Total Hip Replacement Fundamentals
Total hip replacement (or hip arthroplasty) is a technique that has become widespread in recent years in response to the need for improving hip joints that have been damaged by injury or arthritis. Joint replacement surgery may offer the best treatment option for long-term improvement for the hip joint when other treatments have proven inadequate. In most cases, having a total hip replacement reduces joint pain and means a return to pain-free movement.
What causes hip pain?
The human hip is a ball and socket joint. It is the most flexible and free-moving joint in the body, and can move backwards and forwards, to the side, and can perform twisting motions. Full function of the hip is dependent on the coordination of bones, muscles, tendons, ligaments and nerves.
Hip pain can be caused by a variety of factors, including:
- An injury that does not heal properly.
- A chronic illness.
- Normal wear and tear from years of constant use.
- Severe arthritic conditions, especially osteoarthritis.
- Injuries as a result of trauma, such as a hip fracture or dislocation caused by a fall.
If hip replacement surgery is the best treatment option for you, your physician will refer you to an orthopaedic surgeon with expertise in this procedure. Your orthopaedic surgeon will evaluate your hip joint with a full physical exam and X-rays and develop a treatment plan about how surgery can best benefit you. Your surgeon will also ask you about any past medical problems.
What are the benefits of hip replacement?
Relief from pain is the greatest benefit and the major reason for hip replacement surgery. The procedure offers other benefits, such as:
- Improved movement, strength and coordination of the torso and leg.
- The ability to walk, climb stairs and maintain an active lifestyle in greater comfort.
What are the risks of surgery?
There are possible risks and complications that may happen through hip replacement surgery associated with anesthesia, including respiratory or cardiac malfunction. Other complications include:
- Blood clots
- Injury to nerves and blood vessels
- Stiffness or instability of the joint
- Need for additional surgeries
Patients at increased risk for complications are those with severe rheumatoid arthritis or systemic lupus. In addition, patients with insulin-dependent (type 1) diabetes, malnourishment, hemophilia, or those who have had previous prosthetic joint infections are at higher risk. Make sure to contact your orthopaedic surgeon immediately, if you experience any of these problems after surgery.
Joint replacements do not last forever, usually 10-15 years. Hip revision surgery may become necessary when an artificial hip becomes painful. Learn more information on hip revision surgery.
Several variables affect the ultimate success of hip replacement surgery. These include the strength of the patient’s bones and muscles and his or her general health and lifestyle. Commitment to a rehabilitation program is also an important part of the recovery process, since improvement to the hip joint is determined by the patient’s rehabilitation effort.
How do I prepare for surgery?
In order to prepare for surgery, patients are requested to schedule a series of appointments prior to the surgery date to receive testing and clearance for surgery. You will receive a routing schedule in the mail one to three weeks before you are to have surgery to tell you what appointments you have and their locations. During these appointments, studies including lab testing, urine analysis, EKG, and X-rays are conducted. Based on the results of these tests and the patient’s health history, clearance is initiated for the surgery. Depending on the patient’s condition, additional testing may be required prior to surgery.Patients can also take steps at home to help ensure an easier recovery after surgery. Make a few simple changes around the house, and arrange for someone to help you during the few weeks following surgery. Discuss with your surgeon about whether you should donate your own blood for surgery, and schedule appointments to see your primary care doctor and your dentist. If you smoke, try to stop or cut down to improve your surgery risk and recovery rate.Do not eat or drink anything after midnight the night before surgery.You can try these tips at home prior to surgery:
- Remove any loose rugs, as they can be hazardous when you are walking in the house. Make sure you tape down all electrical cords.
- Store additional canned and frozen foods, and make sure all supplies are between waist and shoulder level.
- You will need to keep both legs elevated for the first 4 to 6 weeks following surgery. This is best accomplished in a recliner chair, or a chair with armrests and an ottoman for appropriate leg support.
- Prepare a sleeping room on the main floor, or ensure that you only have to climb the stairs once a day.
- Make sure you have a cordless phone for greater efficiency in answering any phone calls.
