Total Hip Replacement

The hip joint is one of the body's largest weight-bearing joints, located between the thigh bone (femur) and the pelvis (acetabulum). It is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The joint surface is covered by a smooth articular cartilage which acts as a cushion and enables smooth movements of the joint.

As we get older the cartilage in our joints becomes more brittle and is likely to wear out or degenerate. This can lead to osteoarthritis, which is the wearing out of the lining (articular) cartilage, and is the most common cause for a total hip replacement. Due to the osteoarthritis, the cartilage in the hip breaks down and the result is a badly damaged joint surface, often, with bone rubbing on bone. The commonest symptoms are pain, stiffness and a limp. Pain is most commonly felt in the groin, but may also be on the side of the hip, the buttock, the thigh and the knee (occasionally knee pain is the only sign of hip arthritis). The pain is often constant, with and without activity, and present at night as well as during the day. Stiffness makes it difficult to get to your feet, put shoes and socks on, pick things up off the ground, get into and out of low chairs and cars.

If you have arthritis in your hip, the first step is to try simple treatments such as taking painkillers and anti-inflammatories and gentle exercises. Weight loss can also significantly improve symptoms. Used in combination, these treatments can improve your pain and level of function significantly and you may not need anything else at this stage.

If you have tried all of the above, and you are still getting significant pain and stiffness that is preventing you from doing the things you want to do or you are not able to sleep because of the pain, a hip replacement may be the best solution for you. Hip replacement is the best treatment for arthritis when the symptoms are severe enough. Click here for more information on hip arthritis.

Hip replacement is very effective treatment for arthritis, but like any other surgery it has risks. It should be done only when painkillers, exercise and weight loss have been tried and have failed. Some patients worry that if they wait too long they won’t be able to have a hip replacement, or that they should have the replacement straight away to stop the arthritis getting worse in the future. That is not necessarily the case – if you are managing okay with the arthritis now, then it is not yet time for replacement; when it gets hard to manage, it will be time. If there are activities that you want to do, but you can’t, or you are limited because the hip is too painful or stiff, then it may be time for hip replacement. If you are woken or can’t sleep because the hip is sore, then it may be time.

Hip replacement surgery is widely regarded as being the most effective of all orthopaedic operations. More than 90% of patients are satisfied or very satisfied with their operation and recovery. For many patients, six months after hip replacements the hip is so good that in day to day life patients ‘forge’ that they have had a problem, or an operation at all.

A Total Hip Replacement (THR) or Total Hip Arthroplasty is a surgery to remove the damaged ball and socket of the hip joint and replace them with an artificial hip made of metal, hard wearing plastic and ceramic. It is a very good way of getting rid of pain from hip arthritis, a broken hip (fractured neck of femur), or a damaged hip.

In the hip replacement procedure, each prosthesis is made up of four parts.

The femoral stem sits within the hollow central canal of the femur (thigh bone). We use femoral stems made of either polished stainless steel cemented into the femur or roughened titanium which grips the femoral bone.

The femoral head is the ball that sits on the stem; it is made of polished stainless steel or hard ceramic.

The socket which is made of roughened titanium and grips the pelvic bone.

The liner is made of hard polished polyethylene (plastic) that allows the head to slide smoothly. When the bone in the pelvis is soft we will cement the polyethylene directly into the pelvic bone.

Hip replacement is carried out under either a spinal anaesthetic (needle in the back to numb the legs) or a general anaesthetic (completely asleep). Either way, the patient feels nothing during surgery. A cut is made on the side of the hip, or on the front for the Anterior Hip Replacement (see below). The muscles and hip joint lining are held apart with retractors or divided and repaired at the end. The damaged bone is removed, and the new socket, stem and head are put in. Local anaesthetic is infiltrated to numb the area. The skin is stitched with dissolving stitches, and a waterproof dressing covers the wound.

Direct Anterior Approach is a technique used by some surgeons at MHK to perform Total Hip Replacement surgery. The incision is made at the front of the hip rather than on the side. The anterior approach is made to the hip joint between muscles, rather than having to split muscles. It is routinely combined with Robotic Joint Surgery. The replacement components that are implanted are the same well performing components, regardless of approach.

What are the benefits of the anterior approach?

Because the approach is made between muscles rather than splitting the muscles, patients may report less pain and pain medication use after surgery. This may result in patients recovering a little quicker from surgery. 

Depending on the approach to hip replacement, a patient may have restrictions on certain movements (eg. avoiding low, deep chairs). There are less post operative restrictions for the anterior approach, as the major stabilising muscles of the hip are not released during the operation. 

While there are short term benefits to anterior approach hip replacement surgery, longer term studies show that the different approaches perform equally well.

Once you and your surgeon have decided to proceed with surgery, there are several steps to be taken to ensure your procedure goes smoothly.

