Total hip prosthesis

If you are just beginning to look into various treatment options or have already decided to undergo hip replacement surgery, the following information will help you better understand the benefits and limitations of total hip replacement surgery.
If the hip has been damaged by arthrosis, a fracture, or other problems, normal activities such as walking or sitting/standing in a chair can be painful and difficult. The hip may be stiff and fitting shoes or socks may be difficult. You may feel discomfort even while sleeping.

If medications, reduced physical exertion in daily activities, and the use of walking supports do not adequately help your symptoms, you may consider hip joint replacement surgery. Hip joint replacement surgery is a safe and effective procedure that can relieve pain and help you return to normal daily activities.

The first hip replacement surgery took place in 1960 and was one of the most successful operations in medical history. Since then improvements in surgical technique have been made and according to the Agency for Healthcare and Quality Research, more than 285,000 total hip arthroplasties are performed annually in the United States.

Anatomy

The hip is one of the largest joints in the human body.
The coxofemoral joint or hip joint connects the femur to the hip bone and is one of the most robust joints in the human body, combining stability with mobility, thanks to the combination of a very strong joint capsule and three thick ligaments.
– joint capsule
– iliofemoral ligament
– ischiofemoral ligament
– greater trochanter of the femur

Description

– A synovial and spheroid joint
– It is considered a synovial joint because the bones articulate in a space called the joint cavity. This is covered with a layer of hyaline cartilage, the articular cartilage, which covers the bones with a smooth layer, which reduces friction during movement and cushions shock.
– At the same time, it is spheroid, which means that the spherical surface of one bone, in this case the femur, fits into the deep, cup-shaped, concave cavity of another bone, in this case the hip bone (iliac bone). The acetabulum, the cavity bounded by the ilium, the ischium and the pubis, where the rounded head of the femur articulates, limits the range of motion by its depth, but gives the joint a significant force. On its anterior side, there is a notch, the acetabular incision, which forms a foramen (orifice) that serves as a passageway for nerves and blood vessels.

Elements

– Joint capsule
Very dense and very strong, it extends from the circumference of the acetabulum to the femoral neck. Its fibers, circular and longitudinal, form, on the one hand, a collar around the femoral neck: the orbicular zone. On the other, they are reinforced by three ligaments: femoral, pubofemural and ischiofemoral.
– The ligaments
– The iliofemoral ligament is the thickened portion of the joint capsule that extends from the iliac spine of the iliac bone to the femoral intertrochanteric line (separating the two trochanters)
– The pubofemoral ligament, another thickened portion of the capsule from the pubic part of the circumference of the acetabulum to the femoral neck.
– The ischiofemoral ligament connects the ischial wall of the acetabulum to the femoral neck.
– The ligament of the femoral head is a flat triangular band that stretches from the acetabulum cavity to the facet of the femoral head, the fovea capitis (femoral head fossa).
– Transverse acetabular ligament. Connected to the ligament of the femoral head and the joint capsule, very strong, this ligament supports the acetabular labrum.
– The acetabular labrum
This is a ring of fibrous cartilage, fixed around the circumference of the acetabulum.

Miscari

The extreme stability of the coxofemoral joint is due to the strength of its joint capsule, as well as the way the femur inserts into the acetabulum and the muscles surrounding it. The movements in three planes, allowed by its spheroid shape, are as follows:
– Flexion
– Extension
– Abduction
– Rotation
All these movements are limited in amplitude by the depth of the acetabulum.

Common causes of hip pain

The most common cause of chronic hip pain and disability is arthrosis. Arthrosis, rheumatoid arthritis and trauma are the most common causes.
– Coxarthrosis. This type of arthritis is an age-related “wear and tear”. It usually occurs in people over 50 and often in people with a family history of arthrosis. The bones rub against each other, causing hip pain and stiffness. Coxarthrosis can also be caused or accelerated by subtle irregularities in the way the hip develops in childhood.
– Rheumatoid arthritis. This is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can lead to cartilage damage, resulting in pain and stiffness.
– Post-traumatic arthritis. Secondary to a fracture of the femoral head or acetabulum. The cartilage can deteriorate and lead to hip pain and stiffness over time.
– Avascular necrosis. Trauma to the hip, such as a sprain or fracture, can limit the blood supply to the femoral head. This is called avascular necrosis. The lack of blood supply can cause the bone surface to collapse and arthrosis to develop. Some diseases can also cause avascular necrosis.
– Childhood hip diseases. Some infants and children have hip problems. Even if problems are successfully treated during childhood, they can cause arthrosis throughout life. This happens because the hip cannot grow normally and the joint surfaces are damaged.

