Total Hip Replacement. Patient Guide

Transcription

1 Total Hip Replacement Patient Guide

2 Table of Contents Introduction...4 Total Joint Replacement Class...4 What Is Total Joint Replacement?...5 Anatomy...5 Rationale for Surgery...5 The Total Joint Team: Who Are They? What Do They Do?...6 The Patient...6 Orthopedic Surgeon...6 Nursing Director...6 Nursing Staff...6 Physical Therapist...6 Occupational Therapist...6 Social Worker...7 Pharmacist...7 Getting Ready for Surgery...8 Visit to the Orthopedic Surgeon...8 Total Joint Replacement Class...8 Blood Donation...8 Pre-admission Testing...8 Insurance and Financial Counseling...8 Advance Directive...9 Spiritual Care...9 Preparing Your Home...9 Checking into the Hospital Admission Reminders...10 Getting Ready to Go to the Operating Room...11 Anesthesia...11 In the Operating Room...12 The Artificial Joint...12 The Operation Blood Transfusions...14 Complications...14 Thrombophlebitis Infection...15 Loosening...15 Dislocation...15 After Surgery Your Hospital Stay...16 Post-Anesthesia Care Unit (PACU)...16 Pain Management

3 3 Patient Guide On the Orthopedic Unit...17 Getting Back on Your Feet...18 Recuperation After Your Hospital Stay...18 Your Home...18 St. Patrick Hospital and Health Sciences Center Outpatient Physical Therapy (Providence Center)...18 St. Patrick Hospital and Health Sciences Center Transitional Care Unit (TCU)...18 Nursing Home...18 Follow-Up Doctor Visits...18 Rehabilitation...20 Weight Bearing...20 Total Hip Replacement Precautions...20 Risk of Dislocation...21 Hip Precautions...21 Anterior Approach Posterior Approach Inpatient Physical Therapy...25 Total Hip Replacement Excercises Using a Walker...28 General Guidelines and Adaptive Equipment...29 Bathing Dressing...30 Toileting...30 Household Safety...31 Furniture...31 Kitchen...31 Carrying Things...31 Car Transfers...32 Dental Work...32 Appendix...33 Phone Directory...34 Preoperative Assessment Worksheet Total Hip Replacement Checklist...37 My Choices: Advance Directive for My Health Care State of Montana Application for Special Parking Permit or License Plates for a Physically Disabled Person Map...44

4 Introduction Arthritis of the hip is a common condition causing pain and impaired lifestyle for many people after middle age. In the past, little was done for the condition. Fortunately, modern surgical procedures can alleviate arthritis of the hip. A total hip replacement is the ultimate solution for advanced hip arthritis. The procedure can help you feel better and move more easily after your recovery. The Total Joint Team at St. Patrick Hospital and Health Sciences Center provides joint replacement services of the highest quality. We want you to be an active participant in our team. That's why we've provided you with this booklet. The chapters that follow explain how to prepare for surgery, what happens during the operation and during your hospital stay, and what to expect as you recover. We strongly recommend that in addition to reviewing the booklet you attend the free, preoperative total joint replacement class offered at the hospital. The class is designed to answer many of your questions about joint replacement surgery. We believe that being well informed about your surgery can improve your recovery and outcome. Total Joint Replacement Class You and your family members or others who may participate in your care are encouraged to attend the total joint replacement class before surgery. You will be contacted by phone to register for the class. If you have not been called, please contact the admissions department at to register. The class covers critical aspects of total joint replacement. Topics include instructions for the day of your surgery operating room procedures post-anesthesia care unit (PACU) procedures nursing care, including equipment and your postoperative routine pain management physical therapy, including your daily activities, exercise program, and rehab choices occupational therapy, including bathing, dressing, use of adaptive equipment, and household activities exercises started preoperatively and continued after surgery planning for continued care after your hospitalization 4

5 What Is Total Joint Replacement? A painful hip can severely affect your ability to lead a full, active life. Total joint replacement, also called arthroplasty, is surgery done to reconstruct a diseased joint. Hip replacement surgery is becoming more and more common as the population of the world begins to age. Over the last twenty-five years, major advancements in hip replacement have improved the outcome of the surgery greatly. Anatomy The hip joint is one of the true ball-and-socket joints of the body. The hip socket is called the acetabulum. It forms a deep cup that surrounds the ball of the upper thighbone, known as the femoral head. The connection of the ball and socket is held in place by the hip joint capsule, a soft tissue sheath that encloses the joint. The hip is surrounded by the thick muscles of the buttock in the back and the thick muscles of the thigh in the front. Artificial Hip Replacement Hip Anatomy The surface of the femoral head and the inside of the acetabulum are covered with articular cartilage. This material is about one-quarter of an inch thick in most large joints. The articular cartilage surface is a tough, slick material that allows the surfaces to slide against one another without damage to either surface. A healthy hip moves without pain. In an arthritic hip, the articular cartilage wears away and leaves the bones unprotected, causing pain and stiffness. Rationale for Surgery The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. Replacing the painful, arthritic joint with an artificial joint gives the joint a new surface that moves smoothly without causing pain. The goal is to help people return to many of their activities with less pain and with greater freedom of movement. 5

