Dr Peter Johnstone - Orthopaedic Surgeon
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Revision Hip Replacement


Introduction

This means that part or all of your previous hip replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone and hence is difficult to describe in full.

Total Hip Replacement (THR) procedure replaces all or part of the hip joint with an artificial device (prosthesis) with a plastic liner in between to restore joint movement


Why does a hip need to be revised?

Pain is the primary reason for revision. Usually the cause is clear but not always. Hips without an obvious cause for pain in general do not do as well after surgery.

Plastic (polyethylene) wear This is one of the easier revisions where only the plastic insert is changed

Dislocation (instability) means the hip is popping out of place.

Loosening of either the femoral or acetabular component. This usually presents as pain but may be asymptomatic. For this reason, you must have your joint followed up for life as there can be changes on X-ray that indicate that the hip should be revised despite having no symptoms.

Infection usually presents as pain but may present as an acute fever or a general feeling of unwell.

Osteolysis (bone loss) This can occur due to particles being released into the hip joint that result in bone being destroyed

Pain from hardware e.g.. cables or wires causing irritation


Pre-operation

  • Your surgeon will send you for routine blood tests to rule out infection, CT scan to look closer at the anatomy, and bone scans to help to determine if a component is loose
  • X-rays are essential
  • Aspiration of the joint is occasionally done to diagnose or rule out infection
  • You will be asked to undertake a general medical check-up with a physician
  • You should have any other medical, surgical or dental problems attended to prior to your surgery
  • Make arrangements for help around the house prior to surgery
  • Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
  • Cease any naturopathic or herbal medications 10 days before surgery
  • Stop smoking as long as possible prior to surgery

Day of your surgery

  • You will be admitted to hospital usually on the day of your surgery
  • Further tests may be required on admission
  • You will meet the nurses and answer some questions for the hospital records
  • You will meet your anesthetist, who will ask you a few questions
  • You will be given hospital clothes to change into and have a shower prior to surgery
  • The operation site will be shaved and cleaned
  • Approximately 30 minutes prior to surgery, you will be transferred to the operating room

Surgical Procedure

Hip Revision will be explained to you prior to surgery includingwhat is likely to be done, but in revision surgery the unexpected can happen and good planning can prevent most potential problems. The surgery is often but not always more extensive than your previous surgery and the complications similar but more frequent than the first operation.

The surgery varies from a simple liner exchange to changing one or all of the components. Extra bone (cadaver bone) may need to be used to make up for any bone loss.


Post-Operation Course

When you wake, you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder and a number of other monitors to check your vital observations. You will usually have a button to press for pain medication through a machine called a PCA machine (Patient Controlled Analgesia).

Once stable, you will be taken to the ward. The post-op protocol is surgeon dependant, but in general your drain will come out at 24 hours and you will sit out of bed and start moving you hip and walking on it within a day or two of surgery. The dressing will be reduced usually on the 2nd post op day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist.

To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.

Dr Johnstone will use one or more measures to minimize blood clots in your legs, such as inflatable leg coverings, stockings and injections into your abdomen to thin the blood clots or DVT's, which will be discussed in detail in the complications section.

A lot of the long term results of hip replacements depend on how much work you put into it following your operation.

Usually, you will remain in the hospital for 5-7 days. Then,  depending on your needs, either return home or proceed to a rehabilitation facility. You will need physical therapy on your hip following surgery.

You will be discharged on a walker or crutches and usually progress to a cane at six weeks.

Your sutures are sometimes dissolvable but if not, are removed at approximately 10 days.

Bending your hip is variable, but by 6 weeks should bend to 90 degrees. The goal is to obtain 110-115 degrees of movement.

Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks.

More physical activities, such as sports previously discussed, may take 3 months to do comfortably.

When you go home you need to take special precautions around the house to make sure it is safe. You may need rails in your bathroom or to modify your sleeping arrangements, especially if they are up a lot of stairs.

You will usually have a 6 week and 3 month check up with Dr Johnstone, who will assess your progress. You should continue to see Dr Johnstone annually for the rest of your life to check your hip and take x-rays. This is important as sometimes your hip can feel excellent but there can be a problem only recognized on x-ray.

You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the blood stream and find their way to your hip.

If you ever have any unexplained pain, swelling or redness or if you feel generally poor, you should see your doctor as soon as possible.


Special Precautions

Remember this is an artificial hip and must be treated with care.

AVOID THE COMBINED MOVEMENT OF BENDING YOUR HIP AND TURNING YOUR FOOT IN. This can cause DISLOCATION. Other precautions to avoid dislocation are

  • You should sleep with a pillow between your legs for 6 weeks. Avoid crossing your legs and bending your hip past a right angle
  • Avoid low chairs
  • Avoid bending over to pick things up. Grabbers are helpful as are shoe horns or slip on shoes
  • Elevated toilet seats are helpful
  • You may shower once the wound has healed
  • You can apply Vitamin E or moisturizing cream into the wound once the wound has healed

If you have increasing redness or swelling in the wound or temperatures over 100.5 degrees you should call your doctor.

If you are having any procedures such as dental work or any other surgery you should take antibiotics before and after to prevent infection in your new prosthesis. Consult your surgeon for details.

Your hip replacement may go off in a metal detector at the airport.


Risks and Complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that you are informed of these risks before the surgery takes place.

Complications can be Medical (general) or specific to the Hip

Medical Complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reactions to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death

Specific complications to the hip include

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates vary.  If it occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Blood Clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.

Dislocation

This means the hip comes out of its socket. Precautions need to be taken with your new hip forever. If a dislocation occurs it needs to be put back into place with an anesthetic. Rarely this becomes a recurrent problem needing further surgery.

Fractures (break) of the femur (thigh bone) or pelvis (hipbone)

This is also rare but can occur during or after surgery. This may prolong your recovery, or require further surgery.

Damage to Nerves or Blood Vessels

Also rare but can lead to weakness and loss of sensation in part of the leg. Damage to blood vessels may require further surgery if bleeding is ongoing.

Wound Irritation

Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint.

Leg length inequality

It is very difficult to make the leg exactly the same length as the other one. Occasionally the leg is deliberately lengthened to make the hip stable during surgery. There are some occasions when it is simply not possible to match the leg lengths. All leg length inequalities can be treated by a simple shoe raise on the shorter side.

Wear

All joints eventually wear out. The more active you are, the quicker this will occur. In general 80-90% of hip replacements survive 15years.

Failure to relieve pain

Very rare but may occur especially if some pain is coming from other areas such as the spine.

Unsightly or thickened scar

Pressure or bedsores

Limp due to muscle weakness

Discuss your concerns thoroughly with your Orthopaedic Surgeon prior to surgery.


Summary

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan as it may help to restore function to your damaged joints as well as relieve pain.

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Dr Peter Johnstone
Orthopaedic Surgeon
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© Dr Peter Johnstone Orthopaedic surgeon Arthroscopic surgery, Sports injuries, Joint replacement QLD Australia.