Post Op Hip Replacement Care Guide

A Complete Guide on What to Expect After Surgery and How to Improve the Long-Term Success of Your Joint Replacement

By Bert J Thomas, MD

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After Your Operation

Physical Therapy

The physical therapist will get you up on the first or second day after surgery, and will teach you the right amount of weight to put on your operated leg. You will also be taught all the necessary restrictions to prevent your hip from dislocating.

You should pedal your feet up and down every five minutes or so while you are in the hospital to help prevent blood clots from forming.

Special pneumatic pumps will be applied to your legs in the recovery room, and will be kept in place for several days. They massage your calves every forty-five seconds. Most patients find them very comfortable. The pedaling exercise, the pumps and the Coumadin all help to prevent blood clots from forming in your legs.

Most patients by the second or third day after surgery no longer have an IV, and are feeling quite well. Many patients complain that the operated leg feels “too long” for the first few weeks after surgery, even when the legs are absolutely equal in length. It can take several months for this false sensation to disappear. We usually transfer our patients from the orthopedic floor to the rehabilitation unit approximately the second or third day after surgery.

You will be allowed to go home when your temperature is normal and you are able to get in and out of bed by yourself, and go to the bathroom by yourself. Some patients reach this goal within five days, others take as long as ten days.

Equipment You Will Need At Home

While you are in the hospital, the occupational and physical therapist will help you decide what equipment you will need when you get home. You will definitely need crutches or a walker. The hospital will provide these. Crutches are actually easier to handle, but most people feel more secure with a walker. The physical therapist may try you on both.

Unless otherwise instructed, try to go to a single cane (on the opposite side from your surgery) as soon as you can. Some of Dr. Thomas’s patients are off all walking aids by one to two weeks. Most of his patients are on one cane by three weeks after surgery. Use a walker or cane for as long as you feel the need.

A hospital bed is hardly ever needed at home, but we will be happy to order one for you if you want it. Most insurance plans cover it. We will provide a “reacher” to help you dress, or pick things up off the floor. A toilet seat extension will also be provided so that you do not sit too low on your home toilet. You will need to purchase a thermometer, a shower stool and a rubber bath mat for the shower. If you live in a two-story house, it is recommended that you move a bed downstairs and convalesce there, rather than risk using stairs.

The Rehab or Skilled Nursing Unit

Older patients, especially those who live alone, are advised to stay in a Rehabilitation Unit for additional therapy and general care. This will, in any case, greatly speed your progress to full recovery. The Rehab Units are superbly geared to the special needs of joint replacement patients. Medicare will cover your stay there. Some private insurance companies will not. In the Rehab Unit, a doctor who is specialized in physical medicine will see you daily. Your internist will also see you there regularly.

What to Expect After You Get Home

You will be able to go home in a regular sized car. It is better if someone can be at home with you for at least portions of each day to assist you with shopping, meal preparation, etc. Constant nursing care is rarely needed at home. We will arrange for a physical therapist as well as a visiting nurse to see you at home, if your insurance will cover these services (Medicare does). The visiting nurse may draw your blood three times a week so that the internist can monitor the dose of Coumadin you should take, unless a fixed daily dose is prescribed. After you run out of Coumadin at home, you should take a single regular Aspirin daily for a further 14 days.

You must call our office after you get home to set a date for your first office visit, which is usually 6 weeks following the day of surgery. Call and come in at ANY TIME sooner, if any problem develops. Until then, continue all the restrictions which you were taught in the hospital. But get off your crutches or walker as soon as you can, as mentioned above.

The precautions to prevent dislocation must be strictly observed until Dr. Thomas tells you it is safe to discontinue them.

It is not uncommon to develop some swelling of the knee, foot and ankle in the weeks after surgery. If this occurs, you should elevate your leg on pillows when you are not up and about.

Wound sutures or staples are usually removed on the fourteenth day after surgery. If you are discharged before that time, they may be removed by a visiting nurse at your home, or you maybe asked to come to the office for removal. One day after staple removal you may take a shower. Up to that point the wound should be kept dry. It is best to shower rather than get into a tub. We recommend avoiding a tub for at least two months after surgery. A shower stool is helpful so as to avoid slipping while taking a shower.

Once you get home you are not expected to stay in bed. You should be up and about on your walker or crutches most of the time, but rest as much as you need to.

