Hip Replacement

Before you consider surgery

There are several ways you can resume an active lifestyle with significant pain relief before you consider having surgery.  This first section will discuss:

• Arthritis
• Osteoarthritis
• nonsurgical options available

Discuss each nonsurgical option with your primary care doctor to determine which are best for your specific needs.

What is Arthritis?

Did you know there are over 100 different types of arthritis? Arthritis is an inflammation of the joints that can take several forms:  

• Osteoarthritis is the most common type.  It is the "wear and tear" and breakdown of the cartilage within the joint.
• Rheumatoid arthritis is an autoimmune disorder that targets the lining of the joints. 
• Gout arthritis is cause by too much uric acid in the blood and can cause pain, stiffness, and swelling of a joint. 
• Psoriatic arthritis is an inflammatory arthritis that can affect people with psoriasis. 

Arthritis can also be caused by prior injury, especially breaks in the bones of a joint, or could have developed based on how the joints formed during childhood.  

Symptoms of arthritis can include:

• Joint pain
• Joint stiffness
• Decreased motion
• Swelling in the joint
• Difficulty walking, going up and down stairs, squatting, or kneeling

What is Osteoarthritis?

Osteoarthritis is an inflammation of the joint, commonly the hip or knee joint.

• Cartilage is the smooth shock absorbing Teflon-like covering on the ends of the bone
• Inflammation results in a destruction of the cartilage
• Damaged cartilage allows the rough bones on either side of the joint to rub against each together causing pain and restricted motion

Diagnosis is made by your physician based on a physical examination and x-rays. The doctor is looking for:

• pain around the joint
• grating or crunching in the joint
• decreased motion
• swelling around the joint

What should I do before I consider surgery?

Explore nonsurgical ways to reduce your pain.

The pain of osteoarthritis can be dramatically decreased in several ways before you decide to have joint replacement surgery. The following pages will explain each nonsurgical option in more detail.

• Weight loss
• Strengthening exercises
• Bracing the joint
• Adaptive Equipment
• Gait aids
• Medication
• Injections

Weight Loss

Weight loss can be extremely helpful in decreasing the pain of arthritis.

• Your body weight is magnified up to 7 times as it passes through the hip or knee joint.
• Even a small decrease in weight can result in a significant decrease in the pain. 

What is your Body Mass Index?

Many physicians recommend avoiding joint replacement surgery if your Body Mass Index (BMI) is greater than 40. Folks with a BMI over 40 have a significant risk for increased complications after surgery including: 

• skin healing problems
• infection
• ligament injury
• blood clots in your legs or to your lungs.

You can determine your BMI using the BMI calculator provided. 

Strengthening Exercises

A light stretching and strengthening program can often be of benefit.

These exercises are typically recommended by a physical therapist for hip and knee pain. Performing these exercises can help strengthen the muscles and maintain range of motion which can help relieve pain and improve joint function. 

NOTE: Reference to the "operated leg" refers to the joint that is causing you discomfort.

Click each image for a video demonstration of the exercise.

Adaptive Equipment

If you could benefit from the use of adaptive equipment, your doctor can recommend you meet with an occupational therapist. 

Adaptive equipment:

• Reacher: for picking up dropped items from the floor and for reaching to don pants and shoes
• Sock aid: allows donning socks without excessive bending of the hip or knee
• Grab bars: to assist in getting in/out of bath and on/off toilet
• Bath/Shower chair: for safety and ease in bathing.  

Gait aids

Gait aids may help patients feel more stable and help prevent falls. Using gait aids could both relieve pain while walking and also help you get up and down from a chair or out of bed.

Types of gait aids:

• Canes
• Crutches
• Walkers 

If you feel you would benefit from a gait aid, speak with your doctor.  Your doctor may write you a prescription for a cane or walker and consultation with a physical therapist.  

Medication

There are a number of medications that can help with the pain of osteoarthritis.

Discuss the risk and benefits of each with your doctor to determine which one is best for you.