Physician review

Joint replacement surgery is a fairly big operation and the anaesthetic for this is a stress on the body. There is always a small chance of heart attack or stroke with this anaesthetic. While you may have had a check-up or some blood tests by your GP we think your health is worth a more careful check. As a routine we organise an appointment with a specialist physician. This specialist will have a careful listen to your heart and lungs, review your blood tests and ECG and discuss your health and hospital care with you. If you are on any medication they may want to stop this or change it prior to your surgery especially if you take blood thinning medication (eg warfarin or Plavix). It is important that the physician you see prior to your operation works at the hospital where you are having the operation. They will then help with your care and if there are any problems after the operation someone who has seen you before and knows you will be there to give you the best possible care.

Pre-Admission Clinic

Most hospitals run a specific joint replacement preadmission clinic to help patients prepare for their hospital admission. These sessions include presentations from nurses, physiotherapists and occupational therapists. It is strongly recommended that you attend one of these clinics.

Start pre-operative exercises

It is important to be as flexible and strong as possible before undergoing a total hip replacement. Many patients with arthritis favour the pain free leg, as a result muscles can become weaker, making recovery slower and more difficult.  It is important therefore, to begin an exercise program before surgery to learn and practice the exercises that will improve your strength and flexibility making recovery easier and faster. Melbourne Hip and Knee offers pre and post-operative physiotherapy sessions onsite at our main rooms in Hawthorn East. To book an appointment call , alternatively, if you have a regular physiotherapist they will be able to get you on track.

Make arrangements for help around the house

It is important to have your house ready for when you return home. You may need to modify sleeping arrangements if they are up a lot of stairs. You should also put things that you use often within easy reach, remove cords or obstructions from walkways, arrange for someone to walk the dog and collect the mail.

Stop smoking

Stop smoking as long as possible prior to surgery. Smoking delays your healing process. It reduces the size of your blood vessels and decreases the amount of oxygen circulated in your blood. Smoking greatly increases your chances of getting an infection of your prosthesis or the wound breaking down. Smoking can also increase clotting, which can cause problems with your heart. Smoking increases your blood pressure and your heartrate. If you quit smoking before you have surgery, you will increase your ability to heal.

• Arrival: You will be asked to attend the hospital approximately two hours before the anticipated time of your operation. There are several stages to your admission process and this ensures that adequate time is available.  
• Fasting: Fasting is important to ensure your procedure can occur, and it includes refraining from all food and fluids, including water, chewing gum, mints or lollies.  You will be asked to fast for at least six hours before your surgery
• Medications: Please bring all current medications with you to the hospital. Generally you can take your usual medication on the day of surgery with a sip of water, however, if you are on any blood thinning or rheumatoid arthritis medication please check with your physician in advance regarding if or when to cease them.
• X-rays/Scans/Imaging: please bring all that you have to the hospital. This includes the actual scans (not just the reports).  
• Luggage: space is limited so avoid bringing unnecessary items. We strongly recommend you do not take valuables to hospital, no liability for loss, theft or damage of valuables will be accepted by hospitals.

The following processes will occur:

• Clerical admission- you will be initially admitted by a clerical staff member at the hospital. They will check all of your administrative details and take any payments due.
• Clinical admission- you will then undergo a clinical admission where a nurse will discuss your medical history, this may include recording your height, weight and blood pressure. If any blood tests or other investigations are required they will be taken at this time. You will be changed into a theatre gown.
• Anaesthetic review- your anaesthetist will visit you prior to your surgery to explain the type of anaesthetic you will be receiving.
• Surgeon- your surgeon will again explain the procedure you are about to undergo. They will mark the correct part of your body where the procedure will happen. You will also sign surgical consent.

Recovery

When you wake you will be in the recovery room with intravenous drips in your arm, you may have a tube (catheter) in your bladder and a number of other monitors to check your vital observations. You may have a button to press for pain medication. Once stable, you will be taken to the ward. The post-operative protocol is surgeon dependant. You will start moving your hip and walking on it within a day of surgery. You are encouraged to begin physiotherapy exercises straight away.

Dressings

We use dissolving stitches and waterproof dressings. You can shower with the dressing on, but try not to soak it as it may peel off. Avoid swimming pools (including hydrotherapy pool) until after your two-week review appointment. If the dressing peels off within the first two weeks, then replace it with a waterproof dressing from the chemist. DO NOT clean the wound itself or apply antiseptics to the wound, just cover it up again. If there is increasing pain or leakage, then get in touch with the rooms straight away. DO NOT start antibiotics even if you think the wound is infected, without talking to your surgeon first.

Going Home

Going home is based on being safe, controlling pain and regaining mobility. Most patients spend 3-4 days in hospital. Some patients prefer to spend less time in hospital, and as long as they are safe can get out sooner. Other patients prefer a more gradual return to activity and go to a rehabilitation facility for 1-2 weeks after their surgery. You will be discharged on a walker or crutches and usually progress to a cane at six weeks. Please ensure you arrange for someone to pick you up.

