Total Hip Replacement (THR) Surgery
The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the pelvic bone. The ball is the femoral head, which is the upper end of the femur (thighbone).
A lubricated tissue called articular cartilage covers the surface of the ball and the socket. It creates a smooth, low friction surface that helps the bones glide easily across each other.
The outer rim of the acetabulum is encased by a rubbery ring of tissue called the labrum.
The labrum is similar to the meniscus in the knee that patients often refer to as the cartilage.
The entire joint is surrounded by a tough fibrous capsule and special thickenings in this, called ligaments, help resist specific forces and provide extra stability.
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- Electrocardiogram (ECG) which is a non – invasive heart investigation which takes couple of minutes to perform.
- Blood pressure and heart rate.
- Urine sample to test for urinary tract infection (UTI) and diabetes.
- Methicillin Resistant Staphylococcus Aureus (MRSA) screening this includes swabs from nose and groin. This is a bacteria resistant to some antibiotics.
- Blood tests.
- Blood type and screen this is done in case we need to give a blood transfusion during or after your operation.
- Body mass index (BMI).
- Detailed patient history.
- Examination by medical doctor.
- All medication in the original labelled containers, that you are currently taking. It is important that the medication is not repackaged into a weekly pill dispenser/pill box.
- Relevant x-rays, MRI, CT including any chest x-rays taken within the last three months or relevant joint x-rays taken within the last six months.
- Please bring the address and phone number of your GP and any other consultant or specialist you are currently attending.
- Please bring any results or reports from any past ECG, ECHO or angiograms.
- Please ensure that your first name and date of birth is as it appears on your birth certificate.
- Please ensure that the pre-operative questionnaire is completed.
- The whole PAC visit will approximately take one hour.
from physiotherapy after your operation and give you some practical tips.
- If you take medication on a regular basis please bring this with you, in its original packaging, as we may use this when you are in SSC.
- Please remember to remove false nails/long term nail varnish before coming into SSC.
- We advise that you bring nightwear, a dressing gown, slippers (flat, closed heel slippers) or walking shoes, reading glasses and toiletries. You will also need some day wear for your discharge from the clinic.
- We advise that you do not bring valuables into hospital with you. You may keep your wedding ring on (which will be covered with tape) when you go to theatre but this is the only jewellery that you will be allowed
- The doctor will draw an arrow on your hip to indicate which one is being operated on.
- You cannot eat or drink anything for at least 4 hours before your operation, so you will usually be ‘Nil By Mouth’ from 12midnight (for a morning operation) or 6a.m. (for an afternoon operation). The nursing staff will remind you about this. This includes chewing gum.
- On the morning of your surgery you will be given a theatre gown to change into. You will be asked to remove make up, nail polish and jewellery apart from a wedding band, which can be taped over.
- You will be wearing one white stocking, which is called a TED stocking, on the opposite leg i.e. the leg you are not having your operation on. The stocking is applied to help improve the circulation in your legs and so reduce the risk of getting a blood clot. A stocking will be applied to your operated leg after your operation.
- The anaesthetist, who is the doctor that will be administering your anaesthetic, will talk to you before your operation. He / she will talk to you about your general health and any previous anaesthetics. He/she will check your lab tests and all other relevant tests and letters from other specialists. They will then advise you of the safest anaesthetic for you with regard to the operation you are having done.
- You will be taken to theatre on your bed. A nurse will accompany you to theatre. In the reception area the theatre staff will check your details and ask you several questions such as when you last ate or drank and which hip is being operated on. This is all quite normal, as we like to check these details several times.
- From the reception area you will be wheeled into the anaesthetic room where you will have your anaesthetic. Once you have had your anaesthetic you will be transferred into the operating theatre.
- The operation usually takes 1 hour to do but you will be off the ward for longer than this because you will need time to have the anaesthetic before the operation and to recover after the operation.
- You will be wheeled from the operating theatre into the recovery room where you will be closely monitored by the nursing staff. The nurses will check that you are recovering from your anaesthetic by checking your blood pressure, pulse, breathing rate and so on. Once they have assessed that you are recovered enough you will be transferred back to the ward on your bed.
- You will have oxygen delivered either through a mask over your nose and mouth or through a small double pronged tube which sits at the nasal passages and you will have a bag of fluid running through a tube into one of your veins.
- You may be attached to a pain pump. This pump is called a Patient Controlled Analgesia (PCA) pump. The PCA delivers a small amount of painkiller called morphine into your bloodstream when you press button on the handset. You cannot overdose yourself, as there is a lock out device on the machine. This means that you can press the button on the handset many times but you will only get the one dose that is due within the timeframe. The PCA can make you feel dizzy or sick Please let the nurses know if you have any side effects.