6 The Total Joint Team: Who Are They? What Do They Do? Achieving the greatest benefit from total joint replacement surgery takes a team effort. The Total Joint Team works together to help you along the way, making sure you know what to expect and assisting you toward your best recovery. The Patient You and your spouse, family, or significant other are the most essential members of the team. Taking the time to learn about your health and your surgery helps with your recovery. Orthopedic Surgeon Your orthopedic surgeon is the leader of the team. In addition to planning and performing your surgery, your surgeon will work with the other team members to assure your complete and rapid recovery. Feel free to discuss any aspect of your care with your surgeon. Your complete satisfaction is the surgeon's concern. Nursing Staff During your hospital stay, registered nurses and other skilled workers will care for you. Nurses attending you after surgery are specialists in orthopedic care. Each morning you and your nurse will develop a plan for the day. The staff will assist you with personal care activities, such as bathing and changing positions in bed. They will assist you with pain management, medication administration, care of your surgical site, bowel function, walking, and other aspects of your recovery. Physical Therapist The physical therapist focuses on developing your independence by increasing your ability to move with ease. Your therapist will tailor an exercise plan to increase your strength and endurance. You will be shown special ways to walk and move to ensure your safety and protect the new joint while it heals. Occupational Therapist The occupational therapist provides training and recommends equipment for independence in your daily activities. The therapist assesses your physical capabilities and limitations and determines your need for equipment such as a raised toilet seat, hand rails, a reacher, a sock aid, a tub bench, and so on. 6

7 7 Patient Guide Social Worker/Case Manager A social worker or case manager may assist with your discharge from the hospital. The social worker may help plan outpatient physical therapy, home health care, or a short stay at a nursing home, if necessary. They can also assist in helpin you obtain durable medical equipment if needed. Pharmacist The pharmacist helps with pain management and provides information on medications.

8 Getting Ready for Surgery Getting ready for surgery is a process that involves a number of steps. Preparing will make your experience easier. Visit to the Orthopedic Surgeon The decision to proceed with surgery should be made jointly by you and your doctor. The decision should only be made after you feel that you understand as much about the procedure as possible. Talk to your doctor about what is expected of you, such as participation in a rehabilitation program, and which activities should be restricted after surgery. Your doctor will explain the benefits and risks of the procedure. Total Joint Replacement Class The best way to plan for your surgery is to attend the free total joint replacement class at St. Patrick Hospital and Health Sciences Center. The scheduler will contact you with the class schedule. If you have not been contacted, please call the pre-admissions scheduler at to register. Blood Donation You may choose to donate your own blood prior to surgery in case a transfusion is needed while you are in the hospital. This reduces the risk of having an allergic reaction or getting an infection, such as AIDS or hepatitis, from a blood transfusion. Blood can be donated three to five weeks before the operation, giving your body time to make new blood cells before your scheduled surgery. A blood donation requires a physician's order, so discuss it with your doctor. Pre-admission Testing Between two and fourteen days before surgery, you must come to the hospital for preadmission testing. Your doctor may order lab work, X-rays, and possibly an EKG (electrocardiogram). In some situations, your doctor may order the testing done at a facility closer to your home. Insurance and Financial Counseling Most people review their insurance and financial situation before planning a total joint replacement surgery. If you have insurance, the pre-admission nurses can check whether your surgery has been authorized. If you have questions or concerns, our pre-admission nurses are available to assist you at

9 9 Patient Guide Advance Directive An advance directive is a legal document that some patients prepare before surgery. It provides guidance to the health care team about your wishes if you become incapable of making or communicating decisions. An advance directive often appoints a representative to make decisions for you and includes a living will. A sample advance directive is located in the appendix of this booklet. On admission to the hospital, you will be asked if you have an advance directive. A copy of the advance directive will be added to your chart. Feel free to fill out the form at the back of this booklet and bring a copy with you to the hospital when you check in. Spiritual Care Caring for your spiritual needs during your hospitalization is very important. Hospital chaplains are available, and your pastor or bishop is also welcome to visit. Chaplains provide spiritual care and support to patients, families, and staff, both in and out of the hospital. They are especially sensitive to the needs of anyone who is without spiritual care in a congregational setting. Staff chaplains can help with advance directives, family matters, grief and other emotions, faith, and ethical issues. Preparing Your Home Preparing your home for your return after surgery is an important step in the planning process for any total joint replacement surgery. Most importantly, you will need someone who can assist you at home for the first week after you leave the hospital. You and your caregiver should attend the total joint replacement class at the hospital so you can learn the best way to prepare your home for your safety and comfort after the operation.