Acetaminophen:

• Tylenol, which is also called Acetaminophen, is generally a safe medication (unless you have liver disease) 
• Dosing should be limited to 3 grams or 3,000 milligrams per day, which is up to 6 extra strength Tylenol per day or 4 Extended Release Tylenol per day.
• If you have any questions about the dosing, speak with your doctor or pharmacist.

Anti-inflammatories:

• Advil, Motrin, Ibuprofen, Aleve, Naprosyn, Celebrex, Mobic, and many others.
• These medications relieve inflammation and pain in an arthritic joint and can be very effective.
• Can be taken on a regular basis or occasionally only when you need them.
• Risks can include: stomach upset, bleeding in your stomach or bowels, and kidney or liver injury.
• Take these medications only as prescribed and do not increase the dose without speaking to your doctor.
• If you are on these medications for several months, ask your doctor about checking some blood work to monitor your kidney and liver function.

Injections

Your doctor may recommend injections directly into the aching joint. The purpose of the injections is to reduce the irritation caused by bone rubbing on bone. Injections are more typically done for patients with knee arthritis and only infrequently for patients with hip arthritis.

Corticosteroid Injections:

• About half to two-thirds of the patients find these injections relieve pain.
• Pain relief will last anywhere from several weeks to 3-6 months. 
• Some patients will not have any improvement after an injection.
• Leave at least 3 months between corticosteroid injections.
• The injection is typically performed in the office and doesn’t interfere with your ability to drive home.

Hyaluronan Injections:

• Medications such as Synvisc, Hyalgan, Orthovisc and others.
• There is disagreement about the effectiveness of this medication in the orthopaedic community and the American Academy of Orthopaedic Surgeons has not recommended its use.
• You may have a large copay for these medications as well - even up to several hundred dollars, depending on your insurance.

When should I consider having surgery?

First, have a discussion with your doctor.  The decision to have surgery is typically made based on the answers to the following questions: 

• How much is the arthritis interfering with your lifestyle?
• How much pain is it causing?
• What are your other medical conditions?

Our recommendations:

• Try each of the nonsurgical treatments before considering joint replacement surgery.
• There is generally never any hurry to do a hip replacement.
• Waiting to have the surgery will not necessarily make recovery more difficult -- recovery is much faster than it used to be.  

Once you have chosen surgery

Also called arthroplasty, joint replacement surgery is performed to relieve pain and restore range of motion by realigning or reconstructing a joint.  After all nonsurgical treatment options have been exhausted, joint replacement surgery may be right for you.  Discuss your options with your doctor.  

If you and your doctor choose joint replacement surgery, review this section to learn: 

• How to prepare for surgery
• What happens during surgery
• Who will perform the surgery
• How pain is controlled
• Information about the hospital stay

How should I prepare for surgery?

Once you’ve made the decision to proceed with surgery there is still much to do.

The following pages will review each item on the pre-operative checklist in more detail. 

• Medical clearance form
• Dental examination
• Get your flu or pneumonia shots
• Schedule any invasive procedures at least two weeks prior to surgery
• Have a friend or family member accompany you to your preoperative visits
• Attend the joint replacement education class
• Begin preoperative strengthening exercises
• Arrange for care after the surgery
• Arrange for transportation to and from the hospital
• Prepare your home for recovery
• Schedule physical therapy
• Pick up medications at your pharmacy

Medical clearance

Your surgeon will let you know if you need a medical clearance from your family doctor and/or specialist.

• If needed, schedule an appointment within 30 days of your surgery. 
• You will be given a surgical clearance form to take to your doctor.

Schedule other exams and procedures

Schedule a dental exam within 6 months prior to joint replacement surgery.

• Good dental health is very important prior to surgery
• If you do not have dental insurance or if you have financial concerns regarding dental care, please contact the orthopaedic clinic

Schedule any invasive procedures at least two weeks prior to joint replacement surgery.

