Hip

TOTAL HIP REPLACEMENT

Replacing Your Problem Hip

A painful, stiff hip can keep you from doing the simple things in life, even walking without pain.  Today, physicians can replace your problem hip, thanks to improved surgical techniques and materials.  Total hip replacement is a safe, reliable procedure that can relieve your pain and stiffness and return you to most of the activities you enjoy.  Nearly 600,000 primary hip and knee arthroplasties are performed in the United States each year.  Total hip arthroplasty is the replacement of a worn out hip with an implant that is designed to function like the patients own joint prior to the onset of the disease process.

When Walking Hurts

As hip pain and stiffness increase, you may find more and more things you cannot do.  Simply walking or getting up from a bench can hurt.  Hip pain and stiffness often result from osteoarthritis (the breakdown of cartilage in your joints), which makes your hip bones grate painfully together.  Osteoarthritis (OA) is the most common cause of musculoskeletal pain and disability.  Generalized susceptibility is reflected by the age association, positive family history, diabetes, and hypertension.  Patients who have had childhood hip disorders such as congenital dislocation, Perthes disease, and slipped capital femoral epiphysis are at an increased risk of developing OA at an earlier age.  This is because these childhood afflictions alter the mechanics of the hip joint leading to increased pressure and subsequently, early loss of articular cartilage.   Other causes of OA include trauma or infection, both of which can lead to loss of joint cartilage or altered joint mechanics.

All hip pain is not OA.  There are many disorders of muscle and soft tissue around the hip that can mimic the pain caused from arthritis.  Pain from disorders in the spine such as spinal stenosis or slipped disk can also be referred to the hip region.  Other hip problems include rheumatoid arthritis, injury, and loss of blood supply to the bones of your hip.

Your Hip Anatomy

Your hip is a simple ball-and-socket joint where your thigh bone joins with your pelvis.  Surrounded by cartilage, muscles, and ligaments, your hip is the largest weight-bearing joint in your body.  Smooth cartilage and bone help you walk easily and without pain.  In the normal situation both the femoral head and the acetabulum are covered with a thick layer of articular cartilage.  It is this thick layer of cartilage that protects the underlying bone and acts as a gliding surface (with less friction than water on ice) during pain free joint motion.

Your New Hip

Technical advances have given us new materials to replace your problem hip with a prosthesis (artificial hip joint).  Like your own hip, your prosthesis is made up of a ball and socket that fit together to form a joint.  Our team chooses the best prosthetic design for you after carefully diagnosing your particular hip problem.  In fact, 90% of the hip replacements will still be in place at 15 to 20 years.  Activities such as walking, swimming, golf, and bicycle riding are all encouraged.  Activities involving impact loading of the hip joint such as basketball and jogging are discouraged because they can accelerate the wear of the plastic liner.

Your Orthopedic Evaluation

Our team specializes in bone and joint surgery.  Your surgery is recommended only after diagnosis of your hip problem, including your degree of pain and lack of mobility.

Your history includes questions about your hip pain, medications you may be taking, prior injuries, and other bone and joint problems you may have, such as rheumatoid arthritis.

Your physical examination includes assessing the range of motion in your hip and other mechanical medical factors.

X-rays provide our team with a picture of your hip bones and joints.  X-rays also  help in the precise fitting of your new hip.

Joint aspiration (removing a small amount of fluid from the affected hip joint) to check for infection may also be performed.

Before Surgery

In addition to following our team's instructions, there are several things you can do to prepare yourself for surgery.  You may be asked to lose extra weight, since extra weight puts extra stress on your new hip.  You will be asked to AVOID ASPIRIN, BLOOD THINNERS, OR ANTI-ARTHRITIS MEDICATIONS FOR TWO WEEKS PRIOR TO SURGERY to help decrease the chance of post-operative lung complications.

Understanding the Risks

Total joint replacement is only undertaken after all non-operative measures are exhausted.  Because hip replacement is an elective surgical procedure with inherent medical risk, optimal medical status is assured prior to surgery.  Risks include infection, blood clots, pneumonia, stroke, heart attack, loosening of the hip, dislocation, fracture of bone or implant, injury to nerve or blood vessels, leg length discrepancy, persistent pain, and other post-operative complications.  Infection in your hip joint is the most devastating complication of total joint replacement.  Infection occurs in .5% of all patients.  Patient awareness of this complication may prevent the need for removal of the implants.  It is important to seek medical advice from your orthopedic surgeon as soon as possible if your previously painless hip implant becomes painful.   Diagnosis of infection in the hip joint can be difficult.   Your doctor will discuss these with you before surgery.  Make sure you understand the risks and alternatives prior to surgery.

