HIP REPLACEMENT
 
Hip joint is a ball and socket type of joint. There are extensive forces acting on this joint in all directions.
 
Anatomy:

Hip Replacement Anatomy It is the joint formed by the Pelvis (hip bone) with femur (thigh bone). The head of the femur articulates with the socket of the pelvis forming the ball and socket joint giving wide range of movements with extremely good stability.

The head of the femur and the cup of the Pelvic (Acetabulum) are lined with cartilage. Cartilage is a smooth, glistening stricture devoid of nerve supply and blood supply and hence makes the movement painfree.

Hip replacement can be of different types depending on the structures replaced in the hip.

Hemi-Arthroplasty1. Hemi-Arthroplasty - only the ball (Femoral Head) is replaced.

Surface Replacement2. Surface Replacement (Birmingham Surface Replacement) - here the head and the cup are just resurfaced. The worn out cartilage is shaved off over the head and cup and resurfaced with metal implants as shown here.
Total Hip Replacement3. In Total Hip Replacement, we replace the head of the femur (Ball) and the acetabulum (socket). Here a part of the neck with the head is also taken out.
 
Depending on the technique used to secure the components of the replaced Hip
The hip replacement can be classified into:
  1. Cemented total hip replacement- Here cement is used to mechanically bind the component to the bone.
  2. Non-cemented total hip replacement- Here the implant is coated so that the bone grows into the implant crevices to hold it biologically.

The decision of which to use depends on patient’s age, the disease condition, the bone quality and the surgeon’s experience.

 
The components of Total Hip Replacement:
The components of Total Hip Replacement

1) Cup : Which lines the Acetabulum – it can be made up of plastic, metal or ceramic liners.

2) Femoral stem: Which replaces the normal head and neck of the femur (thigh bone). The head part of this femoral stem can be of ceramic or metal alloy.

Once operated with a total hip replacement, patient can do almost all normal activities including running, sprinting and even normal sexual activities.

 
Indication for Total Hip Replacement:
  • Primary Osteoarthritis (Normal ageing process - most common)
  • Secondary Osteoarthritis
      Includes:
    • Avascular necrosis – Associated with alcoholism, fractures, dislocations of the hip, patient on steroid treatment.
    • Congenital problem – congenital dysplasia of the hip can lead to early degeneration.

The most common symptoms patient in all above condition patient presents with in descending frequency are:
• Pain
• Limb length discrepancy
• Loss of mobility – inability to sit cross legged or squat.

In the Early Stages, lifestyles modifications, Painkillers, walking stick can be suggested.
But once the symptoms limits over everyday activities, patient has to take painkiller on everyday basis, hip replacement is suggested.

Advantages after hip replacement
• Pain relief
• Limb length discrepancies can be corrected
• Normal hip range of motion can be achieved
• Improves the overall quality of life.

 
Precautions before the surgery:
  1. The possibility of an infection any where in the body has to be ruled out. A thorough dental check up, routine urine check up, any ulcers on the body have to be ruled out. A physician has also to examine for any systemic infection. Any infection any where in the body can infect the new replaced joint.
  2. Stop any antiplatelets drugs – like Aspirin or Clopidogrel at least 3 days before surgery, to avoid the risk of excessive bleeding during the surgical procedure.
  3. Inform the doctor incharge of all medications that you’re consuming as certain medications can be detrimental to the whole procedure.
  4. Smoking has to be avoided at least 4 weeks prior to the surgery as it increases the risk of complication during the surgery.
  5. Try to remain as active as possible prior to the surgery.
  6. When will the physiotherapy start after surgery?
    A common question asked, and I like to answer it by saying, Before Surgery. The stronger and flexible the muscles quicker are the recovery. With this thinking in mind, I have been able to mobilize the patient full weight bearing within 22 hours after surgery.

I prefer to give hip exercises (http://www.boneandjointcare.net/hip.html) before the surgery. Apart from this brisk walking, swimming, cycling can be encouraged.

 
At Hospital:

Get admitted at least on day prior to the surgery so that you settle well if medical fitness is given prior. Your anesthetist will visit you and check your heart, chest and back.

You will stop having any form of oral feeds 6 hours prior to the surgery. The area of hip and the involved leg is shaved and prepared well with Povidone Iodine solutions the night before. The groin area is than drapped in sterile condition and kept over night.

 
Day Of Surgery:

An hour before surgery some tablets and injections are given to relax you. You are later wheeled into the operation theatre where you are given anesthesia – mostly spinal and Epidural anesthesia with sedations. The operation takes 1 -2 hours to complete.

You will regain yourself back to senses in the recovery room, where you will be closely monitored. You will see a drip, a suction drain, a pump (epidural pump). You might experience extreme cold, tremors or nausea which is normal side effects of the anesthetic drugs. Some pain may be experienced at the surgical site, which can be minimized to minimal by epidural analgesics and painkillers. You are shifted later to your room once you are safe to do so.

 

Post-operative period:
Immediate post-operative period : In the 1st 48-72 hours -
The surgical negative suction drain, catheter, IV canulas are removed. Bedside mobilization is encouraged.
This is usually painful but important to avoid complication like deep vein thrombosis, bed sore, quadriceps wasting.

1st Week Post operation -
After returning home, you may need help to shop, drive and to do household activity for the first few weeks.
The quickest way for full recovery is to continue the same hip exercises( www.boneandjointcare.net/physical therapy/ hip exersise) as before.

Things to be avoided in the first three weeks to avoid dislocation -
• Bending your hip more than 90'
• Do not sit with cross legs
• Do not roll or turn your operated leg inwards.

Once you are confident of the leg operated weight bearing can be encouraged with the help of crutches / walker over the next 4-6 weeks. (Avoid crossing the legs or sitting on low lying chairs where hip bending is more than 90' – as the chances of hip dislocation increases).

 

Staircase climbing:
• When climbing up staircase – you always put your non-operated leg up first, followed by your operated leg and walking aid together
• When walking down stairs - you need to put the operated leg and walking aid down first then followed by your non-operated leg.

Type of chair preferred:
Sit on a high chair with arm rest is ideal in the first three weeks.

Wearing foot wear:
It is ideal to wear slippers and avoid excessive bending forward to do so.

Daily activities:
• Do not stand for long periods
• Allow yourself to rest
• Avoid heavy activities for 1st few weeks after leaving hospital.

However with the newer LDH (large diameter head) hip replacement / surface replacement; this chances have been greatly reduced.

After 4-6 weeks:
After 4-6 weeksIndependent walking can be encouraged without support. With the newer LDH. Sitting cross legged can also be advised. You can actually do all activity including driving, gardening, playing golf and this activity will keep improving in the 1st year after joint replacement. A fully healed hip replacement is sometimes difficult for even the patient to identify. To have a successful joint replacement, the surgeon, the physician, physiotherapist and the family members should work as a team with positive attitude towards the success.

 

Complications:
1. Infection – Any fewer 101oF / 38.3oc or any infection anywhere else in the body (Tooth infection, respiratory tracting infection, urinary tract infection) should be immediately reported to the doctor
2. Unusual redness, heat, oozing at the wound site is a probable warning of something going wrong deep within and should be consulted immediately
3. Troubled breathing or shortness of breath, pain in the caft, and increase in swelling of the leg not relieved by elevation could be a sign of deep vein thrombosis. (Clots in the legs) and has to be given immediate attention. Such thing can occur every 4 – 6 weeks after surgery.
4. Hip dislocation. Consult your orthopaedic
5. Peri-prosthetic fractures. Surgeon immediately.

 
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