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A Complete Guide for
Patients Having Hip Replacement Surgery
Choosing to have a total hip replacement is a big decision. For
many patients, the prospect of a “new hip” – with
the greater mobility and reduced pain it offers – is exciting.
But, as with any major surgery, patients also have questions and
concerns.
This handbook provides much of the information you will need to
prepare for your upcoming surgical experience. You should read this
entire booklet and share it with your family and primary caregiver
– the person who will be helping you at home after surgery.
Gaining as much knowledge as possible ahead of time will help both
you and your caregiver to be relaxed and ready for the experience
that lies ahead.
Before Your Surgery
Preparing for a total hip replacement begins weeks before your actual
surgery date. First, you will need to prepare yourself physically.
It is important to be in the best possible overall health to help
ensure the best possible surgical experience. Activities that will
increase upper body strength are of special importance because you
will be using a walker or crutches after the operation. Ask your
physician for specific recommendations.
Many times, hip replacement results in the need for autotransfusion,
a safe and effective procedure in which the blood that you lose
during surgery is salvaged and recycled. During surgery, the blood
you lose is collected under sterile conditions and filtered of all
impurities. The collected blood is then washed to remove bacteria
and other contaminants, resuspended in clear crystalloid fluid,
and transfused back into your body.
It is also possible that your hip replacement may necessitate a
blood transfusion. While autotransfusion uses your own blood, a
blood transfusion requires that you be given someone else’s
donated blood – unless you donate your own blood ahead of
time. Because a blood transfusion may be necessary, you may want
to consider donating several pints of your own blood. In the weeks
before surgery, you should talk with your physician about these
procedures.
In the weeks before surgery, talk with your physician about autotransfusion
and blood transfusion.
Before your surgery, your physician may order blood tests and a
urinalysis to check for any infections. Also, your teeth need to
be in good condition as an infected tooth or gum could be a source
of infection for the new hip. For these reasons, your orthopaedic
specialist may ask you to see a medical doctor or dentist for a
check-up.
You may be instructed to stop taking any anti-inflammatory medications
(aspirin, ibuprofen) a week or two before surgery. You may take
Tylenol® (acetaminophen), but if you need stronger pain relief,
call your physician.
Pre-Surgery Checklist
Night Before Surgery Pack a small
suitcase with personal hygiene items, non-skid slippers, and comfortable
loose clothing Nothing to eat
or drink after the time appointed by your anesthesiologist Take a bath or
shower Review this booklet
Day of Surgery Take medications
only as instructed by your anesthesiologist Arrive at the
hospital at the appointed time. Check in at the registration desk.
Pre-Op Visit
Prior to your surgery, you will have a pre-op visit to the hospital.
This educational visit can last several hours, and will provide
a great deal of helpful information for you and your caregivers.
Be sure to prepare a list of questions ahead of time and bring it
with you.
The pre-admission nurse will inquire about your past medical history
and current medications, have you sign a permit for surgery, and
provide some basic pre-op teaching. Be sure to provide complete
and accurate medical information; bring all medications you normally
take and a list of past surgeries.
Your anesthesiologist will conduct a teaching session to explain
your anesthesia options for surgery. He or she may also ask for
more detailed medical information, and may order some basic pre-operative
testing for you, such as a blood test, EKG, and/or chest x-ray,
to confirm that you are in optimal health for surgery.
The orthopaedic nurse educator will discuss your “patient
pathway” – our specific plan for your personal care
during your hospitalization. Areas covered in detail will include
pain management, total hip precautions, use of assistive devices,
breathing exercises, and blood clot prevention.
Pain Management
Your surgery and ensuing activity will likely cause you some discomfort.
Our goal is to help you manage your pain so that it doesn’t
inhibit your recovery. Do not wait until the pain becomes unbearable
to take your pain medication. Taking the medication will help you
breathe easier and move sooner, which will help you progress more
quickly.
Following surgery, you will be asked to rate your pain on a 0 to
10 pain scale, where 0 is no pain and 10 is the worst pain you’ve
ever had.
After your surgery, your pain will be controlled in one or more
of the following ways: PCA (Patient-Controlled Analgesia) – PCA
is a pump connected to your IV (intravenous tube) that you control.
