Orthopaedic Surgery - You and your hip replacement

Introduction

Those with arthritis know how unbearable pain can be. Joint replacement offers relief from this pain and an improved quality of life. It involves a major operation and there are some risks as with all types of surgery.

The medical and nursing staff, physiotherapist and occupational therapist, all have an important role to play in helping you to return to a better quality of life.

What is arthritis?

Arthritis is the wearing away of the cartilage which covers the joint surface. At first, this may cause pain and swelling, but can later lead to the bones actually rubbing together.

In severe cases the bone ends become roughened, and movement becomes difficult.

Can it be cured?

It is not actually possible to prevent arthritis progressing once the surface of the joint is damaged. If the pain or disability cannot be controlled by a change of lifestyle, weight loss, painkillers, walking aids, exercise and in some cases joint injections - then surgery can replace the worn joints with artificial ones.

What is a total hip replacement?

A total hip replacement is an operation designed to replace a hip joint that has been damaged, usually by arthritis. The hip joint is a ball and socket joint. The ball is formed by the head of the thighbone (femur) and fits snugly into the socket in the pelvis (acetabulum).

The total hip replacement operation involves replacing the worn head of the femur with a metal or ceramic ball mounted on a metal stem and relining the socket with a cup that can be metal backed and a liner that is made of a special plastic/polyethylene/ ceramic.

This joint is NOT a metal-on-metal type of hip replacement. Fixation to the bone is either with cement or a coating on cementless implants.

How will the operation benefit me?

There are two objectives of surgery - to reduce pain and to improve the function of the joint, thereby giving sufficient freedom of movement to allow most normal activities. It can also correct any obvious deformity.

Will the operation be painful?

You may have some pain immediately after the operation. However, instead of the constant dull aching pain from the arthritis, the sensation becomes a pain that will eventually ease over the 4-6 weeks after surgery. The specialist pain nurse may visit you prior to your operation and discuss pain relief options with you.

What are the risks of having a joint replacement?

It must be emphasised that complications following hip replacement are rare. The majority of patients are very happy with their new joint.

Any operation involves an element of risk. It would be wrong to over-emphasise these risks, but you should be aware of them to make an informed decision. Approximately 1 in ten patients will not be completely satisfied at 2 years after surgery.

Infection - wound or deep tissues

All infections must be cleared up prior to the operation, particularly tooth abscesses, urine infections and skin infections, otherwise bacteria circulating through the body can lodge on the bone surface of the new joint and cause infection in the bone.
Patients are screened for MRSA and a routine urine sample is obtained prior to surgery. You will be given an antibiotic prior to surgery in theatre to reduce this risk of postoperative infection.

Following surgery, about 1% of patients develop an infection in the joint. To treat any infection, it may be necessary to undergo further surgery and infection is the most worrying complication.

Thrombosis

Up to one third of patients are at risk of developing a blood clot in the veins of the leg (DVT). This may occur with any operation and steps will be taken to prevent this. The main method of prevention is to get you walking as soon as possible, providing blood thinning medication for 28 days and using leg stockings for 6 weeks.

Blood clots cause swelling in the leg, usually in the calf muscles and may be accompanied by pain or a burning sensation. In about two per cent of cases, these clots travel to the lungs and cause a blockage, preventing normal breathing. This can rarely be fatal.

Dislocation

One in fifty people may suffer a dislocation after a hip operation. This is where the ball comes out of the socket. There are four basic movements that can cause dislocation:

• Crossing your legs
• Excessive bending of the hip
• Twisting the leg which has been operated on, in or out
• Lying or rolling onto your unoperated side

You will be provided with information from the rehabilitation team on how to avoid the risks of dislocation.

Nerve damage

Very occasionally one of the main nerves that travel past the hip can be damaged during the operation. This can cause footdrop or paralysis of other muscle groups in the leg. Although the nerve often recovers over a period of months the paralysis can persist. There can also be ongoing symptoms of pain from the damaged nerve.

Remember, it is not unusual for the skin around your incision to have numbness that can improve over time but could occasionally be permanent.

Limb length

The operation may cause shortening or lengthening of the limb. This may be short term whilst your new hip 'beds in' and you find a new pattern of walking with your new hip.

It may persist, in which case it will be reviewed by your consultant who will discuss with you if a shoe raise is required.

