Introduction
The doctor’s goals are to restore your hip to a painless, near functional status and to make your hospital stay as beneficial, informative, and comfortable as possible
Contents
Total Hip Replacement
Preparing for Surgery
Pre-op Visit
Day of Surgery
After Surgery
Home Exercises
Total Hip Replacement
Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts–the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the ” ball „ or head of the thigh bone (femur). During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal. These artificial pieces are implanted into healthy portions of the pelvis and thigh bones and affixed with a bone cement (methyl methacrylate).
Cement less total hip replacement
An alternative hip prosthesis has been developed that does not require cement. This hip has the potential to allow bone to grow into it, this is an important consideration for the younger patient. In some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cement less. This would be called a ”Hybrid„ hip prosthesis.
When do we consider total hip replacements?
Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies). Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons. Circumstances vary, but generally patients are considered for total hip replacements if:
Pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living
Pain is not relieved by arthritis (anti-inflammatory) medicine, the use of a cane, and restricting activities
Significant stiffness of the hip
X-rays show advanced arthritis, or other problems
What can be expected of a total hip replacement ?
A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your physician’ s instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.
What are the risks of total hip replacement ?
Total hip replacement is a major operation. The effect of most complications is simply that the patient stays in the hospital longer. The most common complications are not directly related to the hip and do not usually affect the result of the operation. These include:
Blood clots in the leg
Blood clots in the lung
Urinary infections or difficulty in urinating
Complications that affect the hip are very uncommon, but in these cases, the operation may not be as successful:
Difference in leg length
Stiffness
Dislocation of hip (ball pops out of socket)
Infection in hip
A few of the complications, such as infection or dislocation, may require re–operation.
How do artificial hips stand up over time?
As we noted earlier, 90 to 95 percent of hip replacements are successful up to 10 years. The major long-term problems are loosening or wear. Loosening occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (reabsorbs) from the cement. By 10 years, 25 percent of all artificial hips will look loose on an X-ray. Somewhat less than half of these (about 5% to 10% of all artificial hips) will be painful and require revision.
Wear can occur in the plastic socket after some years. Small wear particles can cause inflammation resulting in thinning of the bone and risk of fracture. Loosening and wear are in part related to how heavy and how active you are. It is for this reason we do not operate on very obese patients or young, active patients. Loose, painful artificial hips can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complications are higher.
Preparing for Surgery
Maintaining good physical health before your operation is important. Activities which will increase upper body strength will improve your ability to use a walker or crutches after the operation.
Pre-operative Visit
The day begins in the clinic, where an interview by the Doctor concerning past medical history and current medications will be taken. You may be instructed to stop taking your anti-inflammatory medications (ibuprofen, Naprosyn, Relafen, DayPro, aspirin) one week before surgery. You will be attending a teaching session which will include the following topics and other information about your surgery. There will also be time for discussion and questions. Bring a written list of past surgeries and of the medications and dosages that you normally take at home.
Diet
You should follow your regular diet on the day before your surgery. DO NOT EAT OR DRINK AFTER MIDNIGHT. The day of surgery you may brush your teeth and rinse your mouth without swallowing any water.
Bathing
A shower, bath or sponge bath should be taken the evening before and morning of surgery
Deep Breathing Exercises
You will be instructed in deep breathing exercises to minimize the risk of lung complications after surgery. These exercises are necessary to remove any excess secretions that may settle in your lungs while you are asleep during surgery. These exercises are to be done every one or two hours after surgery. An incentive spirometer may be demonstrated. This bedside device assists you in deep breathing exercises.
Blood Clot Prevention
You may be fitted with elastic support stockings. The morning of surgery, you will receive these stockings to aid in the circulation of your legs and feet to reduce the risk of blood clots.
Examination
The physician will also review your medical history and the medications that you take. He will listen to your heart and lungs, and do a general physical exam. He will check for any type of infection. Any blisters, cuts, or boils should be reported. If the infection is found, surgery is generally delayed until the infection is cleared. During your pre-op visit, blood will be drawn and lab tests to ensure that you are in good general health. X-rays are taken if necessary (an ECG is obtained if you have not had one taken for six months or if otherwise indicated).
