Total Hip Replacement
Preparing for Surgery
For a healthy recovery,
the decisions you make and the actions you take before
your surgery can be as important as the procedure itself.
Getting a second opinion from another qualified surgeon
is often advisable, particularly in rare or unique cases.
to your return home from the hospital, make sure that
you have received any equipment you will need when you
get home. 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 before you go home from
the potential risks and benefits of the surgery, and
ask your surgeon any questions that will help you better
understand the procedure. It can also help to talk to
someone else who has undergone the same surgery.
physical problems or changes in your overall health,
such as a fever or infection, should be reported to
your surgeon, and you should notify your surgeon of
any new medications you are taking.
the weeks prior to surgery, your physician may recommend
that you donate some of your own blood to be used for
transfusion after surgery. Your physician will instruct
you about where and when you can donate blood.
possible, discontinue the use of any anti–inflammatory
medicine, especially aspirin, a week prior to surgery,
to prevent excessive bleeding during the procedure.
reduce the risk of infection, improve healing, and decrease
complications, try to quit smoking or decrease the amount
you smoke. In general, smokers have a higher infection
and complication rate overall.
possible, practice walking with your walker or crutches
in case you need to use them after surgery.
sure your orthopedic surgeon is board–certified.
This can be determined by calling the American Board
of Orthopaedic Surgery at 919-929-7103.
You may be instructed to go to the hospital for pre–admission
testing a few days before surgery. A nurse will review
your medical history and provide you with all the preoperative
instructions you need. You will be asked about your
past medical history, given a complete physical exam,
and undergo the appropriate routine blood and urine
tests and diagnostic studies, such as X–rays and
an electrocardiogram. If you are taking any medications,
you will receive instructions about the appropriate
dosing prior to your surgery.
At most medical centers, you will
go to "patient admissions" to check in for
your operation. There may be separate check–in
areas for ambulatory outpatient (patients go home the
same day after surgery) and for overnight inpatient
surgery. Be sure to ask your doctor or one of his assistants
about this. After you have checked in to the hospital,
you will go to a holding area where the final preparations
are made. The mandatory paperwork is completed, and
your hip and thigh area may be shaved (this is not always
necessary). You will be asked to change into a hospital
gown and, if applicable, remove your watch, glasses,
dentures, and jewelry. You will have the opportunity
to speak with your orthopedic surgeon or one of his
assistants and 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. Unless requested, most patients are not sedated
until they go into the operating room. Here are some
important things to remember for the day of your surgery:
will probably be told not to eat or drink anything after
midnight on the night before your surgery. In general,
you should not eat for eight hours before surgery. This
will reduce the risk of vomiting while you are under
usually wear hospital gowns for most of their stay.
Pack a bag for that contains toiletries, underwear,
personal phone numbers you may need, and any other items
you would like to have during your hospital stay. Bring
at least two changes of clothes and a loose pair of
shorts or sweatpants that will fit comfortably over
your hip bandage when you leave the hospital.
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.
During a total hip replacement surgery,
your orthopedic surgeon will replace the damaged parts
of your hip joint with artificial materials. Using the
same muscles, ligaments, tendons, and soft–tissue
structures as before, the artificial components and
materials used in a total hip replacement may enable
your hip to move normally. Generally, a metal or ceramic
ball (femoral head component) is designed to fit closely
and move easily within a plastic or ceramic socket (acetabular
component). The metals vary and can include alloys of
cobalt, chrome, titanium, or stainless steel. The plastic
material is ultra high–weight molecular polyethylene
(UHWMPE), a material that is extremely durable and wear
resistant. In many cases, bone cement (polymethylmethacrylate)
is used to anchor the artificial components into bone.
In general, cement is used in older, less active patients
with weaker bones, who are unlikely to need later revision
surgery. Cement provides immediate mechanical fixation.
"Cementless" joint replacements have also
been developed. Cementless joint replacements depend
on a tight, intimate fit directly between the prosthesis
and bone. Bone grows into crevices within the surface
of the prosthesis; this provides a "biologic"
fixation that can potentially last a lifetime. This
process takes time, and your orthopedic surgeon may
limit the amount of weight that you can place on your
hip while this occurs. While the bone grows into the
prosthesis, you may experience some thigh pain, but
the prosthesis may be easier to remove with less bone
loss should later revision surgery be necessary. In
general, cementless joint replacements are used in younger,
more active patients who may require later revision
surgery. The advantages of cemented hip replacements
include stable fixation that allows immediate full weight
bearing on the operative hip and a decreased risk of
fractures during surgery. The disadvantages of cemented
hip replacements include difficulty removing cement
if later surgery is needed. You and your orthopedic
surgeon can weigh the pros and cons of each type of
total hip replacement to decide which is best for you.
