Hip replacement

The head and the socket of a normal hip joint are covered with cartilage. If the cartilage is worn down or if there is arthrosis, each movement becomes increasingly difficult and painful.

Pain can present in the groin, the upper leg and, in some cases, can radiate to the knee. People can begin limping and some people are only able to move with the help of a cane or walker. Stiffness and difficulties with walking up and down stairs are also possible symptoms.

The goal of placing a hip prosthesis is to:

• take away the pain
• allow the hip joint to move more easily
• improve mobility and function

During an operation for a total hip replacement, a portion of the broken joint is removed and replaced by the prosthesis.

The way in which the hip joint is approached varies. There are three major access pathways used worldwide:

1. the anterior access pathway (the front of the thigh bone)
2. the lateral access pathway (from the side of the thigh bone)
3. the posterior access pathway (the back of the thigh bone)
   

Every access pathway has its advantages and disadvantages. You may discuss these with your physician.

Poor quality cartilage and bone is shaved off in the socket and the socket portion of the prosthesis is inserted. That portion, also called the 'cup', may be completely made out of plastic (polyethylene) or a combination of metal (titanium or cobalt chrome) on the outside, with the inside made of polyethylene, ceramic or metal.

The ball of the hip is removed almost completely and replaced by a shaft that is fixated in the bone marrow canal of the thigh bone. In some cases, the exterior portion can be replaced by a shell that is placed over it (e.g. resurfacing or superficial prosthesis). The shaft is made out of metal (titanium or cobalt chrome). It can be fixed in the thigh bone with or without cement.

A ball that is the same size as the inside of the socket is placed on the shaft. The head may be made out of metal or ceramic. Discuss the selection of material as well as the advantages and disadvantages of each with your surgeon.

There may be complications after the procedures. Your orthopaedic surgeon will do everything possible to minimise the risk of complications.

• Bleeding: a haematoma may form around the wound sutures.
• Fever: a fever may develop a few days after the operation.
• Infection: you will be given antibiotics to prevent infection.
• Phlebitis, deep vein thrombosis and pulmonary embolism: you will receive the appropriate anticoagulant medication.
• Hip luxation or dislocation: the attending orthopaedist, physiotherapists and occupational therapists will advise you on how to keep the femoral head from coming out of the socket.
• Leg-length difference: it is possible that a small difference in leg length will be present after the operation. That different can be compensated for, if necessary, with an thicker shoe sole.
• Nerve damage: the chance of nerve damage is very small.

Several factors influence how long the prosthesis will last: being overweight and overuse can quicken the wear-and-tear process. If the hip prosthesis is worn out, it will need to be replaced. With the current prostheses and surgical techniques, the prosthesis should be able to last for 15-20 years, with normal use. It may even last you the rest of your life.

Your GP will perform pre-operative tests. An ECG (e.g. electrocardiogram, an image of your heart) is also usually performed. Blood samples will be collected, an electrocardiogram will be performed and, if necessary, an X-ray will be taken of the lungs. In consultation with your GP, you will stop blood-thinning medications (e.g. Marevan, Plavix, Sintrom, Ticlid and Marcoumar) for at least one week prior to the surgery. Your GP will decide which medication is the best substitute.

Your hospital stay will be relatively brief. If you suspect that your discharge may lead to problems, we suggest that you speak with your attending physician and the hospital social worker as soon as possible, before your hospital admission. The hospital social worker will then be able to work with your family in a timely way to look for a modified solution so that your discharge can proceed smoothly. The hospital social worker is able to provide extensive information about care and servces.

It is sometimes necessary to recuperate at a rehabilitation centre after discharge. That should be prepared for ahead of time.

Besides the general things you bring with you for a hospital stay, please bring the following specific items:

• Test results that you have (X-rays, ECG, blood tests).
• Crutches (you may rent these from one of the rental services through your health insurance or from a home health-care organisation).
• Closed-toe, well-fitting shoes with a wide heel that give good support and plenty of room. Keep in mind that your leg or foot may be swollen for a while after the surgery.
• long-handled shoe horn
• Forms for work disability

• Please shave the surgical site the day before your admission.
• On the day of admission, please arrive at the time you were given and proceed to the check-in desk.
• You will be given a identification bracelet to wear during your stay. Admission staff will accompany you to the care ward for Prosthetic Surgery. A nurse will then take you to your room. He or she will also give you the necessary information regarding your stay and ask some questions.
• Please arrive at the hospital fasting. This means that you may not eat, drink or smoke after the time indicated by your physician. He or she will also tell you which daily medications to take on the day of your admission. Smoking not only negatively affects your breathing during anaesthesia, but it can also negatively affect the prosthetic bone growth afterwards. Smoking is also prohibited in the hospital.
• It is also important to remove your contact lenses or glasses, dentures, hearing aids, nail polish, make-up and piercings before the operation.
• A nurse from the ward will help you put on your surgical gown.

