Desert Orthopedic Specialists

Hips

Total Hip Replacement

Normal Anatomy :: Total Hip Replacement THR
Hip Resurfacing :: Revision Hip Replacement

Normal anatomy of the hip joint

How does the hip joint work?
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Hip anatomy

   

Total Hip Replacement


Introduction

After a trial of non-operative, conservative therapy a hip replacement for your painful, arthritic hip has now become a consideration. This is one of the most effective operations known and should give you many years of freedom from pain, improved range of motion of your stiff hip, and improvement in lifestyle.

Total Hip Replacement


Arthritis

Arthritis is a general term covering numerous conditions where the joint surface (cartilage) wears out. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint. This surface can wear out for a number of reasons. When the articular cartilage wears out, the bone ends rub on one another and cause pain. There are numerous conditions that can cause arthritis and often the exact cause is never known. In general, but not always, it affects people as they get older (Osteoarthritis)

Other causes include

  • Childhood disorders e.g., dislocated hip, Perthe's disease, slipped epiphysis etc.
  • Growth abnormalities of the hip (such as a shallow socket) may lead to premature arthritis.
  • Trauma (fracture)
  • Increased stress e.g., overuse, overweight, etc.
  • Avascular necrosis (loss of blood supply)
  • Infection
  • Connective tissue disorders
  • Inactive lifestyle- e.g., Obesity, as additional weight puts extra force through your joints which can lead to arthritis over a period of time.
  • Inflammation e.g., Rheumatoid arthritis

In an arthritic hip

  • The cartilage lining is thinner than normal or completely absent.
  • The degree of cartilage damage and inflammation varies with the type and stage of arthritis.
  • The capsule of the arthritic hip is swollen.
  • The joint space is narrowed and irregular in outline; this can be seen in an X-ray image.
  • Bone spurs or excessive bone can also build up around the edges of the joint.
  • The combinations of these factors make the arthritic hip stiff and limit activities due to pain or fatigue.

Diagnosis

The diagnosis of osteoarthritis is made on history, physical examination and X-rays. There is no blood test to diagnose Osteoarthritis (wear & tear arthritis)


Indications

Total hip replacement is indicated for arthritis of the hip that has failed to respond to conservative (non-operative) treatment.

You should consider a Total hip replacement when you have

  • Arthritis confirmed on X-ray
  • Pain not responding to analgesics pain medicine or anti-inflammatory medications.
  • Limitations of activities of daily living including your leisure activities, sport or work.
  • Pain keeping you awake at night.
  • Stiffness in the hip making mobility difficult.


Benefits

Prior to surgery you will usually have tried some simple treatments such as analgesics, weight loss, anti-inflammatory medications, modification of your activities, walking sticks, physiotherapy.

Once these have failed it is time to consider surgery. Most patients who have total hip replacement are between 60 to 80 years, but each patient is assessed individually and patients as young as 20 or old as 90 are occasionally operated on with good results.

The decision to proceed with total hip replacement surgery is a cooperative one between you, your surgeon, family and your local doctor. Benefits of surgery include

  • Reduced hip pain
  • Increased mobility and movement
  • Correction of deformity
  • Equalization of leg length (not guaranteed)
  • Improved quality of life, ability to return to normal activities
  • Enables you to sleep without pain
  • Discontinue pain medications which can have potentially serious side effects


Pre- operation

You should be ready to be discharged from the hospital on the second post operative day. If, for example, you have your surgery on a Monday, you should be ready for discharge from the hospital on Wednesday. Prior to coming to the hospital it is imperative that you make arrangements for discharge with family or friends to help care for you at home. If you will not have adequate assistance at home or are not progressing well with physical therapy, the social workers at the hospital will make arrangements for you to go to a rehabilitation center.

