Total Hip Replacement

Transcription

1 Total Hip Replacement What is a Total Hip Replacement? Total Hip Replacement is a surgical operation aiming to replace a damaged or diseased hip joint. It means resurfacing the bones of the knee joint and implanting an artificial prosthesis in the knee. The most common form of damage seen is arthritis. The hip joint is described as a ball and socket type of joint and fits together by the head of the thigh bone (Femur) sitting snugly in the socket in the pelvis (acetabulum). Covering the surface of these bones is a smooth and compressible gristle (articular cartilage). When arthritis occurs, the gristle (articular cartilage) is worn away and the underlying bone becomes exposed. This results in roughening and distortion of the joint surface and you the patient will perceive pain and restriction in movement. Also, development of a limp can occur and your leg may feel shortened and look wasted. The Total Hip Replacement will replace the damaged head of the femur with a stainless steel ball mounted on a stem and relines the socket (acetabulum) with a plastic polyethylene socket. These components are usually attached to the bone with a type of stems (prostheses) may be used and this is always at the discretion of your surgeon. The new total joint aims to relieve pain, decrease stiffness and in most cases, restores your leg length therefore helping to improve mobility. Osteoarthritis of the hip is, generally, a disease of the older person, but may be seen in younger people following rheumatoid arthritis, fractures of the hip and other, rarer, conditions. What happens before the operation? Dr van Zyl may arrange for certain preoperative investigations. These usually consist of: - A new X Ray of you hip. - An X Ray of your chest - A tracing of your heart-beat this is called an electrocardiograph or E.C.G. - Blood tests to check whether you are anaemic and to match up blood to your own type in case you need blood after your operation Sometimes these investigations are performed before you are admitted to hospital this means you will attend the hospital as an out patient approximately 2 weeks before you are due to be admitted. Or they can be done when you arrive at the hospital for admission. It is likely that because of the pain you have been experiencing, you will already have been treated by a physiotherapist. Dr Van Zyl works in partnership with your physiotherapist seeking an assessment,

2 advice and a home exercise programme. Where necessary, walking aids may be considered and, in selected cases, techniques for pain relief are reviewed. Before admission to hospital, a home exercise programme will considerably assist your recovery in the post operative period. This includes breathing exercises as well as leg exercises and will be explained in detail by your physiotherapist when attending for assessment. Briefly this includes:- - CHEST PHYSIOTHERAPY. Regular sessions of deep breathing and coughing, both in lying and sitting position. - LEG EXERCISES. These help to maintain as much movement as possible in your arthritic hip and strengthen knee and hip muscles. Pain is often a limiting factor, so always be guided by your physiotherapist. - The OCCUPATIONAL THERAPIST for assessment and, if necessary, the provision of specific aids to enable you to perform daily activities more easily. You are usually admitted to hospital at least one day before the operation to allow time for blood tests, anaesthetic assessment and shaving of the operative area. You may also see your surgeon again. On the day of the operation Approximately 6 hours before you go to theatre, you will be allowed your final drink and something to eat. If you have anything after this time, you may delay or even postpone your operation. To make sure that your skin is very clean, you will probably be asked to have a bath or shower sometime during the morning. Your nurse will give you an operation gown to wear. You will then be given a pre- medication, to help you settle down before going to theatre. Normally, when you come out of theatre, you will be taken to a recovery area where you will be taken care of until you are properly awake. You will then be taken back to your own ward. Once awake after your operation you may find - A MASK for oxygen. This assists you in the waking up process and may be on for up to 4 hours. - A DRIP. This may either be clear fluid (saline) or blood. This replaces any fluids which may have been lost during the operation. The doctor will prescribe which one you need. It is important to try and keep your arm still to protect the drip - A CUFF around your arm. This records pulse and blood pressure. - A DRESSING over the wound on your operated hip. - DRAINS. There can possibly be three tubes from your wound which drains away blood into bottles. This helps the wound heal. Quickly by reducing bruising. Points to Note: - Pain. You have had major surgery so it is usual to feel quite sore. Please tell the nurse if you are in discomfort. The doctor will have prescribed medication to ease discomfort. - Drinking and eating. Once awake if you are not feeling too sick, you may try a glass of water. If you are feeling alright after this, you may try tea or coffee with something light to eat. If you feel sick or are sick, call the nurse for assistance - Moving. You will stay in bed today and will need to call the nurse if you need anything. After the operation After the operation, you will need to stay in hospital for about a week. During this time you must lie on your back with a triangular pillow between you legs to keep them apart. This and other precautions are necessary to prevent unwanted harmful movements causing undue stress on your new hip and to ensure that the hip remains in the correct position. Movement of your operated leg as instructed by the physiotherapist is a very important part of the recovery programme.

