Total Hip Replacement - Hip Surgery Cape Town

To help you fully understand the process of Total Hip Replacement, it may be useful to have an understanding of what a hip is and how it works.

What we call a ''hip'' is actually a ball and socket-type joint, which unites two separate bones - the thigh bone, or femur, and the pelvis. The pelvis has two cup-shaped depressions called the acetabula or sockets. The head of the femur or ball fits into the acetabulum, forming a joint which allows the leg to move forward, backward and sideways in a wide range. The acetabulum is lined with cartilage, which cushions the bones and allows the joint to rotate smoothly and with minimal friction. An envelope of tough ligaments connect the pelvis and femur, covering the joint and stabilizing it. The cartilage also makes the joint strong enough to support the weight of the upper body, and resilient enough to absorb the impact of exercise and activity.

A healthy hip will allow the leg to move freely within its range of motion, while supporting the upper body and absorbing the impact that accompanies activities like running and jumping.

Non Surgical Alternatives to Hip Surgery:

• Lifestyle Modification
  The first alternative to hip replacement involves such lifestyle modification measures as weight loss, avoiding activities involving long periods of standing or walking, and the use of a cane to decrease the stress on the painful hip.
• Exercise and Physical Therapy
  Exercise and physical therapy may be prescribed to improve the strength and flexibility of your hip and other lower extremity muscles. Your exercise program may include riding a stationary bike, light weight training and flexibility exercises. An aquatic therapy program is especially effective for the treatment of arthritis since it allows mild resistance while removing weight bearing stresses. For an appropriate exercise program, contact an experienced physical therapist.
• Anti-inflammatory Medications
  Arthritis pain is primarily caused by inflammation in the hip joint. Reducing the inflammation of the tissue in the hip can provide temporary relief from pain and may delay hip replacement surgery. If the non-surgical treatments no longer relieve pain and inflammation in your hip, you and your surgeon may consider total hip replacement. If you both decide that this is the best way to restore your ability to carry on your normal activities of daily life, the following information will be helpful for you to know.
• Total Hip Replacement Surgery
  Total hip replacement is a surgical procedure for replacing the hip joint. During the procedure, the two parts of the hip joint, the hip socket (acetabulum) and the ball (femoral head), are removed and replaced with smooth artificial surfaces to make the hip strong, stable and flexible again.

The artificial socket is commonly made of metal with a high density plastic liner, and the artificial ball is made out of metal or ceramic.

Hip Implant Components

In total hip replacement surgery, the prosthesis or implant, is made up of three components. The femoral stem is made out of a metal, such as titanium, and is implanted down the shaft of the thigh bone or femur. The ball, or femoral head, is attached to the stem and is designed to replace the arthritic femoral head. The third part, the acetabular component, is a metal shell with a plastic inner socket liner.

These components are implanted into the pelvis and thigh bone, and are designed to closely approximate the mobility of the natural hip joint.

The most recent and effective hip replacement technology

Some questions you are probably thinking about are: what kind of implant device you will be receiving, what is it made of, and why is your surgeon using a particular kind of device? If you haven’t discussed this with your surgeon, you should, because not all hip implant devices are made of the same material.

Due to significant advancements in technology, there is a new material for hip implant devices called OXINIUM* Oxidized Zirconium that is a superior metal for use in hip implants. This is due to its hardness, smoothness and resistance to scratching and abrasion. It also exhibits superior performance characteristics over the alternative material options of cobalt chrome and ceramic. Ask your orthopaedic surgeon about OXINIUM and if it is the right implant option for you.

The hip implant is comprised of four parts that work together to restore the original function of your ball-and-socket joint:

• A metal hip stem that is inserted into the top of your thighbone
• A metal cup which holds the cup liner
• A cup liner which holds the femoral head
• The femoral head or ball which is attached to the hip stem and inserted into the liner to form the ball-and-socket joint

Hip implants are not one-size-fits-all, therefore your orthopaedic surgeon will choose the right hip implant for your body. Your surgeon will determine which design options will work best together to restore accurate leg length, while minimizing risks of dislocation and premature implant wear.

The Procedure

Before you are taken to the operating room, your anesthesiologist will talk with you about the medications used during the procedure and will administer medication to help you relax.

Next, the surgeon will make an incision in your leg to access the hip joint. Your surgeon will select the appropriate incision length and approach that is best for your case. After the incision is made and exposure is adequate, the ligaments and muscles are separated to allow access to the bones of the hip joint.

The femoral head is then dislocated from the hip joint and removed at the level of the femoral neck. After the femoral head is removed, the cartilage of the acetabulum is removed using a special reamer that forms a hemispherical shape. The remaining shape will allow for a proper fit of the metal shell. A trial component is placed in the reamed area to determine the proper size and fit. Once your surgeon is satisfied with the size and positioning of the trials, he will implant the metal shell.

