TOTAL HIP ARTHROPLASTY

What is it?

Total joint replacement is a surgical procedure in which certain parts of an arthritic or damaged joint, such as the hip, knee or shoulder joint, are removed and replaced with a plastic or metal device called a prosthesis. The prosthesis is designed to enable the artificial joint to move just like a normal, healthy joint.

Hip replacement involves replacing the proximal end of the femur (head of the thighbone) and the acetabulum (hip socket). Typically, the artificial ball is made of a strong metal, and the artificial socket is made of polyethylene (a durable, medical grade plastic). In total hip replacement, the artificial joint is composed of metal and polyethylene and it is used to replace the diseased joint. The prosthesis is anchored into place with bone cement or is covered with an advanced material that allows bone tissue to grow into it.

What are the treatment options?

Total hip arthroplasty is usually indicated in cases of severe degeneration of the hip and/or when conservative treatment options have failed to relieve pain. There are several common causes of hip degeneration including:

• Osteoarthritis: a disease process that affects the smooth covering on the ends on the bone that allow the joints to move smoothly.
• Rheumatoid arthritis: a disease caused by an overactive immune system that causes inflammation in the joints that then begins to cause damage to the joint surfaces.
• Osteonecrosis: a loss or decrease in blood supply to the ball portion of the hip joint, which can cause “death” of the hip tissue.

You might consider hip replacement if you're experiencing hip pain that:

• Persists, despite pain medication
• Worsens with walking, even with a cane or walker
• Interferes with your sleep
• Affects your ability to go up or down stairs
• Makes it difficult to rise from a seated position

Procedure Goals

Damaged sections of the hip will be removed and replaced with artificial parts made up of metal and hard plastic. The artificial joint (prosthesis) should help reduce pain and improve hip function.

Risks of the Procedure

The complication rate following joint replacement surgery is very low. Serious complications, such as joint infection, occur in less than 2% of patients. Nevertheless, as with any major surgical procedure, patients who undergo total joint replacement are at risk for certain complications, many of which can be successfully avoided and/or treated.

Blood clots are the most common complication after surgery. Your orthopaedic surgeon may prescribe one or more measures to prevent a clot from forming in the veins in your leg veins. These measures may include a special support hose, inflatable leg coverings, and blood thinners.

Fracture: It is possible that healthy parts of the hip will fracture during surgery. Smaller fractures should heal on their own, but larger fractures may require the use of wires, pins and possibly bone grafts to correct them.

Dislocation: Because certain positions may cause the ball of your new joint to dislodge, it is recommended that you don’t bend more than 90 degrees at the hip and don’t let your legs cross the midline of your body. If a dislocation occurs, a secondary surgery may need to be performed to stabilize it.

Change in leg length: Although the surgeon will do all that they can to avoid this, sometimes muscle weakness around the hip can cause the leg with the new hip to shorten or lengthen.

Loosening: This is rare, but if over time the new joint does not become fixed to your bone or loosens over time, surgery may need to be done in order to fix the problem.

Second hip replacement: Depending on age and activity level, it is possible that your new artificial hip will wear down over time. If this is the case, it is a possible that a second hip replacement would need to be done, although new materials are making artificial hips last longer.

What to Expect

In the days following surgery, your condition and progress will continue to be closely monitored by your orthopedic surgeon, nurses, and physical therapists. Much time will be given to exercising the new joint, as well as deep breathing exercises to prevent lung congestion. Gradually, pain medication will be reduced, the IV will be removed, diet will progress to solid food, and you will become increasingly mobile.

Joint replacement patients are generally discharged from the hospital within a few days and when they are able to achieve certain rehabilitative milestones, such as getting in and out of bed unassisted or walking 100 feet. Whether you are sent directly home or to a rehabilitation facility will depend on your physician’s assessment of your abilities.