After all of these tests and exams are completed, an anesthesiologist will talk with you to determine the type of anaesthesia that is best suited for you. After you see the anesthesiologist, your pre-op evaluation is usually over. Before you leave the hospital make sure your questions are answered. If at any time you become ill, such as with a cold or flu, you need to call your physician. Remember we want you to be in your best possible health.
Care after Surgery
After surgery, you will be taken to the Recovery Room for a period of close observation, usually one to three hours. Your blood pressure, pulse, respiration and temperature will be checked frequently. Although circumstances vary from patient to patient, you will likely have some or all of the following after surgery
You will find that a large dressing has been applied to the surgical area to maintain cleanliness and absorb any fluid. This dressing is usually changed 2 to 4 days after surgery by the surgeon.
A hemovac suction container with tubes leading directly into the surgical area following surgery. The hemovac is usually removed by your doctor two to three days after surgery.
Post-operatively you may have temporary nausea and vomiting due to anesthesia or medications. Anti-nausea medication may be given to minimize nausea and vomiting.
Diet: You will be allowed to progress your diet as your condition permits; starting with ice chips and clear liquids to diet as tolerated.
Coughing and Deep Breathing: To help prevent complications, such as congestion or pneumonia, deep breathing and coughing exercises are important. Inhale deeply through your nose; then slowly exhale through your mouth. Repeat this three times and then cough two times.
You will be encouraged to use your incentive spirometer.
Activity
Some patients experience back discomfort after surgery. This is caused by the general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown. The head of your hospital bed should not be elevated more than 70 degrees during the first few days after surgery. Sitting up may allow the artificial ball to dislocate from the hip socket. There will be some precautions, mostly to prevent dislocation, which is more likely to occur the first six to eight weeks after surgery. These precautions include:
Using 2-3 pillows between your legs and not crossing your legs
Not bending forward 90 degrees
Using a high-rise toilet seat
Initial rehabilitation
The first day after surgery you will be assisted to a reclining chair, and physical therapy may begin. You will gradually begin to take steps, walk, and learn to climb stairs with the aid of a walker or crutches. This initial rehabilitation generally takes 4-6 days. During this time, discomfort may be experienced while walking and exercising. Pain medication will be ordered by the doctor as needed. Most patients are relieved of their painful pre-surgical hip condition.
Therapy and rehabilitation program
Following surgery, you will work with a physical therapist to become independent in walking, going up and downstairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of your hip. You will be instructed by your physical therapist in a specific home exercise program to meet your needs.
Do the home exercises two to three times a day (see home exercises section). Do your exercises indefinitely. Walking is not a substitute for exercise. If an exercise is causing pain that is lasting, reduce your intensity. If it continues to cause pain, contact your physical therapist or physician.
Home Exercises
Here is a list of potential exercises you may be asked to complete. Please refer to the exercises given in Articular resurfacing these exercises are sometimes done before surgery to help maintain the strength and range of motion of your hip.
Advantages of Hip Resurfacing
Cobalt-chrome cast parts. Parts are precision machined to fit each other with small space for body fluid to lubricate. The backside of the cup has a roughened surface to allow bone to grow into implant. Nearly all major implant makers either have in production or are developing metal-on-metal hip resurfacing components.
Femoral head is preserved.
Femoral canal is preserved and no associated femoral bone loss with future revision. Also, the risk of microfracture of femur with uncemented stem implantation is eliminated.
Larger size of implant “ ball ” reduces the risk of dislocation significantly.
Stress is transferred in a natural way along the femoral canal and through the head and neck of the femur. With the standard THR, some patients experience thigh pain as the bone has to respond and reform to less natural stress loading.
Use of metal rather than plastic reduces osteolysis and associated early loosening risk.
Use of metal has low wear rate with expected long implant lifetime.
Activity
Some patients experience back discomfort after surgery. This is caused by the general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown.
The dislocation rate is very low.
There will be some precautions, mostly to prevent dislocation, which is more likely to occur the first six to eight weeks after surgery. These precautions include:
Using 2-3 pillows between your legs and not crossing your legs
Not bending forward 90 degrees
Using a high-rise toilet seat
Initial rehabilitation
The first day after surgery you will be assisted to a reclining chair, and physical therapy may begin. You will gradually begin to take steps, walk, and learn to climb stairs with the aid of a walker or crutches. This initial rehabilitation generally takes 4-6 days. During this time, discomfort may be experienced while walking and exercising. Pain medication will be ordered by the doctor as needed. Most patients are relieved of their painful pre-surgical hip condition.
