Total Hip Replacement PATIENT INFORMATION

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1 DEPARTMENT OF ORTHOPAEDICS Total Hip Replacement PATIENT INFORMATION

2 Welcome to Orthopaedic Department at Warwick Hospital TOTAL HIP REPLACEMENT Welcome to the Orthopaedic Department at Warwick Hospital. You are going to be admitted for a total hip replacement. This booklet is intended as a guide for your information. Treatments can and do vary from person to person and from Consultant to Consultant so please feel free to ask questions from any member of staff. Your Hip Joint The hip is one of your body s largest weight-bearing joints. It consists of two main parts: a ball (femoral head) at the top of your thighbone (femur) that fits into a rounded socket (acetabulum) in your pelvis. Bands of tissue called ligaments connect the ball to the socket and provide stability to the joint. The bone surfaces of your ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily. All surfaces of the hip joint are covered by a thin, smooth tissue called synovial membrane. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in your hip joint. Normally all of these parts of your hip work in harmony, allowing you to move easily and without pain. Why do I need a Total Hip Replacement? A total hip replacement is usually performed when you have arthritis of the joint; this may also be referred to as wear and tear. The Cartilage covering of the hip joint is worn away by friction and causes the bones to grate together. You may experience pain and stiffness in your leg as well as in your hip and groin. This can make you immobile and reduce the quality of your life. Your arthritis will get progressively worse.

3 Traumatic arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as avascular necrosis. The articular cartilage becomes damaged and causes hip pain and stiffness. Your General Practitioner may have treated you with tablets for your arthritis. These reduce the swelling and inflammation in the joint but are not a cure for arthritis. As your arthritis becomes more severe, you may find the benefit of your tablets is reduced. The decision whether to have replacement surgery should be a cooperative one between you, your family, your GP, and your orthopaedic surgeon. The process of making this decision begins with a referral by your GP to an orthopaedic surgeon for an initial evaluation. Other treatment options such as medication, physiotherapy or other types of surgery may be considered. If you decide to have hip replacement surgery, you will be invited to attend a pre-operative assessment clinic. Here a physical examination to assess your general health is undertaken to find conditions that could interfere with your surgery. It would be advisable to ask your practice nurse to check your weight and blood pressure. Your operation will be cancelled if you are found to be overweight or have high blood pressure. Your GP/practice nurse will be able to give you advice or treatment for this while you are waiting for your operation. Near the time of your operation you will be contacted by the hospital and asked to attend pre operative assessment clinic.

4 Pre operative assessment clinic. Prior to your admission to hospital you will attend pre operative assessment clinic to ensure you are fit and adequately prepared for your surgery. A nurse will carry out all necessary investigations during this visit. You should be aware of what to expect during your stay in hospital, both before your operation, and most importantly afterwards. You will also see a physiotherapist pre-operatively. He/She will teach you exercises to practice at home prior to your surgery. Breathing exercises to prevent chest complications Foot and ankle exercise to maintain circulation Leg exercises to maintain muscle strength. The physiotherapist will also talk to you about your rehabilitation and use of walking aids. The Do s and Dont s following surgery will also be explained to you. Blood donations You may be advised to donate your own blood prior to surgery. It will be stored in the event you need blood after surgery. Bone donations You may be eligible to donate your discarded hip bone as it can be used to help treat other orthopaedic problems. A member of our nursing staff will approach you pre operatively to discuss this with you in greater detail and to give you more information. If you are a suitable donor we will ask for your consent. Medications Tell your orthopaedic surgeon about the medications you are taking and bring them with you. If you are taking Warfarin or hormone replacement therapy It is very important to inform the Doctor at the pre admission as this will need to be stopped prior to surgery. Planning for your discharge begins during your attendance to pre assessment clinic. You will be referred to the occupational therapist who will visit you at home to ensure that you have all the necessary equipment that you will need following your operation.