The next step involves preparing the femoral canal to accept the femoral stem implant. Special instruments are used to hollow out the femur to match the shape of the metal stem of the femoral component. Trial components of the femoral stem, femoral head and acetabular shell are temporarily implanted to ensure the proper size and fit of the final implants.

At this stage, the surgeon will move your hip in all directions to make sure the trial components are implanted appropriately. Once he is satisfied with the placement of the implant trials, he will insert the final components. For some patients, a special type of acrylic cement, which is well-tolerated by the body, is used to fix the components to the underlying bone.

For other patients, the implants are fixed to the bones without cement. In these cases, the implants are coated with a special porous surface that allows the living bone tissue to adhere to the implant. Finally, the wound is closed, an external dressing is applied to the incision, and you will be taken to the recovery room.In the recovery room, the staff will monitor your vital signs until you are transferred to your hospital room.

Hip Replacement: Pre-op and Surgery Day

When you and your orthopaedic surgeon decide that total hip replacement is right for you, here is an idea of what you may expect during the days and weeks leading up to surgery, as well as the day of surgery.

Pre-operative Procedure

You and your orthopaedic surgeon may participate in an initial surgical consultation. This appointment may include preoperative X-rays, a complete medical and surgical history, physical examination, and comprehensive list of medications and allergies. During this visit, your orthopaedic surgeon will likely review the procedure and answer any questions you may have.

Your orthopaedic surgeon may require that you have a complete physical examination by your internist or family physician as you will need to be cleared medically by your physician before undergoing this extensive procedure. And you may be instructed by your internist on whether you need to donate blood prior to surgery in the event that you will need a blood transfusion post-operatively. Also, your orthopaedic surgeon may ask you to consult a physical therapist to discuss the recovery period, rehabilitation program, and important precautions, as well as instruct you in exercises that you can begin prior to surgery that will make the recovery much easier.

Your physician and hospital may also require that you visit the admissions department prior to surgery to pre-certify the procedure with your insurance company. Finally, maintaining good physical health prior to surgery will also improve the recovery period and overall post-operative outcome.

Preparation for the Hospital

You may want to bring the following items to the hospital for your hip replacement surgery:

• Clothing: underwear, socks, t-shirts, exercise shorts for rehabilitation
• Footwear: walking or tennis shoes for rehab; slippers for hospital room
• Walking aids: walker, cane, wheelchair, or crutches if used prior to surgery
• Insurance information

You should follow your regular diet on the day before your surgery. DO NOT EAT OR DRINK AFTER MIDNIGHT. Follow your doctor's instructions regarding use of medication in the days leading to surgery. Finally, try to get a long, restful night's sleep.

Day of Surgery

On the morning of the surgery, you will be admitted to the hospital and taken to the appropriate pre-surgical area. The nurse will spend a few minutes preparing you for surgery by taking your vital signs, starting IV fluids, and administering medications as needed. You will be asked to empty your bladder just prior to surgery, and to remove all jewelry, contacts, dentures, etc. You will change into a hospital gown, be placed on a stretcher, and transported to the operating room.

The anesthesiologist will meet you and review the medications and procedures used during the surgical case.

Surgery and Recovery

After the surgical case is completed, you will be taken to the recovery room for a period of close observation. Your blood pressure, heart rate, respiration, and body temperature will be closely monitored by the recovery room staff. Special attention will be given to your circulation and sensation in the feet and legs. When you awaken and your condition is stabilized, you will be transferred to your room.

Although the protocols may vary from hospital to hospital, you may awaken to some or all of the following:

• A large dressing applied to the surgical area.
• A hemovac suction container with tubes leading directly into the surgical area. This device allows the nurses to measure and record the amount of drainage being lost from the wound following surgery.
• An IV will continue post-operatively in order to provide adequate fluids. The IV may also be used for administration of antibiotics or other medications.
• A catheter may have been inserted into your bladder as the side effects of medication often make it difficult to urinate.
• An elastic hose may be applied to decrease the risk of deep vein thrombosis (DVT). Furthermore, a compression device may be applied to your feet to further prevent a DVT.
• You will typically be placed on a floor of the hospital with other patients who have had surgical procedures. As a result, the nursing staff is well-trained to manage the post-operative program following total hip replacement.

Hip Rehabilitation After Surgery

Hip replacement surgery is a very complex procedure. However, the outcomes following hip replacement are usually very successful. One of the important critical success factors for a successful outcome is following the physical rehabilitation process. In order to help achieve the goals for a successful total hip replacement, you must actively participate in the rehab process and work diligently on your own, as well as the physical therapists, to achieve optimal results.

Early rehabilitation

Your recovery program usually begins the day after surgery. The rehabilitation team will work together to provide the care and encouragement needed during the first few days after surgery. You may be given a device called an incentive spirometer that you inhale and exhale into. It measures your lung capacity and assists you in taking deep breaths. These exercises reduce the collection of fluid in the lungs after surgery, preventing the risk of pneumonia. Coughing is an effective tool for loosening any congestion that may build in the lungs.