You determine, within safe limits that we set, how often you receive
your pain medication. It is important to have adequate pain relief
before walking and physical therapy so that you will not be inhibited
in your activity. Oral – medication given by mouth, usually
after you have stopped PCA. Shots – medication given by injection.
For some patients, temporary nausea and vomiting can be caused by
anesthesia or medications for pain (for example, PCA). Anti-nausea
medication may be given to help ease this effect.
What to Expect the Day of Your Surgery
On the day of your surgery, you will be admitted to the hospital.
Once the admission process is complete, you will then be taken to
the pre-surgical unit and asked to change into a hospital gown.
A final pre-surgery assessment of vital signs and general health
will be performed. After this, you will be transported to a “holding
area” near the operating room. At this time, your family will
be instructed to wait in the designated surgery waiting area while
you are away. They will be updated on your progress.
In the holding area, you will have an IV catheter (tube) inserted
into a vein in your arm so that you can receive the necessary medications
during surgery. You will be given an antibiotic through your IV
to reduce the risk of infection. (All surgery carries the risk of
infection because of the bacteria that are normally present in the
body.)
Your anesthesiologist and operating room nurse will meet with you
in the holding area. At this time, be sure to ask any last-minute
questions. When your surgeon is prepared and all of the pre-surgery
tasks are complete, you will be transported to the operating room
on a stretcher.
After your surgery, you will be taken to the recovery room where
you will stay for about 1 hour. A nurse will frequently check your
vital signs and surgical dressing. When your condition is stable,
you will be transferred to your room on the surgical unit.
Once you are in your room, a nurse will continue to check your progress
and help you get oriented to your surroundings and the routine of
your stay. You can expect the nurse to: Examine you and
listen to your heart and lungs Check your vital
signs Check your surgical
dressing and drain; reinforce the dressing as needed Possibly perform
an autotransfusion, as instructed by the physician Reinforce use
of the PCA pump for pain management Record what you
eat and drink and monitor how much urine you produce (you will have
a Foley catheter in your bladder attached to a urine collection
bag; this monitoring of intake and output is called I&O) Apply cold packs
to your operative leg Keep pillows
between your legs to remind you not to cross your legs Apply “TED
stockings” to your non-operative leg to help prevent blood
clots Apply foot pumps
to help prevent blood clots Assist you in
turning, coughing, deep breathing, and using incentive spirometry
(breathing exercises) to help prevent complications, such as congestion
or pneumonia, due to decreased activity Maintain your
IV Reinforce pre-
and post-op teaching; answering any questions you and your family
members may have
During the rest of the day, you will: Be able to have
clear liquids or soft diet as tolerated Be encouraged
to do the post-op activities you were taught during your pre-op
visit and physical therapy
What to Expect: Post-Op Days 1 to 3
Most patients who have a hip replacement stay in the hospital about
3 days. Your doctor will visit you each day to evaluate your progress
and make any needed changes to your plan of care. This section provides
an outline of what else you can expect in the days following your
surgery.
Post-Op Day 1
The nursing staff will: Continue to monitor
and assess, making no major changes Maintain the
PCA pump for pain control Continue to apply
cold packs to your operative leg Maintain the
TED stockings and foot pumps Assist you in
getting out of bed Reinforce Coumadin
teaching (see section of this booklet titled “Use of Coumadin”) Assist you with
bathing Reinforce pre-
and post-op teaching
Another crucial part of your recovery is physical therapy. A physical
therapist will visit you in your room to: Evaluate your
condition Instruct you
in an individualized program of rehabilitation exercises Assist you with
getting out of bed, walking, and exercises
The occupational therapy staff will: Meet with you
to discuss home equipment needs Assist and instruct
you in daily living activities, such as dressing, bathing, and toileting
The case manager will: Discuss your
plans for returning home Start making
any necessary arrangements for care or equipment
Post-Op Day 2
The nursing staff will: Check your surgical
dressing and drain (physician may discontinue the drain);change
the dressing Discontinue the
PCA pump and provide oral pain medication upon your request Change your IV
to a “Heparin-lock,” a small sterile tube that will
allow easier movement while keeping a vein accessible for antibiotics Discontinue the
Foley catheter Monitor your
bowel function Continue to apply
cold packs to your operative leg Maintain the
TED stockings and foot pump Assist you in
moving around Answer questions
and continue discharge teaching, including hip precautions
As soon as you feel any discomfort, promptly ask for your oral pain
medication – don’t wait too long!
