Four Steps Toward Total Hip Replacement

Four Steps Toward Total Hip Replacement

If it seems that you are hearing about increasing numbers of younger people having hip replacement surgery, you are hearing correctly.    Each year, over 400,000 people in the U.S. undergo total hip replacement surgery and of that group half are under the age of 65 years old. Both movie stars and your “average Joe” are afflicted with the process we know as osteoarthritis. Typically, these younger patients are unwilling to accept the chronic pain and limitations of a deteriorating hip joint that severely diminishes their ability, not only to play sports but even to perform normal daily activities. This often leads to a loss of independence and self‐esteem not to mention, family bliss.   A replacement joint can make a big difference in your ability to return to work or other activities that you enjoy.  But this is a BIG step and it is critically important that you find out all you can about the options, the materials and the surgeon before you commit to this important procedure.  Below is a simple plan to gather the important information that you will need to do this right!

STEP 1:  Get Answers to Preliminary Questions

What is arthritis and why does my hip hurt? In the hip joint there is a layer of smooth cartilage on the “ball” part of the upper end of the femur (thigh bone), and the corresponding “socket” part of the pelvis which receives the ball. This cartilage serves as a cushion and gliding surface which allows for smooth motion of the hip. “Osteoarthritis” –the most common type of arthritis is a wearing away of this smooth cartilage. Eventually it wears down to bone and deformation of the ball occurs along with painful bone spurs. Rubbing of bone against bone causes pain, stiffness and loss of function.

What is total hip replacement?

A total hip replacement is really a “mechanical cartilage” replacement with an artificial surface. The hip joint is reconstructed with metal components typically made from titanium metals which allow bone to grow into the surface of the metal to stabilize it; and various artificial surfaces for the articulating or moving portion of the new joint.    The articulation is usually either a metallic or ceramic ball bearing that rolls around on a metal, ceramic or plastic cup contained on the socket side.
This creates a new smooth cushion and a functioning joint that does not hurt. Typically the muscles that control the hip joint are not damaged during hip replacement if done from a direct anterior  approach so that they can work normally immediately after surgery.

What are the results of total hip replacement?
Most patients (>90%) achieve good to excellent results with relief of discomfort and significantly increased activity and mobility. Return to normal activity is typical in 4‐6 weeks and the hip replacement will probably last a lifetime.

When should I have this type of surgery?
Orthopaedic surgeons at Rogers Park Surgery Center will determine if you are a candidate for the surgery. This will be based on your history, physical exam, x‐rays and response to conservative treatment. The decision will then be yours as this is elective surgery.   In general principle, you are encouraged to keep your own joint for as long as it allows you to function in relatively low levels of pain. When the pain, dysfunction and inability to perform daily activities have come to rule your life, it is time to strongly consider a hip replacement surgery.  Although a big step, it can truly be a life changing experience for you.

Am I too old / too young for this surgery?
Age is not a strong consideration by most surgeons. If you are in reasonable health and have the desire to continue living a productive and active life, there is no reason not to have a pain free hip joint.  We have patients in their 90’s who get hip replacements and do very well. Conversely, the average age for hip replacement is dropping every year as younger patients refuse to live with pain that keeps them from enjoying not only the daily life, but the fun things that they are missing such as hiking, biking, tennis and golf.  If a relatively predictable surgical procedure can get you back to these activities, why not get your “end of the line” hip replaced?

How long will my new hip last, and can a second replacement be done?
All implants have a limited life expectancy depending on an individual’s age, weight, activity level and medical condition(s). We expect most hips (>90%) to last more than 15‐20 years especially with the newer bearing surfaces currently available. However, there is no guarantee that yours will last that long, and 5‐10 percent will not last that long. A second replacement or a “revision” of the first joint replacement may be necessary.  Although revision total hip surgery can be done, it often doesn’t last as long as the first and carries a higher level of risk for a complicating event

Why might I require a revision?
The most common reason for failure is loosening of the artificial surface from bone. The cause of this loosening is complicated, but this is a known problem with artificial joints and loosening is not usually a failure of the surgeon who put it in your hip. Wearing of the plastic bearing may also result in the need for revision surgery. Newer plastics for the bearing surface (with Vitamin E impregnated) and ceramic heads have improved the longevity of hip replacements and represent an exciting improvement in these implants.

