Hip > Arthritis > Treatments

    Osteotomy

Preparing for Surgery

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Try to arrange to take home any equipment you will need when you get home from the hospital. This may include a walker, crutches, ice packs or coolers, or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. Try to understand what is involved and what can be expected with the rehabilitation process. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   If possible, discontinue the use of any anti–inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, try to refrain from smoking for at least a week prior to surgery.

   Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable in any case.

   Make sure the orthopedist performing the surgery is board–certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929–7103.

At most medical centers, you will go to "patient admissions" to check in for your open reduction–internal fixation surgery. There may be a separate department for overnight inpatient surgery check–in, so be sure to ask your doctor. After you have checked in to the hospital or clinic, you will go to a holding area where the final preparations are made. The paperwork is completed and your hip and thigh area may be shaved (this is not always necessary). You will wear a hospital gown and remove all of your jewelry. You will meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. In general, you should not eat or drink for eight hours before surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Pack a bag for someone to bring you the day after surgery that contains a full length robe, toiletries, underwear, personal phone numbers you may need, and any other items you would like to have around during your hospital stay. Generally patients wear hospital gowns for the majority of their stay. Therefore, one change of clothing is really all that is necessary. Bring a loose pair of shorts or sweatpants that will fit comfortably over your hip bandage when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

Here is how an osteotomy is performed:

   After anesthesia is administered, which may be regional, or general, the surgical team sterilizes the leg with antibacterial solution.

   Surgeons map out (pre–operatively plan) the exact size of the bone wedge they will remove, either using an X–ray, CT scan, or 3D computer modeling.

   A large six– to ten–inch incision is made along the outside of your thigh.

   Guide wires are drilled into the top of your thighbone, usually below the prominence called the greater trochanter. The configuration of precisely placed wires guides the predetermined bone cuts to match the pre–operative plan.

   A standard oscillating saw is run along the guide wires, removing most of the bone wedge from underneath the top of your thighbone, below the femoral neck and greater trochanter. The cartilage surface on the top of the thighbone (femoral head) is left intact.

   Surgeons usually refine the exposed thighbone surface with chisels until it is smooth.

   The top of your thighbone is then lowered onto the shaft and attached with surgical screws and a plate. The femoral head is then tilted in a new position so that healthy cartilage absorbs more of your body weight when you are walking.

   The layers of tissue in your hip are stapled together and you are taken to the recovery room.

One of the common complications of an osteotomy is that your leg's length is slightly shortened. You may need to wear orthotic devices in your shoes to lift your heal after surgery. An osteotomy is a complicated procedure and has a risk of infection (less than one percent), blood clots (one to five percent), failure of fixation (screws/plate breakage), nonunion (bones do not heal), malunion (bones heal in the wrong position). There also is a slight risk of reduced range of motion, weakness, and persistent pain.

After an osteotomy, you usually will stay in the recovery room for at least two hours while the anesthetic wears off. Your hip will be bandaged with white gauze pads and tape, and may have ice on it. You may have lost a significant amount of blood during surgery and there may be a small amount of bleeding afterward. Depending on your age and the volume of red blood cells in your blood stream, blood may need to be replaced in the recovery room through an IV. To allow fluid drainage, you may also have a small tube (two to three millimeters in diameter) inserted in the incision that usually is removed within 24 to 48 hours after surgery. Drainage tubes attach to a collection device and are vacuum operated. You will be given adequate pain medicine, either orally or through an IV (intravenous) line, as well as instructions for what to do over the next couple of days. Antibiotics and blood thinners (anticoagulants) also may be administered to help avoid infection and blood clots. You should try to move your feet, ankles, and knees while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the recovery room and be admitted for a three to five night stay. The length of your stay varies depending on your post–operative pain control, rehabilitation, and absence of complications. In rare cases, your hip may need to be immobilized in a spica cast. The spica cast attaches around your lower torso/waist and to the thigh of the affected leg. It can be made of casting material (plaster) or as an orthotic (plastic, metal, and foam), much like a knee immobilizer.

Post-op in Hospital

After an osteotomy, some patients remain in the hospital for as long as five days. Some patients may have to stay longer and in rare cases may need to be transferred to rehabilitation centers or nursing homes. Nurses typically apply a fresh bandage two days after surgery. The bandage may need to be replaced once or twice while at home and the nurses can teach you to change the bandage yourself. There likely will be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. Though physicians generally limit weight bearing on your leg, you will be instructed to sit up and move around to help circulate blood. Beginning in the hospital, you probably will need to use a walker or crutches while the reconstructed bones heal for between three and 12 months. Your physician, nurse, or a physical therapist will teach you to use your walker or crutches and begin gentle rehabilitation exercises to avoid muscle atrophy. Your physician usually takes X–rays of your hip before you leave the hospital. Patients usually visit their physicians two weeks after surgery for an incision check and removal of sutures. Patients generally are seen again at six and 12 weeks after surgery. X–rays usually are taken at the 12 week check unless there have been prior concerns. You will probably be instructed to return again at six and 12 months after surgery for more X–rays. Most patients receive a prescription for pain medication. You will be unable to drive a car, so be sure to have arranged a ride home.

Here is what you can expect and how you can cope while recovering at home from a hip osteotomy:

   After this procedure, there is usually pain and discomfort for about two weeks. If needed, take pain medication as instructed. The pain tends to decrease each day after surgery. Check with your doctor if unexpected pain arises.

   Staples are usually removed about two to three weeks after surgery. You may need to change your bandage yourself once or twice during the first week at home after surgery as instructed by the nurses in the hospital. You can normally stop using bandages when the wound is dry.

   Keep your incision dry when showering. Depending on your surgeon's advice, the time you are instructed to keep the incision dry varies, usually from two to three weeks.

