HIP JOINT REPLACEMENT

HIP JOINT REPLACEMENT Information for Patients WHAT IS HIP JOINT REPLACEMENT? The hip joint is a ball-and-socket joint formed by the upper part of the thigh bone (femoral head) and a part of the pelvis (acetabulum). It is the largest joint in the body and allows movement in several directions. Total hip replacement is a surgical procedure that involves replacing the hip joint with an artificial socket and an artificial upper part of the femur. The most common cause of damage to the hip joint is osteoarthritis; less common causes are inflammatory arthritis (rheumatoid or psoriatic arthritis), developmental disorders (dysplasia of the hip, Perthes' disease), previous injury or bacterial inflammation. The patient s main symptoms are pain, limitation of motion and loss of function in the hip. Hip joint replacement is performed when all non-operative and all other surgical treatment options have been exhausted. Since the replaced parts of the joint can wear out over time, we generally advise patients to postpone the operation as long as possible. WHAT ARE THE EXPECTED BENEFITS OF HIP REPLACEMENT SURGERY? Total hip replacement is expected to relieve pain in the hip and improve mobility. The majority of patients are able to carry out their usual activities as early as 3 to 6 months of the operation. Walking, cycling and swimming are beneficial for patients with an artificial hip joint, but more intensive and strenuous sports (jogging, tennis, alpine skiing, riding, contact sports, football or basketball) are generally not recommended. Most patients are very satisfied with the outcome of surgery, and most of them are able to maintain adequate pain-free mobility in their hips for at least 10 to 15 years or longer. 1

WHAT ARE THE RISKS OF HIP REPLACEMENT SURGERY? Serious complications after total hip replacement are uncommon. In most patients, the benefits of the procedure outweigh its risks. However, complications can occur during the operation, during the hospital stay, or several years after the operation. Before deciding on surgery, you must be aware of possible risks. - Bone fracture and nerve or blood vessel damage can occur during the procedure. Most of these complications are successfully treated directly after their occurrence. - Blood loss during and after the operation does not usually exceed 500ml. Greater blood loss requires replacement by transfusion. - Hip surgery slightly increases the risk of blood clot formation (deep vein thrombosis, pulmonary embolism). With preventive measures (medication, compression stockings, early mobilisation), blood clots occur in only about 1% of patients. - Bacterial infection of a total hip prosthesis is a rare complication with serious consequences, which occurs in 0.4 to 1.5% of patients. It can develop several years after surgery as a result of blood-borne spread from a distant site. Infections are prevented by the use of antibiotics during and sometimes also after the operation. Infection is treated with antibiotics given through an intravenous infusion, and it often requires additional surgery. - Dislocation of the artificial joint occurs in less than 2% of patients. In most cases, the surgeon can put the femoral head back into place while the patient is given a mild anaesthetic. Occasionally, reoperation is required, and parts of the prosthesis must be replaced. To keep the artificial joint from dislocating, the patient must follow special precautions. - The operation can result in leg length inequality. In some patients, the operated leg must be lengthened to prevent dislocations of the artificial joint after the operation. Patients with a considerable difference in leg length are advised to wear a lift on the shoe on the shorter leg. - Loosening of the prosthetic joint may develop several years after implantation as a result of wearing out or infection of its components. 2

- Fracture of a bone or a part of the prosthesis can occur as a result of fragility of the bone or decreased endurance of the prosthesis, usually several years after the procedure. - Stiffness in the joint after the operation can be a consequence of several factors, e.g. contracted tendons and muscles about the hip or, less frequently, bone formation within the soft tissues (heterotopic ossification). Some patients are referred to a rehabilitation centre after the procedure. In most cases, however, this is not recommended because of the risk of dislocation. ARE THERE ANY ALTERNATIVES TO SURGERY? If you decide not to have hip joint replacement surgery, you can expect the pain and loss of motion in your hip to grow worse over time, which means that you will eventually need to use a walking aid and take pain medication on a regular basis. The operation cannot improve your overall health, and your deciding against it can have no life-threatening consequences. Nonsurgical treatment for osteoarthritis of the hip includes: - weight reduction or maintenance of a healthy body weight; - physiotherapy; - use of walking aids (crutches, walking stick); - anti-pain and anti-inflammatory medication; - hip joint injections for pain relief. Patients with rheumatic diseases (e.g. rheumatoid arthritis) also receive special antirheumatic drugs. HOW SHOULD YOU PREPARE FOR ADMISSION TO HOSPITAL? While you are still waiting for your surgery at home, it is advisable that you regularly perform stretching and range-of-motion exercises for the affected hip. With stronger muscles, you will make faster progress in your rehabilitation after the operation. It is important that you 3

