Total Hip Arthroplasty - Who Needs One?

Total Hip Replacement

What is a total hip replacement?

Total hip replacement (sometimes called total hip arthroplasty) is the surgical replacement of your hip joint involving both the acetabular (cup) side and femoral (head and stem) side. The aim of the hip replacement is to provide pain relief and allow the patient to return to pre-morbid activity level with physiotherapy led rehabilitation of surrounding musculature.

What are the indications for a hip replacement?

Pain and disability due to degenerative arthritis of the native hip joint after non-operative measures have failed to improve the significant deterioration in quality of life of the patient due to the pain and disability. In select cases a hip fracture can be treated with total hip replacement

Are there alternatives?

Yes. Your surgeon will evaluate if you have tried alternatives such a medical analgesia, weight loss and physiotherapy. If your surgeon feels that your symptoms may be as a result of arthritis in your back or knee they may opt to perform a diagnostic injection to your hip wherein if your pain is temporarily relieved by a steroid injection to the joint the cause of your pain is confirmed.

Are there risks to surgery?

Yes. All surgery carries a degree of risk. The main risks that you should be informed of are:

Infection – runs at 0.6-2%. This includes deep and superficial infection. A Superficial infection is usually managed with a short course of antibiotics. A deep infection can require admission for intravenous antibiotics, wound washout and debridement, revision of the hip replacement which may require more than one operation.

Bleeding – you will have some degree of blood loss, however, you will have cross-matched blood available should there be a significant amount requiring blood transfusion.

Damage to local structures -  to get at the hip joint some muscles will be cut and reattached. Depending on the surgical approach, the nerves that run past your hip are at risk of injury. The sciatic nerve runs directly behind the hip joint and can be injured when approaching or dislocating the hip, this risk is approximately 0.25%. Should it be injured it can result in reduced sensation in the foot and outer lower leg or loss of power in the muscles that lift your foot during normal walking, leading to  “foot drop”. Nerve injury is managed expectantly to see if it regains function which it often does however the injury can sometimes be permanent.

Clots – Total hip replacement carries a risk of developing deep venous thrombosis (clots) in the leg. You will be on anticlotting medication after the surgery to reduce this risk, but it is not eliminated. A clot in your leg has the potential to travel to your lungs to cause a pulmonary embolus which can be fatal.

Dislocation – primary total hip replacement can dislocate at any stage but if they do it is usually early. If they dislocate multiple times the implant will need to be revised.

Leg length discrepancy – patients will sometimes notice a difference in leg lengths after their surgery. The aim of the surgery is to provide a stable pain free hip, which can result in a small discrepancy.

Intraoperative fracture – when preparing and implanting the device there is a risk of causing a crack in the bone. If this is noticed at the time of surgery and is amenable to immediate fixation this will be done. Rarely the crack goes unnoticed at the time of surgery and is detected on follow-up, at which point the surgeon will decide what treatment is required.

Post-operative infection – these include but are not limited to urinary tract infection, respiratory tract infection

Anaesthetic risks – Depending on your anaesthetic and your co-morbidities your anaesethist will discuss the risks associated with the anaesthetic. Although anaesthetic complication is rare the complications can be fatal.

Failure of the implant – your implant will eventually wear out and need revision. Current implants are rated and the highest rating an implant can achieve is to have up to 97% all cause survival at 10 years.

So you and your surgeon have decided that a total hip replacement is the best treatment for you…..what do you need to know?

Pre-assessment: After you have been listed for surgery you will not be seen in clinic until your pre-assessment. You will be brought in to the hospital usually 6 weeks prior to the operation (this can vary depending on hospital scheduling) to be assessed by the anaesthetic team. This means that they will assess your fitness for surgery and will need to know all your co-morbidities and what medications you are on. They may recommend further investigations or treatments prior to declaring you fit for elective surgery.