5 On discharge you will need some help at home for at least six weeks. You will be issued with Surgical stockings are to be worn for the first six weeks day and night. A second pair can be purchased if required from the occupational therapist on the ward. As you will not be allowed to bend you will need some help when washing your feet. You will not be able to get in and out of the bath for the first three months. The occupational therapists will advice you about bath/shower management. When dressing sit on the bed or chair. Dressing equipment will be loaned and demonstrated. This will enable you to put on your trousers, pants, socks/stockings and shoes safely without bending. It is easier to put your operated leg into your clothes first. As you will be using walking aids you will need help with your shopping. If you are unable to arrange help from any relatives/carers please inform the Nurse at Pre assessment clinic. If you require transport to and from the hospital please contact your GP surgery. They will be able to arrange this for you. Your stay in hospital should be between 5-7 days. Your Surgery You will be admitted to the hospital on the day before your surgery. After admission a member of the anaesthetic team will come and talk to you and help decide which type of anaesthetic is best for you. The choices are explained in anaesthesia & anaesthetics THE OPERATION A nurse will take you to theatre from your ward. The operation takes some time. Your orthopaedic surgeon will remove the damaged cartilage and bone, then position new metal and plastic joint surfaces to restore the alignment and function of your hip. The operation will last one and a half - two hours.

6 AFTER THE OPERATION After the operation you will remain in the theatre recovery area until the anaesthetist is happy that your condition is stable. A nurse will be with you all the time whilst you are here. He/she will be monitoring your heart, blood pressure, temperature and level of conscious, and ensuring that your wound is satisfactory. When they are happy with your condition, you will return to the ward. On return to the ward your blood pressure, pulse and temperature will be recorded at regular intervals and your wound and circulation will also be checked PAIN There will be some pain following your operation. This should not be severe. You will be prescribed pain killing medicines that you can alleviate any pain. This will be commenced in the theatre recovery area. If you are in pain please inform the nursing staff. You should not put up with it just because you have had an operation. When your infusion is discontinued, you will be offered tablets for pain relief on a regular basis. Most patients find that it is not necessary to take many of these once the operation has settled down. You will return to the ward with an intravenous infusion, (a drip). This is used to replace the fluid that you would take by mouth whilst you are waiting for your operation. It prevents you from becoming dry. It also replaces any fluid which is lost during the operation It is often necessary to have a blood transfusion after this type of surgery. This prevents you from becoming anaemic, and to replace any blood that you have lost during the procedure. Your drip will be discontinued as soon as you are able to eat and drink adequately after your operation. CHARNLEY WEDGE After the operation you will return from theatre lying on your back

7 with a triangular pillow, (charnley wedge) between your legs to keep them apart. This position and other precautions are necessary to prevent unwanted harmful movements causing undue stress on your new hip. Movement of your operated leg as instructed by the physiotherapist is, however, an important part of the recovery program. You must assist the nursing staff to move you in bed by using the overhead bar and your nonoperated limb. In particular lifting your buttocks off the bed is important for pressure care and use of bed-pans. WOUND You will have quite a large wound which will curve around the back of you hip joint. It is expected that your wound may ooze blood through the dressing. The nursing staff will change this as necessary. Although this may not be every day, they will assess it at regular intervals. surface of the wound. This may lead to an infection or to excessive bruising if it is allowed to remain there. The drains are removed after 24 hours. You may have stitches or clips in your wound, which are removed at about fourteen days after your operation, depending upon when the wound heals. The District Nurse will visit you at home to remove these. The wound area and your leg may be fairly bruised after your operation. Do not be alarmed, as this is quite normal. To help relieve any swelling in your operated leg and foot, sit with your legs up on the settee, taking care not to have too much bend at your hip, or lie on the bed for some of the day. X-RAY Soon after your operation you will be taken to the x-ray department on your bed in order to get a x-ray of your new hip. You will have 1-2-wound drains, which contain a vacuum and are used to remove any blood or fluid that may collect beneath the

