Treatments

Anatomy of the Hip:

Joints are formed where bones meet. Most joints are mobile, allowing the bones to move without friction or discomfort. The hip joint is a ball-and-socket joint, which allows backward, forward, sideways, and rotating movements. The ball part of the hip joint is the head of the femur (thigh bone), and the acetabulum is the socket, a cup-like structure in the pelvis. The hip joint has significantly more bony contact and stability compared with other joints, such as the shoulder.
A hip joint consists of the following:

• Cartilage – A type of tissue that covers the surface of a bone at a joint. Cartilage helps reduce the friction of movement within a joint.
• Synovial membrane – A tissue that lines the joint and seals it into a joint capsule. The synovial membrane secretes synovial fluid (a clear, sticky fluid) around the joint to lubricate it.
• Ligament – A type of tough, elastic connective tissue that surrounds the joint to give support and limits the joint’s movement.
• Tendon – A type of tough connective tissue that connects muscles to bones and helps to control movement of the joint.
• Bursa – A fluid-filled sac located between bones, ligaments, or other adjacent structures that helps cushion joints.
• Femur – Thighbone or upper leg bone.
• Acetabulum – A socket or cuplike structure that holds the femur head.

Reasons for Total Hip Arthroplasty:

Knee Hip replacement surgery is a treatment for pain and disability in the hip. The most common condition that results in the need for hip replacement surgery is osteoarthritis. Osteoarthritis is characterized by the loss of joint cartilage in the hip. Damage to the cartilage and bones limits movement and may cause pain. People with severe pain due to degenerative joint disease may be unable to do normal activities that involve bending at the hip, such as walking or sitting, because they are painful. Other forms of arthritis, such as rheumatoid arthritis and arthritis that results from a hip injury, can also lead to degeneration of the hip joint.

Hip replacement may also be used as a method of treating certain hip fractures. A fracture is a traumatic event that may result from a fall. Pain from a fracture is severe and walking or even moving the leg is difficult. If medical treatments are not satisfactory at controlling pain due to arthritis, hip replacement surgery may be an effective treatment. Some medical treatments for degenerative joint disease may include, but are not limited to, the following:

• Anti-inflammatory medications
• Glucosamine and Chondroitin Sulfate
• Pain medications
• Limiting painful activities
• Assistive devices for walking (such as a cane)
• Physical therapy

Before the Surgery

• In addition to taking a complete medical history, the doctor may perform a complete physical examination to ensure that the patient is in good health before undergoing the procedure. The patient may undergo blood tests or other diagnostic tests.
• Notify the doctor if the patient is sensitive to or is allergic to any medications, latex, tape, and anaesthetic agents (local and general).
• Inform the doctor of all medications (prescribed and over-the-counter) and herbal supplements that the patient is taking.
• Notify the doctor if the patient has a history of bleeding disorders or if he/she is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for to stop these medications prior to the procedure.
• If the patient is pregnant or suspect that she is pregnant, the doctor should be notified.
• The patient will be asked to fast for eight hours before the procedure, generally after midnight.
• A sedative is usually given prior to the procedure to help the patient relax.
• A physical therapist may meet the patient prior to surgery to discuss rehabilitation.

During the Surgery

Hip replacement requires a few days’ stay in a hospital. Hip replacement surgery is performed under general anaesthesia or spinal anaesthesia. The anaesthesiologist will discuss this with the patient in advance.
Generally, hip replacement surgery follows this process:

