Hip prosthesis

Total hip replacement

1. Definition

Hip joint replacement is called arthroplasty. It includes removing the affected part of the joint and replacement by an “artificial” joint, called prosthesis.

Hip joint consists of femur, which will articulate the acetabulum (the bone that is found in the pelvis).

Bone surfaces are covered with a very smooth, flexible layer, called cartilage. Over time, these smooth surfaces wear and decrease in thickness.

The bone underneath will be stripped and friction will occur between bone surfaces. This friction is the explanation of pain, arthrosis corresponding therefore to cartilage wear.

Hip arthritis is calledosteoarthritis of the hip.

Mounting a total hip replacements may also be proposed to patients with hip fractures (with an average wear of the cartilage), or in patients with femoral neck fractures, with ages around 55-60 years.

2. Total hip replacement

It is composed of three parts:

  • •the femoral stem,
  • •acetabulum,
  • •femoral head.

The stemis made of a special-alloy part that is implemented in the femur. It will be fixed with cement or by simple impaction. The other end, left free, is the neck of the prosthesis attached to the femoral head.

The femoral head will articulate with the acetabulum, of which bottom is covered with a smooth surface (polyethylene, ceramic, metal worked differently).

Each material has its advantages and disadvantages; there is no ideal prosthesis.

Type of prosthesis will be adapted according to the pathology, patient’s age and hip damage. Prosthesis is selected by the surgeon based on these criteria.

Currently, total hip prostheses have a lifespan of about 15-25 years. This life span depends on the materials composing the prosthesis. At the end of that period, the prosthesis can be changedin full or only the worn part.

Cemented prostheses are indicated for the elderly (over 80 years of age); when bone consistency is less good, cementing of the prosthesis increases its stability, allowing early resumption of support.

In younger people, uncemented prostheses are covered by a layer of hydroxyapatite that allows a biological osteointegration of the prosthesis.

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3. Indications

The purpose of a total hip prosthesis is pain relief and affected joint improvement.

Patients with hip disease often have a very painful hip that keeps them from normal walking, especially over long distances. Hip is often rigid, patients are awoken at night by the hip pain, which, over time, alleviates only with strong painkillers.

Several diseases can lead to destruction of the hip joint:

•arthrosis.

•rheumatism

•hip tumour

•femoral head necrosis in various diseases – femoral head fracture

Over time, the pain will become increasingly acute, diminishing the comfort of life. Patients will curtail their activities, will go out increasingly less from home, and will be forced to use walking sticks. As hip destruction advances, patients will be “pinned” in a wheelchair.

4. Before surgery

Before the intervention you will meet your surgeon. He/she will address questions about possible diseases you are suffering, treatment administered, will examine you and your X-rays. You may be subjectedto further examination.

After diagnosis, an intervention will be recommended. A meeting is scheduled with the anaesthetist, who will choose the most appropriate type of anaesthesia with the surgeon (general anaesthesia -> complete, spinal anaesthesia -> both legs, or local anaesthesia -> leg operated on).

During this meeting, you can address all questions related to anaesthesia and treatment of postoperative pain.

The anaesthetistmay request other complementary tests that can be performed by your GP (blood balance, ECG, chest radiography,….) and ask if you have associated diseases (heart, lung, kidney disease), etc.

It is preferred to treat any dental infections before any prosthetic hip replacement.

Before the intervention, you should consider interrupting certain medications, as advised by your anaesthetist.

Rehabilitation of the operated hip can begin in the hospital and continues at home or in a specialized rehabilitation centre, according to your wishes
6. Intervention

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You will be hospitalized in the orthopaedic trauma surgery department on the eve of intervention; if intervention is planned for the afternoon, you can be hospitalized in the morning of intervention.

If other tests are required, you will be hospitalizedfor several days before surgery.

Nurses will do everything possible to make you feel comfortable in your room.

On the eve of intervention, a light meal is offered; you are no longer allowed to eat or drink after midnight.

Surgery itself will take about 60-80 minutes. If you have not chosen general anaesthesia, you can listen to your favourite songs during surgery.

In the 48 hours following the intervention, you will receive antibiotics. After intervention, you will be conducted in the ICU, and as soon as you wake up, you are taken to your room.You will notice two small tubes coming out of the skin near the hip. These are drains to evacuate blood that may accumulate in the hip after surgery. Typically, these drains are completely removed two days after surgery.

Strong painkillers will be administrated by infusion, to fight against the post-operative pain.

