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).
What can be expected of a total hip replacement?
A total hip replacement will provide complete, or near-complete, pain relief in 90-95% 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 will have improved motion.
There are many conditions that can result in degeneration of the hip joint. Osteoarthritis is perhaps the most common cause of hip replacement surgery. This condition is commonly referred to as “wear and tear arthritis”. Osteoarthritis can occur with no previous history of injury to the hip joint – the hip simply “wears out”. There may be a genetic tendency in some people that increases their chances of developing osteoarthritis.
Avascular necrosis is another cause of degeneration of the hip joint. In this condition, the femoral head (the ball portion) loses a portion of its blood supply and actually dies. This leads to the collapse of the femoral head and degeneration of the joint. Avascular necrosis (AVN) has been linked to alcoholism, hip fractures and dislocations of the hip, and long term cortisone treatment for other diseases.
Abnormalities of hip joint function resulting from hip fractures and some types of childhood hip conditions can also lead to degeneration many years after an injury. The mechanical abnormality of the joint causes excessive wear and tear – just like the out-of-balance tire of a car that wears out too soon.
The symptoms of a degenerative hip joint usually begin with pain when bearing weight on the affected side. One may limp, which is the body’s way of reducing the forces of impact the hip has to deal with. This degeneration will eventually lead to a reduction in the range of motion in the affected hip. Bone spurs usually develop, which can also limit movement of the hip joint. Finally, as the condition progresses further, the pain may be present all the time and may keep one awake at night.
The diagnosis of a degenerative hip joint starts with a complete history and physical examination by the doctor. X-rays are taken to determine the extent of the degenerative process and may suggest a cause for the degeneration. Other tests may be required if there is a reason to believe that other conditions are contributing to the degenerative process. A Magnetic Resonance Imaging (MRI) scan may be necessary to determine whether avascular necrosis is causing the hip condition. Blood tests may be required to rule out systemic arthritis or an infection in the hip.
Not all hip conditions require a hip replacement as the initial treatment. We may suggest several alternative treatments to put off replacing the hip as long as possible. Using a cane may help alleviate some of the pain and allow a patient to walk more comfortably. Anti-inflammatory medications may reduce the inflammation from arthritis and, therefore, lessen the pain.
Most degenerative problems will eventually require replacement of the painful hip joint with an artificial hip joint, called a prosthesis. Once the decision to proceed with surgery is made, there are several things to be done. A complete physical examination is done by a medical or family doctor. This is to ensure that the patient is in the best possible condition to undergo the operation. The patient may also need to spend time with a physical therapist who will be managing the rehabilitation after the surgery. The therapist may begin the teaching process before the surgery to ensure the patient is ready for the rehabilitation afterward.
The Artificial Hip Joint, Called a Prosthesis
There are two major types of artificial hip joint:
- Cemented Prosthesis
- Uncemented Prosthesis
A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone.
An uncemented prosthesis has a fine mesh of holes on the surface area that touches the bone. The mesh allows the bone to grow into the mesh and “become part of” the bone.
Both types are widely used. The type of prosthesis used for the surgery is usually decided by the surgeon based on the patient’s age and lifestyle. Each prosthesis is made up of two parts:
- The acetabular component, or socket portion, which replaces the acetabulum.
- The femoral component, or stem portion, which replaces the femoral head.
The femoral component is made of a metal stem with a metal or ceramic ball on the end. The acetabular component is a metal shell with a plastic inner socket liner that acts like a bearing. The type of plastic used is very tough and very slick – so slick and tough that you could ice skate on a sheet of the plastic without much damage to the plastic.
As with all major surgical procedures, complications can occur. The most common complications following hip replacement are:
- Infection in the joint
- Dislocation of the joint
- Loosening of the joint
This is not intended to be a complete list of the possible complications, but these are the most common.
Thrombophlebitis, sometimes called Deep Venous Thrombosis (DVT), can occur after any operation. It is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg form as clots within the veins. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart they can travel into the lung. Once in the lung, they can get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. Pulmonary means “lung”. An embolism is a fragment of something traveling through the vascular system. Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting the patient moving around as soon as possible!
Some of the commonly used preventative measures include:
- Pressure stockings to keep the blood in the legs moving.
- Medications that thin the blood and prevent blood clots from forming.
Infection can be a very serious complication following an artificial joint replacement. The chances of getting an infection following a total hip replacement are probably around 1 in 100. Some infections may show up very early – before the patient leaves the hospital. Others may not show up for months or even years after the operation.
Just like a real hip, an artificial hip can dislocate. Dislocation is when the ball comes out of the socket. There is a greater risk of dislocation right after surgery before the muscles and tendons around the new joint have healed. However, there is always a risk of dislocation.
The therapist will carefully instruct the patient on which activities and positions increase the risk of hip dislocation. A hip that dislocates more than once may have to be revised, which means another operation, to make the joint more stable.
How do artificial hips stand up over time?
The major long-term problems with hip replacements are loosening or wear. Loosening occurs either because of the cement crumbling (like old mortar in a brick building) or because the bone melts away (resorbs) from the cement. At 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 occur 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 the patient is. 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.
How long should I use the pain medication?
This is different for each patient. Some patients are able to use Tylenol or Advil after they leave the hospital and others require narcotic pain medication. Generally, you should try to decrease the use of medications as time passes.
When should I go to outpatient therapy?
If you are going home or to a rehab center, in either case you should schedule physical therapy within a few days of your release. If you do not have a prescription for physical therapy, please call our office and we will provide a prescription and list of physical therapists in your area.
