Hip Replacement

Why is total hip replacement surgery done?
Total hip replacement surgery is a procedure done to replace all or part of the hip joint with an artificial hip joint or prostheses in order to restore movement. The prosthesis consists of
  • A metal shell with an inner plastic lining that replaces the hip socket (acetabulum)
  • A metal ball that will replace the fractured femoral (thigh bone) head
  • A metal stem that is attached to the shaft of the bone to add stability to the prosthesis

When is total hip replacement surgery done?

Hip replacement surgery is considered imperative when there is
  • Hip pain that has failed to respond to conservative therapy hip osteoarthritis or arthritis confirmed by X-ray
  • Inability to work, sleep, or move because of hip pain
  • Loose hip prosthesis
  • Some hip fractures
  • Hip joint tumours
  • Advanced arthritis or other problems revealed on X-rays

Who are not ideal candidates for total hip replacement surgery?

  • People who suffer from Parkinson's disease or severe muscle weakness are more likely than healthy people to damage or dislocate an artificial hip.
  • People who are at high risk of infections or in poor health are less likely to recover successfully from the surgery.

What are the risks and complications involved?

Complications associated with the procedure rare but may include
  • Thrombophlebitis which is a condition due to formation of blood clots in the veins leading to
        - blood clots in the leg
        - blood clots in the lung
        - urinary infections or difficulty urinating
  • Difference in leg length
  • Stiffness
  • Dislocation of hip (ball pops out of socket)
  • Infection in hip
  • Loosening of the joint
  • Heterotropic bone formation which is bone growth beyond the normal edges of bone

What are the diagnostic tests done before total hip replacement surgery is finalized?

  • A complete history and physical examination by the doctor is done.
  • X-rays taken to determine the extent of the degenerative process and to determine the cause for the degeneration. Additional  tests may be required if there is reason to believe that other conditions are contributing to the degenerative process.
  • MRI Scanning to determine whether avascular necrosis is causing the hip condition
  • Blood tests to detect presence of systemic arthritis or infection in the hip

What are the preoperative procedures for total hip replacement surgery?

  • The patient must try to maintain good health and perform activities to increase upper body strength, which will improve ability to use a walker or crutches after the surgery.
  • Blood tests, EKG and urinalysis is done two weeks before surgery
  • The patient must inform of any illness or medical conditions that develop
  • The patient must schedule an appointment with his dentist to rule out possibilities of an infected tooth or gum which may be a possible source of infection for the new hip.
  • The patient must arrange for assistance at home to help him around the house for a week or two after coming home from the hospital or make arrangements to stay in a rehabilitation or skilled nursing facility for a period of time.
  • The patient must set up a recovery station at home by placing his essential requisites and facilities in proximity to his recuperation area.
  • The patient is scheduled to visit the hospital few days prior to surgery during which the complete medical history, medical conditions or medications being taken are understood.
  • The patient is instructed to stop taking anti-inflammatory medications one week before surgery
  • The doctor provides guidelines on eating and drinking, smoking, taking or avoiding certain vitamins and medications
  • The doctor discusses and advises on options of anaesthesia, surgery, type of facilities and cost with the patient.
  • The patient must arrange for transportation and assistance to leave for home after the surgery.
  • The patient must not shave his legs within 3-4 days of surgery.
  • The day before the surgery, the patient must not eat or drink after midnight
  • A shower, bath or sponge bath must be taken the evening before and morning of surgery making sure to scrub the hip for a period of five minutes, which may require some assistance.
  • The patient is instructed in deep breathing and coughing exercises that must be done every one to two hours after surgery, helping to minimize the risk of lung complications after surgery.

On the day of surgery
  •  The patient may brush the teeth and rinse his mouth without swallowing any water.
  •  The patient is be fitted with elastic support stockings to aid in the circulation of your legs and feet to reduce the risk of blood clots
  •  A blood test is done on the day of the surgery based on which blood drawn about three to five weeks before the surgery from the patient or taken from a donor is arranged, if blood transfusion is required following surgery.
  •  The patient is taken to a presurgical care unit where an intravenous (IV) line is started for fluids and medications during and after surgery and then taken to the operation room.

How is total hip replacement surgery done?

  • An incision is made along the affected hip joint and the muscles and tendons are separated in order to cut and remove the femoral head and cup. 
  • The cartilage is removed from the hip socket where the metal shell is placed and the metal stem is inserted in the aptly shaped and hollowed femur, both fixed in place by either screwing or cementing them.
  • Finally the metal ball is attached to the metal stem and the muscles and tendons are replaced against the bone after which the incision is closed.
  • A large dressing is applied to the surgical area to maintain cleanliness and absorb any fluid.  Drains may be inserted in the surgical area to drain out any fluid accumulated.
The surgical procedure may take two to four hours.

What are the postoperative symptoms and procedures in total hip replacement surgery?

  • Patients do not spend more than 10 days in the hospital after hip replacement surgery.
  • Patients may experience back discomfort due to general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery, which can be relieved by periodic change of position
  • The patient may experience temporary nausea and vomiting due to anaesthesia or medications, which can be minimized by anti-nausea medication prescribed
  • The patient is taken to the recovery room for a period 1-3 hours of close observation during which the blood pressure, pulse, respiration, temperature and circulation and sensation in the legs and feet is monitored.
  • The patient is transferred to his room once his condition is stabilized.
  • The dressing is changed 2 days after surgery.
  • The IV, started prior to surgery, will continue until the patient takes adequate amounts of fluid by mouth.
  • Antibiotics are administered every eight hours, until all drains are out, to reduce the risk of infection.
  • A sterile tube called a catheter inserted into the bladder prior to surgery to insure a passageway for urine is removed the day after surgery.
  • The patient is made to wear compression foot pumps to promote blood flow and decrease chances of blood clots.
  • Medications and exercise instructions are given to prevent clots.
  • The patient is allowed to progress his diet as the condition permits; starting with ice chips and clear liquids to diet as tolerated
  • The day after surgery the patient is assisted to a reclining chair and physical therapy is started that will help the patient to gradually take steps, walk, learn to climb stairs with the aid of a walker or crutches and improve the range of motion and strength of the hip.
  • 1 to 2 days after surgery, a patient may be able to sit on the edge of the bed, stand, and even walk with assistance
  • The physical therapist devises and instructs the patient in a home exercise program
  • Initial rehabilitation takes 3-4 days during which discomfort may be experienced while walking and exercising. Pain medication is prescribed by the doctor to relieve any such discomfort.
  • Following precautions must be taken to prevent dislocation of artificial ball from the hip socket
        - The hospital bed must not be elevated more than 70 degrees during the first few days after surgery as sitting up too high may cause the artificial ball to dislocate from the hip socket.
        - using 2-3 pillows between the legs
        - not crossing legs
        - not bending forward past 90 degrees
        - using a high-rise toilet seat if necessary
        - not turning the toes in toward each other

What are the guidelines for recuperation to be followed?

  • Assistance at home is required for the next six weeks until the energy level of the patient has improved.
  • The patient must continue the medications as prescribed by the doctor. Pain medications prescribed must be taken 30 minutes before exercises
  • The patient must continue to walk with crutches or a walker and follow the exercise regime as directed by the doctor or physical therapist. The amount of weight that can be placed on the operated leg is determined and advised by the doctor.
  • The patient must avoid sitting for more than 60 minutes at a time and take the precautions mentioned earlier.
  • The patient must not bend over to pick up things from the floor for the first eight weeks.
  • The patient is advised not to drive until six weeks following surgery. When getting into a car, the patient must back up to the seat of the car, sit and slide across the seat toward the middle of the car with the knees about 12 inches apart.
  • The patient must avoid sexual intercourse for the next 4-6 weeks.
  • The patient can return to work within two-to-three months, or as instructed by the doctor
  • The patient must continue to wear elastic stockings as instructed by the doctor
  • The staples are removed in three weeks and showers may be only taken two days after
  • The patient must not sit in a bathtub until recommended by the doctor.
  • The patient must keep the incision clean and dry
  • The patient must always carry the medical alert card given to him giving information on antibiotics that are needed during dental or oral surgery, or if a bacterial infection develops.
  • The patient must inform his general doctor or dentist of the surgery prior to any procedure or medication.
  • The patient must return for a follow up 3-6 weeks after surgery during which he is examined and X-rays are taken.
  • The patient must do the home exercises two to three times a day for an indefinite period of time.  If the exercise is causing pain, the intensity must be reduced.
  • The patient must not consider walking as a substitute for exercise.
  • The patient must avoid high-impact activities, such as basketball, jogging and tennis.
  • Full recovery from the surgery takes about 3 to 6 months, depending on the type of surgery, the overall health of the patient, and the success of rehabilitation.
  • The patient must notify the doctor immediately under any of the following circumstances
        - In case of swelling, increased pain, drainage from the incision site, redness around the incision, or fever
        - Exercise is causing pain that is lasting and continuous

What types of exercises are recommended following total hip replacement surgery?

  • The patient must follow exercises devised by the physical therapist which begin with safe range-of-motion activities and muscle-strengthening exercises gradually moving on to on to more demanding activities.
  • The patients must avoid high-impact activities, such as basketball, jogging and tennis as they can damage the new hip or cause its parts to loosen. 
  • Exercises such as cross-country skiing, swimming, walking and stationary bicycling that increase muscle strength and cardiovascular fitness without injuring the new hip are generally recommended.

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