University of Iowa Department of Orthopaedics
Peer Review Status: Internally Peer Reviewed
First Published: March 1986
Last Revised: December 1999
This booklet is designed to provide information about total hip replacements and what to expect before and after this surgical procedure. Instructions are provided to help you prepare for surgery, recovery and rehabilitation.
It is recommended that you read this booklet before your surgery and write down any questions you may have. If you have questions, please feel free to ask the professional health staff.
The staff's goals are to restore your hip to a painless, functional status and to make your hospital stay as beneficial, informative, and comfortable as possible.
Contents
What is it?
Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts--the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the "ball" or head of the thigh bone (femur).
During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal.
These artificial pieces are implanted into healthy portions of the pelvis and thigh bones and affixed with a bone cement (methyl methacrylate).
Cementless total hip replacement
An alternative hip prosthesis has been developed that does not require cement. This hip has the potential to allow bone to grow into it, and therefore may last longer than the cemented hip. This is an important consideration for the younger patient. In some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cementless. This would be called a "Hybrid" hip prosthesis.
When do we consider total hip replacements?
Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies). Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons. Circumstances vary, but generally patients are considered for total hip replacements if:
What can be expected of a total hip replacement?
A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your physician's instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.
What are the risks of total hip replacement?
Total hip replacement is a major operation. The effect of most complications is simply that the patient stays in the hospital longer. The most common complications are not directly related to the hip and do not usually affect the result of the operation. These include:
Complications that affect the hip are less common, but in these cases, the operation may not be as successful:
A few of the complications, such as infection or dislocation, may require reoperation. Infected artificial hips sometimes have to be removed, leaving a short (by one to three inches), somewhat weak leg, but one that is usually reasonably comfortable and one on which you can walk with the aid of a cane or crutches.
How do artificial hips stand up over time?
As we noted earlier, 90 to 95 percent of hip replacements are successful up to 10 years. The major long-term problems are loosening or wear. Loosening occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (resorbs) from the cement. By 10 years, 25 percent of all artificial hips will look loose on an X-ray. Somewhat less than half of these (about 5% to 10% of all artificial hips) will be painful and require revision. Wear can ocur in the plastic socket after some years. Small wear particles can cause inflammation resulting in thinning of the bone and risk of fracture.
Loosening and wear are in part related to how heavy and how active you are. It is for this reason we do not operate on very obese patients or young, active patients. Loose, painful artificial hips can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complications are higher.
Preparing for a total hip replacement begins several weeks ahead of the actual surgery date. Maintaining good physical health before your operation is important. Activities which will increase upper body strength will improve your ability to use a walker or crutches after the operation.
Management of blood loss during and shortly after surgery is handled by several different methods. A simple blood test will be drawn on the day surgery is scheduled. That test will help decide the best blood management protocol for you. Depending on your hemoglobin level you may have a choice. You may be able to donate your own blood or you may receive injections that increase your own red blood cells. It is possible that you could use the cell saving system, which returns your own blood to you during or shortly after surgery. To donate your own blood is best for you; usually two pints of blood are taken prior to your surgery. Then if you require a transfusion you will receive your own blood. This is called autologous blood donation. The first donation must be given within 42 days of the surgery and the last, no less than seven days before your surgery. The usual amount of donation is two to four units, which requires separate visits to the blood center. The first donation must be given at this hospital, but the blood bank personnel will make arrangements to have the rest drawn at a blood center nearer your home. Blood taken elsewhere is transported here automatically, so you will not need to get involved with this.
When donating blood, you must be healthy, without a cold, flu or infection, as you could get this same illness when your blood is transferred at the time of surgery. Eat a nourishing meal two to four hours prior to donation, and avoid strenuous exercise for twelve hours following the procedure.
The blood donor center will check the blood count before drawing additional units. A prescription for iron will be given. Iron may be constipating for some people, so sometimes a stool softener is prescribed. Stool softeners can also be purchased over the counter. If your hemoglobin level is determined to be low, you may have the option to receive Procrit injections to increase your red blood cell levels before surgery. You will receive information about this medication from your physician and the nurses in the clinic.
You may be a candidate for autotransfusion after your surgery. Blood collected from the wound drain is filtered and transfused back to the patient early in the postoperative period. The physician will assist you in deciding whether this procedure will be done.
The physician may order blood tests and urinalysis two weeks before surgery to make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected. Please schedule an appointment with your dentist if you have not had a dental check during the past year. An infected tooth or gum may also be a possible source of infection for the new hip. The orthopaedic physician may ask you to see a medical doctor, especially if medical problems have been present in the past.
