Hip > Arthritis > Treatments

    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.

   Prior 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 hospital.

   Understand 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.

   Any 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.

   In 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.

   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, 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.

   If possible, practice walking with your walker or crutches in case you need to use them after surgery.

   Make 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:

   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 for eight hours before surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Patients 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.

   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.

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 components.

   After 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 solutions.

   Depending 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.

   The 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 hip joint.

   Your surgeon uses devices called retractors to hold the sides of the wound open.

   After 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.

   A 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.

   Usually, 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.

   In 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.

   Specialized 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.

   After 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.

   If not done previously, the final plastic liner for the acetabular component is placed in your new hip socket.

   If 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.

   If a cementless femoral stem is to be used, the final artificial femoral stem is carefully inserted into the hollow marrow canal.

   The 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.

   In some cases, a drain that exits your skin may be placed into the wound to prevent fluid from collecting.

   The 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.

   The 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.

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

   After 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.

   Staples 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.

   You 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.

   If applicable, follow the weight bearing instructions given to you by your surgeon.

   Continue to use the walker, crutches, or other assistive devices as instructed by your surgeon. They will help you with balance and safety.

   For 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.

   After 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.

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

   A balanced diet, vitamin supplements, proper hydration, and exercise may help you recuperate and get you back on your feet again.

   A 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.

   While 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.

   Since 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.

   Your surgeon will schedule regular follow-up visits to evaluate your progress and to ensure your prosthetic hip functions properly.

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.

STRETCHING

Your physical therapist will help you safely regain range of motion of your new artificial hip. Some patients receive pain relief from daily stretching.

AEROBIC EXERCISE

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.

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 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:

   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 your hips.

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.