You should also do the exercises illustrated in. You may lie on the operated side when it is comfortable. However, for at least the first 12 weeks after surgery, you should put one or two fluffy pillows between your knees when you lie on either side. This is to make you more comfortable and also to prevent dislocation of the hip joint. We prefer that you do not attempt to sleep on your side because the pillows will dislodge once you are asleep and you may then dislocate your hip. You should not cross your legs for the first 12 weeks after surgery. You should not bend your thighs up to a greater than 80 degree angle. It will therefore be difficult for you to pick up objects from the floor, and also for you to put on your shoes and socks. A reacher is helpful for this purpose. You should strictly avoid low chairs, low stools, low toilet seats, and stuffed chairs, since they may cause the hip to dislocate.

A pool rehabilitation program may be prescribed by Dr. Thomas.

Driving After Hip Replacement Surgery

You could drive an automatic as soon as you get home if your left hip has been replaced. However,driving is best avoided until about 6 weeks after the surgery, especially if it is your right hip that has been operated upon. Some patients, however, may need to drive sooner, and this can be discussed with Dr. Thomas. We can only advise you about the effects of driving on your hip, and not on driving safety, or legal issues. If you have a car accident, you are on your own!

Returning to Work After Hip Replacement Surgery

How soon you will return to work depends on what you do, and on how motivated you are to get back to work. People who work at a desk could be back by two weeks after surgery, provided they have the means to get to work, but most people take off at least six weeks. If you do heavy manual work you may be off for as long as twelve weeks.

First Office Visit After Surgery

The first office visit after you leave the hospital is usually 6 weeks after surgery. You should call Dr. Thomas’s secretary to schedule an appointment. Sometimes Dr. Thomas will have you come in earlier than six weeks to check the wound.

Problems You May Encounter At Home

1. Excessive swelling of your leg and foot

It is not uncommon to develop some swelling in the first few weeks after surgery. If this occurs, you should elevate your leg whenever you are not up to walking. However, excessive swelling of the foot and lower leg can be due to thrombosis (blood clots) in the veins in the leg. We should be notified if swelling is associated with pain or tenderness in the calf muscles, or if the swelling just seems over-excessive, and doesn’t respond to elevation.

2. Chest pain, a cough or shortness of breath

These may be signs of embolism. Please do not ignore these symptoms. Call us right away.

3. Drainage from the wound, or increasing redness around the wound

This could signify impending infection. Our office should be notified, and in most instances you will need to come in and let Dr. Thomas take a look at it.

4. High fever

A high fever could also be a sign of impending infection. You need to take your temperature twice a day for a month after surgery. Take it three times a day if it is elevated over 99 degrees. If you get two readings, at least three hours apart, of over 100 degrees, you need to notify us immediately.

5. Increasing hip pain.

Pain should be decreasing from day to day. If it seems to be steadily increasing, let us know.

6. Dislocation of the hip.

If your hip dislocates, you will immediately recognize what has happened. You will have severe hip pain, your foot will “point the wrong way” and you will not be able to walk.

7. The operated leg feels too long.

After hip replacement, most patients complain that the operated leg feels too long. This is usually a false sensation and goes away after a month or two. It is somewhat akin to the felling one gets that the filling is too prominent after the dentist fills a tooth. A week or so later, the filled tooth feels normal! A great deal of effort is put into trying to get the leg lengths correct. But accurate measurement is very difficult during surgery. It is common to be off by a quarter of an inch or so. Most people easily adjust to a difference of a quarter-inch, and are hardly aware of it. Many “normal people” have up to a quarter-inch in difference. Sometimes, however, the patient may feel that the leg isan inch or more too long when, in fact, the leg lengths are absolutely equal. This brings us to the difficult concept of “true” and “apparent” leg length differences. True leg lengths are measured from the pelvis to the ankle. Apparent leg lengths are measured from the navel to the ankle. In a normal person, the true and apparent leg lengths are equal. If one hip is pulled outwards (abducted) by tight ligaments, it will feel too long, even though it is not (and the apparent leg length will be longer than the true leg length). If one hip is pulled inwards (adducted), it will feel too short, even though it is not.

8. Thigh pain.

Patients with cementless hip replacements may have thigh pain for 18 to 24 months after surgery, until the implant is securely locked in place by bone growth. This pain can be expected to be minimal and can be ignored.

IN GENERAL, THE LEG SHOULD BE GETTING BETTER EACH DAY. IF YOU THINK YOU ARE GETTING WORSE IN ANY WAY,PLEASE GIVE US A CALL.

