by Jim Driggers
Movement and good health are intertwined — when one of that pair declines, the other soon follows. When arthritis pain in one or both hips prevents even basic activities such as walking, many people decide that it is time for hip replacement surgery. According to a statistic cited by the American Academy of Orthopaedic Surgeons, every year more than 285,000 total hip replacements are performed in the United States. And a study published in The Journal of Bone and Joint Surgery in 2007 estimated that the number will grow to 572,000 by 2030. Replacing a damaged hip with an artificial implant can relieve pain and increase mobility when medicine, physical therapy, and other strategies no longer do so. By some estimates, 87% of hip replacement patients are satisfied with their new hip.
Although total hip replacement is common, it is major surgery and not something to be taken lightly. To access the joint, a surgeon must make an incision near your hip that goes through several tissue layers. He or she takes out the bone and cartilage that are damaged, replaces the socket in your pelvis with a prosthetic one, and inserts an artificial ball and stem into your femur, or thighbone. (See Replacing the Hip Joint.) This process involves the cutting and manipulation not only of bone but also of soft tissues such as muscles, tendons, nerves, and the capsule that encloses the joint. Such an invasive procedure is tough on the body, and recovering from it takes time. A successful recovery depends not only on your following the rehabilitation program that your surgeon and physical or occupational therapist lay out for you but also on the preparations you make before surgery. This article will help you learn what to expect so that you can increase your chances of recovering well and being part of the majority of satisfied hip replacement recipients.
The path to a successful hip replacement and recovery begins with choosing a surgeon who has a lot of experience, whose former patients are happy with his or her work, and who takes the time to answer your questions. There are several different approaches to total hip replacement surgery, and your surgeon will decide which is best based on the condition of your hip, your medical history, the surgeon’s experience, and other considerations. Here is an overview of some of the more common approaches to total hip replacement and what they may mean for your recovery.
Posterior approach. The posterior approach is the conventional and most commonly used method of getting to the hip joint. The patient lies on his or her good side, and the surgeon makes a 6- to 12-inch cut near the buttocks. The surgeon separates the buttocks muscles and cuts several muscles that hold the femoral ball in the socket to expose the hip joint. The joint is replaced, the muscles are reattached, and the skin edges are sewn. Because the muscles holding the new hip were cut, this approach typically requires a longer recovery time and several movement restrictions to prevent dislocation of the new joint while the muscles heal. Most people who undergo posterior-approach hip replacement need a walker or crutches for the first 4–6 weeks after surgery and a cane for another 4–6 weeks after that. Typically, it takes about 10 weeks to be able to walk without assistance.
Minimally invasive approach. There are several different approaches to total hip replacement that are “minimally invasive,” but generally speaking, the term means that the surgeon makes one or two smaller-than-normal incisions to gain access to the hip joint. (If one incision is used, it is typically 3–6 inches long; if two are used, the first, near the groin, is 2–3 inches long and the second, near the buttock, is 1–2 inches long.) Since most of the postoperative pain and recovery challenges following hip replacement surgery are due to soft tissues being cut, smaller incisions and less cutting typically mean faster recovery times. Minimally invasive surgery is more complex than conventional surgery, however, and the odds of a misplaced or misaligned prosthesis increase. Even with smaller incisions, minimally invasive surgery is still major surgery, so all the usual precautions and risks of major surgery apply.
One minimally invasive approach that has been gaining popularity in the United States is the anterior approach. The patient lies on his or her back, and the surgeon makes an incision at the front of the hip and moves muscles aside rather than cutting through them. With the muscles pulled out of the way, the damaged joint is cut out and replaced with the new joint.
The biggest advantages of this surgery are that because the thigh muscles are not cut, the risk of dislocation after surgery is lower, the postsurgical movement restrictions common with the posterior approach may not be necessary, and recovery times are faster. Most people who have anterior-approach hip replacement need a walker or crutches for the first two to three weeks after surgery and a cane for another two or three weeks, and they may be able to walk without assistance soon after that.
The anterior approach has some disadvantages. It is not considered the “gold standard” approach to hip replacement and requires additional specialized training and skill from surgeons; consequently, surgeons in a local area may not be experienced with this technique. In addition, there is a chance of numbness occurring in the thigh because of injury to a nerve in the front of the thigh. The numbness usually goes away in a year or two as the nerve heals.
Cemented versus cementless implants. During recovery, how much weight your new joint is allowed to bear and when will depend on whether the surgeon attaches the replacement joint to bone with cement or uses a cementless implant, which has a porous surface into which bone grows. If you have a cemented implant, you will probably be able to put some weight on your leg right away, and you will use a walker or cane for four to six weeks after surgery. If your prosthesis is attached without cement, your surgeon will give you specifics about when you can lean on your leg and use a walker or crutches. It could be eight weeks until you can put weight on your leg with just slight support. This allows time for your bones to grow into the prosthesis.
Whatever you and the surgeon decide about the surgery itself, you want to be sure you are ready for the challenges that you will face during the recovery period. This includes preparing yourself physically and mentally, as well as making necessary changes to the place where you will be recuperating after surgery.
Physical preparations. As a result of surgery, your hip muscles may lose a great deal of their strength. Doing exercises to strengthen your muscles before surgery can help you get back up to normal strength and function more quickly afterward. Talk to your surgeon or a physical therapist about exercises that will help you. He or she may recommend moves such as ankle pumps and circles, heel and leg slides, knee straightening while seated, bed and chair push-ups, and leg lifts. If you find land-based exercise too painful, water exercises done in a warm pool can be a great alternative. Isometric exercises, which work muscles without requiring movement of the joints, can also help to strengthen muscles with minimal pain.
Mental preparations. While factors such as general health, smoking, body weight, pain tolerance, and level of physical fitness can all affect the speed and ease of recovery, one of the most important factors is your attitude. If you expect the recovery to be easy and pain-free, the reality of it may throw you into a tailspin and make regaining hip function more difficult. Prepare yourself to be an active participant in your recovery and deal with its challenges. It’s important to form realistic expectations about how long it may take you to recover, and to set aside enough time to focus on recovery rather than work or other distractions. It typically takes three to six months to fully recover from hip replacement, but different people recover at different rates, and complications such as infections or falls may prolong the process. Talk with your surgeon and make sure you know what to expect.
Preparing your recovery environment. This includes not only the place where you will recover but also the people who will care for you. You may underestimate how incapacitated you will be for the first week or two after surgery. Someone will need to be available to help you around the clock during this time.
If there are no serious complications, you will probably leave the hospital three to five days after surgery. Hospital staff will ensure you are able to get in and out of bed and walk with crutches, a walker, or a cane before you are discharged. It may be several weeks, however, before you are able to do many daily tasks on your own or drive a vehicle. According to Brian Hill, PT, of Pleasant Hill, California, if you do not have family or friends who are willing and able to help you after surgery or if you have special needs, you may want to recover at a skilled nursing facility until you are able to take care of yourself.
If you will be recovering at home and family members or friends will be taking care of you, ask them to read this article. You are all about to begin a journey that requires a lot of hard work and patience. Preparing meals and helping you with ice packs, exercises, and dressing and undressing may overwhelm those not used to caregiving. You want to make sure that your caregivers know what to expect so they can give you the help you need.
To avoid dislocating your new hip, you are likely to have restrictions on the types of movements you can make during your recovery period. For example, you may be instructed not to cross your legs, bend your hips past 90 degrees, or turn your feet too far inward or outward. Your surgeon or a physical therapist will go over these restrictions with you after surgery, but you may find it helpful to talk about them ahead of time so you can prepare your recovery space accordingly. Talk with a physical or occupational therapist about equipment such as a grabbing tool, a long-handled shoehorn, and elastic shoelaces to help with dressing and undressing. In the bathroom, a raised toilet seat, toilet tissue tongs, and grab bars may be helpful. You can purchase these items at a medical supply store, and your insurance plan may cover some or all of the cost.
Create a recovery center at home, where a telephone, TV remotes, music, books, a water pitcher and a cup, a blanket, a pad of paper and a pencil, and your medicines are within easy reach. Be sure your bed and chair are firm and high enough that you can get in and out of them without making restricted movements. To avoid potential tripping hazards throughout your house, put away loose rugs, remove any clutter from well-trafficked areas, and tape electrical cords to the floor.
Finally, preparing frozen meals like casseroles and soups, stocking the pantry with food staples, paying bills, and cleaning the house before you have surgery can all make recovery easier by letting you focus on resting and rehabilitation, not chores and shopping.
After surgery, three factors will play major roles in your recovery: pain management, physical and occupational therapy, and your mental state.
Pain management. Of course, the long-term benefit of hip replacement is to reduce arthritis pain. But in the short term after your hip replacement, you will feel pain as a result of the surgery itself. Your doctor will prescribe a powerful painkiller called an opioid to help you handle this pain. Opioids include hydrocodone and codeine, and they are often combined with other pain relievers such as acetaminophen or ibuprofen in the same pill. (For example, the brand-name drug Vicoprofen combines hydrocodone and ibuprofen, and Tylenol With Codeine No. 4 combines codeine and acetaminophen.) Aaron K. Salyapongse, MD, of Pleasanton, California, points out that if you took opioids or pain relievers such as ibuprofen to handle arthritis pain before surgery, you may have built up a tolerance to those drugs. Be sure to tell your doctor the type and amount of each medicine you were taking before surgery so he or she can factor that into your prescription.
Be sure to take your pain medicine as your doctor prescribes it. If that doesn’t sufficiently control your pain, tell your doctor, who may adjust the dosing. Living with pain is counterproductive to your recovery — you need rest and exercise to recover from surgery, and pain can interfere with both. Some people avoid painkillers for fear of addiction. But according to the National Institutes of Health, studies illustrate that so long as people take painkillers in accordance with their doctor’s orders to reduce physical pain, the risk for addiction is low.
Physical and occupational therapy. Getting your joint moving again is key to a successful recovery. On the same day of or a day after surgery, when enough of the anesthetic has worn off and a physical therapist is ready to assist you, you will probably be encouraged to stand and walk a few steps with a walker or crutches. One of the important benefits of movement after surgery is to increase blood flow, which reduces the risk of blood clots. Physical activity also increases balance, stretches tendons and muscles, and strengthens muscles. As your recovery progresses, you will be given more exercises to improve your hip strength and mobility. A physical or occupational therapist will recommend a program of exercises and show you how to move properly to stay within any movement restrictions you have.
Mr. Hill tells his clients that when they start their rehabilitation program, they should begin with several short sessions of 5–15 minutes throughout the day. As their bodies become conditioned to the exercises, they should gradually increase the length of their exercise sessions. Starting conservatively and ramping up can prevent you from overdoing it in one session and missing the next one or more sessions because you feel too sore.
Mental state. Depending on your mental outlook and how you handle challenges, total hip replacement surgery can range from being a very grueling experience to a series of mostly pleasant surprises. Realize that in the early part of even a normal recovery, you will have severely reduced personal independence.
Physically, you may sport a large bruise surrounding the wound that should disappear on its own in a week or two. Your hip and leg will be quite swollen as well. Some swelling is to be expected for three to six months after the surgery, but applying ice packs and elevating your leg can help to relieve most of the swelling within four to six weeks. And you will be tired at first, but day by day your energy will return.
As your recovery progresses, you will need to push yourself hard enough in your rehabilitation exercises to rebuild physical strength, balance, and endurance, but not so hard that you exhaust your body. If you are too aggressive in exercising, your body will let you know. Be patient. Even as you rest, your body is working hard to heal from the surgery. Take time to recover. With patience and a positive mental attitude, you will recuperate and begin to enjoy a relatively pain-free life.
Everyone who gets a hip replacement has the same question: How long will my new joint last? Dr. Salyapongse says, “Look, what you have in your body now is like a nice sports car. Drive it well and it will last for a very long time. Keep it on smooth, level highways at safe speeds, and it will provide you a lifetime of reduced pain, increased mobility, and almost normal function. Take it off road, drive it over potholes, or crash it into walls and it’s going to wear out fast.” Hip replacement recipients are typically advised to stick to low-impact physical activities such as walking, swimming, and biking. High-impact activities such as running, downhill skiing, and contact sports may increase the likelihood of dislocation or wear of your replacement joint. Get specific recommendations from your surgeon and physical therapist, and remember — how you recover and how long your new joint lasts are largely up to you.
Last Reviewed October 10, 2012
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