1. What is a hip replacement?
Hip replacement, or total hip arthroplasty, is a surgical procedure which replaces the worn out “ball and socket” hip joint with an artificial joint. The components of the joint are called the ” implants” or the “prosthesis.” Hip replacement is performed to alleviate pain, increase motion, and improve function.
2. Who should have hip replacement surgery?
The most common reason for hip replacement surgery is arthritis. The most common variety of arthritis is osteoarthritis, sometimes also called “degenerative joint disease.” Osteoarthritis is the ” garden variety” of arthritis that almost everyone has to some degree by the age of 60. Less common causes of arthritis are rheumatoid arthritis, post-traumatic arthritis resulting from prior trauma, arthritis resulting from congenital/developmental disorders, and avascular necrosis (a loss of blood supply to the femoral head).
Arthritis pain usually responds initially to conservative treatments such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, heat, ice, heating rubs, massage, and the use of a cane. When pain is not controlled by these measures, or when pain and stiffness interfere with a person’s normal daily activities and ability to function, total hip replacement is often recommended.
Historically, hip replacement surgery has not been recommended for patients under the age of 60. Standard total hip replacement components do not hold up well in younger, heavy, or more active patients. Recently, newer technologies have provided more durable implants for use even in younger, more active patients. Nevertheless, total hip replacement components will not last a lifetime in many patients, and these patients may require revision total hip replacement sometime down the road.
3. What are the alternatives to total hip replacement?
Various non-surgical methods of treatment for hip arthritis should be utilized before resorting to surgery. These include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and the use of a cane. Newer NSAIDs, called Cox-2 inhibitors, tend to have fewer side effects than the older NSAIDs, although some have been taken off the market due to cardiovascular side effects. There has been no real evidence that these newer, more expensive Cox-2 inhibitors are any more effective in alleviating arthritis pain than the less expensive “non-selective” NSAIDs such as Motrin (ibuprofen) or Naprosyn (naproxen). Both Motrin and Naprosyn are available over the counter in the forms of Advil and Aleve, respectively.
Occasionally, steroid injections may give temporary relief of arthritis pain. The hip joint is less often injected than the knee joint due to more difficulty and discomfort injecting the hip joint. Steroid injections reduce the inflammation that accompanies arthritis, thereby giving temporary partial relief of arthritis pain. When these methods no longer provide adequate pain relief, surgery is usually recommended.
Younger patients with hip arthritis caused by congenital or developmental problems (such as congenital/developmental dysplasia of the hip) may be candidates for a procedure known as an “osteotomy.” An osteotomy procedure essentially cuts and re-orients either the ball or socket of the hip joint to provide a better surface to bear the body’s weight than the original joint surface. Osteotomies usually take longer to recover from than total hip replacement, but have the advantage of retaining one’s own natural hip joint for a while, often 5-10 years; then conversion to a total hip is often necessary. These procedures are most commonly used in younger patients where it is desired to “buy some time” before total hip replacement.
4. What does hip replacement surgery involve?
Total hip replacement surgery replaces the worn out ball and socket hip joint with an artificial joint. Using the minimally invasive technique, a 3-4 inch incision is made on the back of the hip. Through this incision, the worn out femoral head is removed. An artificial socket having a metal shell and a plastic or ceramic insert is implanted into the worn out socket, sometimes with the use of 1 or 2 screws to help secure the socket to the patient’s bone. A metal stem with attached metal or ceramic ball is inserted into the femoral canal to replace the worn out femoral head. After the new joint has been implanted, the tissues surrounding the hip joint are repaired and the incision closed. Total hip replacement surgery using the minimally invasive technique usually takes around 1 hour to complete.
5. What are the total hip components made of?
Most artificial sockets (“acetabular components”) are made of a titanium shell, which has a roughened outer surface that contacts the bone of the patients own hip socket. Titanium screws can be placed through the shell to help secure the socket in place during the first 6 weeks when bone grows into the pores on the roughened surface of the implant. This is called “porous ingrowth” or “cementless” technology. Inside the metal shell is attached a “liner” (or “insert”) made of high-density polyethylene, or in some cases, a hard, smooth ceramic material.
