TOTAL HIP REPLACEMENT

Objectives
 Introduction
 History
 Principles and considerations
 Indications
 Contraindication
 Implants (its part and type)
 Techniques
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 Nursing management
 Health education
 Exercise guide for hip replacement
 Complication
 Alternative management
 Prognosis
Introduction
 Hip replacement is also known for “Arthroplasty”.
 Arthroplasty is a reconstructive surgery to restore the joint
motion and function and to relieve pain. It generally involves the
replacement of bony joint structure by a prosthesis.
 It is the most common orthopaedic surgery.
 Hip replacement surgery can be performed:-
Total replacement :- It consist of replacing both the
acetabulum and the femoral head.
Half (hemi) replacement :- It consist of replacing of
only femoral head in general.
History
 Charnely (1979) revolutionized the management of the
arthritic hip with the development of low-friction arthroplasty.
 His three major contribution to the evolution of hip
replacement were:-
1. The concept of low-friction torque arthroplasty.
2. The use of acryclic cement to fix the components.
3. The introduction of high-density polyethylene as a bearing
materials.
Principle & Considerations
 The prosthetic implant must be durable.
 They must permit extraordinary low-friction movement at the articulation.
 They must be firmly fixed to the skeleton.
 They must be inert and not provoke any unwanted reaction in the tissue.
 The prostheses are of various designs and may be fixed to the remaining
bone by cement, press fit, or bone ingrowth.
 Selection of the prosthesis and fixation technique depends on patient’s
bone structure, joint stability, and other individual characteristics, including
age, weight, and activity level.
 Arthroplasty is an exacting and meticulous procedure. To reduce the risk of
an infected prosthesis, special precautions are carried out in OT room to
reduce particulate matter and bacterial count of the air.
Indications
 For patients with unremitting pain and irreversibly damaged
joints:-
 Severe osteoarthritis
 Rheumatoid arthritis
 Selected fracture (femoral neck fracture).
 Failure of previous reconstructive surgery ( osteotomy, cup
arthroplasty, femoral neck fracture complication – non union,
avascular necrosis)
 Congenital hip diseases.
 Pathologic fractures from metastatic cancer.
 Joint instability.
Contraindication
 When the infection is recent or remote.
 When the person is under 60years of age, especially when
alternative surgery is available.
 When pain is not severe.
 When manual labovers are gainfully employed.
Implants
 The prosthetic implant used in hip replacement consist of
different part.
i. The acetabular cup
ii. The femoral component
iii. The articular interface
 Options exist for different patients and
indications.
 Correct selection of the prosthesis is important.
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Type of fixation
a. Cemented fixation :- cement stem use acrylic bone cement to
form a mantle between the stem and the bone.
b. Uncemented fixation :- uncemented stem use friction, shape
and surface coating to stimulate bone to remodel and bond to
the implant.
Types of implants
1. Ceramic