What to do If Your Hip Dislocates

If this happens, call Dr. Thomas immediately and he will meet you in the emergency room of the hospital and relocate the hip. Do not eat or drink anything, since you may need an anesthetic to get the hip back in place. You may be brought to the hospital by car, but, if you have too much pain, an ambulance may be necessary. Sometimes it takes an open operation to get the hip back in place, but most of the time it can be "pulled" back in place.

Long Term Care of Your Hip Replacement

The main long-term problems of joint replacements are wear of the socket or loosening of the components' attachment to the bone.

Annual visits to have your hip examined and x-rayed are essential for monitoring the results of your surgery, and giving you periodic advice for the care of your hip replacement.

With time and stress, fixation of cement to bone can fail. It is hoped that cementless replacements will be able to withstand more vigorous activities, and have greater longevity than cemented replacements. They have not been in use long enough for anyone to be sure yet that this will be the case. Both cemented and cementless hips should, therefore, be treated with the same care. You should minimize activities which could cause loosening (see below). If the implant comes loose, movement between it and bone can cause pain and require re-operation. Most patients are pain free after 3 months. However, from time to time, especially in the first year, you may have a twinge of pain which you can ignore. If you have pain that does not go away, or seems to increase from day to day, you should come in to see Dr. Thomas for x-rays and evaluation. It could signify infection or loosening.

The longevity of your hip replacement can be increased by:

AVOIDING stressful activities such as all types of impact sports including: running, jogging, tennis, racquetball, badminton, football, baseball, horseback riding, and other activities. Heavy lifting, weight- lifting, jumping from heights, falls and some exercise machines for the legs are dangerous for you.
Never lift or carry more than forty pounds.
It is important that you not become overweight, since excess weight increases the stresses on the hip replacement, and can cause loosening. Every pound of weight gained increases the forces on your hip by three pounds!

Possibility of infection

The possibility of infection occurring around the replacement is another concern.

For the rest of your life if you develop an infection elsewhere in your body" (for example bladder infection, infected cuts, boils, dental abscesses) this infection can travel via your bloodstream to the replacement.

Therefore, if you develop any infection, you should consult your family physician and have him treat it promptly. Viral infections, such as colds and most sore throats, are not a problem. Dental work can push bacteria into your bloodstream and cause an infection in your joint replacement. We recommend that you take antibiotics before dental work (other than simple cleaning of your teeth). You will be given a plastic card to keep in your wallet containing information about dosage. Note that the American Academy of Orthopedic Surgery has recommended that antibiotics be taken for dentistry for two years after hip replacement. Dr. Thomas recommends that you do so for the rest of your life.

Always Notify Your Dentist or Any Treating Physicians That You Have A Joint Replacement.

If you are to have cystoscopy, bronchoscopy, or colonoscopy you should also be covered by an antibiotic. Doctors vary on their recommendations as to which antibiotics should be used and for how long.

Our recommendations for Antibiotics

Dental, Upper Respiratory, Gastrointestinal and Genitourinary Procedures:

Not Allergic to Amoxicillin: Amoxicillin 500 mg. Four capsules one hour before the procedure.

Allergic to Amoxicillin: Keflex or Duricef 500 mg. Five tablets one hour before the procedure.

OR: Clindamycin 600 mg, Zithromax 500 mg, or Biaxin 500 mg 1 hour before the procedure.

Call your doctor immediately if you develop any infection. Never, ever allow any physician to inject Cortisone or any other medication into or near your artificial joint. It may cause disastrous infection in the hip joint

Total Hip Precautions For The First 8 Weeks After Surgery

Don't bend your operated hip beyond 80 degrees
Don't raise your knee higher than your hip
Don't sit on sofas or low chairs. Put cushions down first
Use an elevated toilet seat
Don't lean forward while sitting. Get assistance for lower extremity dressing or use your dressing aids
When you sit down, back up until you feel the bed or chair against your legs. Reach back for the bed or armrests of the chair and slide your operated leg straight out in front of you. Don’t lean forward as you sit! When you stand up, push up from the bed/chair keeping your operated leg straight out in front of you. Raise yourself without leaning forward. It is in standing up from sitting that you have to concentrate the most on not bending your hip more than 80 degrees.Hip pain can make it very difficult to perform simple daily activities. It can take a person that is normally a "go getter" and reduce their activity to slowly walking from place to place. The pain is usually mother nature's way of saying, "there is a problem in this area." The pain could be caused from trauma, arthritis, or any other possible form of disease process

Allowable Activities After Hip Replacement

The key word is common sense. Even a cemented hip will probably last for your entire lifetime if you stayed in bed and subjected it to no stresses at all! The aim is therefore to minimize stresses. You will be able to take part in physical activities which were impossible before surgery.You can walk as much as you like. The best recommended activities are walking and swimming. You can ballroom dance, play golf, and ride a stationary or mobile bike. It is best to use spikeless shoes for golf, and to use a golf cart (so that you don’t have to carry a heavy bag of clubs). Bicycling on a level surface is less stressful then biking in hill country. Skiing smooth, groomed slopes in good light is relatively safe. Hard falls, such as from a horse, could result in serious injury to someone with a hip replacement. The femur bone can fracture just below the tip of the femoral implant which is a “weak point”.

