[Clinical Information]
Organisation of your operative replacement is in four parts: -
Optional pre-operative visit and understanding potential complications
Part 1: Outpatient Visit <Back to Menu>
An outpatient appointment is made through your family doctor. This will take several months. Unfortunately the rate-limiting step in the system is available operating time, so if this delay is not acceptable I encourage you to seek an opinion from a less busy unit. Resource allocation to elective orthopaedics is poor around the world, which in my opinion is inappropriate as the relief of pain and disability is arguable more important than other aspects of health care.
Previous x-rays are very useful but often a new x-ray is taken at this first visit. A self-assessment 'pain' score questionnaire is very useful and you are welcome to ask for help to fill this in. A special service for patients from remote areas of the world makes use of the Internet and may avoid this visit. Sometimes further tests such as an injection of local anaesthetic to the joint needs to be arranged at a later visit to ensure that the source of pain is from the troubled area.
Please also check that your blood pressure is not high as this is the commonest cause for last-minute delay. A heart-attack or stroke may also delay the operation, as will a recent cold or ‘flu. It is advisable to give up smoking, although I realise this is difficult.
Please stop taking Non-steroidal pain killers for the 10 days prior to your operation (Aspirin, Brufen, Naproxen, etc.) and take paracetamol or codeine for the pain.
Part 2: Preoperative assessment <Back to Menu>
You will usually be invited by Sue in admissions ( 01691 404324) to come for a check-up two weeks before your operation. This will take a few hours to organise and will include a health questionnaire for you to fill out, another pain score, blood tests, a check-up of your heart, and an up-to-date x-ray of your hips while you stand.
Potential Complications
Infection in an operative replacement can be a major disaster. Oswestry is fortunate in having the most sterile operating theatres in the world, developed by my predecessor Professor Brian O’Connor. The operating theatres have a unique ‘open plan’ design, and sterile air is supplied at an unprecedented 400 changes per hour. Our infection rates are audited by an expert team comprising Dr Rob Warren and his wife who happens to be our infection control sister. In an ongoing international audit we are usually top of the list.
Dislocation is a possibility in the first few months following your operation, and this risk can be minimised by following the advice of the Occupational therapist. Bending the joint past 90 degrees is to be avoided for the first three months, and so low seats must be avoided, and a toilet raise will be provided for you to take home. If dislocation does occur then a reduction under general anaesthetic is required, and occasionally the implant needs to be realigned.
Clotting in the leg veins can lead to a fatal situation where clot passes in a large clot to the lungs. This risk is minimised by the use of foot pumps which keep the circulation moving. You must also help by keeping your feet moving up and down, gently but regularly, all the time you are awake following the operation. Footpumps must be in use for 16 hours of each day, and you are invited to decide whether you prefer this to be at night or not - a proportion of patients find them restful at night while others find it keeps them awake.
Leg lengthening always happens. Usually this is such a small amount that you will not notice it. The arthritic joint often is shorter so needs to be lengthened. A shoe raise on the other side may help you adjust to the new length of your leg and can be arranged on the second or third day after your operation.
Metal absorption from the joint replacement peaks at around six months following implantation. Metal surfaces later bed in and thereafter small amounts of chromium and cobalt continue to be absorbed from the implant. It is unfortunate that any artificial bearing surface wears a little and the body absorbs the wear products. The only good news is that with the metal on metal joint the particles are smaller in volume and in size. All metal implants produce a raised level of these metals in the tissues around them. There is a concern that cancer might develop as a result, but studies fail to demonstrate that the risk is higher than in the general population.
Squeaking occasionally happens. So far this has only lasted for a few months and then settles. This is also part of the bedding-in process.
Fracture of the neck of the femur has happened. This is perhaps the most common significant problem for this operation. This is usually because of abnormal shape in the neck of the femur. This will require a revision operation. Occasionally these fractures can heal. The fractures are in the first three months, so do not overdo things or fall during this time.
Bone Density Scan. This is a method of measuring bone strength. I hope it will be the way forward in chossing which patients are suitable for hip resurfacing. Currentky it appears that a density of the Femoral Neck of over 0.8 g/cm is sufficient.
Failure to provide pain relief may result if the source of pain is not your troubled joint. This is possible most commonly when back-ache produces pain around the hip region, although hip replacement can help back pain.
