Hip arthroplasty (hip replacement) is normally done to relieve pain and restore motor function in a severely damaged hip joint. Sometimes, a joint replacement isthe only way to restore joint function effectively and improve the life quality of a patient.
During asurgery, diseased joint components are replaced by an orthopedic prosthesis (an implant) that anatomically replicates a healthy joint and enables a full range of movements. Modern endoprostheses are made of ceramic, metal or high-strength polymers with high biological compatibility with the human body, and their lifetime is 15-20 yearson the average. When an artificial hip wears out, it is replaced with a new one.
Many patients have an opinion that joint replacement can be only total. This is far from being truth. There are also some other types of surgeries. Let's have a brief survey of each method.
Total Joint Replacement
Total joint arthroplastyis the most common kind of replacement surgeries. It is performed when not only cartilage, but also bone tissue is severely damaged. It involves a complete removal of the joint and its replacement with an implant, including both the acetabular cup and femoral component.
This procedure is performed in case of secondary contracture, which may occur due to the poor quality of primary surgery or patient’s wrong actions in a rehabilitation period. Prosthesis failure, poor fixation of the implant and dislocation of the femoral and acetabular components of the artificial joint are the main causes of revisions. The purpose of this procedure is to replace damaged components and improve joint fixation.
As the name implies, this surgery involves resurfacing of a diseased joint. If only joint cartilage is damaged, but the femoral head is not affected, your doctor may decide on a joint resurfacing (an articular surface replacement), which allows maximal preservation of bone tissue and provides maximum amplitude of motions. In this case, only the upper cartilaginous layer is removed from the femoral head and, then, a metal cap is placed on the top of it. The acetabulum is replaced in the same way as with total arthroplasty.
Bilateral Joint Replacement
This is a simultaneous replacement of both joints in a single surgical intervention, if a patient's condition allows such a large-scale operation. It may benefit the patient, since there is the only one rehabilitation period instead of two as with consecutive surgeries.
Joint replacement can be done using traditional open surgery or by a minimally invasive method. With the minimally invasive technique, a smaller incision (not more than 8 cm) made via aposterolateral or anterolateral approach to the articular cavity. The main advantage is lesser tissue damage, which leads to faster recovery. However, minimally invasive hip arthroplasty is not widely used, as it is more demanding in terms of surgeon skill, because access to the joint is more difficult and visibility of the operational site is worse, and all this increases complication risks.
By the type of fixation, there are two kinds of endoprostheses:
- cemented fixation implants;
- cementless fixation implants.
When choosing a suitable hip joint prosthesis and the type of attachment, bone quality, physical activity, age and health status play an important role.
Cemented hip endoprosthesis: fixation of an artificial hip joint with bone cement
In the case of a cemented hip endoprosthesis, the leg of the artificial hip joint and the acetabulum are fixed with bone cement in the femur and pelvis. This method allows the patient to quickly return to physical activity and provides maximum stability of the hip joint prosthesis.
Cementless hip endoprosthesis: fixing an artificial hip joint using a press fit
In the case of an uncemented hip joint prosthesis, the thigh and acetabulum are pressed or screwed into the femoral and pelvic bones. The material of the components, to which bone responds well, stimulates the growth of surrounding bone tissue. Such a prosthesis of the hip joint requires a long fixation. However, it promotes quality bone healing.
Hybrid Hip Endoprosthesis
This combination of both methods, which includes the advantages of cemented and cementless fixation of the artificial hip joint. The acetabulum is screwed or pressed into the pelvis, while the leg of the prosthesis is attached to the femur using cement.
After hip replacement is considered and a day of an operation is assigned, you need some preparations, as listed below:
- Full clinic examination, including tests and consultations witha range of specialists.
- In case of concomitant diseases, such as cardiovascular diseases, diabetes mellitus, gastric ulcers and others, make sure they are in the phase ofremission.
- Foci of chronic diseases, such as e.g.,infections of the urinary and respiratory tractmust be eliminated. There should be also no any skin damages (abrasions, ulcers, cracks). Consult a doctor ifit is necessary.
- Dental check-up, and treatment, if required. If you had a tooth extraction recently, please wait at least two weeks to heal the wound.