The physical therapy staff will: Assist you 2
or 3 times with your hip exercise program, range of motion (ROM),
and walking Reinforce instruction,
including hip precautions, use of walker/crutches, and exercises
Post-Op Day 3
As you prepare to return home, you should feel comfortable with
ambulation (walking with a walker or crutches) and should understand
your pain medication and Coumadin therapy regimens. Make sure that
you understand all of the instructions you have been given and ask
any questions you may have.
The nursing staff will: Check your surgical
dressing; change the dressing if needed Remove the Heparin-lock Provide oral
pain medication upon your request Maintain the
TED stockings and foot pump Answer questions
and review discharge teaching
The physical therapy staff will: Assist you 2
or 3 times with your hip exercise program, ROM, and walking Reinforce instruction,
including hip precautions and use of walker/crutches
The occupational therapy staff will: Ensure you have
all the information and equipment needed to function independently
at home
The case manager will: Finalize discharge
arrangements
Getting Moving Again
It may come as a surprise to you that you will be encouraged to
get up and start moving around as soon as possible after your surgery,
usually the first day post-op. When you are med- ically stable,
your physical therapist will teach and assist you to take steps,
climb stairs, and perform certain hip exercises. To ease the discomfort
these activities will initially cause, remember to take your pain
medication prior to therapy.
Physical therapy is a key part of your recovery. The more quickly
you get moving again, the more quickly you are likely to progress.
However, there are some precautions that you must take. For example,
for the first few days in the hospital, you must not elevate the
head of your bed more than 90 degrees.
If dislocation occurs, it most likely will happen in the first 6
to 8 weeks after surgery. For this reason, your physical therapist
will advise you on certain precautions you must continue to take,
including: Use 2 or 3 pillows
between your legs Do not cross
your legs Do not bend forward
90 degrees Do not turn the
hip or knee inward
In addition, your physician and case manager will discuss your longer-term
rehabilitation plans. You will also see an occupational therapist
who will teach you how to use certain devices to help you put on
socks, reach for household items, and bathe in a safe manner. Your
therapist can also recommend ways to make your recovery at home
as easy – and safe – as possible. A case manager will
talk with you about your plans to go home and to ensure that you
have all the necessary help to support you in your recovery. If
needed, the case manager can help arrange a visiting nurse.
Your Diet
After your surgery, your physician will limit your diet to liquids
for the first 6 to 8 hours. Many people will experience some nausea
due to the anesthesia and pain medication. Your food selection will
be limited to clear liquids such as apple juice, ginger ale, tea,
broth, and gelatin.
Once any nausea has passed, you will be able to select from our
dining menu. Any member of the patient care staff can assist you
with making meal selections.
Constipation can also be a side effect of the inactivity following
surgery and of certain medications. If you experience constipation,
try these suggestions: Eat 5 to 7 servings
of fresh fruit and vegetables daily Eat a hot breakfast
with a hot beverage daily Increase fiber
in your diet by eating whole grain cereals and breads Drink at least
6 to 8 8-oz. glasses of water daily Increase your
physical activity as much as you can tolerate
Preventing Complications
Patients who undergo total hip replacement are at risk for certain
complications, including infection, lung congestion, and blood clots.
To help reduce these risks, you will be given medications, materials,
and instructions for use in the hospital and at home:
Antibiotics – Following surgery, you will
receive antibiotics to prevent infection. However, for the rest
of your life you will need to follow the Antibiotic Regimen to reduce
risk of infection (see section in this booklet titled “The
Antibiotic Regimen”). Incentive spirometry – a series of deep breathing
exercises to keep the lungs clear of congestion. Foot pump – felt sleeves that fit over your
feet and are connected to a machine that pulsates. This promotes
blood flow in your legs and decreases the chance of blood clots. TED stockings – elastic support stockings
that improve blood circulation in your legs. These must be worn
correctly each day in order to prevent blood clots (see section
titled “Use of TED Stockings”). You should continue
to use your TED stockings until your physician tells you otherwise. Coumadin® – a medication that thins your
blood to reduce the risk of clot formation. Elevation – raising your feet and legs helps
keep blood from pooling in the lower extremities.
