Notes Total hip replacement A total hip replacement is a surgical procedure that replaces your hip with an artificial hip (prosthesis). Your hip is a ball-and-socket joint where the thighbone (femur) meets the pelvis. This joint is surrounded by cartilage, muscle and ligaments that allow it to move smoothly. In a healthy hip, smooth cartilage covers the ends of the thighbone and pelvis. This allows the ball to glide easily inside the socket so you can walk without pain. Conditions such as arthritis, old fractures, and aging may cause changes in the joint surfaces, creating pain and stiffness when you move your hip. In a problem hip, the cartilage becomes worn and no longer serves as a cushion. As bones rub together, they become irregular, with a surface like sandpaper. The ball grinds in the socket when you move your leg, causing pain and stiffness. We want you to know as much as possible about your hip surgery. This booklet helps explain the total hip replacement procedure, recovery and rehabilitation. Diseased head and hip socket Acetabulum (hip socket) Head of femur Neck of femur 16 Total Hip Replacement Total Hip Replacement 1
Total hip replacement (cont.) When a natural hip must be replaced, your surgeon uses an artificial hip joint (prosthesis). The surgery you have depends on your age, the amount of damage and your medical history. Like your own hip, the prosthesis is made of a ball and socket that fit together to form a smooth joint so you can walk easily and without pain. Usually, a metal ball replaces the head of the thighbone. A plastic cup replaces the worn socket. The ball includes a stem which is inserted into the bone for stability. All parts have smooth surfaces for comfortable movement once you have healed. Hip Precautions (cont.) 2. DO NOT allow your legs to rotate inward when lying, sitting or standing. DO keep your kneecap and foot pointed forward. Inserted into femur DO NOT turn your operated leg inward (pigeon-toed). Fits into hip socket 3. DO NOT cross legs at knee or ankles in lying, sitting or standing positions. Area of bone removed Hip socket Side view Femur Prosthesis inserted into femur Back view DO place a pillow between your legs while lying on your back or side. DO NOT cross your legs at the knees or ankles. 2 Total Hip Replacement Total Hip Replacement 15
Hip Precautions The muscles around your new hip will be weak from the surgery. Your surgeon will choose to replace your diseased hip either from the back (posterior approach) or from the front (anterior approach). Depending upon the type of approach your surgeon uses you may have precautions that you need to follow. If your doctor prescribes hip precautions for you, there will be three positions you must avoid to prevent your new hip from sliding out of place (dislocating). It may take six to eight weeks for your muscles to heal. Your surgeon will tell you when you no longer have to follow these precautions. The most common hip precautions are for a posterior approach. Please note that these precautions may not apply to you (depending on the type of surgery you had done and your doctor s orders). Once you are in the hospital, your therapist will help teach you how to move using any prescribed precautions. Please check with your doctor for clarification if you have any questions. POSTERIOR HIP PRECAUTIONS: 1. DO NOT allow your hip to bend more than 90 degrees in lying, sitting or standing positions. Getting Ready for Surgery Poudre Valley Hospital has classes available that you can take before your surgery to help you prepare for the operation and your recovery. Ask your nurse about the class schedule, or call PVH s Regional Orthopedic Center, 970.495.8260. An appointment is scheduled with a PVH pre-admission nurse before the procedure. You are asked questions about your medical history and allergies. Bring a list of all medicines you currently take so the nurse can review them with you. This list should include the name of the medications (indicated if the prescription is written with an EX-ER or SR), the dose that you take and how many times a day you take that medication. This should also include all vitamins, herbs, supplements and over-the-counter medication you take routinely. Your doctor may order: Visits with other doctors. Blood and urine tests. X-rays. Electrocardiogram (EKG). Completion of any needed dental work at least one month prior to surgery. DO sit so that your hip is higher than your knee. Keep repaired leg in front to stand up or sit down. DO sit on surface that is 1-2 inches above bend in the knee. Medications List all medications you are taking (include prescription, over-the-counter, herbal or natural products, vitamins, and drugs you take as needed, such as Tylenol). Include the name, dosage and when you take each medication. Cross off any medications your doctor has told you to stop taking. We prefer if you leave your medications at home, but if you bring them, they must be in their prescription bottle. Supplements must be in new, unopened bottles. Medication: Dose: Directions (when and how often you take it): Doctor name: Reason for taking: Correct Benacar Hct 20/12.5 by mouth daily Incorrect Benacar Hct 20 by mouth daily Correct Albuterol 0.083% 2 puffs every 4-6 hours as needed Incorrect Albuterol 2 puffs by mouth daily Correct Vitamin C 500 mg by mouth daily Incorrect Vitamin C 1 by mouth daily DO NOT bend forward more than 90 degrees. 14 Total Hip Replacement Total Hip Replacement 3
