Total Hip Replacement Patient Guide

There are three primary goals of having a total hip replacement:

1. Eliminate pain in the hip
2. Improve mobility/motion in the hip
3. Improve quality of life

A total hip replacement involves removing the head of the femur as well as the remaining cartilage inside the hip socket (acetabulum). Metal, ceramic, and/or plastic (polyethylene) pieces are inserted to replace the removed bone and cartilage. The artificial pieces move smoothly over one another to restore motion of the hip.

The two metal pieces are made of titanium. The cup is inserted into the native socket (acetabulum) after it is machined to accept the metal cup. The femoral stem is inserted into your femur bone after it has been machined to accept the stem. Both of these metal pieces are "wedged" into the bone which created initial stability. Over a period of weeks to months, your bone grows onto the metal, creating a stable composite. The reason these metals are selected is because they do not create adverse reactions in the body.

The two metal pieces used do not touch each other. In between them is the bearing surface, which has both an acetabular (liner) side and a ball side. The ball is made of ceramic or, less commonly, metal (cobalt chromium). The acetabular liner can be made of either ceramic or plastic (polyethylene). Polyethylene, is a plastic polymer that has been processed to create a smooth surface with low wear characteristics. Either plastic (polyethylene) or ceramic liners are excellent choices, and have excellent longevity.

It is uncommon to use bone cement in total hip replacements, but in certain circumstances, this technique may be used to secure the femoral stem.

There are several surgical approaches to access the hip. Regardless of the approach, the pieces used in the surgery are typically the same.

We use the anterior approach to the hip, which is the least invasive way to access the hip and does not cut any muscles. Instead, we use a natural plane BETWEEN two muscles in the front of the hip to access it. After the hip components are placed, the muscles are allowed to return to their normal position and cover the hip components. 

There are several advantages to the anterior hip replacement over other approaches. The first is rapid mobilization. By not compromising the major muscle groups around the hip, you may walk more normally than when having a different approach. The second advantage is a reduced risk of dislocation. By not cutting the small muscles in the back of the hip, the hip biomechanics are not disrupted and this leads to less instability. With this technique, you do not have any "hip precautions", or rules of where you can or cannot move your leg. You may move it however you like immediately after surgery.

Another advantage to anterior approach hip replacement is the ability to use an x-ray machine when placing the components. This allows for an accurate and precise placement of the components and adjustment of the leg length.

Anterior approach total hip replacement has been performed in the US for around 20 years, and is gaining popularity due to improved patient outcomes. Dr. Foster spent one year learning the technique from the primary innovator of the technique, and performs the surgery in an identical fashion to his mentor, Dr. Joel Matta.

1. The surgery takes between 1 and 2 hours depending on the difficulty.
2. The incision is typically 9-10 centimeters in length, or 3-4 inches. It sits generally in line with where the pocket would be on a pair of pants. In some circumstances, it is necessary to extend the incision to gain access to the hip.
3. All absorbable sutures are used, so there are no sutures or staples to be removed in the office. A tissue glue may be used over your incision to create a waterproof seal, however you should not submerge your incision until it is healed, usually 2-3 weeks after surgery.
4. An antibiotic is used through your IV just prior to surgery to reduce the risk on infection. We use methodical sterile technique throughout the surgery to further reduce this risk.
5. A local anesthetic is used during your surgery to reduce pain levels for up to 48 hours.
6. Either general or spinal anesthesia can be used, which is determined by your anesthesiologist.

1. Typically you will stay between 1-2 nights in the hospital. The length of hospitalization is different for every patient and is based on pain control, progress with physical therapy, and general medical condition.
2. Physical therapy starts, in most cases, on the same day as your surgery. Your therapist will help you stand and walk. Walking is your goal for the first two weeks, after that you will start strengthening exercises and formal physical therapy.
3. We prefer for most patients to go to their own home following discharge from the hospital. In some special circumstances, you may go to a skilled nursing facility for a short time.

Short term recovery is different for every patient, and is based on your pre-surgery conditioning level and overall medical condition.

You will start by walking with a walker or cane in the hospital. Most patients have stopped using the cane by around 2-3 weeks after surgery, but this is variable as well. If you need a cane for a longer period of time, you are not behind and it does not necessarily signify a problem in your recovery.

You will continue physical therapy to improve your range of motion and strengthening for around 3 months after surgery, and can continue if necessary after that.

If generally takes about 6 weeks to 3 months for you to return to your pre-surgery conditioning level so that you are able to perform activities without limitation. Maximal recovery is seen at one year.

