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Hip Arthroplasty

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Author:    David Tilton (RN, BSN)

Purpose/Goals

This course teaches healthcare personnel pre-operative and post-operative care for patients having a hip arthroplasty.

Objectives

After completing this course, the learner will:

  1.  discuss the prevalence,   
  2.  discuss pre-operative care,   
  3. discuss post-operative care,   
  4. discuss the rehabilitation timeline, and   
  5. Identify post-operative activity limitations.

Introduction

The goal of hip arthroplasty is to return a good level of function to the hip joint without pain. Hip arthroplasty removes damaged bone and replaces the hip joint with prosthesis made of metal, ceramics, and plastics. Total hip arthroplasty is the replacement of the acetabulum and femoral head. Hemiarthroplasty is a replacement of only one side of the hip joint. Indications for these include osteonecrosis, osteoarthritis, hip fracture, and congenital malformation of the hip that causes abnormal wear of the joint.

Components of Hip Prosthesis

  • Femoral portion, ball and stem, consists of a metal or ceramic ball with metal stem
  • Acetabular portion, cup, is generally composed of a metal shell with plastic lining, though other materials are sometimes used

In the United States more than 120,000 total hip arthroplasties are performed each year; over 800,000 total hip arthroplasties are performed internationally each year. Before the advent of the hip arthroplasty, in the early 1960's, significant hip disease was a sure sentence of protracted pain and disability, without recourse. The total hip arthroplasty was such an important advancement that it is held by many to be the most important operation developed in the 20th century. The Queen of England honored the surgeon who first introduced it with knighthood (Jacobson, 2004), (Leopold, 2003).

Pre-operative Care

Patients preparing for a hip arthroplasty should receive the standard pre-operative care for a major procedure. In addition to the standard care, the patient should start the recovery and rehabilitation process. Introductions and sessions with the physical therapist should begin weeks prior to the procedure date. Detailed expectations regarding the post-operative recovery, along with realistic timelines should be provided. Post-operative range of motion exercises should be practiced pre-operatively.

Adaptive techniques are changes in the way an activity is performed. These should be introduced pre-operatively to decrease patient anxiety and promote recovery. Measurements for fitting assistive devices, such as a walker, canes, crutches, and reach extenders, should be made pre-operatively. Inform a patient, if appropriate, of the expectation of being able to stand and partially bear weight soon after the procedure. Teach the patient know that partial weight bearing means to first stand then walk using a supportive device. Most of the weight that is usually held by the hip should be transferred onto other areas of the body, such as the palms of the hands.

Let the patient know that he will be relearning how to walk with the new hip. This may come as some surprise as patients assume because they have already mastered walking that no new learning is needed. It is common to begin post-operative rehabilitation with a walker, so that balance is supported from many angles. Once balance and articulation of the hip for forward movement (stride) have been regained, the walker is sometimes replaced by two crutches for a period of 4 to 6 weeks.

Post-operative Care

The patient will have a large dressing which covers the hip and a small drain tube coming from the incision to prevent blood from pooling at the surgical site. A foley catheter is common and an abduction pillow is usually used to hold the new hip in its best position during the initial post-operative period.

Following a hip arthroplasty pain can be controlled using patient controlled analgesia (PCA), intravenous narcotics, or epidural analgesia. After the first one or two days, pain diminishes and a switch to oral narcotics can begin. It is important to coach patients to schedule their pain medications for about one half hour before attempting to walk or participating in physical therapy.

Reassure the patient that pain control will not end at the time of discharge. Oral narcotics, non-steroidal anti-inflammatory agents and a wide range of other pain control adjuncts are available. Physical adjuncts to a good pain control regimen include the use of ultrasound for pain control, diathermy, transcutaneous electrical nerve stimulation, whirlpool, massage, and the application of heat or cold (Hoenig, Siebens, 2003).

Rest for pain:
Rest is an important part of post-operative pain control. If pain occurs with an activity or movement, it is a signal that there is irritation. An increase in pain signals an increase in the irritation to that area.

Ice for pain:
Ice makes the blood vessels in the area to vasoconstriction. This helps control inflammation that causes pain and can easily be done as part of a home program. Some ways to apply ice include cold packs, ice bags, or ice massage. Cold is generally applied for only 10 to 20 minutes.

Heat for pain:
Heat makes blood vessels vasodilatation. This helps to flush away toxins causing irritation. It also helps bring in nutrients and oxygen, which help the area heal. True heat, in the form of a moist hot pack, a heating pad, or warm shower/bath is more beneficial than creams that merely give a feeling of heat. Heat is usually applied for 15 to 20 minutes. Special care must be taken to make sure the skin does not overheat and burn. Sleeping with an electric hot pad at night could cause burns.