2. Metal-on-metal

3. Cemented, cementless or hybrid fixation of prosthesis.

Techniques
 There are several incisions, defined by their relation to the gluteus medius.
 The approaches are :-
1. Posterior (Moore) :- The posterior (Moore or Southern) approach
accesses the joint and capsule through the back, taking piriformis muscle
and the short external rotators off the femur.
2. Lateral (Hardinge or Liverpool) :- The lateral approach is also
commonly used for hip replacement. The approach requires elevation of
the hip abductors (gluteus medius andgluteus minimus) to access the
joint.
3. Antero-lateral (Watson-Jones) :- The anterolateral approach
develops the interval between the tensor fasciae latae and the gluteus
medius.
4. Anterior (Smith-Petersen):- The anterior approach uses an interval
between the sartorius muscle and tensor fascia latae.
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5. Greater trochanter osteotomy.
6. Minimally invasive approach.
 There is no compelling evidence in the literature for any
particular approach, but consensus of professional opinion
favours either modified anterolateral (Watson-Jones) or
posterior approach.
 Nursing
Management
Pre-operative management
 Infections (bladder, dental, skin) are ruled out. Potential foci of infection for
seeding prosthesis infection.
 Pre-operative teaching is provided.
a) Post operative regimen (eg:- extended exercise program) that will be
carried out after surgery is explained; atrophied muscles must be re-
educated and strengthened.
b) Isometric exercises of quadriceps and gluteal muscles are taught.
c) Bed-to-wheel chair transfer with out going beyond the hip flexion limits
(usually 60-90º) is taught.
d) Non-weight and partial weight bearing ambulation with ambulatory aid
(walker, crutches) is taught to facilitate post-operative ambulation.
e) Abduction splint, knee immobilizer, or continuous passive motion is
demonstrated if equipment will be used post-operatively.
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 Anti-embolism stockings are applied to minimize development of
thrombophlebitis.
 Skin preparation includes antimicrobial solution to reduce the skin
microorganisms, a potential sources of infection.
 Antibiotics are administered, as prescribed, to ensure therapeutic blood
level during and immediately after surgery.
 Cardiovascular, respiratory, renal and hepatic function are assessed and
measures are taken to maximize general health conditions.
 Review discharge and rehabilitation options post-surgery.
Post-operative management
1.Use of appropriate position
To prevent dislocation of prosthesis and facilitate healing. Numerous
modifications are required in positioning the patient post-operatively.
 After Hip Arthroplasty
a) Patient is usually positioned supine in bed.
b) The affected extremity is held in slight abduction by either abduction splint
or pillow or Buck’s extension traction to prevent dislocation of the
prosthesis.
c) Avoid acute flexion of the hip.
Nurse alert:- The patient must not adduct or flex the operated hip – may lead
to subluxation or dislocation of hip.
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Signs of hip dislocation
 Shortened extremity
 Increasing discomfort
 Inability to move
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d) Two nurse turn patient on un-operated side while supported operated hip
securely in an abducted position; the entire length of leg is supported by
pillows.
 Use of pillows to keep the leg abducted; place pillow at back for comfort.
 Use of overhead trapeze to assist with position change.
d) The bed is not usually elevated more than 45-60º; placing the patient in an
upright sitting position, put a strain on the hip joint and may cause
dislocation.
e) A fracture bed pan is used. Instruct patient to flex the un-operated hip and
knee & pull up on the trapeze to lift buttocks onto pan. Instruct patient not
to bear down on operated hip in flexion when getting off the pan.
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2. Deterring complications
 Provide aggressive care and continuous assessment.
 Prevent thromboembolism by continuous use of elastic hose and SCD
while patient is in bed. Discontinue SCD when patient is ambulatory.
3. Promoting early ambulation
i. Within 1 day after surgery, short period of standing may be ordered.
 Monitor orthostatic hypotension.
 Weight bearing may be limited with ingrowth prosthesis to prevent
disruption of bone growth.
ii. Transfer to the chair or ambulation with aids, such as walkers, are
encouraged as tolerated and based on patient’s condition and type of
surgery.
Health Education
1. Encourage patient to continue to wear elastic stockings after
discharge until full activities are resumed.
2. Ensure that patient avoid excessive hip adduction, flexion and
rotation for 6 weeks after hip arthroplasty.
 Avoid sitting low chair or toilet seat to avoid flexing hip > 90º.
 Keep knees apart :- do not cross leg.
 Limit sitting to 30 minutes at a time – to minimize hip flexion
and the risk of prosthetic dislocation and to prevent hip
stiffness & flexion contractures.
 Avoid internal rotation of the hip.
 Follow weight-bearing restrictions from surgeon.
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3. Encourage quadriceps setting and range of motion exercise
as directed.
 Have a daily program of stretching, exercise and rest
throughout life time.
 Do not participate in any activity placing undue or sudden
stress on joint.(jogging, jumping, lifting, excessive bending)
 Use a cane when taking fairly long steps.
4. Suggest self-help and energy-saving devices.
5. Advise patient to sleep with 2 pillows between the legs to
prevent turning over in sleep.