When making preparations for surgery, you should begin thinking about the recovery period following surgery. A patient with a new total hip replacement may need help at home for the first several weeks. Assistance with dressing, getting meals, etc. may be necessary. Most often discharge from the hospital is anticipated in about 4-6 days. Your energy level will not have returned. If assistance from someone at home is not possible, it may be necessary to think about making arrangements to stay a few weeks in an extended care facility.
Due to changes in insurance coverage, it is necessary for most patients to make a visit to the hospital a few days before their actual surgery date, This visit usually lasts several hours, so plan to spend most of the day. The day begins in the clinic, where an interview by the nursing staff concerning past medical history and current medications will be taken. You may be instructed to stop taking your anti-inflammatory medications (ibuprofen, Naprosyn, Relafen, DayPro, aspirin) one week before surgery. You will be attending a teaching session which will include the following topics and other information about your surgery. There will also be time for discussion and questions. Bring a written list of past surgeries and of the medications and dosages that you normally take at home.
Diet
You should follow your regular diet on the day before your
surgery. DO NOT EAT OR DRINK AFTER MIDNIGHT. The day of
surgery you may brush your teeth and rinse your mouth without
swallowing any water.
Bathing
A shower, bath or sponge bath should be taken the evening before and
morning of surgery. You will be given antiseptic scrub brushes to
use. Using the spongy side, scrub your hip for a period of five
minutes. This may require assistance from a family member. The
brushes contain a special soap which will reduce the risk of
infection. If you are allergic to iodine or soap, please inform the
nurse. If possible, you should shampoo your hair. Nail polish and
make up should be removed.
Deep Breathing Exercises
You will be instructed in deep breathing exercises to minimize the
risk of lung complications after surgery. These exercises are
necessary to remove any excess secretions that may settle in your
lungs while you are asleep during surgery. These exercises are to be
done every one or two hours after surgery. An incentive spirometer
may be demonstrated. This bedside device assists you in deep
breathing exercises.
Blood Clot Prevention
You may be fitted with elastic support stockings (TEDS). The morning
of surgery, you will receive these stockings to aid in the
circulation of your legs and feet to reduce the risk of blood clots.
Anesthesia
You may be scheduled for an appointment with the anesthesiologist to
discuss how you will be put to sleep. The anesthesiologist will
advise you about taking routine medications on the day of your
surgery.
Pain Control
Please read the booklet on "Patient Controlled Analgesia" (PCA) which
is the preferred method of pain control for the first 2-3 days after
your surgery. When the PCA is discontinued, your doctor will
prescribe pain medication to be taken by mouth. It is important to
continue taking them because preventing pain is easier than chasing
it. If you continue to experience pain after taking the medication,
we encourage you to notify your doctor or nurse so alternate methods
of pain control can be started.
The physician will also review your medical history and the medications that you take. He will listen to your heart and lungs, and do a general physical exam. He will check for any type of infection. Any blisters, cuts, or boils should be reported. If infection is found, surgery is generally delayed until the infection is cleared.
During your pre-op visit, blood will be drawn and lab tests one to insure that you are in good general health. X-rays are taken if necessary (an EKG is obtained if you have not had one taken for six months or if otherwise indicated). After all of these tests and exams are completed, an anesthesiologist will talk with you to determine the type of anesthesia that is best suited for you. After you see the anesthesiologist, your pre-op evaluation is usually over. Before you leave the hospital make sure your questions are answered. If at any time you become ill, such as with a cold or flu, you need to call your physician. Remember we want you to be in your best possible health!
Surgical checklist
Night before Surgery
Day of Surgery
You should arrive at the Presurgical Evaluation Clinic at the instructed time, with your hip scrubbed. The nurse will spend a few minutes again making sure that you are still in good health and ready for surgery. The nurses try to give you a good estimation of when you need to be at the hospital. However, it is hard to predict how long every surgery is going to take, so expect some waiting time. Bring something to do to help pass the time.
You will be asked to change into a hospital gown. You will be transported to the operating room on a stretcher. Your family may accompany you on the elevator and then will be instructed to wait in the Day of Surgery Lounge. Your doctor will talk to your family after the surgery to report your progress.
You will be taken to a presurgical care unit where an intravenous (IV) line is started for the administration of fluids and medications during and after the surgical procedure. From there you will be transported to the operating room by your anesthesiologist.
The actual surgical procedure may take two to four hours. However, preoperative preparation as well as wake-up time may make your operating room and recovery room stay longer.
After surgery you will be taken to the Recovery Room for a period of close observation, usually one to three hours. Your blood pressure, pulse, respiration and temperature will be checked frequently. Close attention will be paid to the circulation and sensation in your legs and feet. It is important to tell your nurse if you experience numbness, tingling, or pain in your legs or feet. When you awaken and your condition is stabilized, you will be transferred to your room.
Although circumstances vary from patient to patient, you will likely have some or all of the following after surgery:
Activity
Some patients experience back discomfort after surgery. This is caused by the general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown.
The head of your hospital bed should not be elevated more than 70 degrees during the first few days after surgery. Sitting up may allow the artificial ball to dislocate from the hip socket.
There will be some precautions, mostly to prevent dislocation, which is more likely to occur the first six to eight weeks after surgery. These precautions include:
Initial rehabilitation
The first day after surgery you will be assisted to a reclining chair, and physical therapy may begin. You will gradually begin to take steps, walk, and learn to climb stairs with the aid of a walker or crutches.
This initial rehabilitation generally takes 4-6 days. During this time, discomfort may be experienced while walking and exercising. Pain medication will be ordered by the doctor as needed. Most patients are relieved of their painful pre-surgical hip condition.
Therapy and rehabilitation program
Following surgery, you will work with a physical therapist to become independent in walking, going up and down stairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of your hip. You will be instructed by your physical therapist in a specific home exercise program to meet your needs.
Do the home exercises two to three times a day (see home exercises section). Do your exercises indefinitely. Walking is not a substitute for exercise.
If an exercise is causing pain that is lasting, reduce your intensity. If it continues to cause pain, contact your physical therapist or physician.
Here is a list of potential exercises you may be asked to complete. These exercises are sometimes done before surgery to help maintain the strength and range of motion of your hip.
Range of motion exercises
Active hip and knee flexion:
Lying on your back with legs straight, toes pointed toward the ceiling; arms by your side. Keeping the heel in contact with the bed, bend your hip and knee. Return to starting position. Progress to 20 repetitions, 2 times a day.
Active Internal and External Rotation:
Begin with your legs straight and a comfortable distance apart. Roll your legs inward so that your kneecaps are facing each other. Hold for 5 seconds. Roll your legs outward and hold for 5 seconds. Progress to 20 repetitions, 3 times per day.
Active Abduction:
Place a smooth surface (card table, plywood sheet, etc.) under your legs. Begin with your legs together, then spread them apart as far as you can. Hold them apart for 5 seconds. Return to the starting position. Progress to 20 repetitions, 3 times a day.
Strengthening Exercises
Quadriceps Setting:
Tighten the muscles on the top of your thigh. At the same time push the back of your knee downward into the bed. The result should be straightening of your leg. Hold for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 3 times a day.
Gluteal Setting:
Lie either on your back with your legs straight and in contact with the bed. Tighten your buttocks in a pinching manner and hold the isometric contraction for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 3 times a day.
Isometric Hip Abduction:
Keeping your legs straight, together, and in contact with the bed, place a loop or belt around your thighs and attempt to spread your legs. Hold the contraction for 5 seconds, relax for 5 seconds. Progress to 20 repetitions, 3 times a day.
Straight Leg Raising:
Bend uninvolved leg by raising the knee and keeping the foot flat on the bed. Keeping your involved leg straight, raise it about 6 to 10 inches. Lower the leg slowly to the bed and progress to 20 repetitions, 3 times a day.
If you have a hip contracture (problems with straightening your hip), your physician and physical therapist may recommend that you lie on your stomach with your feet hanging off the bed for 15-30 minutes 2-3 times a day. If you do this exercise after your surgery, it is important to carefully position your hip while turning onto your stomach. Follow the total hip precautions-do not let your leg cross midline, internally rotate or bend past 90 degrees while rolling onto your stomach.
Hip Extension:
While lying on your stomach, raise one of your legs off the bed with the knee kept straight and the pelvis held in contact with the bed. Slowly lower the leg. Repeat 10 times. Avoid hyperextending the back. Repeat procedure for other leg. Progress to 10 repetitions each leg, 3 times a day.
Do's and Don'ts
Your new hip is designed to eliminate pain and increase function. There are certain movements that place undue stress on your new hip. For your safety, these should be avoided. This is especially true during the first few months after your surgery.
DO NOT move your operated hip toward your chest (flexion) any more than a right angle. This is 90 degrees.
DO NOT sit on chairs without arms.
