Modern hip surgery allows increasingly tissue-sparing procedures, less blood loss and faster mobilization of patients. How does osteoporosis affect the choice of implant and surgical technique, which patients are suitable for such an intervention and how long can a modern artificial joint last? Prof. Vasil Yablanski, head of the Orthopedics and Traumatology Clinic at Acibadem City Clinic University Hospital Tokuda, spoke to FAKTI on these issues.
- Prof. Yablanski, let us explain in simple terms what “minimally invasive” hip replacement actually means. Is it merely a smaller skin incision, or does it also involve a technique that spares the muscles and soft tissues? What are the real benefits for the patient?
- In the public domain, minimally invasive hip replacement is understood as replacement through the smallest possible incision. In fact, this is not the case. Minimally invasive hip replacement means replacing the joint with as little cutting or disruption of normal anatomical structures in the joint area as possible. The skin incision is not the only criterion for minimal invasiveness. An operation may involve a small incision, but many other tissues, such as muscles, tendons and ligaments, may be cut deeper down, meaning that it is not actually minimally invasive. At the same time, we may have an operation with a larger skin incision that does not cut any structures deeper down. Such an operation could more accurately be described as minimally invasive.
The real benefits for the patient when minimally invasive techniques are used are less blood loss and, consequently, a reduced need for blood transfusions. We now almost never require our patients to undergo special preparation for a blood transfusion. The patient experiences less pain after surgery, given that the tissues around the joint are not cut or damaged. When we do not damage the muscles and ligaments, the newly placed artificial joint is much more stable, especially in the first days after surgery, allowing us to get the patient upright much earlier and even greatly reduce the use of walking aids. Patients operated on using a minimally invasive technique are mobilized on the very day of surgery, which gives them a sense of confidence and freedom.
In many places in the United States and Western Europe, this intervention is already performed as day surgery in standard patients—the patient is admitted in the morning, undergoes surgery and returns home in the evening.
- Could the drive toward a smaller incision create false expectations?
- Today, almost all patients search online or ask artificial intelligence programs how the operation is performed, whether a smaller incision is possible and so on. As a result of the information obtained online, patients expect to start returning to their normal daily activities the day after surgery, which unfortunately is still not the case. Although undergoing surgery using a minimally invasive approach is much easier, time is still needed for the tissues around the joint and motor function to recover.
- What are the main risks and limitations of minimally invasive surgery, and how can patients determine whether promises of rapid recovery are realistic?
- This is a process in which the entire team involved in the patient’s treatment must be prepared. First and foremost, this is the surgeon, because minimally invasive surgery requires experience accumulated over the years with the technique being used and with the large number of patients on whom it has been successfully applied.
The experience of the rehabilitation specialists is also of great importance, because minimally invasive surgery allows earlier weight-bearing and faster mobilization.
In summary, I believe that the risks of this type of surgery are lower, and I would emphasize that the team’s experience with such surgery is essential. It is important to note that not all patients are suitable for minimally invasive techniques. In fact, they can be used in 70–80% of patients, but there is also a percentage of patients in whom this is not possible due to a number of contraindications—patients with severe excess weight, patients with specific conditions related to changes in the structure of the hip joint, patients who have previously undergone procedures in the joint area, and others.
- Which patients are best suited for minimally invasive hip replacement?
- These are the so-called “standard patients,” who suffer from advanced degenerative disease in the hip area or specific conditions such as osteonecrosis.
- How do age, body weight, anatomical features, previous surgeries and overall health affect the choice of technique?
- Age in itself is not a factor that limits our use of minimally invasive techniques. Body weight can be in some cases—overweight patients and specific cases involving an accumulation of fatty tissue are not entirely suitable, especially when a direct anterior approach is used, which is understandable. The incision is located in an area where obesity may involve an accumulation of fatty tissue, making wound healing more difficult. The anatomical features that influence the choice include patients requiring revision arthroplasty or patients who underwent surgery during childhood, which means that their joint has a more specific morphology. The range of factors limiting the use of minimally invasive techniques is not broad.
- How does osteoporosis change the preparation for and the actual performance of hip replacement surgery?
- Osteoporosis is a significant factor. We know that it involves a loss of bone density. In patients with severe osteoporosis, we sometimes need to use more specific implants. Most often, these are implants fixed to the bone with bone cement, because the bone is not strong enough to provide the initial support for the prosthesis while the bone itself grows onto the implant. Osteoporosis changes the choice of implant and the choice of surgical technique. Patients with osteoporosis are older or have an underlying condition, most often of hormonal origin. We know that osteoporosis is present, so we can prepare accordingly and take the patient’s condition into account.