Following hip arthroplasty, it is very common to be up and starting to walk early the next day or late that same day if the procedure was in the morning. Early mobility helps prevent respiratory problems and deep vein thrombosis (DVT) of the legs. The use of a spirometer and frequent deep breathing and coughing should be done for the first one to two days post-operatively to prevent respiratory difficulties.

A sequential compression device (SCD) may be used following a prolonged procedure such as a hip arthroplasty. SCDs are composed of leggings and a pump. The SCD rhythmically compresses the tissue of the legs from bottom to top in order to prevent venous pooling and DVTs. Subcutaneous anticoagulants may also be used to prevent the formation of venous clots. When the post-operative patient is in the bed, have him perform ankle movement exercises such as pedaling or pumping of the foot frequently to encourage circulation.

Ankle Pumping Exercise

Move the foot/ankle up and down, make circular movements with the foot. Repeat on both feet 50 times, once every hour while awake.

Dorsal Flexion

Plantar Flexion

Circular Movement

 

Rehabilitation

Many patients are reluctant to attempt standing post-operatively. Pain makes initial weight bearing a true test of courage. Generally, the physical therapist will be present to encourage and assist in the initial weight bearing exercise. From two to three hours later a second round of weight bearing typically follows, this time a few steps away from the bed then back are encouraged. The presence of a walker for these first excursions is invaluable, because the procedure can affect balance and coordination. As strength and confidence is regained excursions become progressively longer. Hesitancy to ambulate may be overcome by the discontinuation of the foley catheter and the need to go to the toilet.

Initial physical training concentrates on balance and coordination of the affected leg. Constant positive encouragement is key to this process, with the goal always being a few more steps away. It is essential to respond to any negative self-talk that the patient reveals. Comments like "I cannot do this" or "I will never be able to walk right" reveal an attitude of self-depreciation that must not be tolerated for success to be achieved. Negative self-talk is best handled by flipping any comments around and immediately responding back. "I cannot do this" should be dealt with using responses such as "Look how far you have walked this time".

When teaching the patient to climb stairs, tell him to hold onto the handrail with one hand and take his walking aid in the other hand. The non-operative, good leg goes up first. Then the operative leg and walking aid are brought up together to that same step. Going down the stairs the operative leg, the bad leg, and walking aid go down the step first, followed by the non-operative leg to the same step.

After three to five days in a hospital the patient is discharged with instructions about how to continue physical therapy at home and with appointments scheduled for further physical therapy and physician visits. The level of physical therapy varies based on patient age, fitness, and level of motivation. Therapy usually lasts around a month with two to three sessions per week, either at home or in an outpatient location (Leopold, 2003).

During outpatient sessions, balance and safe walking are emphasized. Hip precautions are constantly reinforced and muscle-strengthening work begins. All patients are given a set of home exercises to do between supervised physical therapy sessions, and the home exercises make up an important part of the recovery process.

Once it is safe to put full weight on the surgical leg, fine tuning of the gait begins. Retraining is especially needed if the person had developed an antalic gait (limp) before the procedure, otherwise the habit of limping will continue. The first thing to relearn is how to shift weight when walking. Hesitation to shift the weight leads to a limp. Have the patient stand on the foot of the operative side and prepare to step through with the opposite foot, swaying as he does so. Each step should be consistent and equal in width and length.

A typical course of recovery is ambulation with a walker (or two crutches) for 4 to 6 weeks; then using a cane for another month or so. The assistive devices should remain available to the patient for the entire rehabilitation period, including after independent ambulation, because even with younger patients balance and coordination suffer with fatigue (Leopold, 2003).

Rehabilitation Timeline Post Hip Arthroscopy

Day of The procedure:

Immediate post-operative activities to help prevent problems with breathing and blood clots begin. These are encouraged by nursing staff every hour.

  • Breathing deeply
  • Coughing
  • Ankle pumping
  • Tightening the muscles in legs and buttocks

Day 1:

Exercises and activities to help strengthen leg muscles and increase the movement in the hip joint begin.

  • Bending each leg while sliding the heel toward the hip while in bed
  • Sitting on the side of the bed
  • Walking a few steps with a walker or crutches
  • Sitting in a chair

Day 2:

Stretching and strengthening exercises are added. These may include;

  • Stair climbing
  • Standing leg and knee raises
  • Bathing
  • Walking to the bathroom

Day 3 to Hospital Discharge:

Continue to increase activities and exercises. Before discharge the patient should:

  • Demonstrate safe walking with a walker or crutches
  • Move to the chair or toilet without help
  • Independently bathe and dress

Hospital Discharge to six weeks post-operative:

The number and duration of the exercises increase as tolerated. Activities of daily living are added.

