Total Hip Replacement

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Content Partner

Introduction to hip replacement surgery 4

The surgery 7

Complications of the surgery 9

Preparation for surgery 13

Hospital stay 15

After surgery 16

Exercise program after surgery 17

After discharge from hospital 26

CONTENTS

4 5

INTRODUCTION TO HIP REPLACEMENT SURGERY What to expect from a total hip replacement

If whether you have just begun exploring treatment option of having already decided with your orthopedic surgeon to undergo hip replacement surgery, this booklet will help you understand the benefits and limitations of this orthopedic treatment. You will learn how a normal hip works and the cause of hip pain, what to expect from hip replacement surgery and what exercises and activities will help restore your mobility and strength and enable you to return to everyday activities.

If your hip is damaged by arthritis, a fracture or other conditions, common activities such as walking or getting in and out of a chair may be difficult and painful. You may even feel uncomfortable while resting.

If a medication, changes in your everyday activities and the use of walking aids are not sufficiently helpful, you may want to consider hip replacement surgery. By replacing the diseased hip joint with an artificial joint, the surgery can relieve your pain and help you get back to employing normal, everyday activities including low risk sports.

First performed in 1960, hip replacement surgery is one of the most important surgical advances of this century. Since then, improvements in surgical techniques and technology have greatly increased the effectiveness and durability of this surgery. Similar procedures are performed on other joints, including the knee, shoulder and elbow.

Your orthopedic surgeon will review the results of your evolution with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. You will be informed about potential risks and complications of hip replacement surgery, including those related to the surgery itself, and those that can occur over time after surgery. These risks and complications are discussed later in this booklet.

An important factor in deciding whether to have total hip replacement surgery understands what the procedure can and cannot do.

The vast majority of individuals who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in the ability to perform common activities of daily living. However, hip replacement surgery will not enable you to do more than you could before your hip problem developed.

Following surgery, you will be advised to avoid some type of activities for the rest of your life, including jogging and high impact sports. You will however be able to participate in low impact sports and activities such as golf and lawn bowls. Even with normal use and activities, an artificial joint [prosthesis] develops some wear over time. If you participate in high impact activities this wear may accelerate and cause the prosthesis to loosen and become painful.

This guide outlines important information, which you and your family need to know about the hip replacement operation. It outlines the operative and postoperative care that you will be given. Our doctors, nurses and physiotherapists are dedicated to making your stay pleasant and your recovery speedy.

Your co-operation and assistance is essential, your stay in hospital will depend on how quickly you recover.

We will be encouraging you to be as independent as possible to accelerate your return to home

THE SURGERYHow the normal hip worksThe hip joint is one of your largestweight-bearing joints. It consistsof two main parts: a ball {femoralhead} at the top of your thighbone{femur} that fits into a roundedsocket {acetabulum} in your pelvis.Bands of tissue called ligamentsconnect the ball to the socket andprovide stability to the joint.The bone surfaces of yourball and socket have a smooth durable cover

of articular cartilage thatcushions the ends of the bones and enables them to move easily.A thin, smooth tissue called synovial membrane covers all remainingsurfaces of the hip joint. In a healthy hip, this membrane makes a smallamount fluid that lubricates and almost eliminates friction in your hipjoint. Normally, all of these parts of your hip work in harmony, allowingyou to move easily without pain.

The operationThe aim of total hip replacement is to replace the head of the femur {ball}

and reline the acetabulum {socket/cup} with man made components.

There are various types of hip replacements and your surgeon would have

discussed with you the type of prosthesis you are likely to receive. It is

occasionally necessary for your surgeon to use a different prosthesis from

the one that has been prescribed.

The standard total hip replacementMost patients require a standard hip replacement. During this operation

the femoral head is removed. A stainless steel ball mounted on a stem

is used to replace the damaged part. The socket is relined with a cup

made of plastic, which sits in a metal shell. The components are fixed to

the bone using a type of medical cement {Methacrylate} in the case of

a cemented hip or by bone growing onto the surface of the implant in

the case of an uncemented hip. This new joint relieves pain, decreases

stiffness and in most cases restores leg length and corrects the limp.