3 On the first day you will rest in bed. The nurses will assist you with anything you may need. if you are managing to drink and eat normally, the drip will be removed. An X Ray may be taken of the hip for the doctor to check and a blood test may be performed. Continue to ask the nurse for pain- killing tablets if you are in any pain. You must assist the nursing staff to move you in bed by using the overhead bar and your unoperatedon, functional limbs. In particular, lifting your buttocks off the bed is important for pressure care as is the use of bedpans initially. You will be allowed to sit up gradually, supported by a bed rest and pillows. It is beneficial to lie, twice a day, completely flat for half an hour at a time to stretch the muscle over the front of the hip. (This may also be done on your stomach and you will be shown the correct procedure). Nursing points to remember - Usually between day 2 and day 4, depending on your consultant s instruction the dressing over your hip will be removed and your wound checked. The drains will also be removed; this is only mildly uncomfortable. - Depending on your doctor s instruction, the stitches will be removed, usually between days 10 and Try not to interfere with your wound dressing as this can introduce an infection; re- dressing will be done as necessary. - Pain killers may cause constipation. If you have any problems which last longer than three days, please inform a nurse. Medication may be prescribed. - Once you have recovered from your anaesthetic, try to eat a healthy diet as this will help the wound to heal. If possible, try to drink at least 2 litres (4 pints) of liquid per day, as this helps to flush the anaesthetic out of your system. There are 4 basic movements which must be avoided for 6 10 weeks after the operation: - Do not cross your legs : The operated leg must always be held out to the side, away from the mid-line of the body - Do not bend the operated hip excessively: You should try to avoid sitting completely upright or lifting the knee of your operated leg too high. - Do not twist the operated leg in or out: when walking or turning you should always keep your toes and knee-cap pointing straight ahead - Do not roll or lie on unoperated side: It is advisable not to lie on either side in the early stages of recovery. However turning to the operated side may be permitted, with a nurse s help for washing purposes and at a later date when sleeping with a pillow between the legs Rehabilitation Bed Exercises

4 Your physiotherapist will show you a range of basic exercises you can start while you are still confined to bed. You should begin these before the operation. They consist of: 1. Breathing exercises and coughing to keep your lungs clear to prevent chest complications. 2. Leg exercise for both legs to - Minimise risk of blood clot formation - Strengthen the muscle and keep joints moving - Prepare your operated leg for improved walking technique The leg exercises are particularly important because the leg muscles on the affected side are often weak and tight as pain and stiffness in the arthritic hip has limited normal movement. Exercises will also aid recovery, helping to develop good strong muscle around the new hip and assist in their healing. Board Exercises with the Physiotherapist Board exercises will usually start after two days, under the physiotherapists instruction. The exercises are performed initially on a sliding board to minimise resistance. Eventually, you will manage them without this. You need help to position the board and pull back the bed clothes. Do not attempt it by yourself. Your physiotherapist will show you those exercises which are appropriate for you as an individual. These exercises are usually: - Pushing the foot up and down slowly and pumping calf muscles. - Clenching the thigh muscle by pushing your knee onto the bed and tightening the knee cap. - Bending the knee up towards the chest not over a 90 degree angle. - Taking the leg out to the side, keeping the leg straight, and back in to the mid line but not past the mid-line. - Hip hitching. This is, in effect, making the leg shorter and longer by tightening the buttocks and the leg muscle. These exercises should be repeated up to 15 times. Do not worry if they sound confusing as your physiotherapist will be there to assist you. Walking Walking with your Physiotherapist Once you have acquired balance and become accustomed to the upright position, you will begin walking; this is usually 48 hours after the operation, with a walking frame or crutches to ease the weight on your new hip. The sequence is always:- - Walking aid moved forward first - Then the operated leg - and finally the unoperated leg

