Total Hip Replacement Guide - Cappagh National Orthopaedic

Total HipReplacement Guide

C A P PA G HN AT I O N A L

O RT H O PA E D I CH O S P I TA L

FINGLAS, DUBLIN 11. TEL: 01 814 0400 FAX: 01 814 0327

Founded 1908

Total Hip Replacement Guide

Contents

Introduction

What is a total hip replacement

Precautions

Nursing

Physiotherapy

Social Worker

Occupational Therapy

The 1st 3 months

Recovering at home

3-6 months

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Introduction

Welcome to Cappagh

This booklet has been written to give you andyour family a basic understanding of a total hipreplacement operation, including things youshould know about before the operation andafter it happens. It is important, however, thatyou not alone understand the advantages butalso the possible problems that can occur withthis form of surgery.

Bear in mind that your Physiotherapist andOccupational Therapist play an important partin helping you achieve a good result.

Keep this booklet in a safe place as you shouldrefer to it from time to time. If there is anythingthat you do not understand, please ask yourNurse, Surgeon or Therapist.

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What is a Total Hip Replacement?

A total hip replacement is an operation designedto replace a hip joint which has been damaged,usually by arthritis. The hip joint is a ball andsocket joint. The ball is formed by the head ofthe thigh bone (femur) and fits snugly into thesocket (acetabulum) in the pelvis.

The surface of the bones in the joint are coatedby a smooth and compressible substance knownas gristle (or articular cartilage). Arthritis occurswhen the articular cartilage wears away,exposing the underlying bone (figure 2). Thiscauses roughening and distortion of the joint,resulting in painful and restricted movement. Alimp will often develop and the leg may becomewasted and shortened.

Think before you move

Understanding Hip Replacement

By understanding the anatomy of your hip, youcan better understand how the recovery processworks. Your hip is a ball-and-socket joint wherethe thighbone meets the pelvis. This joint issurrounded by cartilage, muscles and ligamentsthat allow it to move smoothly.

A Healthy Hip

In a healthy hip,smooth cartilagecovers the ends ofthe thighbone, aswell as the pelviswhere it joins thethighbone. Thisallows the ball toglide easily insidethe socket. Whenthe surroundingmuscles supportyour weight andthe joint movessmoothly, you canwalk painlessly.

Figure 1

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A Problem Hip

In a problem hip,the worn cartilageno longer serves asa cushion. As theroughened bonesrub together, theybecome irregular,with a surface likesandpaper. Theball grinds in thesocket when youmove your leg,causing pain andstiffness.

A Prosthesis

An artificial ballreplaces the head ofthe thighbone, andan artificial cupreplaces the wornsocket. A stem isinserted into thebone for stability.These partsconnect to createyour new artificialhip. All parts havesmooth surfaces forc o m f o r t a b l emovement onceyou have healed.

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Figure 2

Figure 3


The total hip replacement operation replaces theworn head of the femur with a stainless steel ballmounted on a stem and re-lines the socket(acetabulum) with a cup made of a specialplastic-polyethylene. These two componentsare usually fixed to the bone by a type of cementcalled methyl methacrylate. In special casesother types of stems (prostheses) may be used.This is at the discretion of your surgeon. Thisnew joint aims to relieve pain, decrease stiffnessand in most cases restores leg length and hencehelps improve mobility.

Osteoarthritis of the hip is generally a disease ofthe older person, but may occur in youngerpeople following rheumatoid arthritis, fracturesof the hip and other rarer conditions.

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Assessment

You may have to attend the Pre-OperativeAssesment Clinic. This is not always necessaryand will be decided upon by your surgeon.During this time your suitability for jointreplacement will be assessed by a team ofdoctors and therapists. This will involve havingsome blood tests, x-rays and a full medicalexamination by a doctor. You will be seen byPhysiotherapists who will introduce you to theexercises you will be required to do before andafter your surgery and an OccupationalTherapist will see you regarding safetyrequirements in your home.

Any anxieties you may have regarding youroperation can hopefully be alleviated at thisstage.

If you have a weight problem you shouldconsult your General Practitioner with a view tolosing some weight prior to surgery.

If everything regarding your health issatisfactory you will be called back for your hipreplacement operation within a few weeks fromthe time of assessment.


Suitable Clothing & Footwear

All patients following joint replacement inCappagh Hospital are encouraged to dress intheir everyday clothing as soon as is practicallypossible.

We have found this promotes a feeling of wellbeing and independence among our patients,encouraging them along the path of recoveryand rehabilitation.

Footwear:

We would recommend comfortable lace up orslip-on shoes with low heels, flat if possible.Trainers or runners are ideal but not necessary.

We do not recommend old slippers or backlessshoes.

Do not wear tight fitting footwear as the surgicalleg/foot may experience some temporaryswelling after surgery.

