Pre-operative evaluation
Age of patient:
Osteo-arthritis of the hip is a very common problem in the western population. Several thousands of patients undergo hip replacement every year. These patients are usually over 55-60 years of age.
In Indian population osteo-arthritis is relatively uncommon. Most of the patients with hip arthritis have rheumatoid arthritis or ankylosing spondylarthropathy, avascular necrosis, hip dysplasia, post-traumatic arthritis or failed fracture fixation. All these problems occur at a relatively younger age than osteo-arthritis. Quite a few patients undergoing hip replacement are young. Surgery is recommended after considering the individual circumstances of the patient – single versus multiple joint involvement; patient’s lifestyle and expectations; effects of arthritis on career; effects on marital life; economic responsibilities and family commitments; willingness to modify his/her lifestyle, etc. Some of these young patients will require a revision surgery at a later date.
Many elderly patients have hypertension, diabetes, previous angioplasty or coronary bypass surgery, hypothyroidism, etc. Most of these patients can safely withstand hip replacement. Preoperative assessment by physician, cardiologist, endocrinologist and others may be necessary to optimize the patient’s condition.
Co-existing medical problems:
Control of hypertension, diabetes, asthma, etc. is necessary. Any infection in the teeth, bladder, skin, ears, etc. should be treated before the surgery.
Pre-operative evaluation:
Routine blood tests, ECG, chest–X ray and echocardiography are necessary. The patient is assessed by physician, anaesthetist and other specialists like cardiologist, pulmonologist, endocrinologist, etc. to optimize his/her condition before the surgery. Two units of blood are reserved.
Surgery
Anaesthesia:
Hip replacement is done usually under epidural anesthesia. Epidural anesthesia provides excellent pain relief in the post-operative period. It also helps reduce incidence of venous thrombosis. General anesthesia can also be given and is preferred under certain circumstances. The choice of anesthesia will be discussed by the anaesthetist.
Procedure:
In a total hip replacement, the worn out surfaces are replaced by artificial device (prosthesis). The socket is replaced by a hemispherical cup which has a metallic shell and an inset high-density-polyethylene liner. The head is replaced by a metal sphere supported on a tapered stem which fits into the bony canal of the femur. The implants have specially textured surface which allows them to grip the bone. Sometimes acrylic bone cement is also used to fix the implants.
The surgery takes about 90 minutes. However, the patient is in the Operation Theatre for about three hours because of the time required for administration of anaesthesia; setting up the patient, equipment and surgical team; and recovery from anaesthesia, dressing and shifting the patient after the procedure.
Postoperative course
Immediate post-operative care:
The patient is kept under close observation for about 24 hours, either in the ICU or High Dependency Unit (HDU). One or two plastic tubes (drains) are placed to drain excess blood from the knee. Antibiotics are given for 24-48 hours. Other medications for diabetes, hypertension, etc. are continued with some modifications. Anti-coagulants are started 6-8 hours after the surgery. Food intake is started after 4-6 hours.
Pain control is achieved by various means: intravenous painkillers (regular doses or via Patient Controlled Analgesia device), epidural infusion, transdermal patches, etc.
Patients are made to sit up and walk with support on the next day. When uncemented implants are used, partial weight bearing is advised for first six weeks. Physiotherapy is started for regaining movements, improving muscle strength, improving chest function, and preventing venous thrombosis. The drains are removed after 24-48 hours. Most patients are able to walk the length of the hospital corridor by fourth day.
Patients are discharged 4-7 days after the operation. The wound is kept covered with a sterile dressing which should be kept dry. The sutures are removed between 10-14 days. Physiotherapy is continued at home for 4-6 weeks.
Follow-up:
The patient is reviewed in the OPD at regular intervals. Staples are removed at two weeks. Recovery of movements and strength are monitored and appropriate modifications to physiotherapy or exercise programme are suggested. Full weight bearing is started after six weeks. Initially the patient is followed up every 3-6 weeks. After 6 months, yearly follow-up is advised.
Short stay surgery:
These days, the trend is towards early discharge. Many patients can be discharged after 2-4 days. Early discharge is facilitated by a team of patient care co-ordinator, home care nurses, physiotherapists and other staff.
Precautions after hip replacement:
For the first 6 weeks the patient should not engage in any vigorous activity with respect to the operated limb. After that progressive increase in the activity is permitted depending on the patient’s progress. Certain activities like sitting on the floor may have to be avoided. A western toilet with elevated rim is recommended. Care should be taken to avoid falls and injuries.
Normal activities can be started after 6-8 weeks. The patient should not indulge in athletic activities, contact sports or high impact activities.
Prophylactic broad-spectrum antibiotics should be started before undergoing any dental, genito-urinary surgery or any major surgical procedure. Whenever there is any suspicion of infection anywhere in the body – like skin infection, urinary infection, ear infection, tooth infection, chest infection or systemic bacterial infections – the patient should seek immediate medical attention to start antibiotics and take other measures as required.
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