Bilateral Total Hip Replacement (Simultaneous)

A number of patients suffer from bilateral hip arthritis requiring a total hip replacement of both the hip joints. The total joint replacement of both the hips may be performed in a staged manner or in a single sitting. The replacement surgery of both the hips done in one surgery is known as simultaneous total hip replacement.

Total hip replacement has revolutionized the treatment of arthritis due to any cause which cannot be managed with conservative options. The patients getting a total hip replacement benefit from a significant increase in quality of life.

Total hip replacement is indicated for the management of hip pain not relieved by non-surgical methods. Nonsurgical methods include such as physical therapy, hip injections, or pain relief medications.

Hip pain may interfere with daily activities such as walking, climbing stairs, getting up from a chair, or even tying shoelaces.

Pain and stiffness of the hips may result from a number of conditions:

• In osteoarthritis, the smooth cartilage overlying the bone wears down interfering with the smooth gliding of the joint. It is age-related wear and tear disorder, which affects all the tissues forming the hip joint. Arthritis may also affect younger age groups due to injury (post-traumatic osteoarthritis).
• Some patients may have an improper growth of the hip joint by birth. With growing age, the joint becomes incongruous leading to early osteoarthritis.
• Rheumatoid arthritis is a medical condition where the body’s cells destroy the structures forming the joint. Commonly affecting both the hip joints, rheumatoid arthritis usually involves multiple joints.
• In avascular necrosis, the blood supply to the hip joint is compromised. This leads to the collapse of the hip joint as a result of damaged or reduced blood supply.

In the majority of the patients of rheumatoid arthritis, both the hip joints are usually involved. In patients suffering from osteoarthritis of one hip, the other hip also gets involved subsequently. Avascular necrosis resulting from non-traumatic causes generally affects both the hips simultaneously.

The patients suffering from bilateral disease may have an option to get both hips replaced in the one surgery. Generally, both hips are replaced in a staged manner, with a gap of 3-4 months between both surgeries. But recently some patients opt for the bilateral replacement in on setting.

Advantages

The advantages of simultaneous bilateral total hip replacement include a single visit to the operating room. The patient needs anesthesia only once rather than getting it twice in case of staged procedure.

Active and working patients have the benefit of taking less time off work for the surgery. They need the time off only once and then are able to get back to their jobs. Meanwhile, in staged procedures, the patients need time off twice.

The patients may also start the rehabilitation of both the hips together after the surgery. In staged bilateral joint replacement, the patients need rehabilitation for both the times they get operated. 

With a growing elderly population, most patients want to prolong their function and independence. Therefore a greater number of hip replacement surgeries are being performed each year. A simultaneous bilateral hip replacement may, therefore, may have cost benefits for the healthcare system.

Disadvantages

A simultaneous both hip replacement surgery may be associated with an increase in risks associated with the procedure. There is increased blood loss in bilateral hip replacement surgery. The postoperative hemoglobin levels of the patients are usually lower than the patients undergoing staged replacement.

There are increased chances of requiring intraoperative blood transfusion during bilateral hip replacement. Blood transfusions are associated with an increased risk of a number of medical complications.

The operative time in simultaneous both hip replacement is longer than a single hip replacement. Bilateral hip replacement patients may have an increased length of stay at the hospital. There are increased chances of stay at an inpatient rehabilitation center after the procedure.

There are increased chances of postoperative complications associated with hip replacement. Complications such as deep vein thrombosis, pulmonary embolism, or infection may also be increased in the bilateral procedure.

Candidates

Patients undergoing a simultaneous bilateral total hip replacement generally belong to a younger and more active age group. The patients are carefully selected after clearance from their primary care physicians.

Most patients undergoing simultaneous bilateral hip replacement are under 70-75 years of age. For a candidate, all other forms of conservative treatment must be tried before finally undergoing a hip replacement. 

The patients undergoing bilateral hip replacement should not have any major cardiac, respiratory, kidney, or vascular disease. The patients should ideally be non-obese and motivated for rehabilitation.

Procedure

Both the hips are draped and prepared simultaneously but the surgery is started on one of the hips first. Different techniques can be used to access the hip joint. Most commonly, the hip joint is accessed from behind (posterior approach). 

The hip can also be accessed from the front (anterior approach). The type of approach is dependent upon the anatomy of the patient and the surgeon’s expertise. The anterior approach makes the subsequent positioning of the second hip easier.

After incision and separation of tissues, the damaged part of the acetabular socket is removed. A cup made of metal alloy or ceramic is then fixed with screws or press-fitted in the socket. The head of the femur is cut with a saw and removed. A stem made of metallic alloy is then inserted in the upper part of the thigh bone. 

The stem may be press-fit or fixed using a special form of bone cement. A prosthetic head made of metal alloy or ceramic is placed on the stem replacing the natural head of the femur. A special form of highly durable plastic called polyethylene is placed between the head and socket to allow smooth gliding.

The surgical incision is closed and the position checked with intraoperative fluoroscopy. The second hip is then positioned similarly for the procedure. The surgery on the second hip is performed in a similar manner.

Conclusion

Simultaneous total hip replacement offers benefits of surgery of both the hips in one setting in selected otherwise healthy patients. Total hip replacement offers increased mobility and independence in patients with bilateral hip arthritis. The merits, demerits, and the possibility of undergoing bilateral total hip arthroplasty should be discussed with your orthopaedic surgeon.

Read more about Total Hip Replacement here.