maintain your body weight at an ideal level or reduce it if necessary, since excessive body weight significantly increases the risk of surgical complications. Before your hip replacement operation, you will need to see an internist, who will decide if you are fit for surgery. This is especially important if you suffer from a chronic medical condition. You will also see an anaesthesiologist, who will explain the anaesthetic procedure and possibly recommend additional tests or medication to be taken before the operation. You will need to undergo some basic blood and urine tests and a chest x-ray to rule out any inflammation or other major abnormality. The method of blood conservation will need to be discussed. The most frequently used methods are preoperative donation of autologous blood, perioperative blood salvage (i.e. collection and reinfusion of the patient's own blood), and treatment with erythropoietin, which stimulates the production of red blood cells. In this way the need for allogeneic blood transfusion is restricted to emergency cases. The abovementioned methods are safer because the risk of disease transmission and allergic reaction is smaller. You might consider making some changes in your home to make your return from the hospital easier. For instance, change the position of your bed or reorganise the shelves in your kitchen and wardrobe to make them more accessible. Sitting in low seats must be avoided after a hip replacement. You may need to put an extra cushion on your armchair and use a raised toilet seat. WHAT HAPPENS ON THE DAY OF SURGERY? You will be admitted a day before the operation. You should bring to the hospital your health insurance card and a referral note and findings received from your primary care doctor. You will be asked to sign a consent form for anaesthesia and surgery, and you will meet with your surgeon, who will answer any questions you may have. On the day before the operation, you will be given a laxative to cleanse your bowel. You will fast (have nothing to eat or drink) for at least 6 hours before the procedure. In the morning of the day of the operation, you will take only those of your regular medications that have been approved by your doctor. You will be asked to remove all jewellery, and you will take a bath or a shower. During the morning ward 4

round, as a safety precaution, the doctor will mark the lower limb on which the operation is to be performed with a pen. A nurse from the ward will take you to the operating suite and leave you with the anaesthesia team. An anaesthesiologist and a nurse anaesthetist will check your identity and prepare you for the operation. Hip replacement surgery is performed in the operating theatre under general anaesthetic, with the patient fast asleep, or under local anaesthetic, which numbs the lower half of the body, from the waist down. HOW IS THE OPERATION PERFORMED? The operation takes about 60 to 80 minutes. An incision is usually made on the outer side of the hip and thigh. Its length depends to a considerable extent on the thickness of the subcutaneous fatty tissue on the hips. At the beginning of the procedure, the upper part of your thigh bone with the ball (femoral head) and the damaged surface of the socket in your pelvis (acetabular cup) are removed. The femoral and the pelvic components of the prosthesis are then inserted into the prepared bones. The choice of the type of prosthesis depends on the biological condition of the patient and the hip joint, firmness of the bones, the patient s age, and individual needs. Different types of hip prostheses are available. They are divided into cemented prostheses, suitable for elderly patients and patients with osteoporosis, and uncemented prostheses, suitable for young and active patients. Every type of prosthesis has its advantages and shortcomings. The selected device must give the optimal result for the patient. HOW LONG WILL I NEED TO STAY IN HOSPITAL? The length of the hospital stay depends on a number of factors. If there are no complications, most patients complete their rehabilitation programme in 6 to 8 days. After the operation, you will spend a short time in the recovery room and then in the intensive care unit (ICU), where you will receive infusions of fluids, pain medication, and occasionally an antibiotic to prevent infection. On the first day, you will be given medication to prevent 5

blood clots from forming in your legs and lungs. You will start doing exercises to prevent cardiorespiratory complications. Physiotherapy is an important part of the rehabilitation process. With the help of a physiotherapist, you will learn to sit up and stand up without help and to walk with support. You will perform exercises to improve mobility in your hip and strengthen the muscles about the joint, and you will practice activities of daily life. At discharge, you will be able to walk independently on level ground and to climb up and down stairs on crutches. During your hospital stay, your wound dressings will be changed regularly, and blood tests will be performed as required. You will be taking all your regular medication, with the exception of diuretics (drugs that increase the excretion of water from your body) and certain anti-hypertensives (blood pressure lowering drugs) on the day of surgery and in the first postoperative days. Detailed instructions will be given to you by your doctor. You will continue to receive anticoagulant therapy, and you will be taught to administer the injections yourself. WHAT SHOULD YOU DO AFTER DISCHARGE FROM HOSPITAL? After discharge, your dressings will be changed regularly every two to three days by your primary care doctor, who will also remove the sutures or clips from your wound about 12-14 days after the operation. After returning to your home environment, until the first follow-up appointment with your orthopaedic surgeon (1-2 months after the operation), it is advisable that you walk on two crutches, bearing no weight on the operated leg. In this period, you must continue to wear compression stockings. You should remain on anticoagulant therapy until the 35th postoperative day, and take your pain medication only when needed. It is important that you carry on with the exercises you have learned, and that you avoid sitting on low chairs and crossing your legs, which may cause your artificial hip to dislocate. To prevent this, tall patients are given a prescription for a raised toilet seat. Special care is needed when getting into a car or sitting down on a low chair, squatting, lying on your side, bending forward, picking up objects from the ground, and putting on shoes. 6

You can start driving once your muscles are strong enough to allow safe pressing on the pedals usually no sooner than 10 weeks after the operation. The same restriction applies to sexual activity, household chores, gardening, bowling, and swimming. Ask your surgeon during your first follow-up visit when you may resume these activities. WHO SHOULD I CONTACT IN CASE OF DIFFICULTIES AFTER DISCHARGE? If you have any kind of difficulties after discharge from the hospital, first consult your primary care doctor or, outside regular working hours, the doctor on duty at the community health centre. When seeing a doctor, always bring with you your discharge summary from the hospital. In case of a major complication, your doctor will arrange an urgent appointment with an orthopaedic surgeon. Consult your doctor if you notice any signs of infection in the operated area, such as redness, heat and swelling, or if your wound starts to leak fluid. If a bacterial infection is suspected, you may not take any antibiotics before seeing an orthopaedic surgeon. 7