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total hip replacement

TOTAL HIP REPLACEMENT

Total Hip Replacement OVERVIEW

If you've been experiencing continued hip pain and limited joint function despite nonsurgical treatments such as medications and therapy, it may be time to consider joint replacement surgery. First performed in 1960, hip replacement surgery is one of the most successful operations in medicine. During a Total Hip Replacement (or Total Hip Arthroplasty) the damaged bone and cartilage is removed from the hip and replaced with prosthetic components. Continued medical advancements in total joint replacement surgical techniques and technology have greatly increased the effectiveness and outcomes of Total Hip Replacement.

One of the first steps when considering hip replacement is to meet with your surgeon to see if you are a candidate for Total Hip Replacement surgery. Your surgeon will take your medical history, perform a physical examination and X-ray your hip. Even if the pain is significant, and the X-rays show advanced arthritis of the joint, the first line of treatment is nearly always non-operative. This includes weight loss if appropriate, an exercise regimen, medication, injections, or bracing. If the symptoms persist despite these measures, and with corroborating X-rays, surgery becomes a consideration. The decision to move forward with surgery is not always straight forward and usually involves a thoughtful conversation with yourself, your loved ones and ultimately your surgeon. The final decision rests on you based on the pain and disability from the arthritis influencing your quality of life and daily activities. Those who decide to proceed with surgery commonly report that their symptoms keep them from participating in activities that are important to them like walking, taking stairs, working, sleeping, putting on socks and shoes, sitting for long periods of time. Surgery is the next option when non-operative treatments have failed.

basic hip anatomy

The hip is one of the body's largest joints. The hip is a ball-and-socket joint formed by the acetabulum, which is part of the large pelvis bone and the ball of the femoral head, which is the upper end of the femur (thighbone). The boney surfaces of the ball and socket joint are covered with a layer of articular cartilage which cushions the ends of the bones and enables the joint to move easily. A thin tissue called the synovial membrane surrounds the hip joint and makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement. Strong bands of tissue called ligaments connect the ball to the socket and provide stability of the hip joint.
hip bone anatomy
The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: Osteoarthritis, Rheumatoid Arthritis, and Post-Traumatic Arthritis.
Osteoarthritis is an age-related "wear and tear" type of arthritis. Osteoarthritis typically occurs in people over the age of 50 but may at times occur in younger people. In Osteoarthritis, the cartilage that cushions the bones of the knee thins and wears away. Damaged cartilage causes the bones that then rub against one another, leading to knee pain and joint stiffness.
Rheumatoid Arthritis is a disease in which the synovial membrane that surrounds the joint becomes inflamed and can thicken. Chronic inflammation within the knee joint can damage the cartilage and eventually cause cartilage loss, pain, and knee joint stiffness. Although there many types of "inflammatory arthritis" Rheumatoid arthritis is the most common form in this group.
Post-traumatic Arthritis can follow a serious knee injury. Fractures of the bones near the knee joint or tears of the supporting ligaments can damage the articular cartilage over time, resulting in joint instability, pain and limited knee function.

description of total hip replacement

In a Total Hip Replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components (pictured below). The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur (thighbone). The femoral stem may be either cemented or "press-fit" into the bone. A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed. The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place. A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface replicating the original ball and socket joint of the hip.
artificial hip replacement anatomy

Are all hip replacement implants the same?

