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
- 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.
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.
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 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.
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:
1. using 2-3 pillows between your legs and not crossing your legs
2. not bending forward 90 degrees
3. using a high-rise toilet seat
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.
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.
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.
- 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.
- 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.
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.
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.
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.
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.
- 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.