- Check your weight and BMI (body mass index), which is calculated by the formula: mass (kg) / height2 (m2). BMI should not exceed 35-40. If you are overweight, you may be advised to reduce your weight before hip joint surgery. Please, take this advice seriously, because weight reduction lowers the risk of postoperative complications, significantly improves an outcome and extends the artificial joint lifespan.
- Smoking weakens the blood circulation. You should stop smoking one month before the operation.
What you need to do at home before going to a hospital for surgery,in order to make you more comfortable and safe on return:
- Place the items you use regularly to make them accessible, so you do not have to stretch or bend to take them.
- If you live in a housewith stairs, consider how you can avoid unnecessary climbing. For example, you can temporarily switch room designations and use a living room as a bedroom.
- Rearrange the furniture to have enough space to walk on crutches or with walkers.
- Get a suitable chair, the durable one and high enough to keepyour knees lower than your hips, and with armrests to make it easier to get out of the chair.
- To make your moving safer after your discharge from a hospital, examine your place together with your relatives so as if you are a detective or security specialist: remove or glue with double-sided adhesive tape the corners of all rugs so that you cannot stumble over them. Remove loose wires from the floor, if any. If you have parquet floor in your home, check all the planks to make sure that none falls out. Cover the sharp corners of tables and other furniture with special soft pads sold in children's stores. Ensure you have proper lighting everywhere in your home.
- Prepare your bathroom. If you normally take a shower standing in a bathtub,find a reliable stool without armpits. If you have a shower cabin, you can use a chairof any style but steady enough.
- The chair must have legs with rubber pads that prevent slipping.
- Fix secure hand rails on a bathroom wall or in a shower.
You arrive to a hospital for arthroplasty one day before the scheduled surgery. In a waiting room you will see a general physician and an orthopedist. They will explain all what you need to know about the upcoming surgery. If necessary, an additional examination can be done, such as tests, radiography, and functional examination. Then, you will have a consultation with an anesthesiologist.
After the examination you also will meet a rehabilitation physician who explains you:
- How to use crutches
- How to walk with supports without excessive load on the limb
- How to sit down, sit and get up
You may have a massage or functional electric stimulation (FES) of the lower limb muscles, if necessary.
In the night before surgery you need to take a bath or shower. After 6 p.m. you should not eat any more, and after midnight you also do not drink.
In the morning before surgery you need to remove false teeth, hairpins, contact lenses, glasses, watches, rings, earrings, chains and other jewelry and wash off the nail polish.
Before starting hip replacement surgery, a surgeon introduces a catheter to your vein. Regardless the method, surgery may be performed under general anesthesia or regional spinal anesthesia. With the latter, an injection is made in the lumbar region, after which the low extremities become numb for several hours. After the anesthesia, a urinary catheter is introduced. During all surgery, you will be conscious, but you can sleep if you want.
The duration of hip replacement is 1 hour on average.
Let us consider the traditional procedure for hip arthroplasty.
- The surgery area is extensively treated with an antiseptic; a tourniquet is applied.
- Next, the joint is opened without crossing the muscles and ligaments, using an anterior or posterior approach. Minimally invasive techniques have many advantages, but open surgeryis also widely applied.
- A surgeon accurately pushes aside soft tissues and fixes them with a clamp, then, reaches the articular capsule and removes it.
For different types of implant fixation further procedure may be different.
Cemented Fixation Implantation
- A surgeon cuts off the diseased bone of the femoral head and neck using a bone saw.
- The femoral canal is drilled by pasps or reamed with special surgical reamers to widen the canal and prepare it for stem insertion; sometimes, the procedure can be done without reaming with broachers only.
- The surgeon fits a stem of an implant to the canal, puts an artificial femoral head on and checks if the joint moves properly.
- When the fitting is done, the canal is plugged and filled with cement with a tool called a caulking gun.
- After this a centralizer is introduced.
- Excess cement is removed after 5-8 minutes.
Cementless Fixation Implantation
A procedure is nearly the same as above, but a stem is inserted into the canal without cementing. In this case, a special rough surface of the femoral stem ensures adhesion of an implant with the bone and their further fusion.