• The patient will be asked to remove clothing and will be given a gown to wear.
• An intravenous (IV) line may be started in the arm or hand.
• The patient will be positioned on the operating table.
• A urinary catheter may be inserted.
• If there is excessive hair at the surgical site, it may be clipped off.
• The anaesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
• The skin over the surgical site will be cleansed with an antiseptic solution.
• The doctor will make an incision in the hip area.
• The doctor will remove the damaged parts of the hip joint and replace them with the prosthesis. The hip prosthesis is made up of a stem that goes into the femur (thighbone), the ball (head joint) that fits into the stem, and a cup that is inserted into the socket of the hip joint. The stem and cup are made of metal. The ball may be made of metal or ceramic. The cup has a liner that may be made of plastic or ceramic. The 2 most common types of artificial hip prostheses used are cemented prostheses and uncemented prostheses. A cemented prosthesis attaches to the bone with surgical cement. An uncemented prosthesis attaches to the bone with a porous surface onto which the bone grows to attach to the prosthesis. Sometimes, a combination of the 2 types is used to replace a hip.
• The incision will be closed with stitches or surgical staples.
• A drain may be placed in the incision site to remove fluid.
• A sterile bandage or dressing will be applied.

After the Surgery

After the surgery the patient will be taken to the recovery room for observation. Once the patient’s blood pressure, pulse, and breathing are stable and he/she is alert, the patient will be taken to the hospital room. Hip replacement surgery usually requires an in-hospital stay of several days.

It is important to begin moving the new joint after surgery. A physical therapist will meet the patient soon after surgery and plan an exercise program. Pain will be controlled with medication so that the patient can participate in the exercise. An exercise plan will be given to be followed both in the hospital and after discharge.

The patient will then be discharged home. Physical therapy will continue until the patient regains muscle strength and good range of motion.

Rehabilitation

Once the patient is home, it is important to keep the surgical area clean and dry. Specific bathing instructions will be given. The stitches or surgical staples will be removed during a follow-up visit. To help reduce swelling, the patient may be asked to elevate the leg or apply ice to the knee.
Pain relievers can be taken for soreness as recommended by the doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Hence it is important to take only recommended medications.
The doctor should be notified if any of the following occur:

• Fever
• Redness, swelling, bleeding, or other drainage from the incision site
• Increased pain around the incision site
• Numbness or tingling in the affected leg.

Normal diet can be resumed unless the doctor advises differently. The patient should not drive until the doctor allows it. Other activity restrictions may apply. Full recovery from the surgery may take several months.

It is important that the avoid falls after knee replacement surgery, because a fall can result in damage to the new joint. The physical therapist may recommend an assistive device (cane or walker) to help the patient walk until his/her strength and balance improve.
Making certain modifications at home may help during the recovery. These modifications include, but are not limited to, the following:

• Proper handrails along all stairs
• Safety handrails in the shower or bath
• Shower bench or chair
• Raised toilet seat
• Long-handled sponge and shower hose
• Dressing stick
• Sock aid
• Long-handled shoe horn
• Reaching stick to grab objects
• Removing loose carpets and electrical cords that may cause the patient to trip
• Avoiding stair-climbing until recommended by the doctor

Risks / Complications

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• Bleeding
• Infection
• Blood clots in the legs or lungs
• Dislocation
• Changes in leg length or gait
• Need for revision or additional hip surgery
• Nerve injury resulting in weakness or numbness

There may be other risks depending on the patient’s specific medical condition.

Outlook

Patient education is important to ensure longevity of the replaced hip. Strenuous exercises such as running or contact sports are discouraged, since these activities can reinjure the replaced hip. Swimming is ideal in improving muscle strength and promoting mobility and endurance.

Patients should be aware and notify any caregivers that they have an artificial joint. Antibiotics are recommended during any invasive procedures, whether surgical, urological, gastroenterological, or dental. Infections elsewhere in the body should also be treated to prevent seeding of infection into the joint. This is important because bacteria can pass through the bloodstream from these sites and cause infection of the hip prosthesis.

Hip joint replacement surgery is one of the most successful joint surgeries performed today. In well-selected patients, who are appropriate candidates for total hip replacements, the procedure lasts at least 15 years in nearly 95% of patients. Long-term results have been improving impressively with new devices and techniques. The future will provide newer techniques which will further improve patient outcomes and lessen the potential for complications.