Description

In an operation to replace a damaged hip (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.
– The damaged femoral head is removed and replaced with a metal rod, which is placed in the tubular center of the femur.
– a metal or ceramic ball is placed on the top of the rod. This ball replaces the damaged femoral head, which has been removed.
– The damaged cartilage in the acetabulum is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the acetabular component in place.
– insert a plastic, ceramic or metal spacer between the new ball and the socket to allow a smooth surface.

Is hip replacement surgery for you?

The decision to have hip replacement surgery should be one made by you, your family, your family doctor and your orthopaedic surgeon. The process of making this decision usually begins with a referral from your family doctor to an orthopedic surgeon for an initial evaluation.

Candidates for surgery

There is no age or weight restriction for total hip arthroplasty.
Recommendations for surgery are based on a patient’s pain and disability, not their age. Most patients who undergo hip replacement surgery are between the ages of 50 and 80. Hip replacement surgery has been successfully performed on all ages, from young teenagers with juvenile arthritis to elderly patients with degenerative arthritis.

When surgery is recommended

There are several reasons why your doctor may recommend hip replacement surgery. People who have this type of surgery often have:
– hip pain that limits daily activities such as walking
– hip pain that continues at rest, either day or night
– hip stiffness that limits the ability to move or lift the leg
– if the pain is not relieved by anti-inflammatory medication, physiotherapy or walking supports.

Orthopedic evaluation

An orthopaedic surgeon’s evaluation consists of several stages.
– medical history. The orthopedic surgeon will gather information about your general health and will ask questions about the degree of hip pain and how it affects your ability to perform daily activities.
– physical examination. It will assess hip mobility, muscle tone.
– X-rays. These images help determine the degree of damage or deformity of the hip.
– other tests. Occasionally other tests, such as magnetic resonance imaging (MRI), may be needed to further assess joint damage

The decision to have hip replacement surgery

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip resurfacing is the best solution to relieve pain and improve mobility. Other treatment options – such as medications, physical therapy, or other types of surgery – may also be considered.

In addition, the orthopedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that may occur during and after surgery.

Realistic expectations

An important factor in deciding whether to have hip resurfacing surgery is understanding what the procedure can and cannot do. Most people who have undergone hip replacement surgery have noticed a significant reduction in hip pain and an improvement in their ability to perform normal daily activities.

Most surgeons advise patients to avoid high-impact activities such as running, jogging, jumping.

Recommended activities after hip replacement are unlimited walking, swimming, golf, golfing, driving, hiking, biking, dancing and other low-impact sports.

Preparing for surgery

Medical evaluation
If you decide to have hip resurfacing surgery, your orthopaedic surgeon may require a complete physical examination by your family doctor before the surgical procedure. This is necessary to ensure that you are healthy enough to undergo surgery and complete the recovery process. Many patients with chronic medical conditions, such as heart disease, may also be evaluated by a cardiologist before surgery.

Tests
Several tests, such as blood and urine samples, an electrocardiogram (EKG) and X-rays, may be needed to help plan the surgery.

Skin preparation
Your skin should not have any infections or irritations before surgery.

Blood Donations

You may be advised to donate your own blood before surgery. This will be stored in case you need blood after surgery.

Medically

Inform your orthopaedic surgeon about the medications you are taking. He or she will advise you which medications you should stop and which you can continue taking before surgery.

Weight loss

If you are overweight, your doctor may ask you to lose weight before surgery to reduce the stress on your new hip and possibly reduce the risks during surgery.

