Bertram Total Joint Centers

Total Hip: An Overview of Total Hip Replacements

History of Total Hip Replacements (THR)

Joint replacement surgery has been popular since the 1960s. Sir John Charnley was the father of successful total hip replacement surgery. Several advances in design as well as materials used in the hip replacement have given us the current state of hip replacement surgery. 90 to 95 percent of patients have a good or an excellent result with this type of surgery. Total hip replacement is generally recommended when patients have unacceptable levels of pain with everyday activities, increasingly severe deformity or unacceptable function. Current hip replacement design consists of two components. The femoral component fits in the canal or marrow space of the femur bone, the acetabular component fits in the socket of the pelvis. The combination of components is frequently referred to as a prosthesis.

Indications for Surgery

The main indication for a total hip replacement arthroplasty is arthritis of the hip accompanied by considerable pain and loss of function that does not respond to conservative treatment. Pain from arthritis of the hip is a personal experience-your friends, family and Dr. do not know how much pain you have. The decision regarding proceeding with surgery is ultimately the patient's decision. Arthritis of the hip is not a malignant condition nor is it life-threatening. Quality of life is the main consideration in the decision-making process. The operative goals are to relieve pain, improve function and restore strength to the hip.

The Process

Total hip replacement surgery can be divided into phases.

Phase 1: Presentation

This is the phase in which the patient presents to the physician. It is in this phase that the patient comes to see the physician for their arthritic joint. At this time after a variable length of time it is determined that the patient needs surgery. In addition the patient has had a workup by the surgeon consisting of an interview, physical exam and x-rays. After it has been decided that surgery is to be performed we enter into the next phase of treatment.

Phase 2: Immediate Preoperative / Prehospital

Phase 2 involves all work that is done to prepare the patient for surgery up until the time that they are actually admitted to the hospital for the procedure. This is a very labor-intensive parlor workup as we are trying to identify reasons for this patient to vary from their pathway or have complications. Prior to admission to the hospital you will be required to have laboratory studies, electrocardiogram, chest x-ray and a urine analysis and culture. This would include workup to eliminate any active infections in our patients. The cardiac and pulmonary status of our patients should be optimized. Vascular surgery problems such as arterial or venous insufficiency should be addressed. Dr. Bertram will do a nutritional screen on his patients. This consists of an albumin level, transferrin level and a total lymphocyte count. This will help to identify patients that may be at risk for either delayed wound healing or increased risk for infection postoperatively. This is particularly important for larger procedure such as revision total joint surgery. This phase requires careful integration of the primary care physician and the orthopedic surgeon. It is their important that the patients be honest with or surgeon regarding their medical conditions and social habits. Unrecognized alcoholism and the development of postoperative delirium tremens is a serious complication which has as high as a 50 percent post operative mortality rate. Also during this phase the physician will review the x-rays of the operative joint and plan for appropriate prosthesis selection and sizing. If your surgeon prefers that you donate your own blood in preparation for the surgery it will be done at this time. For a routine primary joint arthroplasty procedure two units of autologous blood will be sufficient. For a revision joint arthroplasty are three to four units of blood are needed. Any type of blood thinner medication needs to be stopped at least two weeks prior to surgery. These medications include Coumadin, Aspirin or Persantine. Anti-inflammatory medication such as Motrin, Advil, Aleve, Indocin, Feldene, Naprosyn and Clinoril should also be stopped two weeks prior to surgery. Use only Tylenol as your pain medication. You will also be enrolled in patient education classes that will teach you as much as possible about joint replacement surgery during the hospital stay. We feel that if our patients know what to expect they will have a better outcome and a better hospital experience.

Phase 3: Preoperative /In Hospital

Once you present to the hospital, everything is geared toward getting you ready for surgery. Do not bring any valuables or jewelry to the hospital. You will wear a hospital gown into the operating room. Jewelry, wigs or nail polish are not allowed. Glasses and dentures will be secured for you and given back to you when you are awake after surgery. You will be given medication prior to surgery to help relax you. The medication may cause drowsiness or dry mouth. Your family should wait in the family waiting area during your surgery. The doctor will call the waiting room to talk with your family or come over to talk with them. If we need to call someone outside the hospital, let us know.

