Minimally invasive hip replacement post surgical muscle weakness

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Same-Day Hip Replacement Surgery-Minimally invasive hip replacement

While many people are waiting for their hip replacement surgical date, many people are also exploring alternatives to prolonged pain medications and managing along until they get the surgery. Some people are trying to avoid surgery altogether and are exploring non-surgical options. One option many people keep in the “short list,” of their choices is minimally invasive hip replacement. The benefits that is most appealing is a short hospital stay and less complication.

Many people get a great benefit from this surgery. These are typically not the people that we see in our offices. We see the people who may have significantly less hip joint pain, but they have developed another problem. Lack of strength in their buttocks, thighs, and hip and groin area. This is a well-known side effect of hip replacement surgery, whether traditional or minimally invasive.

We also see many people exploring options to an already recommended hip replacement surgery. Before we begin this article and research findings, if you would like to contact our medical team, please use our contact form page. We can help assess your candidacy for our treatments and answer your questions.

How less complicated is a minimally invasive hip replacement? Research from surgeons suggest that the benefit of a smaller incision may be higher complication rates: The surgeons suggest: “proceed with caution”

There is a misconception that minimally invasive hip replacement is a much less dramatic surgery than a traditional hip replacement procedure. We want to let surgeons explain the difference to you. So we begin this article with the reported findings of UK surgeons published in the Annals of the Royal College of Surgeons of England.(1) This is the opinion of the surgeon/authors:

Higher complication rates

• “The introduction of minimally invasive techniques for hip replacement into clinical practice has been driven by the perceived benefits of smaller incisions, shorter in-patient stays and faster rehabilitation. This may be at the cost of higher complication rates.

Minimally invasive techniques implants may not survive as long as traditional implants

• It was of interest that, despite a desire to avoid complications and have an implant with long survival (minimally invasive techniques implants may not survive as long as traditional implants), a majority of patients still expressed an interest in minimally invasive arthroplasty.
• This is in keeping with the clinical experience that patients often express a desire to have the latest development in surgery, perceiving that new techniques are likely to be better. However, it appears that although patients can make appropriate judgments about the relative importance of short-term benefits and long-term complications, they are easily seduced by the allure of something new, perhaps particularly when it is portrayed in the media as desirable and a great advance. It is up to their surgeons to temper this enthusiasm, and proceed with caution.”

This is our opinion, this is a hip replacement surgery, we agree with the research above, “proceed with caution.”

That study was from 2007. Certainly the techniques have seen improvements, heven’t they? In May 2018, a review paper from the Department of Orthopaedics, University of Utah School of Medicine made these observations on the Direct anterior hip replacement a minimally invasive surgical technique. Simply, the surgeons are making the incisions from the front and you are lying on your back. Why is this minimally invasive? Because if the surgeon comes in from the front, they do not have to detach or cut through muscles typical of side incisions or coming in from the back, with you laying on your stomach during surgery. Cutting through muscles is a problem as we will see below.

Is there potential for nerve damage, fracture risk, revision risk?

So the direct anterior approach total hip arthroplasty approach is better? Here are those observations from the University of Utah team. They were published in the journal Annals of Joint. (2)

As the number of primary total hip arthroplasties (replacements) utilizing the direct anterior approach increases it is important to understand the complications and potential pitfalls of this approach. We review the literature for the learning curve, potential for nerve damage, fracture risk, revision risk, radiation exposure, potential for increased blood loss and wound complications or infection associated with the direct anterior approach. . . Conflicting evidence in the literature makes it difficult to draw conclusions about the anterior approach total hip arthroplasty and increased fracture risk, revision risk or blood loss. ”

“I have to work, I cannot take the time off to rehab a hip replacement, same-day hip replacement sounds right for me.”

The main reason that someone is in our clinic exploring non-surgical treatments for their degenerative hip condition is mostly the same reason they are looking at minimally invasive hip replacement: they cannot take the time off from work to rehab.

• While the idea of same-day hip replacement certainly has its appeal. It also has some misconceptions.
  
• Many people believe the same-day hip replacement is a walk into the hospital in the morning and they walk out at night with a new hip without further ado. Of course, this is not how the procedure works. There is preparation for the surgery and there is the rehabilitation from the hip surgery.
• For many, it simply means a smaller surgical incision and getting out of the hospital faster. Getting out of the hospital faster is, of course, a great benefit.

The realistic expectation of same-day hip replacement: Same day hip replacement is not right for everyone

Minimally invasive hip replacement – same risks as a standard hip replacement – increased risk in an iatrogenic (surgery causing) nerve palsy (nerve damage/paralysis) during the minimally invasive approach.

Minimally invasive hip replacement can provide benefits over traditional open hip replacement. When the surgery works, it can work very well. But that can be said for open hip replacement surgery as well. The problem is when it does not work that well. Let’s listen to the surgeons.

