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Total Hip Replacement

Introduction

This booklet gives you and your family a basic knowledge of hip joint replacement, outlining things you should know both before and after your operation. The aftercare may vary according to your surgeon’s wishes.

The success of your operation is a team effort including doctors, nurses, physiotherapists, occupational therapists, your family and most importantly you.

Why may I benefit from Total Hip Replacement?

Joint problems develop when the head of the thigh bone (femur) and its socket in the pelvis (acetabulum) lose their protective cartilage due to wear and tear (osteoarthritis), injury or types of inflammatory arthritis e.g. rheumatoid arthritis. The bone ends become rough and misshapen and this can lead to stiffness, pain and sometimes shortening of the leg (Figure 1). As these changes progress they can interfere with normal daily life. Walking, climbing stairs, shopping, housework, gardening and employment can become more difficult and sometimes impossible.

What is a Hip Replacement?

A hip joint replacement operation involves removing the damaged bone, replacing the head of the femur and relining the hip socket (acetabulum), see Figure 2. The type of replacement operation or components used will depend on the degree of damage to the joint surfaces, your consultant’s preference and your suitability for a particular joint.

A hip replacement has a long metal femoral stem which sits inside the thigh bone; it has a ball which replaces the damaged femoral head (this may be metal or ceramic) and a cup which relines the hip socket (this may be plastic, metal or ceramic), see Figure 3. These components may or may not be cemented into place. Your consultant will discuss what type of hip replacement is most suitable for you.

What should you do once on the waiting list for a hip replacement?

You should make sure you are as fit as possible before coming in for your operation. This will make it easier for you to recover after the operation and help you get home quickly. We will have you mobile as soon as possible after the operation to prevent complications. You will find this easier if you exercise before you come into the hospital. We suggest you stay as active as possible and start the exercises in this booklet straight away.

It is also important to eat healthily as this will help your body recover from the operation. If you drink alcohol or smoke, cutting back will help reduce the risk of any complications and help you recover more quickly.

In some hospitals you may have a health check at a clinic before your operation. However if this is not the case and you have any concerns regarding your health you should discuss these with your GP. It is useful if you have your GP check your blood pressure and make sure you receive treatment for any skin problems as these may delay your operation. It will also be beneficial to attempt losing weight if you are overweight.

To prepare for going home after your operation it may be useful to discuss the following with family or friends.

Things to consider are:

• How you will get home from hospital

• Who will help out at home

• Any questions you have regarding the operation and recovery afterwards (write these down)

• Organising your home so things you need are easy to get to and anything you could trip over is cleared away.

We aim to get you home as soon as you are safe to do so and have met your discharge criteria. This is to reduce the risk of post-operative complications such as hospital acquired infection.

Pre-operative Assessment Clinic

Before coming into hospital, we will ask you to attend the pre-operative assessment clinic.

At this clinic you will see a nurse or a doctor, and you may see a member of the occupational therapy team (please bring your measurement sheet to the clinic if you were provided with one beforehand).

We carry out full investigations to make sure that you are as fit as possible before your operation. This involves taking a record of your medical history and a list of your current medications (it is useful if you bring a list of these with you). At the clinic we will:

• Measure your height and weight

• Check your blood pressure

• Take samples of your urine and blood for analysis

• Take an ECG (a tracing of your heart)

We will also take swabs of your nose, throat and groin. This is to make sure that you are clear of MRSA (methicillin resistant staphylococcus aureus) before coming into hospital.

The staff at the clinic will also discuss your operation with you. Please take this opportunity to ask any questions you may have regarding your operation and hospital stay. It may help if you write a list and bring it with you (there is space for questions at the back of this booklet).

What to bring into hospital

You should bring any medication you are already taking in its original packaging.

You should expect to be in hospital for 2 – 4 days so bring enough comfortable daytime clothing and nightwear. You should bring sensible footwear: flat shoes or slippers that are easy to get on and off. Slippers should preferably have support around the heel. Your feet often swell up a little after the operation so make sure if you buy new slippers that they are big enough.

Before the operation

You will come into hospital either the day before or on the morning of your operation. We will give you advice on when to stop eating, however normally you will have nothing to eat from midnight the night before your operation.

The anaesthetist may visit you before your operation, if they haven’t already seen you. They will discuss the type of anaesthetic you will have. They may prescribe a pre-medication which the nursing staff will give to you before you leave the ward.

