Welcome to the Total Hip Arthoplasty section. The pages are laid out in the same order as treatement will take place so to read about the procedure for the first time choose introduction and follow on from there.
Total hip arthroplasty is undertaken for hip arthritis. With age or following rheumatoid arthritis the weight bearing surfaces of the hip joint become worn away. They are no longer smooth and free running and this leads to stiffness and pain. Eventually the joint wears away to such an extent that the bone of the femur grinds on the bone of the pelvis or acetabulum. Joint replacement is then required. New technology, new techniques and new types of hip replacements have made this procedure in recent years very successful and the results are now very reliable.
When the arthritis is severe in a younger patient the hip may be replaced without the use of cement. This is dependent on the use of special metal components with porous surfaces or coatings, which allow the bone to grow into the metal surface and thereby, stabilise the new replacement joint. This technique does require the use of crutches in the early postoperative period.
A total hip replacement replaces the surfaces of the hip with plastic and metal components. The femoral replacement is a smooth metal component which fits snugly into the inside of the upper end of the thigh or femur bone. The socket or acetabulum of the hip in the side of the pelvis is replaced by a replacement cup.
This is usually made of high density polyethylene which is cemented into place or alternately in younger patients a metal cup which is inserted without cement.
In certain circumstances special components may be "press fitted" to the bones without the additional use of cement. These components use micro-porous metallic surfaces and may have an additional hydroxyapatite coating to promote osteo-integration or bonding to the bone. More recently a resurfacing hip replacement has become popular in younger patients which uses minimally invasive surgical techniques to replace only the surface of the hip joint. This avoids excessive removal of bone and may be considered a more conservative procedure. The early results of this type of surgery have been encouraging
Total Hip Arthroplasty - Indications / Contra-indications
Anatomy / Ailment detail : -
The hip comprises the joint between the upper end of the femur and the pelvis or acetabulum. Either or all of these parts of the hip may be affected by arthritis to various degrees. The procedure of joint replacement includes removing the affected joint surfaces and replacing them with metal components usually with a high-density polyethylene-bearing surface between the metal components. The metal components are usually (but not always in special circumstances) cemented to the bone. Using new techniques often joint replacement may be undertaken using minimal access surgery utilising much smaller incisions than previously utilised. This assists with rapid recovery and return of function.
Who Needs it / Who Doesn't : -
The symptomatic arthritic patients with pain, limp, deformity or a restricted function are those which should consider hip replacement. The symptoms include hip pain, or alternately pain is commonly experienced in the buttock, groin, lower thigh or in the knee joint. Alternately joint replacement may be considered for patients with restricted function and walking ability and increasing stiffness or deformity of the hip. Alternately in some patients the pain may only be moderate and stiffness, deformity, instability may be the principal complaint. Function may be limited in that walking may be restricted or activities such as golf or bowling may be difficult. These problems may also promote patients to consider hip replacement.
Total Hip Arthroplasty - Non-operative Treatment
Management usually includes a detailed history of the condition, details of the current symptoms and disability, current and previous medications and past medical history. Clinical examination is undertaken by Mr. Johnson and subsequently radiographs or MRI scans can be arranged if necessary. An opinion is usually then available and discussed with the patient. Mr. Johnson will outline options for further treatment, and patients will then be encouraged to participate in the decisions about which treatment options are most appropriate.
Initial management for early degeneration may include physiotherapy, use of anti-inflammatory medication (Ibruprofen, diclofenac, vioxx etc). Joint injections either with hyluronic acid (Synvisc) or methyprednisiolone may occasionally be considered. For early degeneration or in patients in whom there has been a rapid deterioration or injury keyhole arthroscopic treatment may prove to be very helpful. Alternately joint replacement may be appropriate because of advanced disease or where the other treatments prove to be ineffective.
Total Hip Arthroplasty - Surgery
Prior to Surgery : -
Walking Aids: -
If pain is experienced during walking this may be eased in several ways. A walking stick may be helpful when used in the opposite hand to the painful hip. If there is a difference in the length of your legs, help may be gained by a shoe raise on one side. This can be manufactured to fit un-noticed into your shoe.