8 MOBILISATION This usually begins the first day after your operation once the wound drains have been removed. The physiotherapist will then teach you how to get in and out of bed correctly in order to prevent any damage to you new hip. You may feel dizzy or nauseous when you first get out of bed. This is only because you have been lying down for a period. Walking with your Physiotherapist The walking sequence is always: - Walking aid moved forward first Then the operated leg And finally the non -operated leg. Turning round can be to either side, but you must prevent twisting or pivoting on your new hip. Therefore, feet must be picked up at each step. As your confidence and leg control improves, you will progress to walking with crutches or walking sticks. You should practice with these until a satisfactory walking pattern is achieved. It is important that you are measured correctly by your physiotherapist for the walking aid you are using. It will take time and effort to regain a normal walking pattern, but it will get better if you persevere. Your physiotherapist will help and instruct you in the best way to correct both walking and posture thus enabling you to use your new hip to its full advantage. You should use your crutches for 6 weeks until you see the consultant and can progress to a stick and when ready walk normally. Rehabilitation Rehabilitation excercises to strengthen the muscles in your thigh should be carried out 3-4 times daily for the first 6 weeks. o 1. Pull your toes up towards you and push your knees down firmly against the bed. Tightening up the muscles on the front of your thigh. Hold 3 seconds, then relax. Repeat times. 2. Place a rolled towel under your knee, pull your toes up towards you, tightening your thigh muscles, lift your heel up off the bed to straighten your knee.hold approx. 3seconds, then relax. Repeat times.

9 Board exercises to help movement in the hip join These are exercises performed initially on a sliding board to minimise resistance. Eventually, you will manage them without this. Board exercises will usually start the day after the operation, under the physiotherapist s instruction. You will need help to position the board and pull back the bedclothes. DO NOT ATTEMPT IT BY YOURSELF. Your physiotherapist will show you those exercises, which are appropriate for you as an individual. 1. Bend and straighten your hip and knee by sliding your foot up and down the board. You are aiming to bend your hip to a right angle (90 ) and not beyond this. Repeat times. 2. Slide your leg out to the side and then back to mid position. Repeat times.

10 Getting in and out of bed Your bed will need to be at least 18 higher than the floor. Appropriate equipment can be loaned to raise the bed to the correct height. 1. Take your legs over to the side of the bed. 2. Slowly sit up taking care not to bent the hip past 90 degrees 3. Push up into standing with your hands on the bed and operated leg out in front of you 4. Once standing take hold of your frame

11 Getting in and out of chairs Sitting is usually commenced one to three days after the operation. Initially you must sit in a firm, high chair with arms. The chair should be 18 or higher. Sitting down on a chair 3. Slide your operated leg out in front, keeping your knee as straight as possible 1. Position yourself so that the backs of your legs are right up against the front of the chair 4. Sit down on the front of the seat, then move backwards until comfortable Standing is the sequence in reverse 2. Reach back for the arms of the chair, one hand at a time The hospital does not provide chairs but advice can be given and the chair can be raised to the correct height.

12 Stairs You will be taught to safely go up and down steps and stairs by your Physiotherapist before discharge always using walking aids to support the operated leg. The sequence is as follows Going up stairs you should place the non-operated leg first, followed by the operated leg, and finally the sticks or crutch. Use the bannister with the free hand, if possible. Going down stairs you should place the sticks or crutches first, followed by the operated leg and finally the non-operated leg. This is often found to be much easier than you think, but with patience and practice you will soon be confident.

13 DISCHARGE HOME. You will be discharged home 5-7 days following your operation. An out patients appointment will be made for you to see the Doctor or physiotherapist 6-8 weeks following your operation. He will want to make sure that you are coping with you new hip. If you have any questions it is a good idea to write them down and bring the list to your appointment. You should not drive your car until you have checked at this appointment that it is all right to do so. If you are being discharged on medication the hospital will give you seven days supply, it will then be necessary for you to contact your own G.P. for another prescription. YOUR RECOVERY AT HOME The success of your surgery will depend on how well you follow your orthopaedic surgeon s instructions regarding home care during the first few weeks after surgery. WASHING You will need someone to help you wash your feet for at least the first six weeks. BATHING & SHOWERING You are advised not to get in and out of the bath for the first six weeks. Following your postoperative appointment with your surgeon please contact the Occupational Therapist if you require any advice about Bath/shower management. A walk in shower may be used earlier if you feel confident to do so. Using a non slip mat is advisable. Remember do not bend down to your feet. DRESSING When dressing sit on the bed or chair. Dressing equipment will be loaned and demonstrated. This will enable you to put on your trousers, pants, socks/stockings and shoes safely without bending. It is easier to put your operated leg into your clothes first. Remember please bring your dressing equipment with you when you come into hospital.