• These include other surgeries and colonoscopies

Flu or pneumonia vaccines 

• Should be given at least two weeks prior to surgery

Attend pre-operative appointments

Plan on spending most of the day at Milton S. Hershey Medical Center for your pre-operative appointments.

• Ask a family member or friend to accompany you during the pre-operative visits  
• Your appointments will be in different areas of the hospital
• There is a shuttle bus to transport you, if needed
• Bring snacks and a drink along with you.  There are cafeterias, cafes and vending machines available

The following occurs during the pre-surgical visit with your surgeon or physician assistant:

• Review details, risks and benefits of the surgery
• You will be asked to sign a consent form
• We will do a nasal swab to look for the possibility of Methicillin-Resistant Staph Aureus (MRSA), a skin bacteria (The risk is small, at approximately 5%, however we like to do everything possible to minimize the risk)
• You will receive a prescription for a blood thinner (there is about a 1% chance of a blood clot to the lungs, but we want to make every effort to prevent that from happening)

The following occurs during the pre-surgical visit with anesthesia team:

• Discuss your anesthesia options
• Perform a physical examination to be sure that there aren’t other medical issues of concern with regard to the anesthesia
• You will be able to eat freely up until midnight on the evening before surgery
• You can continue to drink clear liquids up to 2 hours prior to the procedure, and we would encourage you to do so

Attend Joint Replacement Education Class

You will also attend a pre-operative Joint Replacement class.

• Taught by our nurse in conjunction with Occupational and Physical Therapists
• Bring a family member or friend to the class who will assist you after the surgery
• The nurse will review the pain management protocols, physical therapy protocols, pre-operative information, post-operative information
• You can ask questions in a class with other joint replacement patients 
• Please arrive 15 minutes prior to the class

Start Pre-operative Exercises

You may be given a prescription for a physical therapy evaluation before surgery. The physical therapist will teach you exercises you can do at home to begin strengthening your legs. 

NOTE: Reference to the "operated leg" refers to the joint that is causing you discomfort.

Click each image for a video demonstration of the exercise.

Arrange for care and transportation

Arrange for transportation:  

• You will need transportation to all clinic appointments and therapy visits
• Discharge usually occurs one day after surgery

Make arrangements for someone to stay with you for a few days after your surgery:

• Many insurance companies will not cover inpatient rehabilitation unless you have other qualifying medical conditions
• This will be discussed further at the Joint Replacement Education Class

Prepare your home for recovery

Prior to surgery it is recommended that you make the following preparations:

• Remove cords that are on the ground at your home
• Remove throw rugs and any other items that could cause trips or falls
• Place night-lights in your bedroom and bathroom
• Arrange for a shower chair and a hand-held shower head 
• Consider putting safety bars beside your toilet or in the shower
• Fill your prescription for a walker or crutches prior to surgery

Schedule physical therapy

Make arrangements for your physical therapy needs. Hip replacement patients will receive a home exercise program and walking instructions for after discharge.

Pick up medications

You'll want to have your medications on hand before having surgery:

• Pick up your blood thinner at your pharmacy - this is prescribed to reduce the risk of blood clots
• Pick up a stool softener and a laxative as well, as pain medication often causes constipation

Meet the surgical team

You're in good hands.

All of our board-certified surgeons have completed orthopaedic subspecialty fellowships in the area of joint arthroplasty. 

What happens during surgery?

The following video was produced by the National Health Service in the United Kingdom.  It does an excellent job explaining how the joint works, how osteoarthritis affects the joints, and what happens during hip replacement surgery.  

Note: The hip replacement video references the use of acrylic cement to keep the prosthesis in place. At Penn State, and in the U.S., most hip replacements are performed using the bone ingrowth method, though both approaches can work very well.

Total Hip Replacement:

How will the pain be controlled?

Pain control is one of the most important considerations for our patients around the time of surgery. We will do everything that we can to help manage your pain in an acceptable manner. Patients who are on regular narcotic pain medications prior to surgery have a much more difficult time managing their pain after surgery.

We use a multi-modal approach to pain management.