Although the metal-plastic combination is most commonly used, there

are times when your surgeon will choose to use a different combination,

such as highly crossed-linked plastic liner {a new form of plastic that is felt

to be durable} with a metal or ceramic ball head; ceramic with ceramic;

or metal-with-metal. There are advantages and disadvantages with each

form of articulation – long term results are not yet available for the new

type of plastics, ceramic joints have been associated with breakages and

there has been some concern about possible carcinogenic effects and

toxic effects of raised metal ions with metal-on-metal joints as yet there is

no conclusive evidence of these side-effects.

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Arthritis of the hip jointVarious forms of arthritis can affect the hip joint, e.g. osteoarthritis {wear and tear arthritis}, traumatic arthritis or rheumatoid arthritis {an inflammatory form of arthritis} and traumatic arthritis are the most common forms. When the joint is affected by arthritis, the lining of the ball and socket wears off causing pain and stiffness. Early stages of arthritis are usually treated with medication, exercises and walking aids. More advanced arthritis may require total hip replacement surgery for effective long-term pain relief. Your surgeon will help you make a decision about whether to have a total hip replacement or not.

Femoral Head

Acetabular

Greater Trochanter

Lesser Trochanter

Femur

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Total hip surgery is safe and affective. The vast majority of patients who undergo

total hip replacement surgery do not experience complications. Your orthopedic

surgeon and the hospital staff will do their best to minimize the risk of these

complications from occurring. Chronic illness may increase the potential for

complications. Although uncommon, when these complications occur they can

prolong or limit your full recovery.

The following paragraphs describe some of the complications associated

with total hip replacement surgery. This list is not exhaustive and your

surgeon and his clinical assistants would have discussed with you other

possible complications. Please ask your surgeon if you have any questions

about this or other aspects of the surgery.

Anaesthetic complicationsAnaesthetist is the best person to discuss this with your prior to your surgery. If

you have any questions regarding the type of anaesthetic you are going to

receive, or if you have had previous problems with anaesthesia, please do not

forget to let your anaesthetist know. Some medications interact with anaesthetic

agents, so it is necessary for you to inform your anaesthetist of any medication

you are taking.

InfectionThe risk of infection after total hip replacement is between 1-2%. Infection

is more common in people suffering from diabetes, rheumatoid arthritis

and infection elsewhere in the body, such as in the bladder or chest and

amongst patients who have a condition affecting their immune system.

Bone conserving total hip replacementSome patients may be better treated with a hip replacement that

removes less bone. Not all patients are suitable for this form of hip

replacement. In general there are two varieties of bone conserving

total hip replacement.

Hip resurfacing

Neck conserving

Both varieties have only been in use in

recent years. Unlike the standard total

hip replacement, long-term studies

are not yet available. However early

experience with the procedures suggest

that there are some advantages over

the standard procedure. Although the

principles governing this type of hip

replacement is similar to that of the

standard total hip replacement, there are differences in some of the

operative steps.

A brief description of the standard total hip operationThe operation is performed through a skin incision on the side of the

hip. The incision is usually about 15-20 cm long. The length of the

incision will vary according to the requirements of the operation.

The operation generally takes about 1-2 hours to complete. After the

operation, you will be brought to the recovery ward. There will be an

intravenous drip in your arm, as well as a surgical tube connected to

your knee to serve as a drain. You will be given an oxygen mask to

help breathing.

COMPLICATIONS OF THE SURGERY

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Clots in the lungs cause shortness of breath and chest pain. Inform the nursing

staff if you experience such symptoms. Treatment is by oxygenation and

administration of blood thinners {e.g. heparin}.

Fat embolismFat from the bone marrow can reach circulation and could travel to the lungs.

This condition is quite similar to the previous complication of pulmonary

embolism. That is why it is called a fat embolism. The symptoms are quite similar

to those of pulmonary embolism.

Wound complicationsWound necrosis {which means that the wound edges turn black} and wound

breakdown {which means the surgical wound opens up} are two complications

that sometimes occur. When these complications occur, a further operation to

repair the wound may be necessary.