Revision Hip Surgery

Cemented hip replacements may fail after 10 to 15 years, or occasionally sooner. The parts may come loose or wear out, or they may break. In some patients with cementless implants, the porous surfaces may not bond properly to the bone. Loose, worn or broken parts may need to be replaced (“revision surgery”).

Revision surgery is much more complex and technically much more difficult than first-time surgery.

It involves longer operating time and increased blood loss, and may require an increase in the length of the hospital stay. A mini-incision operation is not possible for revision surgery, even though some revision cases are relatively straightforward. Much depends on how difficult it is to remove the prosthesis, and on the quality and quantity of bone left behind after the implant has been removed. The trochanter bone may need to be cut to remove the implant. Wires may be needed to hold the parts together until the bone has healed. Bone grafts from your pelvis and/or from a bone bank may be needed if defects need to be filled with bone. With bank bone, infections can be transmitted in the same way as with blood transfusions.

There is a chance that your leg may be shorter or longer than it was before the operation. The femur bone can be fractured during surgery, requiring extra repair procedures. The range of motion may be less than after first-time hip replacements. There is a high risk of dislocation for 12 weeks after revision hip surgery, and restrictions must be continued for at least that long to prevent dislocation. Patients who have revision operations are frequently advised to use a cane full-time, in order to protect the replacement from re-loosening.

These complex operations are much riskier than first-time hip replacement surgeries. All the risks associated with first-time hip replacements are present, but the chances of complications occurring are greatly increased. These are among the most difficult procedures performed in orthopedic surgery. Dr. Thomas has performed more than 700 such revision total hip operations

Potential Complications of Hip Replacement Surgery

Unfortunately, even the most minor of surgical operations carries some risk of complications occurring. Hip replacement surgery is very successful, and complications are relatively uncommon, considering the complexity of the procedure.

Most complications are temporary setbacks. You have about a 98% chance that you will go through the operation without some significant complication which causes an ongoing problem.

The most common complication is blood clots in the legs. The most serious complication is infection. The most important long-term complication is loosening or wear.

1. Bloodclots

in the veins of the legs are the most common complication of hip replacement surgery. As long as the clots remain in the legs they are a relatively minor problem. Occasionally they dislodge and travel through the heart to the lungs (pulmonary embolism). This is potentially serious, since (very rarely) death can result from embolism. The chances of embolism are one out of several hundred. The internist will prescribe Coumadin (a blood thinning drug) to help prevent clots from forming after your surgery. Additionally, compressive calf pumps are used and leg exercises are encouraged to prevent blood clots. Blood clots can occur despite all these precautions. They are usually not dangerous if appropriately treated, but may delay your discharge from the hospital by two to three days.

2. Infection

Pioneer surgeon John Charnley found that the risk of infection after joint replacement was much greater than with most other operations, unless special precautions are taken. Since bacteria can enter the open wound at the time of the surgery in a regular operating room, he invented the laminar flow operating room in which special filters provide clean air, free of most bacteria. In addition, Charnley devised a sterile space suit for the surgeon and his attendants. The suite encloses the entire head and body, and includes a sterile face mask. Antibiotics given to you before, during and after the operation further help to lower the rate of infection. Dr. Thomas uses all these special precautions, and has had no infections following hip replacement (and only two infected knee replacements) in twenty years as a joint replacement surgeon.The risk of an infection in first-time hip replacement is currently reported as being about 0.5%.

* The risk of infection in the weeks after the operation is increased if you have rheumatoid arthritis or diabetes, if you have been taking cortisone for prolonged periods of time, if the affected joint has had previous infection, or if you have infection anywhere else in your body (teeth, bladder, etc.) at the time of surgery.

The artificial joint can become infected many years after the operation.