Special equipment will help to ensure an easier recovery following surgery. Your physical and occupational therapists will recommend equipment for you and will help you and your family in obtaining this equipment following surgery. Some of this equipment may include:
- Elevated toilet seats
- Shower seats
- Handrails and grab bars, especially when getting in and out of the bathtub
- Grasping device for putting on socks and shoes
Inform your surgeon about all of your medications, both over-the-counter and prescription. Some medications do not react well with anesthesia, and others such as aspirin, ibuprofen and blood thinners, increase bleeding. For these reasons, you may need to stop taking certain medications before hip replacement. If you are taking aspirin or aspirin-based medication for arthritis, you must discontinue these 2 weeks before your surgery. If you are taking medications for other medical problems, do not discontinue taking these without checking with your primary care physician. Make sure to bring a list of all medications, the dosages, and how often you take them. This includes all herbal supplements and vitamins. This is important information that will be documented in your hospital records.
Have your teeth cleaned and make sure you do not have any cavities that might need to be taken care of during the first few months following surgery. Since the blood supply to the hip is increased during healing time, it is better to have any routine dental work done either before surgery or 3 months after. In addition, any emergencies must be taken care of immediately. You will continue to use antibiotics prior to any dental work for the rest of your life once you have a total joint replacement.
Someone from The Cleveland Clinic Anesthesia Department will meet with you before your surgery. They will explain the various types of anesthesia available to you and the risks and benefits of the surgery. The spinal, or regional anesthetic block, is the most common and safe method used for orthopaedic procedures. You will also be asked to complete a health questionnaire from the Anesthesia Department for surgery clearance to ensure your safety.
An evaluation by the Cleveland Clinic Physical Therapy Department is conducted on all patients prior to surgery. After surgery, you will have daily physical therapy.
It is possible for you to donate your own blood for surgery. You should notify your doctor or physician’s assistant if this is of interest to you.
Are there exercises that I can start now prior to surgery?
It is important to do strengthening exercises and conditioning prior to surgery to help ensure a better outcome and recovery. Being stronger prior to surgery is a big benefit and helps in your rehabilitation program progress.The following exercises are recommended prior to surgery:
- Tighten muscles in the thigh then straighten your knee flat. Hold for a count of 5 then relax. Do 10 times, twice a day.
- Tighten buttocks, pushing heels down into the bed. Hold for a count of 5 then relax. Do 10 times, twice a day.
If you have any questions about these exercises, please contact your Cleveland Clinic physician assistant or nurse.
What happens during surgery?
The surgery technique involves removing the diseased portion of the hipbone and replacing it with an artificial hip joint (called a prosthesis).
What happens after surgery?
After surgery, medicines or physical therapy may be prescribed by your surgeon to prevent blood clots. To decrease your chances of having a Deep Vein Thrombosis (DVT) after surgery, you may be given medication, wear special stockings and do ankle pumps two to three days following surgery. You also may be given patient-controlled analgesia (PCA) which allows you to control your own pain medication through an IV and lasts for 1 or 2 days after surgery. You may have an appointment after surgery depending on the wound closure method preferred by your surgeon to have the sutures removed. You should call your surgeon before this appointment if you experience any of the following symptoms:
- Increased redness
- Pain or swelling
- Drainage at the incision
- Bumps or pimples
- Any other changes you question
Recovery and Outlook
How long is the recovery period after surgery?
The recovery period after surgery depends on the patient and their individual needs and medical condition.
What is the rehabilitation after hip replacement surgery?
Rehabilitation and physical therapy are started immediately following surgery and continue throughout hospitalization and at home for one year after surgery. On the first day after surgery, the physical therapist will meet with you in your hospital room for an assessment. On the second day, you will go to the Physical Therapy department by wheelchair for treatment. Your physical therapist will monitor the strength and flexibility in your leg and hip, as well as your ability to stand and sit. In addition, a physical therapist will provide goals and instructions for you to complete while in the hospital and at home.Your doctor may determine that it is best for your recovery if you go to a rehabilitation center after discharge from the hospital. At the rehabilitation center, you will have concentrated time with a physical therapist and occupational therapist and will regain your strength, learn about all your exercises and the precautions that you’ll need to follow. Your length of stay at this facility is approximately 5 to 14 days. Your doctor’s physician assistant or nurse will discuss facilities available for your needs, and a Case Manager specializing in Discharge Planning will meet with you during your admission. The Case Manager handles all of the planning for your rehabilitation.
