Total Hip Replacement

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Total Hip Replacement

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Replacement surgery is the first step to reclaiming your mobility and life when medication, physiotherapy and walking aids don’t work. It is the answer to end stage osteoarthritis.

Hip replacement is also called hip arthroscopy and is one of the most successful and life enhancing procedures. It relieves almost 95% of pain and improves mobility hence enabling patients to return to work and lead a near normal life. Hip replacement surgery is a safe and effective surgery. Doctors usually suggest replacement surgeries as a treatment modality, after trying medication, walking aids and physiotherapy.

It can be described as a resurfacing as only the surface of the bones of the joint are replaced. After surgery there is pain relief and this improves the ability to walk. A total hip replacement needs hospitalisation for 3-5 days. The procedure is done under general anesthesia or spinal anesthesia or a combination of both.

A hip joint is a ball and socket joint. The socket is the cup shaped part of the pelvis called the acetabulum and the ball is the head of the thigh bone.

THR is a surgical procedure where the diseased cartilage and bone of the hip joint is surgically replaced with artificial materials. Damage to the joint occurs due to arthritis or injury and leads to hip pain and limited mobility. Initially the doctor offers medication, modification of activities and physiotherapy.

The surgery itself takes a few hours. After surgery the patient will be in the recovery room till the anesthesia recovery criteria is met.

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 noncemented socket may also be used.

Your orthopaedician will help you decide on the type of implant best suited for you. The most common condition requiring hip replacement is osteoarthritis, (an aging process) with injury being the next common cause. This means the cartilage of the hip joint has worn out resulting in the bones being exposed. When the bones rub against each other, it is very painful. Total hip replacement is done to relieve chronic progressive pain, correct deformity and improve stability and mobility of the patient.

It is done for those who have irreparable damage of the hip joint that has not responded to medication and physiotherapy. This may be due to osteoarthritis age related degeneration, injury or rheumatoid arthritis. Regardless of the diagnosis, all patients with severe disabling hip pain that interferes with quality of life and activities of daily living qualify for this surgery. Usually it takes 2-3 months after surgery to see the full benefits of surgery.

When is hip replacement surgery not advised?

  • Medical fitness for surgery is a must. For instance, a patient with a history of heart attack in the previous 6 months would not be a suitable candidate.
  • Other serious medical conditions like uncontrolled diabetes, hypertension etc., need to be optimised.
  • Active infection in any part of the body

Expected outcomes of hip replacement surgery

  • 95% of patients experience relief from pain.
  • Improvement of mobility and quality of life

Risks and complications

These can be treated with little or no impact on the outcome of surgery and include but are not limited to:

Minor risks

  • Post operative nausea and vomiting
  • Headache
  • Pneumonia
  • Nerve injury causing numbness or weakness in the foot
  • Fracture of the thigh bone
  • Blood clots in the legs
  • Leg length discrepancy

Major risks

  • Heart attacks
  • Stroke
  • Pulmonary embolism
  • Infection
  • Bleeding requiring transfusion
  • Allergic reaction to medication

What is the difference between a cemented and uncemented hip replacement?

When it comes to the cup (socket) portion of the replacement, all of these are uncemented components placed in with a press fit. The sockets are placed in fairly tightly, but in some cases a few screws may be used to secure the cup. Your own bone will eventually grow into the rough surface of the implant to secure it permanently.

Most of the femoral components are also placed in without cement. In certain rare patients with poor bone quality, a smooth femoral component will be used with bone cement at the surgeon's discretion.

Is the procedure painful?

The procedure itself is done under general or spinal anaesthesia and you will not experience pain. Most patients experience pain in the first week after surgery, which with medication gradually reduces.

Will I need physiotherapy?

All patients need physiotherapy following surgery. This is started on the immediate post operative day and at discharge, you will be advised to see a physiotherapist to assist with leg exercises. Home physiotherapy is also available. Exercises will gradually be increased and over time you will be able to switch over to walking and exercising by yourself.

Once you are comfortable you can do stationary bicycling, golf, swimming and walking. Activities like jogging, football, gymnastics, rock climbingetc. are not permitted.

How long will the hip replacement last?

This depends on the patient's weight and demands placed on the implant. Typically an implant is expected toast between 10-20 years. Newer implants have better longevity and can tolerate higher impact activity.

Your surgeon will give you more information on which implant is suitable for you, its advantages and disadvantages and cost.

What is total hip replacement?

It is also called total hip arthroplasty and can be described as a resurfacing as only the surface of the bones of the joint are replaced. After surgery there is pain relief and this improves the ability to walk. A total hip replacement needs hospitalisation for 3-5 days. The procedure is done under general anaesthesia, spinal anaesthesia or a combination of both.

Implant components include the ball (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal). The prosthetic components may be cemented into the bone to allow the bone to grow onto the components. Depending on the quality and strength of the bone, a cemented stem or noncemented socket may be used.

The surgery itself takes a few hours. After surgery the patient will be in the recovery room till the anaesthesia recovery criteria is met.

The aim of the surgery is to remove the damaged cartilage and bone and replace them with new metal plastic or ceramic implants to restore alignment and function of the hip.

Steps in the surgery

Step 1: The damaged thigh bone head is removed and replaced with a metal stem that is fitted or cemented into the hollow centre of the thigh bone.

Step 2: A metal or ceramic ball is placed on the upper part of the stem and represents the head of the thigh bone.

Step 3: The damaged cartilage surface of the socket is removed and replaced with a metal socket. Screws or cement are used to hold the socket in place.

Step 4: A plastic, ceramic or metal spacer is inserted between the new ball and socket to allow for a smooth gliding surface.

Indications

  • Hip pain that restricts activities of daily living, such as walking or bending etc.
  • Hip pain at rest and also disturbing sleep
  • Stiffness that limits movement
  • Inadequate pain relief from medication, physiotherapy or walking aids.

How to ensure good results of surgery?

  1. Weight loss in those who are overweight
  2. Adherence to physiotherapy regimen
  3. Adequate and correct exercises

Risks associated with total hip replacement

Complications following total hip replacement are low.

As with any surgery there are anesthesia related risks, exacerbation of associated medical problems and allergic reactions to medication. Complications specific to total hip replacement although uncommon, range from minor to serious life threatening problems

  • Difficulty passing urine: It occurs in 20% of patients and may necessitate the need for a bladder catheter for a day or two.
  • Nausea and vomiting: It is seen in the immediate post-operative period in 10% of cases.
  • Delayed wound healing: It is common in obese individuals, diabetics and those who have a poor immune system. This is often seen in redo surgeries. It should be managed promptly to avoid infections.
  • Infection: Despite all precautions taken during surgery, infection may occur and is cited at less than 2% of patients undergoing the procedure. This is more common in those who are elderly, cancer patients, have diabetics or on immunosuppressant medicines after transplants. Infection can be in the wound or deep seated around the implant. Some infections like MRSA (methicillin resistant staphylococcus aureus) may be resistant to common antibiotics and more difficult to treat. Minor infections may be treated with antibiotics but if the implant gets infected, it may need to be removed and replaced at a later date. Infections can also occur many years after the surgery, especially in immunocompromised patients.
  • Deep vein thrombosis (DVT): It is a blood clot in the deep veins of the calf or top of the inner thigh. If a clot develops and breaks free, it can travel to the lungs and cause a condition known as pulmonary embolus, which is potentially life threatening. Without adequate preventive measures, the incidence of DVT is cited at 40–88% and mortality due to pulmonary embolism up to 2%. The incidence falls dramatically to less than 1% if DVT prophylaxis is followed. Patients of total hip replacement will be given stockings to improve circulation and also medicines to thin blood. The physiotherapist assists in exercises and also helps the patient mobilise as soon as possible after the operation. Elevation of the limb, lower leg exercises to improve circulation also help to prevent formation of clots.
  • Leg length equality: Sometimes after surgery, one limb may appear shorter than the other, despite all efforts to make the legs even. This may have also been done to maximise stability and biomechanics of the hip. In some cases, a shoe lift may be advised.
  • 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 can usually put it back into place without the need for more surgery. In situations in which the hip continues to dislocate, redo surgery may be necessary.
  • Wearing out and loosening of implant: The life span of a total hip replacement is 10-20 years. Over time the components of hip replacement may wear away and become loose needing surgical correction. This may also occur due to trauma, migration of the prosthesis, bone degeneration or biologic thinning of bone called osteolysis. If this happens, a redo surgery may be required. Wearing out of the implants may be prolonged, up to about 30 years, by using the latest CERAMIC implants but these are costlier and are beneficial in relatively younger patients (around 50 years of age).
  • Stiffness and inability to move the joint freelyIt can usually be corrected with exercises. Although an average of 115° range of motion is anticipated after surgery, scarring of the hip can occur limiting movement, especially in those who had limited movement before surgery. It is seen in about 10% of patients. One of the treatment options is manipulation under anaesthesia
  • Continued pain: It is rare but happens in a few cases.
  • Haematoma In the thigh,it is seen in 5% of patients where a swelling occurs due to bleeding.
  • Neurovascular injury occurs due to pressure or injury to the nerves or blood vessels outside the joint and usually resolves by itself.

Evaluation before total hip replacement

This is a screening to ensure fitness for surgery. The doctor will explain what is done during the surgery, follow-up, give post operative advise and when you are likely to be fit for surgery, before taking your consent for surgery. Physiotherapy and occupational therapy requirements will also be explained.

Advice before surgery

  • Some medicines like hormone replacement therapy, contraceptives etc. will be stopped at least 6 weeks before surgery.
  • One needs to stop smoking for at least 6 weeks before surgery, as this causes changes in blood flow patterns, delays healing and slows recovery.
  • Weight reduction: BMI > 30 increases the risk of anaesthesia and surgery. It also reduces the life span of the artificial hip.
  • Address dental problems before surgery in order to prevent any post-operative infection being triggered.
  • Practice sleeping on your back as sleeping on the side is uncomfortable for at least 6 weeks after TKR.

Orthopaedic evaluation:

  • A medical history of the current symptoms, extent of pain and range of movements, functional disability and current level of activity.
  • A history of associated diseases like diabetes, asthma, obesity and treatment is taken.
  • History of allergies.
  • Treatment taken previously for the hip joint problem.
  • A physical examination to assess hip mobility, stability, strength and alignment.
  • X rays to determine the extent of damage and deformity in the hip
  • Routine blood tests like complete blood count, blood sugar level, routine urine test, chest x-ray, ECG and ECHO if needed will be advised.
  • Depending on the age and associated diseases like diabetes, hypertension, one may be advised clearances by a cardiologist, diabetologist and others.
  • Those with urinary issues should have a urological evaluation as this may be a source of infection later.
  • In some cases an MRI may be done to determine the condition of the bone and soft tissues of the hip

A preanaesthetic check will be done and the anaesthetist will inform you of the type of anaesthesia to be given and all risks associated with it. One is asked not to eat or drink anything for 6 hours before surgery. Advice on what medicines you may take on the day of surgery from your regular medicines will be told to you by the anaesthetist. You may be asked to stop some medication like blood thinners, a few days before the surgery. An informed consent will be taken for performing the procedure. Your doctor will explain in detail about the surgery and post operative requirements, including rehabilitation at home. You will be given an opportunity to clarify all your doubts and fears before signing the consent.

Recovery at home

Strictly follow all post operative advice given.

Wound care The wound at the operation site is stitched with staples. This needs to be removed about three weeks after the surgery. Care should be taken not to get the wound wet until it is thoroughly healed. The wound will need dressing to prevent irritation from clothing or support stocking.

Diet A balanced diet with an iron supplement is advised to ensure quick healing and restoration of muscle strength.

Activity Exercise is very important for a good recovery after surgery. It takes 3-6 weeks to resume most normal activities of daily living, after surgery. A graduated walking programme to slowly increase the amount of walking is to be planned. The physiotherapist will teach you the exercises to be performed several times a day. Initially you may need help and support but gradually you may be able to do them on your own.

Post operative period

A post operative stay of 3-5 days is required. There will be a splint, such as a foam pillow placed between your legs to protect the hip joint during your early recovery. An intravenous drip may be given till you resume taking fluids. There may be an oxygen mask also. All these will be removed as soon as possible after the surgery. You will be mobilised as soon as possible. The physiotherapist will help you with this. Over the next few days you will be taught exercises, how to use walking aids and how to climb stairs.

Pain management: After surgery, some pain and discomfort is common. Pain relief medication and ice packs will be given. These medicines will be continued orally after discharge depending on the patient‘s tolerance to pain. Swelling and pain will persist for some time and will resolve over time. You will be advised to sit with lower limb elevated and not to stand in one position for long.

Blood clot prevention: The surgeon may prescribe compression stockings, a DVT pump and blood thinners while in hospital. The stockings and oral blood thinners may be continued after discharge for some time. Foot and ankle movement is encouraged immediately after surgery to increase blood flow and prevent blood clots.

Preventing pneumonia: In the early post operative period shallow breathing is common especially in the elderly and smokers. Anaesthesia, pain medication and prolonged stay in bed contribute to this. Shallow breathing can lead to retention of secretions that can cause partial lung collapse and pneumonia. To prevent this, the physiotherapist will encourage you to take frequent deep breaths and provide you with a simple tool called a spirometer to help you with breathing improvement.

Walking: It is advised on the first or second post operative day with walking aids and someone beside you. It is necessary to improve walking pattern while in hospital. While walking with aids, follow the steps as given. First move the aid, then step forward with the operated leg and then bring up the other leg. Avoid twisting or pivoting. Walking, while essential should not be overdone. Increase the walking speed and distance gradually.

Physiotherapy: Exercises are started on the day after surgery. The physiotherapist will help you with specific exercises to strengthen the leg and restore hip movements.