What can go wrong?
Most surgeries go well, without any untoward event, but you should know
Infection and blood clots are two serious complications that concern us greatly and which we try to prevent. To avoid these complications, we use antibiotics and blood thinners respectively. We also take special precautions in the operating room to reduce risk of infections. It is important that you understand that the risk of getting an infection can never be completely eliminated and some patients do get infections.  In addition, although the chance of a joint replacement infection is very small, it can occur even many years after surgery which can happen if you develop an infection elsewhere in your body and the infecting agent travels to your joint replacement.

Blood clots forming in the legs after surgery are serious as they can break off and float to your lungs which can in rare instances be fatal.  Great effort is made to get you up walking immediately after surgery and to get you on a blood thinner, Coumadin, to try to prevent the formation of a blood clot.    Although not foolproof, this combination of precautions is the best known way to minimize your risks against blood clots forming or ending up in your lungs.

The most common complicating event is instability or “dislocation” after surgery. The artificial joint has great motion inherent in the design, but if the muscles are weak from lack of use, the hip is put in an unfavorable position or a sudden twist or fall occurs—the artificial metal ball can “pop” out of the socket resulting in pain and loss of function.  For most surgeons this occurs at a rate of <5% of patients and for highly skilled surgeons the rate is far less, especially if a direct anterior approach is used.  But even in the hands of the best surgeons—some patients will dislocate their hips.   Usually the joint can be stabilized with additional surgery, but not always.
In addition, there is the possibility of persistent limp, permanent nerve and artery injury and significant blood loss.   Other issues that will concern your surgeon and of which you should be aware are wound problems, nerve and blood vessel injury,   fracture around the implant, implant failures and blood loss as well as problems that arise with the urinary and gastrointestinal tracks. Although rare, stroke, heart attack and death have occurred with this surgery.
*Although this list of untoward events is thorough, it is by no means complete and you should ask your surgeon about any other concerns that you have.

STEP 2:  Preparing for the Surgery

Get in shape before the surgery It is well known by your surgeon that patients who are physically fit prior to surgery recover much faster and return to activity sooner than patients who are sedentary.    If you want your recovery to be shorter in time and have less pain then you need to get yourself in shape.  It is, in fact, your responsibility to make yourself as strong as you can.

You will be directed to a physical therapist for instruction on which muscles to strengthen and joints to stretch. Exercises should begin as soon as possible.

Patients who enter surgery with good flexibility and strength will recover more quickly than those who are in poor physical condition.  Additionally, fit patients tolerate pain much better. Establishing a relationship with a physical therapist prior to surgery is very helpful and will set the tone for the therapy that will be required after surgery.

The therapist will get to know where your starting point is and this makes the rehabilitation process more helpful to you. Most of the preoperative exercises that you will be directed to do take little time each day to do but will make a huge difference in how you recover!

On occasion, when a patient starts to work out, the pain starts to diminish and surgery can be delayed indefinitely!  It is certainly worth the effort to try.

Contact your insurance company

Before surgery we will be contacting your insurance carrier to inquire whether authorization, pre‐certification, second opinion, or a referral form are required.   Any problems that arise with the insurance coverage will be sorted out prior to this elective surgery so that no surprises develop during your stay in the hospital or in the post‐operative time frame.

It would be worth your while to confirm your benefits as they apply to coverage of the surgery, hospital stay, post‐op rehab and extended stay at a rehab facility so that you are comfortable with the projected expense and your responsibility for payments. Some insurance companies insist on having the opinion of another surgeon to justify the surgical procedure (although this is more common with HMOs and not Medicare or commercial insurers).

Our office coordinator will contact your insurance company to pre‐authorize your surgery. If a second opinion is required, you will be notified.