Bleeding

Total hip replacement is a major operation and there is a certain amount of blood loss anticipated. In some cases, a blood transfusion may be required.

Death

Death is a risk, due to the physical stress of a major operation and the risks associated with anaesthetic.

Preparing for surgery and the pre-operative assessment clinic

Preparation for a total hip replacement usually begins two weeks before the proposed date for surgery. You will be asked to attend the pre-operative assessment clinic where your level of fitness for surgery and anaesthesia will be assessed. You will be screened for infection prior to surgery. You may also be introduced to some of the members of the multidisciplinary team who will be responsible for your care in hospital.

On the ward

The doctor will explain the operation to you and will confirm your consent to proceed. He or she will identify the leg to be operated on by marking it with a black marker pen.

Your operation may be performed under either a spinal or general anaesthetic. The anaesthetist will visit you prior to your operation to determine which the most suitable option for you is and to answer any questions you may have.

The physiotherapist will discuss the operation with you and tell you what is expected of you after surgery (this may already have been done in pre-operative clinic).

You will be advised when to stop eating and drinking. The operation usually takes between one and a half to two hours to complete.

When the operation is finished, you will be taken to the anaesthetic recovery room where your condition will be monitored. Once the recovery nurse is satisfied that your condition is stable, you will return to the ward.

After the operation

Points to note:

• You will be in bed with a wedge-shaped pillow keeping your legs apart. This is to ensure optimum positioning of your new hip
• You will have a large dressing over your wound
• Drains are sometimes placed to remove any excess fluid from the operation site
• Urinary catheterisation is occasionally required after surgery
• You may be given oxygen for a short time to aid in recovery from major surgery
• Fluids may be given intravenously via a vein in the back of your hand
• Occasionally a blood transfusion may be required
• Any post-operative pain will be managed with appropriate pain relief
• You will have an x-ray of your hip
• You should start the exercises taught to you by the physiotherapist as soon as possible
• Due to the fluid loss during surgery, reduced mobility and certain painkillers, you will be more prone to constipation, which can then affect urine output. It is vital to drink plentyof fluids, eat foods containing fibre and gentle laxatives will be prescribed to reduce the risk of constipation. If you are normally prone to constipation, follow the above advice prior to admission or consult your GP
• Stitches or clips will be removed 10-14 days after your operation
• Discharge usually occurs as soon as you are safely mobile and medically fit

Physiotherapy

When muscles are not used, they become weak and do not perform well in supporting and moving the body. Your leg muscles are likely to be weak because you have been unable to use them effectively due to your condition. Surgery can correct this problem, but the muscles will remain weak and will only be strengthened through regular exercises.

You will be assessed and advised how to progress through the exercises but the overall responsibility for carrying this out is you.
 
The physiotherapists have an information leaflet with pictures of the exercises to perform.

• Hip exercises start under the supervision of a physiotherapist
• Depending on your consultant’s regime you will begin to mobilise on the day of surgery or the day after surgery
• Two physiotherapists will help you out of bed and take you for a walk
• The physiotherapist will progress your mobility and exercises. The aim is to increase your mobility daily and increase your muscle strength

Exercises

Getting in and out of bed

• You usually get out of bed the same side as your operated leg, but you may be instructed otherwise by your physiotherapist
• Bend your un-operated knee, push your foot into the mattress and lift your bottom to move yourself over the edge of the bed. Allow your operated leg to go over the edge of the bed and allow the knee to bend slightly
• Place your hands behind you and turn yourself so you are sitting on the edge of the bed. Allow your un-operated leg to touch the floor
• Using your hands, push yourself up into a standing position, putting most of the weight through your un-operated leg
• You may then reach for the frame or crutches and slide your operated leg back under you
• Do not pull yourself up with the frame, as it will tip over. Getting back into bed is the reverse of the above, again getting in the same side as your operated leg

Walking

The sequence is always:

1. Move the crutches forward
2. Step to the crutches with your operated leg
3. Lean on the crutches and step the un-operated leg through, placing it slightly in front of your operated leg

Turning should be performed using small steps. DO NOT swivel on your ‘new’ hip.

Once the physiotherapist is happy that you are safe and walking correctly you will be able to get up and walk on your own with the appropriate walking aid.

