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The hip replacement operation

Once the decision has been taken to proceed with operation there are many things to be done before and after the day itself to ensure the best outcome. NHS Choices gives information about the operation and an animation of what goes on during it and there is more discussion on Wikipedia's Hip Replacement page.

Preoperative Assessment

Pre-operative assessment clinics are a common way of assessing patients prior to operation. A nurse can take a history and check various aspects of the person’s condition, an anaesthetic assessment can be taken and investigations performed.

Common investigations include the following:

  1. Haemoglobin level (blood count) to check the oxygen carrying capacity of the blood
  2. Blood cross-matching in case transfusion is needed during operation
  3. Electrocardiogram (ECG/EKG) to check the electrical activity of the heart. An irregularity here may mean cancellation of the operation until the problem is checked out
  4. Blood tests for the salts and other chemicals
  5. Urine testing can tell us whether diabetes is present which has not be noted
  6. X-Rays (chest and hip). Hip x-rays are to check the status of the hip so the surgeon can plan what he wants to do. The chest x-ray is a screening check to make sure the chest is clear for the anaesthetic
  7. A physiotherapy assessment will cover what to expect in the time you are in hospital and check out your exercises, mobility and use of walking aids
  8. An occupational therapy assessment will cover your day to day activities and the suitability of your home for you to return there after the operation. If necessary the occupational therapist will ask for aids or appliances to be delivered or installed in your home

Planning for after the operation

It can be really useful to do some planning for after the operation before you come into hospital.

What facilities/type of house do you have? You should be able to get up and down stairs but if your staircase is very steep or difficult you may need to sleep downstairs. Can you get a bed downstairs? Is there a downstairs toilet or will a commode be necessary?

Do you have family or friends who can be relied on to help you during the post-operative weeks - perhaps up to 12? If not a convalescent bed may need to be booked - it will be too late to avoid delay if the booking is attempted while you are already in the hospital for the operation. A bit of planning at this stage can prevent a lot of difficulty later.

Admission to hospital may be on the day before surgery, or on the day of operation itself. Coming in on the day of surgery allows you to remain in your home environment up to the last minute.

The Operation

exeter hip stem

Initially most people are taken into an anaesthetic room next to the operating theatre. Here the anaesthetist usually administers a general anaesthetic (hip replacements can be performed under local anaesthesia). For the induction of anaesthesia a small needle is used to carry the drugs into the bloodstream. Once the patient is asleep a tube is passed through the mouth and into the windpipe to monitor and control the person’s breathing. This tube is called an endotracheal tube.

Now the person is wheeled on a trolley into the operating theatre and lifted onto the operating table. Usually the hip replacement is performed with the person lying on their side with the operated side upwards. The surgical team scrub up (thoroughly clean their hands and forearms), put their operating gowns on and enter the operating theatre.

The first job is to ensure the patient’s skin is clean and free of the huge numbers of normal skin bacteria. For this a special solution is painted on to kill the skin bacteria. Skin preparation, as this is called, is essential to reduce the risk of a hip replacement becoming infected and is followed by the application of surgical drapes. Then the operation itself begins.

A large skilled team of people are necessary to perform a hip replacement. The surgeon may have a surgical assistant standing opposite, who will assist with tasks such as helping to position the patient, tissue retraction for the surgeon to get a good view and coagulation of blood vessels to control bleeding.

The theatre sister will hand the appropriate instruments to the surgeon - usually without being asked as he or she will be experienced in this type of operation and know what is required. Another nurse will be assisting the theatre sister and an operating department assistant (ODA) will help the anaesthetist. Other individuals may be recovery nurses, instrument cleaners, auxiliaries, and clerks/administrators.

90 minutes is a typical operating time from first incision to final skin closure, however, if we add the time for inducing the anaesthetic and time spent in the recovery unit, the time away from the ward may be much greater - three hours or more. It is important that relatives waiting for news are prepared for this long absence and understand it is normal and not an indication of any problems.

To properly understand the operation, since we are not surgeons, the best way is to watch a hip replacement video. In the hip replacement video, treatment is clearly indicated. initially there is the approach to the joint, the dislocation of the hip, removal of the bony surfaces, coring out the surfaces, cementing, implantation of the components and closure of the wound. A hip resurfacing video will be just as worthwhile watching if this alternative to hip replacement is planned.

After The Operation

Once the final skin closure is made, the patient is transferred from the operating table to a bed and taken to the recovery room. Usually the legs are immobilised to some extent and the most common method is to use an abduction pillow, a triangular pillow placed between the legs to hold them apart. This ‘abducted’ position is the most stable position for the hip.

Mobilisation (getting up and walking again) normally starts on the first, or occasionally on the second day after operation. The wound drains may be removed after twenty-four hours, or may remain in place for forty-eight hours. Some surgeons use a small incision and do not employ drains.

Blood tests may be performed at 48 hours and treatment given to reduce the chances of a thrombosis forming in the calf veins. Treatment may include wearing stockings, having foot pumps applied when in bed or taking anticoagulants, or aspirin.

Antibiotics may be prescribed, although they are usually given in a few intravenous doses to cover the period immediately surrounding surgery.

Time to discharge varies greatly in different hospitals, countries and with people of differing ages and physical ability. A fit 70 year old person with an uncomplicated hip replacement may be ready for discharge by five days after operation, though often seven is more common. In exceptional cases people may be ready for an earlier discharge and the general view in medical circles is to minimise hospital times as long as safety is observed.

Surgeons use what they call a surgical approach, which is the direction in which they cut into the hip and involves cutting through various structures such as tendons, muscles and bone. A total hip replacement video could illustrate a variety of hip replacement approaches, with the anterior hip replacement video illustrating a popular approach, from the front of the hip joint.

Knee replacement is the sister technology to hip replacement and becoming more common and more expensive that a replacement hip. Watching a total knee replacement video can also be helpful in understand this very successful medical intervention.

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