• Right before the surgery, you will receive several medications by mouth to help with the pain control during the surgery.
• During the surgery you may receive pain medications through your IV from the anesthesia team
• We also typically provide an injection around the joint at the time of surgery to provide pain relief for 12-18 hours which allows early function including walking.
• Many patients will walk on the day of surgery.
• After surgery, you will receive several pain medications including Tylenol, Tramadol (Ultram), and an anti-inflammatory, on a regular basis.  Other pain medications such as Percocet or Vicodin are also available if needed. 
• IV pain medications are available as determined by the patient and the nursing staff.
• To help reduce swelling and decrease pain, have ice applied to your surgical site several times a day. 

You will be asked frequently during your hospital stay what your pain level is as a way of monitoring the effectiveness of the pain control.

Can I go home the same day as surgery?

Some patients may be eligible for an outpatient hip replacement. This means that the patient would be able to go home on the same day as their replacement surgery. Patients who are considering this should be in excellent health with good strength. 

For certain patients in good health, who have a strong support system at home, outpatient hip replacement may be an excellent choice.

What should I bring to the hospital?

Bring the following with you: 

• Advance directives 
• Inhalers and medications  
• A list of your medications including the dosage and the time you take each one.
• Toiletries
• Loose-fitting shorts, culottes, pants, t-shirts or sweatshirts
• Loose-fitting pajamas with short legs
• Calf-or knee-length robe
• Well-fitted slippers, tennis shoes, or flat shoes with nonskid soles
• CPAP machine, if applicable
• Cell phone + charger
• Joint Replacement Guidebook 

Do not bring:

• Jewelry
• Large amounts of money
• Other electronic devices

The day before surgery

The day before surgery, an admissions nurse will call and tell you:

• What time to arrive at the hospital the next day
• When to stop eating and drinking 

Evening before surgery:

It is important to prepare your skin before surgery to reduce the risk of infection at the surgical site.  Your surgical team has chosen disposable cloths, or wipes, moistened with a special rinse-free antiseptic solution.  Follow the pre-operative skin preparation process outlined on the following page.  

Pre-operative skin preparation

Important Notes:  

• Once you begin prepping your skin, do NOT apply any creams, lotions, moisturizers, powder, or make up at or near the surgical site.
• Do NOT shave or use hair removal lotions or creams on the area of your body where surgery will be done.
• Do not microwave the package prior to use.
• Avoid contact with your eyes, ears, mouth, and genitals. 

Prepare your skin the evening before surgery:

How to prep:

1. Shower or bathe at least 2 hours before using the disposable cloths
2. Use all six of the disposable cloths to prep your entire body. Wipe down your body like you would with a washcloth
   1. One wipe is for your neck, chest, and abdomen
   2. One wipe is for your arms
   3. One wipe is for each leg
   4. One wipe is for your back
   5. One is for the surgical area - wipe your surgical site last, moving back and forth for about 3 minutes making sure to wet the entire area
3. Allow the area to air dry for 1 minute. Do NOT rinse off (unless you develop a skin irritation from the medication in the wipes)  
4. Do not apply any powders, creams, deodorant, creams, or lotions
5. Put on clean clothing

The morning of your surgery, you'll perform this process again:

• Do not bathe or shower the morning of surgery, but you can wash your face and brush your teeth
• Do NOT apply any makeup
• When you arrive for surgery, the nurse will provide you with another set of wipes 
• The procedure is the same as the night before surgery

What can I expect during the hospital stay?

On the morning of surgery, report to the Admission Department at the main entrance of the hospital.