Pre‐register with the Surgery Center/Hospital
In most surgery centers/hospitals you will need to pre‐register in the admitting department of the surgeryc center/hospital prior to your surgery day.  An appointment will be made for you.  Plan about 1 hour for this visit.  The admitting department is found in the front lobby of the hospital.  Usually there are hospital volunteers at the information desk to assist you in finding this area.

At this visit you will be providing personal information to the surgery center/hospital which is needed to provide appropriate service during your stay here.  In addition, you will be seen by a pre‐admissions nurse who will review your medical history and medication so that this info is appropriately listed on your surgery center/hospital record.

Please bring the following information with you when you pre‐register:
 Your insurance card
 Photo I.D.
 Advance Directives, and Living Will if you have one
 List of all medications and the correct dosages of these meds

Important medication issues

Start taking Iron supplement 325 mg per day prior to surgery.  This is to build up your blood count.    This can be obtained at your local pharmacy without a prescription.

Discontinue the use of aspirin, aspirin‐like products, non‐steroidal anti‐ inflammatory medication, vitamins (except for Iron 325 mg), and herbal supplements one week prior to your surgery.

If you are on a blood thinner such as Coumadin, please let our office know so appropriate arrangements can be made prior to surgery, which usually involves stopping this blood thinner 5 days before the planned surgery.

Please do not take your usual morning prescription medications on the morning of your surgery unless instructed by your medical clearance physician and then only take the medication with a small sip of water.

Medical clearance exam

A very important part of preparing for your hip surgery is the medical exam and laboratory results to be done by your family doctor or a trusted physician known by your surgeon.  By having your current medical situation well documented and well understood, you have the best chance of avoiding complicating events either during or shortly after surgery.

Your medical doctor will let you know which of your medications can be stopped just prior to surgery and which ones you will need to take.

This medical exam is extremely important and must not be cancelled. Without pre‐operative medical clearance, Our Orthopedic doctors will not perform the surgery.

 Please remember to check with the medical clearance physician for special instructions on medications that you take routinely, such as heart medications, Insulin, Coumadin, etc.

Prepare your home for your return from the surgery center

Have your house ready for your arrival back home. Clean your home beforehand, do the laundry and put it away. Put clean linens on the bed. Prepare meals and freeze them in single serving containers. Cut the grass, and tend to the garden and other yard work as it will be some time before you will be ready for this activity.

Pick up throw rugs and tack down loose carpeting. Remove electrical cords and other obstructions from walkways. Install nightlights in bathrooms, bedrooms, and hallways. Arrange to have someone collect your mail and take care of pets or loved ones, if necessary.

Most hip surgery patients return home using a walker for about one week.    A walker is usually provided by a physical therapist that comes to your home for 7‐ 10 days to re‐train you in walking with your new hip and teach you the proper method to sit, get out of a chair and to move about your home. The fewer obstacles that you have to avoid, the easier will be your therapy.

STEP 3:  What to Know for Post‐operative Care

How long will I be incapacitated right after surgery?

We expect you will get out of bed and walk the day of surgery. This is extremely important to get your muscles moving to help prevent blood clots from forming in your legs.  In addition, the next morning you will get up and will be walking with a walker to participate in physical therapy.  You will be allowed to shower the day after surgery.

Most patients are able to walk ¼ mile around a track set up in the hospital prior to leaving for home two days after surgery.   Over 95 percent of patients go home.   Very few need to go to a rehab facility but if you wish to go to a rehab facility, this can be arranged for you by the hospital care manager.

Where will I go after discharge from the surgery center?

Virtually all patients are able to go home directly after discharge.  We believe that for most patients this is preferable to a rehab center and generally leads to quicker return to normal activity.  Patients in poor health, however, may have to transfer to a sub‐acute facility for rehab.    You, the orthopaedic team, your insurance company and the rehab facility will influence this decision.  You should check with your insurance company to see if you have sub‐acute rehab benefits.

When can I take a shower?

Usually a plastic protective dressing is applied over the incision at the time of surgery. This helps to keep the wound dry and clean and because it waterproofs the incision, you may shower immediately after surgery if you wish.  You may not, however, go into a pool, bath, hot tub, or the ocean until you have been advised to do so.

