Information For Patients Considering Anterolateral Total Hip Replacement

Brian J. McGrory, M.D.

You have seen Dr. McGrory and are considering anterolateral total hip replacement. Total hip replacement is a very good operation and over 95% of people having this procedure can expect excellent pain relief and full use of the hip postoperatively. Despite this, total hip replacement is major surgery and should not be considered lightly. Hopefully this handout will answer some of your questions and increase your understanding of the procedure. This is not meant to replace talking with Dr. McGrory or asking any questions.

Before Surgery

Total hip surgery is major surgery and requires careful preparation to get the best result. There is a lot to be done before surgery and because of that you will probably find that the date of your surgery will be around four to six weeks after your visit with Dr. McGrory. In this period of time you will be asked to do several things.

• You will be asked to visit your dentist (if you have teeth) as cavities or gum disease can be a source of infection that can travel to the hip during or after surgery, creating major problems. A visit to your dentist could prevent this.
• You may be asked to see your regular doctor or perhaps a specialist for evaluation to ensure you can tolerate the surgery well.
• You will be asked to get some preoperative lab work done at Brighton Medical Center and meet with the anesthesiologist.
• You will be asked to come into the office approximately two weeks before the surgery for a history and physical examination and some preoperative x-rays. This will also allow you to have any additional questions answered. Any medications that you take will be reviewed at that time. You will also be informed if any of those medications need to be stopped or changed prior to surgery.
• You will be asked to wash your hip with antibacterial soap each of the three nights prior to surgery.
• You may be asked to take special pain control medicines prior to surgery.

Procedure

Total hip arthroplasty, sometimes known as hip replacement, involves the removal of bone from the end of the femur (thigh bone) and replacement with a metal implant.  The acetabulum (cup of the hip joint) is also replaced with a metal or metal and plastic component.  Bone near the hip may need to be cut (osteotomy) at the time of surgery.  Bone cement is sometimes used to hold the femur (thigh part) in place, but this depends on the bone strength of the femur.

This procedure generally takes about 90 minutes in the operating room, but takes longer (four to five hours) when you consider preparation for surgery and recovery time in the recovery room. It is usually done under general anesthesia. During and after the procedure there is blood loss that may require a blood transfusion, although this is not common.

As with any surgery, there are risks inherent with this procedure. The major risks for this procedure are the risks associated with anesthesia and stress of the surgery, risk of infection, risk of fracture, risk of phlebitis or blood clots in the legs, risk of leg swelling, risk of stiffness, risk of the legs not being exactly equal in length after the surgery (necessitating a shoe lift), risk of nerve or artery damage, and risk of the hip coming out of joint (dislocation) in the postoperative period. Even with a well-functioning joint, pain can be present after surgery.

In the long run, there is a risk that you will need re-operation, or that the wear particles that accumulate at the joint surface can cause bone softening (osteolysis). Prosthesis or bone fracture, loosening, and infection can also happen months or years after surgery. The joint is mechanical and will wear out over time.

Anterolateral total hip arthroplasty is unique in that the hip joint is approached from the front side. Although the incision is only slightly different from the traditional posterior approach, we have found that the anterolateral approach allows for decreased pain and early discharge from the hospital. Because the posterior capsule is left intact, patients do not have to follow standard hip precautions and many patients feel comfortable driving sooner than with a posterior approach.

Because the implants require the bone to go into the prosthesis, the healing time for the bone is not changed compared with the traditional posterior approach. Many patients locally consider this approach to be “minimally invasive hip replacement surgery.” Although it is true that this operation has significantly less pain and fewer restrictions in the immediate postoperative period, it is still a major surgery.

There are limitations after the surgery that will protect the hip. Running and impact activities are not usually a good idea after hip replacement surgery.

After Surgery

After surgery you can expect to have some pain, but you will be given pain medication to control this. You will also be given antibiotics to try to minimize the risk infection. Patients are also placed on a blood thinning agent to decrease the risk blood clots. If necessary, in the time after your surgery you may be given a blood transfusion.

Most patients having an anterolateral total hip replacement are in the hospital overnight. Generally, Dr. McGrory likes to have his patients able to safely get in and out of bed, climb stairs, and walk before they are discharged from the hospital. While in the hospital you can expect to have physical therapy by a trained therapist. You will need to continue using a walker or crutches for one week following your surgery.

Immediately after surgery you will still have the intravenous lines that were started before surgery. These will be discontinued as soon as you are taking food and fluids well and are no longer requiring any intravenous medications. You will have a surgical drain overnight; this will be removed the day after surgery. You will wear graduated compression stockings (TED hose) while in the hospital and will continue wearing these until the swelling in the operative leg is diminished. Normally, after you leave the hospital you will need to wear these for ten days. You need only wear these during the day. You will take medicines for pain, including Celebrex, Tylenol, and Lyrica for five days after surgery. You will take narcotic pain medications as needed.

After Discharge

After leaving the hospital you can expect to be walking with crutches or a walker for approximately one week. Almost all patients are allowed to put full weight on the hip and after a week may go to using a cane in the opposite hand. Physical therapy is very helpful in early recovery and will be arranged at your home. Follow-up appointments will be arranged with Dr. McGrory’s office and are arranged before surgery. Be sure to check your appointment dates and times. Prior to surgery you will be given several pain medications that you will take for five days after surgery. Dr. McGrory will check prior to your discharge from the hospital that you have filled these prescriptions.

Most patients are on warfarin (Coumadin) blood thinner for 10 days after surgery. Home nursing will check your blood (INR – a measure of how “thin” your blood is on the medication) once or twice after you are home and call the results to our office. We will let you know by phone if your Coumadin dosage needs to be changed. After the Coumadin is finished, you will need to take one 325 mg coated aspirin each day for 35 days.

It is usually recommended that patients undergoing hip replacement do not drive until they are comfortable. With the anterolateral approach, this is often two to three weeks after surgery. It is also wise to avoid situations where you might fall, be jostled, or otherwise injure your hip. Until the bone grows into the prosthesis, there is a risk for fracture around the prosthesis even with minor trauma. For most patients, Dr. McGrory suggests avoiding pushing off with the operative leg when climbing stairs or getting out of a chair.

As mentioned above, dental infections or bad teeth can be a source of infection for a total hip even after the surgery is completed. For this reason it is wise to advise your dentist that you have a total hip. We ask that you do not have any dental work done for ten weeks following your surgery. For any dental procedures, including cleaning of your teeth, you should have antibiotic prophylaxis. This is taken one hour before the dental procedure. This single dose of antibiotics should prevent any problems. Other infections in the body such as boils or bacterial infection could also represent a source of problems for a person with a total hip. For this reason, if you should have any infection it is wise for you to consult your doctor promptly so that proper treatment can be carried out.

Expectations

Total hip replacement surgery is major surgery and should not be undertaken lightly. It is wise to keep in mind when considering this surgery that even the best total hip replacement is not as good as your hip was when it was healthy. It is hoped that the surgery will relieve your pain, if not totally, then at least to a significant degree. It is hoped that you will maintain reasonable stability and flexibility as well.

Even if you feel much better you must keep in mind that this artificial hip is a mechanical device. Just like any mechanical device, including your automobile, there can be problems or failures. In general, contemporary total hip replacements now last 15 years or more. It is hoped that in the near future this period of time can be extended to 20 years. As with any medical procedure, there is no guarantee.

Even if you feel much better following your surgery it is wise that you limit your activities, especially those which cause marked flexion of the hip and impact to the hip.

If you have any further questions, please feel free to call the office at (207) 828-2100.