Total hip replacement surgery is a procedure that was first performed in its present form in 1963. Over 150,000 patients in the United States undergo this operation every year, and the procedure has proven to be highly successful in the vast majority of patients with prolonged relief of pain and improvement in their walking ability.

Total hip replacement surgery is most commonly performed in patients with disabling arthritis of the hip joint. Osteoarthritis is usually caused by 1 of 3 factors: aging, injury, and congenital deformity. Hence, a hip condition present at birth may cause problems in adolescence and adulthood and can lead to osteoarthritis many years later. Similarly, an injury to the hip can later lead to osteoarthritis of that joint. Rheumatoid arthritis is a disease affecting many joints and the hip joint may be severely involved.

As a result of the pain experienced by patients with arthritis affecting the hip, walking becomes more difficult and hip motion may become limited. In advanced cases of arthritis of the hip joint, shortening of the affected limb may occur. Associated pain in the groin, buttock, and knee on the same side as the arthritic hip is common as is pain in the low back and the opposite knee and hip.

Once attempts at conservative treatment of the arthritic hip are no longer successful, total hip replacement will be recommended to the patient for pain relief and improvement of function.

The hip joint is composed of two bones and is referred to as a "ball and socket" joint. The "ball" is the top part of the femur, or thigh bone, and the "socket", or acetabulum, is part of the pelvis. The arthritic process affects both parts of the hip joint, making it necessary to correct both parts of the joint, using two separate components.

The arthritic process is first removed from the hip socket by using special instruments and the replacement socket called the acetabular component is selected specifically for the patient by using measuring trials during surgery. The acetabular component is made of extremely durable metal and plastic or ceramic which has excellent properties of wear resistance and allows the artificial hip to move with minimal resistance.

The arthritic ball is removed with part of the neck of the femur and the marrow portion of the femur is prepared to receive a stemmed component which is made of a super alloy metal material. The canal of the femur is gauged, as was the socket, to accept the correct size prosthesis for the patient. A new metal or ceramic ball is placed on the stemmed component of the femur.

Both components are inserted into the bone and are held in place by the bone growing into the prosthesis or by bone cement similar to what a dentist uses to fix a bridge in place.

WHAT CAN THE PATIENT UNDERGOING TOTAL HIP REPLACEMENT EXPECT?

You will be examined by an internist who will perform a complete history and physical before surgery. You will also be evaluated with a complete set of pre-surgical tests prior to entering the hospital. This will include blood tests, urine tests, EKG, chest x-rays and any other tests deemed necessary by the internist. Your test results will be reviewed by the internist and if any of the tests demonstrate significant abnormality or if the internist feels, based on the physical examination that surgery should not proceed, a delay will take place until all of your problems have been corrected. You must be in satisfactory medical condition prior to undergoing this operation.

The anesthesiologist will also see you prior to surgery. Regional anesthesia is recommended for total hip replacement unless some condition is present which makes this not feasible. Regional anesthesia is generally achieved by administering a spinal and/or an epidural anesthetic which is commonly used when women give birth. The patient is sedated and will not be aware of any part of the surgical procedure. However, the level of anesthesia will be light and this allows the patient to awaken very quickly in the recovery room, avoiding the recovery problems of general anesthesia. Blood loss is also significantly reduced by the use of regional anesthesia.

You may require a blood transfusion during hip replacement surgery and may require further transfusions afterwards. All attempts to keep the use of blood replacement to a minimum will be exercised. For most patients, it is possible to give blood prior to surgery and then receive their own blood during the operation and afterwards.

The operation itself takes about 1½ hours and you will be brought to the recovery room after your surgery is completed. If the operation is performed late in the day, you may be kept in recovery over night and transferred to your room early the next morning.

The patient undergoing total hip replacement will have an intravenous line running for approximately 48 hours after surgery to provide fluids and antibiotics. If further blood transfusion is necessary, this will also be given via this intravenous route. A drain may be placed into the area of the hip during the operation and this will generally be removed the day after surgery. Fluids will be started by mouth the day after surgery and your diet advanced over the next few days.

The nurses will be moving you to prevent pressure sensitive areas from developing. It is important that you take deep breaths and cough in order to keep your lungs clear; the nurses will help encourage you.

Usually on the first or second day after surgery you will be allowed to sit up at the bedside and, depending on how you feel, you will be allowed to stand at this point. You will generally begin walking on the 2nd or 3rd day with a walker. You will be advanced to crutches or a cane depending on your progress and you will be discharged with them. An exercise program will be given to you by the physical therapist who will work with you. These exercises are to be continued after your discharge from the hospital.

You will be expected to demonstrate that you can care for yourself independently prior to discharge from the hospital. You will be expected to transfer in and out of bed unassisted, walk the circumference of the hospital with a cane or crutches, and climb stairs to the satisfaction of the physical therapist. In addition, your wound must be healed, without problems and you must not have a medical problem. The average length of stay for a patient undergoing total hip replacement is 2-5 days.