In the August 2018 edition of International Orthopaedics (3), university medical hospital surgeons in Germany and Italy combined research to publish a study that compared the clinical outcomes of patients who either had a total hip replacement performed via the minimally invasive technique or a standard-invasive total hip replacement.

• There were 4761 patients, included in the study, 4842 total hip replacements (81 patients had both sides done).
• The patients were followed up at about 22 months after the procedure.
  • Findings in favor of the minimally invasive group:
    • less total estimated blood loss
    • shorter surgical duration
    • and a shorter length of stay in the hospital.
  • Findings in favor of the standard-invasive group
    • less hip pain after surgery
    • better hip function, range of motion.
    • less leg length discrepancy, which may account for less pain.

Both surgeries still presented similar risks:

• femoral fractures
• hip dislocation, and
• the need for revision surgery.

The surgeons did note that there was an increased risk in an iatrogenic (surgery causing) nerve palsy (nerve damage/paralysis) during the minimally invasive approach.

Study conclusion: “Based on currently available evidence concerning the outcomes following total hip replacement and the analysis of our results, we stated no remarkable benefits of the minimally invasive compared to the standard-invasive surgery.”

“no remarkable benefits of the minimally invasive compared to the standard-invasive surgery.”

In the medical journal Clinical Orthopaedics and Related Research, (4) doctors at the Anderson Orthopaedic Research Institute & Inova Center for Joint Replacement at Mount Vernon Hospital, Virginia, and The Rothman Institute & Thomas Jefferson University Hospital, in Philadelphia provided these insights into the same-day hip replacement procedure:

• “Patients should understand that published studies that have examined same-day and early discharge protocols after total hip replacement have been done in highly selected patient groups operated on by senior surgeons in a nonrandomized fashion without control subjects.”
  • In other words: published studies are issued on only the patients that have the best chance of success. Same-day hip replacement is not right for everyone.

The supportive research findings:

• The purpose of this study was to evaluate and compare patients undergoing total hip replacement who are discharged on the same day as the surgery. Those called “outpatients” who were in the hospital less than 12 hours with those who are discharged after an overnight hospital stay (“inpatient”) with regard to the following outcomes:
  • (1) postoperative pain;
  • (2) perioperative complications and healthcare provider visits (readmission, emergency department or physician office); and
  • (3) relative work effort for the surgeon’s office staff.

Who is a good candidate for same-day hip replacement?

The researchers then identified who would be a good candidate for the procedure.

• Patients who were younger than 75 years of age at surgery,
• who could ambulate (walk) without a walker,
• who were not on chronic opioids, and
• whose body mass index was less than 40 kg/m2 (less than morbidly obese or grade III obesity)

What were the results of this study: The researchers then identified the success ratio of the same-day hip replacement procedure.

The researchers found 24% (27 of 112) of patients planning to have same-day release surgery were not able to be discharged the same day. Some had to stay overnight in the hospital.

Is a same-day hip replacement discharge, good or bad?

While many people have concerns about staying in the hospital longer than necessary, here is an interesting survey from doctors who perform same-day hip replacements published in The Journal of Arthroplasty.(5)

Survey results of patients offered same-day release joint replacement:

• Very few patients expected same–day discharge or a one night stay in the hospital.
• Only  55.3% of men and 31.7% of women reported that they were comfortable with outpatient same-day joint replacement
  • The same group believed that the best benefit of same-day release joint replacement was faster recovery and decreased the likelihood of infection.

Recovery and rehabilitation from Same Day Hip Replacement Surgery

• Very limited mobility for 4 to 5 days. You will need a caregiver or family member.
• If after the surgery you can walk on crutches or with the use of a walker, you will likely have in-home physical therapy. If you cannot walk with aids, then it will be strongly suggested that you go to a nursing home to recover.
• You must be careful and not fall! During recovery some patients may “overdo it,” and their activities make them a fall risk. A fall can damage the hip replacement hardware and require further surgery.
• No driving at least 3 to 6 weeks, maybe longer
• After 6 weeks, as long as there is full hip movement, your doctor may recommend that you can return to work if it is not a physically demanding job.
• Sexual activity can be resumed at this time as well, after 6 weeks, as long as there is full hip movement.

All the while there is also physical therapy, visiting nurses, and other home help people.

The side effects of a successful surgery – hip and leg weakness. The problem of post-surgical muscle weakness

We see many people in our offices who did have a successful hip replacement. Successful in that the surgery significantly reduced their hip pain. But the surgery was not as successful as these people hoped. In what way? Some people have an expectation that they will be able to walk out of hospital and all will be well. Muscle weakness and atrophy was not a problem they anticipated.

Here are some of the things we may hear:

Following the surgery, I did not expect to have the back and knee pain that I am having. I am not even going to physical therapy for my hip, I am going for the low back pain and knee pain. I was hoping to get back to work in 4 – 6 weeks, now it is more like 8 weeks at least.