  • Walking increasing distances with a walker, crutches, or cane
  • Placing increasing amount of weight on the leg
  • Exercises such as leg and knee raises and hip extensions
  • Activities of daily living such as washing dishes, cooking, and laundry

Six to 12 weeks post-operative:

Continue the leg and hip exercises while gradually returning to normal activities of daily living. Such as;

  • Walking without a walker or crutches
  • Exercising with an elastic band or tubing
  • Driving an automatic shift car
  • Resuming sexual relations

12 weeks post-operative:

Resume most of the activities performed before the procedure while using good judgment to avoid undue stress on surgical hip;

  • Walk 20 or more minutes daily
  • Return to work
  • Drive a stick shift car
  • Recreational activity like golfing or sedate dancing

 

By watching the patient walk during the post-operative rehabilitation, health professionals can encourage corrections for stride and balance. At times, orthotic devices may aid a person on a temporary or even permanent basis. Orthotic devices are externally applied devices that act as a support to the musculoskeletal system. Common examples are shoe inserts or specially adapted shoes and braces to support an unstable or weak joint. Orthotic devices are available to assist in balance and security while walking (Hoenig H, Siebens H. October 2003).

The large majority of patients are able to return to a good level of function without hip pain. Most patients are able to walk without a limp, and may resume reasonable personal and recreational activities gradually in the weeks and months following the procedure.

Limitations

Dislocation of an artificial hip is possible, but uncommon. When it does occur, it is usually within the first three months post-operative. The problem generally starts with what patients describe as a popping sensation or a slipping sensation. When dislocation occurs, that person will be unable to bear weight on the affected limb and may have pain. Instruct them to contact their surgeon immediately and advise that they need to visit an emergency room. Putting the hip back in the socket usually requires conscious sedation to relax the large leg muscles, allowing the hip to be eased back into place.

The new hip prosthetic replaces an intricate and wonderfully designed work of art. As the largest articulating joint in the body, the natural hip takes great pressures and continues to smoothly glide the surface of the femoral head across the surface of the acetabulum. We can reproduce this pressure bearing surface and even the smooth glide, to an extent. What is difficult to reproduce is the elastic resiliency of the supporting tissues that both cover and surround natural articulating surfaces.

 

The natural hip shifts, adjusts load-bearing points on the articulation surfaces, pulls surfaces away from each other, and returns surfaces together.

The artificial hip responds like a cork being twisted from a bottle. Given the proper pressures, pulls, and angles, POP.

 

Certain precautions are important in order to minimize the likelihood of dislocation. Stress the need not to over-extend any bending, twisting or pulling motions to the upper leg and hip. Showing a working model of hip prosthetics helps make the concept understandable.

Arthroplasty Precautions to Avoid Dislocation

Avoid crossing the legs beyond the midline (either in bed or seated)

  • Wedge a pillow between the knees when lying on the back
  • While in bed or seated avoid crossing legs
  • When lying on the non-operative side, a large pillow should always be between the legs, and the bottom (non-operated side) leg should be bent at the hip and knee. The top (operated side) may also be slightly bent at the hip and knee for comfort
  • Keep the feet approximately 6 inches apart
  • When sitting in chair, sit with the knees comfortably apart

Avoid bending forward beyond 90 degrees (as when seated upright or bending forward to tie a shoe);

  • When seated, the knee on the operative side should be below the level of the new hip, avoid low chairs
  • Use an elevated chair or lean back slightly when sitting and while standing to keep the hip from bending greater than 90 degrees. (If an elevated chair is not available, place a couple of pillows on a standard firm chair)
  • Use an elevated toilet seat

Avoid bending over at the waist;

  • Use a sock donner to put on socks
  • Use a long handled shoehorn
  • Use shoes with elastic laces, Velcro or slip-on shoes
  • Use a long handled reacher to pick things up off the floor

Avoid turning the foot inward;

  • Avoid rotating or twisting the body
  • Avoid pivoting on the operative leg

 

Explain the risks that certain motions and stresses place on the artificial hip, and then teach the patient to use good sense when it comes to choice in activities and actions. Coach them to ask the question will this put my hip at risk? By using critical thinking, people can govern their own actions with good judgment.

Since the joint prosthetic components have no capacity to heal from injury, it is necessary to offer some common-sense guidelines for athletic, leisure, and workplace activities. As the artificial joint includes a bearing surface that can with time accumulate wear, walking or running for fitness should be limited. Frequently individuals will eventually feel well enough for this, yet should exercise caution in order to prolong the life span of the implant materials. Alternatively, swimming, water exercises, cycling, cross-country skiing, and cardio fitness machines simulating skiing motions can provide a high level of cardiovascular and muscular fitness without excessive wear on the prosthetic joint material.

