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What Is Hip Arthroplasty?
It is one of the most successful orthopaedic operations performed today.
With total hip arthroplasty
- Reduction of pain
- Restoration of function
- Improving the quality of life can be achieved.
It is performed more than 1 million times a year in the world.
Why Is Total Hip Arthroplasty Necessary?
- Osteoarthritis: most often
- Rheumatoid arthritis, psoriatic arthritis, spondyloarthritis
- Developmental dysplasias
- Childhood hip diseases: perthes, epiphyseal slippage etc.
- Trauma, femoral neck and acetabulum fracture, neoplasm, osteonecrosis
What Is Done In Total Hip Arthroplasty?
The affected joint surfaces are replaced with synthetic material. It is an elective procedure. The success rate of operations is more than 90%. Revision rate is 1% per year. Patient satisfaction is quite high.
After the operation, 3-6 months are required for complete recovery. The 30-day mortality rate is 0.7%. Mortality rate increases with elderly patients and comorbidity. Mortality risk is higher in total hip arthroplasty for hip fracture treatment.
Who Should Undergo Total Hip Arthroplasty?
- Persistent, persistent pain and extreme difficulty in performing daily activities without response to appropriate conservative treatment or previous surgical treatment options
- Total hip arthroplasty is recommended if the disability caused by marked deformity and limitation of movement is advanced in patients without pain.
It can be performed in all age groups except for the period when the skeleton is immature. The longer the surgery is delayed, the lower the revision rate. Surgical results are better in patients who are operated on at a better functional level. The balance of benefit and harm should be well evaluated.
Who Should Not Undergo Total Hip Arthroplasty?
Absolute Contraindications:
- Active infection: local or systemic
- Concomitant serious medical conditions: Recent MI, unstable angina, heart failure or severe anaemia
- Immature skeleton
- Para/quadriplegia
- Permanent or irreversible loss of muscle strength without pain
Relative Contraindications
- Neuropathic joint
- Inability of the patient to ambulate not related to hip disease alone
- Absence of hip abductor muscle mass
- Progressive neurological loss
- Vascular disorders of the extremities
- Processes that rapidly destruct bone:
- Insufficient bone stock for fixation of components
- Morbid obesity
- Vascular disorders of the extremities
What Is Examined In The Preoperative Evaluation?
The preoperative aim is to make an accurate diagnosis of hip pathology, to identify the appropriate candidate for surgery, to assist in surgical planning and to minimise preoperative and postoperative complications.
Detailed history taking, examination, necessary laboratory investigations and imaging tests, review of treatment alternatives, discussion of hip prosthesis alternatives and selection of prosthesis components should be performed.
Story:
- Pain story
- Comorbid medical diseases
- Medication use
Physical Examination:
- Inspection, palpation, ROM, muscle testing, neurological examination and vascular examination
- Leg length measurement
- Trendelenburg sign
- DBKT
Laboratory Investigations:
- Complete blood count, PT, INR, aPTT, biochemistry
- ECG, TIT and urine culture
- Imaging
- Standing AP and lateral radiographs of the hip and pelvis
Review of Treatment Alternatives:
- Conservative treatments: weight loss, physiotherapy, medical treatment, use of assistive devices
- Demonstration of symptoms due to structural hip damage in patients with inflammatory arthritis
Preoperative Exercises and Training:
- Breathing exercises
- Isometric gluteal and quadriceps exercises
- Ankle exercises
- Precautions for total hip replacement
Selection of Prosthesis Components:
- Femoral component (stem)
- Acetabular component (cup)
- Loading area
- Fixation of the prosthesis:
- Cemented
- Cementless
- Hybrid (cemented femoral, cementless acetabular component)
Cemented Prostheses:
- Bone cement: polymethylmethacrylate
- Filled into the bone in the consistency of dough during the operation
- Then the component is inserted
- 90% of methylmethacrylate polymerises and fixes to bone within 15 min
- Advantage: early stable fixation
- Disadvantage: separation of cement particles and loosening of the prosthesis, abrasion of bone and/or polyethylene
Cementless Prostheses:
- Covered with a porous metal surface
- Pore diameters 150-300 mmicrons
- Growth of living bone tissue and fibrous tissue through the pores
- Stability development takes 6-12 weeks
- Advantage: more bone stock
- Disadvantage: high incidence of postop thigh pain
Acetabular Implant:
- High density polyethylene
- Mostly cementless, porous and modular
Loading Area:
- High density polyethylene
- High cross-linked polyethylene
- ceramic-polyethylene
- ceramic-ceramic
- metal-metal
Femoral Component:
- Replacing the femoral head and neck
- The stem is inserted into the medullary canal
Femoral Implant:
- Cemented
- Elderly patients with poor bone structure (thin cortex and wide canal) and low level of expectation
- Cementless
- Young patient
- Patients with good bone structure: with thick femoral cortex and small diameter femoral canals
Stability.