My surgeon told me that I had been walking “funny,” for years as I made adjustments for my hip pain. I totally whacked my gait and natural movements. Fixing this can take months of therapy, maybe up to a year.

In April 2020, in the medical journal Orthopedic reviews (6) a team or orthopedic surgeons reported these findings:

“(We) show lower postoperative pain levels during passive and active physical therapy with the direct anterior approach when compared to the lateral approach (traditional hip replacement) due to less muscle damage. These correlations are valid until 6 postoperative weeks, afterward, we saw no difference between the two groups.”

In other words, if your muscles have not rebounded after 6 weeks post-operation. The muscle saving benefit of minimally invasive surgery is lost.

In our article Why physical therapy and exercise does not help your hip pain and what can help, we go into much more detail about the role of physical therapy before hip replacement. We especially focus on the aspects of why physical therapy may not work for you.

Options that keep your own hip

The purpose of our writing this article is because many people who contact our office are looking for an alternative to traditional total hip replacement. They see possibilities in Prolotherapy and stem cell therapy as a completely non-surgical option.

In the video below, a patient examination is performed and discussed to show who would be a good candidate for Prolotherapy, a non-surgical, in-office procedure.

The benefits of Prolotherapy:

• Same-day, in-office simple procedure
• Can often go back to work the same day

We invite you to continue on with your research at these articles on our site:

• The evidence for Prolotherapy as a hip-preserving alternative to arthroscopy and hip replacement
  • For someone in chronic pain, in this case, from degenerative hip disease, we know you will spend hours in front of a computer searching for information that will help you. The times you are searching the most are most likely when you are in a more acute painful situation. If you are like others we have helped, you have reached a point of “hip preservation treatments.” This means that your hip has not degenerated enough for hip replacement and that there is a chance that you can save your hip from replacement surgery at least for a while. But in what condition? We hope this article will offer you some insights and answers in helping you understand, manage and make decisions in regard to your chronic hip pain.
• Platelet Rich Plasma for treating Hip Osteoarthritis
  • Our offices have been offering regenerative medicine injections since 1993 as a service to people who wish to avoid hip replacement surgery. As part of our comprehensive program, we offer Platelet Rich Plasma Therapy, or as we describe it Platelet Rich Plasma Prolotherapy.
    • Platelet Rich Plasma treatment may have been explained to you as a one-time injection treatment. You may have been told this one injection will help with your problems of hip joint erosion and address the concern of irreversible hip damage.

    This is not how we offer this treatment.

    In our experience when somebody has degenerated hip disease and the cartilage is wearing away and being lost, you simply cannot repair the cartilage without addressing what is causing the cartilage damage. This is the joint erosion or irreversible joint damage you are hearing so much about. It manifests itself as instability in your hip, the feeling that your hip is giving way or is loose and wobbly.

• Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis
  • We get many emails asking about hip pain treatments. In people with osteoarthritis of the hip, the questions usually surround a treatment that will delay or prolong the need for hip replacement surgery. One such treatment is viscosupplementation, commonly referred to as hyaluronic acid injections or “gel shots.”
  • Gel shots are usually not the first, second, or even third-line treatment for hip osteoarthritis. They are usually given when other treatments have failed to alleviate someone’s hip pain. These treatments include the typical conservative care of corticosteroid injections, pain medications, and anti-inflammatory medications. In some instances, physical therapy and yoga are recommended for hip pain patients.
  • In theory, the idea of replacing or supplementing the protective and lubricating fluids of the hip sound like a good idea. So why is it not the first line of treatment for hip osteoarthritis and why do leading research centers suggest that the treatments do not work as well as hoped?

In our clinical experience and empirical observation has led us NOT to recommend viscosupplementation for hip osteoarthritis

Are you a candidate for our treatments?

In the video below, Ross Hauser, MD explains the physical examination and shows good and inappropriate candidates for Prolotherapy.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

• This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
• This patient has a suspected labral tear and ligament injury.
• The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
• The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
• From the front of the hip (1:05) we can treat the pubofemoral ligament and the iliofemoral ligaments
• From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles too, including the Obturator, the Piriformis attachments onto the Greater Trochanter
• Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.

Do you have a question about hip replacement surgery or need help?
Get help and information from our Caring Medical staff

1 Gerrand C, McNulty G, Brewster N, Holland J, McCaskie A. What do patients think about minimally invasive total hip arthroplasty?. The Annals of The Royal College of Surgeons of England. 2007 Oct;89(7):685-8. [Google Scholar]
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4 Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH, Hamilton WG, Hozack WJ. Otto Aufranc Award: A multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clinical Orthopaedics and Related Research®. 2017 Feb 1;475(2):364-72. [Google Scholar]
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6 Nistor DV, Bota NC, Caterev S, Todor A. Are physical therapy pain levels affected by surgical approach in total hip arthroplasty? A randomized controlled trial. Orthopedic Reviews. 2020 Apr 22;12(1). [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.