• You will be taken from there to the pre-operative area where the nurses will prepare you for surgery.
• Your family can accompany you to the pre-operative area
• Your family can wait in the surgical waiting area while you proceed to the operating room

In the operating room:

• The anesthesia team will prepare you for surgery and will administer anesthesia
• Anesthesia may be spinal anesthesia or general anesthesia
• Your surgical team will inject numbing medication around your joint that will help substantially with your pain relief after the surgery
• Once your surgery is complete the surgical team will speak with your family to review the procedure

Recovery room:

• After the surgery you will be transported to the recovery room
• You will be there approximately one to one and a half hours before you are transferred to the Orthopaedic unit

Orthopaedic unit:

• Once you're in the Orthopaedic unit, the nurses will provide you pain medications, monitor your progress, provide eating instructions, and address any other needs
• A physician assistant monitors the progress of patients in the hospital and helps with discharge planning.
• You will also see the orthopaedic residents and your surgeon on a daily basis

Physical and Occupational Therapy

We try to provide most patients with physical therapy the afternoon of surgery. During these sessions, you will learn:

• Exercises for after surgery
• Getting in and out of bed 
• Walking using cane, walker, or crutches
• Going up and down stairs

Occupational Therapy sessions will:

• Teach you dressing techniques
• Recommend equipment you may need to maintain any post-surgical precautions
• Recommend techniques you can use while performing self care activities including dressing, bathing, toileting, home tasks and transferring to and from a car
• Provide guidance on using the cane, walker or crutches

When can I go home?

Most patients can expect to return to their own home after leaving the hospital, typically the day after surgery.

• You will receive a prescription for pain medications for you to have at home
• Constipation is a side effect of pain medication. Use the medications you typically use to help with your bowels including fiber, Metamucil, stool softeners, Milk of Magnesia, or Magnesium Citrate
• If you have not had a bowel movement after 4 days following surgery, contact the Bone and Joint Institute
• You will have a blood thinner medication, which is typically started the morning following surgery and continues for several weeks
• In general, you can put as much weight as you like on the operated leg, but you should use a walker to help you get around
• It is very important to work on your exercises after the surgery and to keep moving

Recovery after surgery

After joint replacement surgery, there is still much work to be done.

Rehabilitation begins almost immediately after joint replacement surgery, and there are certain things you need to watch out for. This section will discuss:

•  When you should call the doctor
• Precautions and possible surgical complications
• Physical therapy exercises for after surgery
• Occupational therapy 
• How to care for your new joint
• Joint replacement do's and don'ts
• Life after surgery 

When should I call the doctor?

90% or more of patients do well after their hip replacement, though some patients do have complications.  It’s better if you can return to the Milton S. Hershey Medical Center, however, if you experience chest pain or shortness of breath, go to the nearest hospital.

What are the risks?

As with any surgical procedure, there are risks. Let's review each potential complication in more detail.

Injuries to the large nerves or blood vessels around your hip:

• Very uncommon - occurs less than 1% of the time
• Can result in permanent injury

Infection:

Infection is one of the most severe complications after hip arthroplasty, though it is uncommon (it occurs approximately 0.5% to 1.5% of the time)

• Can occur around the time of surgery or many years after the surgery
• The treatment is complex but the incidence is quite low
• We recommend taking antibiotics by mouth for dental work or urologic procedures if you have a joint replacement

Blood clots:

• Deep Vein Thrombosis is a blood clot in your legs
• Pulmonary Embolism can occur when a blood clot travels to your lungs
• Patients who undergo a hip arthroplasty are at increased risk, however pulmonary embolism typically occurs only in about 1%-3% of patients
• Death from a pulmonary embolism can occur in 1 or 2 patients out of 1,000 after hip replacement
• All patients typically take medication after surgery to help reduce the likelihood of blood clot formation. Discuss these medications with your surgeon
• Most of the increased risk for blood clot in the legs or to the lungs is in the first 6 weeks after surgery

Persistent pain:

Persistent pain is not common in hip arthroplasty patients, perhaps 5% or less of patients experience this.

Some patients will experience a leg length difference after a hip replacement:

• Sometimes it is necessary to lengthen the leg in order to improve the stability of the hip so that it will not come out of joint or dislocate
• In most cases the difference is relatively small, a quarter inch or less, but occasionally can be up to half an inch
• Can be addressed with a shoe lift on the short side, though this is uncommon

Limp:

2% to 3% of patients will continue to limp after hip arthroplasty.