Dental evaluation

Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal procedures) should be completed before hip replacement surgery. Teeth whitening should be postponed for a few weeks after surgery.

Urinary evaluation

People with a history of recent or chronic urinary tract infections should have a urologic evaluation before surgery. Older men with prostate disease should consider completing the necessary treatment before surgery.

Social planning

Although you will be able to walk in a crutch or cane for a short time after surgery, you will need help for several weeks with activities such as cooking, shopping, daily toileting and laundry.

Home baking

The following accessories can help with everyday activities:
– well-secured guard rails or shower or bath railings
– handrails along staircases
– a high toilet seat
– a stable shower bench or bath stool
– a sponge with a long handle for easy handling and a shower hose
– a shoehorn to avoid excessive bending of the new hip
– a “grasper” that allows you to grasp various objects without excessive bending of the hip
– firm cushions for chairs, sofas and the car that allow you to sit with your knees at a shorter distance from your hips
– removing all carpets and electrical cords from areas where you walk around the house

Surgery

You will most likely be hospitalized on the day of your surgery.

Anesthesia

After hospitalization, you will be evaluated by an anesthesiologist. The most common types of anesthesia are general anesthesia or spinal anesthesia (you remain awake during the operation, but your body is numbed from the waist down). After your anesthesiologist’s assessment, he or she will decide which type of anesthesia is right for you.

Type of implant

For the artificial hip joint, there are currently many types of designs and materials. They all consist of two basic components: the ball-shaped component (made of highly polished, strong metal or ceramic material) and the socket component (in the shape of a plastic, ceramic or metal cup, which may have a metal outer shell).

Prosthetic components can be placed in the bone or they can be cemented. The decision to place them in bone or cemented is based on a number of factors, such as bone quality. A combination of a cemented stem and an uncemented socket can also be used.

Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.

Surgical procedure

The surgical procedure takes a few hours. The orthopedic surgeon will remove the damaged cartilage from the bones and then position the metal, plastic or ceramic prosthesis to restore alignment and function of the hip.
After the surgery, you will be moved to the recovery room where you will stay for a few hours until being monitored. After you recover from anesthesia, you will be moved to a hospital ward.

Hospitalization
You will most likely stay in hospital for a few days. A pillow will be placed between your legs to protect your hip.

Pain monitoring
After surgery, you will feel some pain, but your surgeon and nurses will give you medication to make you as comfortable as possible. Pain monitoring is an important factor in your recovery. Movement will begin shortly after surgery, and when you feel less pain, you can start moving more quickly. Talk to your doctor if postoperative pain becomes a problem.

Physiotherapy
Walking and daytime activities are important for your recovery, and this will start after the first day or two after surgery. Most patients who have undergone this type of surgery start to stand and walk with the help of a support (metal frame) and a physiotherapist as early as the second day after surgery.

Prevention of pneumonia
It is normal for patients in the early postoperative period to have shallow breathing. This is usually due to the effects of anesthetics, pain medication and time spent in bed. This shallow breathing can lead to a partial collapse of the lungs and may lead to pneumonia in certain more sensitive patients.

Recover

The success of the operation will depend largely on how well you follow your orthopaedic surgeon’s instructions regarding home care during the first few weeks after surgery.

Wound care
You will have sutures or staples along the wound. Sutures or staples will be removed a few weeks after surgery. A suture made under the skin will not need to be removed.
Avoid contact with water until the wound is completely healed and dry. You can continue to bandage the wound to prevent irritation from clothing or stockings.

Diet
Loss of appetite is normal in some patients for several weeks after surgery. A balanced diet, often with an iron-based supplement, is important to help the wound heal faster.

Activities
Exercise is a very important part of home care, especially in the first few weeks after surgery. The patient should be able to resume normal daily activities within 3 to 6 weeks after surgery. The patient may have pain even during the night for several weeks after surgery, which is normal.

The patient’s activity program should include:

– A graded walking program to gradually increase mobility, initially at home and later outside
– Resumption of other normal activities, such as sitting or getting up in a chair, going up/down stairs
– Specific exercises several times a day to restore blood circulation and strengthen the hip. You will probably be able to perform these exercises on your own, but you may need a physical therapist to help you at home or in a therapy center for the first few weeks after surgery.

