Hip Replacement

Introduction

The purpose of this handbook is to give you an overview of hip replacement surgery. It will give an explanation the working of your hip joint, explain when surgery is needed, and discuss the options for hip placement. You will learn about what to expect while in the hospital both before and after surgery, and how we will help you return to a normal life style at home.

The Hip Joint

A joint is a junction where two or more bones meet. The hip joint forms where the femur (thigh bone) meets the acetabulum (the socket of the pelvic bone). The top of the thigh bone is ball shaped and fits snugly in the socket formed by the acetabulum. The bones of the hip joint are covered with a layer of smooth shiny cartilage which cushions and protects it allowing for easy, frictionless motion. Cartilage contains no nerve or blood supply and receives its nutrition and lubrication from the fluid contained within the joint, the synovial fluid. It is also not capable of reproducing itself. Surrounding the hip joint is the synovial lining, which produces the synovial fluid. Tough fibers, called ligaments, connect the bones of the joint. They help stabilize and control the joint during motion. Muscles and tendons, which attach muscles to bones, move the joint and also play an important role in keeping the joint stable.

When Joint Problems Arise

The development of total hip replacement began over 40 years ago. Today, over 250,000 people in the U.S. annually undergo hip joint replacement surgery as a means of diminishing pain and stiffness, and restoring mobility.

The most frequent source of debilitating pain is arthritis. It is estimated that 37 million people in the United States have some form of arthritis. That’s one in every seven people, one in every three families. Of the more than 100 types of arthritis, the following three are the most common forms causing joint damage.

Osteoarthritis, commonly termed degenerative arthritis, is a disease that involves the breakdown of tissues that allow joints to move smoothly. The layers of cartilage and synovium become damaged and wear away leaving the bone joints unprotected from wearing against each other. It occurs primarily in people over 60, but can affect people of all ages.

Rheumatoid arthritis, is a systemic disease that may attack any or all joints of the body. It affects women more often than men and can strike young and old. It causes the body’s immune system to attack the synovial tissue (the lining tissue of a joint). The synovial tissue grows very fast covering the joint surfaces which destroys the protective cartilage and the joint surface.

Trauma-related arthritis, which results when the joint is injured, is the third most common cause of arthritis causing joint damage, pain and loss of mobility.

Avascular Necrosis, happens when the blood supply to the ball is temporarily cut off. As the blood vessels make their way into the bone, the bone may weaken and collapse. If this happens, an irregular surface is created. This will cause wearing of the cartilage and subsequent destruction of the joint and arthritis.

When conservative methods of treatment fail to provide adequate relief, hip replacement is considered. Pain, stiffness, and limitation of motion are some of the symptoms which are experienced with arthritis. As cartilage deteriorates it cannot be replenished, so progressively the arthritis becomes worse. The end result is the loss of cartilage over the ends of the bones eventually leaving nothing but bone-on-bone contact. If your x-rays show severe destruction of the joint, you must decide if the degree of pain you experience, and the loss of use is severe enough that you are prepared to undergo surgery.

Today, we can replace your problem hip thanks to technology which has been developed and proven to provide long-term relief. Joint replacement is a remarkably successful operation that has transformed the lives of many people.

Total Hip Replacement

Total hip replacement or “arthroplasty’ is the replacement of the ball and socket of the hip joint with artificial parts called prostheses. There are two components which make up the hip arthroplasty. The femoral component replaces the ball. The acetabular component resurfaces or replaces the socket. These two components are then placed together to give you a functioning hip.

In order to insert the components, the damaged “ball” is removed. The remaining femur is then contoured to hold or support the femoral component which contains the new “ball”. The acetabulum, or socket, is then reshaped to hold the acetabular component. The prostheses may be “fixed” to the bone either biologically (bony in-growth) or by using cement. The new ball and socket are then fitted together and stabilized by your ligaments and muscles, just as your original hip had been.

Hemi Hip Replacement

The hemi hip replacement or “arthroplasty” is the replacement of the ball portion of the hip joint with an artificial part called a prosthesis. The prosthesis or femoral component replaces the ball.

Resurfacing Arthroplasty

In some younger patients, typically 60 years old or younger, the ball of the femur can be resurfaced or capped rather than replaced. The benefit is the removal of very little bone from the femur. The femoral bone is contoured and the prosthesis is placed over the bone. The new ball fits into the socket or acetabulum and is stabilized by your ligaments and muscles, just as your original hip had been.

The Incision

We will make every effort to use the Minimal Incision Surgery cut in the skin. At best, this is a 3” cut. However, please note that if we need to extend the incision in order for us to perform the surgery well, we will not hesitate to make the incision bigger. (The Resurfacing Arthroplasty has to be done through a larger incision, typically 6”- 9”.)