Alternatives

Osteoarthritis is characterized by joint pain and stiffness.  The pain tends to be aggravated by activity and is usually worse at the end of the day.  The pain can be felt in the groin, buttock, or lateral thigh.   Conservative treatment entails gentle activity to maintain joint motion and muscles strength.  Non-steroidal anti-inflammatory medication is helpful in reducing joint discomfort associated with OA.  However, over zealous use of these medicines can be harmful in some situations, and have been associated with side effects such as GI bleeding, and liver dysfunction.  Reduction in the stress that the hip joint receives can be quite helpful in reducing pain.  This can be accomplished with either weight loss or by use of a cane held in the hand opposite the affected hip.  Other alternatives may also include alternate surgeries.

Your Surgery

You may be admitted to the hospital one or two days prior to surgery.  You cannot eat or drink anything after midnight the evening prior to surgery.  The day of surgery, you may also be given an injection to help you relax.  You can also expect an IV (intravenous) line for medications and for blood transfusions, which are usually needed.  Most patients donate their own blood prior to surgery for blood transfusions.

In the Recovery Room

After surgery, you may wake up feeling a bit groggy.  Specially trained nurses will be with you to make you comfortable and give you pain medication for any discomfort.  A pillow between your legs may be used to keep your new hip in position.  An IV provides antibiotics and fluids if needed, and a small tube drains your incision.  Your nurses can help you with coughing and deep breathing exercises, to help prevent lung complications and start you on the road to a safe recovery.

Your Hospital Recovery

The key to your successful hospital recovery is keeping your hip in position as it heals.  After a short period of initial healing, you will be started on easy physical therapy exercises to promote healing and get you walking again before you go home.  While you are in the hospital your surgeon and physical therapist will teach you about the care of your new hip.

Initial Healing

After a total hip replacement, you can expect to mobilize quite quickly.  To keep your new hip in position, you may have a special bed that keeps your hip from bending beyond 90 degrees.  An abduction pillow keeps your legs shoulder-width apart and prevents them from rotating inward.  Support stockings may be used to help prevent circulation problems.  It is important to remember that extreme positions, especially in the early post-operative period, can cause hip dislocation.  Do not be afraid to use pain medicine liberally as post-op discomfort can slow your rehabilitation.

Physical Therapy

Gentle physical therapy exercises help strengthen the muscles around your new hip and regain your hip's range of motion.  As soon as possible, your physical therapist helps you start walking, a few steps at a time, to promote healing.   As you progress from a walker, to crutches, and then a cane, you may feel somewhat off balance at first.  Gait training helps you regain confidence and your normal walking motion before going home.  The lengths of both your legs will be measured.  Sometimes there will be a mild difference, because you now have a new hip on one side and possibly a worn hip on your other side.   Occasionally, a shoe lift is used to correct this.

Going Home

Once your hospital recovery is complete, our team discharges you, and your nurses can help you pack and make arrangements for going home or to a rehabilitation center for a short time.  Your sutures and bandages are usually removed before going home, and you may be given pain or other medications to take with you.  Before you leave the hospital, you are given any necessary instructions for your safe home recovery.  Be sure to ask any questions you may have.

Your Home Recovery

At home again, you will still need to limit your hip bending; otherwise, your new hip can slide out of position.  Your family and friends can help you follow our team's home recovery instructions, especially important during the first few months of healing.

Back at Work

Work can be resumed as soon as you have greater than 90% of the strength back in your leg, and can perform activities while in therapy that mimic the range and flexibility required for your occupation.

Limit Hip Bending

With your new hip, your safe maximum hip bend is 90 degrees.  Four rules of thumb is remember to keep your hip in position:

• When sitting, keep your knees below your hips (sitting on a small pillow helps).

• Avoid crossing your legs while lying down or sitting.

• Avoid bending over at the waist.

• Sit with your legs 3-6 inches apart.

Some Helpful Hints

Follow tour doctor's advice on using crutches or a cane to keep weight off your hip as it heals.

To limit bending, you may want to buy a raised toilet seat, a bath bench, long-handled grippers to reach things on the floor, or other self-help devices.

Playing golf with a cart, swimming, upper-body exercises, and other moderate activities are fine; more active sports such as tennis and skiing are not recommended.

Since your balance may be off, use hand rails and wear low shoes for your safety.

Before minor surgery or dental work, remind your doctor that you have a prosthesis; antibiotics are usually needed to prevent infection.