   Avoid full weight bearing on your hip without an assistance device (a walker or crutches) until X-rays have shown that your bones have healed. Always use your walker or crutches when moving around.

   Your physician may prescribe a wedge-shaped pillow to be worn between your legs that can act as a splint.

   Gently move your toes, ankles, and knees as much as possible to help circulate blood.

   A balanced diet, iron supplements, and proper hydration can help restore healthy tissue.

   An osteotomy can make it difficult to move around your house and perform even simple household tasks like cooking, bathing, and laundry. Try to have friends or family members available to visit you once or twice a day for several weeks. Generally, most patients are reasonably mobile and self serving by six to 12 weeks. Most household duties should be possible within three and six months. Wheelchairs may be helpful during times of otherwise prolonged standing or during difficult transfers during the first few weeks.

   If you live alone, your insurance company will decide whether you qualify for a nurse. Otherwise, you can hire help through a social worker at the hospital who can put you in contact with nursing and therapy agencies in your area.

   Expect to begin non-weight bearing walking exercises within two days of surgery. You should not remain sedentary because you run the risk of developing blood clots and bedsores. Your physician usually refers you to a physical therapist who can help you learn to walk after surgery.

   Your physician typically evaluates your ability to walk and prescribes further physical therapy as needed.

Most patients can begin stretching and strengthening around six to eight weeks after surgery. Osteotomy relies on bone healing before more vigorous, weight bearing exercises in the gym can begin. Light exercise is one of the most effective ways to relieve arthritis pain by stimulating circulation and strengthening the muscles around your hip. Strong muscles take pressure off the bones so there is less grinding in the hip joint during activities. The key is to work with your therapist to find a balance between low–impact and weight bearing activity. Too much weight bearing can damage your hip, but some weight bearing is needed to increase bone strength. In conjunction with a healthy diet, exercise also can help you lose weight, which reduces stress on your arthritic hip.

STRETCHING

Your physical therapist usually helps you stretch the muscles in your hamstrings, quadriceps, buttocks, groin, and back while flexing and extending your hip to restore a full, pain–free range of motion. Stretching should be continued for the rest of your life. Many patients receive effective pain relief from daily stretching.

AEROBIC EXERCISE

When pain has decreased, physicians generally recommend at least 30 minutes of low–impact exercise a day for patients with arthritis. You should try to cut back on activities that put stress on your hips, like running and strenuous weight lifting. Cross–training exercise programs often are prescribed when you have arthritis. Depending on your preferences, your workouts may vary each day between cycling, cross–country skiing machines, elliptical training machines, swimming, and other low–impact cardiovascular exercises. Walking usually is better for arthritic hips than running, and many patients prefer swimming in a warm pool, which takes your body weight off your hips and makes movement easier.

STRENGTHENING

Strength training usually focuses on moving light weights through a complete, controlled range of motion. Your physical therapist typically teaches you to move slowly through the entire motion with enough resistance to work your muscles without stressing hip bones. Once your physical therapist has taught you a proper exercise program, it is important to find time each day to perform the prescribed exercises.

After an osteotomy, you can prevent or minimize recurrent symptoms as well as slow the progression of osteoarthritis. Until doctors find a cure for osteoarthritis, you remain at risk of continued hip pain after treatment. Maintaining cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic hip than occasional, heavy exercise. You should avoid high–impact or repetitive stress sports, like football and distance running, that commonly cause severe hip injuries. Depending on the severity of your arthritis, your physician may also recommend limiting your participation in sports that involve sprinting, twisting, or jumping. Because osteoarthritis has multiple causes and may be related to genetic factors, no simple prevention tactic will help everyone avoid increased arthritic pain. To prevent the spread of arthritis, physicians generally recommend that you take the following precautions:

   Avoid anything that makes pain last for more than an hour or two.

   Perform controlled range of motion activities that do not overload the joint.

   Avoid heavy impact on the hips during everyday and athletic activities.

   Gently strengthen the muscles in your thigh, groin, and back to help protect the bones and cartilage in your hip.

Non–contact activities and stretching are a great way to maintain fitness and keep joints and bones healthy over time. Exercise also helps promote weight loss, which can take stress off all weight–bearing joints.

Hip osteotomy is commonly used to realign your hip structure if you have arthritic damage in only one portion of your hip. The goal is to shift your body weight off the damaged area to a different part of the ball shaped femoral head, where the cartilage is still healthy. Surgical realignment osteotomy involves predetermined bone cuts that optimize the distribution of your body weight over relatively healthy, normal joint surface. Imagine the ball-shaped femoral head at the top of your thighbone as the planet earth. Arthritis may have destroyed cartilage around the North Pole, where your weight has been pressing it into the hip joint. An osteotomy can rotate the globe in the socket so your weight is stressing North America instead of the North Pole when you are walking. Osteotomy is also used as a substitute for a total hip replacement in active patients who are under 65 years old. Prosthetic hips are known to wear out over time. An osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their hip and can delay the need for a total hip replacement for up to ten years. There are two general types of osteotomy procedures. The common method, called a femoral osteotomy, removes a wedge of bone from your thighbone so that the top of your thighbone angles differently in the socket. Depending on the area of damaged cartilage, the wedge is removed to tilt the ball–shaped femoral head towards healthy cartilage. A less common osteotomy procedure, cuts the pelvis so the socket (acetabulum) can be rotated into a new position. Because this procedure is rarely performed and its use for arthritis is controversial, the following discussion deals with the femoral osteotomy. It is important for physicians to preoperatively asses your hip range of motion. Poor or reduced range can prevent a good outcome and must be considered before embarking on what is considered a major procedure. The time necessary to perform an osteotomy varies depending on the complexity of the deformity or correction that your hip requires. Generally, the operation lasts anywhere from 1 1/2 to 2 1/2 hours.