10 Checking into the Hospital Admission Reminders Avoid food and drink after midnight the night before your surgery. This includes medication, water, gum, and hard candy. An exception to this would be a sip of water with any medication your doctor has asked you to take. Before surgery, make sure your surgeon is informed about any medications you take, especially aspirin, anti-inflammatories, and Coumadin (warfarin sodium). On the day of your surgery, bring with you to the hospital a list of all the medications you take. Include the name of the medication, the dose you take, when you are prescribed to take it, and who prescribes the medication for you. Include all vitamins and herbal supplements. Pack sleepwear for the hospital, including an open-front robe and low-heeled, comfortable shoes with nonslip soles. Also bring loose-fitting clothing for your trip home. Bring your crutches or walker and other adaptive equipment to the hospital so you can practice using these items with your physical or occupational therapist. The therapist will check proper fit and safety. Please mark your full name clearly on any equipment brought from home. If you would like an advance directive added to your medical chart, bring a copy of it with you to the hospital. Plan to report to St. Patrick Hospital and Health Sciences Center Day Surgery two hours before your scheduled surgery time. The family waiting area for orthopedic surgeries is on the fourth floor by the elevators. The orthopedic-surgical unit is also on the fourth floor. The following items should be removed and left with a family member or nurse: all metal objects, such as hair clips or pins partial dental plates and bridges glasses and contact lenses all jewelry. 10

11 11 Getting Ready to Go to the Operating Room Before going into the operating room, you will change into a hospital gown. You will be asked to mark the hip you are having surgery on. The nurses will assist you with this. The hip you are having surgery on will be scrubbed with special cleaners to remove bacteria normally found on your skin. You may be given a pre-anesthetic medication that helps reduce nausea. Patient Guide An intravenous line (IV) will be placed in a vein, most likely in your arm. The IV is used to replace fluids and administer medications, antibiotics, or blood. It is important not to touch or tamper with the tubing or equipment and to report any pain or swelling to your nurse. Anesthesia Just before surgery, the anesthesiologist will review your medical history and briefly examine you. The anesthesiologist will talk to you about which anesthesia he or she feels is best for you. The technique most patients are familiar with is general anesthesia. With general anesthesia, the patient is unconscious during the procedure. The anesthesiologist may administer a variety of drugs and gases to keep you unconscious during the operation. This type of anesthesia requires a machine to breathe for you during the operation. Another anesthetic technique is spinal anesthesia. With this technique, a small needle is used to inject an anesthetic solution into your lower back, near the spinal canal. This numbs the body from the waist down, but you are still awake. You will also be given other medications that make you groggy so you won't know the surgery is going on. An additional option may be the epidural technique. This technique is similar to the spinal anesthesia and involves an injection into the lower spine. A small catheter is placed through the epidural needle to add more analgesic-anesthetic solution during the operation. After surgery, small amounts of medication may be infused through the catheter for one or two days for pain relief. Your anesthesiologist may suggest a modification or combination of any of these techniques and will be glad to explain the pros and cons of each type of anesthetic technique to you.

12 In the Operating Room You will probably talk with your doctor before surgery about the specifics of your joint replacement operation. The overview below describes a typical hip replacement procedure. Ask your doctor if you have any questions about the procedure. The Artificial Joint There are two major types of artificial hip replacements: cemented prosthesis uncemented prosthesis Both are widely used. In some cases, a combination of the two types is used. The ball portion of the prosthesis is cemented into place, and the socket is not cemented. The decision about whether to use a cemented or uncemented replacement hip is usually made by the surgeon based on your age and lifestyle and the surgeon's experience. Each prosthesis is made of two main parts. The acetabular component (socket) replaces the acetabulum. The acetabular component is made of a metal shell with a plastic inner liner that provides the bearing surface. The plastic used is so tough and slick that you could ice skate on a sheet of it without damaging the material much. The femoral component (stem and ball) replaces the femoral head. The femoral component is made of metal. Sometimes, the metal stem is attached to a ceramic ball. Hip Components A cemented prosthesis is held in place by special epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface. Over time, bone grows into the mesh and attaches the prosthesis to the bone. The Operation The surgeon begins by making an incision on the side of the thigh to allow access to the hip joint. Several different approaches can be used to make the incision. The choice is usually based on the surgeon's training and preferences. Once the hip joint is entered, the surgeon dislocates the femoral head from the acetabulum. Then the femoral head is removed by cutting through the femoral neck with a power saw. Femoral Head Removal 12

13 Patient Guide Attention is then turned toward the socket. The surgeon uses a power drill and a special reamer (a cutting tool used to enlarge or shape a hole) to remove cartilage from inside the acetabulum. The surgeon shapes the socket into the form of a half-sphere. This is done to ensure that the metal shell of the acetabular component will fit perfectly inside. Cartilage Removal After shaping the acetabulum, the surgeon tests the new component to make sure it fits just right. In the uncemented variety of hip replacement, the metal shell is held in place by the tightness of the fit or by using screws to hold the shell in place. In the cemented variety, epoxy cement is used to anchor the acetabular component to the bone. Metal Shell Insertion To begin replacing the femur, special rasps (filing tools) are used to shape the hollow femur to the exact shape of the metal stem of the femoral component. Once the size and shape are satisfactory, the stem is inserted into the femoral canal. Again, in the uncemented variety of femoral component the stem is held in place by the tightness of the fit into the bone. In the cemented variety, the femoral canal is enlarged to a size slightly larger than the femoral stem, and the epoxy cement is used to bond the metal stem to the bone. Stem Insertion The metal ball that makes up the femoral head is then attached. Ball Insertion Once the surgeon is satisfied that everything fits properly, the incision is closed. Several layers of stitches are used under the skin, and either stitches or metal staples are used to close the skin. A bandage is applied to the incision, and you are moved to the recovery room. Hip Replacement Hip X-ray 13

