Arthritis and Hip Replacement

The purpose of this pamphlet is to help you understand hip replacement surgery.  We will discuss how arthritis affects the hip and causes pain and stiffness.  Further, we will describe hip replacement surgery and the usual recovery process.  Finally, we will explain the typical results of the operation and possible complications which may occur.  It is our hope and intention that this knowledge will assists you in making an informed decision concerning your own need for hip replacement surgery.

Orthopedic Evaluation
Your orthopaedic evaluation assesses the severity of your arthritis.  This evaluation leads to a treatment recommendation.

The evaluation begins with questions concerning the severity of your hip pain.  We attempt to discover how your hip pain and stiffness limits your usual daily activities such as walking, stair climbing and driving and riding in a car.  We also ask about previous treatments such as medications, cortisone shots and the use of a cane.

Examination of the hip includes assessment of the range of motion and the presence of any fixed contractures (stiffness).  In addition, ability to walk and the presence of a limp are noted.

X-rays are very useful in determining the severity of arthritis.  As arthritis and cartilage deterioration progresses, the "cartilage space" between the bones decreases in size and may disappear altogether ("bone rubbing on bone").  When this occurs pain usually becomes significant.  Abnormal calcifications or spurs also develop as arthritis progresses.

After completion of the orthopedic examination (symptoms, exam, x-rays) the various treatment options and specific recommendations can be discussed.

With mild arthritis, some moderation of activities and arthritis medications may be adequate.  Occasional use of a cane may be helpful and exercise and weight loss are often recommended.  Physical therapy or a Cortisone injection into the affected joint may occasionally be of benefit.

As arthritis progresses, the hip pain and loss of function usually becomes more resistant to conservative or nonoperative treatment.

Arthritic Hip and a Normal Hip

The question as to when to proceed with hip replacement surgery is a highly individual matter.  This depends on the patient's pain threshold, their activity level, their social situation, and the help that they may have available at home.

Most patients choose to proceed with hip replacement when their pain becomes generally disabling.  This usually occurs when pain is present everyday and often with every step and interferes with realistic activities for the patient's age.  Night pain that interferes with sleep is a significant disability and usually prompts people to seek operative intervention. Most patients who come to hip replacement surgery have difficulty tying their shoes, going up and down stairs and getting in and out of a car.  They are frequently dissatisfied with their general quality of life.  One final factor that frequently is considered in joint replacement surgery is if the hip arthritis is aggravating arthritis elsewhere in the body, such as the knee or the spine to a significant degree.

As the pain becomes more severe or constant, and the inability to carry out daily activities increases, surgery with hip replacement may be the recommended treatment.

"Hybrid" Hip Prosthesis

Non-Cemented Hip Prosthesis

Hip Prosthesis
The standard hip replacement consists of two basic components.  The acetabular or socket component is a high density polyethylene plastic which has an indentation for the metal ball of the femoral component.  The socket component often includes a thin metal shell around the surface of the plastic where it meets the bone to help provide more stability.  The femoral component is a long peg that extends down into the shaft of the femur or thigh bone.  The top of the stem is made up of a round highly polished ball that articulates with the plastic socket.  The ball is held into the socket by the muscles of the hip and gradually a new capsule around the ball is formed after surgery as the healing process occurs.

Total hip replacement surgery requires replacement of the damaged joint surfaces with metal and plastic components (prosthesis).  Metal on plastic artificial joints have proven to be self-lubricating and show minimal wear despite years of use.

The artificial hip components are held to the bone with a plastic cement.  In younger patients, components which allow "bone ingrowth" will be placed without cement.  A more recent trend in hip replacement involves implanting a noncemented "bone ingrowth" acetabular (socket) component and cemented femoral component ---- a "hybrid" total hip.  Recommendations regarding the use of cement versus bony ingrowth fixation will be made on an individual basis preoperatively based on your age, weight, activity level and bone density.

Results of Hip Replacement
After hip replacement you can expect nearly complete relief of pain.  While an artificial hip is not a normal hip, you can expect to resume most activities of daily living with comfort and ease.  Studies have confirmed that approximately 95% of all hip replacements can expect a very good result.  Unlimited walking tolerance without pain is usually the case.  Recreational activities such as bicycling, swimming and golf are likely to be possible.  More strenuous sports such as jogging, tennis and skiing could damage the artificial hip and are not recommended.

Many patients notice a significant improvement in their over-all energy level when the strain of constant pain is eliminated.  Less dependence on others is another frequent benefit noted after total hip replacement.