14 DO S AND DON T S FOLLOWING A TOTAL HIP REPLACEMENT. There is a risk of dislocating your new hip replacement. Please read through the list for things that you can and cannot do. DO:- Continue to do the exercises taught to you by the physiotherapist. Stand and sit as shown in hospital. Make sure that you sit on a firm chair that is high enough for you, rather than a low, soft armchair or sofa. When picking up objects from the floor use your helping hand that is given to you by the Occupational Therapist Go to your Doctors if you have any unusual pain, if you develop a temperature or notice any discharge from your wound Take care getting out of bed Activity is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within three to six weeks following surgery. Some discomfort with activity is common for several weeks. Your activity program should include: Graduated walking programs initially in you re home and later outside. Slowly increase your mobility and endurance Resuming other normal activities, sitting, standing, walking up and down stairs. Following your surgery, you should take antibiotics prior to dental work, including dental cleanings, or any surgical procedure that could allow bacteria to enter your bloodstream. Keep a pillow between your legs whilst you are in bed. This will help to prevent your legs from becoming crossed.

15 DO NOT:- Cross your legs or ankles. Bend your operated hip toward your chest more than ninety degrees until your doctor advises otherwise, i.e. do not sit completely upright or bend forwards to pick things up. You must avoid bending down towards your feet. Sit in very low chairs. Be too hasty to cut your toenails or put on your shoes and socks yourself. Use the gadgets which been given to you or get help from someone else DO NOT ROLL OR LIE ON NON- OPERATED SIDE Sit with your legs down for long periods as you may notice your ankles swelling. If possible sit with your legs up and exercise your ankles as shown by the physiotherapist Do too much too quickly, gradually increase your daily activity, as you feel comfortable. Do not twist on the operated leg causing it to turn inward or outward. When walking or turning, you should always keep your toes and knee-cap pointing straight ahead. Take small steps lifting your feet from the floor in order to change direction when walking. It is not advisable to lie on either side for the first 6 weeks. However, turning onto the operated side may be permitted, with the nurses help, for washing purposes and at later dates when sleeping with a pillow between the legs. Do not drive until you have seen your doctor at the out patients appointment, usually 6 weeks after your operation.

16 Four basic precautions (summary):- These precautions will help to reduce the risk of dislocation until healing is completed. There are three basic movements, which should be avoided for at least 3 months after the operation. These precautions apply in all situations including sitting and whilst moving in and out of bed or chairs. DO NOT CROSS YOUR LEGS DO NOT LIFT YOUR KNEE HIGHER THAN THE LEVEL OF YOUR HIPS You must avoid bending down towards your feet. DO NOT TWIST ON THE OPERATED LEG HAZARDS OF RESTING IN BED Risk of blood clots, (thrombosis) Normally your blood moves freely throughout the body without any problems. However, if a blood clot forms in any of the veins in your legs, this is called a Deep Vein Thrombosis (DVT).There are many reasons why a DVT forms, including restricted movement, smoking, taking the pill and a family history of blood clots. Another cause can be that your blood can become more thick and sticky after an operation, a natural response to reduce excessive bleeding from wounds. This, in combination with bed rest and other factors, can make it easier for a clot to form in the legs. The blood clots may arise suddenly and can become extremely serious, making you very ill. If the blood clots in the veins break apart, they can travel to the lung, where they get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. It is better to take number of simple steps to try to prevent the problem before it arises.

17 What can be done to try and prevent a DVT from developing? The most effective way of preventing a blood clot from forming is by keeping active. After your operation you will be advised to get up and about as soon as possible. Until then, you can perform simple foot and ankle exercises that your nurse or physiotherapist can show you. You will be asked to wear specially designed elasticated stocking, which will feel tight on your calves. These apply pressure to your legs, which then increases the blood flow through the veins back up to the heart. It is very important that you continue to wear these stockings for as long as advised that you keep them smooth and never roll them up or down as this will cut off the blood flow. You will also wear a calf pump that will help the blood flow from your legs to your heart. This will reduce the chance for a clot to form. You may be given some anticoagulant therapy, which may be in the form of injections or warfarin tablets daily to help to thin the blood. Pressure sores defined as damage to the tissue caused by prolonged pressure. To prevent them from occurring it is important to change your position regularly and thereby relieve the pressure. You will be nursed on an air bed in order to reduce the risk of developing sore skin. Constipation This is often a problem after you have been starved for an operation and during the period when you are not allowed to get out of bed. It is important that you try to eat plenty of fruit, vegetables and fibre and drinking plenty of fluids. Toileting While in bed you will have to use a bedpan or bottle. When you get out of bed you must sit on a raised toilet seat to prevent dislocation of your hip. The occupational therapist will loan you a toilet raise which you will need for 3 months following your operation. Put your operated leg straight in front of you and one hand behind onto the toilet seat before sitting slowly down. Advice will be given in the hospital.