Use of TED Stockings
Blood clots are a serious concern for hip replacement patients because
your decreased activity level following surgery puts you at risk.
TED anti-embolism (anti-blood clot) stockings improve the flow of
blood in your legs. During activity, your muscles help pump blood
from your heart to your legs and back again by applying pressure
on the veins. During long periods of decreased activity, muscle
involvement in assisting blood circulation is decreased. As a result,
there is an increased risk of blood pooling and clotting in the
legs.
TED stockings create pressure that helps push blood out of the legs
and back to the heart. The pressure is strongest at the ankle –
the lowest part of your leg. By wearing your TED stockings as instructed
by your doctor, you are reducing the risk of blood clots forming
in your legs. You must wear your stockings correctly each day for
them to be effective. Following are instructions for the proper
use of TED stockings:
Before You Begin
1. Make sure your legs and feet are clean. Gently bathe them daily.
Do not massage the skin on your legs. Do not apply cream or lotion
to the skin.
2. Make sure your legs are dry. You may lightly powder your legs
to decrease irritation and help the stockings slide on more easily.
3. Make sure you put the stockings on straight. Twisted stockings
will not provide the proper pressure.
How to Apply Your Stockings
1. Insert hand into stocking as far as the heel pocket. Do not roll
up stocking before putting it on. (Stockings are interchangeable
for either leg.)
2. Grasp center of heel pocket and turn stocking inside-out to heel
area.
3. Carefully position stocking over foot and heel. Work the stocking
with the flat of your hand until the foot and heel are in place.
Be sure the heel is centered in the heel pocket.
How to Remove Your Stockings
1. Remove your stockings once daily while you wash your legs and
feet.
2. Take hold of the upper edge of the stocking and pull toward the
heel. With the flat part of your hand, work the stocking over the
heel and remove.
3. After removing the stocking, check your legs and feet for changes
in color, temperature, sensation (numbness), irritation, abrasions
of the leg, tenderness, or pain. These are signs of decreased blood
flow.
How to Care for Your Stockings
1. Clean your stockings every 3 days. Wear your clean pair while
the other pair is being washed.
2. Machine or hand wash your stockings. Do not use bleach –
only soap and water.
3. Dry your stockings by laying them flat or by machine-drying them
on a low setting. When done, remove from the dryer immediately.
4. Do not use ointments, oils, lanolin, or creams on your legs.
These can cause the elastic in the stockings to wear out.
5. Be careful of fingernails; they can puncture the stockings.
6. Do not stretch or pull on the stockings more than necessary;
the elastic will begin to weaken.
When to Call Your Doctor
1. If you notice any of these conditions on your legs or feet: rash,
open sores, reddened areas, changes in skin color or temperature,
numbness, or tenderness.
2. If your stockings become loose, torn, or fit improperly.
The Antibiotic Regimen
After hip replacement, you must – for the rest of your life
– follow the Antibiotic Regimen outlined below. This is because
any infection that develops in your body can spread bacteria to
your artificial joint, putting it at risk. Early treatment of the
infection will prevent this complication.
Following is the Antiobiotic Regimen:
1. Any time – even years after your surgery – you develop
an infection such as strep throat or pneumonia, or if you think
you have developed an infection anywhere in your body, you must
notify your doctor. This includes infections in the gums, skin,
bladder, etc. In such cases, it is recommended that your family
doctor promptly prescribe antibiotics and culture any drainage.
2. It is also important that, for the rest of your life, you advise
any physicians and dentists you visit that you have had a joint
replacement. Oral anti-biotics are recommended for all routine dental
procedures, including teeth cleanings and treatment of dental cavities.
IV anti-biotics are recommended for extensive surgical procedures
of the gums or jaw.