5 Turning round can be to either side, but you must prevent twisting or pivoting on your new hip. Therefore, feet must be picked up at each step so that the operated leg is not placed too far in or out. As your confidence and leg control improves, you will progress to walking with crutches. You should practice with these until a satisfactory walking pattern is achieved. Most people will manage with two walking sticks by the time the hospital discharge occurs, unless there are associated problems other joints. Your physiotherapist will assess these problems with you. It is important that you are measured correctly by your physiotherapist for the walking aid you are using. Returning to a normal walking pattern is extremely important. Often because of pain and deformity in the affected hip, you have had to change the way you move. This will vary from patient to patient. It will take considerable time and effort to regain a normal walking pattern, but it will get better if you persevere. Your physiotherapist will help and instruct you in the best way to correct both walking and posture, thus enabling you to use your new hip to its full advantage. Getting in and out of chairs Sitting is usually commenced three days after the operation. Initially you must sit in a firm high chair with arms and you will be taught how to do so safely by your physiotherapist and occupational therapist. - Position yourself so that the backs of your legs are right up against the front of the chair - Reach back for the arms of the chair, one hand at a time - Slide your operated leg in front, keeping the knee as straight as possible - Sit down on the front of the seat, then move backwards until comfortable Getting on and off dining chairs without arms - Position yourself sideways onto the chair, with the back of your legs touching its side. Support yourself with one hand on the back of the chair, place your operated leg out in front of you, keeping the knee as straight as possible and reach the other hand for the seat of the chair. - Lower yourself into the seated position. With both hands on the seat of the chair, pivot on your keeping the leg straight out in front until you are facing forwards. - Adjust yourself into a comfortable position. Getting up is the reverse procedure In the early stages, it is usual for the leg to be given extra support in the sitting position, by using a stool. Stairs You will be taught to negotiate steps and stairs by your physiotherapist before discharge - always using aids to support the operated leg.

6 The sequence is as follows: - Going up stairs you should place the unoperated leg first, followed by the operated leg, and finally the sticks or crutches. Use the banister with the free hand, if possible. - Going down stairs you should place the sticks or crutches first followed by the operated leg, and finally the unoperated leg. This is often found to be daunting at first, but with patience and practice you will soon be confident. Helpful Hints on Leaving Hospital When you leave hospital, you may go home alone or to family or friends. This decision will be made by you, in conjunction with your medical advisors and therapists. The decision will depend on your home situation, the amount of assistance at home and the rate of your progress and physical condition. Once home, you must continue to exercise as you have been instructed, and progress with your walking. The surrounding tissues and muscles take time to heal, so follow all the precautions given to safeguard against dislocations. A Short List Of Do's and Don ts DO NOT: - Twist the operated leg, the hip is out at risk if swivelled when turning, particularly inwards too far. - Bend your operated leg up too far ie: not fast 90 degrees - Move your operated leg across your body ie: not past the midline - Go on long journeys as a passenger - Kneel. Avoid kneeling where possible for the first four months after your operation. If you have to kneel then follow the diagram. - Lean forward from the waist - Pick things up from the floor by bending forwards. DO: - Go for short walks regularly. NOT long walks which may tire you or involve prolonged standing. - Use two walking sticks for 6 weeks after the operation, you may then progress to one stick but it must be held in the OPPOSITE hand to your "new" hip. - Lie flat on your back or your tummy for one hour per day up to 8-10 weeks after the operation or at your surgeon's or therapist's discretion.

7 Daily Activity Your occupational therapist will see you whilst you are in hospital to assess your ability to manage safely and independently when at home. Advice will be given and, where necessary aids supplied. After the operation you will temporarily need to alter the way in which you perform some daily activities and may require assistance from other people at first. Whatever activity you are undertaking, always remember the basic principles described before, namely: DO NOT bend your hip beyond the amount bent in a normal sitting position DO NOT turn your operated leg in or outwards DO NOT cross your legs DO NOT bend your operated leg excessively Getting On and Off the Toilet First place one hand against the wall, the side of the bath, or a fixed hand basin for balance. Next, make sure your operated leg is out in front of you, then reach down for the toilet seat with your free hand. Lower yourself slowly onto the seat, sliding your operated leg out in front as you do so. As you sit on the toilet you will find that it feels different and low - this is because you are sitting on the toilet seat rather than sitting on a dining chair seat which is the same height but is a flat surface. GETTING OFF THE TOILET IS THE REVERSE PROCEDURE A raised toilet seat will be provided if the occupational therapist feels that you need one. These are often used in the early stages and are not needed later. Getting In and Out of the Bath Do not attempt to get in our out of a bath without using a bath board and seat for ten to twelve weeks following your operation. - Firstly sit on the bath board fitted over the board and lift your legs into the bath, one at a time, preferably the unoperated leg first. You should try to ensure that you keep the operated leg as straight as possible. - Next, lower yourself on to the bath seat taking the weight through your unoperated leg and your arms - To get out, bend the unoperated leg and place your hands behind you on the bath board. Push yourself up onto the board and lift your legs out - Pivot on your bottom, looking at the foot of your operated leg, keeping it as straight as possible - Position yourself so that your feet are on the floor and your bottom still on the board

