ANATOMY
The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).
The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.
A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.
Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.
COMMON CAUSES OF HIP PAIN
The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.
Osteoarthritis: this is an age-related “wear and tear” type of arthritis. It usually occurs in people 50 years of age and older and often in individuals with a family history of arthritis. The cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by subtle irregularities in how the hip developed in childhood.
Rheumatoid arthritis: this is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage the cartilage, leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed “inflammatory arthritis”.
Post-traumatic arthritis: this can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
Post-traumatic arthritis: this can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
Childhood hip disease: some infants and children have hip problems. Even though the problems are successfully treated during childhood, they may still cause arthritis later on in life. This happens because the hip may not grow normally, and the joint surfaces are affected.
DESCRIPTION OF THE PROCEDURE
In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components:
- The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow centre of the femur. The femoral stem may be either cemented or “press fit” into the bone;
- A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed;
- The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place;
- A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface.
(Left) The individual components of a total hip replacement. (Centre) The components merged
into an implant. (Right) The implant as it fits into the hip.
IS HIP REPLACEMENT SURGERY FOR YOU?
The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.
WHEN SURGERY IS RECOMMENDED
There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:
- Hip pain that limits everyday activities, such as walking or bending;
- Hip pain that continues while resting, either day or night;
- Stiffness in a hip that limits the ability to move or lift the leg;
- Inadequate pain relief from anti-inflammatory drugs, physiotherapy, or walking supports.
Candidates for surgery
There are no absolute age or weight restrictions for total hip replacements.
Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.
Orthopaedic evaluation
An evaluation with an orthopaedic surgeon consists of several components:
• Medical history: your orthopaedic surgeon will gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform everyday activities;
• Physical examination: this will assess hip mobility, strength, and alignment;
• X-rays: these images help to determine the extent of damage or deformity in your hip;
• Other tests: occasionally other tests, such as a Magnetic Resonance Imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.
(Left) In this X-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This X-ray of an arthritic hip shows severe loss of joint space and bone spurs.
DECIDING TO HAVE HIP REPLACEMENT SURGERY
Talk with your doctor
Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physiotherapy, or other types of surgery — also may be considered.
In addition, your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.
Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.
Realistic expectations
An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.
With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports.
Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.
With appropriate activity modification, hip replacements can last for many years.
Possible complications of surgery
The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery
Infection
Infection may occur superficially in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later.
Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots
Blood clots in the leg veins or pelvis are the most common complication of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilisation.
Leg-length inequality
Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopaedic surgeon will make every effort to make your leg lengths even, but may lengthen or shorten your leg slightly in order to maximise the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.
Dislocation
This occurs when the ball comes out of the socket. The risk for dislocation is greatest in the first few months after surgery while the tissues are healing. Dislocation is uncommon. If the ball does come out of the socket, a closed reduction usually can put it back into place without the need for more surgery. In situations in which the hip continues to dislocate, further surgery may be necessary.
Loosening and implant wear
Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biologic thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary
Other complications
Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. In a small number of patients, some pain can continue or new pain can occur after surgery.
PREPARING FOR SURGERY
Medical evaluation
If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.
Tests
Several tests, such as blood and urine samples, an electrocardiogram (ECG), and chest X-rays, may be needed to help plan your surgery
Preparing your skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.
Medications
Tell your orthopaedic surgeon about the medications you are taking. He or she or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.
Weight loss
If you are overweight, your doctor may ask you to lose some weight before surgery to minimise the stress on your new hip and possibly decrease the risks of surgery
Dental evaluation
Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.
Urinary evaluation
People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery
Social planning
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry
YOUR SURGERY
You will most likely be admitted to the hospital the day before your surgery.
Anaesthesia
After admission, you will be evaluated by a member of the anaesthesia team. The most common types of anaesthesia are general anaesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anaesthesia (you are awake but your body is numb from the waist down). The anaesthesia team, with your input, will determine which type of anaesthesia will be best for you.
Implant components
Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).
The prosthetic components may be “press fit” into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket may also be used.
Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs
(Left) The acetabular component shows the plastic (polyethylene) liner inside the metal shell. (Right) The porous surface of this acetabular component allows for bone ingrowth.
Procedure
The procedure itself takes approximately one to two hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip.
After surgery, you will be moved to the recovery room where you will remain for several hours while your recovery from anaesthesia is monitored. After you wake up, you will be taken to your hospital room.
Your stay in the hospital
You will most likely stay in the hospital for estimated 7- 8 days. To protect your hip during early recovery, a positioning splint, such as a foam pillow placed between your legs, may be used.
Pain management
After surgery, you will feel some pain, but your surgeon and nurses will provide medication to make you feel as comfortable as possible. Pain management is an important part of your recovery. Movement will begin soon after surgery and the physiotherapist will help you to manage pain effectively. When you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your surgeon if postoperative pain becomes a problem.
Physiotherapy
Following hip replacement surgery, physiotherapy programme is a key part of your recovery as it will help you to return back quickly, safely and independently to your daily life activities. The day of surgery, your surgeon will refer you to a physiotherapist to initiate your rehabilitation and provide you basic recommendations on how to manage effectively your pain by positioning, ice programme and mobilisation. The physiotherapist will teach you on how to protect your hip during transfer, to walk with crutches or walking frame and to recover the mobility and the strength of your operated leg. Following discharge, your physiotherapy programme should be continued for four to six weeks as outpatient service under the supervision of a physiotherapist.
Please refer to our brochure “Hip replacement rehabilitation”.
Preventing pneumonia
It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anaesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.
YOUR RECOVERY AT HOME
The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon’s instructions regarding home care during the first few weeks after surgery.
Wound care
You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 12-14 days after surgery.
Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.
Diet
Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.
Activity
Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within three to six weeks following surgery. Some discomfort with activity and at night is common for several weeks.
Your activity program should include:
• A graduated walking program to slowly increase your mobility, initially in your home and later outside; • Resuming other normal household activities, such as sitting, standing, and climbing stairs;
• Specific exercises several times a day to restore movement and strengthen your hip. You probably will be able to perform the exercises without help, but you may have a practice with a physiotherapist the first few weeks after surgery.
Please refer to our brochure “ Hip replacement rehabilitation”
AVOIDING PROBLEMS AFTER SURGERY
Blood clot prevention
Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
Warning signs of blood clots
The warning signs of possible blood clot in your leg include:
• Pain in your calf and leg that is unrelated to your incision;
• Tenderness or redness of your calf;
• Swelling of your thigh, calf, ankle, or foot
Warning signs of pulmonary embolism
The warning signs that a blood clot has travelled to your lung include:
• Sudden shortness of breath
• Sudden onset of chest pain
• Localised chest pain with coughing
Preventing infection
A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.
Following your surgery, you may need to take antibiotics prior to dental work, including dental cleanings, or any surgical procedure that could allow bacteria to enter your bloodstream. For many people with joint replacements and normal immune systems, the American Academy of Orthopaedic Surgeons (AAOS) recommends taking preventative antibiotics before dental work.
Warning signs of infection
Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:
• Persistent fever (higher than 38 °C orally)
• Shaking chills
• Increasing redness, tenderness, or swelling of the hip wound
• Drainage from the hip wound
• Increasing hip pain with both activity and rest.
OUTCOMES
How your new hip is different
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.
Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopaedic surgeon for a card confirming that you have an artificial hip
Protecting your hip replacement
There are many things you can do to protect your hip replacement and extend the life of your hip implant:
• Participate in a regular light exercise program to maintain properstrength and mobility of your new hip;
• Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery;
• Make sure your dentist knows that you have a hip replacement. You will need to take antibiotics before any dental procedure;
• See your orthopaedic surgeon periodically for routine follow-up examinations and X-rays, even if your hip replacement seems to be doing fine.
Reference: American Academy of Orthopaedic Surgeons (AAOS).
ORTHOPAEDICS & HAND SURGERY DEPARTMENT
FV Hospital, 3rd Floor, V building
Tel: (028) 54 11 33 33 – Ext: 1226, 1227