Use of Coumadin®
Coumadin is a prescription medication that thins your blood to prevent
clot formation. When taking Coumadin, follow the instructions below.
Special Instructions for Patients Taking Coumadin Take the exact
dosage of Coumadin that your physician prescribes for you. Take Coumadin
at the same time every day. Note that the
amount of the drug you take may vary over time. Your physician will
determine the dosage schedule based on the results of a routine
blood test. This test may be taken on a weekly basis until your
physician discontinues the medication. Because Coumadin
thins your blood, it can cause excessive bleeding. Take special
care not to bruise or cut yourself. If you do get a cut, apply pressure
over the area and apply a bandage. If you need any
dental work or other surgical procedures, inform the dentist or
physician that you have had a joint replacement and are taking Coumadin. Follow the dietary
guidelines sheet for foods that may affect the medication. Do not take Ecotrin,
aspirin, or any arthritis medications without talking to your physician.
Medications such as these can thin your blood. Only use pain medication
prescribed by your physician, or Tylenol. Continue to take
Coumadin until your physician tells you to stop. While on Coumadin,
take the following precautions to reduce your risk of bleeding:
– shave with an electric razor
– use a soft-bristled toothbrush
– wear shoes at all times
– arrange furniture and rugs to reduce your risk of bumping
or tripping Call your physician
if you develop any of the following conditions:
– excessive bruising
– red or black stools
– nosebleeds
– red or dark urine
– bleeding gums
– unexplained swelling
Exercising Your New Hip
After your total hip replacement, be sure to exercise your hip as
instructed by your surgeon or physical therapist. Proper exercise
builds leg strength and improves the hip’s range of motion.
Quad Sets
• Slowly tighten muscles on thigh of straight leg while counting
to 10 out loud. Gluteal Squeezes
• Squeeze buttocks muscles as tightly as possible while counting
out loud for 10 seconds. Abduction
• Slide one leg out to the side. Keep kneecap pointing toward
ceiling. Gently bring leg back to pillow. Repeat with other leg. Heel Slides
• Bend knee and pull heel toward buttocks. Hold ____ seconds.
Return. Repeat with other knee. Advanced Abduction
• Lift leg up toward ceiling. Return. Repeat with other leg. Ankle Pumps
• Bend ankles up and down, alternating feet. Short Arc Quads
• Place a large can or rolled towel under leg. Straighten
knee and leg. Hold ____ seconds. Important Reminders for the First Month
You will eventually be able to return to your usual activities,
but during the first month, please follow these instructions: You can put a
light amount of weight on your surgical leg while walking, but continue
to use your crutches or walker until your 1-month visit. Walk as
much as you like. Remember your
hip precautions:
– do not cross your legs
– do not bend more than 90 degrees
– do not turn your hip or knee inward Continue your
hip exercises as instructed by your physical therapist. No jumping, lifting,
or kneeling activities yet. Use a toilet
seat riser. When relaxing, sit in a high, firm chair to prevent
bending more than 90 degrees and placing too much stress on the
hip. Wear your TED
stockings until your 1-month appointment. Note that you may leave
them off for short periods of time and at night. Do not lift any
weights with your surgical leg. Lie only on your
surgery side and place a pillow between your knees. Do not drive
prior to your 1-month follow-up appointment or until the doctor
allows you to drive. Follow the Antibiotic
Regimen for the rest of your life! Expect to be
tired and need rest periods. Lying down a few times a day will help
reduce leg swelling. You may also use ice packs for 20 minutes at
a time on the operated hip. If you go home
on Coumadin®, do not take any aspirin products or arthritis
medications unless approved by your doctor. Keep the incision
clean and dry. If you have staples or stitches, you must not shower
until they are removed. Make an appointment to have them removed
approximately 2 weeks after surgery. Use pain medication
as directed to minimize discomfort while exercising. Do not drive
or drink alcohol while taking narcotics for pain. Call if signs
of infection develop: redness, increased swelling or pain, fever,
chills, or drainage (other than the clear, yellow drainage you may
have had while in the hospital). Call your physician’s
office if you have any questions or problems.
Jeffrey R. Ginther, MD, FACS | Servicing Central Indiana | 317-770-4100