Having convinced that the new joint works perfectly, the surgeon washes the surgery area, installs drainage and suture the wound. At the end, the leg had surgery is fixed with an elastic bandage in a comfortable position.
If necessary, surgeons drain the joint introducing 1-2 thin plastic tubes (drains) so that the post-operative blood does not accumulate in the articular cavity. Flowing through the drains, the blood is collected in removable plastic containers changed by nurses until the drains are removed. The wound is stitched.
Before moving to a ward, you will spend some time in the postoperative care unit. You will have an intravenous catheter in one of your veins.
Please be ready that you will encounter pain in the first time after surgery, but you will be given injections to manage it. If you had spinal anesthesia, you will not able move and feel your legs for some time after surgery. However, the sensitivity and mobility will begradually recovered within 2-4 hours.
The treatment you will receive at the Medical Center depends on the implant type and doctor prescriptions.
The first few days after surgery are the most important. Your body is exhausted, and you have not yet fully recovered from anesthesia, but already in the first hours after you have come to consciousness, try to remember about the operated leg more often to be mindful about its position. As a rule, immediately after the operation, the operated leg is placed in a slightly flexed position. There will be a special bolster between your knees placed so to ensure their moderate spreading. The active regime in bed is allowed already in the first day after the surgery.
The first time you need to change bandaging is the next day after the surgery, and later on it will be done when needed, but at least once every 2-3 days until complete healing. 12-14 days after the operation, the stitches are removed. Sometimes, the wound is sutured with absorbable threads andyou don’t need to remove them.
In the first 2 days after the operation, a light diet consisting of porridge on water, jellies and fermented milk products is prescribed. Food, boiled or steamed, is given in semi-liquid or puree form, with the limitation of refined sugars and salt. Products promoting bloating and fermentation processes should be excludedfrom the ration. Next, one of standard diet plans is prescribed, considering the concomitant diseases.
Any operation has a risk of blood clots in the leg veins. You will be prevented from this complication by elastic bandaging of the lower extremities, and the prescription of anti-clotting medications.
Please remember that:
- In the first days after surgery,you should sleep only on your back.
- When turning in bed on a healthy side, you have to use a bolster between the legs, holding it with your knee slightly bent and ankle joints.
- In the first days, you should reduce a range of movements in the operated joint, and, especially, avoid bending in the knee and hip joints for more than 90 degrees, sharp turns of the leg, and rotation in the hip joint.
Recommended loads on the operated leg:
In case of cemented fixation:
- Partial load: from the first days after surgery
- Full load: by the end of the 1st month
In case of cementless but strong fixation:
- Partial load (15% of body weight):after 7-10 days
- Partial load (50% of body weight): by the end of the 3rd week
- Full load: by the end of the 2nd month
In severely weakened patients (suffering from acute cerebrovascular disease, severe somatic pathologies, cancer patients, and in people older than 90 years):
Full load: immediately after surgery
In patients with acute pain:
Immediate load limitation (in any period of time)
Try to devote all your free time to physical therapy. At first it will be accompanied by a moderate pain, but every day it will become easier.
The main goal of physical therapy is to improve the blood circulation to the operated hip, to prevent thrombosis, reduce edema, and speedup wound healing.
Another important task of physical therapy is strengthening the muscles of the operated limb, restoration of the normal range of movements and ability of the joint to support the entire body weight. Remember that anartificial joint is a bearing with an ideal slipping and minimal friction force. And that is why it is better to exercise actively in order to strengthen the muscles surrounding the joint rather than passive rocking and stretching.
In the first 2-3 weeks after the surgery, you should exercise lying in bed. All exercises must be performed slowly, evenly, and avoiding sudden movements and excessive muscle tension. To breathe correctly while exercising is also very important: breathe in when you strain muscles and breathe out when you relax.
1st exercise is to the gastrocnemius muscles. Gently push your feet up and down. Do this with both feet for several minutes up to 5-6 times in an hour. You can do this exercise immediately after awakening from anesthesia. Clench and unclench your toes.
Starting from the second day after the operation, continue with the following exercises:
2nd exercise is for the hip muscles. Keep your legs straight. Strengthen your knee pressing the knee pits to the bed and hold this tension for 5-7 seconds, then slowly relax.
