Total Hip Replacement

About

Arthritis leads to the surfaces of the hip joint to wear away. The cartilage layer is damaged and lost and is no longer smooth, this leads to stiffness and pain in the joint. Eventually the joint wears out to such an extent that the bone of the femoral head grinds on the bone of the acetabular socket as most of the cartilage is lost.

The two common types of arthritis are osteoarthritis (generalised wear and tear of the joint which often is age-related or post-traumatic) and rheumatoid arthritis (inflammatory arthritis). The main indication for a hip replacement is worsening pain that has not resolved with nonoperative measures (pain relief medications, weight loss, physiotherapy, etc.) and is markedly affecting your quality of life.

There are various options and implants available for a hip replacement. The implant of choice depends on various factors and is patient specific; age, activity levels, and bone quality are some of the factors considered when choosing the type of implant and bearing surfaces (the actual surface that re-creates the ball and socket portion of the hip joint. The implant options include; cemented implants, uncemented implants, and hybrid hip replacements (where one component is cemented and the other uncemented). When using cemented implants, the bone surfaces of the socket and the femur are prepared and widened appropriately to accept the implants and then a plastic cup is cemented into the socket and a metal component is cemented into the femur. Fixation relies on cement integration into the bone. When using uncemented components, the surfaces of the socket and the femur again are prepared and the implants are snugly fit into the socket and femur in a press-fit type mechanism. Fixation in the longer term relies upon direct bone bonding with the implant. The choice of bearing surfaces include; metal on plastic, ceramic on plastic, and ceramic on ceramic articulations. The operation of choice is designed to replace the worn joint surfaces, thereby relieving pain and improving function. The operation is generally performed through a 15-20cm incision.

Benefits Of Total Hip Replacement

The main benefit of this type of surgery is relief of pain. Patients may also notice an improvement of function, allowing them to walk easier and further. Daily activities should become more comfortable and quality of life improved. Some patients may find an improved range of movement after the surgery all though this cannot be guaranteed.

Before Surgery

Exercises to Do

Being active while you wait for surgery is important. People with a painful hip joint are often afraid to be physically active because they worry they may be doing more harm than good. This is not the case. In fact, research has shown that exercise can help decrease pain, improve leg strength, and help keep your heart in good condition before surgery. If you have not been regularly active, remember to speak to your GP before starting to exercise.

Endurance activities are good for your heart, lungs, circulation, and muscles. Some suggestions for endurance exercises include walking, swimming, or the use of a stationary bike. If you have not been involved in any regular exercise, it is important to start slowly. Your goal is to be physically active every day. Begin with a few minutes and gradually progress until you can exercise at least 3 times per week for 20 to 30 minutes at a time. No matter which activity you choose to perform, you should be able to carry on a conversation or talk comfortably while exercising without increased shortness of breath.

Being involved in an exercise program before your surgery will help in your recovery after surgery. After your surgery, a team of physiotherapists, occupational therapists, and nurses will help you regain your strength, endurance, and improve your overall function.

Walking and leg strengthening exercises are an important part of your rehabilitation after your joint replacement surgery.

Guidelines for Performing your Strengthening Exercises

Repetitions

Each exercise should be repeated several times until you feel some tiredness in your muscle. As you get stronger, you can add more repetitions or sets, continuing to use muscle tiredness as your guideline. If an exercise continues to cause you excessive pain that doesn’t go away, stop doing that exercise.

Frequency

1 – 2 times per day

Duration

Hold the desired position for 5 seconds before releasing.

Exercises for Patients Scheduled to Have Hip Replacement

Please note:

In the instructions, the involved knee/leg indicates the leg which will be undergoing surgery.

What does surgery involve?

You will be asked to come to hospital on the evening or morning prior to your surgery. On arrival you will have your blood pressure, pulse, oxygen saturation level and temperature measured. You will be sized for special stockings (TEDS) which are worn to reduce the risks of blood clots in your legs. The anaesthetist and a member of the surgical team will visit you. They will discuss the proposed anaesthetic and surgery with you again. You will have the opportunity to ask any further questions. Once all your questions have been answered and the procedure has been explained to you, you will be asked to sign a consent form.

Surgery usually takes 1 ½ to 2 hours. You will then be taken to the recovery room, where you will be monitored for about one hour. You will then be taken to your room on the ward.

