Hip Problems

Hip Replacements

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There are various reasons that a hip replacement may be necessary. The most common reasons for a hip replacement are: Arthritis including Osteoarthritis & Rheumatoid Arthritis & fractures of the hip.

Osteoarthritis

Osteoarthritis is a degeneration of the joint due to wear & tear which can be insidious or as a result of trauma to the joint. This condition can be very symptomatic from early on and usually has groin, thigh & knee pain. The pain can be intermittent and is usually treated with pain killers and anti-inflammatories.

Osteoarthritis can be caused by other conditions such as incomplete formation of the hip joint or avascular necrosis of the hip.

The decision of when to have a hip replacement is really dependant on your symptoms and not by x-rays or loss of movement. I always say to patients that they should endure the pain and loss of movement for as long as possible, while retaining mobility and quality of life, before going for a hip replacement. When your hip is starting to have a serious impact in your quality of life and you start avoiding certain activities that you would normally enjoy, then it is time for you to consider a hip replacement. Ideally, a patient should be 55 years or older as these hip replacements have a limited lifespan of 20 to 30 years.

Recently joint supplements have been shown to make a long term difference to the symptoms and progression of the disease and they should probably be taken if you discover arthritis in its early stages. I recommend Arthrochoice as it has Chondroitin Sulphate and Glucosamine Sulphate which is absorbed better than the other forms of supplement. The positive effect of these supplements is really only measurable over many years.

Rheumatoid arthritis

Rheumatoid arthritis is an inflammatory disease of the joint; it is caused by your own body’s defense system attacking the joint lining. This is what is known as an Auto-Immune disease. This disease can have a huge variety of presentations but typically involves many joints and usually starts in the hands.

Rheumatoid arthritis can result in the destruction of the hip joint at a very early age and due to the lower demands placed on the joints, hip replacement can be considered earlier.

Hip Fractures

Some hip fractures are best treated with a hip replacement and that decision is based on the type of fracture. Obviously, this category of hip replacement is not really for you to decide when or where as it is invariably an emergency.

There are 3 main options of hip surgery in this scenario:

Hemi-Arthroplasty: this is the replacement of the ball part of the femur and is usually only for people with very limited mobility. Its advantages are cost and time in theatre but they can remain symptomatic & are not suitable for people who are reasonably mobile. I would not consider this option on anyone who still goes out of the house and walks around – even if they need support with a stick or walker.
Total Hip Arthroplasty: this is the replacement of both the ball & socket of the hip joint. This can be done by either cementing the stem into the femur or making use of the structure of the bone to press-fit the stem in place. This is dependant on the quality of bone of the patient and the decision is usually made based on the X-rays.
Resurfacing procedures: This is a procedure that allows a minimal amount of bone to be removed and placing a metal bearing surface as the new joint surface. The worldwide results of this operation are poor when compared to those of Total hip Arthroplasty and therefore I do not do this operation at all.

Surgery

I use a frontal approach to the hip as I believe that this results in a lower complication rate in that the dislocation rate is significantly lower.

Total hip replacement usually takes between 1 and 2 hours. I always have an experienced assistant to help speed thing up and make the operation go smoothly. We have many different sizes and types of hips available in theatre and usually only make a final decision in theatre as to what hip will be used. The hip is custom fitted for you.

There are 4 main layers of stitches to close the wound and we apply a dry, waterproof dressing. We do not use wound drains.

Hospital stay

Usually a hip replacement will stay in hospital between 5 and 7 days. Patients usually need to see a physician before the procedure and are admitted the day before the surgery or the morning of the surgery. The physician checks all the medical systems to make sure that the patient is as strong as possible for the procedure.

After the operation you will go to the High Care Unit as a routine way of monitoring your progress. The physician is the Dr who is in charge in the HCU but there is input from the anaethetist and the surgeon.

Your pain will be controlled using a local anaesthetic infusion into the groin area and this stays in for 3 days.

After 1 night in the HCU we usually transfer you to the orthopaedic ward – C ward.

In C ward the physiotherapists will see you and begin doing your exercises. Usually you will do exercises in bed until day2 and then they will start getting you up and walking with the walking frame. You will have elasticized stockings which need to be worn for 6 weeks and calf pumps to reduce the chance of getting a Deep Vein Thrombosis (DVT). You will also receive injections to thin your blood.

Usually you will be walking reasonably pain free by the 4^th day after surgery but will still need support. You will be ready for discharge between day 5 and day 7 after the operation. Depending on your personal circumstances and progress you could either go straight home to your family, get nursing help or go to a Step Down facility for further training in walking etc. Please speak to Sr Val to help you with arrangements for discharge.

Recovery

The recovery following a THA is initially very quick and one rapidly achieves milestones. Once you have achieved mobility time seems to stop and the progress slows drastically. Your hip will continue improving for up to 18 months after the operation. There are always good & bad days and you may find that the weather becomes very predictable for a while after the operation. You will need to visit the physiotherapist weekly and when the wound has healed at 2-3 weeks you should consider joining the rehab classes run by Marcelle Piennaar and her team. Due to the type of surgery, you will have weak muscles for a couple of months and tend to limp a bit. This will improve as your muscle strength improves.

Complications

Hip complications

The most common complications are infection and dislocation

I am not too concerned about dislocation and although the physios have a generic rehab for all surgeons, I am not as strict when it comes to sitting, raised toilet seats or bending over. Your body will usually let you know when it is uncomfortable and you will need to listen to it and not get yourself into positions where it is uncomfortable.

Infection is a rare complication and we have a far lower rate at Constantiaberg than what is regarded as an acceptable rate. Infection is an extremely difficult condition to treat. Usually by analyzing the bacteria causing the infection we can tell where the infection came from. It almost always happens at the time of the operation and can be either from your own normal bacteria on your skin or from resistant hospital bacteria.

Every attempt is made to avoid the chance of getting an infection by giving antibiotics and cleaning the skin properly but it is not a risk that can be completely eliminated.

Medical complications

The most common medical complications following THA are electrolyte disturbances, cardiovascular complications and DVT with or without pulmonary embolus and chest or bladder infections. The physician looking after you will treat all these conditions if they arise