Buttocks muscle strengthening:
- Toning up the back part of the thigh and lower leg: press the heels to the bed for 5-7 seconds, then, slowly relax
- Moving the leg aside along the bed surface and bringing it back
3rd exercise: Cautiously slide your foot on the surface of the bed toward your buttocks bending the leg in the hip and knee joints. Then slowly slide it back. When doing this exercise, at the beginning you can use with a diaper or elastic tourniquet, by placing it under the knee. Remember that the angle of bending at the hip and knee joints should not exceed 90 degrees!
4th exercise: Put a small pillow under your knee (not more than 10-12 centimeters) and try to strain the muscles of the thigh slowly and straighten the leg at the knee joint. Hold the straightened leg for 5-6 seconds, and then slowly lower it to its original position.
Do all the above exercises through out the day, for several minutes every hour (5-6 repetitions each).
From the second day you can sit down on the edge of the bed, leaning on your elbows, or holding on to the handrails with your feet lowered to the floor. First, you should gradually move the healthy leg, and, then, drag the operated one over it. Your legs should be moderately apart; you can ensure this using a bolster. To move the operated leg, you can use a special elastic bandage. When you move the operated hip to the side, keep the body straight and do not let your leg roll outward.
Always remember to bandage your feet with elastic bandages before you sit down or get up, or wear special elastic stockings to prevent thrombosis of the veins of the lower extremities. To restore normal movement of the joint, from the second day you will start a physiotherapy course with the help ofmechano-therapy appliances, special devices that, according to a specially designed program, will bend and unbend your leg in the hip joint. However, although those simulators are effective, they will not replace your own efforts. You will need to practice and develop your muscles so that they are ready by the time when you are able to walk without help.
The purpose of this rehabilitation period is to learn how to get out of bed, stand, sit and walk without help and safely.
As a rule, you are allowed to get up on your own on the second day after surgery. The first time you should get up only under supervision of medical staff. You are still weak and someone must help and assist you. You may feel slightly dizzy, but try to rely on your own strength as much as possible. Remember, the earlier you get up, the earlier you start walking by yourself.
Get out of bed from the side of the healthy leg. Sit on the edge of the bed, keeping the operated leg straight and extended forward. Place both feet on the floor. Using crutches, step on the non-operated leg and try to stand up. Leaning on the healthy leg, move the crutches forward. Then, slightly bend the operated leg in all joints and move it too. Leaning on the crutches, transfer your weight to them and push forward the healthy leg. Repeat all movements in the same order.
In the first 7-10 days, you can only touch the floor with the foot of your operated leg. Then, slightly increase the load through your leg, trying to step on it with a force equal to the weight of your foot, or 20% of your body weight. You should regulate the time you walk taking into consideration how you feel andcondition of your leg, and without reducing exercise therapytime. If you exercise not enough or do it incorrectly, and, at the same time, walk too long, by the end of the day you will have swollenfeet. In this case, consult a doctor. Concomitant diseases also may contribute to swelling.
After you have learned to stand steady and walk without help, you may start exercising whilst standing, with your hands on a support.
1st exercise: Moving a straightened leg forward
Stand on the healthy leg with your hand resting on the back of a bed or chair. Slowly move the operated leg forward by 20-30 cm. Make sure that the thigh, knee and foot directed forward. Keeping the same pose, slowly bring your foot back to its original position.
2nd exercise: Moving the legaside
Standing on the healthy leg with your hand resting on the back of a bed, slowly move the operated leg to the side for 20-30 cm. Make sure that the thigh, knee and foot directed forward. Keeping the same pose, slowly bring your foot back to its original position.
3rd exercise: Moving your foot back
Standing on a healthy leg with your hand placed on your loin, slowly move the operated leg back. Make sure that the waist does not bend. Slowly return to the original position.
4th exercise: Raising the knees
Slowly bend the operated leg in the hip and knee joints by an angle not exceeding 90 degrees and raise the foot to a height of 20-30 cm above the floor. Try to hold the raised leg for a few seconds, then, slowly lower the foot and put it on the floor.
The above exercises are recommended to do up to 10 times a day for 5-15 repetitions.