The bacteria travel through the blood stream from a source elsewhere in the body, such as from an infected wound, or a gall-bladder infection. Even regular dental work can release bacteria into the blood. Infections of the bladder, teeth, prostate, kidneys, etc. should be cleared up by appropriate treatment well before the day of surgery. Patients who have had joint replacements must take antibiotics by mouth before and after any dental work. and must have all infections vigorously treated.

3. Loosening of the prosthesis from the bone

This is the most important long-term problem. How long the bond will last depends on a number of factors.

a. How well the surgery is done. This is by far the most important factor. Choose a surgeon who has had a great deal of experience with hip replacement, and preferably one who restricts his practice to joint replacement surgery.

b. The quality of your bones. The harder your bones are, the better the bond will be, and the longer the replacement will last. Osteoporosis is a factor of age, as well as the type of arthritis you have. People with rheumatoid arthritis have especially soft bones.

c. How active you are. Excessive force on the implant can cause the bond to loosen. If you stayed in bed for the rest of your life the implant will probably never come loose! Activities such as running and heavy lifting should be avoided. The key thing is to use common sense. (See Allowable Activities After Hip Replacement).

d. Your weight. You should also keep your weight down because every pound you gain adds three pounds to the force on the hip.

e. Whether or not the implant is cemented. At present it is believed that uncemented implants will last longer than cemented ones. We are not certain that this will be the case, even though the results so far are extremely good and promising (see Total Hip Replacement Surgery) with cementless implants.

f. The design of the implant. Small abrasion particles from the implant may play a role in implant loosening. Plastic surfaces shed more particles than metal or ceramic ones.

4. Wear of the Plastic Polyethylene Socket

This starts from the day of surgery. The plastic socket is the weakest link in the implant. The rate of plastic wear against a metal ball is about 0.1 millimeters per year, but is more rapid in very active patients. “Cross-linked” polyethylene promises a wear rate about half that of regular poly. Plastic wear against a ceramic ball is much less in the lab, but this has not yet been shown to be true in the human body. Metal-on-metal bearings will never wear out. Nor will ceramic-on-ceramic implants, but there is a 1/20,000 risk of fracture of the ceramic ball. Dr. Thomas uses and recommends metal on metal implants, or ceramic on ceramic implants for those patients who want them, and have a life expectancy of more than fifteen years. In all others he uses cross-linked polyethylene. (“Marathon” Polyethylene from Johnson & Johnson).

5. Dislocation of the hip replacement

occurs in a small percentage of patients regardless of how good your surgeon is (some surgeons report as high as 4%). Dislocation means that the metal ball slips out of the plastic socket. In the first six weeks after the surgery, the ball is only held in the socket by muscle tension. During this time, before scar tissue forms around the ball, and before muscle strength returns, the hip is more likely to dislocate.Therefore, to prevent dislocation, certain positions have to be avoided for the first six weeks (see Restrictions to Prevent Dislocations).

The physical therapist will teach you what positions to avoid, and how to safely use your hip replacement during this early phase of your recovery. If the hip does dislocate, it is usually a simple matter for the physician to pull on the extremity and “pop” the hip back into place. Revision hip replacements, replacements in people who are grossly overweight and replacements in people with poor muscles are more likely to dislocate. Occasionally patients develop repetitive dislocations, requiring a brace to be worn for several months to prevent further dislocation. Sometimes further corrective surgery is needed to solve the problem.

6. Extra bone formation (ectopic bone)

Extra bone formation around the artificial hip develops less than 1% of the time. It causes the hip to be stiffer than desired. This is more likely to occur in younger males with severe osteoarthritis. Small amounts of ectopic bone appear frequently around hip replacements but do not cause a problem. Very large amounts causing severe stiffness is rare. It can be treated by surgical removal of the bone once it is “mature.” Radiation therapy may be recommended by Dr. Thomas to try and prevent ectopic bone formation if he believes a particular patient is likely to develop it. Such radiation treatment is administered during the first 2 or 3 days after surgery, or on the day before surgery. If you need radiation, the risks will be discussed with you by the radiotherapy doctor. The risks are negligible.

7. Fracture of the femur

can occur during hip replacement. This can be a small crack or a major fracture. It is more common during revision hip surgery, but can occur with first time hip replacement. Occasionally the femur may be accidentally perforated during first time or revision hip surgery. It can also fracture later from any trauma, such as falling down stairs. If your femur is accidentally cracked during surgery, you may have to remain on crutches for up to 3 months to allow healing to occur. You may have to remain in the hospital with traction for several weeks. Complete fracture may require separate surgery for fixation. Small cracks may need to be treated with “cerclage” wires.

8. Residual pain and stiffness

In virtually all cases hip replacement will make a significant improvement in your pain and mobility. In most cases, you will have no pain at all, and the hip will feel “normal.” The completeness of the pain relief, and the degree of mobility is partially determined by your hip problem before surgery. Rarely, patients have pain after surgery which cannot be explained. Some patients with un-cemented hip replacements develop mid thigh pain. The pain is usually mild, and almost always resolves after 18 to 24 months. It has been found that the larger the diameter if the implant installed the more likely “thigh pain” will develop. For this reason, Dr. Thomas almost never installs an un-cemented femur implant larger than 17 millimeters in diameter.
(See Problems You May Encounter at Home).

9. Changing length of the leg

Getting leg lengths exactly right can be very difficult. Some leg length difference may be unavoidable. Sometimes the leg will be deliberately lengthened in order to stabilize the hip or to improve muscle function. Shoe lifts may be necessary if the difference is more than a quarter of an inch. When the leg is more than an inch short to begin with, it may be impossible to equalize the legs for fear of damaging the nerves to the legs. In the first weeks after surgery, most patients complain that the operated leg feels “too long” even when the legs are perfectly equal in length. This is an artificial sensation which will resolve itself after a few months (see Problems You May Encounter at Home). Dr. Thomas has an accurate method for getting the leg lengths correct.

10. Injury to the arteries or nerves of the leg

This is an exceedingly rare but possible complication. The major arteries of the leg lie close to the front of the hip joint. The damaged vessel can usually be repaired by a vascular surgeon if recognized in time. If the nerves to the leg are injured, they usually recover; but it may take 6 months or more. Occasionally, they don’t recover at all. Most patients have some numbness around their wounds which may be permanent.

11. Bleeding complications

a. Sometimes bleeding can occur into the wound in the days after surgery (“hematoma formation”) as a result of the use of blood thinners. It may distend the hip and cause dislocation. If it is excessive, it may require re-opening the wound under anesthesia to let the blood out.

b. Occasionally the blood thinners may cause bleeding into the urine (or elsewhere), but this is usually temporary, and not of serious consequence.

13. Anesthetic complications

Anesthetic complications can occur, and very rarely even death can occur from the anesthesia. Your anesthesiologist will see you before surgery and explain the risks involved.

14. Allergy to the metal parts

About 15% of the population has skin sensitivity to some metals. All metal implants release some metal ions into the body. However, reports of proven allergies to metal implants are surprisingly rare. You should notify Dr. Thomas if you believe you have a metal allergy. People who know they have metal allergies should be tested with extracts of the various metal components of the implant prior to surgery. The tests are not reliable, so they are only performed if a metal allergy is suspected. Allergy to the plastic parts has never been reported. Small particles of plastic or metal from the implant may cause a “foreign body” reaction in the bone, but this is not a true allergy. Some patients with metal implants have had temporary, mild skin rashes, while some have had severe rashes that resolved only with removal of the implant. If you are known to be sensitive to nickel, chromium or cobalt you should probably have a titanium implant, even though there have been reports of allergy to titanium as well. There is no evidence that metal-on-metal implants are harmful in any way, or are more likely to cause metal sensitivity, or that implants are more likely to fail in patients allergic to metals.

15. Complications From Blood Transfusions

The risks of getting AIDS from banked blood is believed to be about 1 in 2,000,000. The risk of Hepatitis B is estimated to be approximately 1 in 550 units, and Hepatitis C is 1 in 100. The risk of disease transmission from directed blood may be the same a the risk from ordinary banked blood. The risk of an allergic reaction (hives) is 1 in 500. You can have an allergic reaction to donor blood even though it has been properly cross matched. The risk of a Hemolytic Transfusion Reaction is 1 in 10,000. The risk of a Fatal Hemolytic Transfusion Reaction is 1 in 100,000. All blood intended for transfusion (including your own) is screened by the blood bank for Hepatitis B virus, Hepatitis C virus, syphilis, Human T Cell Leukemia virus, and the AIDS virus. If cadaver bone is used as part of revision hip replacement, there is some risk of transmitting disease, just as with blood transfusion. The bone is screened for 6 months before being used.

16. Fat Embolism.

Fat from the bone marrow can get into the circulation and cause lung or neurological symptoms. This is a very rare complication. In very rare cases it can be fatal.

