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Hip Replacement Surgery:

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Hip replacement surgery also called as total hip arthroplasty is a surgical procedure in which the painful arthritis of the hip joint is removed and been replaced with a metal or the plastic artificial joint. It is generally done when all the other treatment options have failed to provide adequate pain relief.

The goal of the hip replacement surgery is to replace the parts of the hip joint that have been damaged and to relieve from the hip pain that cannot be controlled by any other treatment options.

A traditional hip replacement surgery involves an incision of several inches long over the hip joint. Latest approach which uses one or two smaller incisions to perform the surgical procedure is called minimally invasive hip replacement surgery. However, the minimally invasive procedure is not suitable for all the patients for hip replacement. Orthopedic surgeon who performs the surgery will determine the best suitable procedure for the patient based on their health conditions.

Reasons for Hip Replacement Surgery:

Hip replacement surgery is mainly opted only to get relief from severe hip pain or treating any disability in the hip joint.
Common conditions which needs the hip replacement surgery are arthritis, few types of arthritis are listed below.

Types of arthritis:

Osteoarthritis | Rheumatoid Arthritis | Traumatic Arthritis

Osteoarthritis:

Osteoarthritis is a degenerative joint disease that affects mostly middle-aged and older adults, may cause the breakdown of joint cartilage and adjacent bone in the hips.

Rheumatoid Arthritis:

Which causes inflammation of the synovial lining of the joint and results in excessive synovial fluid, may lead to severe pain and stiffness.

Traumatic Arthritis:

Arthritis due to injury, may also cause damage to the articular cartilage of the hip.

Hip replacement surgery also be used as a method of treating the hip fractures. A fracture is a traumatic event that may result from a fall. Pain from a fracture is severe and walking or even moving the leg will be very difficult.

When all the medical treatments fail in controlling the pain due to the arthritis, hip replacement surgery may be an effective treatment option.

Types of Hip Replacement Surgeries:

There are two main types of hip replacement surgeries, but a number of different components (parts) and surgical techniques (methods) may be used.

  1. Total hip replacement surgery
  2. Metal-on-metal hip resurfacing

Total Hip Replacement:

hip replacement surgery

In a total hip replacement, part of the thigh bone (femur) including the ball (head of femur) is removed and a new, smaller artificial call is fixed into the rest of the thigh bone. The surface of the existing socket in the pelvis (the acetabulum) is roughened so an artificial socket that will join up (articulate) with the new ball can be fitted.

Many artificial joint components are fixed into the bone with acrylic (a type of plastic) cement, but it’s becoming more common for one part (usually the socket) or both to be inserted without cement, especially in more active patients.

If cement isn’t used, the surfaces of the implants are roughened or specially treated to encourage bone to grow onto them. Bone is a living substance and, as long as it’s strong and healthy, it’ll continue to renew itself over time and provide a long-lasting bond. Where only one part is fixed with cement, it’s known as a hybrid hip replacement.

The replacement metal, plastic or ceramic parts are used in different combinations:

  1. Metal on plastic
  2. Ceramic on plastic
  3. Metal on metal
hip implant

Metal on plastic:

A metal ball with a plastic socket is the most widely used combination.

Ceramic on plastic:

A ceramic ball with a plastic socket or simply ceramic-on-ceramic (where both parts are ceramic) are often used in younger, more active patients.

Metal on metal:

A mela ball with a metal socket is very occasionally used in younger, more active patients.

Metal-on-metal hip resurfacing:

metal on metal hip resurfacing

Resurfacing the original socket and the ball of the thigh bone is a different from of hip replacement. Instead of removing the head of the thigh bone and replacing it with an artificial ball, a hollow metal cap if fitted over the head of the thigh bone. The socket part of the joint is also resurfaced with a metal component.

People who have this type of operation have a lower risk of dislocation and may be able to return to a higher level of physical activity compared with those having a conventional hip replacement.

This type of hip surgery is linked with a release of metal particles from the joint replacement materials, which may cause inflammation in the nearby tissues and have unknown effects on your general health. Complication rates are particularly high in older patients and in women. Metal-on-metal resurfacing isn’t suitable for people with low bone density or osteoporosis, where the bones are weakened.

We don’t know much about the long term performance of these joints as the technique hasn’t been in use for as long as total hip replacements. However, the poorer mid-term performance for these types of design has meant they’re being used less often.

