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).
Cementless 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, and therefore
may last longer than the cemented hip. 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 cementless. 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 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
| urinary infections or difficulty urinating
| blood clots in the lung |
| |
Complications that affect the hip are less common, 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. Infected artificial hips sometimes have to be removed, leaving a
short (by one to three inches), somewhat weak leg, but one that is usually
reasonably comfortable and one on which you can walk with the aid of a cane or
crutches.
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 problem is loosening of the prosthesis. This
occurs either because the cement crumbles (as old mortar in brick building) or
because the bone melts away (resorbs) from the cement. By 10 years, 25 percent
of all artificial hips will look loose on x-ray. Somewhat less than half of
these (about 5% to 10% of all artificial hips) will be painful and require
revision.
Loosening is 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
Maintain Good Physical Health
Preparing for a total hip replacement begins several weeks ahead of the
actual surgery date. 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.
Your teeth
need to be in good condition. An infected tooth or gum may also be a possible
source of infection for the new hip. If at any time you become ill, such as with a cold or flu, you need to
call your physician. It is important that you are healthy for surgery. Donate
Blood
A blood transfusion is often necessary after hip surgery. You may wish to
donate several pints of blood prior to your surgery. Then, if you require a
transfusion, you will receive your own blood. This is called autologous blood
donation. The first donation must be given within 42 days of the surgery and the
last, no less than seven days before your surgery. You must be healthy when
donating blood. Eat a nourishing meal two to four hours prior to donation, and avoid
strenuous exercise for twelve hours following the procedure.
The blood donor center will check the blood count before drawing additional
units. A prescription for iron will be given. Iron may be constipating for some
people, so sometimes a stool softener is prescribed. Stool softeners can also be
purchased over the counter.
You may be a candidate for autotransfusion after your surgery. Blood
collected from the wound drain is filtered and transfused back to the patient
early in the post-operative period. The physician will assist you in deciding
whether this procedure will be done. Pre-op Testing
The physician may order blood tests and urinalysis two weeks before surgery
to make sure that a urinary tract infection is not present. Chest x-rays
and an EKG are obtained if you have not had one taken for six months or if
otherwise indicated. Planning for Recovery After Surgery
When making preparations for surgery, you should begin thinking about the
recovery period following surgery. A patient with a new total hip replacement
may need help at home for the first several weeks. Assistance with dressing,
getting meals, etc. may be necessary. Most often discharge from the hospital is
anticipated in about one week. Your energy level will not have returned. If
assistance from someone at home is not possible, it may be necessary to think
about making arrangements to stay a few weeks in an extended care facility.
Night before Surgery
| Nothing to eat or drink after midnight |
Day of Surgery
The actual surgical procedure may take two to four hours. However,
preoperative preparation as well as wake-up time may make your operating room
and recovery room stay longer.
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. Close attention will be paid to the
circulation and sensation in your legs and feet. It is important to tell your
nurse if you experience numbness, tingling, or pain in your legs or feet. When
you awaken and your condition is stabilized, you will be transferred to your
room.
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 enables the nursing staff to measure and record the amount of drainage
being lost from the wound following surgery. The hemovac is usually removed
by your doctor two to three days after surgery.
- An IV, started prior to surgery, will continue until you are taking
adequate amounts of fluid by mouth. When you are taking fluids well, the IV
may be changed to a Heparin lock, a small sterile tube, that will keep a
vein accessible for antibiotics and allow for easier movement. Antibiotics
are frequently administered every eight hours, for two to three days, to
reduce the risk of infection.
- Elimination: One side effect of anesthesia is often a difficulty in
urinating after surgery. For this reason, a sterile tube called a catheter
may be inserted into your bladder to insure a passageway for urine. This may
remain in place for one to two days.
- Besides the elastic hose (TEDS), you may also have on compression stocking
sleeves. This is a plastic sleeve that is connected to a machine which
circulates air in the plastic and around your legs. This is another method
of promoting blood flow and decreasing the chances of blood clots. You will
also be given medications and exercise instructions (moving your ankles up
and down), which also helps to prevent clots.
- Post-operatively you may have temporary nausea and vomiting due to
anesthesia or medications. Anti-nausea medication may be given
to minimize the nausea and vomiting.
- Diet: You will be allowed to progress your diet as your condition pemits;
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.
Pain Control After Surgery
When the PCA is discontinued, your doctor will prescribe pain medication to be
taken by mouth.
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 5-7 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.
If an exercise is causing pain that is lasting, reduce your intensity. If it
continues to cause pain, contact your physical therapist or physician.