17. Other minor complications

can rarely occur, such as tape allergies, allergies to medications, skin rashes and so on. You should keep in mind that the chances of any significant complication that permanently affects the overall result and your satisfaction with the joint replacement are very small.

Major surgery is not without risk.

There are risks in everything we do in life. Our medical staff will do everything we can to minimize the risks that you undertake. The worse your preoperative symptoms are, the more reasonable it is that you take the risk inherent in having a hip replacement.

Special Studies

To assist us in selecting the most appropriate method of treatment, additional studies may be required on an outpatient basis.

1. Aspiration and Arthrograms.

This is performed if there is suspicion of infection in a hip replacement. A needle is inserted into the joint under x-ray control, using local anesthetic. It is not particularly uncomfortable. Fluid obtained from the hip joint is sent to the laboratory for culture (results usually take 10 days to 2 weeks to be returned to Dr. Thomas). At the same time, an arthrogram is performed: dye is inserted into the joint to see if it spreads to the space between the implant and bone. These tests are helpful in ruling out the presence of infection and, in some cases, outlining areas of loosening of the implant. The results are not always clear-cut. If the test is scheduled you must tell us if you are allergic to Iodine,. Dr. Thomas prefers to perform the procedure himself rather than have the radiologist perform it.

2. Bone Scans

There are several types of bone scan:

The most routine type is done utilizing Technetium Diphosphonaten (TDP). The radioactive material is injected and the whole body is scanned a few hours later. This test is most useful in identifying hairline bone fractures which do not show up on x-ray, and bone tumors. It may be helpful in diagnosing loosening of a hip or knee implant.
Another scan is the Sulfur Colloid Scan. This test evaluates the status of the bone marrow in and around the hip joint, and can be helpful in diagnosing osteonecrosis. (c) A Gallium Scan is ordered if there is concern about infection.
Another test that may be performed if infection is suspected is an Indium-111 Radioisotope Scan. This requires removing some of your own blood, labeling it with an isotopic material (Indium-111) and re-injecting it. You return a day later, and the joint is scanned. This is a relatively new procedure, sometimes used incombination with other, more routine types of scans. The isotopic agents are relatively innocuous. The amount of radiation is generally not much more than that in a single x-ray.

3. Magnetic Resonance Imaging (MRI)

MRI has been a diagnostic revolution. It is done using giant magnets. No radiation is involved. It is useful in diagnosing the early stages of osteonecrosis, or in searching for bone tumors.

4. CAT Scan (Computerized Axial Tomography)

This is used to search for hairline fractures, and also to obtain additional information about the anatomy of the pelvis or thigh bone. Dr. Thomas uses this technique to identify the amount of bone available for performing a total hip replacement if there is any doubt that the bone is adequate. It is frequently used in such conditions as congenital hip dysplasia, or when a custom type of hip prosthesis may be needed.

5. An Epidural Injection

Epidural Injection of a dilute anesthetic agent is helpful in determining whether a patient’s pain is coming from the hip joint, or from a pinched nerve in the back. This is a fairly common diagnostic dilemma. Dr. Thomas administers these in the office quite routinely (he had done more than 4000 of these injections, at the last count). The risks and benefits will be discussed with you in the office.

• Please feel free to ask Dr. Thomas any questions you might have.
We look forward to taking care of you.

• On the whole, total hip replacement has proven to be an extremely beneficial contribution to modern surgery. We are pleased to be able to present you with this manual, which we hope will help you to understand your problem and the possible treatments you can obtain.

Blood Transfusion For Total Joint Replacement

We do everything we can to minimize blood loss during surgery. Your blood pressure is lowered during the operation to cut down on bleeding, and cut blood vessels are zealously cauterized, and we use the smallest incision possible. Even so, almost all hip replacement patients need to be transfused after the operation because of oozing from cut surfaces, much of it occurring after the operation is over.

First time hip replacements require a 1 unit transfusion of blood. Revision hip replacement needs 2 units.

The advent of AIDS has highlighted the risks associated with using other people’s blood . Dr. Thomas has always recommended that his patients donate their own blood prior to hip surgery because of the other risks associated with transfusion. The blood is stored and given back to you at the time of the operation . If you are not able to donate blood for yourself (for whatever reason), it is recommended that you solicit family members or friends to donate on your behalf . Sometimes a combination of these two methods is chosen: that is, you may donate one unit of your own blood and request friends or relatives to donate two units. Your third option is to use “hospital blood”.

1. Autologous Blood

blood donated by you and later given back to you. It is stored in a liquid state and is good for 42 days from the day of collection. It can be stored frozen for up to a year, but freezing triples the cost and is therefore only used in very special circumstances.

Usually units of blood are taken at approximately one-week intervals in the weeks before your surgery

More can be taken over a longer period, but some of the units may have to be frozen if storage is required for more than 42 days. Note that blood already being stored in liquid form cannot be frozen if your surgery is postponed for any reason. Freezing must be done at the time of collection. If you have already given your blood for storage, and your surgery is to be delayed for any reason, we can use the “piggy-back” technique to save a unit of your banked blood that is about to expire. We give it back to you as a transfusion, wait ten minutes, and then take a fresh unit that will be good for another 42 days! There is no age requirement for storing your own blood, and no specific weight requirement. However, if you are anemic (Hemoglobin under 11 gm/dl), we cannot take your blood. There are also some medical conditions which might preclude you from donating your own blood, such as some heart disorders.

It is advisable to take minerals and vitamins to help your body replace the blood lost by your donations. Take these from the day of your first donation until the day prior to surgery:

Iron (Nu-Iron 150), 1 tablet 2 times a day
Folic acid, 1 mg once a day
Vitamin C, 250 mg twice a day

2. Directed donor blood

This is blood donated by a relative or friend. It is carefully labeled and reserved specifically for you. It is rigorously tested for disease, but it is still possible to contract disease through directed blood: the donor may not know he has the disease, and tests may fail to detect it. Directed donor blood is only given to you after surgery if it is medically necessary to do so. If you plan to have directed donors, it is best that you first donate a unit (450 cc) of your blood. Then, when your blood group is known, and the bank has a specimen of your blood to use in cross-match tests, suitable donors can be canvassed. Bear in mind that it takes a minimum of 48 hours to process and test blood before it can be transfused.

Who can give blood for you?

Someone who is:

Seventeen years or older
Weighs more than 110 pounds
Is in good health at present and does not have anemia
Has never had yellow jaundice or liver disease
Has never tested positive for AIDS
Has not donated blood in the past eight weeks
Has not received a blood transfusion in the past six months
Has never been turned down as a blood donor
Has a compatible blood group (see table below)

Once you know your own blood group the following table will help you to determine who might be a compatible donor:

Tell the prospective donor to go to the same blood bank where you gave your first unit, and to inform the bank that they want to give a directed unit of blood for you. You do not need to be present.

3. Volunteer donor blood

This is blood donated by a member of the general public unknown to you. Potential donors fill out an extensive health questionnaire and the blood is rigorously tested. There are risks associated with receiving volunteer blood. Sometimes, in emergency situations, we may have to use volunteer blood if the amount of blood pre-stored for you is insufficient. But we would only do so in a rare, life- saving situation. Volunteer blood is rigorously tested and is safer now than it has ever been in the past.

Disease Transmission Through Blood Transfusion

All blood intended for transfusion is screened for AIDS, but the tests are not sensitive enough. There is a gap (“window”), believed to be between six and 12 months, during which infected persons will test negative. This is the great danger of accepting blood from others. This problem will persist until a test is available which will show positive as soon as an AIDS victim has the virus in his blood. Other diseases can be transmitted through blood; for example, hepatitis. Fortunately the tests for them are more accurate. The chances of getting AIDS through volunteer blood is currently about 1:2,000,000.

Where to Donate Your Blood

You may donate at the blood bank of the hospital at which you will have your surgery. If you live far from that hospital, or out of state, you may elect to donate blood at a major hospital near your home. It will be transferred to Dr. Thomas’s hospital before surgery.

Blood can also be donated at any American Red Cross blood collection facility. Please call (800) 974-2113 to locate the center nearest your home.

When making donations, please come with someone who can drive you home, since you may feel a little dizzy.

Forcing Your Body to Make More Blood

Epogen

This new hormone wonder-drug given by injection, can speed up the rate of production of new blood by your own body. It is especially useful if you cannot give blood for yourself. It can be given to anemic patients before surgery, or after surgery if you did not donate sufficient blood and your hemoglobin level is low.

Jehovah’s Witnesses

Although most patients require two or more units of blood transfusion after hip replacement, such transfusion is not mandatory. We have operated upon many Jehovah’s Witness patients and have been able to avoid transfusion altogether. The main disadvantage is that it takes longer for you to get back to full strength. It may take three months or more on iron and vitamin supplements to return the blood level to normal. Genetically engineered erythropoeitin (“Epo”) given by injection can “force” the body to restore your own blood more rapidly