Porous portion:
- Confined proximal to the femoral implant
- Throughout the entire implant
Femoral Head:
- Should be compatible with the acetabular surface
- Most common Cobalt chrome femoral head
- Different diametres : 22-38 mm
- ROM, stability and wear tendency
- Increasing size: increased ROM and lower risk of dislocation, but increased risk of wear
How Many Types Of Surgical Procedures Are There?
- Posterolateral approach (Kocher-Langenbeck approach)
- Lateral approach (Hardinge/modified Hardinge approach)
- Anterior approach (Smith-Petersen approach)
Lateral Approach (Hardinge/Modified Hardinge Approach)
- The anterior part of the abductors is separating
- Entering through the anterior joint capsule
- Can be performed in lateral, supine or semilateral position
- Higher risk of postop limp and heterotopic ossification
- Movements to be avoided postop: hyperextension, external rotation and adduction
Posterolateral Approach (Kocher-Langenbeck Approach)
- The gluteus maximus muscle is separated and the short external rotators are dissected, the hip abductor muscles are intact
- Lateral position
- Entering through the posterior joint capsule
- Dislocation rate is higher than direct lateral approach
- Movements to be avoided postop: Flexion, adduction and internal rotation more than 70-90 degrees
Anterior Approach (Smith-Petersen Approach):
- Without removing the surrounding muscles, a gap is created between the tensor fascia and the sartorius and the anterior joint capsule is entered
- Supine position and often under fluoroscopic guidance
- Considered to have a lower risk of dislocation
- Complications: intraoperative femur and ankle fractures, lateral femoral cutaneous nerve injury
- Movements to be avoided postop: hyperextension, external rotation and adduction
What Is Done In Postoperative Care And Rehabilitation?
- Monitoring the general condition of the patient
- Antibiotic use for 48 hours after surgery
- Postoperative pain management
- Deep vein thrombosis prophylaxis
What Is Done In Postoperative Care And Rehabilitation?
- Monitoring the general condition of the patient
- Antibiotic use for 48 hours after surgery
- Postoperative pain management
- Deep vein thrombosis prophylaxis
What Are The Postoperative Objectives?
- To prevent dislocation (dislocation) of the implant
- Protecting the patient from the harms of bed rest
- Strengthening the hip and knee muscles
- To teach independent transfer and ambulation with assistive devices
- Providing painless joint movement within safe limits
- The patient’s extremity is kept at 15 degrees of abduction with a triangular pillow between the two legs: Used during sleep and bed rest for 5-6 weeks
- Flexion of the hip more than 90 degrees and adduction and rotation from the neutral position are not permitted
- Pillow should not be placed under the knee while lying down
The Time To Start Exercise Varies According To The Patient's Condition:
- Day 1: A Few Minutes Per Hour While Awake
Deep breathing exercises
Ankle pump
Quadriceps and gluteal isometric exercises
Mobilisation is started with the removal of drains within 24-48 hours - Day 2:
Knee flexion
Assisted sitting on the edge of the bed or in a chair twice a day
Sitting time half an hour - 2-3. Day: Walking: use of a walker
How Much Load Should We Give? What Affects The Amount Of Load?