Prior to surgery it is important to strengthen the muscles of the leg and to reduce the stiffness of the hip joint. Regular exercises for a half hour, perhaps three times a day, should be undertaken to achieve this. Whilst lying on your back, the straight leg should be lifted and held for 5 to 10 seconds, rest for 5 or 10 seconds and begin again. This should be repeated 10-50 times. Hip bending is achieved by lying on your back whilst bending the hip and hip, pulling the thigh up onto the stomach and chest. The abductor muscles on the outside of the hip joint are strengthened by lying on one's side and lifting the straight leg up to the side. Swimming is also a very useful exercise
Prior to admission to hospital, blood tests, a urine test, a hip X-ray, a chest X-ray and an ECG or heart tracing will be performed. Blood will be cross matched so as to be available for transfusion following surgery. If you wish to arrange for your own blood to be pre-donated and ready for autologous transfusion, this should be done some weeks in advance and will require a trip to the blood bank on several occasions.
Prior to the operation any tablets or medications you take, or allergies you may have to medications, should be brought to the attention of the Surgeon. You should stop anti-inflammatory arthritis tablets for one week prior to surgery. Take only Paracetamol for pain relief during this period. Please notify your Surgeon and Anaesthetist in advance if you are taking any anti-coagulants (blood thinners), hormone tablets or suffer from diabetes.
Medication:
In order to relieve the pain of arthritis painkillers may be prescribed. You may be instructed to take the tablets regularly or when the pain is severe. If the pain is particularly bad at night, relief may be achieved if the tablets are taken before going to bed. Anti-inflammatory tablets are commonly used in the treatment of arthritis.
These tablets reduce the inflammation in the joint as well as acting as pain killers. The tablets may cause stomach upset and should therefore be taken with food. If, despite this, the pain continues, then the dose should be reduced or even stopped if necessary.
Surgical Technique : -
A general anaesthetic is generally used, sometime a spinal injection is preferred. To be able to replace the hip joint an incision is made down the side of the hip and the joint is opened. The length of incision may vary from 5-10 cm if minimally invasive surgical techniques are used to 15 - 20 cm in conventional surgery.
The bone is shaped so that the joint replacement components sit firmly within the bone. The components will either be fixed with acrylic cement, or for young patients special components with a roughened or porous surface will be used. The bone then grows into the roughened surfaces anchoring it without the use of cement.
Once the total hip replacement has been inserted, the joint is closed over drainage tubes to take away the bleeding from the joint. They stay in the hip for one or two days. The hip will have a dressing. You will have a drip to administer fluids whilst you do not feel like eating or drinking. A blood transfusion may be given if required. Initially the hip may be painful. Powerful pain-killing tablets and injections will be prescribed. It is usual for these to be required for 1 or 2 days, so do not be afraid to ask for something if you are in pain. Further blood tests and X-rays will be taken. Injections or tablets to thin the blood and to prevent thrombosis will also be given.
Minimally Invasive Surgery; MIS : - Minimally invasive surgery involves the use of smaller wound incisions and special instrumentation to enable surgery to be undertaken. These techniques can result in advantages in respect to improve the speed of recovery, speed of mobilization, shorten hospital stay reduce the period off work and reduce the time until functional and sporting activities can be resumed. The recovery from the operation requires about 3-7 days in hospital. In this time physiotherapy is commenced.
Wound Dressing and Sutures : -
The wound dressing which is applied in theatre may be removed after 4 days if the wound is satisfactory. The sutures should be removed by the General Practitioner or Practice Nurse after 12 days. Sometimes arrangements are made for patients to return directly to the hospital for this.
Total Hip Arthroplasty - Recovery and Rehabilitation
Medication : -
If the joint replaced was the only area of arthritis no further anti-inflammatory tablets will be required. If other joints are affected or you suffer from rheumatoid arthritis, the tablets may be restarted if possible after an interval of 6 weeks. Pain killers may be taken during this time.
Physiotherapy : -
After 1 days the physiotherapist will get you out of bed to commence walking with the help of crutches or a walking frame. The physiotherapists will also begin to encourage you to bend the hip and knee. Sitting is allowed only after 2 days and then only on a high chair. The early exercises and mobilising of the hip will cause some discomfort and swelling. However, this is normal and is just the healing process occurring. Any swelling or discomfort in the calf muscle of either leg should be brought to the attention of the nursing staff.
