Necessary Pre-Op arrangements.
New minimally invasive method.
Postoperative Care sedation
In the hospital
Total Hip Replacement
Total Hip Replacement procedures are becoming increasingly common around the world. Whereas once the replacement of a deteriorated hip joint was either impossible, or extremely difficult (both to perform, and recover from, successfully), today’s new minimally invasive technology makes the procedure significantly less risky, painful, and beneficial.
As people age, many people are faced with the debilitating effects of late-stage degenerative hip disease. Unfortunately, the symptoms accompanying the disease are not only painful, but in the later stages (especially after a fracture), can make mobility close to impossible for the patient. In such a case, Total hip replacement or THR is indicated. Not only does it offer hope for significant relief from the pain of degenerative hip disease, but in most cases can result in the restoration of mobility previously lost.
The actual process leading to degenerative hip disease can be attributed to many factors. Foremost among these possible factors is Osteoarthritis, or “wear and tear arthritis,” meaning, much like a part in a car, the hip joint basically wears out. Further, although there does seem to be a strong genetic component involved in one’s propensity to develop Osteoarthritis, it can still occur in virtually anyone. In addition, vascular problems can also lead to the degeneration of the hip, causing the femoral head, or the “ball” of the hip to die from a lack of blood. Eventually, the dead femoral head collapses, leading to the degeneration of the joint. The risk factors leading to this condition include patient histories of alcoholism, cortisone treatment, as well as injury of the hip from falls or other accidents. Finally, anatomic abnormalities can also lead to hip degeneration. These abnormalities can also be a result of an injury, or even a deformity existing from birth.
Perhaps one of the strongest reasons that people suffering from degenerative hip disease seek hip replacement is due to the debilitating effect of the symptoms associated with it. These may include severe pain, difficulty sleeping, a marked limp, reduced range of motion, and bone spurs. Although many patients first turn to pain reducing medications as a first resort, they soon find that they are either eventually ineffective, or that the risks associated with their continued use outweigh their benefits.
When a patient decides with his or her physician that a total hip replacement is indicated, there are several steps that must be completed as part of the “pre-op” preparation phase of the procedure. Of course, the first step any potential patient should take is familiarizing themselves with the procedure, itself, as well as the issues involved in recovery. Next, the patient will undergo a complete health examination, focused on establishing that he or she can physically withstand the surgery. Indeed, this is so important that many doctors will not proceed with surgery should significant health problems present a risk to the patient during or following the procedure.
After establishing that the patient is indeed healthy enough to withstand the rigors of surgery, the physician’s team will advise the patient on the need for adequate family or other support post procedure. This is because the patient will need sufficient time to recuperate, as well as assistance with personal care and daily living tasks for at least a few weeks. Further, the physician or his or her team will also often advise the patient to “bank” or donate blood should he or she require blood transfusions during the surgery. Finally, it is important (as in any fully anesthetized procedure), that the patent refrain from eating or drinking after midnight on the day of surgery.
Although in previous years the actual hip replacement procedure was actually quite invasive, leaving a long scar from above the hip to mid thigh, today new instrumentation and techniques have led to less invasive measures. For example, in medical centers like Winthrop University Hospital in New York, doctors use a relatively small incision. There, using new technology, the doctor can complete the entire procedure through a single three to four inch incision. The benefits of this procedure using, among other instrumentation, arthroscopy techniques, not only includes cosmetic benefits, but faster recovery times as well. In fact, according to Dr. DiMaio, head of the orthopedic surgery department at the center, “We have been doing small incision total hip replacement surgery at Winthrop for several months utilizing this new instrumentation and have been very successful in our outcomes.” Further, “Our patients have experienced less pain, shorter hospital stays and accelerated recovery.”
Of course, the new minimally invasive procedure for hip replacement is simply following a trend that extends across the surgical realm. However, the instruments actually used in the hip replacement procedure were specifically designed to “remove much of the complexity involved with performing these small incision hip replacements by allowing the surgeon easy mobility and by protecting the soft tissue surrounding the hip joint,” of particular importance in reducing the recovery time and complication rates of post-op patients.
Whatever method or instrumentation is decided upon by the physician and patient, the actual procedures on the day of surgery involves several predicable steps. First, the patient will arrive at the hospital on his or her surgery day, and meet with the anesthesiologist to determine which form of anesthesia will be used. Although general anesthesia is by far the most common form used in hip replacement surgeries, some physicians actually use a regional anesthesia with sedation. This may actually reduce the risk associated with general anesthesia, especially for those patients for whom general anesthesia is counter indicated.