- Form of fixation of the prosthesis
- Presence of trochanteric osteotomy
- Presence of femoral fracture
- Presence of bone graft
- Strength of periarticular soft tissues
Cemented Arthroplasty (No Osteotomy And Bone Graft)
- Load to be given: the opinion of the orthopaedist is important
- Postop 3rd day: 12 kg load (weight to be given with bathroom scale is taught)
- Ambulation twice a day with the help of a therapist and a walker
- Gradual increase in load to 25 kg
- Postop day 7: climbing up and down stairs
- Post-op day 8: assisted transfer to and from the bathroom and trial of sitting on a raised seat
- Stretching the hip flexors at an early stage
- Similar to the Thomas test, the operated side is kept straight while the contralateral hip is flexed.
- Postop day 5:
- Stretching the hip flexors in prone position, stretching using a walker while standing
- Hip extension exercises in prone position
- The most important exercise for the patient to ambulate without limping: strengthening of the hip abductors
- Starting with isometric hip abduction exercises on day 2-3 and increasing them
- 5-6 weeks: standing abduction exercises
Biological Fixation (Cementless)
- Stabilisation takes 6 weeks
- 6 months required for maximum fixation
- Same rehabilitation programme until postop day 4
- with the day walker, with the foot flat, slightly touching the ground (7.5 kg)
- at the end of the week: increase the walking distance and exclude the cane from long walks
- Cane is used for 4-6 months
- Wheelchair use over long distances
- After 6 months, light sportive activities
- It is necessary to protect the patient from rotational forces for the first 6 weeks or longer
- Straight leg raises are not recommended
- Indication that biological fixation has begun: blurred radiolucent areas on the prosthesis on radiographs
- Giving 15 kg load
- per week 25-30 kg load
- per week 35 kg or half the body weight
- at the end of the week: switching to cane
Cases With Trochanteric Osteotomy
- Straight leg stretching and active abduction exercises are not allowed until the trochanter heals
- biological fixation programme is applied until the week
- week: light load if recovery is insufficient
- Week 8-9: partial load if recovery is satisfactory
- Half of the body weight is reached within 2-3 weeks
- 10-12 weeks: crutch is removed from the operated side
- Switch to a cane after 1-2 weeks
- Abductor muscle strength and recovery of limp required for sporting activities: usually after 1 year
Bone Graft Use
- Bone grafting is used in revision arthroplasty and congenital hip dislocation
- Extends the duration of load imposition
- Kansellous small bone graft for up to 4 months
- Up to 11 months for grafts larger than 3 cm
- The rehabilitation programme is decided in close communication with the surgeon according to the level of healing of the bone graft
- Continuous use of walking sticks in revision arthroplasty
What Information Should Be Asked In The Anamnesis And Noted On The Treatment Card?
- Date of surgery?
- How many operations?
- Operative method: anterior, posterior, lateral
- Characteristics of the prosthesis used in the operation: cemented, cementless
- Bone grafting: osteotomy, bone grafting
- The patient’s comorbidities: neurological, vascular, cardiac…
What Is Important When Deciding The Time Of Discharge After Surgery?
- No signs of infection
- Ability to get out of bed independently
- Able to walk
- Ability to climb up and down stairs
- Discharge is usually planned on day 10-12
- Control: control is performed 3-4 weeks after the operation
- The patient maintains abduction and neutral position until the 6th week
- the crutch on the operated side can be removed with a weekly X-ray repeat
- The transition to a cane is planned in the next 2 weeks
- At the end of 2.5-3 months, patients are able to take long walks and walk without a cane except in cases with abductor weakness.
- Cane in opposite hand: can be given until limp and muscle weakness improve
- If active and passive range of motion is not complete, stretching exercises should be started
- 3-6 months for full recovery
- Use of a cane in the opposite hand during this period
After Arthroplasty;
- Sick worker cannot return to work
- Activities that place repetitive load on the hip such as running, racket sports are not permitted
- Light sports such as swimming, stationary cycling, golf
What Are The Complications That May Occur During And After The Operation?
