The hip joint is made of a ball (femoral head) and socket (pelvic acetabulum) mechanism that is subject to disease and wear and tear over time (see figure 1). THR surgery is performed only after there is a severe loss of function in the hip joint as a result of any degenerative disease. Most commonly, destruction of the hip joint is caused by osteoarthritis. Other medical conditions that may lead to hip destruction and eventual surgery include:

1. Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, spondyloarthropathies, etc.)
2. Developmental dysplasia
3. Childhood hip disorders (Legg-Calve-Perthes disease, slipped capital femoral epiphysis, etc.)
4. Fracture
5. Bone tumor

The decision to proceed to surgery should be made only after a careful evaluation of functional limitation, pain and the potential risks of surgery. Since THR is an elective surgery not without risk, you should exhaust non-operative and operative solutions before committing to THR. As well, modern hip prosthetics are limited in terms of their durability lasting anywhere from 10-25 years. The longer you can postpone surgery, the more likely you will be able to avoid future reoperation for prosthetic failure. Reoperations carry a higher risk of complication and are to be avoided whenever possible.

In the following pages we will provide you with guidelines essential for your review prior to surgery. Since you are considering having your surgery in another country you should be informed and participate in all decisions regarding your care. Our responsibility at MedToGo International will be to guide you to excellent orthopedic surgeons and hospitals in Mexico. We cannot however give you direct medical advice or make decisions about your medical care for you. We can however provide you with a step-by-step protocol that, if followed, will ensure your responsible treatment and optimize your positive experience with orthopedic surgery in Mexico. We use treatment and care guidelines based on US medical practices. Our objective is that you receive an equivalent evaluation, treatment and follow up program based on US medicine at a fraction of the cost. You may have to do a little bit of the leg work yourself but if you follow our step-by-step process you will have all that you need without having to mortgage your house to pay for it! Below you will review the indications for hip replacement surgery and your options both surgical and non-surgical. You will understand the contraindications or reasons when THR is not appropriate. You will learn about the potential complications and things to watch out for after your surgery. You will receive information about your preoperative evaluation and medical clearance for surgery. And, finally you will learn how to arrange your own follow-up physical therapy and rehabilitation in your hometown. We will even provide you with a rehabilitation protocol that, if followed, will maximize the proper function of your new hip back home.

GUIDELINES FOR TOTAL HIP REPLACEMENT

Indications for Surgery
THR surgery should be considered in anyone that has severe pain and/or deformity of the hip joint that significantly interferes with the normal activities of daily living. Once bones have stopped growing, anyone at any age can have hip replacement surgery as long as the individual is healthy enough for surgery and has bones strong enough to support the artificial joint. Before making the jump to surgery, you should have exhausted all non-surgical methods to restore function and comfort to your ailing hip. Non-operative interventions may include taking anti-inflammatory medications and/or physical therapy. There are also other surgical interventions that may be more appropriate. Such surgical interventions may provide functional and/or pain relief while postponing the need for THR (see figure 2). Talk to your local orthopedic surgeon. Together you can decide if THR surgery is right for you.

Figure 2: Potential, Alternative Surgical Interventions to THR

• Hip Resurfacing: Hip resurfacing, often referred to as the Birminham procedure or the Zimmer procedure is considered a modified THR. Resurfacing involves partial removal of the femoral head and placement of a ball prosthetic. The acetabulum is also replaced with a prosthetic socket. So an entire, artificial ball and socket hip joint is recreated, but the entire femoral head is not removed and thus the prosthetic does not extend into the femur. This has its advantages should reoperation be necessary at a later date. This “mini” hip replacement surgery is more appropriate for younger patients and is recommended for anyone under the age of 50.
• Surgical dislocation and debridement: Useful to remove bone spurs or other debris that may accumulate in the hip joint and cause pain.
• Hip arthroscopy: May be useful to repair small cartilage tears or other simple repairs of the hip architecture.
• Core decompression: May be used in cases of femoral head osteonecrosis.
• Intertrochanteric osteotomy: May be useful in early or post-collapse osteonecrosis, femoral dysplasia, fracture malunion or nonunion, and congenital deformities such as coxa vara or coxa valga.

• Periacetabular osteotomy: May be considered in cases of acetabular dysplasia.