Your operation will be carried out in a specialised operating theatre.

Immediately after the operation

We will transfer you from the recovery room back to the ward in your bed. You are usually off the ward for roughly 3-6 hours. You may have a tube into a vein, “a drip”, to replace lost fluids but we will remove this as soon as possible. We will encourage you to eat and drink once back on the ward. You may also have a face mask or a nasal cannula to give you oxygen. You may have a large padded dressing over the hip wound.

The nursing staff will regularly monitor your blood pressure, pulse, temperature and oxygen levels.

We will aim to get you up after you have recovered from the anaesthetic.

We advise you to nominate 1 family member or friend to phone the ward to enquire how you are. Ask them to tell others about your progress rather than lots of different people calling the ward.

Pain Management

Some patients having a hip replacement operation have mild pain and others have more pain. Everyone is different but you should expect to have some pain. You must let the nursing staff know when you start to feel pain so that they can help you. It is harder to get the pain under control if you wait too long.

The anaesthetist and ward staff will discuss pain relief options with you and a pain management nurse may visit you after the operation.

We may inject nerve blocks or local anaesthetic into the new joint while you are in theatre. As these wear off you will tend to feel the pain increasing. It is very important that you let the nursing staff know when this happens so they can get you pain killers. Powerful pain-killing tablets (Opiates) are the most commonly used method of pain relief. Sometimes we use patient controlled analgesia (P.C.A.) however this is much less common.

Do not wait until you are very sore before asking for painkillers.

Pain killing tablets:

A long acting tablet taken in the morning will release a powerful pain killer for twelve hours. The nursing staff will give you another one at bedtime to help with pain throughout the night. You will also get regular paracetamol. Most people need more than this to control the pain however you will not get the strong break through painkiller unless you ask for it. It is very important to let the nurses know when you are sore so they can give you this to help you. Always think about how the pain is when you are moving and not just sitting or lying still – the emphasis after the operation is to get you moving so your pain control is hugely important.

Before you go home we will take you off these pain killers and prescribe something that you can take regularly yourself.

Pain killers can cause constipation. If you are affected by this or think you are likely to be please let the nursing staff know so they can give you a gentle laxative to help.

Some patients experience nausea or vomiting after an operation. If you feel sick let the nurse know. They can give you medication to help reduce this.

Recovering from your operation

At first you will be lying on your back and you may find moving around the bed awkward. Try bending your good leg up and push down through the bed with your foot and arms to lift your bottom off the bed. This helps prevent any sores developing. You should also keep your feet moving to help your circulation. People are often scared to move after their operation but there is no harm in starting the exercises shown in this book once you are able to move your legs.

The nursing staff will encourage you to be as independent as possible, whilst making sure of your safety. They will give you whatever help you need with washing and dressing etc following your operation, however they encourage you to do as much as possible on your own.

We will remove the padded bandage the day after your operation, and will usually replace it with a lighter dressing. We will check your wound dressing every day and will only change it if necessary. If you have wound clips or stitches that need to be removed, the nursing staff will organise for a district nurse to do so when you are home.

We encourage you to be as mobile as possible after your operation. When possible the nursing staff or physiotherapists will aim to have you out of bed the same day as your operation. This helps you return to independence, and helps prevent complications after your operation.

One possible complication is a blood clot in the calf, known as a DVT (deep vein thrombosis). A DVT can move to the lungs, this is known as a pulmonary embolism (PE). We will give you medication and or other mechanical means such as stockings to help prevent blood clots. However moving and walking as soon as possible after the operation is one of the best ways of preventing this.

Some people find that their operated leg feels a bit longer or a bit shorter than the other leg. This usually corrects over time. If it is still a problem after several months you can get a raise on your shoe to level the legs out. You will have an x-ray of your hip before you go home. The x-ray will show any difference in length that is unlikely to settle overtime.

Some patients require a blood transfusion or iron tablets after their operation. We will discuss this with you if necessary.

Precautions

Not all patients need to follow precautions following total hip replacement, your physiotherapist and occupational therapist will advise you if you need to follow the precautions outlined in this section.

To prevent you placing your hip in positions that may lead to dislocation please follow the precautions below. You should follow these for 12 weeks:

1. Do not bring your operated leg past the midline of your body i.e. do not cross your legs or ankles (Figure 4).

2. Do not bend your operated leg up past 90i.e. when sitting do not bend down or forward and do not let your knee become higher than your hip level (Figure 5).