Will I need blood?

You may need blood after the surgery.  It has been shown that if you have a low blood count prior to surgery, you will probably need donated blood after surgery.   Pre‐op donation only increases your chance of needing additional blood after surgery and we rarely request this.  Also, a low blood count coming into surgery results in post‐op fatigue and lowers the chance of walking the day of surgery.   Our transfusion rate in patients with a normal blood count pre‐op is very low.   Although the community blood bank is very safe, if you for some reason have a great fear of blood bank blood, arrangements can be made for a family member to donate blood for your use.

How long will my scar be?

The scar will be about 8‐10 cm long and positioned starting just off of the anterior superior iliac spine which is the prominent bump of your pelvis at the belt line.   This is the starting point for the direct anterior approach that we use most commonly for primary hip replacement surgery.

Will I need a walker or a cane?

Most patients will use a walker for about 7‐10 days and then a cane for a couple of weeks.  Often younger patients will use only a cane for a short period of time and then go without any additional assisting device.

Will I need help at home?

Maybe.  Most patients that have done their pre‐op physical therapy are able to function well at home without great assistance. Importantly, our program is designed for patients to have a family member (“Caddy”), who has been with them from the beginning, help them at home. For the first several days or weeks, depending on your progress, you will benefit from someone to assist you with meal preparation, encouragement, etc. Preparation ahead of time, before your surgery, can minimize the amount of help needed after surgery.

Having the laundry done, house cleaned, yard work completed, clean linens on the bed, and single portion frozen meals will reduce the need for extra help. Again, most insurance plans and Medicare will not cover home care help for activities of daily living.  You will have to provide that kind of help from your own financial resources if you want it.

Will I need a private nurse?

No. You do not need a private nurse in the hospital or at home, but if you want one, we can help you make these arrangements.    Most insurances including Medicare will not cover this type of extra care as part of your benefit plan.

What if I live alone?

Most patients leave the hospital independent enough to function at home without great assistance. However, if you are frail, ill or lack the confidence to function on your own it may be wise for you to have an extended stay at a sub‐ acute rehab facility following your hospital stay provided your insurer will cover you for this stay.

Alternatively, many patients who live by themselves with no family or friends to serve as their “Caddy” do well with the short visits of a home health nurse and/or a home physical therapist who visit you at home.    Usually these professional services are covered by your insurance and Medicare. You should, however, make all attempts to arrange for a relative or friend, your “Caddy,” to stay with you for at least the first week after discharge because the home health nurse and physical therapist are with you for only a short period of the day.

Will I need physical therapy when I go home?

Yes. You will typically need home physical therapy for about 1 week. After this you are encouraged to utilize outpatient physical therapy. Your orthopaedic team will help you arrange for outpatient physical therapy shortly after your first post‐ op visit in our office. It helps to make the transition from home therapy to outpatient therapy if you visit the outpatient therapy facility prior to surgery and  set up an appointment schedule with them. Outpatient therapy will usually start about 10 days from the surgery date. The length of time required for this type of therapy varies with each patient but typically goes for 2‐4 weeks.

How often will I need to be seen following the surgery?

You will be seen for your first post‐operative office visit 7‐10 days after hospital discharge to check your wound, take a post‐op X‐ray and review the forthcoming rehab protocol.  Most commonly, the physician assistant performs this review.   Additional visits at 6 weeks post‐op and at 1 year as directed by your surgeon are typical. If any problems or concerns arise, additional visits will be needed to give you the best care.

STEP 4:  Getting Back to Normal  

When will I be able to get back to work?

We recommend that most people take at least one month off from work, unless their jobs are quite sedentary or require little thought or analysis, in which case they can usually return to work with a cane somewhat sooner.    Both pain medications and the effect of surgery on the body’s physiology can keep you from making clear decisions and functioning at peak levels. A physical therapist can make recommendations for joint protection and energy conservation on the job.

How long until I can drive and get back to normal?