Positioning After Surgery
After surgery, your physical therapist will instruct you regarding hip movement precautions and any limitations you may have for range of motion. Keep in mind that your physical therapy and strengthening exercises will help you gain greater mobility and ensure an easier recovery following surgery. It is highly recommended that you continue therapy treatment for the recommended timeframe prescribed by your physical therapist.Your physical therapist will tell you that there are several basic rules about positioning that you should be aware of following surgery. Make sure that you do not bend forward more than 90 degrees, and do not lift your knee on the surgery side higher than your hip. Also, do not cross your legs or rotate your leg outward, or twist or pivot your operated hip. While sitting, make sure that you use a straight back chair with arm rests, and do not sit in chairs or sofas lower than knee height since they require excessive bending at the hips when sitting down and getting up. Do not sit on low soft sofas or on stools and remember not to lean forward or cross your legs. Since most toilet seats are lower than knee height, patients are recommended to use a toilet seat extension, which are available for purchase in the hospital or a medical supply store.
How can I manage at home during recovery from hip replacement surgery?
The following are recommendations for home care activities following hip replacement surgery:
General Safety Tips
Simplify your surroundings
- Remove clutter, keep stairs free of objects.
- Keep supplies in the same place.
- Remove small rugs throughout the house.
Keep walking areas safe
- Secure electrical wires and extension cords or move them away.
- Watch out for your pets when walking.
- Keep hallways/stairways well lit.
- Purchase night lights for bedrooms and bathrooms.
- Stairs should have securely fastened handrails. Non-skid threads on stairs add to safety. If you have problems with your vision, add a contrasting color to mark stair edges.
Stay prepared for an emergency
- Keep smoke detectors in good working order.
- Keep emergency numbers near the phone. If you have a speed dial phone, program the emergency numbers for automatic use. Cordless phones are recommended if walking is difficult, or if access to the phone is a problem.
When riding home from the hospital, make sure to stop every 45 to 60 minutes to get out of the car and do some walking. Also, do ankle pumps in the car while riding. If you are flying home, request an aisle seat and keep the operative leg extended in the aisle. You should request to be boarded last on the plane.
Resting and Sleeping
When resting or sleeping in bed, it is recommended that you lie on your non-operative side for the first 4 to 6 weeks following surgery. Make sure you have a pillow between your legs, and also a second pillow to support your foot and ankle. If you lie on your operative side, keep in mind that this may not be that comfortable in the initial weeks following surgery and is not recommended immediately following surgery. When you lie on your back, you must have a pillow between your legs. If you get up in the middle of the night, sit at the side of the bed for a few seconds to avoid dizziness.
For positioning during sexual relations, make sure to consult your physician or physician assistant. Intercourse may be resumed approximately 3 weeks after surgery, following the precautions outlined by your physician.
Reaching typically requires too much bending and is typically not comfortable for patients following surgery. It is recommended for the first four to six weeks after surgery that you use long handled reachers that may be obtained from your occupational therapist or a medical supply store.
For dressing, to prevent lifting your knee higher than your hip on the surgery side, you may be given a long shoehorn and a dressing stick which will help you in putting on and taking off your shoes, socks and pants independently. Remember to always put your operative leg in the pants first. If you wear tie shoes, elastic shoelaces may be used to eliminate the need for tying.
Your physical therapist will teach you the correct way to go up and down stairs using handrails and/or crutches. Remember to use your good leg first, followed by the crutches and the surgery leg. When going down stairs, the crutches and surgery leg go first, followed by the good leg.
For bathing, do not attempt to get into the bathtub to take a bath or to use an overhead shower. The excessive bending at the hips needed to get into and out of the bathtub should be avoided. Make sure not to use a walk-in type shower or take a sponge bath until 11 days following your surgery. Keep a portable commode (or a urinal) if a bathroom is far from your bedroom.