General medical problemsGeneral medical complication can sometimes occur after any major

surgery. These complications include heart attack, stroke, lung collapse,

pneumonia, various heart problems, kidney dysfunction and bed sores.

Pressure soresPressure sores, especially of the heel area, can develop within 24 hours

of lying in bed. They are prevented by avoiding inactivity in bed. It is

necessary that you relieve pressure from the heels and buttocks {sacral

area} regularly. If you notice sensations of burning or pain in pressure area

you should inform your doctor or the nursing staff.

Infection may be superficial or deep. Deep infections are more serious and

further surgical treatment and prolonged hospitalization may be necessary

to combat the infection. Treatment of infection might mean multiple trips to

operating theatre for drainage and cleansing of the wound.

If the infection is deep, your surgeon might elect to remove all the metal

and plastic parts, together with all non-viable tissue. Depending on the

type and severity of infection antibiotics may be administered through

the veins for a period of two to six weeks. When the infection is controlled,

a new prosthesis can then be implanted.

Deep venous thrombosis and pulmonary embolismClotting of the blood in the veins of the legs is a recognized complication

and perhaps the most common complication of total hip replacement

surgery. These clots, unfortunately, sometimes detach and travel in the

blood stream to reach the lungs. This is known a pulmonary embolism.

This is a serious condition and life is sometimes at risk.

Every effort is made to try and minimize the occurrence of these complications.

These measures include daily or twice daily injections of a substance into the

abdominal wall that thins the blood and reduces the risk of clotting. Your

medical condition and other considerations will influence the use and dosage of

this substance {prophylactic anticoagulants}. During surgery a mechanical

compression device is applied to the leg that is not being operated on. This helps

to maintain the circulation.

After surgery you are encouraged to exercise and move your ankles {calf

exercises} as much as possible. Walking and returning back to normal

activity as soon as possible helps to minimize the risk of the complication.

You will be provided with white compressive leg stockings to wear. Usually these

stockings are worn for a total period of six weeks.

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DislocationDislocation of the hip cap, or more rarely dislocation of the plastic cushion {in

a mobile bearing hip replacement} can happen after total hip replacement.

Vessel and nerve injuryThe hip is surrounded by a number of large blood vessels and the main

nerves that supply the lower limb. These structures are always at risk from

stretching or direct injury. Every precaution is taken to minimize the risk of

these structures. The lateral political nerve is at particular risk of injury in total

hip replacement surgery. Other nerves and vessels can be compromised

during surgery. Nerve and vessels injuries can result in long term disability.

It is not uncommon for some superficial sensory nerve to be divided

during surgical exposure of the hip. This can result in altered or reduced

sensation over the around of the hip.

FracturesFractures of the shaft of the femur and the tibial bone occur sometime,

especially when the bones are soft and weak. The complication is more

common during revision hip surgery. Fractures also occur if you sustain a

heavy fall following surgery.

Loosening and wearYour hip replacement is not expected to last forever. More than 95% of hip

replacements are expected to be functioning well after fifteen years from

implantation. You can help to prolong the life expectancy of your hip[ by

looking after it. This means that you should remain active but not over

active. Squatting, heavy impact sports and activities, and running should

be avoided. If the prosthesis loosen or wear excessively, a revision operation may

be needed to treat the problem.

Limp length inequalityYour surgeon will aim to restore the equal length of the legs during the

operation. Minor difference of up to 10mm is not considered clinically

signification. A significant proportion of the general population has such

minor leg length difference and does not suffer any ill effects. Sometimes

for the sake of achieving adequate stability and preventing dislocation of

the prosthesis, your leg, surgeons have to make surgical adjustments that

result in differences in leg length.

LimpMost patients have a mild limp after surgery and for about six months. The

limp usually disappears or at least subsides significantly after six months.

Some limps are permanent.

PREPARATION FOR SURGERYYou are asked to provide your surgeon with information regarding:

Your general health

Medications that you are taking

Allergies

Previous operations

Bleeding disorders

Other bone and joint problems

If you have any infections, your surgery may need to be postponed.