- There may be a drain placed on one side of your wound to drain any excess blood or fluid from your wound that could cause delayed healing of the wound. The excess blood/fluid is drained into a collection bottle attached to the drain.
- You will have a large triangular shaped foam wedge between your legs, at knee level, which is called an abduction wedge. This is in place to stop you crossing your legs. This will be kept in place for several days whilst you are in SSC. The reason you must not cross your legs is because it can cause the hip replacement to dislocate.
- Once you are back on the ward the nurses will continue to monitor you. You will have your blood pressure, pulse etc checked regularly and your hip dressing will also be checked.
- You will start taking sips of water as soon as you come back to the ward and gradually you will be allowed to eat and drink as you would normally. Many people feel sick after surgery and this can be due to the anaesthetic and medication that you were given during the operation. Once you are eating and drinking again the drip will be taken away. This is usually about 24 hours after the operation.
- If you need to pass urine or have your bowels opened then the nursing staff will assist you in using a bedpan, as you will not be able to walk to the bathroom just yet.
This section outlines the stages you have to complete before you go home. Most people achieve these stages within 2-5 days of having the operation.
Stage 1 (the first day after your operation)
- The nursing staff will help you to have a wash in bed, as you will not have been out of bed yet.
- The physiotherapist, who will aim to get you up out of bed, sitting in a chair and taking several steps with crutches, will visit you. The physiotherapist will remind you of the exercises to do.
- The nursing staff will assess whether you need to continue using the PCA. If you do not need to use the machine then it will be removed. You will be given painkilling tablets whilst you are on the PCA and after it is removed we advise that you take these tablets so that you can do your exercises and start walking.
- If present, the drain will be removed from your hip.
- The physiotherapist will continue to assess how you are doing and help you to progress with your exercises and mobility.
- You will have a blood sample taken to check that you have not lost too much blood during the operation.
- If you have not had an x-ray in the recovery room then you will have an x-ray taken of your hip in the x-ray department. A member of staff will take you to the x-ray department.
- You will be walking with crutches under guidance from the physiotherapist.
- Your prescription will be arranged by the doctor.
- The physiotherapist will practice the stairs with you.
- Transport arrangements will be finalised. You will be asked to arrange for a relative or friend to collect you by car.
- You will be discharged home. The nursing staff will go through with you the prescription that you can fill at any pharmacy. If you have any questions about your medicines then please ask the nurses who will be able to help you. Do not forget to take your walking aids with you.
- You will be sent an appointment by your consultants secretary with the date of your follow-up outpatient appointment on it, usually for 6-8 weeks after you go home.
- help you with bed transfers
- teach you how to walk with crutches (or a zimmer frame in some cases)
- guide you through an exercise program
- practice stairs with you
- Painkillers and reduced mobility can make you constipated therefore it is important that you drink fluids while in hospital and when you get home. The recommended amount to drink daily is 2 litres, which is about 8 glasses. Water is one of the best things that you can take. The nursing staff can give you some mild laxatives if you need them whilst you are in hospital and you may also be prescribed some to take home with you.
- We advise that you keep the TED stockings on for 6 weeks after your operation provided that you have someone at home to help you take them off at least once a week. The reason for this is so that you can wash and moisturise your legs, as the stockings tend to dry the skin on your legs quite quickly.
- If you have staples or stitches in your hip wound these will be will be removed from your wound between 10- 12 days after your operation. You can either attend the wound clinic in SSC or your GP for this.
- It is normal for your leg/hip to be quite bruised after the operation. This will fade in time.
- You should not drive for a period of time after your operation and this will be discussed when you come to the outpatient clinic. You can travel in a car as a passenger from the time you leave hospital.
- You should not fly for approximately 3 months after your operation, as you are at increased risk of a blood clot in your leg veins.
- The leg takes time to adapt to the hip replacement and it is quite common to experience discomfort around the hip for up to 6 months after the surgery. This is not as painful as the arthritis you had and is usually relieved by rest or a mild painkiller. Some patients describe a feeling of tightness around the hip, which usually goes away after a few months but which can return at times. Some patients are left with an area of numbness around the hip, where the nerves, which are cut during the operation, do not rejoin. This does not affect the strength of the hip at all. Not all these events are experienced by every patient but if they happen to you they are part of the normal recovery from the operation.
- Avoid crossing your legs.
- You should not move your leg across your body past its midline i.e. the line that divides one side of your body from the other through your belly button.
- Get in and out of bed preferably leading with your operated leg. You can still get in and out of bed on the other side once your leg does not cross the midline.
- Avoid bending your hips past 90 degrees (i.e. an L-shape between your upper body and legs).
- When sitting down on a chair or toilet seat have your knee lower than your hip.
- Avoid turning your operated leg inwards/outwards.
- When standing or walking do not swivel on your operated leg.