- How does lower bone density affect implant fixation, the risk of fracture and the choice between different types of prostheses?
- I have already mentioned that in patients with severe osteoporosis we prefer to use implants with cemented fixation—or, in more popular terms, implants that are bonded to the bone with bone cement—rather than the majority of prostheses, which are cementless and are implanted into the bone without bonding; over approximately one month, the bone grows into the implant and fixes it in place. This is the so-called biological model of implant-to-bone fixation. With implants for which we use bone cement, we bond the joint to the bone on a chemical basis.
The risk of fracture is higher in patients with osteoporosis, regardless of the implant. However, people with severe osteoporosis are at very high risk of fractures even without undergoing joint replacement surgery, and without any exertion. From our practice, we know that patients with severe osteoporosis may suffer a hip fracture simply by turning over in bed, or a vertebral fracture from the weight of their own body while sitting.
- Should every patient scheduled for arthroplasty be tested for osteoporosis?
- In my practice, we examine patients only if we notice a change in the structure of the bones on their X-rays, or if we already know from their medical history that they have osteoporosis and are being treated for it.
It is not a rule that every patient must be tested for osteoporosis. We assume that it is typical of specific groups—women over the age of 75 or patients with other concomitant diseases that can cause osteoporosis.
- Can long-term untreated osteoporosis jeopardize the long-term outcome of the surgery?
- Yes, it can jeopardize the long-term outcome. During arthroplasty, we insert an implant that performs the function of a joint. If the bone to which we attach it is not of good quality, it is entirely logical that the replacement joint will not last as long as we would like.
- You have already mentioned early mobilization on the day of surgery. What determines whether a patient will be able to get up a few hours after the intervention, and what is the role of pain management, rehabilitation and an individual recovery plan?
- We introduced modern protocols for hip arthroplasty three years ago and strive to follow them strictly. These protocols enable the patient to undergo arthroplasty in the fastest and most pain-free way possible and consist of several components. The first takes place before surgery, when we perform preliminary preparation for some patients. We recommend taking painkillers in advance to reduce the sensation of pain around the time of surgery. We perform the operation itself using minimally invasive approaches—a direct anterior approach, in which we do not cut tendons, muscles or other important anatomical structures, thereby reducing patients’ pain during the early postoperative period. We continue with intraoperative pain management; usually, at the end of the operation, we infiltrate the surrounding tissues with a specific combination of medications to reduce pain for a longer period. Once the operation is complete, we are confident that the joint is in a stable position because we have not cut the structures that stabilize it. This allows us to be much bolder in permitting the patient to get up and stand immediately after surgery; we do not impose restrictions on the range of motion. With this protocol, the risks of an adverse event are very low, so we do not impose such restrictions. We encourage patients to be more confident when bearing weight, and often discharge them with the support of only one or two so-called “Canadian crutches.”
I believe that approaches aimed at achieving the fastest and most pain-free recovery possible after such an operation are extremely important.
- How long does a modern hip prosthesis last, and what does its “lifespan” depend on?
- Over the years, the implants we use have undergone significant development. They are now made from specially structured materials that allow bone cells to grow into the prosthesis itself and stabilize it. The bearing surfaces are now largely ceramic or made of other materials with almost negligible wear. Thanks to this, expectations for the survival of a modern artificial joint are more than 30–35 years—a very long expected lifespan for an implant. In patients around the age of 60 or older, the expectation is that joint replacement will be a once-in-a-lifetime procedure. On the other hand, this gives us the confidence to recommend arthroplasty to younger patients as well, because we know that the joint will last long enough.
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Prof. Vasil Yablanski graduated in medicine in 1996 from the Faculty of Medicine of Trakia University, and in 2001 obtained a specialty in “Orthopedics and Traumatology.” He holds a master’s degree in “Public Health” from the Hebrew University in Jerusalem, Israel, as well as a master’s degree in “Healthcare Management.”
He has specialized extensively in the field of arthroplasty. He has completed training courses in primary and revision arthroplasty in Germany, Austria, Japan, France and Sweden; spinal surgery in Spain, Turkey and Israel; as well as many other specialized courses at leading centers around the world.
Prof. Yablanski has received additional training in bone and joint surgery in Salzburg, Austria, as well as in the surgical department of Duke University Hospital in North Carolina, USA.
He worked for 8 years in the Orthopedics and Traumatology Department of the University Hospital in Stara Zagora, after which he joined Queen Joanna University Hospital in Sofia. When Tokuda Hospital Sofia was opened, he was invited to head its Department of Orthopedics and Traumatology. In 2016, he obtained the academic position of “Associate Professor,” and in 2021—“Professor.”