You will need to wear special drainage stockings to prevent any stagnation of the blood in your legs, because this stagnation could lead to unwanted blood clots, which are at the origin of venous thrombosis.

To prevent thrombosis, injections will be administered daily in the abdomen. They will increase blood fluidity and therefore will prevent the formation of thrombosis.

This treatment will be followed for four weeks (even after your return home).

 

After 48 hours, you will have to sit in an armchair and the physical therapist will begin to help you walk again with a walker or crutches. While walking, you will use two crutches for a month, then a crutch for another month. Even if walking can be made without crutches, I insist to use a crutch for walking until the second month.

Control X-rays are usually performed in the second and third day after surgery, which serve to observe the proper positioning of the prosthesis. During hospitalization, you will walk with crutches until you can do everything safe and alone. We will gradually increase the walking distance with crutches and physical therapist will correct (if necessary) your walking.

Most often, we authorize your return home from the moment you are able to go up and down the stairs using your crutches.

Removal of stitches (clips) will be carried out by qualified medical personnel, 14 to 16 days after surgery.

Most often, hospitalization lasts around one week, after which you can go home.

At the hospital discharge, you will have prescribed three kinesiotherapy sessions per week for six weeks; you can ride a bicycle when you can walk correctly without crutches (normally after six weeks). After four weeks, you are allowed to swim and at the end of six weeks to drive.

If you chose a rehabilitation centre, hospital length of stay will be shortened because these centres are medical institutions.

7: After intervention

Your home should be prepared before the intervention. You should be sure that you have a comfortable bed and tall enough, that you have enough space in the bathroom, and especially around the toilet. You need to prepare an armchair with footstool; remove any rugs that slide or cables that cross the rooms.

Wound dressings must be changed twice a week until the ablation of wires. A shower can be taken after the ablation of wires or before, by using special protective dressing. Your surgeon will see you again for a control check-up 4 to 6 weeks after intervention, with a new control X-ray.

Then you will meet three months after surgery, then once a year. Success of your intervention depends on how well you comply with the instructions given by surgeons in the four weeks after your return home.

Prepare the house;place a stool in the shower to allow washing with minimal risk of slipping.

Some tips if you have a total hip replacement:

  • •Attend physical exercise meetings regularly to maintain your shape,
  • •Take precautions to avoid falls. A fall can be dangerous in case of a total hip replacement, because fractures around the hip prostheses are more difficult to treat than fractures incurred by a person who has no hip prosthesis.
  • •Inform your dentist that you wear a hip prosthesis. He/she will advise you to take antibiotics before any dental work,
  • •Do not forget to see the orthopaedists surgeon once a year with a control X-ray.

8. Possible complications

They are rare, about 2-3% of cases.

L’hématome post-opératoire :

Raison pour laquelle nous laissons en place pendant 48 heures des petits drains qui vont enlever le sang qui risque de s’accumuler après l’intervention.

Postoperative haematoma:

The reason for leaving small drains for 48 hours, which will remove the blood that may accumulate after surgery.

Calcifications:

Calcifications in the neighbouring muscle can be prevented by taking certain anti-inflammatory drugs for about five days.

Thrombosis:

They are prevented by injections which are administered in the abdomen (for one month), and by wearing supporting stockings for six weeks.

Of course, daily walking reduces the risk of possible venous thrombosis.

If there are pains of the calf, you should see the surgeon immediately to rule out a possible thrombosis, which was installed despite preventive measures.

Postoperative infection:

To prevent this potential infection, you will take antibiotics for 24 hours according to a preventive management procedure.

If the wound becomes red, contact your surgeon as soon as possible. Once an infection occurs, an antibiotic will be administered to prevent spread of the infection to the prosthesis.

If you have a fever, you should see your doctor as soon as possible.

Pain, sometimes without precise explanation:

Some patients may develop inflammation around the operated hip (tendonitis, bursitis). This pain generally alleviates after medical treatment (infiltration) and kinesiotherapy.

Dislocation of the hip prosthesis:

It is a rare complication; its frequency depends on the approach of the surgeon. Hospitalization after dislocation remedy is very short.

Limb length inequality: 

A small limb length inequality may be sometimes observed. Wearing a low heel easily adjusts problem. When the difference in length is less than 5 mm, no compensatory heel is needed.

9: News in compensatory hip replacements

An approach with limited sections in muscles may be used (mini-invasive approach): post-operative progress is much simpler with earlier resumption of walking and less lengthy hospitalization.

Use of uncemented prosthesis with friction torque based on ceramic (less wear, offers an extended life of the prosthesis) is especially good for younger people.

 

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