The artificial ball is made either of a hard cobalt-chromium alloy or a ceramic material. The ball is attached to a metal stem (“femoral component”) often made of titanium that also has a roughened surface. The stem is inserted down inside the patient’s femur bone, and over the following 6 weeks, the bone attaches to the stem to hold it in place permanently.
Some surgeons use a special bone cement called ” methacrylate” to attach the femoral stem (and sometimes the socket) to the patients bone.
6. When is cement used for total hip replacement?
Controversy exists regarding when cement should be used in total hip replacement surgery. One of the main disadvantages of cemented total hip replacement is that the components are solid the day they are implanted, but then begin a gradual process of loosening every day thereafter. Although this is usually not a problem in patients with life expectancies less than 15-20 years, younger, heavy, or more active patients will develop loosening and require revision surgery even earlier. Therefore, cementless fixation is felt by most surgeons to be best for young, heavy, or active patients.
Cement can have harmful effects. When cement is injected into the femur, it forces fat, clotting factors, and other debris into the circulation where it is filtered out by the lungs. This can result in difficulty breathing, blood clots, and rarely even death. Many surgeons choose to use a cementless fixation in all patients to avoid the harmful effects of cement.
Some surgeons believe that cement is necessary to secure the femoral component to the femur in certain patients, particularly in older patients with softer bone. However, use of a femoral component design called the “tapered” design allows implantation in almost all patients without the use of cement, thereby avoiding its potentially harmful effects. Additionally, tapered stems allow immediate full weight bearing on the hip, unlike many other cementless designs. Therefore, tapered, cementless femoral components can be used in essentially all patients without delay in weight bearing or recovery.
7. What happens after the surgery?
Patients wake up in the recovery room after total hip replacement surgery. Pain is minimized using a combination of a local anesthetic agent infused into the incision and intravenous pain medication controlled by the patient (PCA-”patient controlled analgesia”). Intravenous fluids are given to replace fluids lost during surgery. Once fully awake and comfortable, the patient is transferred to the patient care floor of the hospital. Often, the patient is allowed to sit on the edge of the bed for dinner the evening of surgery and even take a few steps if you desire.
Physical therapy begins the first day after surgery. Most patients are quite comfortable, even on the first post-operative day. Often the pain from the new incision is less than that of the arthritis that has been alleviated by the surgery. The patient is allowed to place full weight on the new hip and will begin strengthening the muscles and work on getting in and out of bed, in and out of a chair, and will start walking with the aid of a walker or crutches, or even a cane. Walking, stair climbing, and exercises to strengthen the muscles of the hip are taught to the patient over the next day or two. Most patients are able to get up and around well with the use of crutches, walker or a cane within 2-3 days. At this point, the patient can usually be discharged home with visits from a home nurse and physical therapist 3 times per week. Rarely, a patient may need to go to a rehabilitation center for several days after leaving the hospital. This only happens if your walking or general mobility is not considered safe for discharge home by the 3rd or 4th post-op day, or if no one is able to stay with you (or at least check on you daily) for the first few days after you leave the hospital.
The physical therapist will teach you stretching exercises to help cross your ankle over the opposite knee for handling shoes, socks, clipping toenails, etc. Always keep the knee rotated outward when you bend the hip past 90-degrees (such as reaching for something on the floor when sitting in a chair.)
As a general rule, it is always safe to flex the hip past a 90-degree angle if you have rotated the knee outward enough that you can see the inside part of the knee-keep this rule in mind at all times; it will eventually become automatic when you bend over. Additionally, you will be given specific exercises by a Physical Therapist to help strengthen and stretch the muscles around the joint. Do these exercises regularly, at least 3 times daily, during the first 6 weeks after surgery. Stretching exercises are also important, particularly rotating the knee outward. You will be taught to sit in a chair with your feet together and press the knees outward while bending forward a bit.
