TOTAL HIP ARTHROPLASTY - PERIOPERATIVE COURSE

Once a patient has been diagnosed with an arthritic hip or a condition that would benefit from total hip arthroplasty, generally the timing is dictated by the patient’s pain.  Whether the surgery is performed early after diagnosis or after many years, the result of surgery, the technical aspects of the procedure, the choice and selection of components, the risks or benefits of the procedure are generally not affected.  The timing of the surgery is dictated by the pain the patient is experiencing and the limitations that it provides to the patient’s lifestyle.  When the patient feels that the pain and limitations are to a great enough degree to warrant surgical intervention, the time is then appropriate for total hip arthroplasty.  Generally speaking, from the time a patient decides to undergo total hip replacement until when the procedure is actually done is usually approximately four to six weeks.  Generally, it is scheduled when a patient can take six to twelve weeks of time for recovery after the surgery. 

For patients with sedentary employment, many can return to work by four to six weeks.  For patients with more vigorous, standing activities during their work day, where accommodations cannot be made over the short term for a more sedentary type of employment, it is six to eight weeks prior to return to full duty. 

For a cemented femoral stem, the patients are allowed to fully weight bear on the leg after the surgery.  Frequently, they are on crutches or use a walker for approximately seven to ten days.  They are then able to advance to the use of a cane.  For most patients, by four to six weeks they no longer need the cane for the majority of their ambulation.  A slight limp may persist until the patient is two to three months out from surgery. 

For patients with a non-cemented femoral component, they are placed on crutches with limited weight-bearing for the first six weeks.  This is to allow the bone to grow onto the implant itself.  The amount of weight-bearing can vary, depending on the patient=s anatomy and the components used.  Generally speaking, between 25-50% of weight-bearing is commonly allowed in the early postoperative period.  After six weeks, the patients are then allowed to fully weight bear on the lower extremity.  However, as their muscles have weakened, both from the operative procedure as well as from the period of restricted weight-bearing, it may require an additional six to eight weeks to restore normal gait. 

DRIVING

Driving is restricted after total hip arthroplasty.  For the first four weeks, the restriction is primarily based upon the positioning required to get into an automobile behind the steering wheel.  This usually involves a significant degree of flexion.  For patients who are having a left hip arthroplasty performed, they may begin driving again with an automatic transmission at approximately four weeks.  For patients who are undergoing right total hip arthroplasty or for patients who have a manual transmission vehicle, it will be approximately six weeks before they can return to driving.  This is due to the fact that reflex and response times are reduced in the early postoperative period and there is a risk the patient may not have adequate control of the vehicle until these reaction times have returned to normal. 

LATE ACTIVITIES

After total hip and total knee arthroplasty, patients are encouraged to walk both as part of their rehabilitation and for general cardiovascular fitness.  Cycling, swimming, cross country and light downhill skiing are activities are also activities that are readily permitted.  Activities that involve a lot of running, stopping, pivoting, and turning such as jogging, racquet sports, and basketball should be discouraged.  However, occasional activities such as recreational softball or light doubles tennis can be permitted. 

Within gyms or athletic facilities, the patients may do lower extremity weight lifting activities, however, they should keep the weights relatively low and do higher repetition activities.  Other machines such as a Nordic Track, stationary bike, or elliptical trainer and treadmill can be used.   Stair type devices may also be used. 

After a joint replacement arthroplasty, the patient should be careful with invasive procedures.  These include dental procedures, particularly those involving a dental abscess, colonoscopy, cystoscopy, or other major surgeries.  The patient should make their dentist or physician aware that they have a joint replacement.  Commonly, these patients will need to be placed on oral or intravenous antibiotics around the time of the procedure.  This is to protect the replacement from the possibility of infection.  Total hip and total knee arthroplasties are immunologically compromised sites.  The body has a limited ability to clear bacteria from the surfaces of these artificial implants.  If a bacteria were to get into the joint, the joint fluid serves as an excellent growth medium.  If that were to occur and is identified early, attempt can be made to operatively open the joint replacement, thoroughly clean the joint with a Water Pic device, surgically remove of any infected tissue, and to place the patient on intravenous antibiotics.  The success rate of this procedure can be between 25-50% depending upon the specific bacteria identified and its sensitivity to antibiotics.  If this is not successful, the patient may need to undergo a two-staged replacement procedure where the total joint arthroplasty components are removed, the joint area cleaned thoroughly, and then a antibiotic impregnated spacer can be inserted.  The incidence of this complication after dental and surgical procedures is quite low, however, when it does occur it is quite devastating.  In that setting, it is best avoided which is why prophylactic antibiotics are frequently recommended.