Hip Replacement Surgery Procedure:

Preparing for surgery | Surgical Process | Post surgery care

Preparing for surgery:

artificial hip joint

Surgeon team will explain the procedure and offer the chance to ask any questions related to the procedure. Patient / Attender may be asked to sign a consent form that gives your permission to proceed for the procedure. Read the form carefully and ask questions if something is not clear. In addition to a complete medical history, surgeon may perform a complete physical exam to ensure patient is fit for the procedure. This examination is generally called as the surgical profile, which will be performed for all surgeries. The surgical profile may include blood tests, heart related tests and other diagnostic tests required before the surgery.

Once the reports are ready for the surgical profile, patient needs to consult a cardiologist doctor to attain fit for surgery certificate. Cardiologist will review all the medical reports of the surgical profile and closely examine the heart reports like ECG, 2D ECHO, TMT etc. and will give a “Fit for surgery” certificate.

Doctor may also inquire about any sensitivity or allergic to any medications, latex, tape, and anesthetic agents (local and general). Explain all the medications (prescribed and over-the-counter) and herbal supplements that you are taking to the doctor. Inform if the patient has a history of bleeding disorders or taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. Doctor may suggest to stop or change few medications prior to the surgical procedure.

For female, If pregnant or suspecting and pregnancy, better to inform the surgeon prior to the procedure.

Patient will be asked to fast at least for 6-8 hours before the procedure, generally after midnight. Meeting with a physiotherapist prior to the surgery helps in discussing about post surgery rehabilitation.

These precautions may help in fast recovery post surgery.

  • Stop smoking, as smoking can delay wound healing and slow down the recovery period.
  • Lose weight if needed.
  • Perform conditioning exercises as prescribed by the doctor to strengthen muscles.

Surgical Process:

When the surgical team is ready, patient will be taken to the operating room. There patient will be given anesthesia. The anesthesia will help patient to sleep throughout the surgery, or it will make patient numb from the waist down. Then an incision is made, giving the surgeon access to the patient’s hip joint.

Preparing the bone | Joining the new parts

Preparing the bone:

The ball is cut from the thigh bone, and the surface of the old socket is smoothed. Then the new socket is put into the pelvis. The socket is usually press-fit and may be held in place with screws or cement. A press-fit prosthesis has tiny pores on its surface that the bone will grow into.

The damaged ball is removed, and the socket is prepared to hold the prosthesis.

Joining the new parts:

The new hip stem is inserted into the head of the thigh bone. After the stem is secure in the thigh bone, the new ball and the socket are joined. The stem of the prosthesis may be held with cement or press-fit. Surgeon will choose the method that is best suitable for the patient.

After the new joint is in place, the incision is closed with staples or stitches.

Post surgery care:

Protecting New Hip

After surgery patient will be sent to the post-op care unit. Patient condition will be monitored closely, and patient will be given with the pain killer medications. Patient may have a catheter (small tube) in the bladder and a drain in the hip. To keep the new joint stable, a foam wedge or pillows may be placed between the legs. In some cases, a brace is used. Later patient will be moved to the room.

Protecting New Hip:

During the hospital stay, patient will learn how to move in the ways that protect the new hip joint. These are commonly called movement precautions. Precautions depend on the type of surgery used to repair the hip joint.

Better to follow all the guidelines prescribed by the surgeon.

Sitting Precautions:
sitting precautions after hip surgery
flexion precaution after surgery

To keep the hips above the knees, patient should sit in chairs which are height, firm seats. Avoid low sofas or chairs. Patient should avoid crossing the operated leg over the other leg and always keep the thighs apart.

Flexion Precautions:

Patient should not bend over so the upper body is lower than the waist. Patient should be alert while standing and sitting.

rotation precaution after surgery
Rotation Precaution:

Patient should not turn the operated leg inward in a pigeon-toed stance. Patient should be alert while standing and lying down.

Benefits of Hip Replacement Surgery:

After a total hip replacement surgery, patient can look forward to move more easily. Most people gain all of the benefits listed below.

Total hip replacement surgery almost always:

  • Stops or greatly reduces the hip pain. Even the pain from surgery should go away within few weeks  after the surgery.
  • Increases the leg strength. Without hip pain, patient will be able to use their legs more. This will build up the muscles.
  • Improves quality of life by allowing patient to do daily tasks and low-impact activities with a greater comfort.
  • Provides years of easier movement. Most total hip replacements last for many years.

Risk Factors for Hip Replacement Surgery:

Generally complications will occur in any surgical procedure. Some possible complications for hip replacement surgery may include the following:

  • Bleeding
  • Infection
  • Blood clots in the legs or lungs
  • Dislocation
  • Need for revision or additional hip surgery
  • Nerve injury resulting in weakness or numbness

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Complications of Hip Replacement Surgery:

Hip replacement is a big operation and like all major surgery, there are risks. The chance of complications varies according to your general health, and your surgeon will discuss the risks with you. It’s important to be aware of the possible complications and to report any problems straight away. Although they’re rare, some complications can be serious and you may need another operation to correct them. However, most complications are fairly minor and can be successfully treated. Many thousands of hip replacements are carried out each year without any complications at all.