Following surgery

The physical therapist will begin as early as 1-2 days after surgery. They will teach you some simple exercises to be done in bed that will strengthen the muscles in the hip and lower extremity. These exercises may include:

• Gluteal sets: Tighten and relax the buttock muscles.
• Quadricep sets: Tighten and relax the thigh muscles.
• Ankle pumps: Flex and extend the ankles.

Your physical therapist will also teach you proper techniques to perform such simple tasks as:

• Moving up and down in bed.
• Going from lying to sitting.
• Going from sitting to standing.
• Going from standing to sitting.
• Going from sitting to lying.

Although these are simple activities, you must learn to do them safely so that the hip does not dislocate or suffer other injury. Another important goal for early physical therapy is for you to learn to walk safely with an appropriate assistive device (usually a walker or crutches). Your surgeon will determine how much weight you can bear on your new hip, and your therapist will teach you the proper techniques for walking on level surfaces and stairs with the assistive device. Improper use of the assistive device raises the chance for accident or injury.

The occupational therapist will also visit with you to teach you how to perform activities of daily living safely. They will provide you with a list of hip precautions which are designed to protect your new hip during the first 8-12 weeks following surgery.

Precautions

• Do not bend forward to reach your feet. You must maintain a 90 degree angle between your torso and legs.
• Do not lift your knee higher than your hip on the operated side.
• Do not cross your legs.
• Do not allow your legs to internally rotate (feet turned in)..
• Do not twist while lying or standing.
• Sleep on your back with a pillow between your knees to prevent crossing.
• Strictly observe your weight bearing precautions during standing or walking

Also, the occupational therapist will instruct you in the proper use of various long-handled devices for activities of daily living. These devices may include the following:

• A reacher to dress and pick things up from the floor.
• A sock-aid that will assist in putting on socks.
• A long-handled sponge to wash your legs and feet.
• A leg-lifting device to move the operated leg in and out of the car or bed.
• An elevated toilet seat so that you don't violate your hip precautions when using the bathroom.
• An elevated bathtub chair to fit in the shower or tub.
• The precautions following a total hip replacement must be strictly adhered to in order to prevent dislocation of the hip implant and the possibility of re-operation.

At Home

Following surgery, a physical therapist may help you with your rehabilitation protocol. In addition to the exercises done with the therapist, you should continue to work on the hip exercises in your free time. It is also important to continue to walk on a regularly basis to further strengthen your hip muscles.

An exercise and walking program helps to enhance your recovery from surgery and helps make activities of daily living easier to mange.

Here is a list of potential exercises that you may be asked to perform. If an exercise is causing pain that is lasting, reduce the number of repetitions. If the pain continues, contact your physical therapist or physician.

• Ankle pumps
• Quadricep sets.
• Gluteal sets
• Heel slides
• Leg lifts
• Knee extension.
• Hip abduction

While at home, you will continue to walk with the assistive device unless directed by your surgeon to discontinue use. You must also remember to strictly follow the hip precautions and weight bearing instructions during the first few months following surgery. It is recommended that you not drive unless you have been approved by your doctor.

Long-term rehabilitation goals

Once you have completed your rehabilitation program, you can expect to be able to perform most activities of daily living with little to no pain or assistance. Patients following total hip replacement routinely are able to walk, dress, bathe, drive, garden, cook, and return to work. Although final outcomes may vary from patient to patient, total hip replacement surgery is one of the most successful procedures in modern medicine and most patients return to a full and active life.

Life After Hip Replacement

Once you have completed the post-operative rehabilitation process, you should have near normal range of movement and adequate strength in your hip to perform most activities of daily living.

Activities to Avoid

Because total hip arthroplasty is one of the most successful procedures in modern medicine, you can expect to return to a high level of function. However, special precautions should be taken by people with hip replacements. You should avoid high impact activities as running, vigorous walking, downhill skiing, or other high impact activities. Be careful when lifting heavy objects.

Patients having total hip replacement surgery have successfully returned to such activities as walking, driving, swimming, golf, doubles tennis, stationary cycling, and gardening.

Remember to listen to what your body tells you. If you begin to have pain or swelling for over 24 to 48 hours contact your surgeon for advice.

One of the most common problems following total hip replacement is hip dislocation or subluxation. Because the prosthetic ball and socket are smaller than the natural anatomy, the ball can become dislodged from the socket if the hip is placed in certain positions. The following precautions must be taken to prevent hip dislocation:

• Do not bend forward to reach your feet. You must no bend your hips at greater than a 90-degree angle.
• Do not lift your knee higher than your hip on the operated side.
• Do not cross your legs.
• Do not allow your legs to internally rotate (feet turned in).
• Do not twist while lying or standing.
• Sleep on your back with a pillow between your knees to prevent crossing.

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