Potential Risks of Hip Replacement
No surgery is without risk.  Understanding the risks of surgery is necessary in order to make an informed decision about your desire for surgery.

Anesthesia in surgery places increased stress on the body.  Serious complications such as heart attack, stroke or even death have been reported.  Fortunately, these occurrences are extremely rare.  A thorough medical evaluation prior to surgery minimizes these risks.

Infection is also a very serious complication of joint replacement.  Many precautions are taken to avoid infection and as a result, the risk of infection is very low (less than 0.5%).  Further surgery would be necessary if infection should occur.

Blood clots can occur after hip surgery but this occurrence has been minimized by the routine use of special "pump" stockings and either aspirin or blood thinners used after surgery.  Even rarer complications could include artery or nerve damage or fractures of the bones near the hip.

Most patients want to know how long they can expect their artificial hip to last.  Over an extended period of time, the hip prosthesis may work loose from the bone.  This occurs when the bond between the bone and the plastic cement breaks down.  Even though this is the most common cause of artificial joint failure, it is quite unusual.  More than 90% of artificial hips continue to function well after 10 years.  If an artificial hip becomes loose and painful, it can usually be repaired with a second operation.  Only rarely does a hip prosthesis become loose prior to 10 years.

Preparation for Surgery
Once you have made a decision to proceed with hip replacement surgery, a number of arrangements will be made.  A date for surgery will be determined and scheduled at Meriter Hospital.  Many patients have similar arthritis in both hips and will require replacement surgery of each hip.  Usually we recommend performing one hip replacement and having the patient recover from the initial surgery before proceeding to the second operation.  The usual time interval between the first hip operation and a second would be three to six months.  If, however, a patient is wheelchair bound and would not be able to walk or rehabilitate his first hip operation, then we might proceed during the same hospitalization to replace the second hip.

A thorough pre-surgical medical evaluation needs to be completed within one month of your surgery by your primary care physician.  You will also be seeing my physician assistant approximately two weeks preoperatively for a thorough evaluation and exam.  During this session, your surgical procedure and the pre and postoperative routine will be discussed.  Data will also be collected for a hip study we are conducting.  Lab tests, chest x-ray and EKG will be ordered at that time and reviewed.  We will also arrange for you to be seen in the Physical Therapy Department prior to your hospitalization so that you can obtain either a walker or crutches and be instructed on the exercises that you will be doing in the hospital postoperatively.  You should practice using the correct technique with the walker or crutches prior to being admitted to the hospital.

You should not take aspirin, Ibuprofen or other nonsteroidal anti-inflammatory medication during the two weeks prior to surgery.  These medications thin your blood and increase your risk of bleeding complications.  You may take acetaminophen (Tylenol), propoxyphene (Darvon or Darvocet) or codeine for pain if needed.  Stopping smoking preoperatively helps decrease the chance of postoperative lung problems.

You will be admitted to the hospital the morning of surgery.  You will have further instructions on that day by the orthopedic nurses.

One of the anesthesiologists will see you and discuss the type of anesthesia that is recommended.  He/she can also answer your questions concerning anesthesia and the risks involved.  The nurses will orient you to the nursing unit and usual daily activities while you are hospitalized.  You may again be seen by one of the physical therapists who will review your hip exercises with you.

If for some reason the laboratory tests, chest x-ray or EKG have not been previously completed prior to your hospitalization, they will be done prior to surgery.

Blood transfusions may be necessary with hip surgery, particularly in the uncemented variety.  Many patients in this day and age are concerned about getting blood transfusions from unknown donors.  With the present screening techniques used by the blood bank, the risk of getting hepatitis, AIDS or other blood borne diseases is extremely low.  An alternative to getting bank blood is to donate your own blood preoperatively and have it stored in a liquid or frozen state until the time of your operation.  These donations have to be coordinated with the time of your surgery.  We will discuss these options with you preoperatively. My secretary will then arrange for your donation appointments if you decide on "auto-transfusion."

We routinely use a "cell saver" during the operative procedure to return irrigated blood into your system after it has been filtered.  We are also often using a postoperative wound drainage auto transfusion device to try to diminish your need for transfusions.  If you have given your own blood preoperatively, you will likely receive this as a transfusion postoperatively.

