The expert for the hip

Dr. Joachim Hagenah, head physician of the endoprosthetics department at the Hellersen Sports Clinic, explains why experience minimizes risks

Hip replacement surgery is a major operation that should be well planned. For Dr. Joachim Hagenah, however, it is routine. He has been working at the Hellersen Sports Clinic, a large orthopedic clinic in Lüdenscheid, since 2004 and has also been the head physician of the endoprosthetics department since then. In the interest of the patient and especially in view of the personal medical history, the physicians at the Hellersen Sports Clinic initially focus on joint-preserving measures. With their experience, the highly specialized doctors can accurately assess what, when and how surgery should be performed and where an intervention is not yet necessary. Every year, around 850 knee and hip prostheses are inserted or replaced at the Hellersen Sports Clinic.

Many patients are unsettled by reports of unnecessary joint operations and ask: When is actually the right time for an artificial joint? For the specialists at the Hellersen Sports Clinic, the guiding principle here is: as early as necessary, but as late as possible. Most of the time, a patient decides to undergo surgery when he or she is in considerable pain, especially when resting. However, there are also situations where surgery should be performed with comparatively little pain: namely, whenever there is a risk of irreversibly losing valuable bone of the patient by waiting longer. "This situation must first be recognized and then the patient advised accordingly," says Dr. Hagenah. The time when surgery should be performed must therefore ultimately be determined individually for each patient.

If a prosthesis is unavoidable, the chief physician is particularly concerned to keep the risks of the operation to a minimum. For this reason, minimally invasive surgery has been performed at the Sports Clinic for over 16 years. Patients are fit much faster after an operation and require fewer painkillers than with the conventional surgical technique. The decisive factor here is not the length of the skin incision, but the procedure that is gentle on the soft tissue. Here, the hip muscles are no longer cut, but the surgeon "cheats" his way through an existing gap between two muscles without injuring them and thus reaches the hip joint.

There are several different muscle gaps that can be used by the surgeon. "We make our skin incision laterally on the outside of the thigh rather than in the groin, because the groin region is more germ-infested in many people. The skin incision in the groin could therefore potentially pose a higher risk of developing a prosthetic infection," explains Dr. Hagenah. The topic of infection prevention plays a major role in Hellersen, and so for many years the sports clinic has regularly been among the hospitals with the fewest infections in artificial hip and knee joints - an aspect that is becoming increasingly important for many patients.

To minimize the risk of blood transfusion, a so-called cell saver system is regularly used in addition to minimally invasive surgical techniques at the Hellersen Sports Clinic. Patient blood collected during surgery or in the first hours after an operation is purified with this system, reprocessed and returned to the patient so that the administration of foreign blood is rarely necessary.

Every prosthesis operation is carefully planned on the computer in the Sports Clinic using special software. This provides the surgeon with important information before the operation, such as the size of implant required, which is individual for each patient. In addition, the computer also simulates how the prosthesis should be positioned as precisely as possible to avoid impending complications such as prosthesis luxation (dislocation of a joint).

The surgeons can choose from a variety of different artificial joints at the Hellersen Sports Clinic. "Just as we humans are different in size, stature and appearance, there are also completely different anatomies in the area of our joints, which can often only be treated with different prosthesis models in a bone-preserving manner. A single standard prosthesis is therefore far from sufficient," explains Dr. Hagenah. For this reason, the Sports Clinic works with several of the world's leading manufacturers of artificial joints to ensure that each patient receives the best possible replacement.

The main causes for a prosthesis are osteoarthritis, femoral neck fractures and rheumatic diseases. Sometimes, however, a bone infarction leads to the destruction of bone tissue (femoral head necrosis) and ultimately to an artificial joint.

The service life for a prosthesis is given as 15 to 20 years, and surgeons hope that improved materials will make artificial joints last even longer. "I have also operated on patients who had their prosthesis for almost 40 years. It is important that the patient continues to be active after surgery and gets as much exercise as possible," explains Dr. Hagenah. "A rolling stone gathers no moss, and that also applies to people with artificial joints!"

If an artificial joint does become loose, surgeons can draw on their own bone bank for replacement operations: Bone that is lost during a hip prosthesis operation is not simply discarded in Hellersen, but is elaborately prepared and deep-frozen using state-of-the-art technology. This bone is needed, for example, to optimally fill larger bone defects or holes during prosthesis replacement operations.

The specifications and requirements for operating an in-house bone bank are very extensive, and compliance with these specifications is regularly monitored by the responsible district government. The expense for the clinic is thus significantly greater than if the required bone tissue is purchased from large suppliers, with the result that fewer and fewer clinics in Germany are still making this effort. "However, we have the advantage that we do not have to fear supply bottlenecks and ultimately know exactly which bone donor the tissue comes from," explains Dr. Hagenah.


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