3. Do not let your operated leg twist or rotate inward i.e. when turning make sure you take small steps around instead of twisting your hip and don’t roll onto your side when getting out of bed (Figure 6).

Physiotherapy

The physiotherapist will visit you either the afternoon of your operation or the next morning. They will teach you exercises to increase the circulation in your legs and increase the movement and strength of your hip. These are important because the muscles around your hip are often weak and tight. This is because the pain and stiffness of the arthritic hip stopped you from moving it normally. It will help if you start these exercises straight away unless we tell you otherwise. We will show you how to use your walking aid safely.

We aim to have you up walking on the same day as your operation or the next morning. The physiotherapist may also check your breathing and offer advice to help your lungs stay clear of infection.

After your operation the physiotherapist will continue with your exercises and practice walking. You will use a walking frame to walk initially and will progress onto elbow crutches or walking sticks as soon as you are ready. You will also practice going up and down stairs before going home.

At present we aim to get people home within 2-4 days of their operation but this varies and you may get home sooner or later than this.

Please note: there may be some circumstances when your consultant does not want you to start exercises straight after your operation. If this is the case then your physiotherapist will tell you.

Exercises

Below are the exercises that the physiotherapist will do with you. You should aim to do these 4 times a day while in the hospital.

1. Ankle Pumps: Pull your ankles backwards and forwards and circle them around. This increases the blood flow in your legs and decreases the chance of blood clots forming.

2. Static Quads: Point your toes to the ceiling. Press the back of your knee against the bed and tighten up the muscle in your thigh. Hold for 5 seconds then relax. Repeat 10 times.

3. Static Gluts: Squeeze your bottom muscles together and hold for 3-5 seconds then relax. Repeat 10 times.

4. Hip Flexion: Bend your hip and knee up and down. Be careful not to bend it too far (a right angle between your trunk and thigh is your limit!). Do 2 sets of 10.

5. Hip Abduction: Bring your leg out to the side then back in again. Do 2 sets of 10.

6. Hip Abduction: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and lift your leg out to the side. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier). Repeat 10 times.

7. Hip Extension: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and bring your leg backwards. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier). Repeat 10 times.

8. Hip Flexion: While standing, hold onto a steady object (e.g. the back of a chair). Bend your knee and hip as if you were going to lift your leg onto a step. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier). Repeat 10 times.

Although the physiotherapist will be there to teach and guide you it is important that you do your exercises independently and have regular walks on the ward once the physiotherapist says you are safe to do so. It is ultimately your effort that will get your hip working properly again. If you find you are struggling to do the exercises or walking because of pain please let a member of staff know – we cannot help unless you tell us.

Getting in and out of bed

Whilst in hospital the physiotherapist, occupational therapist and nursing staff will show you how to get in and out of bed safely. You will practice from whatever side of the bed you get in at home. The main thing to note is that you should not roll onto your side while doing this as this can cause your hip to twist (Figure 7 and 8).

Standing up and sitting down

Standing up:

To stand always make sure that you place your hands on the bed or chair. Your operated leg should be out in front of you before standing up. Push through your hands and stand up taking most of your weight through your un-operated leg (Figure 9). Do not hold or pull on an object such as a walking frame as these can easily move or tip causing you to fall backwards.

Sitting down:

Always make sure you can feel what you are going to sit on at the back of your legs before sitting. Place your hands back onto the chair or bed and sit down slowly sliding your operated leg out in front of you (Figure 10). The occupational therapist will check that your chair is not too low. We encourage you to sit as normally as possible (do not sit at the edge of your chair with your leg out in front of you). As long as your knee is not above your hip when you are sitting, your position will be fine. Do not cross your legs whilst sitting as this can be harmful to your hip.

Next: Walking

Walking

Initially you will walk with a frame and progress onto elbow crutches or walking sticks as soon as you are able (Figure 11).

You may not be allowed to put your full weight through your operated leg for at least 6 weeks after your operation. If needed, your physiotherapist will teach you how to do this.

To walk, move the walking aid forward. Step forward with your operated leg. Take some weight through your arms as you step forward with your un-operated leg. When turning, make sure that you take small steps. Do not twist on your operated leg.

Going up and downs stairs

If a handrail is available then always use it as well as one crutch or stick. Your physiotherapist will teach you how to carry your other crutch or stick up the stairs as you will need it when you get to the top.