Your Medical Evaluation

Most patients must have a physical exam by their family doctor, internist, or surgeon before surgery. After your physical exam, your doctor will schedule you for pre-admission testing that will take place about one or two weeks before your surgery.

The pre-admission tests will provide your physicians with vital information about your health. You will need to bring your insurance information including referral forms and insurance cards at this time. During your pre-admission tests you will undergo an electrocardiogram (E.K.G.) which measures the activity and health of your heart. Other tests may include x-rays, urine and blood tests. It is important that you inform the medical staff of recent illnesses including colds, sore throats, or flu. If you have dental problems, please report them at this time. To prevent the risk of infection, dental work may need to be postponed or scheduled at least two weeks prior to your surgery. Please discuss this with the medical staff.

Blood Donation

The need for a blood transfusion is uncommon after hip replacement surgery if you begin the surgery with a normal blood count. However, if you are anemic (your blood count is low) prior to surgery, you may need a blood transfusion after surgery. Please discuss this with your physician.

Admission to the Hospital

The day before your scheduled surgery, a representative from the hospital’s admissions office will phone you. They will tell you what time to arrive at the hospital (about 2-3 hours before your scheduled surgery) to complete your admissions paperwork and get prepared for surgery. The evening before surgery, you will be reminded not to eat or drink anything after midnight.

What to Bring to the Hospital

A robe (long or short) that buttons or snaps down the front.
Loose fitting gym trunks and t-shirt for your physical therapy.
After surgery, you will probably wear hospital gowns since it may not be possible to get into pajamas. Women may wear either the hospital gown or their own.
Walking shoes or well-built slippers that will stay on your feet and not slip on the floors. Don’t bring “flip-flops” or high heels.
Books, magazines, stationary, hand crafts or hobbies.
Toiletries.
Walker, crutches, and/or cane if you already have them.

What to Expect the Day of Surgery

The anesthesiologist will speak to you before surgery. You will discuss and choose whether to have a general anesthetic which induces sleep, or a spinal type anesthetic in which the area below your waist is anesthetized. We recommend the spinal anesthesia.
In order to receive medications and fluids, an intravenous (IV) line will be started.
The nursing staff will take your temperature, pulse, respiration and blood pressure.
You may brush your teeth and rinse your mouth, but do not swallow the water.
Your family may visit you the morning of surgery. They should keep the staff at the nurses’ desk informed of their location during your surgery.
You will be asked to empty your bladder.
Only a hospital gown is worn to the operation room.
You should remove jewelry, dentures, wigs, contact lenses and nail polish.
You will be asked to mark your joint with your initials.
Your joint area will be scrubbed and shaved before surgery.
You will be given medicines in the pre-op holding area before surgery.

Family and Friends

The surgical lobby is located near the pre-surgical area, operating rooms, and recovery room. Your family should inform the staff of their arrival in the area and keep the staff posted of their whereabouts at all times. Your family is allowed to see you before you go back for surgery. After you go into the operating room, they will be directed to the waiting area. The surgeon will speak to them following your surgery. It is common for the patient to be in the operating room and recovery room for about four to five hours including the recovery room time.

After Your Surgery: The Recovery Room

You will awaken after your surgery in the Post-Anesthesia Recovery room. You will remain there until you have recovered from the anesthesia, are breathing well, and your blood pressure and pulse are stable. There may be some reactions to the anesthesia and surgery such as nausea, dizziness, sleepiness, pain, etc. If you have any of these problems, the specially trained nurses will administer medication to assist you. Please be aware that you may not remember this experience because of the medicines you have been given.

What to Expect After Surgery

You may have a drainage tube coming through the surgical dressing which is attached to a collection apparatus that will be removed in the first two days after surgery. This system provides gentle continuous suction to remove any blood that accumulates in the surgical area. Some of this blood may be given back to you. In two, or three days, the dressings will be changed.

You will have an abduction pillow between your legs holding them apart. The nurse will help you discover comfortable positions. You may turn with a pillow between your legs. The nurse will encourage you to do ankle pumping exercises every hour to prevent blood clots.

You may be up out of bed the day of surgery with the assistance of the nurses. Please notify the nurses if you want to get up.

An intravenous (IV) line will remain for one to three days to administer antibiotics, fluids and possibly blood. You may begin fluids and eating your meals as you can tolerate them.

To prevent fluids from building up in your lungs, you will receive an incentive spirometer after surgery to encourage you to cough and breathe deeply. This is used every hour while you are awake.