14 Blood Transfusions Total joint surgeries sometimes result in extra blood loss, making a blood transfusion necessary during or shortly after surgery. If you have donated your own blood before the operation, it will be available for you. The transfusion can also be done using blood from a blood bank. Blood transfusions are an important part of modern medical therapy. They save many lives every year. Only a small percentage of patients end up needing a blood transfusion. Medical safety procedures have made blood transfusions safer than ever. However, despite great improvements in blood testing, a low level of risk remains with each transfusion, including a very low risk of Hepatitis B, about 1 in 200,000 transfusions a low risk of Hepatitis C, about 1 in 3,300 transfusions a very low risk of acquiring AIDS (HIV), about 1 in 500,000 transfusions To put this in perspective, the risk of being killed in a car accident in any given year is 1 in 11,000. Please note that these risk estimates may have changed since this document was written. Occasionally patients react to a blood transfusion. Symptoms are usually mild and may include fever, chills, hives, or itching. In rare cases, a blood reaction will be severe. As a precaution, your medical team will treat any reaction you may have as potentially severe. The transfusion will be stopped, and additional testing will be performed. Complications As with all major surgical procedures, complications can occur. Some of the most common complications following hip replacement surgery include thrombophlebitis infection loosening dislocation This is not intended to be a complete list of the possible complications, but these are the most common. Thrombophlebitis Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. 14

15 If the blood clots in the veins break apart, they can travel to the lungs, where they lodge in the capillaries and cut off the blood supply to a portion of one lung. This is called a pulmonary embolism. ("Pulmonary" means lung, and "embolism" refers to a fragment of something traveling through the vascular system.) Most surgeons are very serious about preventing DVT. There are many ways to reduce the risk of DVT, but probably the most effective way is getting you moving as soon as possible after surgery. Other 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 Infection can be a very serious complication following joint replacement surgery. The chance of getting an infection following hip replacement is probably around 1 percent. Some infections may show up very early even before you leave the hospital. Others may not become apparent for months or even years after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want you to take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint. Loosening The main reason that artificial joints eventually fail is loosening of the metal or cement from the bone. Great advances have been made in extending how long an artificial joint will last, but most will eventually loosen and require a revision. You can generally expect twelve to fifteen years of service from an artificial hip, but in some cases the hip will loosen earlier than that. A loose prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to fix, or revise, the hip replacement. Dislocation Just like your real hip, an artificial hip can dislocate if the ball comes out of the socket. There is a greater risk just after surgery, before the tissues have healed around the new joint. But there is always a risk of dislocation. Your physical therapist will instruct you very carefully about how to avoid activities and positions that tend to cause hip dislocation. A hip that dislocates more than once may have to be revised to make it more stable. This means another operation. 15

16 After Surgery Your Hospital Stay Post-Anesthesia Care Unit (PACU) You will be moved to the PACU immediately after surgery. There, a nurse specialized in post-anesthesia care will assist you while monitoring your vital signs. You will wake up with your IV line still attached and wearing a bulky dressing on your hip. A drain may have been inserted into your hip to prevent fluid buildup. Pain Management Pain management is an important part of your recovery and starts in the PACU. You play a major role in helping to manage your pain. The PACU nurse will ask you to rate your pain using the "pain assessment scale." On the scale, zero represents no pain, and ten represents the worst pain you can imagine. The nurse will work with you on pain control. Your doctor may order a device called a PCA (patient controlled analgesia) pump. This pump lets you deliver a dose of pain medication by pushing a button. Safety limits are programmed into the pump to prevent you from taking too much medication. Patients usually begin taking pain pills the day after surgery. At first, you will probably need to take them regularly. The nursing staff and pharmacists will help you with pain management. Pain Assessment Scale 16