When you are discharged, you will be given a prescription for pain medication and an anticoagulant or blood thinner to prevent blood clots in the lower limbs. The internist will recommend that you take the anticoagulant for approximately 6 weeks.

During the initial month after discharge walking is encouraged with your cane or crutches to your tolerance and it will be important for you to be active. Patients often feel fatigued during the 1st week at home, but rapidly gain strength soon after discharge. Pain medication will be given to you upon your discharge, but should only be used if needed.

You will return to see me in the office 4 to 6 weeks after discharge from the hospital and you must call my office for this appointment right after you get home. An X-ray of your hip will be taken when you see me for the first time after surgery.

Special attention should be given to sitting in high chairs or sitting on firm cushions. The reason for this is to prevent the hip from becoming too highly flexed which can dislocate the hip joint. An elevated extension for your toilet seat will also be given to you when you go home and you should use this for 12 weeks following surgery. Sitting for long periods with the operated leg hanging down can produce significant swelling in the leg, so elevation is encouraged. Elastic stockings should be used if there is swelling present. If the swelling continues, you should lie down for 1 hour twice a day with your leg elevated.

Lying on the operated hip should also be avoided following surgery for the first 3 months, since the incision will be sensitive. The physical therapist will instruct you as to which exercises you should be doing at home; if any of these exercises produce pain they should be avoided and you should contact my office.

If at the time of your first return visit to my office, your recovery is satisfactory, you will be able to walk without a cane. All of the hip precautions will be removed at 3 months, and additional exercises will be given to you. If your progress is good, you will be asked to return in one year for an X-ray and examination. After the first year, you will be seen annually, unless you have any problems, in which case you should contact my office.

Most patients experience dramatic relief of their pre-operative pain and are consequently able to walk much better. Any tendency to tilt toward the operated side when walking should gradually disappear as recovery progresses. In addition, strength and mobility will improve. If complications do occur, however, these may impair the result after hip replacement.

As with any major operation, complications can occur. These potential problems fall into 3 major categories:

Medical complications after surgery include, but are not limited to, heart and lung problems, blood clots and phlebitis in the operated leg. If a patient has a medical history of a particular problem, that condition may be aggravated by surgery. You will be thoroughly tested and examined by an internist before surgery and he or she will follow you post operatively should any complications arise. Medical complications are, for the most part, uncommon but can occur and you should be aware of these potential problems.

Although quite rare, a most potentially serious complication is infection around the hip replacement. This may occur in the hospital during the immediate post operative period or, in some patients, after discharge. Because infection from other parts of the body can seed the replaced joint, it is important that you advise a physician treating you for any infection that you have undergone total joint replacement. You may also contact my office if you have any questions about treatment. If you are to undergo any procedure in which you might be exposed to bacterial contamination, you must take prophylactic antibiotics before and after the procedure and my office can furnish you with a prescription. Procedures which require antibiotics include procedures of the intestines or the bladder such as a colonoscopy or cystoscopy as well as any other treatment for abscess or infection. Antibiotics should also be taken before dental prophylaxis or procedures which can produce gum bleeding.

Should an infection occur and become deep around the hip replacement, it will be necessary to remove the components of the hip replacement and the cement; the ensuing treatment will be under the supervision of an infectious disease specialist. That doctor will supervise your care until the infection is eradicated at which time a new replacement can be implanted. The rate of infection following total hip replacement at Pinehurst Surgical is very low (less than ¼ of one percent) and precautions are taken to maintain a low infection rate. All patients receive per-operative, intra-operative and post operative antibiotics and the surgical team operates in special operating rooms in "space suite" type gowns to lessen the chance of contamination of the wound during surgery.

There is the possibility of mechanical problems which refers to problems with the prosthesis itself and includes dislocation, breakage, loosening, and wear. Dislocation may occur in up to 2% of patients, thus requiring a closed reduction of the hip usually under light sedation or regional anesthesia. The incidence of failure of the prosthesis in patients with total hip replacement has been extremely low. The most common source of failure occurs when there is loosening of the bond between the prosthesis, bone, and the bone cement. This can result in pain and shift in the position of the replacement and in severe cases may require insertion of a revision hip prosthesis.

The incidence of loosening has been extremely low and is in the area of less than 5% in long term follow up. Wear and breakage has been an insignificant problem to date.

This pamphlet is designed to give you an overview of what total hip replacement surgery entails. The results thus far have been encouraging and the longevity of the prosthesis appears quite good. There is always a chance that a complication can occur and the above list is incomplete; there are other possible complications that can occur after this as with any surgery. The incidence of these and other complications is low and all possible precautions are taken but, you must be aware that they can and do still occur and can affect your recovery. We encourage patients to call the office, if they are concerned or they have any additional questions.

We have performed many total hip replacements at Pinehurst Surgical and feel that it has provided the disabled patient with a painful, arthritic hip with an excellent return to function and the ability to return to a more comfortable and productive life.

David J. Casey, MD