Must Know Knowledge: Total Hip Replacement (Arthroplasty) Surgery

If you follow along in this blog, you’ll already know that we used to work alongside surgeons.

If not, check out our blog!.

One of these surgeons completed A LOT of joint replacement surgeries – almost entirely on the knee and hip.

Therefore, we’ve treated our fair share of post-operative clients – especially post-hip replacement!

As an FYI, a total hip arthroplasty (THA) is science speak for a total hip replacement (THR), so they are used interchangeably!

The purpose of this blog post is to try and clarify the ins and outs of having a hip replacement surgery.

Knowledge is power!

Be prepared, and things will go smoothly!

Aside: We will use the same headings in this post as we did in the other ‘Must Know Knowledge’ posts.

We’ll try to stick with the same format so that it’s easier to navigate. Some things might look similar, as some advice is “surgery” related, and less specific to the type of surgery.

How do I know if I even need a total hip arthroplasty (replacement)? Typically, to qualify for a hip replacement, many, or all, of the following statements are true:

  • You have significant hip pain that is greatly limiting your ability to complete your activities of daily living (i.e. walk, sleep, work), including pain at rest – you may even walk with a limp because of your hip pain
  • You have imaging results (i.e. an x-ray or MRI) that show significant arthritic changes or hip joint/cartilage damage
  • You have a significant decrease in the range of motion of your hip (enough to prevent you from living your life – i.e. you can’t lift your leg high enough to put your pants on!)
  • You have long standing hip swelling/inflammation that doesn’t improve with rest or conservative treatment
  • You have tried to reduce your pain and improve your function through virtually every other conservative option, including a significant bout of physical therapy
    • ​​​Conservative options include, but are not limited to: physiotherapy, massage therapy, chiropractic care, acupuncture, over the counter medications, and injections (injections can include: cortisone, or viscosupplementation)

Do I have to do pre-operative physiotherapy? In short, yes, you should. It helps in the following ways:

  • Helps you understand what to expect with surgery and postoperatively (just like this blog post should!)
  • Helps strengthen muscles to their maximum potential (not just hip muscles, but also lower extremity, back, and core muscles)
  • May help to improve your range of motion (in your hip, and other joints). This can help limit stiffness in all associated joints
  • Can help you gather baseline measurements to track your progress post-op. It can also help determine your overall prognosis for ongoing pain, or function.
    • For example, in knee replacements, the following can lead to ongoing pain post-operatively:
      • Catastrophizing, poor mental health, high levels of preoperative knee pain, and pain at other sites are the strongest independent predictors of persistent pain after a knee replacement.
        • Source: Lewis, G. N., Rice, D. A., McNair, P. J., & Kluger, M. (2015). Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. British journal of anesthesia, 114(4), 551-561.
    • With respect to this study on knee replacements, and knowing that pain is biopsychosocial/multifactorial in nature, it is likely that those predictors are much the same with hip replacement surgery
  • In some cases, it can prolong the need for surgery (and to be honest, in Ontario, the waitlists for hip replacement surgery are pretty long!)

What else should I do before I get a total hip arthroplasty (replacement)?

  • Understand what you’re getting yourself into. Seriously. This is a big one, so please read on. A total hip replacement is a BIG surgery, with a long rehabilitation period.
  • Eat well and take steps to improve your overall health (i.e. quit smoking)
  • Get any equipment that will help you get around (including equipment your surgeon recommends)
    • Examples include: a walker, cane, or crutches, a raised toilet seat or commode, grab bars for the shower, a shower seat, dressing aids, etc.
  • Organize assistance from other people for after surgery (often, you’re not allowed to drive, heavy chores (grass cutting, snow shoveling) still need to be completed, etc.)
  • Learn the post-operative hip restrictions (READ ON!!!)

How is a total hip arthroplasty (replacement) performed? Every surgeon has their individual preferences, and this section could get extremely lengthy if I’m not careful.

That being said, I will provide a general surgical outline, and then describe briefly the most common methods of hip replacement surgery.