You will also be asked about your plans for discharge post operatively. It is important to plan for discharge home after total hip replacement including:

Adjustments at home to enable you to cope with your rehabilitation. This includes rearranging furniture so you can move around your living space with a cane, walker, or crutches. You may temporarily change rooms (make the living room your bedroom) to minimize the use of stairs. Arranging equipment that you use frequently (phone, remote control, glasses, pitcher and glass, reading material and medications, for example) within easy reach so you do not have to reach up or bend down.
Remove any throw rugs or area rugs that could cause you to slip.
Get a good chair—one that is firm and has a higher-than-average seat, this will allow you to safely sit down within the limits of hip flexion after total hip replacement.
Install a shower chair, gripping bar, and raised toilet seat in the bathroom.
The occupational therapist will advise you regarding assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending over too far.

Day of Surgery Admission (DOSA)

You will arrive to the assigned reception in the hospital on the day of surgery typically early in the morning. Usually, you will need to have been fasting from midnight the day before. The pre-assessment team will inform you as to what medications you cannot take the day of surgery. You will be admitted by the nursing, surgical and anaesthetic teams. You will have acute blood-work taken. You will get a mark on the limb that is to be operated on. You will be informed of the risks again and sign your consent form if not already signed. Depending on the protocol for your hospital you may get some pre-operative medications for pain control at this stage. You will wait in the waiting room until you are called for surgery, at which stage you will be prepared for surgery in the pre-operative reception. You will then be brought to theatre where the anaesethists will admisinister your anaesthetic. You will be then positioned appropriately for surgery and then brought in for your operation.

Post op

You will recover initially near theatre in the post-anaesthetic care unit. Post-operatively people don’t tend to remember all that much. Once you are recovered you will be transferred to the ward and depending on protocols for your hospital you may be mobilised that day. Depending on your recovery you may be mobilized the same day. The next day you will begin mobilizaiton with physiotherapy. You will have an x- ray and post-operative blood work. If there are drains they will most likely be removed the day after surgery. You will be given a short course of post-operative antibiotics. You will be given anti-clotting medications for a pre-determined period of time post operatively. You will be assessed by physiotherapy for suitability for discharge home/to step-down facility as previously planned during pre-assessment.

Precautions

There are certain movements that are to be avoided after a hip replacement to avoid dislocation for the first 6-12 weeks:

Crossing your legs – you are to avoid crossing your legs as excessive adduction can lead to dislocation. Because of this it is recommended that you sleep on your back for the first 6-8 weeks
Do not bend at the waist beyond 90 degrees – this means not sitting in low seats that would bring your knee up higher than your hip, or leaning forwards when sitting.
Do not cross your feet or turn your feet inwards or outwards when bending down to pick something up

Physiotherapy

The physiotherapists will work with you: i) pre-operatively with instructions for excercises to optimise your muscles for the upcoming surgery and recovery; and ii) post-operatively with exercises to get the muscles working again and to get the most out of your new hip. Before discharge you must be able to accomplish certain things:

Getting in and out of bed by yourself.
Having acceptable pain control.
Being able to eat, drink, and use the bathroom.
Walking with an assistive device on a level surface and being able to climb up and down two or three stairs.
Being able to perform the prescribed home exercises.
Understanding any hip precautions you may have been given to prevent injury and ensure proper healing.

Restrictions

Weight Bearing

Follow your doctor's specific instructions about the use of a cane, walker, or crutches and when you can put weight on the leg. Full weight bearing may be allowed immediately or may be delayed by several weeks depending on the type of hip replacement you have undergone and your doctor's instructions.

Driving

In most cases, it is safe to resume driving when you are no longer taking narcotic pain medication, and when your strength and reflexes have returned to a more normal state. This typically takes 6 weeks.

Sexual Activity

Please consult your doctor about how soon you can safely resume sexual activity. You may be able to resume sexual activity within one to two months of surgery.

Sleeping Positions

Depending on your surgery, your doctor may ask you to avoid certain sleeping positions or to sleep with a pillow between your legs for 6-12 weeks. Ask your doctor which sleeping positions are safest and most appropriate for you.

Return to Work

Varies from person to person based on the activities required for your job. People who have physically demanding jobs will take longer to return to work

Sports and Exercise

Continue to do the exercises prescribed by your physiotherapist for at least 2 months after surgery. A stationary bike and swimming are great non-impact activities that you can take part in once your physiotherapist deems you safe.

Air Travel

As soon as you feel comfortable. Remember that total hip replacement increases your risk of clots, as does prolonged flights, so remember to get up and walk every hour or so and keep hydrated during flights.