It is recommended that all total joint patients have antibiotic prophylaxis for dental, GI, and GU procedures that can cause transient bacterium, which could possibly seed a normal implant.   Instructions regarding the right antibiotic and proper dose will be given to you after your surgery.

Because people live longer now, you may outlive your hip.  Your prosthetic hip can be replaced if necessary.

Caring for your Hip

Your hip prosthesis is the result of years of research.  But like any other device, your new hip's lifespan depends on how you care for it.   In your follow-up visits after surgery, your doctor will follow your progress and answer any questions you may have about caring for your new hip.

Back in the Swing of Things

Replacing your problem hip with an artificial hip can relieve your pain and stiffness and return you to most of the activities you enjoy.  A problem hip can be safely replaced at any age, and, with proper care, can last for many active years.  With your new hip, you can look forward to getting back in the swing of things.

N.B. Post-operatively at home, REPORT TO EMERGENCY IMMEDIATELY IF YOU NOTICE REDNESS OF YOUR WOUND, DRAINAGE, CALF PAIN, SHORTNESS OF BREATH, OR ANY CONCERNS.

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TOTAL HIP REVISION SURGERY

Despite the best intentions a hip replacement will wear out, and surgery to reconstruct or replace the present hip replacement will become necessary.  Subsequent surgery is referred to as revision surgery.   Revision surgery is generally more complex than primary surgery because of scarring, bone loss, increased bleeding, and problems encountered with implant removal.   As mentioned previously, revision surgery may become necessary for a variety of reasons.  Infection, bone loss, and most commonly implant loosening.  The focus of this discussion will be on the process of implant loosening referred to as aseptic loosening (meaning loosening not related to an infectious process).

Many of the early total hip replacements were fixed to the bone with a grouting material known as methylmetharylate more commonly referred to as bone cement.  Over time this bone cement can weaken leading to cracks within the cement, and eventual implant loosening.  Another common cause of ascetic loosening is the processes of bone resorption due to the inflammatory processes set up by the body's immune responses to plastic wear particles.  Aseptic loosening is more common in young heavy adults, who put increased stress across their hip joint.  It is this increased force that leads to more rapid plastic wear, particle formation, and inflammatory bone loss.  Another important mechanism leading to implant failure is improper implant position.  Malposition of implants at primary surgery can increase the forces across the hip joint and eventually lead to failure.

It is important to remember that the process of failure can go on for many years without causing any pain.  When enough bone loss has occurred, and the implants become loose, the patient will begin to feel pain.   Generally if the acetabulum is loose the patient will have pain in the groin or buttock, and if the femoral component becomes loose the patient will experience pain radiating down the thigh.  Often by the time symptoms have manifested there is extensive bone loss making revision surgery difficult.  Again this scenario underscores the importance of close annual clinical and radiographic follow up.  Conservative therapy is generally reserved for the patient who is asymptotic, has radiographic evidence of extensive plastic wear, little or nor bone loss, and stable components.  If, however, follow-up reveals progressive bone loss a liner change and debridement of the bone loss areas is recommended.  This early surgery on the asymptomatic patient removes the particle producing plastic liner and settles down the inflammatory response causing the bone loss.  Another option for the asymptomatic patient with early bone loss and stable components is Fosamax.  This medication is an inhibitor of osteoporosis.  Although it can be associated with GI discomfort early results suggest that it may prevent the progression of bone loss associated with the process of aseptic loosening.

In the unfortunate situation where there has been extensive bone loss and implant loosening, revision surgery becomes much more challenging.  The revision surgeon needs to be well equipped with many surgical techniques allowing for successful reconstruction.  A bone bank may be necessary for reconstruction.  This bone is used as structural support for the new implants that are placed.  Allograft is only used in the most severe of circumstances where the patients own bone is so badly destroyed that it is unable to support the new implants.   Ninety percent of the time there is enough bone present that will allow a reconstruction without the need for allograft.

Revision surgery is only undertaken after thorough medical evaluation.  Revision surgery compared to primary surgery is longer, requires more extensive exposure, is associated with more bleeding, and is also associated with higher infection and dislocation rates.  Because of this the results of revision surgery in regards to patient satisfaction and pain is not as good as that associated with primary surgery.  Postoperative the patient can expect to have more pain and have a longer rehabilitation period, the specifics of which depends on the extent and complexity of the surgical procedure.  For example, if allograft has been used, healing between the host bone and allograft can take many months.  This may necessitate an extended period of protected weight bearing.