As you can see, there are many procedures on the hip that don’t require complete replacement. Talk to your local orthopedic surgeon and make sure THR is right for you.

Contraindications: Reasons why you cannot have THR surgery
1. Active infection (local or systemic)- most common contraindication
2. Skeletal immaturity- bones must be fully grown
3. Existing significant medical problems (eg, recent heart attack or near heart attack, heart failure, or severe anemia)
4. Permanent or irreversible muscle weakness in absence of pain
5. Paraplegia/quadriplegia

A thorough PREOPERATIVE EVALUATION must be performed on every patient prior to surgery which includes:
1. Complete history and physical
2. Chest X-ray
3. Laboratory workup (PT/INR, PTT, CBC, CMP, UA)
4. 12-lead EKG (electrocardiogram)
5. Medical Clearance* from a primary care physician.

*If the preoperative evaluation finds that there is an increased risk from any health condition, referral to and clearance from the appropriate specialist is mandatory. Also, you should review treatment alternatives (conservative non-operative interventions or operative alternatives) and discuss the risks and benefits or THR surgery with an orthopedic surgeon in your area prior to booking with MedToGo International.

Prosthetics and Technique:
Some people request information on the prosthetics used by our orthopedic surgeons or the surgical techniques each individual surgeon employs for THR. There are hundreds of prosthetic options and various techniques utilized by our surgeons. For more information, please contact one of our representatives.

Intraoperative (during the operation) complications of THR surgery include:
1. Fracture- this complication occurs more commonly with non-cemented femoral components of the surgery that require a tighter fit. The incidence ranges from 0.1- 1% in cemented components to up to 18% in non-cemented components. Minor fractures may be wired or allowed to heal spontaneous. Major fractures may require bone grafting, screws or extensive revisions.
2. Cement reactions- Less than 5% of patients will experience a sudden drop in blood pressure when cement is used during placement of the femoral prosthesis. Careful monitoring and treatment should prevent this reaction from creating a problem. Theoretically a sudden drop in blood pressure may cause a stroke or heart attack, but his would be extremely rare.
3. Nerve Injury- Although rare, there are many mechanisms whereby a nerve may be injured during surgery. Common causes are excessive leg lengthening (stretches the nerve), a regional blood clot (compressing the nerve), or surgical trauma (stretching, cutting or compressing the nerve). Nerve injury to the sciatic nerve is most common, but other regional nerves may be injured. The standard incidence of nerve injury is up to 0-3%. Of the people who develop an intraoperative nerve injury, 44% resolve completely, 41% have a minor deficit and 15% develop a poor outcome with muscle weakness and or numbness in the affected limb.
4. Vascular (blood vessel) Injury- This rare complication affects 0.2-.3% of all THR patients. This complication may be devastating especially if not recognized and treated immediately. Injuries of this sort are almost always due to poor surgical technique.

Postoperative (after the operation) complications of THR surgery include:
1. Blood Clot formation. Blood Clots that form within the veins of the legs (Deep Venous Thrombosis (DVT)) are commonly associated with orthopedic surgery. DVT’s can break off and travel to the lungs causing what is called a Pulmonary Embolism (PE). If large enough, a PE can be deadly. If left untreated or unprevented, a DVT would be a major source of morbidity and death. Fortunately they can be prevented with anticoagulants before, during and after your surgery. If treated for 7-10 days after surgery the death rate from PE after THR is 0.1% within 90 days of discharge from the hospital. Enoxaparin given as a small shot under the skin twice a day after surgery is the standard method of prevention. Compression hose stockings are equally effective. After surgery, it is important to ambulate (walk) as soon as you are able to prevent DVT formation. Risk factors that increase your chance of DVT include, obesity, smoking, previous DVT, dehydration, family history (hypercoagulable state), previous trauma to the leg and a sedentary life style. Your surgeon may recognize some factors, but it would be important for you to disclose any previous personal history of DVT, family history, smoking, or previous trauma so that extra measures and/or monitoring may be utilized for your protection.
2. Infection: The incidence of infection after THR is 0.4-1.5%. Infection may be devastating, painful and very costly. Infection may require removal of all prosthetics, long-term intravenous antibiotics, long term hospitalization and eventual reoperation. One of the keys to infection is prevention. Most post operative infections occur not because of poor surgical technique, but because there was an infection at the time of operation somewhere else in or on the body that was not recognized by medical personnel or the patient. Examples may be urinary tract infections, wound infections or lung infection. Preoperative laboratory testing and full physical examination immediately prior to the operation are essential steps to prevention. Antibiotics given prior to surgery helps prevent infection.