Before you go home, you will be seen by an occupational therapist who will provide you some assistive devices such as a reacher, a long-handled shoehorn, and a sock applicator to assist with these functions during the first few weeks. The therapist will also teach you some tricks for caring for yourself during the first weeks of recovery. You will be discharged with a walker, crutches or cane and an elevated toilet seat for temporary use.
You will be discharged with a pair of elastic stockings to minimize swelling in your legs and pooling of blood in your veins. You will also be instructed to take one coated aspirin twice daily, 2 or 3 iron pills each day, a non-steroidal anti-inflammatory drug such as Motrin, Advil or Aleve, and pain pills when you need them. You will continue the exercises taught you in the hospital on a daily basis and continue working on your walking.
8. How long is the recovery?
Patients undergoing minimally invasive total hip replacement generally recover quite quickly. The home nurse removes staples from the incision at 10-12 days. Advancement to the use of a cane for balance and support generally occurs within the first 1-2 weeks after surgery. Most patients are able to walk independently without the use of a walker, crutches, or cane by 3-6 weeks after surgery. At this time, most patients are comfortable, no longer requiring pain medication, and are returning to normal activities such as driving, work, shopping, and recreational activities such as swimming or golf.
At 5-6 weeks after surgery, the patient is seen in the office and x-rays of the hip are taken. The exercise program that was taught to the patient in the hospital is modified to include use of a stationary bike to improve mobility of the hip. Over the next 6 weeks, the patient generally regains mobility allowing easy application of shoes and socks without assistive devices. An active lifestyle is usually resumed at 5-6 weeks post-operatively.
The following also occur at 6 weeks:
- Elastic stockings are discontinued. However, a stocking on the operated leg may be used for certain activities when the leg tends to swell a bit, particularly when up on your feet for prolonged periods.
- Aspirin and iron pills are discontinued.
- Use of an elevated toilet seat is discontinued.
- Normal activities such as swimming, cycling, cross-country skiing, golf, doubles tennis, rollerblading, and dancing are resumed. Begin slowly, and advance activity level as your body and discomfort permit.
9. When can I return to activities like showering or driving a car?
- Showering: As soon as the wound has no more drainage (generally 3-5 days after surgery)
- Tub bath or Jacuzzi: At 4 weeks if wound is completely dry and healed with absolutely no opening. (Be careful getting in and out of the tub so as not to violate the dislocation precaution.)
- Leaving the House: It is perfectly acceptable to leave your house for short walks, or to go on short outings (dinner, visiting neighbors) as soon as you feel comfortable. Remember, your comfort should dictate your activity level. If your hip swells and is painful because you have been unable to rest and elevate the leg, you have probably overdone it. Be patient, you will be comfortable doing more and more each week.
- Driving: Left hip-approximately 2 weeks; right hip-approximately 4 weeks. Be sure that you feel comfortable driving and that you are safe. Go out with a friend or spouse the first time, and drive only short distances initially. If you both agree that you are safe, you may continue driving. Be sure to observe the dislocation precautions when getting in and out of the car.
- Putting shoe and sock on without assist device: As soon as your hip mobility allows (in the figure-4 position or with knee rolled outward)
- Traveling: You can begin taking trips, either by car or airplane, as early as 3 weeks post-operatively, although waiting 6 weeks will be more comfortable for you. Move your ankles up and down frequently, and get up to walk around every hour or so to prevent blood clots. You may want to book a seat in bulkhead so that you have more legroom.
- Airport Security: Most total hip replacements will set off the metal detectors at airports, courthouses, etc. Although we used to give everyone ID cards to show security personnel that you have had a hip replacement, it now makes little difference whether you carry a card or not. Simply inform the security personnel that you have an artificial hip joint, and let them run the metal detector over your hip. That is all that is usually required to pass the security checkpoint. However, you may want to allow yourself an additional 5-10 minutes travel time for this screening.
- Sexual relations: In general, common sense must be utilized when resuming sexual relations. Some form of sexual intimacy can be resumed as early as a week or two after surgery. However, your comfort is of highest importance. Do not do anything that causes discomfort to the hip or that puts the hip in a position where it could dislocate. At 6 weeks post-op, a normal sexual life may be resumed, always keeping the dislocation precaution in mind.