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Day before surgeryIf your operation is in the morning you will be fasting from midnight. If your

surgery is in the afternoon you may have a light breakfast at 8-00am. Before

surgery, a wards-person will prepare your hip for surge and the anaesthetist will

examine and discuss the choice of anaesthetic with you. A nurse will then escort

you to the operating suite. The side for the operation will be marketed before

you leave for the operating theatre. Ensure that the leg to be operated on is

correctly marked.

Night before surgeryYou will be given one packet of anti-bacterial soap solution at the education

class, and it is necessary that you shower the night before and the morning of

your surgery using this soap, as this will cleanse your skin before surgery.

Hospital admissionThe booking office will inform you of the time of your admission and about your

fasting time.

MedicationsPlease make sure you tell the nurse of all form of medications you take.

The nurse will give you a pair of elastic stockings [TEDS]. We will also give

you a small injection [clexane] into your abdominal wall that will prevent

blood clots. This injection is usually commenced after surgery. You will

continue to have this injection the whole time you are in hospital and [if

required] it may continue after discharge.

MedicationsYou should cease taking any anti-inflammatory {arthritis} tablets, or any

medications containing aspirin, three weeks before coming to hospital.

[Note: if aspirin has been prescribed by your cardiologist check with your

doctor before discontinuing use].

You may need panadeine or panadol to help with pain relief during this time.

DietDiet is especially important in times of stress such as surgery. Be sure to

include as many iron rich foods in your diet as possible, example; red

meats, liver, beans, nuts and dried fruits.

If you are overweight, reduce weight will generally help your exercise

program, make you feel better and reduce extra stress on your hip. Avoid

crash dieting however as this is not healthy prior to surgery.

Blood transfusionTotal joint replacement is major surgery, so you may require blood transfusion.

Up to three units of blood may be needed.

Patients wishing to pre-donated antilogous blood, should discuss this

with their surgeon, and then arrange an appointment with Fortis blood bank

HOSPITAL STAY

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Wound careYour wound must stay clean and dry before your sutures are removed.

This means you will need to cover your hip when having showers, for

example plastic bags or covers.

Showering & dressingInitially the nurse will assist you to shower in a seated position using a

commode chair. The nurse will demonstrate how to put on your clothing

more easily, I.e. dressing the affected leg first. You will need help with your

TED stockings, socks and laces for a while.

Duplex dopplerDuring the course of your stay in hospital, a surveillance examination known

as a duplex Doppler will be conducted to diagnose any clots in the vein. This

examination enables your doctor to treat deep vein thrombosis promptly.

EXERCISE PROGRAM AFTER SURGERY

Home and hospital exercise programThe physiotherapist at the education class, to enable you to commence the

exercises before your surgery, will demonstrate a home exercise program. This

will help strengthen the muscles and keep joints mobile, reduce the risk of blood

clots, prevent chest infection and subsequently assist to speed your recovery.

Breathing exerciseRegular deep breathing and coughing practiced in the seated position

will help keep your lungs clear and free from congestion and reduce the

risk of infection.

Immediately after your surgeryWhen you return to the ward from the recovery room, you will have an IV drip in

your arm for volume replacement, antibiotic therapy, and [if necessary] blood

transfusion. After the operation the nursing staff will continue to measure your

temperature, pulse and blood pressure. You will also have a small drain inserted

into your hip. Special air filled calf compressors may be used after your operation

to help your circulation by automatically inflating and deflating.

If you feel up to it, you may have something light to eat.

You will feel very sleepy after your operation so our staff will assist you

with your needs.

Your surgeon or the resident doctor will visit you regularly to discuss your surgery

and progress. The physiotherapist will visit you on the first day and

each day thereafter to help you with your walking and exercise program.

Blood samples will be taken to check your condition after surgery and you

will be able to resume your normal medications. You will also be given regular

pain relief medication to maintain your level of comfort. During the first 2 days

you are likely to be prescribed narcotic pain medication, as they are most

effective in controlling pain some patients experience drowsiness, nausea and

vomiting when given narcotic medication less regularly.