Remember not to bend too far or stoop when performing household chores. Chores that you should avoid that may involve excessive bending include cleaning the floor, taking out the rubbish, and making beds.
Following surgery, you will need to use a walker or crutches based on your condition, which your occupational or physical therapist will provide for you. Make sure to stay on your crutches or walker until your doctor or physical therapist advises that you use a cane. Your doctor will decide how much weight you can put on your surgery leg. In most cases, you will be able to put 100 percent of your weight on your surgery leg, unless otherwise notified. Your physical therapist will help you learn how to use your walker or crutches correctly and help you to obtain the appropriate equipment for use at home. A bag or basket attached to your walker will allow you to carry small items when walking.Keep in mind that walking does take effort following surgery. While physical therapy will help patients learn how to correctly use a walker or crutches, an individual’s recovery is based on their dedication to therapy and exercises following surgery.
Eating and Exercising
Eat well-balanced meals and make sure to complete the exercises that you have been taught in physical therapy 3 times a day. Keep in mind that it can take over a year for your muscles to become strong, so it is extremely important to do your exercises to help ensure a safe and effective recovery. Also remember to elevate both of your legs when sitting to minimize swelling.
It is recommended that you not drive for 8 weeks following surgery. You may go out in a car (as a passenger) approximately 3 weeks after you return home, but make sure to avoid sports cars and cars with bucket seats because of the low seat height. To get in and out of a car, park the car several feet away from the curb. Stand on the street and turn your back to the car and sit down. Slowly slide back on the seat, keeping your legs straight, not leaning forward. Get into the car by swinging your legs around to the front of the seat, keeping your legs straight.
How should I get into a car after my total hip replacement?
- The front passenger car seat should be pushed all the way back before you enter the car.
- Have the driver park on a flat surface and/or near the driveway ramp.
- Walk toward car using the appropriate walking device.
- When close to the car, turn and begin backing up to the front passenger car seat. Never step into the car! (see figure 1)
- Placing a plastic bag on a fabric seat may make moving easier.
- Reach with your right hand and hold the door frame or headrest. Place your left hand on the car seat or dashboard. (see figure 2)
- Slowly lower yourself to the car seat. (see figure 3)
- Slide yourself back onto the car seat.
- Swing your legs into the car. Try to move one leg at a time. Keep your toes pointed upward. (see figure 4)
- Do NOT cross your legs! (see figure 5)
- Reverse these steps to get out of a car.
When taking extended car rides, make sure to take breaks every 30 to 45 minutes. Get out of car and walk/stand for a few minutes so you don't become too stiff.
How to Sit Down and Stand Up After a Total Hip Replacement
To sit after a hip replacement:
- Back up to the bed/chair until the back of your knees are touching the bed/chair.
- Reach your hands back for the armrests of the chair. Maintain your weight-bearing status!
- Lower your body slowly into a seated position. Avoid bending forward at your trunk.
- Sit on a firm chair with straight back and armrests. Keep hips and knees at 90 degrees (i.e., knees below hips).
- DO NOT sit on low, soft or overstuffed furniture that may cause excessive bending of your hip.
- Follow the precautions and weight-bearing status as instructed by your doctor or therapist.
- Scoot to the edge of the bed/chair. Avoid bending forward at your trunk.
- With your hands on the bed or chair, push up to the standing position. Bring one hand at a time up to your walker.
How frequently should I schedule follow up appointments with my doctor following surgery?
Post-operative visits help your surgeon know that your hip is healing well. Make sure to schedule your first evaluation within the recommended timeframe indicated by your surgeon. This recommended timeframe is 4 to 6 weeks following your hip replacement surgery. Also request that any X-rays be sent to your orthopaedic surgeon’s office. X-rays are typically taken the week of surgery, at 12 months and then yearly.If you have a problem before you schedule your return appointment, make sure to call your doctor’s physician assistant immediately.In addition to the first follow up appointment after discharge, this additional schedule is recommended:
- Three to six months following the date of surgery
- One year following the date of surgery
- Annually on the anniversary date of surgery
It is important to comply with this schedule and to see your doctor regularly for routine office visits to ensure safe and effective recovery from total hip replacement.