17 On the Orthopedic Unit Once you have recovered sufficiently from the anesthesia, you will be moved to the orthopedic nursing unit for the rest of your hospital stay. A typical hospital stay after total joint replacement lasts four days or less. The IV line started before surgery will remain in place after surgery. It won't be removed until you can take fluids and pain medication orally and until you've completed any antibiotics or blood transfusions (if needed). The nurses will keep track of your fluid intake (both IV and oral) and also your fluid output (how much you urinate). You may need a catheter placed in your bladder if you can't urinate on your own. A nurse will explain the proper way to cough and take deep breaths. This helps prevent pneumonia by keeping your lungs well expanded and clear. With your doctor's order, the nurse may administer blood-thinning medications (anticoagulants) to help prevent blood clots. A nurse will reposition you approximately every two hours after surgery to stimulate circulation, prevent pressure sores (bed sores), and keep your lungs clear. The large dressing on your hip will be checked frequently and changed according to your doctor's orders. You will be served well-balanced meals so that your body will have the nutrients it needs for proper healing. Maintaining adequate fluid intake is very important for good digestion. Even with good nutrition and fluid intake, constipation is a common side effect of inactivity and pain medication. Please let the nurse know if you have any special routine or medication for your bowels. The nurse will be glad to assist you. An occupational therapist and a physical therapist will visit you on the orthopedic unit. You will be taught safe methods of transfer (getting in and out of bed, standing up and sitting down, and so on) and how to shower and dress safely. You will begin walking with your physical therapist the day after surgery unless your doctor orders otherwise. (See the "Rehabilitation" section of this booklet for more information.) 17

18 Getting Back on Your Feet Recuperation After Your Hospital Stay After your stay in the hospital, you will probably complete your recovery in one of four places, depending on how much care you need. Your physician, therapists, social worker, and nursing team will help you and your family decide on the best choice for you. Patient Guide Your Home We hope you are among those patients who can return directly home. Some people require no further assistance at all, while others may need additional physical or occupational therapy, nursing care, or home maintenance. All of these are available through home health care agencies. We feel the best place for you to recover is in your own home, and we will make every effort to get you there. St. Patrick Hospital and Health Sciences Center Outpatient Physical Therapy (Broadway Building) You may benefit from additional therapy at an outpatient rehab program. The Total Joint Team will make this recommendation if it seems appropriate for you. You will still go home but will return to the physical therapy center two to three times per week. St. Patrick Hospital and Health Sciences Center Transitional Care Unit (TCU) This unit is located on the fifth floor of St. Patrick Hospital and Health Sciences Center. It is designed for patients who need additional rehabilitation before returning home. The Total Joint Team may recommend that you stay a few extra days until you are ready to go home. A stay on the TCU can range from three to twenty-one days. Nursing Home If you require a rehabilitation stay of longer than twenty-one days, a nursing home may be the best choice for you. There are a variety of nursing homes in and around Missoula. If you don't live in Missoula, you may want to choose a nursing home in your own community. The Total Joint Team can help arrange your transfer to one of these facilities. SPH Inpatient Rehab (Providence Center) Follow-Up Doctor Visits In any of the above settings, your doctor will continue to monitor your progress. Once you return home you should continue to practice all the precautions you have been 18 taught for another six to eight weeks.

19 Your doctor should be notified of any of the following: temperature above one hundred degrees Fahrenheit infection anywhere in your body redness, swelling, or drainage from the surgical site any openings in your incision questions about medication such as Coumadin (warfarin sodium), Lovenox Patient Guide (enaxaparin sodium), or aspirin chest pains or shortness of breath increased pain in the operated hip pain, swelling, or tenderness in either calf Ask your surgeon when you can resume driving, bathing, swimming, and other physical activities.

20 Rehabilitation A well-planned rehabilitation program is essential for optimum recovery. You will learn as you go, and the goal will be getting you back to your normal activities. It is very important for you to discuss your individual goals with your physician and the rest of the Total Joint Team. Recovery can be demanding and sometimes painful. Therefore, we feel it is essential that you are a part of the team and that you feel good about your progress. Getting safely back in motion will involve walking with crutches or a walker going up and down stairs maintaining healthy posture and body alignment avoiding certain positions if necessary, especially while bathing, dressing, and working learning the best way to move while walking and sitting learning how to change positions while sitting, standing, and lying down learning to use adaptive equipment performing regular exercises for strength and endurance The Total Joint Team will teach you about the things you can do, things to avoid, and approaches to daily activities. Always ask before doing something you are unsure about. Weight Bearing The amount of weight you can put on the foot of your operated leg after surgery will depend on your doctor and the procedure used. If a cemented procedure was used, your doctor may recommend placing a comfortable amount of weight through your operated leg after surgery using your walking aid. If the surgery was done without cement, you may be directed to place only the toes of the operated leg on the ground for four to six weeks after surgery. Total Hip Replacement Precautions Hip surgeries such as total joint replacement require the surgeon to open the hip joint capsule and cut some of the ligaments around the hip joint. Until these ligaments heal, the hip is at risk of dislocating. You need to follow special precautions about hip positions and movements to avoid after surgery in order to keep the hip safe. While you are in the hospital, your health care team will remind you often about the need to follow these hip precautions. They may place a sign by your hospital bed as a reminder. Once you get home, you will have to remember to follow these rules until your surgeon approves motion beyond these limits. This usually happens six to twelve weeks after surgery. 20

