Hip Replacement Surgery

Total hip replacement

Understanding Hip Replacement

Total hip replacement (or hip arthroplasty) is a technique that has become widespread in recent years in response to the need for improving hip joints that have been damaged by injury or arthritis. Joint replacement surgery may offer the best treatment option for long-term improvement for the hip joint when other treatments have proven inadequate. In most cases, having a total hip replacement reduces joint pain and means a return to pain-free movement.

Overview

This begins with a Pre-Op education class that helps you understand what to expect, and continues through your discharge from the hospital and recovery at home or in a skilled nursing/rehabilitation facility.

Services may include:

  • Pre-operative total joint education class
  • Navigators, nurses, therapists, care managers and patient care technicians who specialize in the case of knee replacement patients
  • Emphasis on group activities and individual care
  • Patient support person is educated to act as “coach” in the recovery process
  • A comprehensive patient guide for you to follow before your surgery and beyond
  • Reunion luncheons for former patients and coaches
  • Newsletters to update you with new information about arthritis and joint care
  • Public education seminars about hip and knee pain

What to Expect During Surgery

If you are scheduled for hip replacement surgery, here’s what to expect while you are in the hospital.

Surgery Day

The Pre-Op surgery nurse will greet and prepare you for surgery. This includes changing into a gown, reviewing medical information, starting an intravenous (IV) catheter in your arm to keep you hydrated with fluids and removing the hair from the operative area. The operating room nurse and anesthesiologist will review your medical history. Your anesthesiologist will explain the types of anesthesia you will receive and your pain management options.

 

Once your nurse has completed your preparation, a family member can sit with you until it is time for surgery.

After your surgery is finished, the surgeon will go to the waiting area to let your family know the procedure is completed. You will be transferred to the Post Anesthesia Care Unit (PACU) where you will wake-up after anesthesia. During this time, the PACU staff will work with you on managing your pain, monitor your vital signs, and take an X-ray of your new joint. Your stay in PACU is usually 1-3 hours.

You will then be taken to the orthopedic unit, where a nurse will care for you. Upon arrival to your room, you will be evaluated by a multi-disciplinary team to determine your plan of care. Your nurse will check your vital signs frequently. Only one or two family members or friends should visit you on this day.

It is very important that you begin ankle pumps on the first day. This will help prevent blood clots from forming in your legs. You should also begin coughing and deep breathing, along with using your incentive spirometer.

Day 1 – After Surgery

You will be given an opportunity to wash your face and hands and brush your teeth. Then, the staff will assist you with getting dressed.

Your surgeon and physician’s assistant (if applicable) will visit you during the day. IV pain medication will be stopped, and you will begin oral medication. Your nurse will begin teaching you about anticoagulation therapy, signs and symptoms of deep vein thrombosis, infection, medication management/side effects and incision care. You can expect a visit from your case manager to discuss any services, equipment and/or alternate placement required.

Group therapy will begin today and will be held twice a day. They will make sure you can safely go up and down stairs.

Day 2 – After Surgery

Your day will start with a morning walk to exercise class. Most patients will be discharged after their first physical therapy session. Depending on your progress and special needs, you may be seen by an occupational therapist to go over any needs you have at home to help with daily functions such as dressing, bathing, hygiene and taking care of yourself at home.

Day 3 – After Surgery

This day applies to patients who are going to a skilled nursing facility or who were not discharged on Day 2. Day 3 is similar to Day 2.

 

 

After Surgery

Leaving the Hospital

When you go home, there are a variety of things you need to know for your safety, recovery and comfort.

If you are going home with home health:

You will receive written discharge instructions concerning medications, physical therapy, activity, etc. Your physician will write orders for you to have home health. Case managers will work with your insurance company to make these arrangements before you are discharged.

If you are going to a skilled nursing/rehabilitation facility:

The decision to go home or to a skilled nursing rehabilitation facility will be made collectively by you, the care manager, your surgeon, therapist and your insurance company. You will be asked for your preferences early in your hospital stay, so it is wise to visit 2-3 facilities prior to surgery. Also, check with the insurance company for preferred facility coverage.

Please remember that your insurance company must approve skilled nursing stays. A patient’s stay in a rehabilitation facility must be arranged in accordance with the guidelines established by Medicare.

Expect to stay seven to 21 days, based on your progress.

Please keep in mind that insurance companies are not involved in “social issues,” such as lack of a caregiver, caring for pets, etc. These are issues that you will have to address before admission.

Caring For Yourself At Home

When you go home, there are a number of things you need to know for your safety, recovery and comfort.

Controlling Your Discomfort

  • Take your pain medicine with food at least 30 minutes before physical therapy.
  • Do not take extra Tylenol® plus your pain medicines that contain Tylenol together or any additional over-the-counter products containing Tylenol.
  • Gradually wean yourself from prescription medication to Tylenol®. You may take two Extra Strength Tylenol in place of your prescription medication up to four times per day.
  • Change your position at least every 45 minutes throughout the day.
  • Use ice for pain control. Applying ice to your affected joint will decrease discomfort, but do not use the ice for more than 20 minutes at a time each hour. You can use it before and after your exercise program.

Body Changes

  • Your appetite may be poor. Drink plenty of fluids to keep from getting dehydrated. Foods may taste different. Your desire for solid food will return.
  • You may have difficulty sleeping. This is normal. Do not sleep or nap too much during the day.
  • Your energy level will be decreased for the first month.
  • Pain medication that contains narcotics promotes constipation. Increase your fluid and fiber intake. Eat a lot of fruit. Prunes and prune juice will help. Use stool softeners if necessary.

Stockings

  • You may be asked to wear special white stockings. These stockings are used to compress the veins in your legs, which helps reduce swelling and the chance for blood clots.
  • If swelling in the leg that was operated on is bothersome, elevate the leg for short periods throughout the day. It is best to lie down and raise the leg above heart level using three pillows under the calf. Keep your leg straight.
  • Wear the stockings continuously, removing for 1-2 hours twice a day. Someone will need to assist you with putting the stockings on and taking them off.
  • Notify your physician if you notice increased pain or swelling in either leg.
  • Ask your surgeon when you can discontinue using the stockings. Usually, you can stop wearing them three weeks after your surgery.
  • Make sure the stockings do not get bunched up on your legs, as this can affect circulation.

Caring for Your Incision

  • Keep your incision dry.
  • Please do not touch the incision.
  • Your staples will be removed in 10 to 14 days.
  • Follow your doctor’s instructions on when to resume showering.
  • Notify your surgeon if there is increased drainage, redness, pain, odor or heat around the incision.
  • Take your temperature if you feel warm or sick. Call your surgeon if your temperature exceeds 101.5 degrees Fahrenheit.

Recognizing and Preventing Potential Complications

Infection

Call your doctor if you experience any signs of infection, including:

  • Increased swelling and redness at incision site
  • Change in color, amount and/or odor of drainage
  • Fever greater than 101.5 degrees Fahrenheit

Prevention of Infection

  • Take proper care of your incision as explained.
  • Notify your physician and dentist that you have a total joint replacement.
  • Take prophylactic antibiotics exactly as prescribed by your provider when having dental work or other potentially contaminating procedures. Follow your doctor or dentist’s recommendations.

Blood Clots in Legs

Immobilization may cause the blood flow to slow and coagulate in the veins of your legs, creating a blood clot. This is why you must take blood thinners after surgery. Prompt treatment usually prevents the more serious complication of pulmonary embolus (clotting in the lungs). Call your surgeon if signs of leg clots occur.

Signs of Blood Clots in Legs Might Include:

  • Sudden acute change in affected leg
  • Swelling from ankle up

Note: Blood clots can form in either leg.

Prevention of Blood Clots

  • Sequential Compression Devices (SCDs) such as foot and ankle pumps or Intermittent Pneumatic Compression Device (IPCD) placed around calf
  • Walking
  • Compression stockings
  • Blood thinners, such as Coumadin, Lovenox, Xarelto, aspirin and Arixtra. You need to follow strict compliance while taking these blood thinners.

Pulmonary Embolus

An unrecognized blood clot could break away from the vein and travel to the lungs. This is an emergency and you should call emergency services immediately if you suspect this has happened.

Signs of Pulmonary Embolus

  • Extreme apprehension or panic attack
  • Sudden chest pain
  • Difficult and/or rapid breathing
  • Shortness of breath
  • Sweating
  • Confusion

Prevention of Pulmonary Embolus

  • Prevent blood clot in the legs
  • Recognize a blood clot in the leg and call your physician promptly

Preventing Dislocation for Posterior Approach

  • Do not cross legs
  • Do not rotate your operative leg inward
  • Do not bend at the hip past 90 degrees

Please note: You must follow these directives at all times, and continue to follow these instructions until your surgeon tells you otherwise.

Preventing Dislocation for Anterior Approach

Your surgeon will determine what, if any, precautions you need to maintain.

Post-Op Exercises and Goals

Activity Guidelines

Exercising is important to obtain the best results from hip surgery. You may receive exercises from a physical therapist at an outpatient facility or at home. In any case, you need to participate in an ongoing home exercise program, too.

Weeks 1 and 2

After two to three days, you should be ready to be discharged from the hospital. Most joint patients go directly home, but you may go to a skilled nursing facility for seven to 21 days. During the first and second weeks of your recovery, your two week goals are the following:

  • Continue with walker or cane, unless otherwise instructed
  • Walk at least 300-500 feet with your assistive device daily
  • Climb and descend a flight of stairs (12-14 steps) once a day using a railing
  • Actively bend your hip up to 60 degrees
  • Straighten your hip completely
  • Independently sponge bathe or shower and dress
  • Gradually resume household tasks
  • Do 20 minutes of home exercises 4 times a day, with or without the therapist.

Weeks 2-4

During weeks two through four, you will gain more independence. Even if you are receiving outpatient therapy, you should be very faithful to your home exercise program to achieve the best outcome. Your goals for the period are the following:

  • Achieve one- and two-week goals
  • Wean from full support to a cane or single crutch, as instructed
  • Walk at least a quarter mile
  • Climb and descend a flight of stairs (12-14 steps) more than once daily
  • Bend your hip to 90 degrees, unless otherwise instructed
  • Independently shower and dress
  • Resume household tasks
  • Do 20 minutes of home exercises twice a day, with or without your therapist.

Weeks 4-6

During weeks 4-6, you will get closer to full independence. Your home exercise program will be even more important as you receive less supervised therapy.

Your goals for this time period are the following:

  • Achieve one- to four-week goals
  • Walk with a cane
  • Walk a quarter to a half mile
  • Begin progressing on stairs from one foot at a time to regular stair climbing (few stairs at a time)
  • Actively bend hip
  • Drive a car, with surgeon’s approval
  • Continue with home exercise program twice a day

Weeks 6-12

During weeks 6-12, you should be able to begin resuming all of your activities.

Your goals for this time period are the following:

  • Achieve your prior goals
  • Walk without cane and without a limp
  • Climb and descend stairs in a normal fashion (foot over foot)
  • Walk a half-mile to one mile
  • Improve strength to 80 percent
  • Resume all activities, including dancing, bowling and golfing

Around The House – Protecting Your Joints

Kitchen

  • Have family or friends assist you when you get home.
  • Don’t attempt to carry items in your hands while using the walker—ask for help or use a walker basket.
  • Do not get down on your knees to scrub floors. Use a mop and long-handled brushes.
  • Plan ahead. Gather all your cooking supplies at one time. Then, sit to prepare your meal.
  • Place frequently used cooking supplies and utensils where they can be reached without too much bending or stretching.
  • To provide a better working height, use a high stool or put cushions on your chair when preparing meals.

Bathroom

  • Do not get down on your knees to scrub the bathtub.
  • Use a mop or long-handled brushes or have family and friends assist.
  • Pick up throw rugs and tack down loose carpeting. Cover slippery surfaces with carpets that are firmly anchored to the floor or that have non-skid backs.
  • Be aware of all floor hazards, such as pets, small objects or uneven surfaces.
  • Provide good lighting throughout your home. Install nightlights in the bathrooms, bedrooms and hallways.
  • Keep extension and telephone cords out of pathways. Do not run wires under rugs because this is a fire hazard.
  • Do not wear open-toe slippers or shoes without backs. They do not provide adequate support and can lead to slips and falls.
  • Sit in chairs with arms. It makes it easier to get up.
  • Rise slowly from either a sitting or lying position, so you do not get lightheaded.
  • Do not lift heavy objects for the first three months and then only with your surgeon’s permission.
  • Stop and think. Use common sense.

Do’s And Don’ts for Long Term Joint Health

All joint patients need a regular exercise program to maintain their fitness and the health of the muscles around their joints. With your orthopedic and primary care physicians’ permission, you should be on a regular exercise program three to four times per week, lasting 20-30 minutes. Impact activities, such as running and singles tennis, may put too much load on the joint and are not recommended. High-risk activities, such as downhill skiing, are discouraged because of the risk of fractures around the prosthesis and damage to the prosthesis itself. Infections are always a potential problem.

What to Do in General

  • Take antibiotics as prescribed by your dentist or physician one hour before you have dental work or other invasive procedures. Some patients may need to do this forever. Ask your physician.
  • Although the risks are very low for post-operative infections, it is important to realize that the risk remains. A prosthetic joint could attract the bacteria from an infection located in another part of your body. If you develop a fever of more than 101.5 degrees Fahrenheit or sustain an injury, such as a deep cut or puncture wound, you should clean it as best you can, put a sterile dressing or Band-Aid on it and notify your doctor. The closer the injury is to your prosthesis, the greater the concern.

Occasionally, antibiotics may be needed. Superficial scratches may be treated with topical antibiotic ointment. Notify your doctor if the area is painful or reddened.

  • When traveling, stop and change positions hourly to prevent your joint from tightening.
  • Visit your surgeon yearly, unless otherwise recommended.

What to Do for Exercise

  • Recommended exercise classes
  • Home program as recommended by therapist
  • Regular one- to three-mile walks
  • Home treadmill (for walking)
  • Stationary bike
  • Regular exercise at a fitness center
  • Low-impact sports and activities, such as golfing, bowling, walking, gardening, dancing, etc.

What Not To Do

  • DO NOTrun or engage in high-impact activities
  • DO NOTparticipate in high-risk activities, such as downhill skiing, etc.

The Importance of Follow-Up Visits

During the past several years, orthopedic surgeons have discovered that many people do not follow up with their surgeons on a regular basis. They may not realize they are supposed to or they may not understand why it is important.

So, when should you follow up with your surgeon? These are some general rules:

  • Every year, unless instructed differently by your physician
  • Anytime you have mild pain for more than a week
  • Anytime you have moderate or severe pain

There are two good reasons for routine follow-up visits with your orthopedic surgeon, including:

  • If you have a cemented hip, we need to evaluate the integrity of the cement. With time and stress, cement may crack. You would probably be unaware of this because it usually occurs slowly over time. Seeing a crack in cement does not necessarily mean you need another surgery, but it does mean we need to follow things more closely.

Why? Two things could happen. Your hip could become loose and lead to pain or the cracked cement could cause a reaction in the bone called “osteolysis,” which may cause the bone to thin out and lead to loosening. In both cases you might not know this for years. Orthopedists are constantly learning more about how to deal with both of these problems. The sooner we know about potential problems, the better chance we have of avoiding more serious problems.

In both cases you might not know this for years. Orthopedists are constantly learning more about how to deal with both of these problems. The sooner we know about potential problems, the better chance we have of avoiding more serious problems.

  • In both cases you might not know this for years. Orthopedists are constantly learning more about how to deal with both of these problems. The sooner we know about potential problems, the better chance we have of avoiding more serious problems.

X-rays taken at your follow-up visits can detect these problems. Your new X-rays can be compared with previous films to make these determinations. This should be done in your doctor’s office.

Fortunately, most patients do so well that they do not think of us often.