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6. Tell patient to lie prone when able twice daily for 30 minutes
to promote full extension of hip.
7. Monitor for late complications:- deep infection, increased pain
or decreased function, implant wear, dislocation, Avascular
necrosis.
8. Teach patient use of supportive equipment (crutches, canes)
as prescribed.
9. Avoid MRI studies because of implanted metal components.
10. Advice patient that metal components in hip may set off
metal detectors (airports, some buildings). They should carry
a medical identification card.
Exercise guide for hip replacement
 Regular exercises to restore your normal hip motion and strength
and a gradual return to everyday activities are important for your
full recovery.
 Orthopaedic surgeon and physical therapist may recommend an
exercise for 20 to 30 minutes, 2 or 3 times a day during your early
recovery.
 They may suggest some of the following exercises:-
1. Ankle Pumps
 Slowly push your foot up and down.
 Do this exercise several times as often as
every 5 or 10 minutes.
 This exercise can begin immediately after
surgery and continue until you are fully recovered.
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2. Ankle rotation
 Move your ankle inward toward your other foot
and then outward away from your other foot.
 Repeat 5 times in each direction, 3 or 4 times
a day.
3. Bed-Supported Knee Bends
 Slide your heel toward your buttocks, bending your knee and keeping your
heel on the bed. Do not let your knee roll inward.
 Repeat 10 times, 3 or 4 times a day
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4. Buttock Contractions
 Tighten buttock muscles and hold to a count of 5.
 Repeat 10 times 3 or 4 times a day
5. Abduction Exercise
 Slide your leg out to the side as far as you
can and then back.
 Repeat 10 times 3 or 4 times a day
6. Quadriceps Set
 Tighten your thigh muscle. Try to straighten
your knee. Hold for 5 to 10 seconds.
 Repeat this exercise 10 times during a 10-minute period.
 Continue until your thigh feels fatigued.
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7. Straight Leg Raises
 Tighten your thigh muscle with your knee fully straightened on the bed.
 As your thigh muscle tightens, lift your leg
several inches off the bed.
 Hold for 5 to 10 seconds. Slowly lower.
 Repeat until your thigh feels fatigued
8. Standing Knee Raises
 Lift your operated leg toward your chest.
 Do not lift your knee higher than your waist.
 Hold for 2 or 3 counts and put your leg down.
 Repeat 10 times 3 or 4 times a day
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9. Standing Hip Abduction
 Be sure your hip, knee and foot are pointing straight forward.
 Keep your body straight. With your knee straight,
lift your leg out to the side.
 Slowly lower your leg so your foot is back on the floor.
 Repeat 10 times 3 or 4 times a day
10. Standing Hip Extensions
 Lift your operated leg backward slowly.
 Try to keep your back straight. Hold for 2 or 3
counts. Return your foot to the floor.
 Repeat 10 times 3 or 4 times a day
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11. Walking and Early Activity.
12. Walking with Walker, Full Weight-bearing.
13. Walking with Cane or Crutch.
14. Stair Climbing and Descending.
Complications
 Vein thrombosis
 Pulmonary embolism
 Dislocation
 Osteolytis
 Metal sensitivity
 Metal toxicity
 Nerve palsy
 Chronic pain
 Leg length inequality
 Death
Alternative management
1. Conservative management
 The first line approach as an alternative to hip replacement is conservative
management which involves a multimodal approach of medication, activity
modification and physical therapy.
 Conservative management can prevent or delay the need for hip
replacement.
2. Hemiarthroplasty
 Hemiarthroplasty is a surgical procedure which replaces one half of the
joint with an artificial surface and leaves the other part in its natural (pre-
operative) state.
 This class of procedure is most commonly performed on the hip after a
subcapital (just below the head) fracture of the neck of the femur (a hip
fracture).
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 The procedure is performed by removing the head of the femur and
replacing it with a metal or composite prosthesis.
3. Hip resurfacing
 Hip resurfacing is an alternative to hip replacement surgery. It has been
used in Europe for over 17 years and become a common procedure.
 The minimally invasive hip resurfacing procedure is a further refinement to
hip resurfacing.
4. Viscosupplementation
 Current alternatives also include viscosupplementation, or the injection of
artificial lubricants into the joint.[29] Use of these medications in the hip is
off label.
Prognosis
 Hip replacement surgery results are often excellent. Most or
all of your pain and stiffness should go away.
 Some people may have problems with infection, loosening, or
even dislocation of the new hip joint.
 Over time the artificial hip joint will loosen. This can happen
after as long as 15 - 20 years. You may need a second
replacement.
 Younger, more active people may wear out parts of their new
hip. It may need to be replaced before the artificial hip
loosens.
References
1. Louis Solomon, David Warwick, Selvadural Nayagam,
“Apley’s system of orthopaedics and fractures”, 9th edition, pg
no:- 534-43.
2. Wiesel Dilahay Connel, “Essentials of orthopaedic surgery”,1st
edition, pg no:-237-50.
3. Samuel L Turek, “Orthopaedic – principles & their
applications”, 4th edition, volume-2, pg no:- 1198-1204.
4. William and Wilkins, “Lippincott Manual of nursing practices”,
9th edition, pg no:-1116-1119.
5. Brunner & Suddarth’s, “Textbook of Medical-Surgical
Nursing”, 12th edition, volume-2, pg no :-2036-2044.
Thank You

PREPARED BY:- Sunita –Rai, Bsc. Nursing 2nd year