Day of Surgery
Your hip surgery will either be performed at 8:00 in the morning or 1:00 in the afternoon, depending on the availability of the operating room.  You will be informed of the expected time of surgery when scheduled.  You will not be allowed to eat or drink after midnight the evening before surgery.  You may desire a sleeping pill the night before surgery and this is fine.

On the morning of surgery, you will be taken to the operating room approximately 30 minutes before surgery.  Your family may accompany you and will be directed to the family waiting room near surgery.  The actual surgical procedure takes 1-1/2 to 2-1/2 hours.  You will then spend another 1 to 2 hours in the recovery room where you will be closely observed as you awaken from anesthesia.  When you are awake (but often very drowsy) and your vital signs are stable, you will be returned to your room.  Five to six hours may have elapsed since you first left your room.

When you are back in your room, you will be aware of moderate pain in your hip.  This pain can be greatly relieved by the use of a "PCA pump" which allows you to administer your own pain relieving medication.  By simply pushing a button, a predetermined amount of pain medication is pumped into your IV line, which has been started in surgery.  This provides rapid relief of pain without the usual discomfort and delay of a "hypo."  In some circumstances, however, hypos are still used, particularly if the patient has a problem with nausea and vomiting.  Your IV line is usually left in place for at least 48 hours so that you can be given adequate fluids and also so that necessary antibiotics can be given.  Antibiotics help to prevent infection in your new hip.  After surgery you will have a bulky dressing on your hip. You will also have 1 or 2 drains coming out of the skin, which collect any blood within the joint or subcutaneous tissues.  These will generally be removed the morning of the second postoperative day.

In addition, you will have a triangular pillow between your thighs to prevent you from crossing your legs and dislocating your hip.

After Surgery
Most patients will be allowed and encouraged to get out of bed the first day after surgery.  The increased activity in the upright position of sitting encourages the lungs to expand fully and helps eliminate any fever.  You will likely be given a "tri-flow" device to help expand your lungs every 2 hours during the day.

The muscle strengthening exercises include attempts to tighten the thigh muscle (quad sets) and then to lift the leg off the bed with the knee straight (straight leg raise).  These exercises should eventually be done in sets of 10, at least 6 to 10 times daily, if possible.

Your nurses, therapists, and doctor can help you with these exercises.  Don't be discouraged.  It takes most patients several days before they are able to independently lift the operative leg off the bed.  Physical therapists will instruct you and assist you in walking with crutches or walker.  The therapist will also direct you as to how much weight you can put on the operative leg.  This varies depending on whether the prosthesis is cemented or the bony ingrowth variety.  Some patients start with a walker and then progress to crutches; others prefer the walker and never use the crutches.  By the time you are discharged from the hospital, you should be able to walk with the walker or crutches without assistance.  You should also be able to handle a few stairs. Your therapist will work with you at least twice daily on these activities.

Several other important points about your hospital stay should be noted.  Following major lower extremity surgery, there is a risk of blood clots forming in the leg.  To minimize the risk of this occurrence, most patients are placed on one aspirin per day and also placed in special sequential compression stockings that continually assist in externally pumping the blood through the legs.

If you have had a previous history of blood clots or thrombophlebitis, a blood thinner called Coumadin may be used during your hospitalization.  A blood sample must be drawn every morning so that the proper dose of Coumadin can be determined; thus you should not be surprised if you need daily blood tests in the hospital.  The Coumadin is often continued for several weeks when you are discharged from the hospital.  You will need to have your blood tested on an outpatient basis and adjustments made in your Coumadin level.

Elastic stockings (TED hose) are also used to minimize risks of blood clots and control swelling in the lower leg and foot.  If possible, we like these stockings worn during the day but they may be removed at night for comfort.

Small metal staples are used to close your incision.  These will be removed approximately 7 to 10 days after surgery. This process is relatively painless.

Hip Precautions
It is important for several weeks following total hip replacement surgery that care be taken to keep from dislocating the hip prosthesis.  For six weeks following surgery, the patient should not bend at the hip past a 90° position.  A pillow may need to be placed in a soft chair to add support so that bending does not pass 90°.  For at least eight weeks following surgery, the patient should not cross his or her legs.  It is important that the hip is not internally rotated.  This position will be shown to the patient during hospitalization.  The abduction splint or a pillow should be placed between the legs while sleeping for the first 4 weeks after the time of surgery.

Hospital Discharge
Most patients are able to return home 7 to 10 days after surgery.  At this time we expect you to be able to walk independently with crutches (or walker), get in and out of a chair or bed and to lift your leg with the knee extended straight.  The following instructions are intended to make your return home as comfortable as possible.   Please read them carefully and ask either my physician assistant or myself if you have any further questions.