Note: you must seek medical advice straight away if you have pain or swelling in your leg, chest pain or sudden breathlessness following your surgery.

Blood clots:

After surgery, some people can suffer from blood clots which form in the deep veins of the leg (deep vein thrombosis, or DVT), causing pain and/or swelling in the leg. This is because of changes in the way blood flows and its ability to clot after each type of surgery. There are a number of ways to reduce the risk of this happening, including special stockings, pumps to exercise the feet and drugs that are given by injection into the skin, such as heparin or fondaparinux.

Rivaroxaban, dabigatran and apixaban, which have recently become available, are tablets to help prevent DVT. If your surgeon prescribed these, you’ll need to take them for five weeks after you go home from surgery. The tablets are more convenient than injections and don’t need monitoring, which make them easier to take at home, and so it’s easier to take them as prescribed. However, it’s not yet clear if the treatments really do reduce the overall risk of complications after joint replacement.

Pulmonary embolism:

In a very small number of cases a blood clot can travel to the lungs, leading to breathlessness and chest pains. In extreme cases a pulmonary embolism can be fatal. However, it’s usually possible to treat pulmonary embolism with blood-thinning medicines and oxygen therapy.

Dislocation:

Sometimes an artificial hip may dislocate. This occurs in less than 1 in 20 cases, and the hip needs to be put back in place under anaesthetic. In most cases this will make the hip stable, although you’ll probably need to do exercises to strengthen the muscles or have a brace to keep the joint still. If the hip keeps dislocating, you may need further surgery or a brace to make it stable. Even after you’ve started walking without support it’s important to continue with a programme of muscle-strengthening exercise to help to make your hip stable and improve function.

Infection:

To reduce the risk of infection, special operating theatres that have clean air pumped through them are often used, and most people will be given a short course of antibiotics at the time of the operation. Despite this, a deep infection can occur in about 1 in 100 cases. The infection can be treated but the new hip joint usually has to be removed until the infection clears up. New hip components are then implanted 6 to 12 weeks later.

Wear:

Plastic hip sockets may wear over a period of time. The worn particles of plastic may cause inflammation and this can eat away the bone around the new hip. Ceramic-on-ceramic or metal-on-metal joints tend to wear less and are therefore less likely to cause this problem. New, harded-wearing plastics are also being developed.

Loosening:

The most common cause of failure of hip replacements is when the artificial hip loosens. This can happen at any time but is most common after 10 to 15 years. It usually causes pain, and your hip may become unstable. Loosening is usually linked with thinning of the bone more prone to fracture. A fracture around the implant usually needs to be fixed through surgery and/or revision of the implant.

Bleeding and wound haematoma:

A wound haematoma is when blood collects in a wound. It’s normal to have a small amount of blood leak from the wound after any surgery. Usually this stops within a couple of days. But occasionally blood may collect under the skin, causing a swelling. This can discharge by itself, causing a larger but temporary leakage from the wound usually a week or so after surgery, or it may required a smaller second operation to remove the blood collection. Drugs like aspirin and antibiotics can increase the risk of haematoma after surgery.

Exercises for Hip Replacement Patients:

There are two groups of exercises recommended following your hip replacement surgery – those performed lying down (on the floor, an exercise mat or the bed) and those performed standing.

There are some general rules to remember while doing any of the following exercises:

  • Don’t twist the body while sitting or standing.
  • Don’t bend the hips past 90 degrees (a right angle).
  • Don’t cross the legs or feet.
  • Don’t roll the knees or toes inwards.

Lying down exercises:

Repeat each exercise 10 times, and try to do them three or four times a day.

Glut exercise:

glut exercise

Lie on the back. Squeeze gluteal muscles (gluts, or buttocks) together, hold for five seconds and relax.

Quad exercise:

quad exercise

Pull the toes and ankles towards you, while keeping the led straight and pushing the leg straight and pushing knee firmly against the floor. Hold for five seconds and relax.

Heel slide:

heel slide exercise

Using a sliding boards under the leg, bend the leg and bring the knee towards the chest, keeping the knee cap facing upwards. Slide the heel down again slowly.

Hip abductions:

hip abductions

Using a sliding boards brind the led out to the side and then back to the middle, keeping the toes and kneecap facing the ceiling.