The orthopaedic surgeon and anaesthetist will visit you before you undergo general anaesthesia. Please make sure to ask any questions you may have about the anaesthesia or the operation.

The total hip operation lasts for approximately one hour.

The time spent in pre-operative preparation, the operation itself and the recovery room can last up to four hours. If you are completely awake, the pain is under control and your vital signs are normal (blood pressure, pulse, respiratory rate, pain scale, etcetera), you will be brought back to the care ward.

After the operation, you will receive:

• An infusion: a thin, flexible tube will be inserted into a blood vessel to administer fluids, pain medication and antibiotics.
• A nasal cannula is sometimes necessary to administer oxygen.
• A Redonis sometimes necessary: a catheter that is placed in the wound to drain tissue, fluid and blood.
• A leg support cushion: on the operated leg, in order to prevent the weakened leg muscles from turning your leg sideways, causing your hip to dislocate. The nurse will turn you appropriately, onto your non-surgical side, during post-surgical care.

After the operation, the medical and surgical team will do everything they can to treat your pain. The pain will be recorded on our care ward. This allows us to gain better insight into the intensity of your pain. Explaining how much pain you have is not always an obvious task. In the department, a visual pain scale is used where 0 is no pain and 10 is severe pain.

• When you come back to the care ward, you may drink and eat (a light and easily digestible lunch) as soon as you are able. You may be nauseous or need to vomit. The nurse will give you medication for those symptoms, if necessary. Your home medications can be restarted as per the advice of your physician.

• You may not take any sleep medication on the day of operation.
• Your bandage and vital signs will be checked and recorded every four hours during the first twelve hours.
• You will be regularly offered an ice pack to place on the surgical site. That helps alleviate the pain and to minimise swelling.

The day after the operation, your IV will be removed.

The nurse will help you with going to the toilet in the morning and will help you out of bed. Your bandage will be checked daily. It will be replaced only if it is completed soaked through (with drainage from the wound or blood). During your stay, the occupational therapist and physiotherapist will meet with you daily (except Sundays) to complete a rehabilitation programme and to achieve the following concrete goals:

• to be able to move around independently, such as in and out of bed, to the toilet, etcetera
• to take steps correctly and safely using a walker or crutches
• to walk up and down stairs safely

Exercises are necessary for a good recovery and to regain the mobility and strength in your hip. The physiotherapist and occupational therapist will start the rehabilitation in the hospital and you will be given exercise instructions and recommendations for how to do them at home.

You will be ready to go home any time after two days or up to one week after the operation. This will depend on the nature of the procedure, wound healing, your general recovery and the rehabilitation. Some people, however, will temporarily stay on a Rehabilitation Department.

On the day of discharge (depending on the attending physician), your wound sutures will be taken care of and the bandage will be replaced. You may shower with the bandage on but may not take a bath. If the bandage is dry and not coming loose, leave it on until you see your GP to have the sutures or staples removed. If your wound is still moist, you may be prescribed wound care at home.

Every patient will have X-rays taken of the hip (follow-up image). This may also be carried out at your discharge.

• To get dressed, it is best to start with the leg that was operated on. To get undressed, start with the non-surgical leg.
• Listen to your body. Pain or discomfort mean that it is better to do things a bit more slowly.
• During the first couple of months after the operation, it is recommended that you not bend forward deeply, cross your legs, do heavy lifting nor stand up directly from a sitting position in a deep chair.
• You can find information about medical aids in the Home Care shop. These can help make life at home easier and more comfortable with aids such as an elevated toilet seat or a hospital bed.
• You need to have difficult infections (e.g. urinary tract infections, lung, skin or dental infections) treated immediately. Consult your physician if you have any of these, especially if you have a fever.
• It is best to not receive any injections in the site of the hip operation.