  • Your surgeon will send you for routine blood tests and any other investigations required prior to your surgery
  • You will be asked to undertake a general medical check-up with your primary care physician or appropriate specialists such as your cardiologist or pulmonary specialist.
  • You should have any other medical, surgical or dental problems attended to prior to your surgery.
  • Make arrangements around the house prior to surgery to remove unsafe obstacles, area rugs or other objects that may cause tripping. Consider shower bars and other safety devices.
  • Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding.
  • Cease any naturopathic or herbal medications 10 days before surgery
  • Stop smoking as long as possible prior to surgery.
  • Continue low impact exercising as much as tolerated to maintain strength, endurance and flexibility.
  • Take a high quality multivitamin daily.
  • Begin taking iron to decrease the need for a blood transfusion.
  • Begin taking Vitamin C to enhance iron absorption and to enhance wound healing.
  • Maintain a healthy, high protein diet


Day of your surgery

  • You will be admitted to hospital usually on the day of your surgery.
  • Further tests may be required on admission.
  • You will meet the nurses and answer some questions for the hospital records.
  • An IV will be started.
  • You will meet your anesthesiologist, who will ask you a few questions.
  • You will be given hospital clothes to change into.
  • The operation site will be shaved and cleaned.
  • Approximately 30 minutes prior to surgery, you will be transferred to the operating room.
  • You will be given an antibiotic through the IV.


Surgical procedure

An incision is made over the hip to expose the hip joint

The acetabulum (socket) is prepared using a special instrument called a reamer. The acetabular component is then inserted into the socket. This is sometimes reinforced with screws or occasionally cemented. A liner which can be made of plastic, metal or ceramic material is then placed inside the acetabular component.

The femur (thigh bone) is then prepared. The femoral head which is arthritic is cut off and the bone prepared using special instruments, to exactly fit the new metal femoral component. The femoral component is then inserted into the femur. This may be press fit relying on bone to grow into it or cemented depending on a number of factors such as bone quality, patient's age and surgeon's preference.

The real femoral head component (ball) is then placed on the femoral stem. This can be made of metal or ceramic.

The hip ball is then placed again into the socket.

The muscles and soft tissues are then closed carefully.


Post operative

You will wake up in the recovery room with a number of monitors to record your vitals signs. (blood pressure, pulse, oxygen saturation, breathing temperature, etc.) You will have a dressing on your hip and possibly drain tubes coming out of your wound. A catheter will be placed in your bladder during surgery.

Post-operative X-rays will be performed in the recovery room.

Once you are stable and awake you will be taken back to the orthopedic floor or total joint center.

You will have an IV in your arm to administer fluid, antibiotics and pain medications. This will be explained to you by your anesthesiologist.

Within hours of the surgery the nurse or physical therapist will assist you in sitting at the bedside and possibly walking several steps. You will be allowed weight bearing as tolerated on your lower extremity unless unforeseen events occur.

On the following days after surgery, you will be encouraged to exercise with the physical therapists, get out of bed and walk increasing distances. Pain is normal but if you are in a lot of pain, inform your nurse. It is not possible to control every bit of pain all the time but we will strive to control it well and keep any pain you may have to a very low level so you may be aggressive with your exercising. We have many effective ways to control your level of pain.

To avoid lung congestion and pneumonia, it is important to breathe deeply and cough every hour while you are awake.

Dr. Fox will use one or more measures to minimize blood clots in your legs, such as inflatable leg coverings, stockings and injections into your abdomen to thin the blood. This helps to decrease the risk of blood clots or DVT's, which will be discussed in detail in the complications section.

You will be able to put all your weight on your hip and your Physiotherapist will help you with the post-op hip exercises.

You will be discharged to go home or a rehabilitation hospital approximately 2 days after surgery depending on your progression with physical therapy and help at home.

Sutures (staples) are usually removed in the office at about 3 weeks after the surgery..

You will be advised about how to walk with crutches or walker and will be instructed on going up and down stairs if necessary. You may shower if there is no drainage of fluids from your wound. You can drive at between 3 and 6 weeks as long as you are not on narcotics and have gained good muscular control of your operated leg.

You should be walking reasonably comfortably by 3 weeks.

More physical activities, such as golf, riding a bicycle, yoga or other low impact activities may take 3 months to do comfortably.

When you go home you need to take special precautions around the house to make sure it is safe. You may need rails in your bathroom or to modify your sleeping arrangements, especially if they are up a lot of stairs.