21 Posterior Approach The main positions and movements to avoid after a posterior approach include crossing your legs, turning your hip and leg inward, or bending the hip more than ninety degrees. Don't cross your legs. When sitting, do not cross your operated leg. When lying on your back, don't roll your operated leg toward the other leg as you might do when rolling over. A pillow or triangularshaped wedge may be used to block the legs from crossing. Don't roll your leg and foot in. Use a pillow or wedge between your legs when lying in bed to keep your leg from rolling inward. Use a Pillow to Keep from Crossing Legs Don't allow the knee of your operated leg to cross the midline of your body. Your knee shouldn't move across your body past your belly button. When lying in bed, place pillows between your legs to keep your hip in the correct position. Use a Pillow to Avoid Rolling Leg Inward Don't turn your upper body toward your sore hip. When sitting, swivel your whole body rather than just your upper body. Proper Pivoting While Sitting 23

22 Don't twist your body toward your operated hip. This means you can't stand pigeon-toed. Keep the toes of your affected leg pointed forward when you stand, sit, or walk. If you turn your body in the direction of your operated hip without pivoting your foot, your hip will be placed in an unsafe position. Remember to lift and turn your foot as you turn in the same direction as your surgical hip. Do Not Twist Your Body Don't bend the hip past ninety degrees. This means do not lean too far forward when sitting up in bed. Sitting Up in Bed Also, raising your knee as you lie in bed can cause the hip angle to go past ninety degrees. Raising Leg in Bed To avoid bending past ninety degrees when sitting in a chair, lean back slightly. Avoid Bending Past Ninety Degrees 24

23 Don't bend over past ninety degrees at the waist. Your hip may go past ninety degrees if you bend over at the waist to tie your shoes or pick up items off the floor. Instead, use elastic shoelaces and a reacher. (See "General Guidelines and Adaptive Equipment" for more information.) Avoid Bending Past Ninety Degrees Inpatient Physical Therapy The first inpatient physical therapy visit gives your physical therapist an idea of how well you can move in bed and how safe you are getting up and sitting on the edge of the bed. Your therapist will also see whether you can begin to walk using a walking aid, putting the right amount of weight through your foot. You may do a few exercises in your hospital room on the first visit. Your therapist will demonstrate exercises to begin toning and strengthening the thigh and hip muscles. Ankle and knee movements may be used to help pump swelling out of the leg and prevent blood clots from forming. A 25

24 Total Hip Replacement Exercises After surgery, you should do only those exercises recommended by your doctor or physical therapist. The type of procedure used will determine the exercises. The exercises are designed to achieve a variety of goals. Some exercises help control pain and improve movement in the hip. Other exercises strengthen the thigh muscles. Extra pain felt after these or other exercises is a signal that you are overdoing it. You may need to change the number of repetitions, the amount of pressure, or how often you do the exercises. Caution: Do only the exercises approved by your therapist. Patients who have had a posterior approach should avoid exercise number seven. 1. Ankle Pumps: Slowly paddle your feet by bending your ankles up and down. Quad Sets Ankle Pumps 2. Quad Sets: With your knee straight, tighten the muscles on top of your thigh by pressing the back of your knee down toward the bed. Hold the contraction for five seconds. 3. Gluteal Sets: While lying on your back, tighten your buttock muscles. Hold tightly for five seconds. Gluteal Sets 4. External Rotation: While lying on your back, roll your foot and thigh out away from the other foot, as shown below. Return to the starting position. (Do not do this exercise if your surgeon used an anterior approach.) 26 External Rotation

25 Patient Guide 5. Heel Slides: Lying flat on your back, bend your knee by sliding your heel back toward your buttocks. Try to increase the bend in your knee a little more with each repetition, but avoid bending your hip further than ninety degrees. Heel Slides 6. Short Arc Quads: With your knee bent over a towel roll, straighten your knee by tightening the muscles in the front of your thigh. Hold for five seconds, and then lower your foot back down. Short Arc Quads 7. Hip Abduction: Lying flat, tighten the muscles in the front of your thigh. Lock your knee, and move the operated leg out and then back to midline. Hip Abduction 8. Straight Leg Raises: With one knee bent to take the strain off your lower back, tighten the muscles in the front of your other thigh. Lock your knee, and raise the leg twelve inches off the bed. Hold for five seconds, and then lower your leg back down. Straight Leg Raises Hip Bridges 9. Hip Bridges: Lie on your back with your knees bent, feet flat on the bed, and your arms at your sides. Tighten your abdominal and buttock muscles as you lift your buttocks off the bed. Hold for five seconds. Relax, returning to the starting position. 27

26 Using a Walker Using a Walker on Level Surfaces Do 1. Advance the walker. 2. Step up to the walker with your operated leg. 3. Step forward with your nonoperated leg, using your arms to bear most of your weight. Correct Use Do Not Don't step until all four legs of the walker are firmly placed on the floor. Incorrect Use Using a Walker on Stairs To go up or down stairs with a walker, you will either need to use a handrail or have someone support you on one side. Be sure to bear only the correct amount of weight on your foot. 1. Place your walker sideways with the opening toward you. 2. Firmly grasp the rail with one hand and the walker with the other. Stepping Up Step with your nonoperated leg, and then follow with your operated leg to the same step. Stepping Down Step down with your operated leg, and then follow with your nonoperated leg to the same step. You will progress to crutches or a cane within four to six weeks, with the approval of your physician and physical therapist. 28 Upstairs Downstairs