Going upstairs

The sequence is:

• Un-operated leg
• Push up on walking aid, then bring up operated leg (same step)
• Bring up walking aid (to same step)

Going downstairs

The sequence is:

• Walking aid
• Operated leg
• Un-operated leg

Daily activities

The occupational therapist (OT) will assess your ability to perform activities of daily living. Advice will be given, and equipment may be provided for your use in hospital and at home.

Dressing

• Dress whilst sitting down on the edge of your bed or on a chair
• DO NOT bend forwards or reach beyond your knees as you may dislocate your hip
• Use the equipment provided by the OT to dress your lower half
• Dress your operated leg first and undress it last

Hip precautions

The following precautions are especially important in the first 6 weeks after your operation.

To reduce the risk of your new hip dislocating:

DO NOT:

• Cross your legs or allow your operated leg to cross the midline of your body
• Bend past 90 degrees (a right angle) at your hip
• Shuffle or swivel on your feet when turning
• Twist your operated leg in or out
• Stand for long periods of time
• Discard your walking aid until instructed by your physiotherapist or consultant

DO:

• Wear low-heeled shoes
• Go for regular walks (3-4 per day) instead of one long walk and try to increase the distance gradually
• Keep car journeys to a minimum for the first twelve weeks
• Sleep on your back with a pillow between your legs
• Continue with the exercises shown by the physiotherapist for at least three months
• Continue to rest on your bed for a short period each day, usually after your afternoon exercises to prevent excessive swelling

When can I go home?

The multidisciplinary team will discuss with you when you are ready to go home. However, your overall progress, the amount of pain you are experiencing, the condition of your wound and the availability of home services will determine your discharge date.

A letter will be sent to your GP to inform them of your surgery. If you require support at home following surgery, the hospital social worker will assess your needs and discuss the services available to you. Social Services may provide all or part of the assistance required, but your family, friends or neighbours may also provide support.

You will also be informed of any financial entitlements. There are certain requirements you must meet to be eligible for the above entitlements and you may have to pay something towards the cost of the services received. This will be discussed with you in detail and any agreed services will be written into your care plan.

Your discharge

You may go home by ambulance or you may be asked to make your own arrangements to go home. If transport home is a problem, please tell the nursing staff on admission, or as soon as possible afterwards.

When you are ready to leave the ward, you may be given a supply of medication. A letter will be given to you for your GP. You will also be sent an appointment to see your consultant at the outpatient clinic.

What should I do at home?

On returning home, help may be needed for at least two to three weeks with basic things like cleaning and shopping. You may feel emotionally and physically drained. This can be normal after major surgery.

Try to take things slowly - spread your periods of activity over the day and take frequent rests in between. Balance periods of rest and activity.

Remember to continue with your exercises and gradually increase your mobility by taking short walks outdoors, accompanied by someone at first. Over the next few weeks try to increase your walking as this will help you to achieve as good a result as possible.

Things to remember

• Three to four short walks are better than one long walk
• DO use crutches or sticks when walking outside
• DO sit on a high-seated chair
• DO avoid crossing your legs at the knee and the ankles
• DO use the banister when climbing the stairs
• DO wear low-heeled shoes
• DO NOT stand for long periods
• DO NOT bend at the waist
• DO NOT twist your operated leg in or out
• DO sleep on your back
• You may lie on your operated side as soon as you feel comfortable. Never lie on your un-operated side
• Return to sexual intercourse with care
• Reorganise your household tasks to avoid prolonged standing

Travelling

Driving is not recommended until your consultant has reviewed you which is usually at 6 weeks.

Inform your insurance company what procedure you have had as they may have their own rules on driving after surgery. You may travel in the front seat of a car.

Flying is not recommended in the first 3 months.

A letter from your GP/consultant informing the airport of your hip replacement may prevent embarrassment with metal detectors in security systems.

You will be reviewed by the consultant team in the outpatient department after discharge and at regular intervals afterwards.

Getting in and out of a car

The passenger seat should be moved back as far as possible with the seat reclined slightly

• Position yourself sideways to the car
• Put your operated leg out in front of you and lower yourself onto the seat
• Push yourself backwards towards the driver’s seat
• Leaning backwards and pivoting on your bottom slide your legs into the car, ensuring that you keep the operated leg straight
• Getting out of the car is the reverse procedure

Contact number - Orthopaedic Department - Telephone: 0161 206 4898