Phase 4: Surgery

As you enter the operating room you will be impressed by the brightness of the lights, the number of people busily preparing for your operation, and your anesthesiologist who will be immediately attentive. Your name, age, and operative site will all be verified to ensure proper identification. An intravenous line will be started at this time if not done previously to provide a route for your fluids and antibiotics. A blood pressure cuff and EKG electrodes are routinely applied to monitor your blood pressure and heart beat during surgery. Your anesthetic is administered and the surgery will begin. You will be given medication through your IV before you receive any gases through a mask. If your doctor prefers that you have a catheter in place after surgery, it will be placed in the operating room, after you are asleep. A total hip replacement usually takes approximately two hours. In the event that both hips are being done at the same time, the operative time will be approximately four hours. The doctor will do the surgery, and he will be assisted by another physician or a physician's assistant. You may receive a bill from an assistant surgeon or physicians assistant. The surgery will usually be done through an incision along your buttock and upper lateral thigh. The skin is usually closed with metal staples. A drain may be used or it may not, at the discretion of the surgeon. Upon leaving the operating room you will have a very dressing on your leg. From the operating room you will be transferred to the recovery room.

Phase 5: Postoperative/In Hospital

You remain in the recovery room until your blood pressure is stable in you are alert enough to return to your room to. This usually takes approximately 1 to 1 1/2 hours. In the recovery room your vital signs will be monitored and you will have oxygen delivered through a plastic tube which will be on your nose. This helps to rid the body of the anesthetic agents used during surgery. If your doctor orders a PCA (Patient Controlled Analgesia) Pump, it may be started in the recovery room. You will have your IV in place for several days until you are eating and drinking well, and all your antibiotics have been administered. Oral pain medication is available after one to two days and may be given every four hours upon request. If you had a Foley catheter in place at the time of surgery, it will be removed on the second day after surgery. If you have problems voiding after that, you may have to be catheterized intermittently. The incidence of this is greatly decreased when we place a catheter in your bladder in the operating room. To prevent the development of respiratory problems, you will be asked to use your incentive spirometer every hour while awake. You will be instructed in the use of this device. Depending upon the preference of your surgeon, you may be placed in a traction type of device to help balance your leg. This is actually both more comfortable and more physiologic than other methods. Your diet will be advanced from clear liquids to a regular diet the first postoperative day. You are encouraged to take liquids by mouth to maintain normal body temperature and an adequate intake and output level. The plastic drain in your knee will usually be removed on the first or second day postoperative. There is minimal discomfort from removing the drain. During your hospital stay you may be given medication that contains iron. This may make your bowel movements very dark. This is normal. Physical therapy is under the control of your physician and your therapist. You will be visited by your physical therapist on the first day post op. You progress to sitting and standing usually on the first or second post op day. You will ambulate with crutches or a walker once you do get up. If your prosthesis was put in with cement you may bear weight right away. We usually cement the components in place. An occupational therapist will teach you how to perform activities of daily living after hip surgery.

Phase 6: Discharge from the Hospital

Most patients leave the hospital after 3-4 days. Upon leaving the hospital you will either go home, to a rehab facility, or to a facility that specializes in caring for patients after surgery until they can return home. When you leave you will go home with instructions regarding your therapy at home, prescriptions for pain medication, iron supplements and blood thinners. Arrangements for your follow up visit with the surgeon should have been made prior to your hospital stay, but if not you can call to arrange this.

Additional Guidelines to Follow

• Remain on your crutches or walker at all times during the first 4-6 weeks until you are told otherwise.
• Only take a shower or sponge bath, not a bath during the first 6 weeks to avoid excess strain on the hip. You may get in a whirlpool if supervised by a therapist after 5 days if your incision has no drainage.
• Driving a car is usually not allowed for 4-6 weeks after surgery but is at the discretion of your surgeon.
• Even after your crutches or walker are discontinued you may never lift heavy objects.
• Sports allowed 4-6 months after surgery are golf, swimming, bicycling, bowling and doubles tennis.
• Activities not allowed are contact sports, running, jogging, racquetball, football and skiing.
• For information regarding antibiotic prophylaxis see the portion of our web page devoted entirely to that subject.

Call for Any of the Following

• Sudden and extreme hip pain.
• Fever greater than 101.5 degrees.
• Unusual redness, swelling or drainage around the incision.
• Sudden chest pain, shortness of breath or coughing up blood.
• Any sudden onset of increased swelling in either leg.

Good Luck and Call us if you have any further questions.