In general, total hip replacements take two to three
hours to perform. The length of the surgery will depend
on many factors, including patient size, degree of preoperative
deformity, and the use of cemented versus cementless
general anesthesia is administered, the surgical team
will position you on the operating room table, pad your
bony prominences, and cleanse your skin with antiseptic
on the patient's size and the surgeon's preferred surgical
approach, an eight– to 14–inch skin incision
is made over the back, side, or front of your hip.
joint capsule and underlying soft–tissues, such
as ligaments, muscles, and tendons, are divided and,
if necessary, cut away so your surgeon can access your
surgeon uses devices called retractors to hold the sides
of the wound open.
dislocating the hip to expose the ball (femoral head)
and socket (acetabulum), your surgeon will remove the
arthritic femoral head and a portion of the neck with
a special oscillating bone saw.
dome shaped instrument called a reamer is then used
to remove the arthritic cartilage layer from the acetabulum
and to create a smooth, hemispherical socket that will
accommodate the artificial acetabular cup.
the artificial acetabular component is made of a metal
backing with a plastic liner (metal–backed). These
metal–backed acetabular components are secured
in place by a "press–fit" technique.
Press–fitting prepares a space and then fills
it with an object of a slightly larger size. For example,
if one places a large peg in a small hole, the large
peg will be difficult to remove.
some cases, screws provide additional stability and
fixation to the artificial acetabular component. Sometimes,
the artificial acetabular cup is made of only plastic
and is held in place by cement.
rasps are used to hollow out the center (marrow canal)
of the upper thighbone (proximal femur) to make a space
for the artificial femoral stem to be implanted. The
rasps are used as trials before implantation of the
final femoral prosthesis. Different trial plastic liners,
femoral heads, and stems are placed in your hip socket.
the trial parts are in place, the femoral head is placed
back (reduced) into the acetabular component. Your hip
is then moved through different positions to assess
motion, stability, and leg length relative to the other
leg. The best combination of trial components is determined,
and the correspondingly sized final components are selected.
not done previously, the final plastic liner for the
acetabular component is placed in your new hip socket.
the artificial femoral stem is to be cemented, cement
is prepared and inserted into the hollow marrow canal
previously prepared by rasps. The artificial femoral
stem is then inserted into hollow marrow canal now filled
with cement. The cement is allowed to harden.
a cementless femoral stem is to be used, the final artificial
femoral stem is carefully inserted into the hollow marrow
final femoral head component is attached to the top
of the final femoral stem. The femoral head is reduced
into the acetabular component. A final check is made
to ensure that the new hip has adequate motion and stability
and that the leg lengths are approximately equal.
some cases, a drain that exits your skin may be placed
into the wound to prevent fluid from collecting.
ligaments, tendons, and muscles of the hip are repaired
with sutures to provide maximal function. If they prevent
the hip from obtaining adequate range of motion, they
are released and left unrepaired, excised, or transferred.
layers of the wound are repaired with sutures, and the
skin layer is held together with staples. A dressing
is placed over the wound and around the drain exit site.
You will then be transported to the recovery room.
After a total hip replacement, you
will be transported to the recovery room where you will
be closely observed for 1–2 hours while the immediate
effects of anesthesia wear off. Your hip will have white
gauze pads and tape over your wound. You may also have
a tube exiting from underneath your dressing that is
a drain to prevent fluid from accumulating within your
wound. This drain is usually removed within two days
after surgery. If you have lost a significant amount
of blood during or after surgery, you may require blood
transfusions. It will depend on the amount of red blood
cells in your blood stream, your age, your past medical
history, your present medical status, and anticipated
future blood loss. Your doctors will discuss the relative
risks and benefits of a blood transfusion with you and
make recommendations. Together, you and your doctor
can decide upon what is best for you. However, the ultimate
decision is yours. After surgery, you will experience
some pain. Adequate pain medications will be prescribed
for you. You will either be given an IV patient–controlled
analgesia (PCA) device, a device that delivers pain
medications in safe amounts when you push a button,
or prescribed oral, IV, or intramuscular pain medications
when you ask for them. Some patients have difficulty
urinating after anesthesia and may have a tube called
a urinary catheter inserted into your bladder that allows
urine to leave your system. The urinary catheter is
usually removed within one to two days after surgery.
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
an anesthesiologist, will determine when you are ready
to leave the recovery room and be transported to the
hospital ward for further post–operative care.
In some cases, you may be transported to a ward for
intensive care or heart monitoring if you have special
post–operative medical needs.
After a total hip replacement, most
healthy patients remain in the hospital from three to
five days. However, some patients may require a longer
stay in the hospital due to pre–existing medical
problems, medical issues that may arise after surgery,
or the need for further inpatient rehabilitation. Patients
are not sent home until they demonstrate that they are
safe to go home. Patients should be able to perform
the basic activities of daily living without assistance
or with minimal assistance. Each patient is different
and may have different criteria for being able to go
home. If you require further inpatient rehabilitation,
you may be transferred to a rehabilitation hospital
to receive further physical and occupational therapy.
