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Posts Tagged ‘Hip Replacement’

Every year, nearly 200,000 Americans undergo hip replacement surgery, mostly due to arthritis. The vast majority of those surgeries are done with the traditional method, using a posterior or lateral (side) approach to gain access to the hip joint. With the traditional lateral method, the chance of dislocating your new hip is greater than with the minimally invasive anterior approach.

Hip dislocation after hip replacement surgery rarely occurs, but to reduce the risk even further it’s essential to strictly follow your hip precautions (restrictions of certain hip positions/movements) taught to you by your physical/occupational therapists. Your new hip needs time to heal in place, particularly during the first 6 weeks following surgery. During this period, your hip muscles and bones are healing up around your new hip joint to keep it securely in place.

There are usually three main total hip precautions. 1) Don’t turn your toes inward, 2) don’t cross your legs, 3) and don’t bend your new hip more than 60-90 degrees. Your surgeon will also instruct you on how much weight he wants you to place on your surgery leg while walking.

1) Don’t turn your toes inward. Where your toes go, your hip follows. If you turn your toes in on your surgery leg (pigeon-toed), your hip will internally rotate. This motion can pop your hip out of its new joint. Internal rotation can also occur while standing in place and twisting toward the direction of your new hip. Let’s say your right hip was just replaced. If you reach across your body with your left arm, maybe to answer the telephone or lay an object down on the table, you’re at risk of dislocating your new hip due to internal rotation.

2) Don’t cross your legs. Moving your surgery leg across your body’s midline can cause your new hip to dislocate. This includes sitting in a chair with your ankles crossed or reclining in bed with your legs crossed.

3) Don’t bend your hip beyond a 60-90 degree angle. The best way to know if you’re complying with this precaution is to take a look at your surgery leg when you’re sitting down. Your knee should be lower than your hip. If your knee and hip are level with each other, your hip is at a 90 degree angle. The closer you move your knee to your chest, the greater your risk of dislocating your new hip. And reaching down toward your shoes or the floor also creates this same risk of dislocation. One way to reduce the chance of hip dislocation is to straighten your leg out in front of you when you’re sitting. This reduces the bend of your hip.

While you’re in a standing position, don’t bend down to retrieve something from the floor or a low cupboard. There are devices, called “reachers”, that aid you in picking things up from the floor or getting objects from high cupboard shelves. Your occupational therapist will train you in the proper use of this equipment along with equipment to aid you in putting on your socks, shoes, and pants.

If you have low chairs at home, use pillows to add height. Chairs with arm rests make it easier to sit down and stand up. Don’t sit on a low couch. The top of your bed mattress should be 27″ from the floor. Getting on and off your toilet seat can be difficult and hazardous if it’s too low. While in the hospital, you’ll be using a raised toilet seat. You’ll also need one at home until your hip has healed. Your therapist or case manager will order one for home use before you get discharged from the hospital.

If you dislocate your hip, call 911. You want to get to the hospital as quickly as possible so your surgeon can put your hip back in place. This may require another surgery and rehab. If your surgeon is concerned about another dislocation, he can fit you with a hip brace. Once the hip completely heals, the brace may no longer be needed.

After your hip replacement, your doctor will let you know how much weight you can safely place on your leg while walking. This is known as your “weight bearing status”. It should be strictly followed, as putting too much weight on the leg can damage your new hip. Your doctor will allow you to increase your weight bearing as the hip heals. The following are some common “Weight bearing” terms:

non-weight bearing- no weight at all on the leg toe touch or toe down weight bearing- only your toes touch the floor, usually about 10% of your weight through your surgery leg partial weight bearing- toes and front part of your foot down, about 25-50% of your weight through your surgery leg weight bearing as tolerated- you’re allowed to put as much weight on your surgery leg as your pain level allows, heel down when walking/standing (heel/toe gait pattern) full weight bearing- no weight bearing restrictions, heel down when walking/standing (heel/toe gait pattern)

Your surgeon will discuss your hip precautions with you before and after your surgery. Your physical therapist will teach you how to safely get in/out of bed, transfer, walk, sit, climb stairs, and get in/out of your car while maintaining your hip precautions. Your occupational therapist plays a similarly important role in your rehab. As well as teaching you how to safely dress, the occupational therapist will also train you in bed mobility, walking, and safe toilet and shower/tub transfers. Following your hip precautions in the hospital and at home is an important part of your rehab and will greatly reduce your risk of hip dislocation.

Some of the above information may vary from patient to patient. Your doctor and physical/occupational therapists will instruct you in all total hip replacement precautions.

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Close to 200,000 hip replacement surgeries are performed
each year in the United States. Over 90% are successful
with no hip replacement complications during or after surgery. But as with all surgeries, the risk of complications is always a possibility. However, complications are infrequent and often reversible.