We will organize a normal diet for you as soon as you feel ready. The nurse

will check the dressing on your wound daily and remove the small drain

from your wound upon the doctor’s instructions.

AFTER SURGERY

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Take ten deep breaths; hold each breath for 3 seconds, followed by a

strong cough each hour.

Smokers should stop smoking two will be cleared of phlegm, as to

following surgery.

Activity program after surgeryExercise is a critical component of your recovery, particularly during the

first few weeks after surgery. You should be able to resume most normal

light activities of daily living within three to six weeks after surgery. Some

discomfort with activity, and at night, is common for several weeks.

Your activity program, which deigns during your hospital stay, should

include:

A graduate walking program initially in you home and later outside.

Walking program to slowing increase your mobility and endurance.

Resuming other normal household activities.

Resuming sitting, standing, walking up and down stairs.

Specific exercises several times a day to restore movement.

Specific exercises several times a day to strengthen your hip joint.

Outpatient physiotherapy.

Hip strengthening exercise program

StairsWhen walking up the stairs, you always put your non-operated leg up

first, by your operated leg and walking aid together.

When walking down the stairs, you need to put the operated leg and

walking aid down first, then followed by your non-operated leg.

Precautions

Static quadriceps

Ankle Range of motion exercises

Static gluteals

20 21

Hip range of motion

Hip abduction

Standing hip flexion

Standing knee flexion

Standing hip extension

Standing heel raises

22 23

Hip abduction in side lying

Standing mini squats

The golden rules

Observe these rules regarding use of your new hip for always

Do not bend hip more than 90 degree

Do not cross the operated leg across the midline of your body

Do not roll or turn your

operated leg inwards

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You may feel numbness in the skin around the incision. You also may feel some

stiffness, particularly with excessive bending. These differences often diminish

with time and most patients find these are minor compared to the pain and

limited function they experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports

and some buildings. Tell the security agent about your hip replacement

if the alarm is activated. You may also ask your orthopedic surgeon for a

card confirming that you have an artificial hip.

After surgery, make sure you also do the following:

Participate in a regular light exercise program to maintain proper

strength and mobility of your new hip.

Take special precautions to avoid fall and injuries.

Notify your dentist that you have had a hip replacement. You should

be given antibiotics before all dental surgery for the rest of your life.

Should you sustain cuts or abrasions on the leg ensure that they

receive proper medical attention. Infection from sores or wounds in

the leg could cause an infection in the hip joint.

Urine infection should also receive prompt medical attention.

See your orthopedic surgeon for routine follow-up

examinations and x-rays.

Walking aids

Managing steps

Crutches Rollator Pick up Frame Pick up with Wheels

When walking up stairs

When walking down stairs

How is your new hip different

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Daily activities and managing at homeThe physiotherapist will discuss with you how to manage daily activities at home

after your operation. Here are a few hints to make sure you will be safe and

independent at home.

Safety Make sure there is a clear passageway around your home

Remove loose mats/rugs from the floor

Making sure there are no electrical cords lying across the floor

Use a firm chair with arms – make sure it is not low

Transport Allow plenty of room and sit in the front seat

Ask your physiotherapist to show you the correct and easiest way of getting

in and out of the car

Ask your doctors first before driving

Sexual activity Let your partner take an active role

You may find some positions more comfortable than others due to the

discomfort of your wound

Rest Plan to have frequent rest breaks during the day

Showering A shower is preferable to bath because it is easier to get in and out

If you have a shower over the bath, your may need to use a bath board

and a hand held shower.

This can be arranged if necessary

Before leaving the hospitalYour doctor will discharge you from hospital depending on your

condition and mobility.

