R. Wendell Pierce, MD
955 Main Street, Suite 305
Winchester, MA 01890
Phone: 781-729-9577 Fax: 781-721-0163Website:
TOTAL HIP REPLACEMENT
Total Hip replacement is a major surgical procedure that replaces the severely arthritic ball and socket of your hip with durable metal, polyethylene and ceramic components. It is performed through an incision at the side and back of your hip that varies in length depending on your size and the complexity of your arthritis. As with any large operation there are some potential complications that can be minimized by good preoperative evaluation and preparation. In part this involves the orthopaedic evaluation, vascular evaluation and appropriate X-rays. Equally important to your recovery are several other preoperative preparations and post operative protocols that will be outlined here. In my experience, patients who are thoroughly evaluated and prepared have less complications and better short and long term results.
PRE-OP MEDICAL CLEARANCE: Since this is a major elective surgery under anesthesia, it is very important that you visit your primary care doctor (PCP) to assure that you are medically cleared for anesthesia. This visit should ideally be scheduled far enough in advance (at least 3-4 weeks prior to surgery) to allow for any treatment or additional studies. For example, your doctor may request a cardiac stress test.
EKG & CHEST X-RAY: Most patients should have an EKG within the 3 month period prior to surgery and it should be interpreted by your PCP or a cardiologist and cleared for surgery. If there has been any lung problems, asthma or smoking history, a Chest X-Ray should also be performed within the 6 months prior to surgery.
DENTAL CARE: Preoperative dental evaluation is mandatory for all patients if they have any remaining teeth. This will help reduce infection after surgery. During many routine dental procedures and cleaning some bacteria will be released into your circulation. During the first few months after surgery this is particularly risky for seeding into the new joint and therefore it is best to have cleaning and any dental repairs or restorations done before the surgery. Again, it is best to have your dentist see you at least 3-4 weeks prior to surgery in case additional care needs to be scheduled. Once your joint replacement is completed, you will be instructed on the use of antibiotics before future dental procedures to protect your new joint.
BLOOD DONATIONS: Currently the blood bank supplies are as safe as they have ever been and donating your own blood may not be as important as in years past. Not all patients will need transfusions after surgery. If you feel you want to donate some blood before surgery, you can discuss this with the office. Donations are usually done within the month prior to surgery but not the last week prior to surgery.
CASE MANAGEMENT, REHABILITATION FACILITY AND HOME PREPARATION: The Case management department at the hospital can assist you in making a smooth transition from hospital to home. Most patients stay in the hospital about 3 days and then can go directly home with visiting nurse and physical therapy help at home or go to a rehabilitation facility until independent enough for home. There are many excellent rehab facilities in the area and Case Management can discuss your choices with you. If you go home, they will help coordinate your safe transfer there and arrange for the necessary visiting nurses, home therapy and home lab studies. You will need these services at home until you are comfortable and safe enough to travel by car to outpatient facilities. A stationary bicycle can be useful at home. High armchairs and elevated toilet seats will make daily activities easier.
PRE-OPERATIVE VISIT: We will want you make a final pre-op visit at our office within the week prior to surgery in addition to your visit to Pre-admission testing (PAT) at the hospital This is to check your skin condition and circulation, to review your medical and dental evaluations and to answer any final questions. It would be best to write down any questions you and your family may have for that visit. You will also be given prescriptions for your coumadin anticoagulation pills and for some postoperative pain medication at that time to make your transition home easier.
PHYSICAL THERAPY: Much of the success of total hip replacement depends on consistent physical therapy after surgery. This is started in the hospital and continues in a rehab facility or at home. It is a good idea to visit physical therapy in the pre-op period to become familiar with crutch or walker gait and the postoperative protocol and precautions. Please make arrangements to see the therapist of your choice within the few weeks prior to surgery. It is common to need therapy several times a week for a few months after surgery so you should find a facility convenient for you and your family. Dislocation of the joint rarely occurs after total hip replacement and during the first few months therapy will instruct you in the simple precautions to avoid this. To make the hip stable, we usually will restore leg length with surgery so that your leg may feel long after surgery since your have become used to it being short. Occasionally a temporary lift is needed. Exact equal leg length cannot be guaranteed. Therapy is critical to help you correct old gait faults and retrain your muscles to make your gait as smooth as possible.
WOUND CARE AND PERSONAL CARE: Most often there are stainless steel staples securing the wound. These stay in place for 10-14 days after surgery and the visiting nurse will usually remove these at home. If the wound is dry, the dressings can be removed after 3 days. If there is still any fluid from the wound, sterile gauzes can be used to keep it covered. It is important for you and your caretakers to wash hands carefully before touching near the wound or applying dressings. You can take showers after the wound is clean and dry. It is best to keep a plastic wrap over the wound and, of course, not to scrub it. The visiting nurse will check you wound and call with any concerns. Redness around the staple line is common and not usually a cause for concern. If any drainage persists after 5 days, the wound should be evaluated. A low-grade fever is common during the first week after surgery. If it goes above 102 degrees F or if you have chills, please notify the office.
BLOOD CLOTS AND ANTICOAGULATION THERAPY: Major lower extremity surgeries carry a significant risk of blood clots in the veins (DVT or deep vein thrombophlebitis). To reduce this risk, all patients are treated with some type of anticoagulation medication. The most commonly used medicine is Coumadin, which is a pill that you take daily. The first dose is given the night before surgery. The reason for this is the 48 hour delay before it becomes active which will be the day after surgery. Usually you will stay on coumadin about one month after surgery. If you have had a prior clot (DVT) or pulmonary embolus (PE), then your risks are higher and you will remain on the protocol for 3-6 months.
Regular blood studies are needed to adjust the dose. For the week prior to surgery and during the time you are on coumadin or other anticoagulation medication, you will need to stop aspirin and other NSAID medications (such as Ibuprofen or Naproxen) as well as certain other medications like Plavix You should also discuss other medications such as amiodarone with your primary care doctor. Certain over the counter vitamin and herbal preparations such as gingko, garlic and ginseng should also be avoided. A more complete list can be viewed at our website above or at Your diet while on these medications should be kept well balanced and low in certain foods that are high in Vit K such as kale, collards, chards, spinach and should have little or no alcohol and cranberry juice. Try to keep your diet consistent; don’t eat all salad one day and all meat the next day. Cuts and nicks will bleed longer while on these medicines so extra caution is wise. Other bleeding, such as nosebleeds or hemorrhoid bleeds may actually need to be treated at the hospital if they are significant.
DRIVING: With procedures done on the right leg, we recommend no driving for 4-6 weeks. Physical therapy can help you with your driving skills. It is important that your first attempt driving in a large vacant lot to be sure that the new alignment and somewhat different motion of your leg can be accommodated safely. If you have a car with a clutch, then these precautions apply to left leg procedures and driving should be delayed at least 6 weeks.
TRAVEL: Due to the risks of blood clots, long travel by plane, car, bus or train is not recommended during the first 6 weeks after surgery. When scheduling surgery, you should review your personal and business plans to avoid this. General precautions for all persons traveling are to stay hydrated, avoid alcohol, take frequent short walks, and keep your feet, ankles and legs moving when sitting. Well-fitted elastic stockings help avoid blood pooling in your lower legs and may reduce risks also.
FURTHER INFORMATION AND QUESTIONS: Any questions or concerns that are not answered here should be directed to the office or by consulting the many links and patient information brochures and topics available on the website