Most implants (pictured above) today have become very similar as surgical experience has determined which designs work best. A variable that still remains is the bearing surface (or the ball and liner) that attaches to the stem and cup that fix to the bone. The ball can be composed of either metal (cobalt chromium alloy) or ceramic, and the liner can be made of plastic (polyethylene), metal, or ceramic. The ball and liner can then be used in different combinations and are named for the respective ball liner combination (metal on poly, ceramic on poly, ceramic on ceramic, etc.). Today the vast majority of bearings utilized a polyethylene liner with either a metal or ceramic head, with other combinations being used with less frequency. You can discuss implant differences and preferences with your surgeon to determine which implant is best for you.

hip replacement surgical procedure

Dr. Cory Calendine demonstrates a Total Hip Replacement procedure. The surgery can take up to a few hours. Your orthopedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip. After surgery, you will be moved to the recovery room where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room. You will likely stay in the hospital for one to three  days depending on your rehabilitation protocol and how fast you progress with physical therapy. This is highly dependent upon your condition before surgery, your age, and medical problems which can influence your rehabilitation. A safe discharge plan will be arranged for you by the orthopedic team.

hip replacement recovery

The success of your surgery will depend in large part on how well you follow your orthopedic surgeon's instructions regarding home care during the first few weeks after surgery and your physical condition prior to surgery. Most surgeons and hospitals today emphasize getting you out of bed quickly. Most people are walking with the assistance of a walker on the day after surgery. Early ambulation has been shown to reduce the risk of a post-operative blood clot and is an important part of your recovery. Progression to using a cane or nothing at all typically occurs within the first month or two after surgery and depends on each individual’s progress. You may have stitches or staples along your wound or even a suture beneath the skin. The stitches or staples are typically removed approximately 2 weeks after surgery. Initially you will be instructed to keep the wound  covered and dry. You may continue to bandage the wound to prevent irritation from clothing or support stockings. Some loss of appetite is common for some following surgery. A balanced and healthy diet is important to promote proper tissue healing and restore muscle strength.
The majority of people who undergo Total Hip Replacement are able to participate in a majority of their daily activities within six weeks. Most surgeons allow patients to drive at four to six weeks after surgery, and sometimes sooner if the operative leg is the left leg. There is some literature that states that your reaction time will not be back to normal prior to six weeks. You should not drive while on narcotics, and should discuss returning to driving with your operating surgeon. By three months, most people have regained much of the endurance and strength lost around the time of surgery, and can participate in daily activities with few restriction. Even after daily activities have resumed, it is important to avoid high impact activities to give you the best long-term outcome with your hip. Returning to work is highly dependent on your general health, activity level and demands of your job. If you have a sedentary job, such as computer work, you can expect to return to work in four to six weeks. If you have a more demanding job that requires lifting, walking, or travel, you may need up to three months for full recovery.

physical therapy following Total hip replacement

Initially, you will receive some physical therapy while in the hospital. Depending on your preoperative conditioning and support, you may or may not need additional therapy as an outpatient. Much of the therapy after hip replacement is walking with general stretching and thigh muscle strengthening, which you can do on your own without the assistance of a physical therapist. To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement. Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.

You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery. Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopedic surgeon for a card confirming that you have an artificial hip.

follow-up and precautions following hip replacement

A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and hip strength. Your orthopedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery and when those aides can safely be discontinued.

It is important to follow up with your surgeon after your joint replacement. In most cases, joint replacements last for many years. You need to meet with your physician after surgery to ensure that your replacement is continuing to function well. In some cases, the replaced prosthetic parts can start to wear out or loosen. The frequency follow-up visits after surgery is dependent on many factors including your age, the demand levels placed on your joint, and the type of joint replacement. Your physician will consider all these factors and tailor a follow-up schedule to meet your needs. In general seeing your surgeon every three to five years is recommended.
Source: American Academy of Orthopaedic Surgeons, https://orthoinfo.aaos.org/; American Association of Hip and Knee Surgeons, https://hipknee.aahks.org/total-hip-replacement/
Cory Calendine, MD is an Orthopedic Surgeon and founding partner of the Bone and Joint Institute of Tennessee at Williamson County Hospital in Franklin, TN. Dr. Calendine is an expert in Joint Replacement, specializing in Hip and Knee Surgery. From diagnosis through treatment, the Orthopedic Surgical experts at the Bone and Joint Institute use the latest techniques and technology to improve care for people with musculoskeletal problems. For more information, please contact our office
or schedule your appointment today.
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