Dislocation

• Occurs approximately 3% of the time
• More common in women due to the generally smaller muscle mass around the hip
• Does not typically require an incision or extensive surgical procedure
• Rarely, dislocation may happen multiple times which can require additional surgery
• The incidence of recurrent dislocations is approximately 1% after hip arthroplasty

Wear or loosening of the pieces over time

• Up to 85% of patients will have their hip replacement functioning after 15 years
• Some arthroplasties will fail sooner than we would like 
• Even if your hip arthroplasties wear or become loose, there is good potential for repairing the joint and having good function after the repair

What are the dos and don'ts after a hip replacement?

You have an important role in caring for your “new” hip:

• Do use crutches or a walker to assist with walking; be safe, falls can be disastrous
• Do use pillows between your legs or under your knee on the side of your new hip replacement in bed to keep your operated leg out to the side
• Do continue to wear your TED stockings. A second pair can be provided for you at the time of your discharge so you have a pair to wear while washing the other pair
• Do continue the exercises that you have been instructed in by the physical therapist
• Do use assistive devices to put on shoes and socks
• Do use an elevated toilet seat or bedside commode.You may purchase one from a local medical supply store or possibly borrow one through your local community organizations
• Do avoid constipation. While you are taking narcotics, you may need to take a stool softener and a laxative

There are certain movements that place stress on your new hip and should be avoided until you are instructed to do otherwise by your doctor:

• Do not overdo it; plan your activities with frequent rest periods.
• Do not bend your hip more than ninety degrees; do not sit in low or overstuffed sofas and chairs; do not sit in bucket seats in cars; do not pick up items from the floor – use a grabbing device.
• Do not cross your legs
• Do not drive a car until authorized by your doctor
• Do not lift heavy objects
• Do not have sexual intercourse until after your six-week follow-up visit and your doctor has given you permission; intercourse will be uncomfortable the first weeks after surgery
• Do not bathe in a bathtub or hot tub, swim in a pool, lake, or ocean until your physician gives you permission
• Do not play tennis, downhill ski, water ski, run, jog, or do other demanding physical activities that require quick starts and stops without first consulting your physician 

Post-operative Exercises

It is important that you do the exercises recommended by your physical therapist after your joint replacement.

Click each image for a video demonstration of the exercise.

Occupational Therapy

An occupational therapist will recommend techniques to help you perform daily living tasks as you recover from surgery. Specific recommendations will vary depending on your individual living situation. Your therapy team will teach you safe procedures for common daily activities such as:

• Dressing
• Bathing
• Toileting
• Getting in to and up from a seated position
• Getting in to and out of a vehicle 

Decide what type of vehicle will be used for travel after your surgery. 

Things to consider: 

• Bucket vs. bench seats
• Height of the vehicle
• Size of the door and how far it opens
• Leg room and head room inside the vehicle

Special equipment may be recommended to assist you with your daily activities

You may be instructed to use a "reacher" for donning pants and shoes.  Your therapy team will demonstrate how to use each recommended device, as needed. One commonly used device is the ‘Sock Aid’  demonstrated here:

Life after replacement surgery

After surgery patients can walk, bike, swim, play golf, ski in moderation, play doubles tennis and perform other moderately strenuous activities. Remember, your hip replacement will not make you 18 again. You may still have some mild stiffness, decreased range of motion and limitations of your activity.

• We generally do not recommend running for exercise after a hip or knee replacement
• We also discourage climbing high up on ladders after hip replacement.
• Patients may get into a pool or hot tub beginning 3-4 weeks after the surgery provided the incision is healed.
• Your hip replacement has an approximately 85% chance of being intact and functioning after 15 years

Thank you for visiting

Thank you for taking the time to review this resource!  If you have other questions or would like to discuss hip replacement further we would be happy to meet with you.

Best wishes from the Hip and Knee Arthroplasty Division at Penn State Health!