Exercises before your surgery These exercises will help prepare you for a successful surgery. We recommend that you do 10 repetitions of each exercise, three times per day prior to surgery. Performing exercises with both legs will help with recovery. Avoid the exercises if they cause an increase in pain. CHAIR PUSH-UPS Sit straight in a chair with your hands on the armrests. Straighten your arms and raise your bottom off the chair. (Don t use your legs to help.) Slowly lower yourself back to the chair. GLUTEAL SETS. Squeeze your buttock muscles together. Hold for a count of five. Relax. QUAD SETS Lie flat on your back. Tighten the quadricep muscles above your knee by pushing the back of your knee down toward the bed. Hold for a count of five. Relax. Repeat. After Your Discharge (cont.) Follow your exercise program as directed. Walk the distance you can tolerate each day. Listen to your body. Rest when you are tired. Do not strain your hip by excessive stooping or bending. Always use a walker or other recommended assistive device until instructed otherwise. When going up stairs, step up with your non-operated leg first. When going down stairs, step with your operated leg first. Remember Up with the good, down with the bad. Stand tall and use good posture. Use caution around pets. Remember to wear T.E.D. hose as directed by your doctor. Talk with your doctor about when you can safely return to driving, sports and sexual activitiy. Before having a dental procedure, ask your dentist about taking antibiotics. AFTER DISCHARGE, NOTIFY YOUR DOCTOR IF: You have an elevated temperature (Your doctor will provide specific instructions regarding what temperature should prompt a call.) You have a significant increase in redness, swelling or warmth from the incision. Some swelling, mild redness or warmth are normal after surgery. There is foul smelling drainage from the incision. There are any openings or splitting of incisions. You experience increased muscle weakness, numbness and tingling. You have chest pain or shortness of breath. You have extreme pain not relieved with pain medication. You have a sudden increase in pain, swelling, redness or tenderness in either lower extremity. HEEL SLIDES Lie flat on your back with legs straight out. Slowly slide your foot toward your buttocks so you bend your knee. Then slide your foot back toward the foot of the bed, straightening the leg out again. 4 Total Hip Replacement Total Hip Replacement 13
Home Equipment At home, you may need the following equipment: Walker (most common device after surgery). Cane or crutch to get up and down steps. Tub transfer bench. Toilet riser/commode chair. Grab bars in bathroom and/or in shower. Sock aid. Long-handled reachers, bath sponge and shoe horn. Exercises before your surgery (cont.) HIP ABDUCTION/ADDUCTION Lie flat on your back with legs straight out. Slowly slide your leg out to the side with your knee straight and your toes pointing to the ceiling. Then slide your leg back to the starting position. The therapists help determine your equipment needs. The RN case manager or case manager associate helps make arrangements or recommendations for you to get the necessary items. Information is provided on local loan closets, equipment companies and insurance coverage for medical equipment. Many people borrow equipment from friends or family. After Your Discharge HOUSEHOLD SAFETY Take care to avoid potential hazards by clearing out throw rugs, keeping clothes off the floor and electrical cords out of your path. Be aware of telephone wires, the corners of long bedspreads and be especially wary of spills on the floor. Leave the heavy housework to someone else. Do not stand on a stool, chair or stepladder. In the winter months, be careful on snow and ice. Be sure that the surface you ll be sitting on is steady before you sit down. You may want to use pillows or additional cushions to raise the height of your furniture in order to make getting in and out easier. To avoid excessive bending and lifting in the kitchen, arrange shelves and cupboards with frequently used items at easy to reach waist or shoulder levels. Installing handrails along steps/stairs and grab bars in the bathroom can be helpful. To avoid injuring yourself, always think before you move. Watch out for small pets or objects on the floor. It is very helpful to arrange for someone to stay with you initially after you go home. If you have any pet care responsibilities, you may want to consider having someone else help with these tasks for awhile. Try to prepare meals ahead of time. STRAIGHT LEG RAISES Lie on your back. Keeping your knee straight, lift the leg toward the ceiling about 12 inches. Slowly lower your leg back to the bed. (Keep your opposite leg bent up with your foot flat on the bed to protect your back.) LONG ARC QUADS Sitting in a chair, tighten thigh muscles to straighten knee. Hold two seconds and then slowly lower back down. FOLLOW-UP DOCTOR VISITS Your doctor will continue to monitor your progress regardless of the setting you are discharged to. Once you return home you should continue to practice any precautions that you have been taught until your doctor discontinues them. This typically occurs six weeks after surgery. 12 Total Hip Replacement Total Hip Replacement 5
