonary embolism to get treatment for this life-threatening condition.
Preventing falls: For a few weeks after the operation, due to pain, stiffness and lack of strength in leg muscles, your gait may be slightly unsteady and falls may occur. Stairs and uneven surfaces are particularly hazardous. Falls immediately after operation can cause serious damage to your new hip and may result in need for further surgery. Therefore, you should use a walking stick, crutches, frame or have someone to help you until your balance, flexibility and strength is improved.
• Continue with regular light exercise programme to maintain the strength in the muscles of leg and mobility in the artificial hip joint
• Avoid falls
• Take prophylactic antibiotics before any dental procedures
• Regular follow up examination as advised by Mr Samsani or his team
• Try and avoid putting excessive weight to reduce stress on the artificial joint
With improved surgical techniques and advances in prosthesis manufacturing technology, majority of the artificial hips now function very well for a long period of time. Life of an artificial hip is also affected by the amount of activity undertaken and the weight of the patient. Around 95% of the hip replacements last for 10 years and about 85% of them last for 20 years.
Safe return to sports and other life style activities after total hip replacement is dependent on patient and activity-specific risk factors. Care must be taken to avoid excessive wear and dislocation of the artificial hip from these activities. Golf (with spike-less shoes and a cart), cycling (level surfaces), tennis-doubles, bowls, walking, swimming are allowed 3 to 6 months after operation. Avoid hip impact activities-badminton, tennis-singles, squash, jumping, jogging and contact sports-football, rugby, baseball, cricket.
• Driving: Generally driving can be resumed 6 to 8 weeks after total hip replacement provided you are not on narcotic pain killers. The Physiotherapist will explain to you how to get in and out of the car safely. If in doubt please consult your doctor.
• Sex: Some form of sexual activity can be resumed 6 to 8 weeks after surgery. Ask your doctor if need more information.
• Sleeping positions: Sleep on your back with your legs slightly separated (and a pillow between legs) or on your un-operated side with a pillow between leg for 6 weeks after operation. Avoid lying or sleeping on the operated leg for 6 weeks.
• Return to work: Returning to work depends on the type of activities you do at work and can take up to 3 to 6 months after total hip replacement
• Contact your surgeon if you notice any redness, excessive swelling or leakage of fluid or have an increased pain in the operated hip.
• You should have a regular check up with an x-ray as advised by your doctor.
• If you have had any bowel, bladder or dental surgery, antibiotic cover should be given prior to the surgery to prevent seeding of infection at the artificial hip.
• Artificial joints may activate security alarms (metal detectors) at the airports.
After total hip replacement it is important to review patients at regular intervals to make sure the artificial joints are functioning well and also to detect any problems early. You will normally be reviewed at the following dates after total hip replacement:
2 weeks: clinical review
6 to 8 weeks after surgery: clinical review
6 months after surgery: clinical review and questionnaire
12 months after surgery: clinical review, x-ray and questionnaire Then every 2 years……