Going up stairs (Figure 12)

1. Place your un-operated leg up onto the step

2. Lift you operated leg onto the same step

3. Bring the crutch or stick up onto the same step

Going down the stairs (Figure 13)

1. Place your crutch or stick down onto the step below

2. Step down with your operated leg

3. Bring your un-operated leg down onto the same step

 

Occupational Therapy

It is important that you follow the precautions against dislocation in everyday activities if you have been advised to follow precautions by your occupational therapist. During the first 12 weeks, you may need some equipment and, or adaptations to perform certain activities of daily living safely. You may also need to modify the ways in which you carry out some activities. The occupational therapist (OT) will give you advice on both these aspects, and will assess what would be most appropriate for use in your home. Where possible the OT will see you at the pre-operative assessment clinic and can arrange delivery and fitting of any equipment that you may need.

Bending and dressing lower half:

Do not bend to pick things up off the floor or to reach to your feet. To prevent you from doing this the OT will provide you with long handle aids (helping hand and shoe horn) and teach you how to use these.

Seating:

To prevent your hip bending too much you should sit in a chair that is an appropriate height. If your chair at home is too low it is usually possible to raise it using special blocks or with a cushion. The OT will discuss this with you.

Bed:

You should avoid sleeping in a low bed. Where necessary and if possible the OT can arrange to have your bed raised.

Toilet:

A raised toilet seat and, or rails may be required. The OT can supply these if you need them.

Bathing:

For the first 3 months you should not attempt to use the bath or a shower over the bath unless the OT has shown you how to do so and the necessary equipment is in place. The equipment is usually a shower board. We advise you to have someone with you the first time you use this.

1. Stand with your back to the bath and sit down on the board.

2. Turn yourself around to face the end of the bath, lifting your legs over the side of the bath as you turn (keep your operated leg straight at the knee as you lift it). If it is difficult to lift your legs over the edge of the bath yourself, get someone to help you.

3. To come out of the bath reverse the procedure.

Remain seated while you shower or wash and take care not to twist round while sitting on the board. If necessary get somebody else to operate the shower controls.

Equipment:

Depending on where you stay a central store or community OT will supply your equipment. Some smaller items are supplied on the ward by the OT.

• All equipment provided should be in good working order, and be fitted securely.

• When your equipment is fitted you should be provided with equipment instructions and a contact number.

• Once fitted the equipment should not be positioned elsewhere.

• If the equipment is not fitted securely, do not use it. Contact the supplier or OT Department. The equipment is provided on a short term loan (approximately 12 weeks).

To return equipment no longer required phone the supplier. If you are unable to do this contact the OT Department.

Getting In and Out of a Car

Getting into a car:

1. Move the front passenger seat back as far as it goes and recline the chair.

2. Put a pillow on the seat to make it higher if necessary.

3. With your back towards the seat, sit down with your operated leg stretched out in front.

4. Gradually move your bottom backwards and turn to face forwards. Help your operated leg into the car with your hands. Do not twist.

Getting out of a car:

1. Move your bottom to the edge of the seat.

2. Help your legs out of the car and move your bottom round.

3. Stretch your operated leg out in front of you.

4. Stand up leaning most of your weight through your un-operated leg.

Do not drive for six weeks after your operation.

Information For When You Go Home

You will normally go home 2-4 days after your operation. You should arrange for family or friends to take you home by car. Please note if hospital transport is necessary we will have discussed this at your pre-operative assessment appointment.

Homecare:

Homecare is available if you do not have anyone to help at home but only if it is absolutely necessary. They can assist with personal hygiene, shopping and cooking but may not assist with cleaning. Please think about this in advance and discuss with the nursing staff so there is adequate time to organise. Please note there may be a charge for this service.

Wound:

For a while after you go home, your wound may appear red, warm to touch or the wound may feel itchy. You may have swelling which can affect your whole leg. You may also have a change in sensation around your wound. In most cases these are normal after your operation.

If you notice a marked change and the area around your wound becomes much redder and is very hot and swollen, or if you develop any discharge from your wound it is important that you get this checked for signs of infection as soon as possible. We advise that you see a member of your surgical team. You can either contact them directly or contact the ward where you had your operation and they can direct you to the appropriate person.

Pain:

It is important that you continue to take regular painkillers once you are home. (The ward will give you some home).