Who Provides Your Care The orthopedic team works together to assist you during your hospital stay. We will work to make sure you know what to expect as you recover. It s a joint effort and your complete satisfaction is our priority. PATIENT AND FAMILY You, your spouse, family or significant other are the most essential members of this team. Learning about your health and your surgery helps with your recovery. ORTHOPEDIC SURGEON 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 aspects of your care with your surgeon. NURSES Your nurse will monitor your condition throughout your stay. Your nurse can: Provide information and treatments needed for your recovery. Organize and coordinate your care. Work with you to manage your pain. Answer any questions or concerns. RN CASE MANAGER/CASE MANAGER ASSOCIATE (CMA) Your case manager helps you plan for your release from the hospital. This person can assist or answer questions about: Insurance coverage. Who can help you at home after you are discharged from the hospital. Discharge options, including home with family assistance, outpatient rehabilitation, home health care, skilled nursing facility or acute rehabilitation facility. Equipment needs. Temporary disabled parking permits. Referrals to other community resources. PHYSICAL THERAPISTS (PT) Your physical therapist focuses on your ability to get around and on helping you recover function in your hip. Your physical therapist will: Evaluate your mobility and strength. Teach you how to get out of bed, climb stairs and get in and out of the car. Teach you how to walk with a walker or other devices. Give you exercises to increase your hip strength. Teach you how to move while maintaining hip precautions, if any. OCCUPATIONAL THERAPISTS (OT) Your occupational therapist focuses on your ability to perform functional activities after surgery. An occcupational therapist will: Provide training to maximize your independence in activities of daily living. Evaluate your physical capabilities and limitations in order to determine your needs for equipment. Teach you how to use equipment such as a raised toilet seat, tub transfer bench, and a reacher and/or sock aid effectively. Provide guidelines for home safety. Planning Your Discharge The RN case manager meets with you to plan your discharge. Most patients will be discharged to their home with family assistance. Safety issues, equipment, and the physical layout of your home are discussed. Suggestions are made to make your recovery easier and safer. We recommend that you plan ahead so that assistance is available when you leave the hospital. Your nurse discusses your discharge, including medications, your doctor s discharge instructions, follow up appointments and blood tests, if needed. Most people go home with prescriptions for pain pills and blood thinning medicine (two to four week supply). Any questions or concerns you have about your recovery at home are answered. Many patients go directly home when they leave the hospital without requiring further therapy. However, some people may need further therapy and several discharge options are reviewed below. Your final decision takes into account your doctor s recommendations, your individual needs, ability to tolerate physical activity and insurance coverage. OUTPATIENT REHAB If your orthopedic doctor deems it necessary, you will be given a referral to see an outpatient therapist. Your treatment plan will be determined by your doctor s recommendation and customized by you and your outpatient therapist. ACUTE REHABILITATION CENTER This setting offers the most intense level of rehabilitation. The staff work with you to restore strength, hip motion, and skills needed to resume everyday activities. Physical, occupational, and other therapies are part of your daily routine. You must be able to participate in a minimum of 3 hours of therapy most days of the week. Patients usually have additional medical problems that require frequent rehab physician monitoring. Patients must benefit from 24-hour rehab nursing care. The goal for discharge should typically be home or independent living. You may be referred for outpatient therapy services after you go home. SKILLED NURSING: SUBACUTE CENTER A subacute center is usually located in a skilled nursing facility or long-term-care facility. It provides ongoing nursing care and rehab therapies that you need to complete your recovery. Nursing care is provided 24 hours a day encouraging patient independence. Physical and occupational therapy are available. This environment offers flexibility in establishing a therapy schedule according to your tolerance. The RN case manager coordinates your referral to skilled nursing facilities as needed. 6 Total Hip Replacement Total Hip Replacement 11
