Above Left: Right hip with secondary osteoarthritis. The bone of the ball and socket are no longer separated by cartliage.
Above Right: Normal right hip joint. Note the space between ball and socket where the cartilage is present.
PAIN & DEFORMITY
Pain is the predominant symptom to perform surgery. Commonly pain is caused by osteoarthritis, which is often described as a degenerative wear and tear condition.
Following a careful discussion with your surgeon, it is essential to consider whether the level of symptoms justify proceeding with major surgery. Poor patient satisfaction following surgery can occur when surgery is performed when symptoms are not significantly intrusive. Conversely, the surgical outcome in a patient suffering with a long-standing persistent ache can be impressive.
When the decision to proceed with hip surgery has been made, it is important to understand the steps that remain before and after the operation as they are equally crucial.
BEFORE THE OPERATION
Preoperative Assessment
Preoperative assessment allows the surgical team to review your health, social circumstances and rehabilitation requirements prior to surgery. Importantly, this allows provides an opportunity for you to ask questions.
Additionally the surgeon is able to plan the surgery including assessment of the required size and design of the hip prosthesis before the patient is admitted to hospital.
Above: Preoperative template for a right hip replacement with assessment of leg length and hip biomechanics.
ADMISSION & OPERATION
Patients now commonly attend hospital for surgery on the same day as the procedure. This allows you to remain in the comfortable and familiar surroundings of their own home helping to reduce any anxiety. The anaesthetic is administered in an anaesthetic room, which is adjacent to the operating theatre. Your anaesthetist will discuss your options with you, which are broadly a general anaesthetic or a local / spinal anaesthetic. With a general anaesthetic a patient is given medication through a small needle placed into a vein. Once safely asleep, the anaesthetist will then be able to pass a breathing tube, which remains until the surgery has been completed. With a local anaesthetic no breathing tube is required and the patient has the option of being awake or sleeping through the surgery while the lower limb is numb.
The patient is positioned on their theatre trolley and transferred to the operating theatre. The surgical team then clean the patients skin with solution to kill all skin bacteria and the sterile surgical drapes are applied and the operation begins. A typical operation takes approximately 60-90 minutes, although the time away from the ward is much longer due to the anaesthetic and recovery. Although it is natural for your relatives to worry, they should expect this time from the ward to be typically several hours.
Following the closure of the skin the patient is moved out of the operating theatre to an area for recovery before transfer back to the ward. Patients are encouraged to mobilise on the same day or following day after surgery. Early mobilisation together with mechanical 'pumps' and treatment to thin the blood helps to reduce the risk of blood clots forming (deep vein thrombosis). A patient is typically ready to be discharged home four days following the surgery.
Above: XRay following a hip replacement using an Exeter hip prosthesis.
AFTER THE OPERATION
RESULTS
Surgical technique plays a significant part in the longevity of a total hip replacement with success determined as much by the surgeon as by the type of hip used. Surgeons specialising in joint replacement and operating on large numbers of patients report the best results following surgery.
"How long will it last?" is a common question that many patients will ask prior to hip replacement. Although typical advice is 15 years, it is difficult to give an accurate answer as this depends on many factors including patient age and activity for example. Which ever type of hip replacement is chosen, 95% patients are highly satisfied with the results if the operation has been performed for the correct indications.
ACTIVITIES AFTERWARDS
Advice on suitable activities following surgery can vary between different health care professionals. For example many would agree that a patient should take care for the first six to twelve weeks following the operation with activities such as crossing their legs, bending down low and picking items up off the floor. However, as time passes the risks decline and a person can be more relaxed with what they do. Many routine activities are possible with the new joint such as cooking, washing (bath and shower), household cleaning, DIY, shopping, lovemaking, gardening, driving a car or riding a motorbike or bicycle. Patients also describe returning to the participation of sporting activities, although some could be thought of as ‘risky’.
COMPLICATIONS
Success following a joint replacement procedure is determined as much by your surgeon as the type of artificial joint used. The best results are reported from centres where surgeons have specialised in joint replacement and perform a high number of these operations.
Though hip replacement is now a popular operation with a high rate of success and patient satisfaction, occasionally complications do occur. In reality complications are infrequent although it is important that patients understand the possible risks so they can make informed decisions or ask questions about whether they wish to proceed with surgery.
DURING THE OPERATION
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Nerve damage (rate less than 1%)
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Major blood vessel damage (rate 0.1%)
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Fracture (rate less than 1%)
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Leg length difference (rate less than 5%)
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Anaesthetic complications
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Dislocation (rate 1%)
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Deep infection (rate 0.5%)
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Discomfort at the side of the hip 'Trochanteric' (rate 10%)
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Bowel complications (rate 1%)
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Blood clots 'Venous thromboembolism' – leg deep vein thrombosis (rate 5%). Lung
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Embolism (rate 1%).
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Cardiovascular complications (including heart attack, stroke)
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Respiratory complications (risk 1%)
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Swollen ankles
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Metabolic complications (rate less than 1%)
EARLY WEEKS
LONG TERM
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Loosening and wear of the artificial joint (called aseptic loosening)
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Bone loss
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Component fracture (rare)
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Late dislocation (rate 2%)
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Late infection (rate less than 1%)
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Bone fracture (rate less than 1%)
The list of potential problems is unfortunately not exhaustive, but does represent the reality of major surgery. It may help to focus the mind for patients deciding whether or not they wish to undergo surgery. If ever in doubt please ask your surgeon.