When you awaken you will find a dressing on the side of your hip and you may have a small drain. The drain is to remove any bleeding from the hip; it usually comes out after 24-48hrs on the ward. A drip will be in your arm. The drip makes up for the lost fluid, which may have occurred in your operation and is used to dispense blood or drugs that you may require. The drip is usually removed 48 hours after surgery. You will be given regular pain relief by the nursing staff in the form of an injection or tablet as required (See below section on pain management after surgery). You may also have a urinary catheter which will remain until you are more mobile.

The recovery from the operation requires about 4 to 5 days in hospital for a THR. In this time, usually the day after surgery you will commence your rehabilitation with physiotherapy. This involves exercises to improve the strength of the muscles and to regain the range of motion of the hip. On the day after surgery your physiotherapist will begin to assist you to get out of bed and walk a small distance. This will be progressed over the next days, until you are independently mobile. They will discuss the safe positions you need to keep your hip in following surgery.

The exercising and mobilising of the hip will cause some discomfort and swelling, however this is normal, and is just part of the healing process. Any swelling and discomfort in the calf muscle should be brought to the attention of the nursing staff.

Complications Related to Surgery

Despite the success of total joint replacement, there is a small risk of developing complications. These complications can develop because of health problems, the anaesthesia or the surgical procedure itself.

Possible local complications include: surgical site infection, damage to blood vessels and nerves, blood loss possibly requiring blood transfusion, bone or implant fracture, increased bone formation around the joint, dislocation of the joint, altered limb length, early wear of the prosthesis, and persistent or worsened pain and stiffness in the joint that was replaced. These complications may require additional surgery to improve your function.

Other medical complications include the risk of developing a deep venous thrombosis, pulmonary embolism, heart attack, stroke and even death.

Although the likelihood of such complications occurring is low, your surgical team will make every effort to minimize the risk as much as possible. Your surgeon, anaesthetist and medical team will discuss these issues with you before surgery. Please make sure all your questions are addressed when you meet with your surgical team.

Infection is a possible complication of any surgery. The risk is reduced through careful surgical technique and the use of antibiotics before and after your surgery. Bacteria can travel through your bloodstream from infection elsewhere in your body to your new joint, i.e. from your throat, teeth, skin or urine. This is why it is important to have all infections assessed and treated before your surgery, as well as after surgery to protect your new joint. Despite protective measures, there is still a chance of developing an infection but this is less than 2%. Normally these are superficial wound infections that resolve with a course of antibiotics. Occasionally serious infections occur that require further hospitalisation and treatment. Sometimes they necessitate removal of the hip replacement for a period of time; antibiotics are administered via a drip for a few weeks, prior to re-implantation of another hip replacement.

Breathing problems such as pneumonia can occur after surgery. It is important to do several deep-breathing and coughing exercises every half hour when awake the first few days after surgery. This helps provide oxygen to your lungs and keeps your airways clear. Sitting up, getting out of bed as soon as possible and being active also helps prevent breathing problems.

Cardiovascular complications (heart problems) can occur due to the stress of surgery. Surgery puts an additional workload on the heart. In patients with known heart disease, this can increase the risk for abnormal heart beats, chest pain or very rarely, heart attack. These complications can also happen in patients with no known heart problems. This is why it is important to have a thorough health assessment before your surgery.

Deep Vein Thrombosis (DVT) are blood clots which can develop in the deep veins of your legs. The rate of this is about 2-5%.This is often associated with lack of movement, so getting out of bed and being active as early as possible is encouraged. It is important to move your ankles up and down several times an hour after surgery. This is called “ankle pumping”. You should also tighten and release the muscles in your legs. These exercises promote good circulation. Anticoagulants (blood thinners) will also be used to prevent blood clots. They are given in either a pill or needle form.

Pulmonary Embolism can occur when blood clots from the deep veins in the legs or pelvis break off, travel up to the lung and lodge there. If the clot is large enough, blood circulation to the lungs may be cut off. This is a serious complication. Anticoagulants (blood thinners) are given after surgery to prevent clot formation. Ankle pumping and early activity will also help prevent this complication.

Urinary Problems, such as difficulty passing urine, can happen following any type of surgery. Sometimes a catheter (soft plastic tube) is placed in the bladder to drain urine. The catheter can be left in place for a few days or removed immediately after the bladder has been emptied. Let your nurse know if you have problems passing urine. Following spinal anaesthesia you may pass some urine without being aware of it. This is normal and can happen during the first few hours until the spinal anaesthesia wears off.

Excessive bleeding: Inevitably some blood is lost at the time of surgery. Sometimes people lose larger volumes of blood and a transfusion may be required. Bleeding is more likely to occur with patients taking aspirin or other anti-inflammatory drugs. They should be stopped at least one week prior to surgery.