Therapy and rehabilitation program
Following surgery, you will work with a physical therapist to become independent in walking, going up and down stairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of your hip. You will be instructed by your physical therapist in a specific home exercise program to meet your needs.
Quadriceps Setting:
Tighten the muscles on the top of your thigh. At the same time push the back of your knee downward into the bed. The result should be straightening of your leg. Hold for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 3 times a day .
Gluteal Setting:
Lie either on your back with your legs straight and in contact with the bed. Tighten your buttocks in a pinching manner and hold the isometric contraction for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 3 times a day.
Isometric Hip Abduction:
Keeping your legs straight, together, and in contact with the bed, place a loop or belt around your thighs and attempt to spread your legs. Hold the contraction for 5 seconds, relax for 5 seconds. Progress to 20 repetitions, 3 times a day.
Do ’ s and Don ’ ts
Your new hip is designed to eliminate pain and increase function. There are certain movements that place undue tress on your new hip. For your safety, these should be avoided. This is especially true during the first few months after your surgery.
DO NOT move your operated hip toward your chest (flexion) any more than a right angle. This is 90 degrees.
DO NOT sit on chairs without arms.
DO grasp chair arms to help you rise safely to standing position. Place extra pillow(s) or cushion(s) in your chair so that you do not bend your hip more than 90 degrees.
DO Keep your involved leg in front while getting up.
DO USE high chair at home.
DO USE a chair with arms. Place your operated leg in front and your uninvolved leg well under.
DO NOT sit low on the toilet or chair initially.
DO get up from the toilet as directed by your therapist. Use the elevated toilet seat if we have given you one.
DO use a long-handled reacher to pull up sheets or blankets or do as directed by the therapist.
DO NOT bend way over.
DO NOT turn your kneecap inward when sitting, standing, or lying down.
DO NOT try to put on your own shoes or stockings in the usual way. By doing this improperly you could bend or cross your operated leg too far.
DO NOT cross your operated leg across the midline of your body (in toward your other leg).
DO NOT lie without pillow between legs.
DO KEEP a pillow between your legs when you roll onto your “ good ” side. This is to keep your operated leg from crossing the midline
Activity
Continue to walk with crutches or a walker as directed by the doctor or physical therapist.
Your physician will determine how much weight you can place on your operated leg.
Walking is one of the better forms of physical therapy and for muscle strengthening.
However, walking does not replace the exercise program which you are taught in the hospital. The success of the operation depends to a great extent on how well you do the exercises and strengthen weakened muscles.
If excess muscle aching occurs, you should cut back on your exercises.
Place a smooth surface (card table, plywood sheet, etc.) under your legs. Begin with your legs together, and then spread them apart as far as you can. Hold them apart for 5 seconds. Return to the starting position. Progress to 20 repetitions 3 times a day.
Sitting
Avoid sitting more than 60 minutes at a time. DO NOT cross your legs. In fact, keep your knees 12 to 18 inches apart. Always sit in a chair with arms. The arms provide leverage to push yourself up to the standing position. A high kitchen or bar-type stool works well for kitchen activities. Avoid low chairs and overstuffed furniture because they require too much bending (flexion) in your hip in order to get up. Do not bend forward while sitting in a chair, causing more than a 90 degree bend in your hip. Use the toilet seat riser for the next eight weeks to avoid excessive bending of the hips.
Bending
For the first eight weeks, you should not bend over to pick up things from the floor. You may want to acquire a pair of slip-on shoes and a long-handled shoe horn to avoid excessive bending.
Other Considerations
It is recommended that you do not drive until six weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/ out of the car. For the next 4-6 weeks avoid sexual intercourse. Sexual activity can usually be resumed after your two-month follow-up appointment. You can usually return to work within three to six months, or as instructed by your doctor.
Continue to wear elastic stockings until your return appointment. Don’t shower until after staples are removed. Showers may be taken two days after your staples are removed. Do not sit in a bathtub until your physician okays that activity.
Your incision
Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. Generally, the staples are removed in three weeks.
Remember:
Your physician, physical therapist, and nurses are striving to make a painless, functional hip possible for you. The real success of your hip replacement, however, depends partly on you-especially how conscientiously you exercise and how diligently you apply the principles of home care and self-limitation.