The older the person is the higher the risk of complications.
A person over 80 years old has a 20% chance of developing at
least one complication after hip replacement surgery.

Hip replacement complications during surgery

Nerve damage

The sciatic nerve is at risk of being accidentally surgically
cut due to its close proximity to the capsule of the hip joint. This same nerve may also become
over-stretched during hip manipulation during surgery.

Depending on the extent of the nerve damage, temporary or
permanent damage may result. There may be loss of muscle power
and feeling in parts of the leg. It may take up to 6 months
or more for recovery. Most patients have some numbness
around their incision site which may be permanent.

Vascular damage

The damage involves direct trauma to the blood vessels in
the area of the surgery. The damaged blood vessel can be
repaired by a vascular surgeon if it is caught in time.

Femur fracture

Force is applied during the surgical procedure. This can
result in a femoral shaft fracture, especially in older or
osteoporotic patients. Again, the problem is addressed during
surgery, but may lead to extended rehabilitation. The surgeon
may place weight bearing restrictions while you are walking.

Leg length discrepancy

In some cases, it may be difficult to get the exact same
leg lengths. The result is usually a longer leg on the
surgical hip. It may be unavoidable and deliberate in order
to improve muscle function or stabilize the hip. If there
is more than a quarter of an inch difference, a shoe lift
may be necessary.

In some patients, both legs are the exact same length
but they think their surgery leg “feels” longer. In most
cases this “feeling” goes away as the patient adjusts
to their new hip.

Rarely does shortening of the leg occur. If the
leg is significantly shortened after surgery, it may
have dislocated.

Anesthetic complications

Complications can occur, and in rare cases even death.
Your anesthesiologist will explain the risks involved
prior to your surgery.

Hip replacement complications after surgery

Blood clots (DVT-deep vein thrombosis)

This is one of the most common complications after
hip replacement. The most common area is in the
calf. Increased leg pain is usually the most obvious
symptom. Redness around the area of the clots may also
occur. It’s a minor problem if the clots stay in the leg.
But if they dislodge, they can reach the lungs (pulmonary
embolism) and can possibly result in death (very rarely).

If your surgeon suspects blood clots, he will immediately
order an ultrasound to confirm or rule out clots. Most
surgeons will order bed rest until the test results come
back positive or negative for blood clots. He will prescribe
a blood thinner. Compression boots and ankle/leg exercises
help reduce the chance of blood clots.

Infection

Infection can occur during surgery or develop afterwards.
It is one of the most serious risks to the joint replacement.
If the infection settles deep into the joint and surrounding
tissues, the new joint often has to be removed until the
infection clears with treatment. If the patient develops
an infection elsewhere in the body (bladder, teeth, chest),
it must be controlled to prevent the possibility of it
spreading through the blood to the new joint.

If you have rheumatoid arthritis or diabetes, or have
been taking cortisone for a long time, you are more prone
to infection in the weeks following your surgery.

Infection can occur many years after the surgery. Bacteria
can travel through the bloodstream from an infection in
other parts of your body (bladder infection, infected wound,
kidney infection). Oral antibiotics may need to be taken before
and after routine dental work years after your hip replacement
operation.

Hip dislocation

The first six weeks after hip replacement is the
most vulnerable time for your new hip. During this period,
muscle tension is the only thing holding the metal ball in the
socket. If the metal ball slips out of the socket, it’s
dislocated. As the hip muscles regain their strength and
scar tissue forms around the ball, the risk of hip dislocation
diminishes.

Traditional hip replacement requires that certain precautions
be taken and some positions/movements are restricted, at least
for the first 6 weeks. Your surgeon and physical therapist
will instruct you in your hip precautions. Basically, the
precautions are:

do not turn your toes inward do not cross you legs do not bend your hip more than 60-90 degrees (when sitting, your knee should not be level with your hip, it should be lower)

If dislocation occurs, call an ambulance to get you
to the hospital. Your surgeon will pop the hip back into
place. If it happens frequently, a hip brace worn for several
months will prevent further dislocations. Hip replacement
using the anterior approach eliminates the need for hip precautions or restrictions of positions/movements.

Those people who are overweight or have weak muscles
are more prone to dislocation. Avoid heavy exercise that
puts too much stress on your new hip (running, playing
basketball, tennis, heavy lifting). Instead, participate
in activities such as walking, swimming, stationary bike.

Trochanteric problems

Your greater trochanter, a large boney part of your femur, is
located below and to the outside of the ball of your hip joint.
Many of your large hip muscles anchor on the trochanter, so
it’s essential for normal hip function.