Tendon, nerve or blood vessel damage: Very rarely these structures can be injured during the operation. Normally they recover, but occasionally patients may experience extensive bruising or have difficulty moving their foot up and down.

Prosthesis wear/ loosening: Over time the components of the hip replacement can wear out or become loose. This normally presents with worsening pain and may require further surgery to put a new hip in.

Leg length discrepancy: At the time of surgery, we try and get your leg lengths equal and as close to each other as possible. Sometimes this may not be possible and the operated leg may appear slightly shorter or longer than the other. Normally this is not noticeable and doesn’t cause any problems with walking or gait, rarely this may need addressing with an insole or a shoe raise.

Hip Dislocation: The rate of this is about 1-3%. It is very important that you strictly follow the safety hip positions after your operation as advised by the physiotherapist to minimise the risk of dislocations. If your THR does dislocate, you may need a further operation to re-locate the hip and may need a hip brace for a few weeks. If you have recurrent dislocations then you may need revision surgery.

Nausea is common after surgery. Medication may be given to settle your stomach, so let your nurse know if you are experiencing this. In order to minimize nausea, it is important to take your pain pills with food to protect your stomach.

Paralytic Ileus is a distention of the bowel with gas. This can happen when the bowels stop working properly. As a result, gas builds up and causes abdominal discomfort, bloating and vomiting. To prevent this, early activity is important to stimulate your bowels to function normally.

Constipation can occur because pain medication can make your bowels sluggish. Stool softeners are given twice a day to help prevent this. If they are not effective, ask your nurse for a laxative. Make sure your bowels have moved the day before surgery to help prevent problems after surgery. Lots of fluid, a high fibre diet and activity also help.

Allergic reactions can happen after surgery and vary from a mild rash to an intense reaction that can interfere with your breathing. Please let us know if you have any allergies. They will be documented in your medical record. We will also provide you with an allergy alert bracelet to be worn while you are here.

Skin Irritation and bed sores are caused by pressure from lying in bed. It is important to change your position frequently while in bed and to get up as much as possible after surgery. The nurses and therapists will help you.

Confusion and Delirium can sometimes occur in older people after surgery. You may behave differently, and see or hear things that aren’t really there. This usually resolves in a few days, but can last for several weeks. Many things can contribute to this, such as the anaesthetic, pain medication, lack of sleep, and alcohol withdrawal. It is important to let us know if you have experienced this with previous surgeries. Wearing your glasses and hearing aids can help if you experience this. We also recommend that you reduce your alcohol intake several weeks before your surgery. If you have experienced postoperative confusion in the past, it is helpful to have a relative sit with you after surgery.

Death: This is rare and the incidence of this is about 1 in 300.

Remember…

Getting out of bed and walking as soon as you are able will help reduce many of these complications and allow for a smooth recovery.

After Surgery

During your surgery your doctor cuts through the large muscle on the side of your hip. This weakens the muscle temporarily and makes the hip joint less stable; therefore, there are some positions that you must avoid to reduce the risk of dislocating your hip.

When you return to work depends mainly on what type of duties you perform. Most patients do not return to work until at least 6-8 weeks after their hip has been replaced. However, some patients return to work earlier if their job is sedentary in nature, for example, computer work. If you have made arrangements with your employer to return to work within the first 6-8 weeks after your surgery, you will need to bring your assistive devices with you, specifically the raised toilet seat, carry cushion, and reacher to ensure you maintain your hip precautions. You may need to speak to your employer about modifying your work area and duties to keep your hip safe. Talk to any member of your care team if you have any specific questions regarding returning to work post total hip replacement.

Driving a Vehicle

It is recommended that you refrain from driving until hip precautions are discontinued by your surgeon. Driving may be resumed after 6 weeks unless advised otherwise by your surgeon. Check with your insurance company about any concerns you may have regarding coverage when you resume driving.

Passenger in a Vehicle

You will be able to sit in the front passenger seat of most vehicles. You will need to take frequent rest breaks if you are traveling for long distances.

When walking outside in the winter, consider buying an “ice pick”. This is a cleat that flips down and grips securely in snow and ice. It is attached to the end of your cane and helps you to walk more safely. Speak to your physiotherapist if you would like to see or buy one. Make sure that someone keeps all outdoor walkways and stairs clear of ice or snow and that they are well lit.