8 - Put your hands on the bath side, keeping the knee of the operated leg straight, and stand up, drawing your operated leg back as you stand upright - Always use the bath seat - Do not sit on the bottom of the bath - Do not attempt to wash or dry the foot on your operated leg until shown by the occupational therapist how to do so Showering and Dressing - Place the bath board over the bath under the shower head. - Run the shower and place the shower head into the bath. - Position yourself on the board as for a bath and swing your legs into the bath. Draw the shower curtain. Pick up the shower head, using the hose and start to shower. - Shower whilst seated - Wash the lower part of your legs and feet with a bath brush, towel or loofah. - Do not bend too far GETTING OUT IS THE REVERSE PROCEDURE Showering in a cubicle - Step into the shower cubicle with your unoperated leg first and get into a position where you can operate the controls WITHOUT TWISTING. Wash the lower part of your legs and feet with an aid. It is preferable to use a very high stool in the shower and SIT AT ALL TIMES. - To get out, stand on the unoperated leg, lift the operated leg and step out of the shower, moving the leg backwards. Follow with the operated leg in the same way, bringing it to the floor so that you are now standing outside the shower cubicle on two feet. Dressing your lower half - You must not bend forward excessively to reach the foot of your operated leg nor lift that foot up too far.

9 - Instead, you will be shown how to use a long handled shoe horn and a sock or stocking aid to dress the affected leg. - The hook in the opposite end of the shoe horn, or your walking stick handle, can be used to get pants and trousers over the foot on the operated leg. Getting in and out of the car Both the passenger and the drivers seat should be moved back as far as possible. The backs of the seats should be reclined slightly, if the model has reclining seats. - Ensure you are on a level to start with and not too near the kerb - Position yourself sideways onto the car, with the back of your legs against the sill - Reach for the back of the seat with your left hand and the seat base with your right hand. - Put your operated leg out in front of you, with the knees straight, and lower yourself onto the edge of the seat. It helps if you can lean back slightly. - Using your unoperated leg and your hands, push yourself backwards onto the drivers seat, keeping the operated leg straight in front - Leaning backwards and pivoting on your bottom, slide you legs into the car. Be careful and do not rush, ensure that you keep the operated leg straight during the movement, until you are facing forwards. - Adjust yourself into a comfortable position. GETTING OUT IS THE REVERSE PROCEDURE The general note for driving yourself is that you are usually allowed to drive a car 8 to 12 weeks following your operation, but if the hip which has been replaced is your LEFT one - you may be allowed to drive a little earlier - from 6 weeks. It is always wise to check with your therapist or consultant on your individual case. General household activities

10 - DO NOT stand for long periods. You should try to spread your household chores evenly throughout the week - Allow yourself plenty of time to rest. - Avoid heavy activities for the first six weeks after leaving hospital, including using a vacuum cleaner Kitchen - You can expect to be able to work in your kitchen as you did before your operation, with the one exception of NOT lifting hot dishes out of the oven. This requires using both hands. You are advised to cook on the top of your cooker, use the grill or a microwave, if you have one, for the first four weeks after you arrive home from hospital. - You MUST ALWAYS use your sticks or one stick and the work surface when moving around in the kitchen. You are allowed to STAND without sticks and work at your sink, table or cooker. Bending DO NOT bend your operated leg excessively. Instead, hold onto something solid, such as a table, window ledge or work surface, and slide your operated leg out behind, keeping it straight. You can then go down, bending the knee of the unoperated leg. Getting back to normal You may at 8-10 weeks or at your surgeon's discretion: - Drive a car - depending on which leg is involved - Attempt sexual intercourse (with care) - Try general household activities, spreading chores evenly and again avoiding prolonged standing - Bending and prolonged standing should be avoided in the first three months. Digging during this period is not advisable. - Commence hobbies again eg: gardening, dancing, bowling and swimming, avoiding breast stroke and diving, all very gently and without excessive effort.

11 With all of these activities, timing may vary from surgeon to surgeon, so it is important to check with your surgeon and therapist before you start them. Your surgeon will review you, usually four to six weeks from discharge. If you have any queries then ask for advice at this time. If any serious problems arise before this time, give your surgeon or GP a call. For more information please visit: Information for patients and care guiders on the Smith & Nephew website: