Hip Replacement Including Direct Anterior Approach

Hip replacement surgery may be necessary for an arthritic and painful hip after non-operative measures have failed. If you are a candidate for hip replacement, you should be aware that it is one of the most effective operations known. A successful hip replacement should give you many years of pain free function. Recovery is quick and return to function is rewarding.

Indications

Total Hip Replacement (THR) is indicated for arthritis of the hip that has failed to respond to conservative (non-operative) treatment.

You should consider a THR when you have

  • Arthritis confirmed on X-ray
  • Pain not responding to analgesics or anti-inflammatory medication
  • Limitations of activities of daily living including your leisure activities, sport or work
  • Pain keeping you awake at night
  • Stiffness in the hip making mobility difficult

Benefits

Prior to considering THR most patients will have tried Tylenol, ibuprofen and prescription arthritis medications as well as activity modification.

The decision to proceed with THR surgery is a cooperative one between you, your family, and Dr. Fleeter. Benefits of surgery include

  • Reduced hip pain
  • Increased mobility and movement
  • Correction of deformity
  • Equalization of leg length (not guaranteed)
  • Increased leg strength
  • Improved quality of life, ability to return to normal activities
  • Enables you to sleep without pain

Pre-Operation

  • Your family physician will need to perform a preoperative clearance and medical evaluation that will generally include an EKG and blood tests
  • Please resolve any dental issues prior to surgery
  • Stop aspirin, ibuprofen at least one week prior to surgery as these medications can increase bleeding
  • Stop smoking prior to surgery
  • The hospital will make arrangements to meet with the anesthesia team one week prior to surgery
  • Please make plans to attend the pre-operative education class

Day of your Surgery

  • You will go directly to the holding area, immediately outside the operating room
  • You will meet the nurses and answer a few questions to complete your medical record
  • You will meet your anesthesiologist who will review anesthetic options
  • You will be provided with a hospital gown. Make sure to bring exercise clothes to wear during your recovery.

Surgical Procedure

Modern hip replacements can be performed through small incisions. The surgery can be performed through the back (postero-lateral approach) or the front (direct anterior approach). Each approach has its plusses and minuses. These options will be reviewed prior to surgery. Each approach can allow a rapid return to walking, working and a pain-free life.

At the start of the procedure, an incision is made over the hip to expose the hip joint
The acetabulum (socket) is prepared using a special instrument called a reamer. The acetabular component is then inserted into the socket. This is sometimes reinforced with screws or occasionally cemented. A liner which can be made of plastic, metal or ceramic material is then placed inside the acetabular component.

The femur (thigh bone) is then prepared. The femoral head which is arthritic is removed and the bone prepared using special instruments, to exactly fit the new metal femoral component. The femoral component is then inserted into the femur. This is generally a press fit of the replacement, relying on bone to grow into it.The real femoral head component is then placed on the femoral stem. This can be made of metal or ceramic.
The hip is then reduced again, for the last time.

The muscles and soft tissues are then closed carefully.

Post Operative

You will wake up in the recovery room with a number of monitors to record your vitals. (Blood pressure, Pulse, Oxygen saturation, temperature, etc.)
Post-operative X-rays will be performed in recovery.

Once you are stable and awake you will be taken to the total joint unit.Upon arriving at the door to your room, you will be assisted in walking from your stretcher to the bed. Early ambulation leads to faster recovery.

Most patients sit up for dinner and take short walks on the evening of surgery The day following surgery, you will change into exercise clothes and take several walks with the physical therapy team and attend a post-operative class to teach you about life with your new joint replacement.

Your team of nurses and I will work hard to control pain. We use a multi-modal strategy that has been shown to be effective at alleviating pain.

You can put full weight on your new joint. Sutures are generally dissolvable.

You can shower on the second post-operative day.

Most patients go home in one or two days following surgery. Initially you will use a walker but will progress rapidly to a cane. Physical therapy can begin as soon as you return home

Post-op Precautions

Remember this is an artificial hip and must be treated with care. However, the key to a successful hip replacement is early and frequent walking. You should attempt to use your hip as normally as possible.

Try to avoid sitting in low chairs but you can sleep on either side when you are comfortable. Wear comfortable shoes

  • You can shower once the wound has healed
  • You can apply Vitamin E or moisturizing cream into the wound once the wound has healed
  • If you have increasing redness or swelling in the wound or temperatures over 100.5° you should call your doctor
  • If you are having any procedures such as dental work or any other surgery you may be advised to take antibiotics before and after to prevent infection in your new prosthesis.
  • Your hip replacement may go off in a metal detector at the airport but the body scanner generally is not affected by joint replacements

Risks and Complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to the hip

Medical Complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete.

Complications include

  • Allergic reactions to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death

Specific Complications Include

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates are approximately 1%, if it occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Dislocation

This means the hip comes out of its socket. Precautions need to be taken with yournew hip forever. It a dislocation occurs it needs to be put back into place with an anaesthetic. Rarely this becomes a recurrent problem needing further surgery. With modern techniques and devices, the risk of dislocation is very low

Blood clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.

Damage to nerves or blood vessels

Also rare but can lead to weakness and loss of sensation in part of the leg. Damage to blood vessels may require further surgery if bleeding is ongoing.

Wound irritation

Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint.

Leg length inequality

It is very difficult to make the leg exactly the same length as the other one. Occasionally the leg is deliberately lengthened to make the hip stable during surgery. There are some occasions when it is simply not possible to match the leg lengths. All leg length inequalities can be treated by a simple shoe raise on the shorter side.

Wear

All joints eventually wear out. The more active you are, the quicker this will occur. In general 80-90% of hip replacements survive more than 20 years.

Failure to relieve pain

Very rare but may occur especially if some pain is coming from other areas such as the spine.

Unsightly or thickened scar

Limp due to muscle weakness

Fractures (break) of the femur (thigh bone) or pelvis (hip bone)

This is also rare but can occur during or after surgery. This may prolong
your recovery, or require further surgery. Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Summary

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan- it may help to restore function to your damaged joints as well as relieve pain.

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