So, you walk on crutches quite confidently in the ward and hospital corridor. But in everyday life,it is not enough. You need also walk up and down the stairs. If you have only one joint replaced, you start climbing should be from the un-operated leg. Leaning on crutches, transfer the leg to the next step. Move the crutches over it and transfer the weight of the body to the un-operated leg that is now standing a step higher. Then lift the operated leg and put it on the same step. Crutches are moved last or simultaneously with the operated leg. When descending, you should first move the crutches, then, the operated leg, and, finally, the un-operated one.
More exercises to restore motor functions
1. Lower leg muscles
Take a position lying on your backwith arms and legs spread out. Tighten the abdominal muscles. Pull the toes up and press the heels to the floor. For a few seconds, keep the tension in the lower leg muscles and, then, relax.
2. Extensor muscles
Take a comfortable position lying on your back, with your arms and legs spread out. Tighten the abdominal muscles. Press the knee pit to the pillow under your knees, and pull the toes up. For a few seconds, keep the tension and, then, relax.
3. Muscles of the buttocks
Take a position lying on your back with arms and legs straightened. Tighten the abdominal muscles. Pull the toes up. Do not bend your knees. For a few seconds, strain the buttock muscles, and, then, relax.
4. Bendingat the hip
Place something you can slide on it (for example, a towel) under the foot of the operated leg. Raise the operated limb bending it in the knee, while simultaneously pressing the heel to the towel and pulling it toward the buttocks. When you do it, the toes are moved up. Hold the limb in that position for a while, and, then, return the foot to its original position.
5. Moving the legaside
Take the position lying on your back, stretching your legs. Place something you can slide on it (for example, a towel) under the foot of the operated leg. The toes should point to the ceiling. Slightly move your leg to the side, then, slowly return it to its original position. During the exercises, the knees should not touch each other.
6. Bendingat the hip joint
Take the position lying on the back, so that the operated leg is slightly bent. After this, raise the limb bending the knee at 90°, and keep this position for some time. Slowly return the bent leg to its original position. During the exercise, the healthy leg should be straight and remain on the floor. The toes are pointed upwards.
7. Moving your leg to the side
Take a comfortable lying position on the healthy side. Place a pillow between your legs. Bend the healthy leg and place a bent arm under the head. Put your head on your arm. Raise the operated leg, hold on for some time, and then return to its original position. When lifting your legs, keep them straight. Do not straighten your toes and keep your feet parallel to the floor.
8. Moving a bent leg to the side
Take a comfortable position lying on a healthy side. Place a pillow between your legs. Bend both legs in the knees. Slowly raise the operated one up, hold on for some time, and, then, return it to its original position. Do not straighten your toes, while the knee should be pointed forward.
9. Moving your leg to the side
Place a durable object of a small heighton the floor, and stand on it with a healthy foot. It is necessary that you stand slightly up so that the operated leg does not touch the floor. To keep balance, your hand is resting onthe chair back. Move the operated leg aside, and then return it back. The leg should be straight, but the toesare not stretched.
10. Unbending in the hip joint
Stand in front of the chair with your hands on its back. Move the weight of the body to a healthy limb. Slowly move the operated leg back without bending, and then return it to its original position. When doing the exercise, the upper body should be straightened.
11. Bending the knee
Stand in front of the chair with your hands on its back. Slowly bend the leg at the knee and lift it. Keep such a tense position for some time, and, then slowly lower your leg. The knee should be directed forward, and the foot should be parallel to the floor.
12. Straightening at the hip joint
Take the position lying on the abdomen, while the legs are straightened and the arms are stretched above the head. Bend the operated leg in the knee. Raise the hip upward with the knee bent. Keep this position for some time. Slowly lower your foot to the floor, still keeping the knee bent. Finally, straighten the leg, returning to its original position. Relax for a moment and, then, repeat the exercise.
13. Extension in the knee and hip joints
Ask a doctor if you can do this exercise. Take a position lying on your stomach with a pillow under it to prevent the waist from excessive bending. Stretch your arms above your head. Place the roller under the feet, so that the toes are pointing towards the floor. Raise the knee above the floor with the back of the knee toward to the ceiling. Raise the straightened leg until you feel the tension in the muscles of the thigh. Hold the limb in this position for a while, then relax and return the leg to its original position on the roller.