Total Hip Replacement

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HIP JOINT OR TOTAL HIP REPLACEMENT

Hip joint is the most common joint which requires replacement surgery worldwide. As compared to the knee joint, hip replacement surgery is performed at an early age. But encouraging fact is that Total Hip Replacement surgery is one of the most successful surgeries and has a prolong survival.

Hip joint maybe involved in myriad of clinical conditions, the most common being AVN or the avascular necrosis of femur head, Arthritis of hip joint, Rheumatoid arthritis. The patient has pain and restriction of movements which in severe cases can be debilitating and patient is not able to carry out activities of daily living.

In THR surgery, the damaged portion of the surfaces forming hip joint, namely, the acetabulum and the femoral head is removed and are replaced with prosthesis of suitable material. The aim of the treatment is to provide pain relief and also to achieve pain free movements of the hip joint. The proper preoperative planning, its better execution in surgery and a well-designed post operative protocol are prerequisites for a successful outcome.

BIMS Hospital is known for its efficient, reliable, safe, and world-class treatments. Our team of some of the best surgeons and medical experts strive hard to offer the most advanced medically validated treatments to our patients.

Anatomy

The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.

A thin tissue called the synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.

Common Causes of Hip Pain

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

Osteoarthritis. This is an age-related wear and tear type of arthritis. It usually occurs in people 50 years of age and older and often in individuals with a family history of arthritis. The cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by subtle irregularities in how the hip developed in childhood.
Rheumatoid arthritis.This is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage the cartilage, leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed inflammatory arthritis.

Posttraumatic arthritis.This can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.
Osteonecrosis. An injury to the hip, such as a dislocation or fracture, may limit the blood supply to the femoral head. This is called osteonecrosis (also sometimes referred to as avascular necrosis). The lack of blood may cause the surface of the bone to collapse, and arthritis will result. Some diseases can also cause osteonecrosis.
Childhood hip disease.Some infants and children have hip problems. Even though the problems are successfully treated during childhood, they may still cause arthritis later in life. This happens because the hip may not grow normally, and the joint surfaces are affected.

TYPES OF IMPLANTS:

1) UNCEMENTED

Uncemented hip replacement uses specially designed prosthetic components for the bone to implant fixation. The femoral component is usually covered with a porous surface on the upper end. The porous sprayed surface has microscopic, contoured troughs and ridges.

The natural bone grows on and in the porous surface creating a gridlock that binds the implant to the bone. Uncemented fixation is the most common method of total hip replacement in the United states.

The operating surgeon prepares the bony femoral canal by broaching and inserting the implant slightly bigger than the final broach. The insertion of a slightly larger implant ensures a press-fit prosthesis that is snuggly fit.

2) CEMENTED

A cemented hip replacement uses a polymethylmethacrylate (PMMA) bone cement to fix the implant surface to the bone. The bone cement creates a grout and fixes the implant by acting as an interlocking surface between the implant and the bone rather than simply gluing the implant to the bone.

The bone cement is made by mixing powder and liquid components. The mixing and cementing techniques have evolved in the past decades to achieve maximum fixation. The modern mixing in the operating room involves the use of a vacuum mixer. The bone cement hardens in about 10 minutes in the OR temperature.

3) DUAL MOBILITY

A newer type of implant known as “dual mobility” lowers the risk of dislocation, according to research conducted by Dr. Westrich and published in respected medical journals. Dual mobility refers to a bearing surface of the implant – where the joint surfaces come together to support one’s body weight.

“Dual mobility implants provide an additional bearing surface compared to a traditional implant,” Dr. Westrich explains.

With the dual mobility hip, a large polyethylene plastic head fits inside a polished metal hip socket component, and an additional smaller metal or ceramic head is snap‐fit within the polyethylene head. So, there are two areas of motion, and this improves range of movement for patients and reduces the risk of dislocation.”

4) HEAD SIZE AND MATERIAL

IN 2023, DELTA CERAMIC LARGE HEAD (36MM) ON CROSS LEG POLY ARTICULATION WITH PREFERABLY UNCEMENTED STEM AND CUP IS GOLD STANDARD.

SURGERY

In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.

The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur. 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.

(Left) The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.

COMMON FAQS!!!!

Is Hip Replacement Surgery for You?

The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopedic surgeon for an initial evaluation.

When Surgery Is Recommended

There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:

Hip pain that limits everyday activities, such as walking or bending
Hip pain that continues while resting, either day or night
Stiffness in a hip that limits the ability to move or lift the leg
Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports.

Candidates for Surgery

There are no absolute age or weight restrictions for total hip replacements.

Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

The Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components:

Medical history.Your orthopaedic surgeon will gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform everyday activities.
Physical examination.This will assess hip mobility, strength, and alignment.
X-rays.These images help to determine the extent of damage or deformity in your hip.
Other tests. Occasionally other tests, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.

Deciding to Have Hip Replacement Surgery

Talk With Your Doctor

Your orthopedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physical therapy, or other types of surgery — also may be considered.

In addition, your orthopedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.

Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.

Realistic Expectations

An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.

With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports.

Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.

With appropriate activity modification, hip replacements can last for many years.

Preparing for Surgery

Medical Evaluation

If you decide to have hip replacement surgery, your orthopedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.

Tests

Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest x-rays, may be needed to help plan your surgery.

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopedic surgeon for treatment to improve your skin before surgery.

Medications

Tell your orthopedic surgeon about the medications you are taking. They or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.

Weight Loss

If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery.

Dental Evaluation

Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.

Urinary Evaluation

Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing the required treatment before having surgery.

Social Planning

Although you will be able to walk with a cane, crutches, or a walker soon after surgery, you may need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry.

If you live alone, a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

Securely fastened safety bars or handrails in your shower or bath
Secure handrails along all stairways
A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms
A raised toilet seat
A stable shower bench or chair for bathing
A long-handled sponge and shower hose
A dressing stick, a sock aid, and a long-handled shoehorn for putting on and taking off shoes and socks without excessively bending your new hip
A reacher that will allow you to grab objects without excessive bending of your hips
Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips
Removal of all loose carpets and electrical cords from the areas where you walk in your home

Get more tips on preparing your home for your total hip replacement in this infographic (click on image for full infographic).

Your Surgery

You will either be admitted to the hospital on the day of your surgery or you will go home the same day. The plan to be admitted or go home should be discussed with your surgeon before your operation.

Anesthesia

Upon arrival at the hospital or surgery center, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Procedure

The surgical procedure usually takes from 1 to 2 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.

(X-rays before and after total hip replacement. In this case, non-cemented components were used.)

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 or discharged to home.

Recovery

The success of your surgery will depend in large measure on how well you follow your orthopedic surgeon’s instructions regarding home care during the first few weeks after surgery.

Pain Management

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that, although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Wound Care

You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 to 3 weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.

Activity and Postural Care

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within 3 to 6 weeks following surgery. Some discomfort with activity and at night is common for several weeks.

Your activity program should include:

A graduated walking program — initially in your home and later outside — to slowly increase your mobility,
Resuming other normal household activities, such as sitting, standing, and climbing stairs
Specific exercises several times a day to restore movement and strengthen your hip. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.

Physical therapy will help restore strength and mobility to your hip.

Possible Complications of Surgery

The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications do occur, they can prolong or limit full recovery.

Infection

Infection may occur superficially in the wound or deep around the prosthesis and treated with antibiotics.. It may happen within days or weeks of surgery. It may even occur years later.

Blood Clots

Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. A prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilization.

Leg-length Inequality

Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopedic surgeon will make every effort to make your leg lengths even but may lengthen or shorten your leg slightly to maximize the stability and biomechanics of the hip.

Dislocation

This occurs when the ball comes out of the socket. The risk for dislocation is greatest in the first few months after surgery while the tissues are healing.

Loosening and Implant Wear

Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biologic thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary.

Other Complications

Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. A small number of patients continue to experience pain after surgery.

Other Precautions

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.

Your surgeon and physical therapist will provide you with any specific precautions you should follow.

Recognizing the Signs of a Blood Clot

Follow your orthopedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. They may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clot in your leg include:

Pain in your calf and leg that is unrelated to your incision.
Tenderness or redness of your calf
New or increasing swelling of your thigh, calf, ankle, or foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

Sudden shortness of breath
Sudden onset of chest pain
Localized chest pain with coughing

Preventing Infection

A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:

Persistent fever (higher than 100°F orally)
Chills
Increasing redness, tenderness, or swelling of the hip wound
Drainage from the hip wound
Increasing hip pain with both activity and rest

Avoiding Falls

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 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.

Outcomes

How Your New Hip Is Different

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.

Protecting Your Hip Replacement

There are many things you can do to protect your hip replacement and extend the life of your hip implant.

Participate in a regular light exercise program to maintain proper strength and mobility of your new hip.
Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
Make sure your dentist knows that you have a hip replacement. Talk with your orthopedic surgeon about whether you need to take antibiotics prior to dental procedures.
See your orthopedic surgeon periodically for routine follow-up examinations and X-rays, even if your hip replacement seems to be doing fine.