If you do not have help at home, you may be transferred
to a nursing home or extended care facility until you
are able to go home and live on your own with minimal
assistance from friends, family, or a visiting nurse.
Your surgeon or nurse will change your surgical dressing
one to two days after surgery. Thereafter, your dressing
will be changed as needed. As you get further from your
surgery, dressing changes will become less frequent.
Once your wound has dried, dressing changes are usually
discontinued. After you are discharged from the hospital,
you may have to perform dressing changes at home. Dressing
changes can usually be done by the patient alone or
with some help from a friend or family member. Prior
to your discharge, your surgeon or nurse can teach you
how to correctly change the bandage yourself. After
surgery, you will receive fluids, medications, and,
if necessary, blood products through an intravenous
(IV) line. You will continue to receive fluids through
the IV line until you can drink an adequate amount of
fluids without nausea or vomiting. Then your IV line
will be capped off with the IV line remaining in place
so that you can move around freely without an IV pole
and continue to receive medications and blood products
as needed. If a patient has poor IV access or requires
multiple ports for IV access, you may require placement
of a central line, such as a triple lumen catheter that
is inserted in the neck and has three ports. You may
be instructed to use a wedge–shaped foam pillow
called a hip abduction pillow that helps keep your legs
spread apart and held in a more stable position. These
pillows protect against dislocation. Be sure to ask
for pain medications as soon as you feel pain coming
on because medications are most effective on pain that
is building rather than on pain that is already present.
Your nurses will not give you more than your doctor
has prescribed and what is considered to be safe. One
of the more common and potentially life–threatening
complications of total hip replacement is a blood clot
in the legs, called deep venous thrombosis (DVT). Many
measures are taken in the attempt to prevent this complication,
including the use of elastic stockings, sequential compression
stockings or foot pumps, early mobilization, and anti–coagulation
(blood–thinning) medications. Most patients are
fitted with elastic stockings that prevent blood from
pooling in the legs while you are less active than normal
after surgery. These elastic stockings are worn during
your hospital stay and for a few weeks or months after
surgery until you are active again. Sequential compression
stockings and foot pumps automatically inflate and deflate
on an interval basis to mechanically circulate blood.
Early mobilization also helps to circulate blood and
is beneficial to your heart and stomach function. Usually,
you are allowed to bear weight as tolerated after total
hip replacement surgery, especially on cemented replacements.
Some patients who have cementless hip replacements require
partial weight bearing for four to six weeks. In general,
walkers and crutches are for balance and safety, except
for patients who need partial weight bearing. Your physician,
nurse, or physical therapist will teach you how to move
around with the aid of a walker, crutches, or appropriate
assistive device. With help you can safely perform activities
of daily living, learn what activities and positions
are safe, and start rehabilitative exercises to regain
strength, stamina, and motion. Certain positions are
unstable for your new hip, depending on what surgical
approach was used. In general, the extremes of range
of motion are unsafe. Your physician will obtain X–rays
of your new hip before you leave the hospital. Patients
typically return two to three weeks after surgery for
staple removal then at three, six, and 12 months followed
by annual visits. This routine varies from surgeon to
surgeon. X–rays are not necessary on each visit,
unless some new problem has arisen. Arrange for someone
to drive you home when you are discharged.
what you can expect and how you can cope while recovering
at home from a total hip replacement:
this surgery, it is normal to have some pain for two
to three weeks. You will probably need pain medications
during this period, and you should take them as instructed.
The pain tends to decrease each day after surgery. Check
with your doctor if pain increases dramatically.
are usually removed two to three weeks after surgery.
You may need to change your dressing by yourself or
with the help of a family member or friend at home as
instructed by your surgeon. Prior to being discharged
from the hospital, you will be taught the proper way
to change your dressing. Usually, you can stop placing
dressings over your wound when the wound is dry.
should keep your wound dry and sponge bathe until your
surgeon tells you that you may begin showering. Depending
on your surgeon's protocol and how well your wound is
healing, the length of this period of time can vary
from one to three weeks.
applicable, follow the weight bearing instructions given
to you by your surgeon.
to use the walker, crutches, or other assistive devices
as instructed by your surgeon. They will help you with
balance and safety.
a period of four to six weeks after your surgery, your
surgeon may instruct you to continue to keep a wedge-shaped
pillow between your legs when you are sitting or sleeping.
surgery, you will be instructed on what activities and
hip positions you should avoid. You should usually avoid
crossing your legs and flexing your hips greater than
90 degrees, which is the position where your knees are
at the same height as your hips. This means that activities
such as bending over to tie your shoes, trying to pick
up objects from the floor, and sitting on low chairs
and toilet seats should be avoided for about six to
eight weeks. Often, you will be provided with long-handled
devices to assist you with picking up objects and putting
on stockings and shoes.