You will usually have a 3 week check up with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray.

You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the blood stream and find their way to your knee.


Post-op precautions:

Remember this is an artificial hip and must be treated with care.

AVOID THE COMBINED MOVEMENT OF BENDING YOUR HIP AND TURNING YOUR FOOT IN. This can cause DISLOCATION. Other precautions to avoid dislocation are

  • Consider sleeping with a pillow between your legs for 6 weeks. Avoid crossing your legs and bending your hip past a right angle
  • Avoid low chairs
  • Avoid bending over to pick things up. Grabbers are helpful as are shoe horns or slip on shoes.
  • An elevated toilet seat is helpful to avoid sitting in a low position.
  • You can shower once the wound has healed.
  • You can apply Vitamin E or moisturizing cream into the wound once the wound has healed.
  • If you have increasing redness, drainage or swelling in the wound or temperatures over 100.5 you should call your doctor.
  • If you are having any procedures such as dental work or any other surgery you should take antibiotics before and after to prevent infection in your new prosthesis. Consult your surgeon for details.
  • Your hip replacement may cause activation of a metal detector at the airport.


Risks and complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to the hip

Medical Complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include

  • Allergic reactions to medications or anesthetics
  • Blood loss requiring transfusion which has a relatively low risk of disease transmission such as hepatitis, transfusion reaction or AIDs
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections, stomach ulcers, and diarrhea from antibiotics
  • Complications from nerve blocks such as infection or nerve damage.
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death.


Specific complications include

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates are approximately 1%; if infection occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Dislocation.

This means the hip comes out of its socket. Precautions need to be taken with your new hip forever. It a dislocation occurs it needs to be put back into place with an anesthetic. Rarely this becomes a recurrent problem needing further surgery.

Blood clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.

Hip Bursitis

This may be associated with persistent pain on the outside of your hip and may require cortisone injections and prolonged physical therapy.

Damage to nerves or blood vessels

Also rare but can lead to permanent weakness and loss of sensation in part of the leg. This may require bracing for the foot, ankle, or knee. Damage to blood vessels may require further surgery if bleeding is ongoing.

Wound irritation

Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint.

Leg length inequality

It is very difficult to make the leg exactly the same length as the other one. Occasionally the leg is deliberately lengthened to make the hip stable during surgery. There are some occasions when it is simply not possible to match the leg lengths. All leg length inequalities can be treated by a simple shoe raise on the shorter side.

Wear

All joints eventually wear out. The more active you are, the quicker this will occur. In general 80-90% of hip replacements survive 15-20 years.

Failure to relieve pain

Very rare but may occur especially if some pain is coming from other areas such as the spine.

Unsightly or thickened scar

Pressure or bed sores

Limp due to muscle weakness or leg-length discrepancy

Fractures (break) of the femur (thigh bone) or pelvis (hipbone)

This is also rare but can occur during or after surgery. This may prolong your recovery, or require further surgery. Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.


Summary

For some people with hip arthritis, hip replacement surgery could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan- it may help to restore function to your damaged joints as well as relieve pain, restore your independence, mobility and active life style.

Joint replacement surgery can be extremely beneficial for most people with arthritis that limits their activity level. For some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan-it may help to restore function to your damaged joints as well as relieve pain. Joint replacement surgery can improve your overall health by keeping you active and independent. With improved function exercise will become part of your daily routine which will help maintain an optimal weight, control your blood pressure and blood sugar.

Total hip replacement is one of the most successful operations available today. It is an excellent procedure to improve the quality of life, take away pain and improve function. In general 90-95% of hip replacements survive 15 years, depending on age and activity level.

Surgery is only offered once non-operative treatment has failed. It is an important decision to make and ultimately it is an informed decision between you, your surgeon, family and medical practitioner.

Although most people are extremely happy with their new knee, complications can occur and you must be aware of these prior to making a decision. If you are undecided, it is best to discuss the alternatives, risks and certainly the benefits with Dr. Fox to make sure this is a procedure worth considering.

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