Total Hip Replacement
Hip replacement is a predictable successful procedure. Relief of pain and improved activity levels are the expectation after hip replacement. Total hip replacement was first performed in 1960 and over the last 50 years there has been dramatic improvement in the procedure, implants, and techniques associated with hip replacement. Today over 230,000 total hip replacements are performed in the United States annually. In the recent decade a significant advance in hip replacement surgery has been the refinement of a minimally invasive procedure. Using new techniques and instruments we have been able to make a smaller incision with less injury to the muscles and tendons associated with the approach to the hip resulting in a quicker recovery, better cosmesis, less blood loss, and earlier rehabilitation with fewer wound issues.
Minimally invasive hip replacement, however, may not be for every patient. The most important goal is to have a well-functioning total hip. In some patients it is not possible to accomplish perfect alignment without a larger procedure. Patient factors such as weight and stiffness in the hip or previous hip surgery sometimes compromise the ability to do things through a minimally invasive approach and require a standard, full-size incision.
There are currently 3 major approaches to the hip; standard or posterior approach, lateral, or an anterior approach. The best approach for you should be a decision brought about through a discussion with your physician after reviewing the expectations and the pros and cons of different approaches.
The normal hip is one of your body’s largest weightbearing joints and it is a ball and socket joint. The bony surfaces of the ball and socket are covered by a smooth, durable cover called the articular cartilage. The lining of the joint is called the synovial membrane, which produces a lubricating fluid for the joint. Pain is commonly brought on by wear and tear of this ball and socket joint, the 3 most common causes are rheumatoid arthritis, osteoarthritis, and traumatic arthritis. Osteoarthritis is a progressive breakdown of the cartilage lining of the joint. Soon the bones rub against each other causing hip pain and stiffness. Rheumatoid arthritis, which is an autoimmune disease in which the synovial membrane becomes inflamed and produces damaging enzymes that breakdown the articular cartilage, again leading to pain and stiffness. Finally, traumatic arthritis can be due to injury or a prior fracture leaving the hip joint cartilage injured, resulting in progressively break down over time.
The decision on whether to have hip replacement should be a cooperative decision between you, your family and your orthopedic surgery. After review of your symptoms, your x-rays, and your personal expectations, recommendation for surgery is based primarily on the extent of pain and disability, not on age or necessarily x-ray findings. Patients generally benefit from hip replacement if they have pain that limits their daily activities, pain at rest or at night, stiffness that limits your mobility, and pain that is not relieved by anti-inflammatory medications. All of these conditions are usually dramatically improved by hip replacement.
The vast majority of people who have a hip replacement are very happy with the replacement and never have to have it revised. Following surgery you will be advised to avoid certain activities like high-impact sports that my cause early wear and you may be asked to avoid specific positions of the joint that could possibly lead to dislocation.
Prior to surgery a complete evaluation of your medical history, current medications, and laboratory tests will be performed. On the day of surgery, your skin should be clear of any infections or irritations. You should be sure to let your orthopedic surgeon know if you have any skin problems prior to surgery. You may be advised to donate your own blood prior to surgery and in that case it would be stored in the blood bank and then administered postoperatively. In preparing your home for returning to home after hip replacement it is very important that you are sure all stairs have a secure handrail, that you have a stable chair with a firm back and arm rest for comfortably sitting, a raised toilet seat, a shower bench or chair for bathing, a reacher that will allow you to grab objects off the floor without bending your hips, and be sure to remove all loose carpets and electrical cords in the areas where you will be walking. Although infection after hip replacement is not common, an infection can occur if bacteria enter your blood stream and because bacteria enter your blood stream during dental procedures you should consider getting treatment with antibiotics prior to dental procedures for at least 2 years following hip replacement surgery. Routine cleaning of your teeth should be delayed for at least 3 months following surgery. Individuals with a history of recent or frequent urinary tract infections or older men with prostate disease also need urologic evaluation prior to surgery.
On the day of surgery you will have the opportunity to discuss anesthetic choices with the anesthesiologist. The 2 most common types of anesthesia for hip replacement are general anesthetic which puts you to sleep through breathing gases, or a spinal anesthetic which allows you to breathe on your own, but numbs up your lower body from the waist down.
Typical hip replacement takes a couple of hours. During that time your orthopedic surgeon will remove the damaged cartilage and bone and position a new metal, plastic, or ceramic implant. A typical total hip consists of 2 basic components. The ball component made of highly polished metal or a ceramic material attached to a stem which goes down inside of the thigh bone and the socket component which is a metal cup with a very durable plastic liner. Most hip replacements are non-cemented prostheses where the bone grows into the implant securing it. The prosthesis is coated with a textured metal that allows the bone to attach to it.
You should expect to get up the day of surgery and walk a few feet, walk up and down the hall the next day, and possibly go home in 1-2 days after surgery. Physical therapy will make sure you are safe with stairs or any other components of your environment that you will expect to encounter when you go home. If you live alone or your spouse is unable to take care of you in the immediate postoperative period, a short stay at a rehab facility is readily available and those arrangements will be made with you through the social worker at the hospital.
The complication rate following hip replacement is very low with serious complications occurring less than 3% of the time. The most common complications are blood clots. These clots can develop in the veins of the leg or pelvis associated with decreased activity and the positioning during surgery and typically patients are treated with a blood thinner for at least 1 month after surgery. Other potential complications are leg length inequality, which can occur or seen worse after hip replacement surgery. The orthopedic surgeon will evaluate this and take it into account in addition to other issues including stability and biomechanics of the hip. Some patients are more comfortable after surgery with a shoe lift if there is a small change in leg length. The risk of infection after surgery is extremely low. You will be given antibiotics at the time of surgery to minimize that risk. It is slightly higher in patients that are overweight or have diabetes or immunocompromised conditions such as rheumatoid arthritis. Implant wear or loosening is possible, though very unlikely and more common in young, very active patients that have a hip replacement.
Upon discharge from the hospital, you will be given extensive instructions on your recovery at home. A nurse will typically come out to the home and check on your wounds, as well as a physical therapist to help you with rehabilitation in the initial couple of weeks after surgery. You will have stitches, staples, or a running stitch underneath the skin. To avoid any wound contamination, it is important to keep the wound dry until there is absolutely no drainage and it is very important that who ever changes your dressing washes their hands very well and uses sterile technique in changing your dressing daily. Loss of appetite is common in the first couple of weeks after surgery. It is very important to get adequate vitamins and iron to help with the healing process and drink plenty of fluids. Exercise is critical to your recovery at home. Frequent light, short periods of activity throughout the day are encouraged to decrease your likelihood of stiffness and to enhance your pace of recovery. Your activity program will include graduated walking in your home and later outside. Additionally, a physical therapist will give you exercises to perform daily. Avoiding falls in the first few weeks after surgery is extremely important, therefore most patients will use a walker or crutches in the first couple of weeks until they have more confidence, strength, and balance appropriate for independent ambulation. It is also very important that you have hand rails for any stairs that you encounter.
Hip replacement is one of the most successful procedures in the history of orthopedics. It allows for dramatic improvement in lifestyle with resolution of most pain related to hip degeneration and within a couple of months a rapid recovery to ambulation without discomfort or stiffness.