This is what your day will look like:

  • You will be in a surgical room, with many nurses, a surgeon, an anesthesiologist, and often a few other people (i.e. students, joint implant representatives, etc.)
  • The anesthesiologist will either partially or completely sedate you (put you to sleep a little or a lot), or perform an epidural (numb you from the waist down) (this is often a patient/surgeon preference/decision) – but sometimes, depending on the method, you’ll be able to hear everything going on!
  • The surgeon will perform an incision in one of a few different places (this is where the surgeon preference plays a huge role. I’ll explain further in the “methods” below)
  • Once access to your hip is granted, the surgeon will dislocated your hip from it’s socket, shave down the hip socket (called your acetabulum) bone, and cut off the head of your femur (thigh bone), so that all arthritis/joint damage is completely removed (every case/surgeon/joint prosthesis leads to variations in how much bone is removed)
  • Then, they will screw, or cement new, smooth, replacement parts onto the cleaned up acetabulum (hip socket), and they will hammer in a new femoral head
  • Once all the parts are replaced and all the joint damage is removed, they will ‘re-locate’ your hip back into its socket, your incision will be closed, and you’ll be taken away for recovery.

This animation on YouTube is an average example of what generally happens, but don’t watch it if you’re super squeamish.

It’s an animation, but the drawings would be considered graphic to some people:

Note: not every surgeon uses the posterior approach seen in this video.

More on the methods used: Posterior approach:

  • Access the hip joint from the back. The piriformis muscle and the short external rotators are taken off the femur.
  • Great access to acetabulum and preserves the gluteus medius and minimus muscles (responsible for hip abduction)
  • This one is currently the most common method!

Lateral approach:

  • Hip abductors (gluteus medius and gluteus minimus) are elevated – not cut – to provide access to the joint.
  • The hip joint is then dislocated and the acetabular socket and femur are exposed for preparation and insertion of the prosthesis components.
  • The greater trochanter at the upper end of the femur may also be cut in this approach (also referred to as an osteotomy), which greatly increases the exposure of the hip joint.

Anterior approach (or Direct Anterior Approach)

  • From the front. The posterior capsule and muscles are not cut, surgeon works between front muscles without removing them from femur. Keeping these muscles intact helps prevent post-surgical dislocations.
  • The surgeon uses a special surgical table specifically designed to position the patient so that the hip joint may be easily accessed from the front as opposed to the side or back.
  • This method seems to be gaining momentum, and it will be interesting to see if this slowly becomes the most common.

* There are a few more, but these are the most common

Does method matter?

  • Each has their individual advantages and disadvantages, and this is something you should discuss with your surgeon. That being said, to my knowledge, strong, convincing, high-quality studies comparing the different approaches is lacking. Therefore, we aren’t quite sure if there’s a “best method” yet!

Disclaimer: Before we get into the next part of this blog post, it is important to note that everything in this blog post is for information purposes only.

This blog post is not intended to be strict medical advice.

As previously mentioned, everyone is an individual, and therefore, individual variances do occur.

It is important to consult your physiotherapist, surgeon, or doctor for the most applicable advice for you.

Hip Precautions – The post-operative RULES Each surgeon will have a preference on these precautions, and for how long you should follow them (also, the method at which your surgeon uses may alter the need for these precautions!).

That being said, following these precautions is EXTREMELY COMMON, and they usually apply for THREE MONTHS post-operatively. After surgery, you should:

  1. AVOID bending your hip past 90 degrees This includes bending down to tie your shoes, sitting in a chair that is too low, sitting in a chair and bending forwards, raising your hip upwards in standing, or laying down.
  2. AVOID twisting your leg in or out This includes when your foot is flat on the ground and turning your body, or twisting your leg while laying down
  3. AVOID crossing your legs or ankle This includes when sitting, standing, or laying down

There are some great tips on how these precautions apply to dressing, sitting, bathing, etc., on the U.S. National Library of Medicine website here.

What does the typical rehabilitation process look like? First, it’s important to reiterate that everyone is an individual, with individual circumstances, and therefore, the rehab process will be very individualized.

That being said, in almost every case, it is safe to walk on your leg immediately after surgery, and you will typically spend 1-2 days in hospital post-operatively.

In the hospital, you will learn how to walk with a walker, climb stairs safely, and be monitored for any post-surgical complications.

Once at home, you will often be allotted home physiotherapy appointments with a physiotherapist (for free), through the Community Care Access Centre (CCAC).

That being said, the amount of appointments provided by the CCAC has been significantly reduced in the past couple years (down to 1-4 total appointments), which is not enough.

Due to the limitation in the number of CCAC-funded appointments, you will continue with further physiotherapy via one of two options: publicly-funded (OHIP) physiotherapy, or privately funded (out of pocket/private benefits) physiotherapy.

OHIP physiotherapy often has a limit to it as well, and many people require more than the “program of care” allows for.

Therefore, it is important to consider the potential financial costs of ongoing physiotherapy when undergoing a total hip arthroplasty.

This next sentence is important:

Complete rehabilitation after a total hip replacement will usually take 6-12 months.

It’s likely that someone will tell you 3 months. 3 months of rehabilitation can get you back to work (depending on your job), or allow everyday life tasks to be more easily and comfortably completed.

To get back to 100%, it will probably take longer. You may not be required to frequently attend physiotherapy appointments, but you should expect to be working on exercises, and self-management, for up to 1 year postoperatively.

Overall, post-operative care looks something like this:

  • You’ll be allowed to walk right away – you will learn using a walker, then slowly progress to a cane, then to no gait aid (providing that’s your goal!) (Aside: there is absolutely NO SHAME in using a walker or cane. Using a gait aid in the early stages will actually help you recover FASTER than trying to tough it out and not use one at all!)
    • The surgeon I used to work with wanted everyone to use a walker for FOUR full weeks after a hip replacement before progressing to a cane/no gait aid
  • Physiotherapy will start within 1 day of surgery (in the hospital), and within a few weeks (via an OHIP or privately funded clinic)
    • Note on OHIP-funded clinics: they’re VERY busy, so it’s often a good idea to call weeks before your surgery to set up your physiotherapy assessment for a couple weeks after your surgery (in fact, this is just good practice, even at a privately funded clinic)
  • You will likely have restrictions, called hip precautions, we went over those above. Here they are again (and they apply for 3 months):
    • No flexing you hip past 90 degrees
    • No twisting your new hip
    • No crossing your legs or ankles
  • Your physiotherapist will formulate an individualized program designed to:
    • Decrease your pain
    • Improve your range of motion
    • Improve your balance
    • Improve your strength
    • Get you back to the things you want/need to do!
  • Everyone is progressed on an individualized timeline!

How long does it take to heal after a total hip arthroplasty (replacement)? In uncomplicated cases,

  • Surgical healing of your hip can take up to 3 months after surgery (and swelling might stick around to some degree for 6-9 months).
  • Surgical healing does not always mean full function. It means the surgical sites and joint surfaces are likely physiologically healed.
  • Full function is very individualized in the case of a total hip arthroplasty and usually takes:
    • 3-6 months to feel comfortable/confident with your activities of daily living and for return to work (longer for excessively physical jobs) (and to have the pain under control)
    • Up to 6-12 months for a complete recovery (good range of motion, full strength, full return to work and life activities)
  • Progressive, safe, and necessary functional strength training exercises will take months to appropriately complete.
  • Additional note: in many cases, rehabilitation post-operatively is not just helping you heal from your surgery. You’ll also be rehabilitating the months-to-years of poor function you had before surgery!

As with any surgery, here are some additional things to consider:

  • You may be off work a long time, depending on your job (for example: if you are on your feet constantly doing a lot of squatting and stair climbing, you will be off work much longer than someone with a desk job)
  • Physiotherapy appointments will be necessary for at least 3 months (often longer). Yes, the frequency of appointments will decrease over time, but it will be important to stick with your physiotherapy appointments.
    • You can receive some physiotherapy through OHIP-funded clinics, but it’s often not enough
    • If you have private insurance coverage, that’s great! But keep in mind, depending on how much you have, it is not uncommon to use all of it, and then some.
    • If you don’t have private insurance coverage, rehabilitation costs will be expensive.
    • Couple this with being off work and finances can be a significant added stress that many people do not consider!
    • Be aware of the financial considerations associated with surgery.

What exercises are safe to do right away after a total hip arthroplasty (replacement)? In the hospital, or from the surgeon, you will likely be provided with a list of exercises to get started on. These usually include light range of motion, and muscle activation exercises. These are a great place to start. Remember that these will have to respect the RULES outlined above (the hip precautions) Overall, you will progress in this order with rehab (roughly):

  1. Range of motion exercises (respecting the rules)/Pain management
  2. Strength building exercises
  3. Motor control exercises

In many cases, this order is blended, and you’ll be working on multiple types of exercises at once to ensure a slow, progressive, increase in load.

Your physiotherapist will help you learn an exercise program that accomplishes your goals in the least amount of time, all while trying to limit any negative feelings or complications.

Lastly, it’s highly likely that you and your physiotherapist will work on other areas of your body (such as the back and knee/ankle) together.

This should help to reduce any postoperative complications in your other joints, all while decreasing your pain, and improving your overall function!

How much function and how little pain can I expect at the end of my rehabilitation? Alas, the loaded question. (We know we’ve started this section with that same sentence for each of the ‘Must Know Knowledge’ surgical blog posts… Sorry, but it’s always a loaded question).

Again, everyone is an individual, everyone heals differently, and therefore final pain and function are highly individualized.

Further, if there are complications with surgery, it may alter the progress/end result of your recovery.

Here are some things we consider:

  • How much pain did you have before surgery? Was the pain just in your hip (or also in other parts of your body?), and how long did you have that pain?
    • Again, these can be related. If you were in absolute agony for 3 years before surgery, there will be a lot of additional things to consider when trying to reduce pain post-operatively. Pain has biopsychosocial components. See this awesome blog post on pain for more information here.
  • How is your mental health? Do you tend to catastrophize pain/injuries?
    • As mentioned, higher levels of catastrophization and poor mental health have been linked to ongoing pain after a replacement surgery. That being said, your physiotherapist can help you understand pain, and what referrals can be made to enhance your overall wellbeing/recovery. (Go read that blog post about pain!)
  • What are your goals?
    • If your goal is to be very active, your rehab will probably take longer than if your goal is to walk around your house and sit at your desk at work. Therefore, depending on your goals, your perception of your overall function will also change.
    • That being said, set appropriate, attainable goals with your physiotherapist and work towards these goals!

All that being said, the vast majority of individuals that we’ve treated post-total hip arthroplasty did very well overall, and outcomes are typically very favorable.

Many have no pain at all, and they return to an active lifestyle. The caveat to this is that our experience is based on people who actively attended rehab! (We are physiotherapists after all!)

Remember, the rehabilitation stage after surgery is VERY important to reach a full recovery!

What are the potential complications associated with a total hip arthroplasty (surgery)? All steps will be taken to limit complications postoperatively, however, it’s important to understand the possibilities.

Complications include:

  • Infection. It’s important to follow the hospital’s instructions on keeping your incisions clean, and free of debris. Change your bandages as instructed, and take good care of your wounds.
    • Keep an eye out for:
      • Ill-smelling, discolored discharge coming from your wounds.
      • If you’re running a fever, have a significant increase in pain, swelling, or redness around the hip.
  • Deep vein thrombosis (DVT). This is a blood clot that can form in the blood vessels of your leg. Most commonly, in the calf muscle area (but can also form in the thigh muscle area). Here’s what to look out for:
    • If your calf or thigh is:
      • Red, hot, and swollen
      • Painful to touch, and painful with bending your ankle upwards
      • Throbbing or cramping
    • These are the most common signs of a DVT. If you think you may have a DVT, go directly to the hospital. This is an emergency.
  • Hip joint dislocation
    • In some cases (usually when the hip precautions are not being adequately followed in the early post-operative stages), the hip joint can be dislocated
    • This is extremely painful, and you will have to return to the hospital for medical management/relocation of your hip prosthesis
    • This can usually be very well controlled by following the hip precautions and listening to the advice of your surgeon and physiotherapist!

Final words There’s a lot of information in this blog post. But there’s also a lot to know. Be informed, ask questions (even the hard ones), and look out for yourself.

Let us know if you thought this blog post was helpful, and we will try to post new ones outlining the helpful points for other types of surgeries!  

Are you planning to undergo (or have already undergone) a total hip replacement?

At Strive Physiotherapy and Performance, we are committed to providing an in-depth assessment to ensure we can work together to find the best plan of action for each individual client.

Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists, and they will be sure to help you understand your injury.

Take care, Tyler Allen Physiotherapist at Strive Physiotherapy & Performance

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MIKE MAJOR, PT

BSc Kinesiology, University of Waterloo MSc PT, McMaster University

Physiotherapist

Born in Lahr, Germany

Mike treats people of all activity levels and ages from weekend warriors to elite athletes. He has mentored physiotherapists across Ontario as well as worked on the Board of Directors of the Ontario Physiotherapy Association. Recently, Mike represented physiotherapists within the Pan Am/Para Pan Am Games Medical Services Expert Provider Group. Mike has also had the opportunity to work side by side with orthopaedic surgeons, allowing him to work with many people following complex and traumatic injuries. Mike also consults over 1,000 physiotherapy cases nationally. This has given him a lot of insight into what Physiotherapy looks like across Canada.    

Prior to becoming a physiotherapist, Mike served in the reserves for 9 years as a member of the Artillery in the Canadian Armed Forces. He also enjoys coaching local athletes to help improve their performance through MeFit, a local not-for-profit organization.

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Cats or dogs?

Dogs.

Worst idea you've ever had?

Skiing behind a car.

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Rat Tail

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A baby named Maverick.

Last book you read?

Together is Better: A little Book of Inspiration

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Sewing

 

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A multitool, My Wife, and our baby

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A multitool, My Wife, and our baby

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Most likely to get stuff done

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Eye of the Tiger – Survivor

 

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