Clothing:

Loose, comfortable clothing is advised.

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Precautions

In order to prevent dislocation (ball slipping outof socket) post surgery, certain precautions arenecessary.

There are four basic movements which must beavoided for 12 weeks after the operation. Theseprecautions apply in all situations includingsitting and whilst moving in and out of bed or

chair.

1. Do not crossyour legs (fig. A).

Operated legsmust be always heldout to the side awayfrom the midline ofthe body.

2. Do not bend the operated hip excessively(fig. B).

i.e. not more than 900 by:a) Bending the knee of the operated leg too

high towards the chest.b) Leaning too farforward.

Your knees should belower than your hipwhen seated.

Fig. B Do not bendthe operated hipexcessively

10Think before you move

Precautions

3 Do not twist the operated leg in or out.Likewise do not twist your body on your

leg, i.e. by reachingtoo far across yourbody. Whenwalking or turningyou should alwayskeep your toes andknee-caps pointingstraight ahead.

Fig. C Do not twistthe operated leg inor out.

4. Do not roll or lie on your side.It is not advisable to lie on either side in the

early stages of recovery. You will be nursedon your back with the abduction pillowbetween your legs.

However, individual cases do vary and you willbe advised by the hospital staff as to which wayyou should roll or lie.

Fig. D Do not roll or lie on your side.

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When a natural hip must be replaced, an orthopaedicsurgeon uses a proshtesis (artificial hip joint). Like yourown hip, the prosthesis is made of a ball and socket thatfit together to form a smooth joint, so you can walk easilyand without pain.

Different from your Natural Hip

Your prosthesis has a limited safe range of motion and islikely to need special care until the soft tissue around yournew hip has healed. By following the precautions advisedby your surgeon - like avoiding bending your hip morethan 90 degrees - you can keep your hip from sliding outof position (dislocating). Based on your condition andthe type of prosthesis, your surgeon may also limit theamount of weight or pressure you can put on youroperated leg.

Natural hip bend: greater than90 degreesA healthy hip can bend morethan 90 degrees, allowing youto raise your knees to crossyour legs.

New hip bend: up to 90degreesAt first, your new hip has alimited range of motion.Don’t bend it at an anglegreater than 90 degrees.


Nursing

• Specialist nursing is provided on a 24 hourbasis from admission through to discharge.

• Your nursing requirements will be assessedand specific nursing care will beimplemented which will meet your needsbefore, during and after surgery.

• Before, during and after surgery we willclosely monitor your pain level and provideprescribed pain relief which will make yourpost-operative recovery as comfortable andpainfree as possible. This will aid yourrehabilitation and mobility process. It isimportant that you inform your nurse ortherapist/doctor of any pain you areexperiencing.

• We will monitor your recovery and yourprogress and communicate with the variousother professionals (both in the hospital andcommunity) interested in your care. Thiswill ensure that your discharge home will beas unproblematic as possible.

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Physiotherapy

Before Surgery:

You will be seen by your physiotherapist beforesurgery.

They will advise you on exercises which shouldbe started immediately following your hipreplacement and for the first 3 days until youattend the physiotherapy gym for progressivetreatment.

Bed Exercises:

(1) Deep breathing: These should be doneregularly to prevent chest infection.

(2) Ankle pump exercises: Move feet up anddown at the ankles. These should bedone regularly to prevent risk of bloodclot in the legs.

(3) Strengthening exercises• Press the knee flat onto the bed by

tightening the muscles on the front ofthe thigh. Hold for 3 seconds, relax,repeat 10-20 times.

• Squeeze your bottom muscles together.Hold for 3 seconds, relax, repeat 10-20times.

Remember to keep the unoperated leg movingto prevent it from stiffening up.


Home Exercises

The following exercises are safe to perform athome, and can be continued until your new hipis as strong and flexible as your other hip.

Lying on your back with a sliding board underyour leg.Bend and straighten your hip and knee bysliding your foot up and down the board.Repeat ___ times.

Stand straight holding onto a chair.Bring your leg backwardskeeping your knee straight.Do not lean forwards.Repeat ___ times.

Stand straight holding onto a support.Lift your leg sideways andbring it back keeping yourtrunk straight throughoutthe exercise.Repeat ___ times.

Your physiotherapist willadvise on a suitable homeexercise programme.

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Walking with the physiotherapist

Once you have regained your balance andbecome accustomed to the upright position youwill begin walking, usually 24 - 48 hours afterthe operation, with a walking frame or crutchesto ease the weight on your “new” hip.

When walking with a frame move thewalking frame forward first. Then move theoperated leg and finally the unoperated leg.

Turning round can be to either side but youmust prevent twisting or pivoting on your newhip. Therefore, feet must be picked up at eachstep so that the operated leg is not placed toofar in or out.

As your confidence and leg control improves,you will progress to walking with sticks orcrutches. You should practice with these until asatisfactory walking pattern is achieved.

Most people will manage with one or twowalking sticks by the time hospital dischargeoccurs, unless there are associated problems withother joints. Your physiotherapist will assessthese problems with you.Figure EWalking frame Crutches Walking sticks


Social WorkerThe Social Worker in the hospital provides thefollowing confidential services:

• (1) Advice and support for anyone whosesocial/emotional problems may be ofconcern to themselves or to their families inrelation to their admission for orthopaedicsurgery.

• (2) Assessment and advice for patients andtheir families in relation to hospitalisationand discharge.

• (3) Information on Social Welfare andHealth benefits and entitlements.

These services are available to all patients. Insome cases, your consultant or other hospitalstaff will refer you to the social worker. You arealso welcome to call to the social worker’s officeor you may ask reception or the ward staff tocontact the social worker for you.

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Occupational TherapyThe O.T. will see you before surgery and willoffer information and advice regarding care ofthe new joint. Your Occupational Therapist willdiscuss your personal circumstances with respectto home environment and independence ineveryday activities.

The Occupational Therapist will recommendadaptive equipment if necessary, anddemonstrate alternative methods of performingeveryday tasks ensuring safety of your new hipjoint.

The First Three Months

BedIdeally your bed should be firm and your hipsshould be higher than your knees when seatedon the edge. A board underneath the mattressmay help. If your bed is low, keep your operatedleg straight in front of you. If you are concernedabout the height of your bed, please discuss thiswith your Occupational Therapist.

In BedIn hospital you will use an abduction pillow tokeep your legs apart. This is not usuallyrequired at home, however a standard pillow canbe used if necessary. It is not advisable to lie oneither side in the early stages of recovery. A rollof blanket beside you may help you to stay onyour back. You should discuss your individualcase with a member of your rehabilitation team.


Getting InSit as far back on the edge of the bed as you canso that your operated leg is partially supported.Keep your body straight and don’t twist your legas you bring both legs into the bed. Be carefulnot to cross your legs.

Getting OutMove to the edge of the bed. Pivot on your hipsusing your arms to help and swing your legs overthe side. Sit on the edge of the bed with youroperated leg straight out in front. Put on yourfootwear without bending forward. Push downwith both hands on the side of the bed withoutleaning forward, in order to stand. Ensure yourwalking aids are correctly positioned.

Getting out of bed

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Sitting PostureChairChoose an upright chair with a firm seat andarmrests. Ensure the seat allows your hips tostay higher than your knees. Sit up straight orlean backwards.

Sitting DownBack up until the edge of the chair touches theback of your knee. Reach for the armrests.Keep your operated leg straight out in front andlower yourself without leaning forward. Sit,then slide, back in the chair.

Getting UpMove to the front edge of the chair. Straightenyour operated leg and put the unoperated legunder the chair. Correctly position yourwalking aids. Put both hands on the armrests.Push up with both arms and the unoperated leg.Don’t lean forward. Get your balance beforestepping away. Never pull yourself up using thesticks or walking aid, as these will be unstable.

ToiletAs most toilets may be too low, you may need araised toilet seat. You should ensure that this iscorrectly fitted before use. To help avoidtwisting or bending, keep the toilet paper withineasy reach, or take some before you sit down.Turn your whole body around to flush.


Sitting DownBack up until you can feel the toilet seat touchthe back of your knee on your unoperated leg.Put your operated leg slightly forward. Withone hand reach back to the toilet seat and slowlylower yourself onto the toilet. Let your operatedleg slide forward and keep your weight on yourunoperated leg.

Getting UpWhen standing up, do not lean forward. Putweight through your unoperated leg.

Mastering Daily Activities

The Occupational Therapist will facilitate youin modifying your normal activities of dailyliving. Your therapist shows you how to useequipment that can minimise the amount ofbending you need to do and gives you guidelinesfor home safety.

BendingDo not bend from the hips to pick objects offthe floor. Do not bend forward in bed to pullup clothes. An easireach will assist with manytasks.

DressingComfortable, loose-fitting clothes are best.Gather what you need so they are within easyreach. Sit on the edge of the bed or on a highchair.

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Underwear and trousersDress your operated leg first using easireach orlong shoehorn. Be careful not to bend forwardor lift your knee above your hip. To put on adress or shirt, slip it over your head.

Socks and shoesA sock aid and a long handled shoehorn enablesyou to put on and take off socks, stockings andshoes without bending at the hip. Elasticshoelaces turn your laced shoes into slip onshoes.You must not attempt to put on or take off theanti-embolism (TED) stockings on your own.

UndressingRemove trousers and underwear from yourunoperated side first.