On the first day after your surgery, you may get out of bed and begin physical and occupational therapy, typically for several brief sessions a day. These are first steps on your way to getting back into the routines of your life! As the days progress, expect to become more independent using two crutches or a walker.

If you need to work with a physical therapist after your joint replacement surgery, the therapist will begin an exercise program that you can perform in bed and in the therapy department. The physical therapist will work with you to help you gain confidence and increase your range of motion.

To help you gain confidence with your new joint, the physical therapist (or nurses) will also show you:

• How to get out of bed
• How to use the bathroom
• How to get dressed

Leaving the hospital will depend on when you “graduate” from physical therapy. When you leave the hospital, the physical therapist should give you a list of activities, exercises, and “do’s and don’ts” to follow. An occupational therapist or nurse may also be assigned to help with special needs. An occupational therapist may show you how to use certain devices that assist in performing daily activities, such as putting on socks, reaching for household items, and bathing.

You shouldn’t be surprised if you feel a little shaky and uncertain for the first day or two after you’re discharged. However, you should soon get a routine going and gain confidence in your new joint. As with any surgery, expect to take pain medication for a few days/weeks while you are healing.

You may need a walker and/or crutches initially and then a cane for another few weeks or so to give you support. Your doctor or orthopaedic specialist as well as your case manager will be in touch with you, so use these opportunities to ask questions or discuss concerns, and keep your team up-to-date on your progress.

The decision to resume a normal daily routine is one that only you and your doctor or orthopaedic surgeon can make. However, there are some general guidelines that your doctor may give you.

• You should have no restrictions on leaving your home as long as your safety and comfort are assured. Just don’t tire yourself out; a good balance of exercise, rest, and relaxation is best for helping your body heal and gain strength.
• You may need to take antibiotics before dental work (including dental cleaning) and any surgical procedure that could allow bacteria to enter the bloodstream. Ask your healthcare provider whether you will need to take antibiotics at certain times to prevent infection.
• When to resume driving a car, going back to work, and/or participating in sports activities are all highly individualized decisions. Be sure to follow your doctor’s or orthopaedic specialist’s advice and recommendations.

Before Procedure

Arrange to have a friend or relative prepare meals for you or have some prepared yourself ahead of time. Place everyday items at waist level so that you are able to reach them easily without having to bend down or reach up. Think about any modifications that would need to be made to anything in your home.

After Procedure

After hip replacement surgery, you will probably spend no more than three to five days in the hospital. Most hip replacement patients begin standing and walking with the help of a walker and a physical therapist the day after surgery. However, everyone is different, and you should discuss what you can expect with your doctor.

When you leave the hospital, your family will need to bring extra pillows for you to sit on in the car. It will be most comfortable to sit in the front seat. Your physical therapist will show you how best to get in and out.

All of the tubes will be out. All that should remain is a bandage on your wound site. If you have been instructed to use an abduction wedge you will still need to use this at night when you are sleeping.

You’ll need to continue taking medications as prescribed by your doctor. You may be sent home with prescriptions for preventing blood clots, some of which require monitoring through blood draws two times per week. Make sure to take pain medication 30 minutes before exercise. It’s easier to prevent pain than to chase it later.

Your surgeon may recommend taking a multi-vitamin with iron daily for a month. You may also be advised to take 1-2 enteric-coated aspirin daily for 6 weeks and non-steroid anti-inflammatory medication for pain and swelling unless you are on blood thinners such as Coumadin or Lovenox. Check with your doctor about special precautions while on these blood thinning medications.

After hip replacement, you will need to observe some important safety rules to help prevent dislocation. Here are some of the most frequently advised precautions. Review them with your surgeon and discuss how many months you will need to follow these, or any other safety rules prescribed after surgery:

• Don’t bend your hip past 90º
• Don’t cross your legs; keep knees 12-18 inches apart
• Don’t lean forward while sitting in a chair
• Don’t sit on a chair that does not have arms
• Don’t lean forward while sitting in bed
• Don’t sit more than 60 minutes at a time; get up and walk frequently
• Don’t sit on a toilet or commode that does not have handles or side arms
• Don’t let your knee move inward past your navel
• Don’t turn your feet in or out
• Do use pillows between your legs at night to keep your hips properly aligned.