Recovery and Rehabilitation Nurses will check on you frequently and take your vital signs. You need to ask your nurse for pain medication when you hurt. You are asked to cough and take deep breaths often to keep your lungs clear. Beginning on the day of or the day after your surgery a physical therapist will start you on an exercise program and help you stand, using a walker or other assistive device. You may feel weak or dizzy at first. This is normal. There may be some pain when first starting to move. Let your therapist know if the pain is severe. As your recovery in the hospital progresses, the physical therapist and an occupational therapist will teach you the proper way to sit, walk, bathe, and dress with your new hip. They will teach you (and your family) the skills you need to continue your recovery at home. If you have hip precautions that the doctor has prescribed for you, your rehabilitation team will teach you what these are and how to safely move while following these precautions. Your doctor decides how much weight you can put on your operated leg. This varies from no weight to weight bearing as tolerated. It is important to follow these restrictions to allow proper healing of your new hip. Your therapist will instruct you in the use of the appropriate assistive device for walking after surgery. Most people use a two-wheeled walker. You will be instructed in a home exercise program while you are in the hospital. Helpful Tips You may wear your eyeglasses (no contact lenses) on the day of surgery. Please bring a case for them. You will be asked to remove your glasses before surgery. Bring loose-fitting pants or shorts and walking shoes with low heels. You may bring personal hygiene items (hairbrush, toothbrush, toothpaste, etc.). If you use a CPAP or BiPap, please bring it to the hospital with you. If you have advanced directives, please bring them. Do not bring jewelry, money, or other valuables to the hospital. Do not wear eye makeup or lipstick the day of surgery. Do not bring tobacco products. The Day of Surgery When you arrive at the hospital, you are escorted to the surgery area to prepare for the operation. One or two family members may come with you. Your hip is scrubbed with a special soap. An IV is started in your arm. Fluid and medicines are given through the IV. The doctor who gives you anesthesia visits and answers any questions. Medicine is given to help you relax. You may feel hot, dizzy, or drowsy. This is normal. Operating rooms are cool. Heated blankets are provided for your comfort. Surgery Surgery usually lasts one to two hours, but varies with each person. While you are in surgery, your family may relax in the surgery waiting room. After surgery you are taken to the Post-Anesthesia Care Unit (PACU) or the Recovery Room for about an hour. The doctor informs your family about your condition. While resting in this area: Your blood pressure, breathing and other vital signs are watched closely. Medicine for pain and nausea is available if you need it. Your family may see you once you are transferred from the recovery room to your room on the Orthopedic Unit. 10 Total Hip Replacement Total Hip Replacement 7
Care After Surgery (Orthopedic Unit) Pain Relief During the first 24 hours after the operation, a nurse checks your breathing, pulse, and blood pressure frequently, and changes your body position as needed. You are asked to move your feet and legs often to help blood flow in your legs. Staff help you get out of bed, stand and walk as tolerated. Your family may help with your personal hygiene needs if desired. You may have ice chips and sips of water. Your first meal is liquid. Your next meal is a regular meal if your stomach is not upset. An ice bag is placed on your hip dressing to relieve pain and minimize swelling and bleeding. A tube (urinary catheter) may be inserted into your bladder to drain urine. It is usually removed in two days. You will be provided supplemental oxygen until the morning after surgery. You may need it longer. Breathing exercises are important in the first few days after surgery. You are asked to cough, breathe deeply, and perform other lung exercises to prevent fluid from collecting in your lungs. Gas pain and constipation are common after surgery. Increasing your physical activity, eating a high-fiber diet, and drinking plenty of fluids help prevent these problems. If you need a laxative during your hospital stay, please tell your nurse. Blood is drawn early in the morning while you are in the hospital for testing. Bed baths or showers are given based on your doctor s orders. Pillows may be placed between your legs to keep your knees apart if appropriate for your hip precautions. It is common to have some pain after surgery. Pain is not eliminated completely, but can be reduced to a slight to moderate level. Our goal is to make your stay and recovery as comfortable as possible. Everyone experiences pain differently. We ask you to decide what your own pain goal is. We use a pain scale to help describe your pain. This helps us determine the proper type and amount of pain medicine to use. 0 2 4 6 8 10 Pain is controlled best when you take medicine before the pain becomes severe. Be sure to tell your nurse when you are having pain. Most pain medications are on an as needed basis to reduce side effects. Helping Circulation Good circulation is important to promote healing. There are several things that are done to help prevent circulation problems in your legs, such as blood clots or swelling. These may include: Ted Hose. You will be fitted with either thigh-high or knee-high support hose called T.E.D.s. These help prevent blood clots from forming in your legs. Tell the nurse if you have any tight or burning areas beneath the hose. Blood-thinning medicine may be ordered to help prevent blood clots; it may be given to you daily. Venous pumps. These are plastic sleeves that fit over your legs and massage them by inflating and deflating. This helps prevent blood clots. Gentle exercises. The nurse or rehab therapist shows you gentle exercises to help circulation, strengthen muscles, and improve range of motion. 8 Total Hip Replacement Total Hip Replacement 9