Exercises
We encourage you to be as active as possible.  You should not spend much time in bed other than at night to sleep.  You should walk several times daily.  These walks are by far the most important exercise you can do.  As your recovery progresses, you should be able to walk longer distances and with less fatigue.  Be careful not to push yourself too hard, too quickly.  Conversely, remember not to sit for extended periods of time, as this tends to retard the venous drainage from your leg.  It is better to get up and move around, walking every 30 to 45 minutes.  Exercise as noted previously. Walking is the most important exercise.  You should also continue to do straight leg raises.  Try to lift your leg with the knee straight and hold it up for 10 seconds (do this 10 repetitions, 6 to 10 times a day).

Bathing
You may begin to shower as soon as you return home.  Bathing in a tub is difficult and should be avoided for the first two months.  Neither a shower or a bath is harmful to your incision.

Incision
Usually the incision is well healed at the time of discharge and requires no special care at home.  f the incision becomes excessively swollen, red or begins to drain, you should call us.  It is not unusual for the thigh and hip to remain swollen and feel warm for several months after surgery.

Elastic Stockings (TEDS)
Please continue to wear the elastic stockings while you are awake for the first 2 to 3 weeks after discharge.

Return Appointment
Your first return examination in our office will occur after about 5 weeks.  In most instances, you will be given an appointment card at the time of discharge.  If for some reason you did not receive an appointment card or if your appointment time is not convenient, please call our office during the normal office hours for an appointment time. (608-231-3410).

Driving
We do not recommend that you drive a car until after your first office appointment after surgery.

Traveling
It is reasonable to travel by car or plane soon after leaving the hospital, however you will need a pillow under your buttocks so that you do not sink down and flex the hip greater than 90°.  When traveling long distances, you will be more comfortable if you stop and walk a little every hour.  Airport security metal detectors are generally not set off by these artificial joints.  We can, however, give you a card stating that you have a joint replacement to keep with you just in case.

Medications
Most patients still require the use of pain medication for a period of time following discharge from the hospital.  We will provide a prescription for an appropriate medication.  In addition, you should resume any other medication you were taking prior to hospitalization unless otherwise instructed by a physician.

Dental or Urologic Care
If you require dental work (including regular cleaning) or any urologic evaluation after surgery, you should take a short course of antibiotics.  Many of the bacteria in the mouth are susceptible to Penicillin.  There may be a number that are resistant, so at the present time I am utilizing a combination of Pen VK 500 mg., two tablets orally one hour before and six hours after the procedure.  In addition, I prescribe Keflex 500 mg., one tablet one hour before and six hours after the procedure.  If the patient is allergic to Penicillin, Erythromycin 1 gm. orally, one hour before and then 500 mg. six hours after the initial dose, would be substituted.

Precautions
It is extremely important after total joint replacement to be very careful regarding infections.  There have been reports of infections elsewhere in the body that have shed bacteria into the blood stream which then infect the joint replacement, even years after the initial procedure.  Therefore, it is imperative after a total joint replacement that infections are treated aggressively.  This includes pneumonias, bronchitis, urinary tract infection or external skin sores that may become infected.  The usual sore throat associated with some nasal drainage is frequently a viral infection and of no major concern.  However, if you develop marked sore throat or fever, suggestive of a strep throat, you should see your family doctor immediately to be tested for strep throat and placed on antibiotics if your culture is positive.  In general, if you have questions as to whether or not you may have an infection that should be treated, please call my office so that we can discuss this with you.

Summary
Don't forget that you have a new hip but it is not a completely normal hip.  Your healing pattern will be somewhat cyclical.  It is common for you to feel very good for several days, overdo it and then have the leg swell or stiffen up slightly.  This will improve and go through a number of cycles until you are finally healed.  Don't look at your progress on a day by day basis, but more on a week to week basis.  Don't get too excited or depressed by the cyclical variations.

If you find when you go home that there is something new or different that you have a question about, please feel free to contact me.  I am concerned about you as a person as well as a patient and would be happy to answer any questions that you may have.

Good luck with your new hip.
 

Back to Patient Education - Hip

Patient Education - Main Menu

3/1/2006

OUR SERVICES  |  PATIENT EDUCATION  |  ABOUT DR. ROGERSON
CLINIC INFORMATION  |  OUR TEAM  |  CURRICULUM VITAE