We request that you be capable of:

Getting out of bed and a chair

Going to the bathroom

Attending to your own toilet and showering needs

Walking with the assistance of an aid for about 50-60 meters

Walking up and down stairs with assistance of an aid

Knowing your hip precautions

We will be giving you

A prescription for your discharge medication

A follow up appointment to see your specialist

A referral to a physiotherapist [if required]

Form for Doppler test [if applicable]

AFTER DISCHARGE FROM THE HOSPITAL

Going homeYou will need continue to do your exercise after leaving hospital. Your surgeon

will see you 2 weeks after leaving hospital, where he will remove your sutures.

Warning signsIf you develop any of the following symptoms you must immediately

contact your surgeon or Fortis hospital by phone on or go to

the emergency department at Fortis hospitals:

Chest pain

Pain or swelling in the calf

Wound becoming red or oozing

Pain not relieved by medication

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Sit down to shower

Always use a non-slip mat

Don’t use a tap or soap holder to hold onto as they may be slippery

and are not strong enough

Use soap on a rope or soap in a stocking to save picking up dropped soap

Dressing Sit down to get dressed

A long handled shoehorn will help you to put shoes on

A sock gutter will help you to put socks on

Avoid crossing your legs

An easy reacher or long handled BBQ tongs will help you to pick up

objects off the floor

House hold tasks Avoid pitting thing on the floor. Put them on a bench or table

Use long handled aids such as BBQ tongs

Avoid bending and lifting. Store items used daily on a bench or at waist height

Plan to do small tasks each day and not everything in one day

Washing Wash in small quantities

Use a trolley instead of carrying the basket the basket

Keep pegs at working height

Ironing Using an ironing board

Sit on a stool

Bed making Have your bed moved from the wall for easy access

Use fitted sheet and continental quilts if available

Avoid extension and hip flexion when tucking in sheets and blankets.

If you or your families have any concerns about managing at home after

your operation, please discuss these with your nurse or physiotherapist.

DrivingYou can resume driving following advice from your surgeon. Depending

on your type of surgery this could be between 2-4 weeks.

Home safety checklistAfter surgery, you’ll have special needs. You’ll need to be careful getting

around your home. You’ll need to prevent accidents.

Read each item in this checklist carefully. Correct any item you think are

problems in your home. Remember, only you can prevent accidents that

prolong your recovery.

Walking Remove throw rugs whenever possible to avoid tripping

If you can’t remove throw rugs, use rugs with non skid backing to

avoid slipping.

Make the transition between types of flooring [such as wood floor to

carpeted floor] as even and

Secure as possible to prevent tripping

Stairs The rise between step should ideally be no more than 5 inches/ I 5cm

Make sure handrails are well- anchored [or install handrails] on both

sides of the stairway.

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Bathroom safety

Toilet Use an elevated toilet seat or commode to ease getting on and off the toilet.

Install grab bars around the toilet if you need more support getting on

and off of the toilet.

Bath Install skid- resistant strips or a rubber mat

Use a bath seat of it is difficult to stand during a shower or too difficult

to get up out of the bath.

Install grab bars on the side of the bath or shower for balance.

Install hand- held shower.

Do not use the soap disk or towel bar for balance as these can easily

pull put of the wall.

Remove sliding shower door.

Doors Avoid locking bathroom doors or use only locks that can be opened

from both sides when you.

May need assistance in the bathroom.

Non skid treads can be placed on wooden stairs to prevent slipping.

Make sure carpets on stairs is secure

Furniture layout Arrange furniture so that pathways are not cluttered

Chairs and tables need to be sturdy and stable enough to support a

person learn on them

Avoid furniture with sharp edges and corners. If furniture does have

sharp edges or corners, pad it.

Chairs with arm rests and high backs provide more support when

sitting and more leverage when getting in and out of a chair

Beds/ chairs should be 19-21 inches/ 47 – 53cm from the floor lighting

Be sure that your lighting is ample to prevent falls and assure that you

can read medication

Labels and instruments easily

Light switches should be immediately accessible upon entering a room

Good lighting for hallways, stairs and bathrooms is especially important

Medicines Keep medicines out of reach of children’s.

Dispose of expired medicines properly. Flushing them down the toilet

is usually a safe method.

Sliding glass doors Mark sliding glass doors with stickers to prevent someone from walking

through them.