Pain Management

You should take regular painkillers and ice the hip regularly for the first few weeks to make sure the hip feels comfortable, and also to allow you to do your physiotherapy exercises. You should wear compression stockings (day and night) and take daily blood thinners for one month after surgery to decrease the risk of developing blood clots. It takes several weeks for the pain to settle down and it can be several months before it really feels normal.

Post-operative appointment

You will usually have a post-operative appointment booked to see your surgeon approximately two weeks after surgery. Your appointment information is on your admission letter. Please call Melbourne Hip and Knee if you are unable to locate this information.  If you are still in a rehabilitation facility when you are due to have your appointment, please call us to reschedule.

Physiotherapy

You will have physiotherapy each day in hospital and you should continue to see a physiotherapist after you leave hospital. If you have seen a physiotherapist prior to surgery you should return to them after the surgery for follow up exercises.

Returning to activity

How quickly you return to activity is highly variable. In general, younger and more active patients are able to return to activity quicker. If you have preoperative physiotherapy this will aid your quicker return to activity after your surgery.

Driving.  Regardless of the approach used, leg strength and coordination takes time to return. It is not safe to drive until six weeks after right hip replacement. If you have an automatic car and you have had a left hip replacement, then you can drive when you are off all strong painkillers and can easily get in and out of the car. This may be as soon as 2-3 weeks after your operation. If you have your left hip replaced and you drive a manual car it will often take 5-6 weeks for the hip to be strong enough to drive,

If you have your right hip replaced, then it needs to be strong enough and move well enough to quickly change pedals and push hard on the brake. This will often take 6 weeks or longer.

Work. Return to work depends on your type of work. How you get to work, whether there is walking around or stairs at work and many other factors. Many patients do paperwork from home within two weeks of surgery. If you can comfortably get to and from work you may be able to go in to do office duties at about four weeks. You can do most non-physical/seated duties by six weeks. For full return to work or physically demanding jobs, it is safest to wait three months after surgery.

Walking unaided. After a few weeks you may be able to walk around the house unaided but many people continue to carry a walking stick or crutch for a few more weeks when outside the house for support, balance and to warn the general public that you need more space.

Sport (swimming/hydrotherapy). You can start hydrotherapy as soon as the wound has fully healed, this is normally around 3 weeks after surgery but make sure you get the clearance from your surgeon first. The aim of hip replacement is to get you back to all the activities that you want to do. As a rule of thumb, activities that you regularly did socially before hip replacement are okay after three months. Contact and competition sports should usually be avoided; it’s okay to kick the footy with your kids, but don’t play a match; it’s okay to ski, but don’t go in a slalom race; it’s okay to jog, but don’t run marathons. Discuss any sports with your surgeon.

Sex. Once your wound has healed and you are comfortable you are able to return to sexual activity as long as you take things gently. If there is any pain, then do not go any further in that position. Try gently getting into a position by yourself before trying with a partner. Avoid bending the hip right up beyond 90 degrees as it is more likely to be uncomfortable.

Technology in Hip Replacement Surgery is constantly improving. However, hip replacements can come loose or wear out and need to be revised (re-done). On average there is between half and one percent chance each year that a hip replacement will need to be revised. On average, Australians live to 85 years, so if you have a hip replacement at 60, there is about a 15-20% chance it will need to be redone at some stage in your lifetime; or an 80-85% chance that it will last you the rest of your life.

Anaesthetic

There are risks associated with the anaesthetic, including the possibility of heart attacks, strokes and breathing difficulties. The chance of these occurring is generally very low and this is why you are fully assessed by a physician before you have your operation to see if there is anything that needs to be done to decrease this risk further.

Infection

There is a risk of the hip replacement getting infected. This occurs in 1 in 100 operations. If the knee replacement gets infected, you may need further operations to wash it out. If the infection is severe, the whole knee replacement may need to be removed and then replaced again once the infection is cured. There is a small risk of

Nerve Injury, dislocation, leg length discrepancy

These are all possible, but all rare – less than 1% in our patients.

Blood Loss

If you lose a lot of blood from the operation, you may require a blood transfusion.

Blood Clots (DVT)

As mentioned above, there is a risk of developing clots in the legs which can then go to the lungs. You will be given special stockings to wear and blood thinning medication to reduce this risk. It is also important to do you exercises to increase blood flow to the lower leg.

If you have any further questions, please ask your surgeon.

It is uncommon to need a blood transfusion after joint replacement surgery but some patients, for religious or personal reasons never want to have a transfusion.

If this is the case our surgeons are happy to discuss ways to fulfill your request. We will ensure you have an adequate blood count prior to surgery and various medication and techniques can be used to preserve blood during your operation.