Short arc quad exercise:

short arc quad exercise

Roll up a towel and place it under the knee. Keep the back of the back of the thigh on the towel and straighten the knee to raise the foot off the floor. Hold for five seconds and then lower slowly.

External hip rotation:

external hip rotation

Lie with the knees bent and feet flat on the floor, hip-weight apart. Let one knee drop towards the floor then bring it back up. Keep the back flat on the floor throughout.

Bridging:

Lie on the back with the knees bent and feet flat on the floor. Lift your pelvis and lower back off the floor. Hold the position for five seconds and then lower down slowly.

Stomach exercise:

stomach exercise

Lie on the back with the knees bent. Put the hands under the small of the back and pull the belly button down towards the floor. Hold for 20 seconds.

Standing Exercises:

Hip Flexion:

Hold onto a work surface and march on the spot to bring the knees up towards the chest alternately. Don’t go ahead 90 degrees.

Standing hip abduction:

Lift your leg sideways and bring it back, keeping the body straight throughout. Hold on to a chair or work surface for support.

Hip extension:

Move the leg backwards, keeping the knee straight. Don’t lean forwards. Hold onto a chair or work surface for support.

Heel to buttock exercise:

Bend the knee to pull the heel up towards your bottom. Keep the knees in line.

Mini squat:

Squat down until the kneecap covers the big toe. Hold onto a work surface for support.

Hip hitch:

Standing straight, hitch the leg up at the hip so the foot is a couple of inches off the floor. Lower it back down slowly.

Frequently Asked Questions:

  1. Is hip replacement the best treatment for my pain?
  2. Is hip replacement the only answer?
  3. How has hip replacement surgery changed over the years?
  4. How do I choose an orthopedic specialist?
  5. Will I be free of pain after surgery?
  6. How long till I can resume normal activities?
  7. How long does a hip implant last?
  8. Are there activities that I should avoid to protect the implant?

Is hip replacement the best treatment for my pain?

Get a thorough evaluation and diagnosis, which may include X-rays and Magnetic Resonance Imaging (MRI). Only opt for surgery when all the non-surgical interventions have failed (i.e., weight loss, exercise, physical therapy, anti-inflammatory medicines, and joint fluid therapy). Surgeon may perform a hip arthroscopy, which is less invasive than hip replacement.

Is hip replacement the only answer?

Hip replacement may not be the answer for everyone. Instead, doctor may perform a hip arthroscopy, which can sometimes postpone or even eliminate the need for a hip replacement. An arthroscopy can rule out other problems that produce hip pain but don’t require total hip replacement. The procedure uses small incisions to remove bone spurs and joint debris and/or other conditions that may be causing hip pain.

How has hip replacement surgery changed over the years?

Because of recent innovations, hip replacement surgery is easier and better than ever. Advances in surgical technique and materials have led to improved function and faster recovery for patients. Today, many surgeons use a mini-incision technique which results in a significant reduction in post-operative discomfort and shorter hospital stays.Improvements in the implant materials such as the metal on metal bearing surfaces result in greater range of motion and hip stability and increased durability of the implant.

How do I choose an orthopedic specialist?

Ask your physician for a recommendation.

Book an orthopedic consultation and don’t be afraid to ask the doctor these questions: How many hip replacement surgeries have you performed? What is your success rate? How frequently do your patients experience infections?

Will I be free of pain after surgery?

Surgical pain is present after surgery but the pain of an arthritic hip is gone, and patients are generally up and walking the next day with pain relief that is nothing less than phenomenal.

How long till I can resume normal activities?

Depending on the overall health and the success of the rehabilitation therapy, a complete recovery usually takes from three to six months. Don’t hurry the healing process. Patients usually feel so good that they push themselves too quickly, and some experience an increase in the pain at about the third month from too much activity. However, a year after surgery, it is hard to tell which hip was operated on.

How long does a hip implant last?

The new hip should allow patient to be virtually normal, pain-free activity for many years. Around 80% of cemented hips should last for 20 days. Younger, more active patients often get cement-less hip replacements and these may last longer, although this is not confirmed in long-term studies. Hybrid hips, in which only one part is cemented, work well in active middle-aged patients when used with ceramic-on-ceramic joints.

Are there activities that I should avoid to protect the implant?

Yes. Patients should avoid high-impact activities such as heavy-duty running, high impact aerobics and jumping from high heights. Avoid being overweight, this tends to wear out joints more quickly. Patient should also limit sitting on low seating surfaces and chairs, kneeling for a prolonged amount of time, repetitive lifting or pushing heavy objects.

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