- Avoid putting pillows under your knees.
- Avoid lifting the leg off the bed with the knee straight.
Knee Joint Replacement
The knee is one of the largest joints in the body, formed between three bones – the thigh bone (femur), the shin bone (tibia), and the kneecap (patella).
At the joint, the surface of each bone is covered in a thin layer of substance called articular hyaline cartilage. This cartilage contributes to the smooth movement of the knee, and protects the bone underneath from getting damaged.
Knee pain can be caused by a number of factors including accidents (trauma), malalignment, the way in which the knee moves (biomechanics), and due to aging (degeneration).
Depending on the nature of your condition, conservative methods of treatment, including physiotherapy and / or injections are often trialled prior to surgery.
The knee is a hinge joint. This means that the knee’s main function is to allow the lower leg to bend and straighten up relative to the thigh. The knee also allows a small degree of medial (inner) and lateral (outer) rotation when the knee is bent.
- A joint capsule surrounds the knee joint to provide strength and lubrication. There are also four main strips of tough tissue, called ligaments, which stabilise the knee joint:
- The anterior cruciate ligament (ACL) prevents the largest bone on the lower leg, the tibia, from sliding forward too much. This ligament also provides the knee with rotational stability.
- The posterior cruciate ligament (PCL) prevents the tibia from sliding backwards too much.
The medial and lateral collateral ligaments (MCL & LCL) provide lateral stability by controlling the sideways motion of the knee.
The knee also has two C-shaped rings of cartilage called the medial and lateral menisci. These act as shock absorbers in the knee, whilst also contributing to the stability and smooth movement of the knee.
Small pockets (known as bursae) filled with a fluid called synovial fluid surround the knee joint. These bursae help to cushion and protect the joint from friction.
There are also pockets of a tissue called adipose tissue, known as fat pads, which help to cushion the knee from external stress.
The main muscles that make up the knee are the quadriceps, the hamstrings, the gastrocnemius of the calf, and some smaller, deeper muscles.
When the quadriceps are engaged, the knee is straightened, whereas engaging the hamstrings and gastrocnemius muscle will bend the knee.
One of the muscle groups of the hips, the gluteal muscles, are also extremely important for controlling the knee joint.
The ends of our joint surfaces are lined with articular cartilage. This cartilage is made up of small cells called chondrocytes, along with a combination of proteins, collagen, and lots of water. In healthy joints, this durable cartilage allows joint surfaces to move against one another with minimal friction. Cartilage also acts as a shock absorber, by facilitating the transmission of loads to the underlying (subchondral) bone.
Losing cartilage in certain areas can often interfere with the normal movement of joints and limbs. This can result in pain and being less able to carry out regular daily or sporting activities.
In some cases it may be possible for us to fill missing sections with new cartilage which provides new protection for the joint surface. However, in cases where there are more extensive areas of missing or damaged cartilage there is an increased likelihood of arthritis and other management options may have to be explored.
The meniscus plays a role in joint stability, as well as load distribution. Tears in the meniscus are common, and often happen because of an acute injury.
Meniscal tears are often treated by removing a piece of the torn meniscus, which is called a partial meniscectomy, which may make the joint more vulnerable to degeneration of the articular cartilage.
Some meniscal injuries can be repaired via key-hole surgery (arthroscopically), where the torn piece(s) of the meniscus are sutured / stitched back together. This depends on the type of tear, as well as the overall status of the damaged meniscus and age of patient. Unfortunately due to the relatively poor blood supply of the menisci, many tears are not suitable for repair.
Anterior Cruciate Ligament (ACL)
The ACL is important in controlling rotation of the knee, during lateral, multi-directional and landing movements, and is one of the most commonly injured structures among athletes.
Typical symptoms of an ACL injury include:
- An audible “popping” sensation within the knee
- A feeling of instability like the knee may “give way”
- Stiffness / loss of full range of motion
Treatment options for ACL injury can vary depending on a person’s specific needs.
Reconstructive surgery is often recommended to restore stability of the knee required for multi-directional movement or sport. However for people with a lower level of activity, less invasive measures such as rehabilitation and / or bracing of the knee may be more suitable.
As the ACL cannot usually be repaired, restoring a torn ACL through surgery involves replacing the ACL with a piece of tissue taken from another part of the leg (a graft), such as from the patellar tendon or the hamstring. Other graft options are also sometimes considered.
Posterior Cruciate Ligament (PCL)
The PCL prevents the tibia from sliding backwards too much, and also helps stabilise the knee in rotational movements.
Injuries to the PCL are generally the result of a direct blow to the front of the knee, when the leg is in a bent position, (such as falling on a bent knee). PCL injuries can also occur when the knee twists or straightens too much (hyperextends).