- Returning to work: Most patients return to work 3-5 weeks after surgery. Patients with sedentary (sitting) jobs can often return to work at least part-time within 1-2 weeks. Those with more active, standing, or manual labor jobs may require 4-6 weeks. You may be required to make some modifications to your job description if your job requires repeated heavy lifting throughout the day.
10. What are the possible complications of surgery?
Total hip replacement surgery is a relatively safe procedure. However, it is important that you understand that no surgery is without risks. Luckily, complications from total hip replacement are uncommon, and the risks appear to be even less with the Minimally Invasive technique. Additionally, choosing a surgeon with significant experience in total hip replacement reduces the risk of complications. In short, more than 95% of patient undergoing total hip replacement obtain a good result with absolutely no problems or complications. Although there is no way that all of the possible complications can be listed here, the most common and /or worrisome complications are:
- Dislocation Since use of the “Capsular Noose” technique, developed by Dr. Swanson in 2002, dislocation of the artificial hip is unlikely. However, if dislocation were to occur it is most likely during the first 6 weeks after surgery, and you will be taught specific precautions to follow during this period. After 6 weeks, the risk of dislocation goes down significantly, although Dr. Swanson suggests that you follow one very simple, basic precaution for the rest of your life to further minimize the risk of dislocation. If you have sudden onset of pain in the hip or are unable to bear any weight on the leg, you need to call 911 to be brought to the emergency room for an x-ray. Usually, the hip can be put back in place by traction on the leg after an intravenous sedative in the emergency room or anesthetic in the operating room. If your hip dislocates more than 2-3 times, it may require surgery to stabilize the hip.
- Blood clots can occur in the veins of your legs after any type of hip or knee surgery (“deep venous thrombosis,” or DVT). Although most clots may not even cause symptoms, occasionally a blood clot can travel to your lungs where it can cause more serious problems (“pulmonary embolus,” or PE). You will go home with elastic stockings to prevent blood from “pooling” in your legs and to prevent excessive swelling of the legs. After hospital discharge, these stockings can be removed a few hours at a time for comfort, but you should try to wear them as much as reasonably possible. At four weeks post-op you may begin to remove your TEDS at night. You will require assistance to put on or remove your TEDS.You will also take an adult aspirin twice daily for 6 weeks to thin your blood a bit. Aspirin is a mild blood thinner that helps prevent blood clots in the legs. Patients at higher risk for blood clots may require home injections for 4-6 weeks. You or a family member will be taught how to administer these injections prior to leaving the hospital. Additionally, you should try to move your ankles up and down frequently (“ankle pumps” as this exercise promotes circulation in the legs.If you notice excessive leg swelling, elevate the leg for a few hours to see if it goes away. If it does not, call Dr. Swanson; he may want to send you to the hospital for a simple test to check for a blood clot. Call Dr. Swanson immediately if you are having any difficulty breathing or discomfort in your chest, either which could be a sign of a blood clot traveling to your lungs (“pulmonary embolus”).
- Nerve damage injury can occur in a very small number of patients, generally 1% or less. This may either cause difficulty raising the ankle and toes (called a “drop foot”), or weakness in the thigh muscles causing the knee to buckle with weight. It may also cause some numbness in the thigh, leg, ankle, or foot. Approximately half of all nerve palsies will resolve spontaneously and fully; the other half may leave some permanent weakness in the knee or ankle. Occasionally, a patient may need to wear a lightweight plastic brace inside the shoe to support the ankle; however, this is quite uncommon.
- Infection can occur with any surgery, and total hip replacement is no exception. Although the incidence of infection is low (around ½%), it can be a serious problem, and therefore, additional measures are taken during and after surgery to minimize the risk of infection. If you do develop a deep infection in the hip, it may mean that you will need more surgery, such as removal of the prosthesis, 6 weeks IV antibiotics, and then replacement of the hip once the infection is gone. Patients at slightly higher risk of infection include diabetics, obese, patients with certain types of arthritis including rheumatoid arthritis, patients on steroids, and patients who have had prior surgery or infection in the hip. Superficial infections in the incisional area are not uncommon and are much less serious. If you notice any redness or drainage around the incision, or recurring fevers, chills, or sweats, call Dr. Swanson immediately.
- Leg length discrepancy is a possibility with total hip replacement. Much care and pre-operative planning goes into ensuring that your post-operative leg lengths are equal. However, leg lengths can be off by up to ¼ inch or so in some cases. Most patients will not notice a discrepancy of ¼ inch or less, and it is rare that you would need to use a shoe lift for such a small leg length discrepancy. On a rare occasion, and for various reasons, the post-operative leg lengths may be more than ¼ inch different. Usually this is either the result of a fixed obliquity of the pelvis because of a spinal curvature, or the need to lengthen the leg with certain anatomy types to tighten the muscles and reduce the risk of dislocation. We will do everything possible to ensure that your final leg lengths are equal; however, if we have to choose between a leg length discrepancy vs. a dislocating hip, we will usually choose to lengthen the leg a bit in order to minimize the risk of dislocation. Again, this occurs extremely rarely.
- Wound Healing Problems can occur in a few patients, particularly diabetics, patients with circulatory problems, and the obese. Often these problems require no further surgery and go on to resolve spontaneously. However, it is occasionally necessary to return to the operating room to debride and close the portion of the wound that is not healing.
- Fracture It is remotely possible to fracture the femur or hip socket with total hip replacement. If a fracture occurs, it may require lengthening the incision to place cables around the fractured femur, and a period of non-weight-bearing after surgery for 6 weeks or so.
- Loosening/Wear No artificial joint replacement will last forever. Although we expect your total hip replacement to last 10-20 years, this varies depending on body weight, activity level, implant type, and surgical technique. If your hip replacement fails, it can usually be revised to a new hip replacement.
- Death The most severe complication of any surgical procedure is death. However, the risk of dying during surgical procedures is extremely remote unless you have very serious medical problems such as end-stage heart or lung problems. If this is the case, your medical doctors or we will discuss the risks with you to allow you to make an informed decision about surgery.
Although the list of potential complications is long and many are not covered here, the risk of each specific complication is quite small. The anesthesiologist will discuss the potential risks of anesthesia with you. Overall, total hip replacement is a safe procedure with very predictable results, giving good pain relief and restoration of function while having a low risk of complications.
11. What types of activities can I resume after total hip replacement surgery?
Most patients resume normal, active lifestyles after total hip replacement. In fact, activity levels often improve due to absence of the arthritic hip pain and stiffness. Most activities are felt acceptable after total hip replacement surgery, and can generally be resumed at 6 weeks after surgery. Start slowly, and then progress as your body and common sense allow. Walking, swimming, cycling, cross-country skiing, golf, doubles tennis, rollerblading, gardening, and dancing are examples of activities that are well tolerated by the artificial hip joint. Working out in a gym is also OK as long as specific exercises are avoided (such as leg presses, squats, and Stairmaster), and providing that exercises are done in moderation.
Activities that should be avoided after total hip replacement fall into 2 categories: 1) those that put excessive stress and wear on the hip, and 2) those that present a significant risk of dislocation.
Activities that cause excessive wear and tear on the hip joint include activities such as jogging, singles tennis, racquetball, basketball, and any activity that involves running, jumping, or repetitive heavy lifting. These activities wear out the hip joint either because of excessive repetitive motion or high “impact loading” (the hard, jolting stress to the hip joint such as occurs with jumping or running). Think of your new hip joint as a new tire on your car: if you continuously drive it too fast or over rough terrain, the tire will wear out more quickly than if you drive it sensibly on smooth highways.
Activities that present a significant risk of dislocation include activities where a fall is likely, such as skiing, horseback riding, and rock climbing. Of course, if one is an accomplished skier, for example, skiing the green or smooth blue runs may be safe. Likewise, if one is an accomplished horseback rider, riding on safe terrain on a well-trained horse may also be safe. One should use common sense when deciding whether an activity has a significant risk for a fall and possible dislocation.