move your toes, ankles, and knees as much as possible
to help circulate blood.
balanced diet, vitamin supplements, proper hydration,
and exercise may help you recuperate and get you back
on your feet again.
total hip replacement 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. If you live alone
and are unable to do everything on your own, you may
need a short stay at an extended care facility, nursing
home, or require occasional visits from a visiting nurse.
at home, continue to walk and exercise as instructed
by your surgeon and physical therapist. Your surgeon
will likely refer you to a physical therapist to begin
supervised strengthening and stretching exercises within
a week of surgery. Physical therapy can usually begin
when soft tissues around your hip have healed and motion
does not cause pain.
some patients are able to regain their strength, motion,
and mobility without supervised physical therapy, your
surgeon and physical therapist can evaluate your progress
at regularly scheduled follow-up appointments and prescribe
further physical therapy as needed.
surgeon will schedule regular follow-up visits to evaluate
your progress and to ensure your prosthetic hip functions
Physical therapy is beneficial after
surgery to teach you the proper way to move around as
instructed by your surgeon with the aid of a walker,
crutches, or other assistive device. You can learn exercises
that will help you to regain your strength, motion,
and stamina, and to safely perform daily living activities.
Many patients prefer an easier–to–use walker
or a "quad cane," a special type of cane attached
to a broad base with four small "feet" that
is more stable than a standard cane. Physical therapists
can help you to become independent – able to walk,
sit, stand, and climb stairs – faster than you
would on your own. Stretching and strengthening exercises
are begun after surgery and gradually advanced as hip
soft–tissues heal and as you can tolerate the
activities. The length of your rehabilitation may vary
according to your age, other medical problems, general
health, and healing potential. Exercise is necessary
because it is good for your overall health. Exercise
improves your mental health, cardiovascular health,
and musculoskeletal health. Exercise will strengthen
the muscles, ligaments, and tendons around your hip.
The key is to work with your therapist to find an appropriate
balance between low–impact and weight–bearing
activities. Too much high–impact activity and
exercise can decrease the life expectancy of your artificial
hip, but some weight bearing is needed to maintain bone
density. In conjunction with a healthy diet, exercise
also can help you lose weight, which reduces stress
on your artificial hip.
Your physical therapist will help you safely
regain range of motion of your new artificial hip. Some
patients receive pain relief from daily stretching.
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 is better for arthritic
joints than running, and many patients prefer swimming
or walking in a pool, which takes body weight off your
joints and provides greater resistance and more strenuous
exercise without further loading your joints.
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 your prosthesis.
Once your physical therapist has taught you a proper
exercise program, it is important to find time each
day to perform the prescribed exercises.
If a patient has osteoarthritis or
degenerative joint disease exclusively in the hip, then
a hip replacement will prevent further arthritic damage
because the arthritic joint surface is gone. However,
the actual cause of osteoarthritis is not known. Physicians
are not sure how to slow arthritis down or hinder its
spread. Light, daily exercise is much better for a prosthetic
hip than occasional, heavy exercise. It is always important
to avoid hip injuries. Falls and trauma to a total hip
replacement may damage your prosthesis and require later
revision surgery. The most common reason for revision
total hip surgery is loosening of the components from
your thighbone or pelvis due to stress, overuse, or
osteolysis (bone absorption around the components).
You should avoid high–impact or repetitive stress
sports, like football and distance running, that repetitively
load your joints. 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 halt progression and decrease
your osteoarthritic pain. To help prevent the progression
of osteoarthritis, physicians generally recommend that
you take the following precautions:
anything that makes pain last for more than an hour
controlled range of motion activities that do not overload
heavy impact on the hips during everyday and athletic
strengthen the muscles in your thigh, groin, and back
to help protect the bones and cartilage in your hip.
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 your hips.
| Treatment Introduction
Total hip replacement (also known
as hip arthroplasty) is one of the great medical advances
of this century. In this procedure, an orthopedic surgeon
replaces an arthritic or damaged joint with an artificial
prosthesis. A total hip replacement replaces the bones
in your hip – the top of the thighbone (femoral
head and neck) and the pelvis socket (acetabulum) –
with metal and plastic parts that mimic the shape and
lubricating function of a healthy hip. Your new artificial
hip is implanted with the goals of decreasing pain and
deformity. A prosthesis can increase function without
disturbing muscle strength, sensation, and stability.
Tendons and ligaments that help hold your hip in place
usually are repaired to provide maximal function. However,
if they are contracted and prevent your hip from obtaining
adequate range of motion, soft tissues may be released
and left unrepaired, excised, or transferred.