Resuming an active lifestyle

When you can begin doing your leisure activities following surgery depends on the physical demands of the activity and your stage of recovery. For more information please consult the exercise booklet provided to you by your physiotherapist during your hospital stay.

Activities that may be resumed immediately

Walking
Activities That May be Resumed after 6 Weeks

Swimming – You may be able to swim or do exercises in the pool if your incision is well healed and if you have access to a pool with a graded entry (stairs with hand railing) before the 6 week period. The whip kick is never permitted, however a light frog kick is allowed.
Indoor cycling (stationary bike)
Activities That May be Resumed after 3 Months

Gardening
Outdoor cycling
Curling
Golfing
Activities to Discuss With Your Surgeon after 3 Months

Alpine skiing
Cross country skiing
Tennis – singles and doubles
Weight lifting (lower body)
Activities to Discuss With Your Surgeon after 6 Months

Yoga
High Risk Activities That Are NEVER Permitted

Jogging/running
Squash/racquetball
These lists only include some of the more common leisure activities. Please consult with your surgeon if you are interested in resuming an activity that isn’t listed.

Discharge instruction and follow up

Visit your nearest Emergency Department if you have any of the following:

Shortness of breath or difficulty breathing
Chest pain, tightness or pressure
A significant increase in pain, swelling or redness in your calf/ calves
A sudden, severe increase in pain in your new joint
Notify your surgeon / GP immediately if you have any of the following:

Increased redness, swelling or a sudden increase in bruising around the incision site
Drainage for more than 4 days after discharge
A foul odour or yellow or green drainage at the incision site
Excessive bleeding
Any other signs or symptoms of infection (i.e. bladder infection, tooth infection, etc.)
A persistent increase in your temperature (over 38ºC)
Exercises and activities

It is important to keep active after joint replacement surgery to keep yourself strong and moving well. Balance your activity and exercise carefully with periods of rest. Avoid becoming over-tired or over-working the site of your operation. Gradually increase your activity, e.g. walking, household chores, etc. Follow the instructions you were given by your therapists.

Pain control

Having some pain after your operation is normal. Keep in mind that each person feels pain differently. What is moderately or very painful to some may be mildly painful to others. Pain can be relieved by:

Balancing rest and activity
Using ice to help reduce pain and swelling – use it for 10 minutes at a time for maximum benefit
Elevating your leg above your heart level to help reduce swelling, pressure and pain
Take pain medication as ordered and avoid alcoholic beverages while taking pain medication.
When you are ready, talk to your GP or pharmacist about how to reduce your use of medication.
If your pain is not well controlled, call your GP
Common side effects of pain medicine are constipation, nausea or vomiting, and sleepiness.
Dental and other medical procedures

It is important to let your dentist and other health care providers know that you have had a joint replacement. After your joint replacement, antibiotics should be prescribed before dental work or other surgical procedures to prevent bacteria from infecting your new joint. For some patients, antibiotics may be needed after the two year period (ask your dentist/doctor if this applies to you). Contact your dentist or doctor a few days before any procedure to ensure that you are given a prescription.

What to expect after a joint replacement

Pain & Swelling

It is normal to experience pain and swelling at the surgical site. Over the next 6 weeks, you should feel an improvement in these symptoms. Be sure to take your pain medications as prescribed. You may be able to gradually wean yourself off of your pain medication. Use ice as needed throughout the day (follow the advice of your physiotherapist about the use of ice). A bag of frozen peas wrapped in a kitchen towel makes an ideal ice pack.

General Health

It is normal to feel generally tired and have a poor appetite in the first few weeks after your surgery. Some patients also experience constipation from certain medications. Try not to nap too much during the day to help you sleep better at night. Drink plenty of water and eat fruits and vegetables to help you feel more energetic and prevent constipation.

Exercise

Keep your exercise booklet close and do your exercises 2 to 3 times a day. You should find that in the first 6 weeks after surgery that you feel stronger and the exercises become easier to do. Increase repetitions or sets as you get stronger. Patients who have had hip replacement surgery should continue to make improvement in their range of movement. Stick to the exercises you have been given, they have been designed to maximize your recovery.

Walking

Continue to use your gait aid (e.g. cane, crutches, walker) as your physiotherapist taught you before leaving the hospital. This will help you to develop a normal walking pattern. It is better to walk normally with a cane than to walk with a limp without a cane. Walking with a limp may put more load on your joint replacement, be a hard habit to break even when you have no pain, and your muscles will not strengthen in a pattern that will improve your walking.

Skin Care

It is normal to have some numbness around the area of the surgical incision. This should improve with time.