DO grasp chair arms to help you rise safely to standing position. Place extra pillow(s) or cushion(s) in your chair so that you do not bend your hip more than 90 degrees.
DO NOT get up like this. Keep your involved leg in front while getting up.
DO use a chair with arms. Place your operated leg in front and your uninvolved leg well under.
DO NOT sit low on toilet or chair.
DO get up from toilet as directed by your therapist. Use the elevated toilet seat if we have given you one.
DO NOT pull blankets up like this.
DO use a long-handled reacher to pull up sheets or blankets or do as directed by therapist.
DO NOT bend way over.
DO NOT turn your knee cap inward when sitting, standing, or lying down.
DO NOT try to put on your own shoes or stockings in the usual way. By doing this improperly you could bend or cross your operated leg too far.
DO these activities as directed by your therapist.
DO NOT cross your operated leg across the midline of your body (in toward your other leg).
DO NOT lie without pillow between legs.
DO keep a pillow between your legs when you roll onto your "good" side. This is to keep your operated leg from crossing the midline.
What happens after I go home?
Upon discharge from the hospital, you will have achieved some degree of independence in walking with crutches or a walker climbing a few stairs, and getting into and out of bed and chairs.
Someone at home is needed to assist you for the next six weeks, or until your energy level has improved.
Medication
Activity
Sitting
Avoid sitting more than 60 minutes at a time. DO NOT cross your legs. In fact, keep your knees 12 to 18 inches apart. Always sit in a chair with arms. The arms provide leverage to push yourself up to the standing position. A high kitchen or bar-type stool works well for kitchen activities. Avoid low chairs and overstuffed furniture because they require too much bending (flexion) in your hip in order to get up. Do not bend forward while sitting in a chair, causing more than a 90 degree bend in your hip. Use the toilet seat riser for the next eight weeks to avoid excessive bending of the hips.
Bending
For the first eight weeks, you should not bend over to pick up things from the floor. You may want to acquire a pair of slip-on shoes and a long-handled shoe horn to avoid excessive bending.
It is recommended that you do not drive until six weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/out of the car.
For the next 4-6 weeks avoid sexual intercourse. Sexual activity can usually be resumed after your two-month follow-up appointment.
You can usually return to work within three to six months, or as instructed by your doctor.
Continue to wear elastic stockings (TEDS) until your return appointment.
Don't shower until after staples are removed. Showers may be taken two days after your staples are removed. Do not sit in a bathtub until your physician okays that activity.
If you have to stay alone for the first six weeks, there are some special devices that are available from the occupational therapist.
Your incision
Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. Generally, the staples are removed in three weeks.
Prevention of infection
If at any time (even years after the surgery) an infection develops such as strep throat or pneumonia, notify your physician. Antibiotics should be administered promptly to prevent the occasional complication of distant infection localizing in the hip area. This also applies if any teeth are pulled or dental work is performed. Inform the general physician or dentist that you have had a joint replacement. You will be given a medical alert card. This should be carried in your billfold or wallet. It will give information on antibiotics that are needed during dental or oral surgery, or if a bacterial infection develops.
When Do I Return to the Clinic?
Your first return appointment is 6 weeks after discharge, unless you return here to have your staples removed. (You may wish to have your staples removed by your local doctor.) At your 6 week return you will be examined and have x-rays. Subsequent appointments are then at 6 months, one year, and two years after surgery. You should return every three years after this.
Should I have a total hip replacement?
The total hip replacement is an elective operation; it is not a matter of life or death. There are always nonoperative alternatives. The decision to have the operation is not made by the doctor. It is made by you, for it is you who must accept the risks and complications. The doctor may recommend the operation; however, your decision must be based upon weighing the benefits of the operation against the risks. You may wish to discuss the surgery with your own doctor or even get another opinion. All your questions should be answered before you decide to have the operation. Please feel free to ask any questions you have in order to make your decision easier.
Remember: Your physician, physical therapist, and nurses are striving to make a painless, functional hip possible for you. The real success of your hip replacement, however, depends partly on you--especially how conscientiously you exercise and how diligently you apply the principles of home care and self-limitation.
See related Patient Textbooks about Orthopaedic Surgery.
See related Patient Topics Bones, Joints and Muscles, Hip Injuries and Disorders, Injuries and Wounds, Orthopaedic Surgery, Procedures and Therapies, Rehabilitation or Surgeries.
See related Provider Textbooks about Orthopaedic Surgery.
See related Provider Topics Bones, Joints and Muscles, Injuries and Wounds, Orthopaedic Surgery, Procedures and Therapies or Surgeries.
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