After 5 - 10 days you are usually able to walk with minimal or no pain, although the assistance of sticks, crutches or a frame may be necessary. You should be able to manage stairs with the assistance of a banister, and to care for yourself around the home. When this is possible you will be discharged from hospital. This is usually within 5-7 days.
Whilst at home the exercise programme of hip exercises should be vigorously continued. Approximately 10 minutes each hour will be ample. Out patient physiotherapy sessions should be arranged during this period. The progress is variable, so do not worry if your progress is a little slow at this stage. If the hip becomes more swollen or more painful than during the first day, or the wound becomes infected, please return to your General Practitioner for early review. I will review your progress in the clinic after 4 or 6 weeks.
Results and Complications
Modern techniques and technology ensure that the complication rate is minimal. Beside the anaesthetic risks, which are very low, infection that involves the joint is less than 1:200. This would present as the hip becoming hot, swollen, throbbing and painful after 2-4 days, or alternatively at any period thereafter. Venous thrombosis is in the order of 1:5. To avoid thrombosis anti-coagulant therapy will be given for a short period after the operation. Thrombosis presents with a swollen, tender calf muscle, or intermittent pain in the chest on deep breathing. There is a risk to the major vessels and nerves of the hip, but this is very rare.
Dislocation of the hip replacement may occasionally occur. This usually happens when the hip is bent excessively or the legs crossed. In order to avoid this problem a pillow between the legs should be used at night for 3 months. The legs should not be crossed. Sitting in low arm chairs and couches should be avoided and a raised lavatory seat is available from the Occupational Therapist who is contacted through your General Practitioner.
Generally, hip replacement should, if cared for, last 15 years in over 90% of patients. After joint replacement, in order to avoid infection of the new joint, all infections or dirty cuts must be adequately treated with antibiotics. This includes any urinary infections or bad chest infections. Any further surgery must be covered by a short period of antibiotic therapy. This includes any dental treatment or urinary catheterisation. A yearly review should be undertaken with an up-to-date X-ray. This is to ensure that the prosthesis is not becoming loose. If you move home you should inform the secretary so that follow-up can be arranged.
Return to Work / Sport
If your job is sedentary and mostly sitting you may wish to return after only 3 - 6 weeks. If your job is physically demanding and requires standing or walking for most of the day, your return to work may take several months. Driving can usually be performed after 4 to 6 weeks, providing that the hip is pain free and you are able to control the car with foot pedals and make an emergency stop. Swimming is often possible after 3 - 6 weeks. Return to golf, gentle tennis or badminton may take 3 months. Jogging and squash is not advised.
The list of of Hip Resurfacing Hospitals in India is as follows : -
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A total hip replacement replaces the surfaces of the hip with plastic and metal components. The femoral replacement is a smooth metal component which fits snugly into the inside of the upper end of the thigh or femur bone. The socket or acetabulum of the hip in the side of the pelvis is replaced by a replacement cup.
This is usually made of high density polyethylene which is cemented into place or alternately in younger patients a metal cup which is inserted without cement.
Prior to admission to hospital, blood tests, a urine test, a hip X-ray, a chest X-ray and an ECG or heart tracing will be performed. Blood will be cross matched so as to be available for transfusion following surgery. If you wish to arrange for your own blood to be pre-donated and ready for autologous transfusion, this should be done some weeks in advance and will require a trip to the blood bank on several occasions.
A general anaesthetic is generally used, sometime a spinal injection is preferred. To be able to replace the hip joint an incision is made down the side of the hip and the joint is opened. The length of incision may vary from 5-10 cm if minimally invasive surgical techniques are used to 15 - 20 cm in conventional surgery.
After 1 days the physiotherapist will get you out of bed to commence walking with the help of crutches or a walking frame. The physiotherapists will also begin to encourage you to bend the hip and knee. Sitting is allowed only after 2 days and then only on a high chair. The early exercises and mobilising of the hip will cause some discomfort and swelling. However, this is normal and is just the healing process occurring. Any swelling or discomfort in the calf muscle of either leg should be brought to the attention of the nursing staff. 