You need to be off of all narcotic pain medications, and no longer requiring a walker to legally be permitted to drive.  The ability to drive depends on whether surgery was on your right leg or your left leg, and the type of car you have.

If the surgery was on your left leg and you have an automatic transmission, you could be driving at two weeks.  If the surgery was on your right leg, your ability to drive could be restricted slightly longer.

Getting “back to normal” will depend greatly on your pre‐operative physical condition and what you consider to be normal activity.  Consult with your surgeon or therapist for their advice on your activity.

When could I take an airplane trip?

We prefer to restrict you from air travel until 4 weeks post‐op.  Studies indicate that the risk of a blood clot is significant until 4 weeks after surgery and that sitting with knee bent in a cramped seat in a pressurized airplane and not drinking fluids is a great set up for a DVT (blood clot).  This risk normalizes after 4 weeks.   As with everything in life, each person’s tolerance for risk is different and patients have been allowed to fly within a week of surgery

What physical / recreational activities may I participate in after my recovery?

You are encouraged to participate in low‐impact activities such as walking, dancing, doubles tennis, golfing, hiking, swimming, bowling and gardening. Light weight lifting is also reasonable. In general, a joint replacement is like any mechanical parts that can wear.    If you abuse them, they will wear out sooner than they otherwise might. If you take reasonable care of the new replacement it may well last the rest of your life.

High‐impact activities, such as running, singles tennis and basketball are not recommended, although it is not proven that they can independently wear out the joint prematurely. Injury‐prone contact sports such as downhill skiing or roller skating are also dangerous for the new joint. It is widely believed in the orthopaedic community that these activities have the potential to loosen your artificial joint prematurely leading to a revision of the joint that may have been unnecessary if proper precautions were observed. Common sense applies here as does each patient’s risk tolerance.

Will I notice anything different about my hip?

Hopefully, the thing that you notice first is the lack of pain in the joint.   Of the things that may be unexpected, the one that is more often noted is a feeling of numbness down the lateral (outside) aspect of the thigh beyond the incision.  This area is given feeling from a skin nerve that is variably distributed in the area of the hip surgery and may be injured in the anterior approach.  Although the function of the muscles is usually not involved, the numb feeling may be permanent.

Most patients regain the motion they had before surgery, but lost motion is not typically restored to that remembered in your youth.  Physical therapy can go a long way to improving lost motion, but this is patient dependent.  With the direct anterior approach to hip replacement, no precautions are typically given to patients and they can sit on normal toilets, cross their legs and stretch their muscles with little concern for dislocation of the new hip joint.

Will I still have pain after my recovery?

In general, few patients have incapacitating pain after the recovery period. Some patients, however, have persistent pain that may last permanently. Sometimes a reason for the pain can be discovered in which case it can usually be fixed, but sometimes not. Unfortunately, virtually every surgical procedure carries the risk of persistent pain after the procedure and total hip replacement surgery is no exception.

Some patients develop a condition known as “chronic pain syndrome” which is a complicated condition associated with global (all over) hip and leg pain, warmth, swelling, redness and difficulty walking on the affected limb.  Usually a specialist in pain management is consulted to help manage this difficult situation. Again, this is not a common problem, but one that is well known to hip surgeons. It has been estimated that ~15% of patients will have at least some pain in or around their hip replacement forever even if it is has no clear evidence of failure.

A Note of Encouragement

Despite some real risks associated with this surgery and, indeed, virtually all surgical procedures, you should be confident that you have given this undertaking great thought and weighed the pros and cons of the procedure. You have reviewed all of your questions with your surgeon and have had additional questions reviewed in this section.

In short, this is a very common and very successful operation to relieve the severe pain in your joint that has kept you from enjoying your life.    If there was any reasonable alternative path around this procedure you would have taken that path.  As it is you are on a road that approximately 400,000 people per year take and which leads the vast majority to a point of extreme appreciation with that choice.  In addition, you have chosen a surgeon and his team that which are vastly experienced, dedicated to your outcome and excited to help you through this life changing experience.

Relax… It is going to be alright for you!