During lateral approach surgery, the trochanter is detached
to access the hip joint. It’s then reattached. If the
trochanter does not heal back on the femur bone, it remains
as a separate piece. This may result in pain, weakness, and
loss of hip function.

Bowel complications

Constipation frequently occurs for the first week or so
after surgery. This can be caused by medication, immobility,
loss of appetite, not drinking enough fluids. Stool softeners
or enemas may be needed.

Urinary problems

A catheter may be inserted during surgery. Your doctor will
order its removal as soon as is practical, as catheters pose
an increased risk of urinary infection.

Hematoma formation

During surgery, the main areas of bleeding are controlled
by cauterization. But some oozing of blood and fluids still
occurs, so a drain is attached from the wound to the outside
of the body. If the drain does not work as planned, a
collection of blood and fluids forms in the hip area. This
can cause pain, pressure, and possible infection. Your
surgeon may take you back to surgery to drain the hematoma.

Loosening of the prosthesis

The harder your bones are, the longer your hip replacement
will last. Hard bones create a stronger bond. People with
rheumatoid arthritis and osteoporosis are more at risk.

Running and heavy impact activities can also loosen the
bond of the implant. Keep your weight down, as this will put
more stress on the hip joint. Every pound you gain adds three
pounds of force on your hip.

Choose a surgeon who has performed many hip replacements.
Talk to some of his previous patients to see how they are
doing after their hip replacement. Not all surgeons are alike.
I have seen a few hip revisions that were necessary only because
the initial hip replacement was done poorly by the original
surgeon.

Pressure sores

In the immediate days after your hip replacement, you may be
spending quite a bit more time in bed. Spending a long period of
time in one position can lead to pressure sores. Your heels,
especially on your surgery leg, are very susceptible. A pillow
or towel roll under your calves will float your heels and
relieve pressure. The elderly are especially prone to pressure
sores because their skin is softer and they do not move around
as well. A close eye should be kept on their heels and tailbone
area, and should be regularly repositioned in bed with pillows.

Blood transfusion complications

All blood intended for use in transfusions is screened for
Hepatitis B virus, Hepatitis C virus, syphilis, Human T Cell
Leukemia virus, and the AIDS virus. But infections still occur.
Hemolytic Transfusion Reaction occurs due to incompatibility
with the donors blood type. The most common cause of Hemolytic
Transfusion Reaction is clerical error (mislabelled specimen or
improperly identifying the patient receiving the blood).

If you plan to use your own blood for possible
transfusion, let your doctor know ahead of time so arrangements
can be made. Your blood can only be stored for 35 days.
Collection should begin at least 10-14 days before your surgery.
The final collection occurs not later than 5 working days
before the surgery date. Your blood will be screened as well.

About hip revision surgery

Most people who undergo hip replacement surgery will
never need to replace their artificial joint. But because
more and more people are having hip replacements at a younger
age, the wearing away of the joint surface can create problems.
After 15-20 years of wear and tear, replacement (revision surgery)
of the artificial joint is becoming more common. Revision surgery
does not have as good an outcome as the initial surgery.

Consider all the hip replacement complications before you
decide on surgery. This is not a complete list of risks, as
there may be some rare complications not mentioned here.

Osteonecrosis is a condition due arising from a diminution of blood supply to bone. It affects most importantly the upper end of the femur. If left untreated it progresses to bony collapse and arthritis. The causes are many like alcohol abuse, steroid intake, Caisson’s disease, Gaucher’s disease.

The patient can experience sudden pain in the hips which radiates to the knee and can be confused for knee pain. Gait is painful. In early cases, x- rays are negative and MR scans are diagnostic. Treatment in the early stages is controversial and there are no clear guidelines.

Prolonged bed rest and crutch walking have not been shown to relieve pain or halt progression of the disease.

Treatment in late cases

Core decompression does ameliorate symptoms. It is minimally invasive and does not involve a replacement. If it fails then a replacement is possible at a later date.

Treatment in late cases with advanced destruction

Treatment is by a total hip replacement if bony destruction is extensive. A partial or total surface hip replacement is done if destruction is confined to the surface cartilage alone. Since it occurs in young individuals, a Surface Hip replacement is a better option as it conserves bony stock and a total hip replacement can still be done at a later date. Resurfacing of the hip is restricted to those cases of osteo necrosis where the amount of destruction is less than 30 percent of the head.

Where it exceeds thirty percent, a new type of hip prosthesis called the Proxima hip is available in Chennai.

This Proxima hip is an uncemented metal on metal large diameter bearing. It has been performed for avascular necrosis and other conditions like ankylosing spondylitis, post traumatic arthritis following acetabular fracture.

Vascularised fiblar graft is done with the help of a microvascular surgeon.