Once the patient is anesthetized, the doctor will expose the hip joint, dislocate the ball from the socket, remove the head from the femur, and will “ream” the surface of the socket. He or she will then place a polyethylene socket in place of the old socket surface, and will install a metal ball and stem into the femur bone using a press fit method or bone cement. Once this is completed, the doctor will replace the ball into the socket, and “test” the new joint by moving it trough a range of motion. Finally, the surgeon closes the incision, and the patient is finished with the procedure.
When the patient awakes, he or she will find that a tube has been placed in the new hip joint during the surgery. The function of this tube is to drain fluid and blood from the joint. This usually is only left in place for one day post-procedure. Additionally, a catheter will also often be utilized to allow the patient to urinate without difficulty or excessive effort. Additionally, physical therapy will begin as soon as the day after surgery and the patient will be encouraged to walk with a walker, cane, or crutches within days. However, despite this relatively rapid recovery, the first few days following hip replacement are critical for monitoring the risks associated with the surgery.
When the patient begins the post-op phase of his or her recovery, it is at this point that most of the risks associated with the procedure can present themselves. These may include complications from the anesthesia, infection, bleeding, excessive bone formation, nerve problems or injury, blood clots, leg length inequality, and even fracture and hip dislocation. Although the risks of these problems are small (approximately 5%), and they are usually correctable, the consequences of them can be dire. For this reason, it is important, especially during the first 4-7 days of in-hospital recovery time, that the patient be closely monitored for signs of these problems.
Of course, if any complications do arise, it is essential that they be dealt with swiftly. For example, if an infection does occur, the patient will be prescribed a 6-8-week course of antibiotics, and may even undergo additional surgery to manually “clean out” the new joint components. Further, to prevent or manage blood clots that may form in the veins of the pelvis, legs or thigh, the patient may receive aspirin or Coumadin (two blood thinning medications). This is especially important because blood clots can lead to stroke, heart failure, or respiratory difficulty. In addition, excessive bleeding either during, or after the procedure can require immediate transfusion.
Interesting, of all the complications possible during or following surgery, many patients are surprised to learn that the newly transplanted joint is more prone to dislocation than a normal joint. For this reason, it is important that the patient be instructed to avoid sitting “low” or crossing his or her legs for some time following the procedure. In fact this is precisely the reason that the patient will be confined to bed on the first night following surgery with a wedge pillow between his or her legs.
Once a patient is discharged from the hospital, the recovery phase continues at home. There, the patient must do specific exercises twice a day, avoid specific movements including straight leg raises, and will continue using the wedge pillow in bed for usually six full weeks. Additionally, the patient must avoid tub bathing, swimming, and even driving for at least four to six weeks, or until his or her doctor allows the resumption of these activities.
Although many patients report rapid recovery times, especially if they are young and otherwise healthy, full recovery is most often accomplished after six months to one year following the procedure. Interestingly, one of the most dangerous aspects of this phase is either dislocation resulting from patient complacency (i.e. forgetting post-procedure instructions or rules regarding movement or positioning), or from infection in the joint from something as innocent as dental work. Thus, it is extremely important for the patient to remember that, even if he or she feels better, the new joint must be cared for properly.
Although total hip replacement surgery is considered a major medical procedure, the advances in instrumentation and minimally invasive techniques have rendered the outcomes much more satisfactory for today’s patients. In fact, one of the most spectacular aspects of total hip replacement is the fact that most of them are not only successful (in that pain is reduced or eliminated, and good motion is restored), but that the vast majority of them last the rest of the patient’s life.
Medical Multimedia Group. Health Pages Org. “A Patient’s Guide to Total Hip Replacement Surgery.” Retrieved on September 21, 2004, from http://www.healthpages.org/AHP/LIBRARY/HLTHTOP/THR/INDEX.htm
EMedicine. “Total Hip Replacement.” Retrieved on September 21, 2004, from http://www.emedicinehealth.com/articles/5806-3.asp
Winthrop University Medical Center. “Winthrop University Hospital Orthopedic Surgeon Performs New, Small Incision Minimally Invasive Hip Replacement Procedure.” Retrieved on September 21, 2004, from http://www.winthrop.org/newsroom/archives/release.cfm?id=160
UCSD Orthomed. “Total Hip Replacement.” Retrieved on September 21, 2004, from http://medicine.ucsd.edu/ortho/pdf/hip.pdf. http://www.healthpages.org/AHP/LIBRARY/HLTHTOP/THR/INDEX.htm
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