27 29 Patient Guide General Guidelines and Adaptive Equipment During your recovery, follow these general guidelines. Use crutches or a walker with appropriate weight bearing until your doctor tells you otherwise. Keep walking distances within your tolerance. Use caution around pets when using crutches or a walker. Enjoy sexual relations, being careful that you and your partner avoid certain body positions. Your therapist and physician will be able to answer specific questions for you, and information will be available at the total joint replacement class. Following are specific guidelines for different activities and areas of your home. Some activities, such as bathing, may require special equipment during your recovery. This adaptive equipment is available at medical supply stores. Certain items, such as tub transfer benches, may be rented. Bathing You can stand in the shower with the aid of your walker, or you may find it easier to sit on a chair. You may rent a shower chair from a medical supply store, but any sturdy, abovethe-knee, waterproof chair will do. Consider using safety friction strips or a rubber mat on the floor of the shower or bathtub, a portable grab bar on the wall, and a long-handled sponge. You may also find a hand-held showerhead very helpful. Soap on a rope prevents you from having to reach down and pick up the soap if you drop it. Shower Transfers: For a shower that you need to step up into, place your walker in the shower first. Follow with the nonoperated leg, then the operated leg. In the bathtub, use a stool or a tub transfer bench. When you first try the bench, be sure your knees are positioned slightly lower than your hips. This way, you'll be sure to keep your hip from bending more than ninety degrees while sitting down. Because one pair of the bench's legs sit in the tub while the other pair is outside the tub, you can slide across the seat and avoid the potentially hazardous situation of stepping over the tub wall.

28 Tub Transfers: Caution: DO NOT SIT IN THE BOTTOM OF THE TUB! 1. Using your walker, back up to the tub. 2. Reach back for the chair or bench while the other hand remains on the walker. 3. After you sit, lean back, and lift your legs into the tub. 4. Dry off before leaving the shower or tub, or use a cotton bathrobe to soak up water. 5. To get out of the tub, lean back, lift your legs over the side, and stand up with the aid of your walker. Leave your crutches or walker outside of the tub on a nonslip surface such as a rubber-backed mat. Tub Transfer Dressing Before your surgery, store comfortable, loose-fitting clothing in a convenient place that is easy to reach. When dressing, do not bend over or raise or cross your legs. Also, do not stand on one foot to put on your pants. Get help with putting on pants, skirts, shoes, or socks, or use adaptive equipment such as a shoehorn, sock aid, or reacher. To use a sock aid, pull the sock over the form, insert your foot, and pull the two straps to bring the sock over the foot. Sock Aid A reacher can be used to pick up items from the floor. Wear stretchy socks and flat-heeled, slip-on shoes. Avoid twisting your foot as you place it in the shoe. If you have only tie shoes, elastic shoelaces can eliminate the task of tying laces. Using a Reacher Toileting A toilet can be elevated with a raised, locking seat to prevent your hip from bending too far when you sit down. Getting on and off the toilet seat may be easier with the help of securely fastened handrails (a toilet safety frame) or grab bars. Elevated Toilet 30

29 31 Patient Guide Household Safety Take care to avoid potential hazards. Put throw rugs away. Keep clothes off the floor. Keep electrical cords out of your path. Be aware of telephone wires and bedspread corners. Be wary of spills on the floor and snow and ice on steps. (Spread sand or rock salt outside.) Leave heavy housework to someone else. Do not stand on a stool, chair, or stepladder. Make your bed accessible from both sides. Furniture To prevent your hip from bending beyond ninety degrees, you may need to elevate your couch or chair. Reclining chairs and rocking chairs are often difficult to get out of, and you should avoid them. Instead, sit in a tall, high-backed chair with armrests. A good rule of thumb is to have a seat height that is at least twenty inches above the floor. If you find that your furniture is too low, consider using a platform under your chair or couch to raise it to the desired height. Using four-by-four blocks may be helpful, but be sure that the chair or couch is safe and steady before you sit down. You may also use pillows or firm cushions to elevate the seat height of chairs. Similarly, you may want to raise your bed by placing bricks or wooden blocks under the legs of the bed or by adding an extra mattress. Ensure that your bed is stable after you make these adjustments. Kitchen To avoid excessive bending and lifting, arrange your kitchen shelves and cupboards with frequently used items at waist to shoulder height. For lighter items on lower shelves, be sure to have your reacher handy to keep from bending over too far at the hip. You may want to freeze meals and store groceries before your surgery to make things easier for the first week or two after you return home from the hospital. Carrying Things A great variety of packs and pouches are available to help you carry things. They come with handles, straps, and assorted compartments. They are available at sporting goods stores. If you carry a thermos, get one with a handle. Around the house, an apron or jacket with several large pockets will prove helpful. A front wheel walker tray clips onto a walker and allows you to carry items as you walk.