18 COMPLICATIONS FOLLOWING AN OPERATION AND ANAESTHETIC Chest Infection Following an operation/anaesthetic you are at risk of developing an infection. The physiotherapist will show you some breathing exercises that are to help expand your lungs and prevent any infection. Please remember to do these as often as you can. Dehydration This is prevented by giving you intravenous fluids (a drip). This replaces what you would normally take by mouth whilst you are fasting for your operation. Anaemia This may cause you to feel faint or dizzy after your operation. This is usually associated with the blood loss during the operation.this is the reason why we give you a blood transfusion. Wound infection You will be given antibiotics into your drip at intervals throughout the first 24 hours following your operation. The dressing over your hip will not be removed unless there is any weeping, in order to prevent the introduction of any bacteria. Warning signs of a possible hip replacement infection are:- persistent fever, shaking chills, increasing redness, tenderness, or swelling of the hip wound, drainage from the hip wound, increasing hip pain with both activity and rest. Notify your doctor immediately if you develop any of these signs develop. If left untreated an infection in the wound can lead to further surgery. Urine retention This can occur following an anaesthetic. Sometimes it is necessary to insert a urinary catheter (a tube which drains the urine into a bag). The catheter will be removed as soon as you are able to get out of bed. Dislocation of your hip The risk is greatest for the first 3-6 months after the operation. If you follow all of the instructions that are given to you whilst you are in hospital and use the equipment that we have provided you with, the risk is greatly reduced. M.R.S.A.- you may have heard of this through the media. It is a particular bug that can be difficult to treat as it is resistant to many antibiotics. Many people carry this organism normally, It causes no problems until if finds its way into an operation site. At pre operative

19 assessment clinic you will have swabs taken to determine if you normally carry this organism. Should the swabs be positive to MRSA, you will be referred to your GP for treatment prior to admission to hospital. Should you be found to have M.R.S.A during your hospital stay you will be placed into a room on your own. This is to prevent the passing of the germ to other patients around you. HOW YOUR NEW HIP IS DIFFERENT You may feel some numbness in the skin around your incision. You may also feel some stiffness, particularly with excessive bending. These differences often diminish with time and most patient s find these are minor compared to the pain and limited function they experienced prior to surgery. The operated leg may be slightly longer/shorter than the other. When this occurs the difference may be barely noticable, but sometimes it is necessary to wear a raised shoe on the shorter side. During your surgery there may be some injury or stretching of the sciatic nerve. This may result in foot drop on the operated leg. This can be treated by splinting and maintenance exersises. Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. After surgery, ensure you do the following: Participate in a regular light exercise program to maintain strength and mobility of your new hip. Take special precautions to avoid falls and injuries. See your orthopaedic surgeon periodically for routine follow-up examinations and x-rays. Your orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculo-skeletal system, including bones, joints, ligaments, tendons, muscles, and nerves. Please feel free to ask staff for more information if this booklet has left you with unanswered questions.

20 Useful contact numbers South Warwick General Hospital telephone Pre Operative assessment clinic ext Oken Ward ext Further information As a public organisation the Trust has a statutory obligation to promote race equality. This is set out in the Race Relations (Amendment) Act Our Information for Patients can also be made available in other languages, Braille, audio tape, disc or in large print. PALS We offer a Patient Advice Liaison Service (PALS). This is a confidential service for patients and their families to help with any questions or concerns about local health services. You can contact the service by the direct telephone line on , using the phone links which are available in both hospitals or calling in at the office located at the main entrance at Warwick Hospital. Version 1.0 Dec 2004 Review Dec 2006

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