Isolated PCL injuries generally do not cause instability. A large amount of instability may mean there is a PCL injury combined with an injury to another specific section of the knee called the posterolateral corner.
Treatment depends on how severe the injury is, and whether it is an isolated or combined injury. Rehabilitation is a vital component of recovery in both surgical and conservative cases.
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
Injuries to the LCL are usually caused by an outward twisting force, or varus, to the knee. LCL injuries often occur alongside other knee injuries. Surgery is generally the preferred course of treatment if there is a complete (Grade 3) tear to the ligament or if the ligament becomes detached, or avulsed, from the bone. A structured rehabilitation programme is an essential part of recovery from an LCL injury.
Patellofemoral pain is a broad term used to describe pain at the front of the knee.
There are various factors that contribute to patellofemoral pain, both internal and external to the knee, including malalignment. However, the main risk factors appear to be overuse and overload.
Management of the injury requires a multi-faceted approach. Particular emphasis is placed on load management, along with a structured rehabilitation programme to strengthen the surrounding muscles as well as addressing abnormal movement patterns.
The kneecap (patella) sits in a notch on the femur bone called the trochlea. If this groove is too shallow, the patella can become unstable and slide off, resulting in a partial or complete dislocation of the kneecap.
Dislocation can also occur during an acute injury such as a fall, or a rotational type injury of the knee.
Patients with a high riding patella that sits above the groove and patients with other anatomical variants are also more prone to dislocation.
If the patella becomes dislocated, it needs to be relocated or “reduced”, which often happens spontaneously. If the instability keeps reoccurring, surgery may be needed to stabilise the patella, followed by a rehabilitation programme to strengthen the soft tissue structures of the knee, and to prevent any further dislocations.
Fractures to the patella bone usually happen because of a fall or hard blow to the front of the knee.
Treatment options for this type of injury depend on the type of fracture. An undisplaced fracture of the patella, where the broken bone remains in the correct place, generally responds well to being immobilised in a knee brace or cast. Displaced fractures often require surgical treatment to stabilise the site of the fractured bone.
Both conservative and surgical treatments need to be complemented with a rehabilitation programme to strengthen the muscles around the knee.
Proper knee alignment is essential for normal function and for balance in the joint. Poor movement patterns which cause uneven forces throughout the knee can damage both its articular cartilage and ligaments.
There are two types of misalignment in the knee, which can contribute to its condition:
- Knee varus where the weight passes medially, (more through the inside of the knee joint), causing degeneration to the inside of the knee
- Knee valgus where the weight passes laterally, (more to the outside of the knee joint) causing degeneration to the outside of the knee
A corrective surgical procedure called an osteotomy redistributes the forces bearing down on the knee by cutting a wedge of bone from either the tibia or femur, to reposition and realign the knee.
Osteoarthritis is the most common form of arthritis, and often affects the knee joint.
Osteoarthritis is caused by aging and wear and tear of cartilage. Symptoms of osteoarthritis in the knee may include knee pain, stiffness, and swelling.
If the degree of osteoarthritis is quite severe and debilitating, a Total Knee Arthroplasty is often the recommended form of treatment.
This open procedure involves removing the damaged areas of cartilage loss, and replacing them with synthetic components (often metal), to recreate the joint surfaces. The inner surface of the patella may also be resurfaced if needed. An artificial “spacer” is inserted between the metal components to allow the new joint to glide smoothly and efficiently.
We carry out an orthopaedic evaluation of your knee through the following three activities:
- A medical history to gather information about current complaints, duration of symptoms, pain and limitations, injuries, and past treatment with medications or surgery.
- A physical examination to assess swelling, tenderness, range of motion, strength, instability, and limb alignment.
- Diagnostic tests, such as X-rays or magnetic resonance imaging (MRI), which may be required to assess both the bony and soft-tissue structures of the knee.
We will discuss the results of your orthopaedic evaluation and the various treatment options available to you in detail.
Arthroscopic surgery is when the surgeon inserts a thin, pencil-sized device, containing a tiny lens and lighting system, into a small incision to look inside the knee joint. The images inside the joint are shown on a TV monitor and allow the surgeon to make a clear diagnosis.
Other surgical instruments can also be inserted so that repairs can be made, depending on the diagnosis.
Surgeries such as a partial meniscectomy, meniscal repair, or ACL reconstruction, are generally carried out using these arthroscopic methods.
Knee replacement is an open surgery performed through an incision at the front of the knee. Other surgeries such as collateral ligament reconstruction and osteotomy are also performed by open incisions to the knee of varying lengths and location depending on the specific procedure.
Rehabilitation is crucial to maximise the success of any knee surgery, and commitment to a structured rehab programme is an essential part of your recovery.
This rehabilitation should be closely followed in consultation with your orthopaedic surgeon and chartered physiotherapist.