This booklet is designed to provide information about total hip replacements and what to expect before and after this surgical procedure. Instructions are provided to help you prepare for surgery, recovery and rehabilitation.

It is recommended that you read this booklet before your surgery and write down any questions you may have. If you have questions, please feel free to ask the professional health staff.

The staff's goals are to restore your hip to a painless, functional status and to make your hospital stay as beneficial, informative, and comfortable as possible.

Contents

• Total Hip Replacement
• Preparing for Surgery
• Pre-op Visit
• Day of Surgery
• After Surgery
• Home Exercises
• Activities of Daily Living
• Guidelines at Home
• Other Considerations
• When Do I Return to the Clinic?
• Should I Have a Total Hip Replacement?

Total Hip Replacement

What is it?

Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts--the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the "ball" or head of the thigh bone (femur).

Above: Bones of the normal hip form a ball and socket joint. The socket is part of the pelvis bone, and the "ball" is the upper part or head of the thigh bone (femur).

During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal or ceramic.

Above: A metal-backed, high-density plastic socket and stainless metal ball with stem are used to reconstruct the hip joint.

These artificial pieces are implanted into healthy portions of the pelvis and thigh bones. These are sometimes cemented and sometimes they are cementless.

Cementless total hip replacement

In some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cementless. This would be called a "Hybrid" hip prosthesis.

Above: The artificial plastic socket (acetabular cup) is embedded in the pelvis bone, and the shaft protruding from the stainless metal ball is inserted into the hollowed-out thigh bone. The artificial parts are affixed with a bone cement (methyl methacrylate).

When do we consider total hip replacements?

Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies). Circumstances vary, but generally patients are considered for total hip replacements if:

• pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living
• pain is not relieved by arthritis (anti-inflammatory) medicine, the use of a cane, and restricting activities
• significant stiffness of the hip
• x-rays show advanced arthritis, or other problems

What can be expected of a total hip replacement?

A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your doctor's instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.

What are the risks of total hip replacement?

Total hip replacement is a major operation. The effect of most complications is simply that the patient stays in the hospital longer. The most common complications are not directly related to the hip and do not usually affect the result of the operation. These include:

• blood clots in the leg
• blood clots in the lung
• urinary infections or difficulty urinating

Complications that affect the hip are less common, but in these cases, the operation may not be as successful:

• difference in leg length
• stiffness
• dislocation of hip (ball pops out of socket)
• infection in hip

A few of the complications, such as infection or dislocation, may require reoperation. Infected artificial hips sometimes have to be removed, leaving a short (by one to three inches), somewhat weak leg, but one that is usually reasonably comfortable and one on which you can walk with the aid of a cane or crutches.

How do artificial hips stand up over time?

The major long-term problems are loosening or wear. Loosening occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (resorbs) from the cement. By 10 years, 25 percent of all artificial hips will look loose on an X-ray. Somewhat less than half of these (about 5% to 10% of all artificial hips) will be painful and require revision. Wear can ocur in the plastic socket after some years. Small wear particles can cause inflammation resulting in thinning of the bone and risk of fracture.

Loosening and wear are in part related to how heavy and how active you are. It is for this reason we do not operate on very obese patients or young, active patients. Loose, painful artificial hips can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complications are higher.

Preparing for Surgery

Preparing for a total hip replacement begins several weeks ahead of the actual surgery date. Maintaining good physical health before your operation is important. Activities which will increase upper body strength will improve your ability to use a walker or crutches after the operation.

Management of blood loss during and shortly after surgery is handled by several different methods. A simple blood test will be drawn on the day surgery is scheduled. That test will help decide the best blood management protocol for you. Depending on your hemoglobin level (red blood cells that carry oxygen through the body) you may have a choice. You may be able to donate your own blood or you may receive injections that increase your own red blood cells. It is possible that you could use the cell saving system, which returns your own blood to you during or shortly after surgery. If donating your own blood is right for you, usually two units (pints) of blood are taken prior to your surgery. Then if you require a transfusion you will receive your own blood. This is called autologous blood donation. The first donation must be given within 42 days of the surgery and the last, no less than four days before your surgery.

When donating blood, you must be healthy, without a cold, flu or infection, as you could get this same illness when your blood is transferred at the time of surgery. Eat a nourishing meal two to four hours prior to donation, and avoid strenuous exercise for twelve hours following the procedure.

The blood donor center will check the blood count before drawing additional units. A prescription for iron will be given. Iron may be constipating for some people, so sometimes a stool softener may be used. Stool softeners can also be purchased over the counter. If your hemoglobin level is determined to be low, you may have the option to receive Procrit injections to increase your red blood cell levels before surgery. You will receive information about this medication from your doctor and the nurses in the clinic.

You may be a candidate for autotransfusion using a cell-saving device after your surgery. Blood collected from the wound drain is filtered and transfused back to the patient early in the postoperative period. The doctor will assist you in deciding whether this procedure will be done.

The doctor may order blood tests and urinalysis two weeks before surgery to make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected. Please schedule an appointment with your dentist if you have not had a dental check during the past year. An infected tooth or gum may also be a possible source of infection for the new hip. The orthopaedic doctor will ask you to see a medical doctor, especially if medical problems have been present in the past.

When making preparations for surgery, you should begin thinking about the recovery period following surgery. A patient with a new total hip replacement may need help at home for the first several days. Assistance with dressing, getting meals, etc. may be necessary. Most often discharge from the hospital is anticipated in about 3-4 days. Your energy level will not have returned. If assistance from someone at home is not possible, it may be necessary to think about making arrangements to stay in a rehabilitation or skilled nursing facility for a period of time. The medical social worker can assist with these arrangements.

Pre-operative Visit

It is necessary for most patients to make a visit to the hospital a few days before their actual surgery date. This visit usually lasts several hours, so plan to spend most of the day. The day begins in the clinic, where an interview by the nursing staff concerning past medical history and current medications will be taken. You may be instructed to stop taking your anti-inflammatory medications (ibuprofen, Naprosyn, Relafen, DayPro, aspirin) one week before surgery. You will be attending a teaching session which will include the following topics and other information about your surgery. There will also be time for discussion and questions. Bring a written list of past surgeries and of the medications and dosages that you normally take at home.

Diet
You should follow your regular diet on the day before your surgery. DO NOT EAT OR DRINK AFTER MIDNIGHT. The day of surgery you may brush your teeth and rinse your mouth without swallowing any water.

Bathing
A shower, bath or sponge bath should be taken the evening before and morning of surgery. You will be given antiseptic scrub brushes to use. Using the spongy side, scrub your hip for a period of five minutes. This may require assistance from a family member. The brushes contain a special soap which will reduce the risk of infection. If you are allergic to iodine or soap, please tell the nurse. If possible, you should shampoo your hair. Nail polish and make up should be removed. Do not shave your legs within 3-4 days of surgery.

Deep Breathing Exercises
You will be instructed in deep breathing exercises to minimize the risk of lung complications after surgery. These exercises are necessary to remove any excess secretions that may settle in your lungs while you are asleep during surgery. These exercises are to be done every one to two hours after surgery. An incentive spirometer may be demonstrated. This bedside device assists you in deep breathing exercises.

Blood Clot Prevention
You may be fitted with elastic support stockings (TEDS). The morning of surgery, you may receive these stockings to aid in the circulation of your legs and feet to reduce the risk of blood clots. You may also be fitted with foot pumps to help blood keep moving through your legs. Medication is also part of your blood clot prevention plan. Your doctor will decide what is best for you. Medication is started after sugery.

Anesthesia
You may be scheduled for an appointment with the anesthesiologist to discuss how you will be put to sleep. The anesthesiologist will advise you about taking routine medications on the day of your surgery.

Pain Control
Please read the booklet on "Patient Controlled Analgesia" (PCA) which may be used for pain control for the first day after your surgery. When the PCA is discontinued, your doctor will prescribe pain medication to be taken by mouth. It is important to continue taking them because preventing pain is easier than chasing it. If you continue to experience pain after taking the medication, we encourage you to notify your doctor or nurse so alternate methods of pain control can be started.

The doctor will also review your medical history and the medications that you take. He will check for any type of infection. Any blisters, cuts, or boils should be reported. If infection is found, surgery is generally delayed until the infection is cleared.

During your pre-op visit, blood may be drawn and lab tests done to insure that you are in good general health. X-rays are taken if necessary. After all of these tests and exams are completed, an anesthesiologist will talk with you to determine the type of anesthesia that is best suited for you. After you see the anesthesiologist, your pre-op evaluation is usually over. Before you leave the hospital make sure your questions are answered. If at any time you become ill, such as with a cold or flu, you need to call your doctor. Remember we want you to be in your best possible health!

Surgical checklist

Night before Surgery

• Shower (with 5 minute scrub to surgical area with brush provided)
• Nothing to eat after midnight
• Review booklet; exercises

Day of Surgery

• Routine medications with sip of water (as instructed by your anesthesiologist)
• Second shower and scrub

Day of Surgery

You should arrive at the Day of Surgery Admissions (DOSA) at the instructed time, with your hip scrubbed. The nurse will spend a few minutes again making sure that you are still in good health and ready for surgery. The nurses try to give you a good estimation of when you need to be at the hospital. However, it is hard to predict how long every surgery is going to take, so expect some waiting time. Bring something to do to help pass the time.

You will be asked to change into a hospital gown. You will be transported to the operating room on a stretcher. Your family may accompany you on the elevator and then will be instructed to wait in the Day of Surgery Lounge. Your doctor will talk to your family after the surgery to report your progress.

You will be taken to a presurgical care unit where an intravenous (IV) line is started for fluids and medications during and after surgery. From there you will be transported to the operating room by your anesthesiologist.

The actual surgical procedure may take two to four hours. However, preoperative preparation as well as wake-up time may make your operating room and recovery room stay longer.

After Surgery

After surgery you will be taken to the Recovery Room for a period of close observation, usually one to three hours. Your blood pressure, pulse, respiration and temperature will be checked frequently. Close attention will be paid to the circulation and sensation in your legs and feet. It is important to tell your nurse if you experience numbness, tingling, or pain in your legs or feet. When you awaken and your condition is stabilized, you will be transferred to your room.

Although circumstances vary from patient to patient, you will likely have some or all of the following after surgery:

1. You will find that a large dressing has been applied to the surgical area to maintain cleanliness and absorb any fluid. This dressing is usually changed 2 days after surgery by the surgeon.
2. A hemovac suction container with tubes leading directly into the surgical area enables the nursing staff to measure and record the amount of drainage being lost from the wound following surgery. The hemovac is usually removed by your doctor one day after surgery.
3. An IV, started prior to surgery, will continue until you are taking adequate amounts of fluid by mouth. When you are taking fluids well, the IV may be changed to a saline lock, a small sterile tube, that will keep a vein accessible for antibiotics and allow for easier movement. Antibiotics are frequently administered every eight hours, until all drains are out, to reduce the risk of infection.
4. Elimination: One side effect of anesthesia is often a difficulty in urinating after surgery. For this reason, a sterile tube called a catheter may be inserted into your bladder to insure a passageway for urine. This may remain in place until the first day after surgery.
5. Besides the elastic hose (TEDS), you may also be wearing compression foot pumps. These wraps are applied to your feet and connected to a machine to promote blood flow and decrease chances of blood clots. You will also be given medications and exercise instructions (moving your ankles up and down), which also helps to prevent clots.
6. Post-operatively you may have temporary nausea and vomiting due to anesthesia or medications, i.e. (PCA). Anti-nausea medication may be given to minimize the nausea and vomiting.
7. Diet: You will be allowed to progress your diet as your condition pemits; starting with ice chips and clear liquids to diet as tolerated.
8. Coughing and Deep Breathing: To help prevent complications, such as congestion or pneumonia, deep breathing and coughing exercises are important. Inhale deeply through your nose; then slowly exhale through your mouth. Repeat this three times and then cough two times. You will be encouraged to use your incentive spirometer.

Activity

Some patients experience back discomfort after surgery. This is caused by the general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown.

The head of your hospital bed should not be elevated more than 70 degrees during the first few days after surgery. Sitting up too high may allow the artificial ball to dislocate from the hip socket.

There will be some precautions, mostly to prevent dislocation, which is more likely to occur the first six to eight weeks after surgery. These precautions include:

1. using 2-3 pillows between your legs
2. not crossing your legs
3. not bending forward past 90 degrees
4. using a high-rise toilet seat if necessary
5. not turning your toes in toward each other

Initial rehabilitation

The first day after surgery you will be assisted to a reclining chair, and physical therapy will begin. You will gradually begin to take steps, walk, and learn to climb stairs with the aid of a walker or crutches.

This initial rehabilitation generally takes 3-4 days. During this time, discomfort may be experienced while walking and exercising. Pain medication will be ordered by the doctor as needed. Most patients are relieved of their painful pre-surgical hip condition.

Therapy and rehabilitation program

Following surgery, you will work with a physical therapist to become independent in walking, going up and down stairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of your hip. You will be instructed by your physical therapist in a specific home exercise program to meet your needs.

Do the home exercises two to three times a day (see home exercises section). Do your exercises indefinitely. Walking is not a substitute for exercise.

If an exercise is causing pain that is lasting, reduce your intensity. If it continues to cause pain, contact your physical therapist or doctor.

Home Exercises

Here is a list of potential exercises you may be asked to complete. These exercises are sometimes done before surgery to help maintain the strength and range of motion of your hip.

Range of motion exercises

Active hip and knee flexion:

Lying on your back with legs straight, toes pointed toward the ceiling; arms by your side. Keeping the heel in contact with the bed, bend your hip and knee. Return to starting position. Progress to 20 repetitions, 2 times a day.

Active Abduction:

Place a smooth surface (card table, large plastic bag, flat cookie sheet, etc.) under your legs. Begin with your legs together. Move your operated leg out to the side keeping you toes pointing up to the ceiling. Progress to 20 repetitions, 2 times a day.

Strengthening Exercises

Quadriceps Setting:

Tighten the muscles on the top of your thigh. At the same time push the back of your knee downward into the bed. The result should be straightening of your leg. Hold for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 2 times a day.

Gluteal Setting:

Lie on your back with your legs straight and in contact with the bed. Tighten your buttocks in a pinching manner and hold the isometric contraction for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 2 times a day.

Terminal Knee Extension:

Lie on your back and place a rolled towel or pillow under your involved leg so that your knee bends approximately 30-40 degrees. Tighten your quadriceps, to straighten your knee and lift your heel. Hold for 5 seconds, then slowly lower your heel down to the surface.

Activities of Daily Living

Do's and Don'ts

Your new hip is designed to eliminate pain and increase function. There are certain movements that place undue stress on your new hip. For your safety, these should be avoided. This is especially true during the first few months after your surgery.

DO NOT move your operated hip toward your chest (flexion) any more than a right angle. This is 90 degrees.

DO NOT sit on chairs without arms.

DO grasp chair arms to help you rise safely to standing position. Place extra pillow(s) or cushion(s) in your chair so that you do not bend your hip more than 90 degrees.

DO NOT get up like this. Keep your involved leg in front while getting up.

DO use a chair with arms. Place your operated leg in front and your uninvolved leg well under.

DO NOT sit low on toilet or chair.

DO get up from toilet as directed by your therapist. Use the elevated toilet seat if we have given you one.

DO NOT pull blankets up like this.

DO use a long-handled reacher to pull up sheets or blankets or do as directed by therapist.

DO NOT bend way over.

DO NOT turn your knee cap inward when sitting, standing, or lying down.

DO NOT try to put on your own shoes or stockings in the usual way. By doing this improperly you could bend or cross your operated leg too far.

DO these activities as directed by your therapist.

DO NOT cross your operated leg across the midline of your body (in toward your other leg).

DO NOT lie without pillow between legs.

DO keep a pillow between your legs when you roll onto your "good" side. This is to keep your operated leg from crossing the midline.

Guidelines at Home

What happens after I go home?

Upon discharge from the hospital, you will have achieved some degree of independence in walking with crutches or a walker climbing a few stairs, and getting into and out of bed and chairs.

Someone at home is needed to assist you for the next six weeks, or until your energy level has improved.

Medication

• You will continue to take medications as prescribed by your doctor.
• You may be sent home on prescribed medications to prevent blood clots. Your doctor will determine whether you will take a pill (Warfarin or coated aspirin) or give yourself a shot (Enoxaparin). If an injection is necessary, the nursing staff will discuss it with you, and teach you or a family member what is necessary to receive this medication. Warfarin requires monitoring, including blood draws two times per week.
• You will be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises. Preventing pain is easier than chasing pain. If pain control continues to be a problem, call your doctor.

Activity

• Continue to walk with crutches or a walker as directed by the doctor or physical therapist.
• Your doctor will determine how much weight you can place on your operated leg.
• Walking is one of the better forms of physical therapy and for muscle strengthening.
• However, walking does not replace the exercise program which you are taught in the hospital. The success of the operation depends to a great extent on how well you do the exercises and strengthen weakened muscles.
• If excess muscle aching occurs, you should cut back on your exercises.

Sitting

Avoid sitting more than 60 minutes at a time. DO NOT cross your legs. In fact, keep your knees 12 to 18 inches apart. Always sit in a chair with arms. The arms provide leverage to push yourself up to the standing position. A high kitchen or bar-type stool works well for kitchen activities. Avoid low chairs and overstuffed furniture because they require too much bending (flexion) in your hip in order to get up. Do not bend forward while sitting in a chair, causing more than a 90 degree bend in your hip. Use the toilet seat riser for the next eight weeks to avoid excessive bending of the hips.

Bending

For the first eight weeks, you should not bend over to pick up things from the floor. You may want to acquire a pair of slip-on shoes and a long-handled shoe horn to avoid excessive bending.

Other Considerations

It is recommended that you do not drive until six weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/out of the car.

For the next 4-6 weeks avoid sexual intercourse. Sexual activity can usually be resumed after your six-week follow-up appointment.

You can usually return to work within two-to-three months, or as instructed by your doctor.

Continue to wear elastic stockings (TEDS) until your return appointment, if instructed to do so by your doctor or nurse.

Don't shower until after staples are removed. Showers may be taken two days after your staples are removed. Do not sit in a bathtub until your doctor okays that activity.

If you have to stay alone for the first six weeks, there are some special devices that are available from the occupational therapist.

Your incision

Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. Generally, the staples are removed in three weeks either by your local doctor or at your 3-week, follow-up appointment in orthopaedics.

Prevention of infection

If at any time (even years after the surgery) an infection develops such as strep throat or pneumonia, notify your doctor. Antibiotics should be administered promptly to prevent the occasional complication of distant infection localizing in the hip area. This also applies if any teeth are pulled or dental work is performed. Inform the general doctor or dentist that you have had a joint replacement. You will be given a medical alert card. This should be carried in your billfold or wallet. It will give information on antibiotics that are needed during dental or oral surgery, or if a bacterial infection develops.

When Do I Return to the Clinic?

Your first return appointment is 3-6 weeks after surgery, unless you return here to have your staples removed. At your return appointment you will be examined and have x-rays. Subsequent appointments are then at 6 months, one year, and two years after surgery.

Should I have a total hip replacement?

The total hip replacement is an elective operation; it is not a matter of life or death. There are always nonoperative alternatives. The decision to have the operation is not made by the doctor. It is made by you, for it is you who must accept the risks and complications. The doctor may recommend the operation; however, your decision must be based upon weighing the benefits of the operation against the risks. You may wish to discuss the surgery with your own doctor or even get another opinion. All your questions should be answered before you decide to have the operation. Please feel free to ask any questions you have in order to make your decision easier.

Remember: Your doctor, physical therapist, and nurses are striving to make a painless, functional hip possible for you. The real success of your hip replacement, however, depends partly on you and how well you follow your exercise plan and follow the instructions for the first six weeks.