WashingUse a suitable chair at the bathroom wash basin,or sit on the edge of the bed and have someonebring you a basin of water to be placed directlyin front of you. Use long handled aids to washand dry your feet or get assistance with this.

ShoweringA shower in place over the bath is not suitable.A walk-in shower usually involves a step andshould be negotiated with great care. A showerchair, grab rails and non-slip mat contribute toyour safety.

BathingDo not sit in the bottom of the bath for at leastthree months, if you have existing bath aids,please discuss further with your OccupationalTherapist.


CarYou are not allowed to drive until you receivespecific permission from yourConsultant/Doctor. You should sit in the frontpassenger seat. Getting into or out of a car canbe difficult, so it is important to follow your hipprecautions. Avoid long journeys as much aspossible. Consider taking a stretch break afteran hour’s travel. The following guidelines willhelp.

Before getting in:Your driver should bring a cushion/pillow andblanket to place on the seat to keep your hipsabove your knees, especially if the seat is low.Ensure you are on level ground. Your drivershould also recline the back of the seat and moveit as far back as it will go. Sit on a plastic bag toallow easier transferring in and out of the car.

Getting in:Stand with your back to the car. Lower yourself,keeping your operated leg straight in front ofyou. Slide back into the centre of the seat. Letyour driver assist your legs into the well of thecar, keeping your knees lower than your hips.Do not twist.

Getting out:Without twisting your body, lift your legs out ofthe car. Slide towards the edge of the seat.Stand up, keeping your operated leg out of thecar. Slide towards the edge of the seat. Standup, keeping your operated leg straight and infront of you. Steady yourself on your walkingaids to get your balance.

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Home SafetyKitchen and HousekeepingYou may need to reorganise your kitchen so thatthe most frequently used items are between headand waist level when you are standing. Use ahigh chair or stool for lengthy chores. It isimportant to remember all your hip precautionswhen working in this area. You are likely torequire help with shopping, meal preparation,cleaning and laundry from your spouse, relativesor friends.Sports and HobbiesIf you are concerned about resuming anyactivities within the limits of your hipprecautions, please discuss further with yourOccupational Therapist or Physiotherapist.WorkYour return to work will depend on the type ofwork you do. Do not plan to return to work tooearly after discharge as you will get overtired andmay increase the chance of dislocation. Seek theadvice of your consultant at your reviewappointment.Becoming more aware of hazards in your homecan help make your recovery easier and safer.Your home setting is different from the hospitalso you should adopt the same techniques andprecautions to your home environment.

• Move electrical cords and long phone linesout of the way.

• Store items within easy reach.• Remove throw rugs.• Watch out for children and pets.• Watch out for water spills, bare bathroom

tiles or slippery floors.• Always think before you move.


Sexual Activity

Sex can usually be resumed at 8-10 weeks. Timeshould be allowed for the incision to heal andfor the muscles and ligaments to begin thehealing process.

You may generally resume sex when you feelphysically and mentally ready and when youhave a clear understanding of the precautions tobe followed to protect your new joint.

It is common after most surgery to have a lowdesire for sex, especially if there is a lot ofdiscomfort with pain and stiffness.Communication with your partner aboutpractical positions as well as feelings isimportant. Sharing non-sexual acts of intimacycan also be important. If the side effects of yourmedication are having negative effects on sexualperformance ask your doctor can it be changed.

Please ask your therapist for further informationand advice.

Three - Six Months

At this stage you will have been x-rayed andreviewed by your consultant. By now you arelikely to be driving, relying less on equipmentand returning to a normal daily routine.

When resuming general household activities tryto commence at a gentle pace and don’t useexcessive effort.

You will be offered a physiotherapyappointment three months after your operation.This is an opportunity for you to discuss anyconcerns you may have regarding your recoveryand to receive advice on returning to normalactivities.

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Occupational TherapyEquipment Prescription

Please quote this form when seeing/contactingyour local community occupational therapist.

Name:

Chair

Following your hip operation you must sit in afirm high chair with arms. When seated, chairsshould allow1. Hips to be higher than knees.2. Back support.3. Feet to be flat on the floor.4. Arms to be supported by arm-rests.

(Dining carver chair may be suitable).

Seat height

This sitting height applies to all situations, e.g.Bed, Chair, Toilet - you will require inchRTS.

Small aids will be available from CappaghHospital O.T. Department


Produced by theOccupational Therapy Department

Publication Date Feb 2007Revision No. 2

Review Date Dec 2012

C A P PA G HN AT I O N A L

O RT H O PA E D I CH O S P I TA L

FINGLAS, DUBLIN 11. TEL: 01 814 0400 FAX: 01 814 0327

Founded 1908

Documents

Total Hip Replacement Guide - Cappagh National Orthopaedic