Post operative infections typically occur within the first three months after surgery. Signs of a joint infection include: joint pain and decreased range of motion, swelling, redness in the surrounding tissues, drainage from the wound and fever. Suspected infections need immediate medical and surgical evaluation. Infections after three months are rare but still possible.

Dislocation: Dislocations of the hip may occur in up to 2% of cases. Early dislocations (within the first 3 months after the operation) have a 60-70% chance of healing without reoccurrence. Other dislocations may require reoperation and fixation of the weak point.

Osteolysis: Bone around the implants may start to dissolve. This process called osteolysis is the most common long term complication of THR. Ostelolysis may cause joint loosening and a need for reoperation and fixation.

Fracture: With normal wear and tear, the prosthetic joint may create a local fracture. Reoperation and fixation is often needed. The standard rate of late fracture is less than 1%.

Leg Length Discrepancy: If the length of the femoral component is not calculated correctly you may be left with a discrepancy in leg length. This may cause back pain or limping. A shoe lift can remedy the problem. Preoperative leg length measurements should be done. If you have scoliosis or any other pelvic or lower extremity condition, please tell your surgeon so that he can make the necessary adjustments. Even if leg length is equal you may experience a feeling that your leg lengths are unequal after THR. This may be due to muscle weakness in the operative leg. It should correct itself as the muscles strengthen with physical therapy.

Heterotropic Ossification (HO): HO refers to a somewhat common condition whereby the soft tissues (muscles, ligaments, etc) become calcified with bone. HO is more common in people who have a history of osteoarthritis. Ask your surgeon if you are at an increased risk of developing HO, which may lead to significant joint stiffness down the road. You may benefit from taking an anti-inflammatory medication for the first two weeks after your surgery.

Final Preparations
a. Losing weight before your surgery will help you with your post-operative rehabilitation.
b. Non-steroidal anti-inflammatory medications should be stopped 7 days prior to surgery.
c. Warfarin (Coumadin) should be stopped 3-5 days prior to surgery (consult with your local doctor to determine if stopping Warfarin is safe).

Our physicians and health care coordinators have extensive, hands on experience working with doctors and hospitals throughout Mexico. We began developing our network of Mexico’s finest doctors and hospitals in 2000 by conducting personal interviews and educational background checks on more than 700 Mexican doctors and inspecting over 80 private hospitals. We spent 6 years researching the Mexican healthcare system before we referred our first patient for surgery in February of 2006. As a result, if you decide to let MedToGo coordinate your surgery or medical service in Mexico, you can be assured that you will be working with the country’s finest doctors and institutions.

You will have also hired a team of U.S. physicians and health care and coordinators that will oversee your care and serve as your advocate while you are in Mexico. You will not be alone. Your safety and peace of mind are our primary concern. Furthermore, we can offer you complete healthcare packages with up to 75% off the price of a comparable experience in the U.S.-without a compromise in quality.

• Our physicians meet and hold personal interviews with all Mexican physicians.
• We verify the doctor’s educational experience and credentials, including board certification and licensing.
• We request and check professional references and assess a doctor’s local reputation through various professional and personal resources. Doctors must be in good standing with their community and hospitals. There must be no history of current or repeated legal malpractice.
• We review physician resumés and give preference to physicians who have been consistent with continuing medical education, who are active in their medical societies and who have been entrusted with leadership roles within their institutions.
• We examine evidence of their surgical success rates.

• Prior to including a surgeon or physician into our program, we attend his/her operations to evaluate competence and skill.

But if you hire MedToGo we will not only provide you with a selection of Mexico’s finest health care providers and coordinate your procedure, we will also be your advocates while you are abroad and not rest until have returned home.

Your Mexican hospital and doctor compensates MedToGo for marketing services, and MedToGo does not add additional fees to the cost of your package. MedToGo does not accept cash incentives or alterations in compensation from physicians or hospitals. This ensures that our recommendations are unbiased and based solely on our experience and quality assessment.