Possible complications after surgery

The rate of complications after surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications such as heart attack or stroke are less common. However, chronic diseases can increase the potential for complications. Although their frequency is low, when they do occur, these complications can prolong or limit full recovery.

Infection
Infection can occur superficially in the postoperative wound or it can reach the prosthesis. It can occur during hospitalization or at home after you have been discharged. It can also occur years later.

Minor wound infections are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in the body can spread to the replaced joint.

Blood clots
Blood clots in the veins of the legs or pelvis are the most common complication of hip replacement surgery. These clots can be life-threatening if they migrate to the lungs. The orthopaedic surgeon will present you with a program to prevent them which may include blood thinning medication, elastic leg stockings, etc.

Uneven legs after surgery

Sometimes after a hip replacement, one leg may be more or less short or long than the other. The orthopaedic surgeon will make every effort not to make them unequal, but this can happen in order to maximize the stability and biomechanics of the hip. Some patients may feel more comfortable wearing an elevator-type shoe after surgery.

Dislocation
The risk of dislocation is higher in the first months after surgery, while the tissues heal. If dislocation occurs, it can usually be put back in place without the need for further surgery. In situations where the hip continues to dislocate, surgery may be necessary.

Relaxing and wearing the implant

Over the years, hip replacements can wear out or become loose. This can most often happen as a result of everyday activities, but it can also happen due to thinning of the bones, or as it is also called, osteoarthritis. If when you relax, your hip becomes painful, you may also need a new surgery called revision.

Other complications
Injuries to nerves, blood vessels, bleeding, fracture and stiffness may occur. In a small number of patients, pain may continue or new pain may occur after surgery.

Avoiding problems after surgery

How to recognize the signs of a blood clot
Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of developing blood clots in the first few weeks of recovery. He or she may recommend that you continue taking blood thinning medication after discharge from the hospital. Notify your doctor immediately if any of the following signs occur:
– pain in the calf and leg not related to the incision
– tenderness or redness of the calf
– swelling of the thigh, calf, ankle or leg

Warning signs of pulmonary embolism are those signs in which a blood clot migrates to the lungs and may manifest as follows:

– shortness of breath
– sudden onset of chest pain
– chest pain followed by coughing

Infection prevention
A common cause of infection following surgery is when bacteria enter the bloodstream following a dental procedure, or, urinary tract infections, or skin infections. These bacteria can settle around the hip implant and cause an infection.
After surgery, you should take preventive antibiotics before any dental or surgical procedure that could allow bacteria to enter the bloodstream.

Warning signs of infection are:
– persistent fever
– chills
– redness, tenderness, or swelling of the hip incision
– fluid leaking from the hip incision
– hip pain, both during activity and at rest

Avoiding hospitalizations
A fall in the first few weeks after surgery can damage the new hip and lead to more surgery. Stairs pose a particular risk until the hip becomes mobile. You should use crutches, a metal frame, a support bar or a support person until your balance, flexibility and strength improve.

Other precautions
To ensure that you will have a proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions – usually within the first 6 weeks after surgery, such as:
– not crossing your legs
– not bending your hips more than 90°
– putting a pillow between your legs at night
Your doctor and physical therapist will give you more instructions before discharge.

How different is the new balance

You may feel numbness around the incision. You may also feel stiffness, especially with excessive bending of the hip. These differences may diminish over time and most patients find these differences minor compared to the pain and limited function of the hip before surgery.

The new balance can activate metal detectors in airports and some buildings. Inform the security officer about hip replacement if the alarm is activated. You can ask your orthopedist for a written note confirming that you have an artificial hip.

Protecting your new hip
There are many things you can do to protect your new hip and prolong its life.
– Regularly participate in a light exercise program to maintain the mobility of your new hip.
– take special precautions to avoid falls and injuries.
– make sure your dentist knows you have a hip prosthesis. You will need antibiotics before any dental procedures.
– consult your orthopedic doctor regularly for routine examinations consisting of X-rays and various other tests.