It is normal to feel pain and discomfort after surgery. The nurse should be informed of your pain and medication will be given.

Possible risks that may occur with hip replacement include:

Bleeding
Infection
Nerve injury
Deep Vein Thrombosis/Pulmonary Embolism (Blood Clots)
Dislocation of one of the Prosthetic Components
Wear Debris Cyst formation
Leg Length Discrepancy

Physical and Occupational Therapy

Your hip rehabilitation program begins the day of surgery and is ordered by your surgeon. Isometric exercises (tightening muscles without moving the joint) will begin while you are still in bed. These should be done 10 times per hour while awake. You will be encouraged by your physical therapist to move your ankle and other joints so that you will remain strong, and move about more easily. (For more details, refer to the section in this handout titled “Exercises.”)

These exercises will help you regain strength and mobility. Your therapist and nurses will teach you the safest methods for getting in and out of bed or a chair, and on and off the toilet. You will be taught the do’s and don’ts of joint replacement recovery.

The therapists and you will add walking and exercises which move your hip joint. These exercises will be done twice daily. Initially, the physical therapist and nurses will assist you out of bed to stand at the bedside with the walker. You may progress to a cane or no assistive device as you can tolerate. For your entire hospital stay, you will walk at least two times each day supervised by your therapist and nurse. Your walking distances will gradually increase.

Your therapist will check your progress in therapy daily and will keep your surgeon informed. Pain medication should be taken prior to your physical therapy to allow you to get the most out of your sessions.

Progress

The usual stay in the hospital for hip joint replacement is two to four days. You may go home when your pain is controlled and you are sufficiently independent in therapy. You are not permitted to bend your hip past a 90 degree angle. To accommodate your sitting, there will be a high chair and elevated commode available for your use. This will allow your hip to be higher than or equal to your knee level while sitting. We will order an elevated commode for you to take home. At home you will need a firm chair with arms that you can use.

Your therapists will teach you how to dress, get out of bed without help, and use a walker or crutches. You will continue strengthening yourself in preparation to return home.

It is important for you to adhere to precautions and proper positioning techniques throughout your rehabilitation. Your stitches/staples will be removed ten to fourteen days after surgery. It is not uncommon to still experience pain. Expect your recovery period may last three to six months. Please understand that the quality and rapidity of your recovery is very dependent on your desire to get better and how hard you work.

Preparing to Go Home

Just prior to your discharge, you will receive additional instructions from one of the surgeon’s physician assistants. Until you are told differently you must take certain activity precautions.

As soon as you are home from the hospital, make a follow up six weeks after the surgery, if not already scheduled. (You need to make an appointment for 10 to 14 days after surgery, if you leave the hospital with staples and you don’t already have one.)

Look for any changes around your incision. Contact your surgeon if you develop any of the following:

Drainage and/or foul odor emanating from the incision.

Fever (temperature about 101 degrees F or 38 degrees C for two days).

Increased redness, swelling, tenderness and/or pain.

Take time to adjust to your home environment. It is normal to feel frustrated but these frustrations will soon pass. It is okay to take it easy.

Resuming Activities

Depending upon the physical demands of your job, work may be resumed when authorized by your surgeon. Driving may be resumed once you have attained full weight-bearing, you can move your leg well, and you are not taking pain medicines. Be sure you are comfortable with your strength. Be sure to practice driving in a safe area. Once you are comfortable with your mobility, you may drive elsewhere. Sexual intercourse may be resumed at any time. Always remember the hip precautions.

We encourage you to be active in order to control your weight and muscle tone. You may resume low-impact aerobic activity such as walking, golfing, bowling and swimming as you feel comfortable. Jogging, high-impact aerobics and contact sports are never allowed. Your new hip is artificial and although made of extremely durable materials, it is subject to wear and tear.

Medication/Pain Control

It is normal for you to have some discomfort. You will receive a prescription for pain medication before you go home. If a refill is needed, please call your surgeon’s nurse at least 3 days before you run out of pills. Please contact your surgeon if you have an increase in discomfort or pain.

We will not refill medications after office hours or on weekends. Please allow at least 1 business day for us to get you a refill prescription done for you.

Exercises

Regardless of your age, it is now necessary to regain strength in the muscles which surround your joint. Good muscle strength will help you to walk, climb stairs and get up from a chair. Since your hip had caused you pain, you probably had reduced your walking and exercising before surgery. Although this was necessary to avoid pain in your hip, the muscles that were not used regularly have become weakened. Please do your exercises daily as instructed by your therapist.

ADDITIONAL INFORMATION IS AVAILABLE AT THE FOLLOWING WEBSITES: