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Total Hip Replacement

This information has been designed to give you a basic understanding of your hip replacement operation and to give you some idea of what to expect during your hospitalisation. Please keep in mind that this is only a guideline and that each individual has different needs. You may progress at a different rate to that which is outlined.

Your Orthopaedics SA specialist will be happy to address any questions which might arise after reading this information.

 

Total Hip Replacement is the surgery performed to replace a damaged or worn hip joint. The hip is a ball and socket joint formed by the head of the thighbone (femur) and the socket of the pelvis (acetabulum).

A smooth and compressible substance known as articular cartilage coats the surface of these bones. Arthritis occurs when the articular cartilage wears away exposing the underlying bone. This causes roughening and distortion of the joint, resulting in painful and restricted movement. A limp will often develop and the leg may become wasted and shortened.

The new joint relieves pain, improves walking ability, decreases stiffness and in most cases restores leg length and may correct the limp.

Osteoarthritis of the hip is generally a disease of the older person but may occur in younger people following rheumatoid arthritis, fractures of the hip and other rarer conditions.

The different types of hip replacement

There are many different types available, but all consist of the same basic components – one component replaces the worn socket and is called the acetabular cup and the other replaces the worn head of the femur and consists of a metal alloy ball mounted on a stem. Some hip replacements are fixed in place using special bone cement. Others have a rough, porous surface into which bone grows to lock the implant in place. Each type has advantages and disadvantages. The standard bearing surface is metal on plastic. Occasionally your surgeon may recommend other materials.

The risks involved

  1. Infection – (1-2%) Fortunately, with good surgical technique and the use of antibiotics this is a rare complication but if it does occur it is serious and may result in the need to remove the artificial joint components.
  2. Blood clots – after joint replacement surgery are common. The risk is reduced by giving blood-thinning medication that starts the night after surgery. These clots can rarely break off and go to the lungs leading to severe breathing problems or even death.
  3. Dislocation – (1%) usually occurs in the first weeks or months. May be caused by crossing legs, twisting on leg or sitting in low chair. May require anaesthetic to “put the hip back” and rarely requires revision of one or other component. i.e. removal and replacement with a new artificial one.
  4. Loosening – is the major long-term problem but usually is not significant for 10-15 years. Occasionally the hip may loosen earlier than this and may require revision, i.e. removal and replacement with new artificial joint.
  5. Leg length – some minor alteration in the length of the legs after surgery is common. Usually this is not noticeable but very occasionally requires a heel raise on the other side. In some instances an alteration in leg length is unavoidable.
  6. Nerve damage – Occasionally nerves that run close to the hip can be bruised, leading to weakness of toe or foot movements.
  7. General upset – After any big operation, many body systems can be upset, causing patients confusion. Bladder, chest, kidney or abdominal problems sometime occur.

Overall patients generally have a 95% chance of being happy with their hip for at least 10 years.

Remember

This operation is designed to improve quality of life and is usually undertaken when other avenues of treatment have failed and the benefits outweigh the risks. It should never be entered into lightly! In general terms the pain should be severe, your walking distance significantly reduced and simple analgesics have failed to control the pain before you consider surgery.

Realistic expectations

The aim of surgery is to relieve pain so you can walk comfortably. It does not give you a normal hip and will not allow you to run.

Before Hospitalisation

This is a good time to make sure your home will be a safe environment for you upon your discharge from hospital.

Position furniture to give you clear walkways and roll up any rugs which might cause you to slip.

Put commonly used items within reach in your bathroom and kitchen to prevent you needing to bend down.

It is also a good time to commence some gentle exercises to tone up your muscles, especially the quadriceps. Not all exercises will be possible because of pain or stiffness. You will find examples of some recommended exercises included in this information. Your physiotherapist will advise which of these exercises will be suitable after your operation.

Most hospitals encourage a pre-admission visit to hospital to show you the hospital, streamline the admission process and explain the hospital stay.

You are also encouraged to see the Anaesthetist prior to surgery.

You will usually be admitted to hospital on the morning of surgery and will be seen by the Nursing Staff and Anaesthetist.

Please bring with you any medication that you take and your X-rays, along with your pyjamas, toiletries, etc.

Autologous Blood

You may be suitable to give your own blood, have it stored and then given back to you during and after surgery. This minimises the need for having banked blood (i.e. other people’s blood from the Red Cross). Up to 3 pints of blood are collected and the process takes three visits spread over three weeks. Most people will require a blood transfusion.

Smoking

If you are a smoker it is advisable to stop smoking, or at least reduce the number of cigarettes that you smoke, in order to reduce the risk of chest and circulation problems after surgery. The Hospital is a SMOKE FREE ZONE.

Anti-Inflammatory Medication

Anti-Inflammatory medication including VOLTAREN, FELDENE, NAPROSYN, CELEBREX and ASPIRIN should NOT be taken for seven days, prior to your surgery, as they affect the way your blood clots.

Anti-Platelet Medication

Anti-platelet medication including ASTRIX, CARTIA, CLOPIDOGREL (eg. PLAVIX, ISCOVER) and TICLOPIDINE (eg. TICLID,TILODENE) can also affect the way in which your blood clots. These medications should NOT be taken for seven days prior to your surgery.

If you are unsure about your current medications and the possible complications, please speak with your Doctor prior to surgery.

Hospital Admission

The Orthopaedic Liaison Nurse will phone you prior to your admission to hospital to arrange a suitable time for you to visit the Pre-Admission Clinic. During this visit the nurse will discuss details of your hospital stay and the recovery process and answer any questions that you or your family may have. To streamline the admission process a nursing history and health assessment will be carried out. The aim of this visit is to provide information that will better prepare you for surgery and to commence planning for your recovery.

During your hospital stay, the Orthopaedic Liaison Nurse may visit you on the ward to check on your progress.

This service offers ongoing support and assistance as required after discharge from hospital.

The Orthopaedic Liaison Nurse can be contacted at any time if you or your family have any concerns, queries or problems – phone (08) 8267 8267.

On the day of surgery

You will be required to fast for about six hours before surgery. The operation itself takes approximately two hours. Some time is then spent in the recovery room prior to you returning to the High Dependency Unit or Ward.

The Nursing Staff will:

  • Explain hospital routine and orientate you to your new surroundings.
  • Record your temperature, pulse rate, blood pressure.
  • May shave your hip and wash it with Betadine.
  • Answer any questions you may have.
  • Discuss your medical and surgical history and current medications.
  • Check your heart and lungs.
  • Discuss the type of anaesthetic, e.g.: general or spinal.
  • May order other tests, e.g. chest X-ray, ECG, etc.

Length of stay

The length of hospital stay is usually between 5 and 8 days. We aim to plan your length of stay and have discharge arrangements in place prior to your admission.

After surgery

If necessary you will be in the “high dependency” area: which is part of the routine to keep an extra careful eye on you in the first 18 hours or so after surgery. (High Dependency Units (HDU) have a higher ratio of nurses to patients).

  • You will have a triangular shaped pillow between your legs to keep the new hip in its correct position.
  • You will have an intravenous “drip” in one arm. This is to ensure that you receive adequate fluids and also to give you regular antibiotics, which prevent infection. The drip may also be used to administer pain relieving medication or blood transfusion.
  • You will have a small tube coming from your wound, which is attached to a bottle. This prevents blood collecting in the wound.
  • You may have an oxygen mask on.
  • Sometimes a catheter to drain urine from your bladder will be required.
  • Your pain will be controlled by a drip, injections in the spine or regular medication.
  • Whilst some pain is inevitable, with modern drugs pain relief is much improved compared with years past.

The following routine is a guideline only. It depends on your speed of recovery and individuals do differ in the time needed for muscle strength to return. Each stage has to be completed before progressing to the next.

Pain Control

During the first few days you will experience some pain. This will be controlled by intravenous or epidural medication for the first 24-48 hours. After removal of the drip, you may require injections and/or tablets. It is important, initially, to take the pain relieving medication on a regular basis. This will allow you to exercise and move more freely. It may also be necessary to continue taking pain relief tablets when you return home. The nursing staff or pharmacist will instruct you on appropriate doses.

Anti-Coagulant (Blood Thinning Medication)

A small injection into the skin of your abdomen of anti-coagulant is usually administered once a day during your stay in hospital. This helps to thin the blood and helps prevent the formation of clots in your legs.

Mobility

The Physiotherapist will:

Assist you to become mobile again following your operation and teach you specific exercises.

Usually you will stand and begin walking the day after surgery. All the “tubes” are removed by two days after surgery. A physiotherapist will assist you with exercises and walking. The aim is to walk early and often. This minimises complications.

You will be able to sit for short periods in a high chair and use the toilet with a toilet “raiser” seat. It is important that you don’t sit in a chair, which is too low, as too much hip flexion may result in dislocation.

You may be able to have a soft pillow between your legs during the daytime and the triangular shaped pillow only at night.

The joint is stable immediately after the procedure, but the weakened muscles and soft tissue surrounding the joint require a longer-term program of physiotherapy and exercise to be restored to normal functioning.

Your mobility will gradually increase and with it, your independence. Physio continues and once your wound has healed you may go to the hydrotherapy pool with the physio to perform exercises in water.

Exercises

These exercises are recommended before surgery to help build up muscle tone and during rehabilitation after surgery. You may not be able to complete all exercises due to pain or stiffness. Your physiotherapist will advise which of the exercises are suitable for you after your operation.

Do the following exercises 10 times each and at least 3 times per day.

  1. Gently bend your feet up and down to help the circulation in your legs.
  2. Gently bend your knee so that your foot moves along the bed towards your buttocks. A mild stretching in your hip is normal. You may use your hands to help with this exercise.
  3. Tighten the muscles on the top of your thigh by pushing your knee down onto the bed. Keep your knee as flat on the bed as possible. Hold for 5 seconds then relax.
  4. Squeeze your buttocks together and hold for 5 seconds.
  5. With your knee over a bolster straighten your knee by tightening the muscles on the top of your thigh. Be sure to keep the bottom of your knee pressed onto the bolster. Hold for 5 seconds and then relax slowly.
    N.B Do not sleep or rest with the bolster under your knee.
  6. Keeping your knee straight, gently slide your leg out to the side then back again. Try to keep your knee cap and toes pointing to the ceiling.
  7. Bend both of your knees slightly. Dig your heels and elbows into the bed. Lift your bottom off the bed, squeezing your buttocks together. Hold for 5 seconds, then relax.

Suture Line

You will have a suture line on the side of your hip that requires a dressing while you are in hospital. The nursing staff will attend to this.

Sometimes you may have sutures that lie underneath the skin surface. These do not need to be removed and will dissolve in about 2 weeks. Skin staples are normally removed around ten days.

Prior to discharge your nurse will speak to you regarding care of your suture line once you are home. Wash your suture line daily and pat it dry with a clean towel. Avoid using any powders until the healing is complete as they “clog” the suture line and cause bacteria to grow.

Swelling

Swelling of the leg may take 8 weeks or more to resolve. To minimise this, when resting, have your legs up rather than spend long periods sitting with your legs down.

Observe your suture line for any signs of tenderness, redness, swelling or discharge. If you have any problems, contact your Surgeon, Local Doctor or the Orthopaedic Liaison Nurse.

Sleep Disturbances

As you might expect, wound discomfort and restriction of position will mean adopting a sleep position, which is unnatural for you. This may result in a disturbance to your sleep pattern, and/or restlessness.

Oral analgesia and warm drinks before going to bed may assist in relaxation.

Constipation

Your decreased activity level and appetite, reduced fluid intake and some medication may lead to bowel irregularity. You will be encouraged to drink fluids, increase the fibre content of your diet and, if necessary, take mild laxatives.

Sexual Activity

Resumption of sexual activity depends on when you feel comfortable. There are no restrictions if you keep to the guidelines given to you by your surgeon and physiotherapist for your daily activities.

Going Home

Doctor’s Appointment

Your surgeon will want to see you about 6 weeks after your surgery. The appointment will be make before you leave hospital by the nursing staff. It is important that you keep this appointment, as your surgeon will want to check your progress. You will be able to ask the surgeon questions regarding increasing your level of activity and resumption of driving.

If you attended a pre-admission session then the following will have been discussed.

Discharge

  • Before discharge the nursing staff will advise you regarding the hire of aids such as toilet seat raiser, shower chair, walking frame, crutches, walking stick etc.
  • If you are living alone during your rehabilitation the hospital may be able to provide some useful help.
  • Please consider your own home environment and discuss any problems you anticipate with the staff e.g. if you have stairs at home. You may need to practice with the physio so that you are confident going up and down stairs prior to discharge.
  • If travelling home by car, the car must not be a “mini” or high 4-wheel drive. You will require a few pillows to sit on to reduce flexion of the hip. X-rays and medications will be returned to you. Travel in the front seat to allow leg room. Practice with your physiotherapist before trying to get into a car. A plastic bag on the seat may help you settle on the seat more easily.

Rehabilitation after surgery

  1. Lie on your stomach for ten minutes daily – this allows the front of your hip to stretch out. (Make sure you roll over with a pillow between your knees).
  2. Sitting – Always sit in a chair, preferably with arm rests, that ensures your knees are NOT higher than your hip. Especially beware of couches – if in doubt, sit on a kitchen chair. Use a toilet seat raise and ALWAYS sit with your knees apart and DO NOT CROSS YOUR LEGS.
  3. Showering – Do not sit in the bath. Shower with your feet 15-30cm (6-12″) apart (preferably on a non-slip mat) or you can use a high shower chair.
  4. Sleeping – For the first six weeks sleeping on your back with a pillow between your leg is recommended to minimise the chance of dislocation. If you need to sleep on the non-operated side use a pillow between your legs to prevent your legs crossing.
  5. Bending – Do not bend from your hips to pick up anything from the floor. DO use your pick up stick. Later when you bend, put your operated leg behind, keeping your hip extended.
  6. Dressing – Sit on the edge of the bed (provided it is not too low)/chair with legs straight to dress. Be sure not to pull your operated leg up to put on socks/stockings. There are appliances available for hire to help with these activities. Try to avoid lace up shoes, use slip on shoes preferably with a shoehorn.
    Place operated leg into clothes first followed by the unoperated leg. To take clothes off, remove clothes from unoperated leg first.
  7. Walking and Exercises:
    • Do keep up with your hospital exercises for at least three months.
    • You may do some hydrotherapy after discussion with your doctor/physio.
    • Gradually increase the amount of walking you do. Do not discard your walking aids until instructed to do so by your doctor.
    • Allow time for resting – frequently. Do not pivot on your operated leg, whether sitting, standing or walking.
  8. Driving – Do not drive your car for six weeks and until advised by your surgeon.

CALL YOUR ORTHOPAEDIC SURGEON if you notice any of these symptoms:

  • Increased pain not controlled with medication.
  • Shortening or rotation of the leg on the operated side.
  • Increased redness, swelling or drainage around the incision.
  • Elevated or persistent temperature.
  • Tenderness, redness or swelling of your calf.
  • Chest pain or shortness of breath.

Visits to the dentist

  • If you ever suffer a gum infection or abscess your dentist will need to prescribe antibiotics.
  • This is not necessary for routine dental care – eg. fillings or cleaning.

IF YOU HAVE ANY ADDITIONAL QUESTIONS, FEEL FREE TO CONTACT THE ORTHOPAEDIC LIAISON NURSE. PHONE: (08) 8267 8267

Information regarding your planned surgery

It is in your interest to read this carefully. It concerns what is going to happen to you in hospital. If you do not understand, you should approach your specialist or his secretary, for clarification of any point.

  • If you are not correctly fasted for your anaesthetic, the operation may be cancelled or postponed until you are correctly fasted.
  • If you are taking regular cardiac medications, please do not stop taking them (with the exception of aspirin, plavix and anti-inflammatory medication). Take all medications with a sip of water.
  • Please TAKE YOUR X-RAYS TO THE HOSPITAL
  • If you do not understand the nature of the operation or the possible complications of the procedure, you should arrange to again see your orthopaedic specialist.

Accounts

You will be liable for several accounts in relation to your hospitalisation and operation. An account may be received from:

  • The hospital. This will include a bed fee, theatre fee and a fee for any disposable items and surgical implants used in the operation. If covered by Private Health Insurance, you should check your level of cover and the amount of rebate with the Insurance Company and hospital.
  • The anaesthetist. If you wish to discuss the Anaesthetist”s fee, please contact the Practice secretary for his/her name. You can then contact him/her directly.
  • The assistant. An assistant is required for all major cases and some lesser cases. You may find out if an assistant is required from the Practice secretary.
  • The pathologist. If pathology is required. (Not all cases require pathology).
  • The radiologist. You will require an x-ray of your new knee.
  • The physiotherapist.
  • The surgeon’s fee. There is sometimes a difference between the fee charged by the doctor and the amount you can obtain from the Health Insurance Commission or your Health Fund. The difference is the “gap”. You should find out if your surgeon is using an “EZI CLAIM GAP” COVER SYSTEM, where the Private Health Fund pay for some or the entire “gap” on your behalf.