Climbing the stairs: Learn how to use stairs from the physiotherapist. Use railings or banister and walking aids while climbing up or down the stairs.

Going up: Go up one step with the non-operated leg and bring up the operated leg and then bring the crutch or stick up.

Going down: Take the crutch one step down and place the operated leg down a step beside the crutch. Then bring the non-operated leg to meet the other.

Discharge: Most patients are discharged on the 3rd or 5th post operative day.

Outcomes of total hip replacement

Most people who undergo total hip replacement have a dramatic reduction in pain in the hip and significant improvement in their mobility and ability to perform normal activities of daily living.

But total hip replacement will not allow one to do more than what one was able to do before developing arthritis. Some numbness is felt around the incision on the skin. Some stiffness is possible particularly with excessive bending.

With normal level of activity, the plastic spacer in the implant will start to wear away in time. Excessive activity or overweight will speed up the wear and tear, which may cause the implant to loosen and become painful.

Hence, high impact activities like jogging, athletics or sports like football are generally to be avoided. One can indulge in walking, swimming, driving, biking, dancing and sports like golf.

The lifespan of hip replacements can be increased with appropriate activity modification. The average length of a total hip replacement is 10-20 years depending on the activity

The hip implant may activate metal detectors at airports. You need to carry a card or letter that informs security about your implants.

You may feel some numbness in the skin around the operation site. Stiffness is seen with excessive bending. These will disappear in time.

How to improve outcomes of a hip replacement surgery?

  • Do regular light exercises to maintain stability, adequate strength and mobility of the hip.
  • Take all precautions to avoid falls and injuries.
  • Ensure antibiotics are taken before any dental procedures to avoid infection which may spread to the implant.

How to prevent problems after THR?

Prevention of blood clots in the leg The risk is high in the first several weeks after surgery as mobility is reduced. If these clots break off, they may migrate to the lungs and cause a highly fatal condition called pulmonary embolism. Compression stockings and blood thinners will be advised at discharge for several weeks.

Warning signs of blood clots in the leg include:

  • Increasing pain in the calf
  • Tenderness or redness above or below the knee
  • New or increasing swelling in the calf, ankle or foot

Warning signs of pulmonary embolism include:

  • Sudden onset, shortness of breath
  • Sudden onset chest pain
  • Localised chest pain with cough
  • Sputum which is blood tinged

Preventing infection

Infection of the implant can occur from bacteria in the blood stream. The bacteria may come from dental procedures, urinary tract infections or skin infections. After total hip replacement, patients may need to take a course of antibiotics for dental work or other surgeries however small.

Infection of the implant can occur from bacteria in the blood stream. The bacteria may come from dental procedures, urinary tract infections or skin infections. After total hip replacement patients may need to take a course of antibiotics for dental work or other surgeries, however small.

Warning signs of infection

  • Persistent fever (higher than 100°F
  • Chills and rigours
  • Increasing redness, tenderness or swelling at the operation site
  • Drainage from operation site
  • Pain both at rest and on movement

Avoiding falls

Falls can damage the hip and a redo surgery may be needed. Stairs are to be avoided until the strength in the hip returns with improved flexibility and balance.

Prior to discharge you will receive details of special precautions to follow.

Causes of hip pain

Arthritis is the most common cause of disability and chronic pain of the hip. Other common causes are osteoarthritis, rheumatoid arthritis and traumatic arthritis.

OsteoarthritisIt is an age related wear and tear condition, common after 50 years of age and in those with a family history of arthritis. The cartilage in the joint wears away and the bones rub against each other, causing hip pain and stiffness.

Rheumatoid arthritisIt is an autoimmune disorder where the body reacts against its own cells, which it recognizes as a foreign tissue. The synovial membranes become inflamed and thickened and over time the cartilage becomes degenerated, leading to pain and stiffness.

Post traumatic arthritis It follows a serious hip injury or fracture, where the cartilage becomes damaged leading to pain and stiffness.

Avascular necrosis Any injury to the hip, such as dislocation or fracture, may limit blood supply to the femoral head, leading to death of the part of the bone and the surface of the bone collapses, causing arthritis.

Childhood hip disease Even if treated, It can lead to arthritis in adulthood as the bone growth is reduced.

Anatomy of the hip joint

The hip joint is one of the body’s largest joints and is a ball and socket joint. The ball is the upper end of the thigh bone and the socket is the cup of the hip bone or pelvis. 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 the synovial membrane surrounds the hip joint and this makes a small amount of fluid that keeps the joint lubricated and helps prevent friction on movement. Bands of tissue called ligaments connect the ball to the socket and provide stability to the joint.