Part 3: Admission <Back to Menu>
You will get information posted to you from the hospital about the details of when and where to come, what to bring and visiting times, etc. (Many of our patients come from long distances. I personally encourage visitors to wait until you have returned home - they can be a good help to you then. Tell them to think of your admission as if you had gone on a holiday to Spain for a week!)
Before you go to Theatre you will be visited by one of the team from Theatre and the Anaesthetist. A lot will be explained to you at that time. If you have trouble with passing water then this is a good time to warn us so that a catheter could be inserted while you are asleep. This is much easier than having it done later should there be a problem.
Following Surgery
You will wake with several intravenous lines attached. Toe wiggling is a simple but effective way of preventing the blood from sludging in the calf veins. Do this slowly and steadily or you will tire of it. It is really a process of bringing the foot up and down so that the calf muscles are put on the stretch. A most useful line is the PCAS line with a button you use to give yourself opiate pain-killer. Footpumps will be squeezing your feet. You will feel thirsty but do not drink too much or you may be sick.
The first day after surgery you may not feel like standing, but you must keep on the move in bed, and in particular bend your knee. It is also very helpful to lift your leg straight off the bed as soon as possible - this helps you get in and out of bed. Ask for help to keep on the move as much of the time you can while in hospital - it is much easier than at home as everything you need is to hand
A check x-ray is taken on the second or third day after operation - please ask if you want to see it. The physiotherapist will ensure you are walking properly with your crutches, and before you go home will show you how to get in a bath and how to climb stairs. Rarely you will need help from a physiotherapist after you go home.
Following discharge home, keep active. Ankle swelling is best minimised by keeping your legs above heart level for as much of the day as is convenient.
Weight-bearing: the 3+3 regime.
I advise you to be as active as possible for the first 3 weeks, bearing as much weight as possible on the new hip. Then you must use the crutches to avoid putting excess weight through the limb for the next 3 weeks. I would recommend staying at home for the second three weeks. This allows the new hip to 'bed in' by reducing your activity level. This is unproven as yet, but is based on my research into fracture healing. It certainly seems to be working well.
If you attend a physiotherapist, please show this information to him or her.
Part 4:Outpatient review <Back to Menu>
You will come for review 2 months after your operation for a check x-ray and pain score. Please hand in your crutches and toilet raise when you come. At one year and at two years a clinic review is repeated and after that you may not need to come until 5 and then 10 years after surgery. Be prepared to come annually after that as it is important to get good timing for the next hip replacement, and not let bone be lost. If more information is needed, or if there are any difficulties, it may be possible to simply keep in touch by sending a pain score.
Please let me know if there are any surprises! I can then add more information so future patients will benefit…
Enjoy your new joint!
James B Richardson, MBChB, FRCS, MD
Professor of Orthopaedics
The Robert Jones & Agnes Hunt Orthopaedic & District Hospital
Oswestry
Shropshire
01691 404386
Information Sheet on Discharge from Hospital
Progress
At home you will find everything a little more difficult than in hospital but in the first week or two progress will be rapid. Thereafter progress slows down and indeed continues until after a year following join replacement. If all goes well you will be able to stand at a sink, and at least make a cup of tea very soon. It is however advisable to have someone in to help you in the early weeks after your operation. You will be much more tired than you expect in this time. Getting into a bath is one of the most challenging things and you will be show a good way of doing this before you leave.
Wound Care
Occasionally the wound discharges fluid after you go home. If you are fevered, or there is redness around the wound, this may be a wound infection. Get in touch and phone the ward. You will probably need an antibiotic
Driving is a little more difficult if you have had your right hip done than your left. It is important to check that you can lift your foot off the floor while sitting on a chair before you attempt to drive. Otherwise the right foot may sit on the accelerator and not come off! So always do not drive until you feel safe and even then start in a secure situation and do not commit yourself to any long drive early on. Inform your insurance company than you have had a hip operation and that you feel safe and confident to drive. I would expect you to be able to drive at four weeks following a left hip operation and eight weeks following a right hip operation. These times vary greatly. Few patients now have a limp following their operation and sometimes this persists simply out of habit. Try and push your toes into the ground with each step and this will counter the limp.
Running should be possible after four months and around this time you should be able to return to golf but not until six months or so for games like tennis (assuming you could do these before!).
Aspirin: I advise all patients to take aspirin 75 mg daily, for the three months after surgery. This reduces serious complications like heart attacks and strokes as well as giving protection against deep vein thrombosis (a clot of blood in the leg).