30 Car Transfers For your trip home from the hospital and other trips you make right after your surgery, use a vehicle that is easy to get in and out of. The vehicle should have large doors and high, comfortable seats. Add firm cushions or pillows to raise the seat, if needed. Avoid pickup trucks and sport-utility vehicles with elevated running boards that make the vehicle difficult to get into. Plan in advance the closest and clearest path between the passenger side of the vehicle and the door you'll use to enter your home. Wear slick clothing or sit on a plastic bag to assist with sliding. Car Transfer While getting into the car, don't attempt to swing your operated leg into the car in one motion, and don't attempt to put equipment into the car by yourself. 1. Have the car parked several feet away from the curb. 2. Step off the curb, and back up to the car. Give your walker or crutches to the person helping you. 3. Reach for the seat with one hand, and hold onto the dashboard with the other. Lower yourself slowly onto the seat. Lean back while sliding yourself back and across the seat. 4. Bring your legs into the car by alternately moving each leg a few inches at a time with your hands. 5. Continue this until you are facing forward. 6. Reverse this procedure to get out of the car. Dental Work Artificial joint replacement patients may need to take antibiotics whenever they have certain dental procedures. This helps prevent an infection from occurring in the artificial joint. Bacteria that live in the mouth can be released into the blood stream during dental work and may spread to the joint. Discuss this with your orthopedic surgeon, and notify your dentist and primary care provider. 32

31 Appendix Phone Directory Preoperative Assessment Worksheet Total Hip Replacement Checklist My Choices: Advance Directive for My Health Care State of Montana Application for Special Parking Permit Map 33

32 Phone Directory St. Patrick Hospital and Health Sciences Center Main Operator Admissions Office and Scheduling Financial/Authorization Nurse Physical Therapy/Occupational Therapy Orthopedic Unit (4 South) Nursing Director Outpatient Rehab Services Pastoral Care SPH Inpatient Rehab Gym Home Health Care Agencies Partners in Home Care Missoula Hamilton Interim Healthcare Missoula Hamilton West Mont Home Health Care Missoula Blood Bank American Red Cross (Missoula) Lorraine Martin, Special Services Coordinator American Red Cross (outside Missoula, call for the nearest location)

33 My Choices Advance Directive for My Health Care Print your full name, Date of birth, and Social Security Number. These directions apply only in situations when I am not able to make or communicate my health care choices directly. [Put an X through any sections you are not completing at this time.] I. Health Care Representative (Power of Attorney for Health Care) My Representative may make ALL health care decisions for me as authorized in this document and shall be given access to all my medical records. This appointment applies whether I am expected to recover or not. I wish to appoint a Representative: Yes No [Go to Part II.] A. I appoint as my Representative. Print Representative s Full Name Representative s Address City State Zip Home Phone Work Phone My Representative s authority is effective when I cannot make health care decisions or communicate my wishes. I may revoke this authority at any time I regain these abilities (unless my attending physician and any necessary experts determine I am not capable of making decisions in my own best interest). If, for any reason, I should need a guardian of my person designated by a court, I nominate my Representative, or Alternate Representative(s), named below. B. Alternate Representatives If 1) I revoke my Representative s authority; or 2) My Representative becomes unwilling or unable to act for me; or 3) My Representative is my spouse and I become legally separated or divorced, I name the following person(s) as alternates to my Representative in the order listed Address Address City ST Zip City ST Zip Home Ph Work Home Ph Work Version 2.0 7/98 Witness and Notary on Page 3

34 II. Terminal Conditions (Living Will) I provide these directions in accordance with the Montana Rights of the Terminally Ill Act. These are my wishes for the kind of treatment I want if I cannot communicate or make my own decisions. These directions are only valid if BOTH of the following two conditions exist. IF: 1) I have a terminal condition; AND 2) In the opinion of my attending physician, I will die in a relatively short time without life sustaining treatment which only prolongs the dying process. I authorize my Representative, if I have appointed one, to make the decision to provide, withhold, or withdraw any health care treatment. General Treatment Directions [Check the boxes that express your wishes.] I provide no directions at this time. I direct my attending physician to withdraw or withhold treatment that merely prolongs the dying process. I further direct that: [Check all boxes that apply.] Treatment be given to maintain my dignity, keep me comfortable, and relieve pain even if it shortens my life. If I cannot drink, I do not want to receive fluids through a needle or catheter placed in my body unless for comfort. If I cannot eat, I do not want a tube inserted in my nose, mouth or surgically placed in my stomach to give me food. If I have a serious infection, I do not want antibiotics to prolong my life. Antibiotics may be used to treat a painful infection. I have attached additional directions regarding medical treatment to this form. I have not attached additional directions to this form at this time. III. I have a Chronic Illness or Serious Disability (Optional) My chronic illness or disability can complicate an acute illness, but should not be misinterpreted as a terminal condition. A. Diagnosis: B. Consult my physician. [Name, phone] C. Special directions. [Use additional pages if necessary.] Witness and Notary on Page 3