When can I go to the dentist?
Not for three months after surgery. As the hip is gently healing and there is increased blood flow to this area, there is a higher risk of infection.
You must take prophylactic antibiotics for the next two years, if if any of the following pertain to you:
- You have had another surgical procedure
- You have had any dental procedure
- Any lung, bladder, or colonoscopy procedure
- You develop any kind of infection.
Immuno compromised patients with Rheumatoid Arthritis, Lupus, Insulin Dependent Diabetes, chemical or radiation induced immuno-supression, will need to take prophylactic antibiotics for life.
Total hip replacement patients who require dental work on gums or roots must adhere to the following antibiotic procedure:
For patients not allergic to Penicillin: Cephalexin, Cephradine or Amoxicilin: 2 grams orally 1 hour prior to the dental procedure.
For patients allergic to Penicillin: Clindamycin: 600mg orally 1 hour prior to the dental procedure.
Patients should adhere to this regimen for the first two years following joint replacement. Immunocompromised patients, including those with inflammatory arthropathies, rheumatoid arthritis, drug or radiation-induced immunosuppression, insulin-dependent diabetes or any other major medical problem should follow this antibiotic routine indefinitely.
Antibiotics can reduce the risk of infection but cannot completely eliminate that risk. Preventing infection must be the concern of all the healthcare professionals who treat you. MAKE SURE YOU INFORM YOUR PHYSICIAN AND DENTIST THAT YOU HAVE HAD A TOTAL HIP REPLACEMENT.
When can I drive?
You should not drive as long as you are taking narcotic pain medications. If it is your left hip, you can resume driving when you feel you feel healthy, in about three weeks. If it is your right hip, I would like to evaluate you at 6 weeks - hence no driving before 6 weeks.
Why does my hip click after surgery?
Usually clicking after surgery is normal. The clicking is a result of soft tissue moving across the front of the hip or the metal parts coming into contact with one another. This sensation usually diminishes, as your muscles get stronger.
Is a lot of swelling normal?
Fluid can accumulate in the legs due to the effects of gravity. Usually it is not a problem in the hospital, but it can get worse when you go home or to a rehab center because you will be moving around and doing more. To reduce swelling, you should elevate your legs at night. Lie on your back and place pillows underneath your legs so that they are above your heart, wear then throughout the day and then take them off at night. If you did not get the stockings from the hospital you can purchase knee height, medium, compression, surgical stockings from any pharmacy shop. Try to wear them for 6 weeks if possible. This helps to reduce leg swelling and prevent blood clot formation.
How long do I have to wear the stockings?
You should wear the stockings on both legs. Have someone help you with them in the morning, wear then throughout the day and then take them off at night. If you did not get the stockings from the hospital you can purchase knee height, medium, compression, surgical stockings from any pharmacy shop. Try to wear them for 6 weeks if possible. This helps to reduce leg swelling and prevent blood clot formation in your legs.
Can I travel?
In general, I would like to see you before you travel by air. If you are traveling by car you should be sure to take frequent breaks so that you do not feel stiff in getting up. On an airplane, I would like you to wear compression stocking and take a couple of walks during the flight. Request aisle and/or bulk head seats so you will have more space.
Will I be able to resume sexual relations now that my hip has been replaced?
The vast majority of patients are able to resume safe and enjoyable sexual intercourse after hip replacement. Patients whose sexual function had been impaired by preoperative hip pain and stiffness welcome their new pain-free mobility. However, gaining full confidence with your new hip may take several weeks.
When can I resume sexual intercourse?
In general, intercourse can be resumed safely approximately eight weeks after surgery. Though individual recovery time varies greatly, this timeframe allows the incision and the muscles around the hip to heal. If you recuperate rapidly, you will be able to resume sooner, as long as you are free of pain.
What positions are safe during intercourse?
Total hip replacement precautions need to be observed during all activities, including sexual intercourse. As advised in your discharge instructions, you should avoid excessive hip flexion (knee toward chest), adduction (leg towards center of body), and internal rotation (toes turned inward).
Most patients, male and female, prefer passive intercourse in the bottom position, an option some find less fatiguing. As your hip heals, you may resume a more active role. After a few months, you can resume sexual activities in any comfortable position.
What should I tell my partner?
Good communication is essential. You should share information, including the hip precautions listed above and that information that the hospital or outpatient surgical staff reviewed with you.
Orthopaedic Specialists of Connecticut, also known as Orthopedic Specialists of Connecticut, based in Brookfield, CT and Danbury, CT, provides comprehensive orthopaedic care, sports medicine, joint replacements, and interventional pain management to patients of all ages.
Orthopaedic Specialists of Connecticut, also known as Orthopedic Specialists of Connecticut, provides orthopedic care including: orthopedic examination, foot surgery, ankle surgery, hand surgery, hip surgery, hip replacement, hip resurfacing, knee surgery, knee replacement, orthopedic oncology, shoulder surgery, elbow surgery, and MAKOplasty.
Orthopaedic Specialists of Connecticut, also known as Orthopedic Specialists of Connecticut, also provides sports medicine, physical therapy, pain management, interventional pain management, radiology, x-ray, ultrasound, cortisone injection, and PRP injections.
Orthopaedic Specialists of Connecticut, also known as Orthopedic Specialists of Connecticut, treats sprains, fractures, ligament tears, arthritis, musculoskeletal pain, neurological pain, cancer pain, neck pain, and back pain.