- Intraoperative Complications
- Fracture: 0.1-1% cemented, 3-18% cementless
- Nerve damage: most commonly the sciatic nerve
- Vascular injury
- cement-associated hypotension
- Anaesthesia-related complications
- Excessive blood loss
- Arrhythmia/arrest
- Transfusion reactions
- Postoperative Complications
- Infection 1 per cent
- Dislocation 2%, mostly posterior
- Osteolysis: the most common long-term complication
- Aseptic loosening: the main long-term problem
- Periprosthetic fracture
- Implant failure or fracture
- Leg length inequalities
- Heterotopic ossification
- Thromboembolic disease
- Medical complications (MI, Pneumonia, UTI etc.)
What Are The Prohibited Movements After Total Hip Arthroplasty?
- Adduction of the hip
- External rotation of the hip
- Hip flexion more than 90 degrees
- Squatting for 4 months after total hip arthroplasty
- Leaning forward
- Lifting things located below the waist
What Are The Rules To Be Followed After Total Hip Arthroplasty?
- Avoid crossing legs or crossing legs
- Do not bring your knees close to your chest, you can bend so that your hands touch your knees
- Rotating the toe to the other leg
- Keep your knees apart when sitting
- Low and very soft seating
- Lying on the operated side unless authorised
- Use a raised chair (6-10 weeks)
- Bending forwards more than 80 degrees
- Sit with a slight recline, lean forward, keep your shoulders in front of your hips when sitting or standing up
- Use a high seat in the bathroom
- Do not give up your walker, crutches or cane without asking your doctor
- Avoid sitting for more than 1 hour before standing up and stretching
- If you can use your operated leg well and can easily take your foot off the gas and press the brake, you can drive 6 weeks after surgery.
- Rotating the trunk to the side of the operated leg
- Lie flat on your stomach in bed for at least 15-30 minutes a day
- If swelling occurs in the leg, lift it up, if it persists, consult your doctor
- During the car journey, take a break for at least 20 minutes every 2 hours, change your position and do your exercises
- When getting into the car, make sure the seat is not too low
- After stepping towards the trolley, the patient is seated by holding the backrest and seat and the legs are placed inside the trolley. Adduction and external rotation should not be performed during transfer
What Are Total Hip Arthroplasty Exercises?
- In the supine and erect position
- Resistance exercises
- 20-30 minutes, 2-3 times a day
Exercises In The Early Postoperative Period
DAY 1
- Breathing exercises
- Postural lower limb exercises
- To the operated side
- Isomteric exercises of gluteal muscles, quadriceps femoris and triceps surae
- It is performed in the supine position and with the lower extremity in the horizontal position
DAY 2
- After control radiography and if there is no surgical problem, the patient is placed in an upright position.
- Continue previous exercises
DAY 3
- Walking in the hospital corridor
- How much load should we give?
- Stand up straight with the load equally on both crutches or walker
- The heel of the operated leg should touch the floor first
- Evaluation of limb lengths and symmetry of load transfer
When Should We Use A Walker?
- Usually the first few days
- Helps to maintain balance and prevent falls
- Decision should be made according to the patient’s general condition and comorbidities: can be used for a long time
- Problem of adaptation to the use of crutches in elderly people with disability
Which Walker Should Be Used?
- Wheeled walker
- Patient to be given full load
- If there is upper limb pain
- Standard walker:
- Patient who is not fully unloaded
- Patients who cannot tolerate full weight bearing
- Patient prone to falls
How To Measure A Walker?
- Placed 12 inches in front of the patient
- Partially encircle the patient
- The height is determined with the patient in an upright position with the elbows flexed 20 degrees
How Should Walking With A Walker Be?
- The walker is lifted by hand and put one step forward
- Rest on the walker, lift the operated leg off the floor, bend the knee, step forwards with the heel touching the floor first.
- Step with the healthy leg in front of the operated leg
- Repeated
How To Use Axillary Crutches?