Range of motion exercises
Active hip and knee flexion:
Lying on your back with legs straight, toes pointed toward the ceiling; arms
by your side. Keeping the heel in contact with the bed, bend your hip and knee.
Return to starting position. Progress to 20 repetitions, 2 times a day.
Active Abduction:
Place a smooth surface (card table, plywood sheet, etc.) under your legs.
Begin with your legs together, then move the operated leg out to the side as far
as you can. Keep your toes pointed toward the ceiling. Return to the starting
position. Progress to 20 repetitions, 2 times a day.
Strengthening Exercises Quadriceps Setting:
Tighten the muscles on the top of your thigh, pushing 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, 2 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, 2 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 just above your knees. Slowly spread your legs
against the belt. Hold for 5 seconds, relax for 5 seconds. Progress to 20
repetitions, 2 times a day.
Activities of Daily Living
Do's and don'ts
Your new hip is designed to eliminate pain and increase function. There are
certain movements that place undue stress 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 NOT get up like this. Keep your involved leg in front while getting
up.
DO use a chair with arrns. Place your operated leg in front and your
uninvolved leg well under.
DO NOT sit low on toilet or chair.
DO get up from toilet as directed by your therapist. Use the elevated
toilet seat if we have given you one.
DO NOT pull blankets up like this.
DO use a long-handled reacher to pull up sheets or blankets or do as
directed by therapist.
DO NOT bend way over.
DO NOT turn your knee cap 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 these activities as directed by your therapist.
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.
Guidelines at Home
What happens after I go home?
Upon discharge from the hospital, you will have achieved some degree of
independence in walking with crutches or a walker climbing a few stairs, and
getting into and out of bed and chairs.
Someone at home is needed to assist you for the next six weeks, or until your
energy level has improved.
Medication
| You will continue to take medications as prescribed by your doctor.
| You may be sent home on prescribed medications to prevent blood clots.
| You will be sent home on prescribed medications to control pain. Plan to
take your pain medication 30 minutes before exercises. |
| |
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.
| If excess muscle aching occurs, you should cut back on your exercises. |
| | |
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 (TEDS) until your return appointment.
No 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.
If you have to stay alone for the first six weeks, there are some special
devices that are available from the occupational therapist.
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.
Prevention of infection
If at any time (even years after the surgery) an infection develops such as
strep throat or pneumonia, notify your physician. Antibiotics should be
administered promptly to prevent the occasional complication of distant
infection localizing in the hip area. This also applies if any teeth are pulled
or dental work is performed. Inform the general physician or dentist that you
have had a joint replacement. You will be given a medical alert card. This
should be carried in your billfold or wallet. It will give information on
antibiotics that are needed during dental or oral surgery, or if a bacterial
infection develops.
When Do I Return to the Clinic?
Your first return appointment is 6 weeks after discharge, unless you return
here to have your staples removed. (You may wish to have your staples removed by
your local doctor.) At your 6-week return you will be examined and have x-rays.
Subsequent appointments are then at 6 months, one year, and two years after
surgery. You should return every three years after this.
Once you return home, if you have any questions or concerns regarding your
total hip replacement, please do not hesitate to call us at 515-222-3151.
Should I have a total hip replacement?
The total hip replacement is an elective operation; it is not a matter of
life or death. There are always nonoperative alternatives. The decision to have
the operation is not made by the doctor. It is made by you, for it is you who
must accept the risks and complications. The doctor may recommend the operation;
however, your decision must be based upon weighing the benefits of the operation
against the risks. You may wish to discuss the surgery with your own doctor or
even get another opinion. All your questions should be answered before you
decide to have the operation. Please feel free to ask any questions you have in
order to make your decision easier.
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.
Summary
| When you are ready to schedule your surgery, you may want to donate 1
to 2 units of blood or be typed for donated blood. |
| The hospital will contact you the day prior to surgery to tell you
when you should arrive at the hospital. |
| You will be admitted to the hospital on the same day of your surgery. |
| Anesthetic is typically general or spinal, and that is usually decided by
you and the anesthesiologist on the day of your surgery. |
| Surgical time is approximately one hour. |
| The incision is approximately 10 to 12 inches. |
| When you awake from surgery, you will find a pillow between your legs.
This is called an abduction pillow, and you will be in it approximately 8 to
10 days. |
| The average hospital stay for total hip replacement is 3 to 5 days,
depending on your health and home situation. |
| You may walk the day after surgery with a walker or crutches. |
| The staples will be removed 8 to 10 days following surgery. |
| The average healing time is 2 to 3 months. |
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