Your entire leg can be swollen for up to a month. This does not necessarily signify a problem. Painful swelling in the calf area can be worrisome, so you should come to our office to be evaluated if that is the case. The only intervention found to be effective in reducing swelling after surgery is the Geko device, which is a small band worn around the knee that creates muscular contractions. Unfortunately, this is not covered by insurance companies. You can purchase the recovery pack of Gekos, 10 total devices, for $250. These devices also help reduce the risk of a blood clot (DVT).

We typically allow patients to drive at 2 to 4 weeks after surgery, and sometimes sooner if the operative leg is the left leg. There is some literature that states that your reaction time will not be back to normal prior to 6 weeks. You should not drive while on narcotics.

Returning to work is highly dependent on your general health, activity level and demands of your job. If you have a sedentary job, such as computer work, you can expect to return to work by 2-4 weeks. If you have a more demanding job that requires lifting, walking, or travel, you may need up to 3 months for full recovery.

Typically we let you shower two days after surgery. However, you should not submerge your incision until it is healed, which will be around 2-3 weeks after surgery.

The only major restrictions you have after total hip replacement are in the short term. You must wait 3 months before you start jogging, cycling, skiing, surfing, or horseback riding. The reason for this is to allow time for the bone to grow onto the metal pieces. If you have a hard fall during this time period, it is possible for the metal to spin out of the bone.

You are allowed to walk as far as you like, ride a stationary bike, return to yoga/Pilates after around 2 weeks.

A total hip dislocation occurs when the ball of the femur "pops" out of the artificial socket. The biggest risk of this complication occurs within the first month after surgery. With anterior approach total hip replacement, hip dislocation is exceedingly rare. 

You will not have any "hip precautions" after undergoing anterior total hip replacement. This means you are able to move your hip in any direction at any time.

There is no way to accurately state how long your hip replacement will last. This varies by patient, life circumstances, surgical technique, and a variety of other factors.

The most helpful way to think about this is with overall probabilities from large studies, which tell us there is an 80-85% chance your hip will be functioning well at 20 years.

No surgery is without risks. Overall risk of complications are about 1-2% of cases. The risks of a total hip replacement include:

1. Bleeding - it is very uncommon to need a blood transfusion after total hip replacement, but it is a risk. We would only administer a blood transfusion if absolutely necessary and would need your consent to do so.
2. Fracture of the bone - this would be treated depending on the severity, and would range from limiting your weight bearing to an additional procedure to fix the bone and allow it to heal.
3. Loosening or wear of the implants - total hip replacements typically last a very long time. In most circumstances, this will be the only surgery you need. However, loosening of the implants (becoming unbonded from the bone) or wear of the plastic (polyethylene) inserts can occur many years after. These situations typically require another, or revision, surgery.
4. Infection - this is the most worrisome of the possible complications. A deep infection in a hip replacement is a serious problem and is typically treated surgically and may require removal of the implants. We take multiple precautions to prevent infections before, during, and after the procedure.
5. Dislocation - it is possible to dislocate your total hip replacement, however it is not probable. Risk of dislocation is less than 1%, and may be as low as 0.1%.
6. Blood clots - blood clots in the leg (deep venous thrombosis, or DVT) are a serious concern after hip replacement, but are also uncommon. We use multiple methods to prevent this occurrence during and after the procedure. The most effective way to reduce the risk of blood clots is with early mobilization. You will also take a medication for 4-6 weeks after surgery to reduce the risk of blood clots, typically aspirin. the Geko device offers another layer of protection against blood clots, but stimulating muscular contractions. It is a band work around the knee. Unfortunately, it is not covered by insurance companies, and a pack of 10 can be purchased for $250. It is not mandatory but it is highly recommended by Dr. Foster.

There are no specific activities or therapies you need to do before surgery to get ready.

However, you should engage in a healthy lifestyle with a proper diet. If you are overweight, reducing your weight can substantially reduce your risk of infection and other risks. If you are diabetic, keeping your Hgb A1c level as low as possible will reduce your overall risk as well.

This is a very controversial topic. Some surgeons prefer to have their patients have antibiotics prior to dental procedures, some prefer this practice for 2 years after surgery, and some do not recommend this procedure. 

If your dentist wants you to have antibiotics, that is fine. They will be the one to prescribe them. It is our feeling that you do not need antibiotics prior to dental procedures, but it is a safe practice to do so. We will not be providing antibiotic prescriptions for this situation, so your dentist must provide if to you if he or she wishes you to have them.

Probably. It is reasonable to inform the agent at the airport or other facility that you have a hip replacement, and you will need to follow their instructions. There is no official document you need to carry with you stating you had a hip replacement.