- Two bars with shoulder piece and hand grip or bar
- Length determination: Measuring the distance from the anterior axillary crease to 6 inches (approximately 15 cm) lateral to the 5th toe with the patient standing
- In the measurement for suitable hand piece placement
- With the crutch 3 inches lateral to the foot
- the patient’s elbow is flexed 30 degrees
- if the wrist is at maximum extension
- fingers fist-shaped measurement
Day 4
Beginning to learn how to climb up and down stairs
- A good exercise that increases strength and endurance
- Patient’s agility and strength required
- Initially the stairs should be walked with the help of handrails
- It should be done one step at a time
- Do not work on stairs above standard height (approx. 15 cm)
- Climbing stairs
- First, a solid foot
- Then the crutches
- The last operated leg
- Going down the stairs
- Crutches first
- Then the operated leg
- The last sturdy foot
How To Walk With A Single Walking Stick Or Cane?
- Patient firstly
- be able to stand and balance without a walker
- Be able to transfer his/her weight equally to both feet
- Should not use their hands as a support for themselves when using a walker
- Used on the side of the intact limb
- Recommended until full muscle strength and balance are regained
- How to measure the appropriate cane?
- The distance from the tip of the cane to the greater trochanter is measured with the elbow flexed 20 degrees in the upright patient
- The walking stick or cane is moved forwards with the affected leg, while the healthy leg is in the standing position.
What Are The Walking Patterns With Two Assistive Devices?
- Three-point-swing through gait (long hopping gait)
- Three-point swing-to gait (short hopping gait)
- Four point walk
- Two point march
Three Point Swing Through Walk (Long Hopping Walk)
- Used if one of the legs cannot be loaded
- Two crutches are placed one step forward
- Legs are thrown forward so that they are one step in front of the crutch
Three Point Swing-Yo Walk (Short Hopping Walk)
- Two crutches are placed one step forward
- Legs are thrown forward, slightly behind the crutch
Three Point Alternating Gait (Two Point Gait)
- Both crutches and the affected leg are moved simultaneously
- Then the body weight is transferred to the arms and step forward with the strong leg.
- It is fast, but the arms need to be strong.
Four Point March
- In cases where the legs can carry part of the body weight
- Left crutch, right leg, right crutch, left leg in order
Two Point March
- Left crutch+right leg, right crutch+left leg
Cycling
- An excellent exercise
- For increased strength and range of motion
- A stationary bicycle with a high seat can be started on postoperative day 4-7: surgeon’s judgement is important
- It is usually allowed after 6-8 weeks
- The bicycle saddle should be adjusted so that the feet touch the pedals when the knee joint is in extension
- The intact leg is placed on the pedal first, the operated leg is placed on the other pedal while it is down
- It is easier to start with an inversion
- If inversion can be performed without difficulty, switch to forward inversion
- Start with 2-4 times a day with minimal resistance
- After 4-6 weeks, the load is increased as muscle strength increases
- 6-8 weeks can be increased to 10-15 min
- Increased from 10-15 min 2 times a day to 20-30 min 3-4 times a week
Walking
- It is important for the patient to be able to continue their daily activities.
- If there is no problem with balance and the patient has started walking with a cane, it is considered to progress to longer walks.
- As strength and endurance increase, walking for 20-30 minutes twice a day is recommended.
What Are The Gait Disorders After Total Hip Arthroplasty?
- Trendelenburg gait
- Hip abdomen strengthening
- Leg length inequality?
- Gait disturbance due to hip flexion contracture:
- No pillow under the knee
- Thomas stretching exercise (5 stretches/6 times/day)
- Stretching by the therapist
- Walking backwards
Development Of Hip Flexion Contracture With Incorrect Gait Pattern
- Wide stride with the operated leg and short stride with the intact leg
- Take wider steps with a strong leg
- Excessive and premature heel lift with knee flexion at the end of the pressing period
- Teaching to keep the heel on the floor
- Bending forward at the waist in the middle and at the end of the pressing period
- Walking with pelvis forward and shoulders back
Patients Who Need More Than One Prosthesis:
- Knee and hip replacement required on the same side
- Firstly, the more painful
- If the pain level is equal and there is no severe flexion contracture and deformity in the knee, the hip is operated first.
- Involvement of both hips
- It is recommended that the more painful hip be operated on first and then the other hip should be operated on after 3 months or later.