Recommended Post Recovery Activities

Permitted with Caution

Not Recommended Post Recovery

  • Swimming
  • Water aerobics
  • Cross-country skiing or Nordic Track
  • Cycling or stationary bike
  • Golf
  • Dancing
  • Sedentary occupations (desk work)
  • Hiking
  • Gentle doubles tennis
  • Light labor (Jobs that involve driving, walking or standing without heavy lifting)
  • Weight lifting (check before)
  • Bowling
  • Jogging/running
  • Impact exercises
  • Sports that require twisting/pivoting (aggressive tennis, basketball, racquetball)
  • Contact sports
  • Heavy labor
  • Forms of Yoga
  • High impact aerobics
  • Rope jumping

 

Conclusion

Hip arthroplasty removes damaged bone and replaces the articulation surfaces of the femoral head and acetabulum with man-made materials such as metal, ceramics and plastics. These new surfaces allow the hip to move with minimal pain, and recovery proceeds rapidly with discharge to home in three to five days after the procedure.

Recovery after hip arthroplasty the procedure concentrates on regaining strength and balance, while re-learning to walk with the new hip prosthesis. Frequent encouragement to go a little further, and to keeping a positive attitude are important to recovery. Teaching and encouraging the new hip patient how to best live with the limitations will allow them to take control of their lives and make decisions. As they regain confidence in their ability to move without pain, they become ready to take the world, once again, in stride.

Reference

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"Avascular Necrosis." March 2004. Mayo Clinic. http://www.mayoclinic.com. Accessed December 28, 2004.

"Bone Graft Alternatives." Accessed 2005. North American Spine Society. http://www.spine.org/articles/bone_grafts.cfm. Accessed January 10, 2005.

"Osteonecrosis." Accessed January 3, 2005. NONF - The National OsteoNecrosis Foundation and the Center for Osteonecrosis Research and Education. http://www.nonf.org/nofbrochure/nonf-brochure.htm.

"Total Hip Replacement: Relieve Pain, Improve Mobility." 2003. The Mayo Clinic. http://www.mayoclinic.com. April 18, 2003. Accessed January 13, 2005.

Hoenig H, Siebens H. October 2003. "Geriatric Rehabilitation." New Frontiers in Geriatric Research. The American Geriatrics Society. Chapter 12. http://www.frycomm.com. Accessed January 11, 2005.

Jacobson, J. 2004. "Hip Replacement." E-Medicine. http://www.emedicine.com/radio/topic830.htm. Updated July 14, 2004. Accessed January 11, 2005.

Lee M, Chang Y, Chao E and Shin C. "Conditions Before Collapse of the Contralateral Hip in Osteonecrosis of the Femoral Head." 2002. Chang Gung Medical Journal. Volume 25. Pages 228-37. Accessed January 10, 2005.

Leopold, S. ed. 2003. "What is Hip Replacement? A Review of Total Hip Arthroplasty, Hip Resurfacing, and Minimally-Invasive Hip The procedure." University of Washington. http://www.orthop.washington.edu/faculty/Leopold/hipreplacement/01. Updated December 29, 2003. Accessed January 13, 2005.

Levine M., Rajadhyaksha A, and Mont M. July 13, 2004. "Osteonecrosis." E-Medicine. http://www.emedicine.com/orthoped/topic430.htm. Accessed January 3, 2005.

Lightdale N, Field J, and Danney C. 1996. Wheeless™ Textbook of Orthopaedics. Duke University Medical Center. DataTrace Publishing Company. http://www.wheelessonline.com. 1996.

Mont M, Ragland P, and Garcia E. 2004. "Core Decompression of the Femoral Head for Osteonecrosis Using Percutaneous Multiple Small-Diameter Drilling." Clinical Orthopaedics & Related Research. One (429):131-138, December 2004.

Montanari M and Bronzini N. 2003. "Indication about Hyperbaric Treatment of Aseptic Necrosis of the Femoral Head (NATF)." Clinical Ortopedicae Traumatoligica Universita degli Studi di Verona & 1Istituto Iperbarico, OTI Medicale, Vicenza, Italy. http://www.hbot4u.com/bone3.html. Updated February 12, 2003. Accessed January 10, 2005.

Richardson M. 2003. "Approaches To Differential Diagnosis In Musculoskeletal Imaging", “ Osteonecrosis." http://www.rad.washington.edu/mskbook/osteonecrosis.html. Last updated November 19, 2003. Accessed January 4, 2005.

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