Remember painkillers can make you constipated so please drink plenty of fluids and have fibre in your diet.

Painkillers are important to control your pain and to allow you to continue to do your exercises. If your painkillers are not controlling your pain then please speak to your GP.

Swelling:

When you go home it is important that you have regular rest and raise your leg (not higher than your hip). If you notice that your operated leg is swelling please rest more between your exercises. This is not unusual.

Please note if your calf is hot, swollen and painful to touch then contact your GP urgently. If you suddenly become very breathless and do not normally suffer from breathing difficulties then you should get advice from your GP urgently.

TED Stockings:

If you are given these you can stop wearing them 6 weeks after your operation.

Exercises:

Continue to do the exercises you were shown in hospital 2-4 times every day. Hip movements and the strength in your leg will gradually improve over time.

Walking:

Try not to sit for long periods. Go for short walks regularly and keep using your walking aid(s) as instructed by your physiotherapist. Depending on your type of hip replacement you may need to use 2 crutches for 6 weeks after the operation. Build up your walking distance gradually from short distances around the house to getting out and about. After 6 weeks you can gradually start to wean yourself off the walking aids. If you start to use 1 stick or crutch use it on the opposite side from your new hip.

Housework:

Try to spread your housework evenly over the week. Do not stand for long periods at a time. Try to adapt activities e.g. prepare vegetables or iron sitting down. We advise you to avoid hoovering for 12 weeks.

Sleeping:

Continue to sleep on your back for six weeks after your operation. After this you can sleep on your operated side or on your un-operated side if necessary but you should place a pillow between your legs (Figure 16). It is also good to lie flat for at least half an hour each day to stretch out the front of your hip.

Gardening:

Do not garden for the first 12 weeks. After this you still need to be careful to avoid twisting or excessive bending at the hip. You should avoid digging for several months.

Physiotherapy:

Routine physiotherapy follow up is not usually necessary. However your physiotherapist can arrange this if needed.

Driving:

You should avoid driving for 6 weeks after your operation. This allows some healing to take place and the leg muscles to become stronger. Plan your first drive. Only return to driving when able to comfortably and safely change gear and carry out an emergency stop. Avoid any long journeys at this stage. We advise you to tell your insurance company that you have had a hip replacement.

Sex:

Avoid any kind of strain to the hip during sex for the first 3 months after your operation. Please ask us if you would like an information sheet.

Flying:

There is no universal agreement on this, however we advise you to avoid short-haul flights for 6 weeks after your operation and long haul flights for a minimum of 3 months. If you are flying remember to do some circulatory exercises and if possible get up and move around. At 6 months after your operation the risks associated with sitting for long periods will be back to what they were before the operation.

Return to activity and work

As soon as the wound heals you may start gentle activity such as swimming, however you should avoid breast stroke for 3 months. Swimming is beneficial because you are not weight-bearing and therefore puts less stress on the hip joint and the buoyancy allows you to move and exercise easier.

Activities such as golf or bowls can be played 3 months after your operation. Avoid high impact sports such as jogging, skiing, squash and high impact aerobics are best avoided. If there is a certain sporting activity you usually do please ask for advice. If you are dancing you should take care not to pivot on the operated leg.

Returning to work depends on how physically demanding your job is. Your consultant will advise you about this.

Follow Up

In some hospitals the orthopaedic outcomes team or arthroplasty service will carry out your routine follow up on behalf of your consultant. In other hospitals your consultant or their registrar will see you in clinic.

Your follow up appointment will be 6-12 weeks after your operation. This will depend on your Consultant’s instructions.

The purpose of the appointment is to monitor your progress and to offer advice, reassurance and information on any aspects of your surgery and recovery. You may have an x-ray carried out at this time and we will ask you to complete some questionnaires at your follow-up clinic to help us monitor your progress.

Visiting Times

Visiting times vary in different hospitals. Please ask for the visiting times on your ward.

Visitors do not need to stay for the full time. They can pop in and out any time during these periods. There should be no more than 2 visitors at a time.

Please note that visiting times can be very long and you may have to undergo treatment or go for x-ray during these times. We apologise for this but it is simply not possible to see everyone out with these times.

Useful telephone numbers

This booklet gives you some information and advice but please ask any member of the team who cares for you in hospital about anything you are unsure of.

Once you are at home if you have any questions then please speak with your GP or if out of hours contact NHS 24 on 08454 24 24 24.