When fully recovered, most patients can expect to return to work with two to six weeks, unless your type of work is not advisable for people with artificial joints. Examples of these include construction work, certain types of carpentry, and occupations that involve repeated high climbing or lifting. You should discuss your situation with your doctor.

You may also be advised to avoid certain activities, including some athletics, as they may place excessive stress your new joint. Examples of these activities include:

• Skiing (snow or water)
• Basketball
• Baseball
• Contact sports
• Distance running
• Frequent jumping

After Joint Replacement, a Good Rule of Thumb is that Acceptable Physical Activities Should:

• Not cause pain, including pain felt later
• Not jar the joint
• Not place the joint in the extremes of its range of motion

The success of your joint replacement will strongly depend on how well you follow your orthopedic surgeon’s instructions. As time passes, you will potentially experience a dramatic reduction in joint pain and a significant improvement in your ability to participate in daily activities. Remember, however, that joint replacement surgery will not allow you to do more than you could before you developed your joint problems.

It’s important to have realistic expectations. For example, artificial joints have limitations:

• Excessive joint “loading” because of the patient being overweight or strenuous activity, such as running and hiking, may injure the artificial joint.
• The artificial joint will not restore function to the same level as normal, healthy bone.
• The life span of the artificial joint is not infinite. It cannot be expected to equal that of normal, healthy bone.
• Adverse effects may result in a need for additional surgery, including revision or removal of the artificial joint.

Rehabilitation Plan- Exercises

It may come as a surprise to you that total joint replacement, patients are encouraged to get up and start moving around as soon as possible after surgery.

When you are medically stable, the physical therapist will recommend certain exercises for the affected joint. Physical therapy is a key part of recovery. The more quickly a joint replacement patient gets moving again, it is more likely that he or she will regain independence just as quickly. To ease the discomfort the activity will initially cause, pain medication is recommended prior to therapy. In addition, the physical therapist will discuss plans for rehabilitation following hospital discharge. Depending on your limitations, an occupational therapist may provide instruction on how to use certain devices that assist in performing daily activities, such as putting on socks, reaching for household items, and bathing. A case manager will discuss plans for your return home and will ensure that you have all the necessary help to support a successful recovery. If needed, the case manager can help arrange for you to have a home therapist.

Frequently Asked Questions

How is a total hip replacement performed?
In a total hip replacement operation, the surgeon replaces the worn surfaces of the hip joint with an artificial hip joint. The worn head of the femur (thighbone) is replaced with a metal or ceramic ball mounted on a stem; the stem is placed firmly into the canal of the thighbone at its upper end. The acetabulum (hip socket) is prepared and implanted with a metal cup and plastic or ceramic insert. The ball and insert glide together to replicate the hip joint.

How long is recovery?
Recovery varies with each person. It is essential that you follow your orthopedic surgeon's instructions regarding home care during the first few weeks after surgery; especially concerning the exercise program you are prescribed. You should be able to resume most normal light activities of daily living within three to six weeks following surgery. Some discomfort during activity and at night is common for several weeks. Complete recovery can take from about three to six months.

While most people will gradually increase their activities and return to doing things like playing golf, doubles tennis, shuffleboard, or bowling, you will be advised to avoid more active sports, such as jogging, singles tennis, and other high-impact activities.

How long does a hip replacement last?
The conventional arrangement of a metal ball into a special plastic (polyethylene) cup has been shown to have positive results over the years. How long it will last depends not only on age, but also a patient's activity level. Newer hip replacement materials using more durable alumina ceramic and titanium have made major advances in hip replacement technology. Demand and activity levels are generally considered when the surgeon works with you to decide which type of hip replacement materials are best for you.

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