TOTAL HIPREPLACEMENTA PATIENT’S GUIDE

Anthony Bianchi, 56Total Hip Replacement 2009

Prep

aring

foryo

ursur

gery

� PPrree--AAddmmiissssiioonnTTeessttiinngg:: This is a phys-ical examination and a series of tests (x-rays, blood work, etc.) that will beperformed in preparation for your sur-gery. During Pre-Admission Testing youwill also meet with an anesthesiology staffmember to discuss the type of anesthesiayou will undergo.� MMeeddiiccaall CClleeaarraannccee ffoorr SSuurrggeerryy:: Ap-proval for you to undergo surgery is re-quired from your primary doctor - or wecan arrange for you to be examined byone of our doctors.This examination, incombination with Pre-AdmissionTesting,is necessary to review your overallhealth and identify any medical condi-tions that could interfere with your sur-gery or recovery.� HHiipp RReeppllaacceemmeenntt CCllaassss:: You will bescheduled to take a two-hour classwhere our staff will review the most im-portant information covered in thisGuide and answer any other questionsyou might have about your surgery. Ifscheduling permits, we will arrange foryou to take this class the same day asPre-AdmissionTesting.In the weeks before your surgery youmay also be asked to:� BBeeggiinn eexxeerrcciissiinngg uunnddeerr aa pphhyyssiicciiaann''ssssuuppeerrvviissiioonn:: It is important to be in thebest possible physical condition for yoursurgery. Special exercises to increase yourupper body strength will help you use awalker or crutches in the early days aftersurgery, and exercises that strengthenyour legs can reduce recovery time.� WWaattcchh yyoouurr wweeiigghhtt:: If you are over-weight, losing weight will help reduce

stress on your new joint. (If your weightis normal, keep it that way.)� CCoonnssiiddeerr pprree--ddoonnaattiinngg bblloooodd ffoorrttrraannssffuussiioonn:: If your surgeon determinesthat your operation may require a bloodtransfusion, you can choose to donateyour own blood ahead of time.� HHaavvee aa ddeennttaall eexxaammiinnaattiioonn:: Althoughinfections in joint replacements are notcommon, one can occur if bacteria enterthe bloodstream somewhere else in yourbody.Therefore, you should arrange tohave dental procedures such as extrac-tions and periodontal work completedbefore your surgery.

� SSttoopp ttaakkiinngg cceerrttaaiinn mmeeddiiccaattiioonnss::Your surgeon can advise you which med-ications to stop taking before your sur-gery. Be certain to tell your physician allthe medications that you are taking, in-cluding over-the-counter medications,because some of these may increaseyour bleeding during surgery.� BBee ssuurree yyoouurr ppoossttooppeerraattiivvee mmeeddiiccaa--ttiioonn wwiillll bbee aavvaaiillaabbllee: Ask your surgeonahead of time whether you will requireanticoagulation medication (to preventblood clots) after your surgery. If you do,call your pharmacy to ensure that theyhave it in stock.

Preparing for your surgeryPreparation for your total hip replacement surgery begins

several weeks before the date of the surgery itself. To beginwith, you will be asked to keep the following appointments:

ABouT Blood TRAnsfusionsPatients undergoing joint replacementsurgery may require a blood transfusion.This is an issue that you should discusswith your surgeon. If you are a candidatefor transfusion, you have several options:AAuuttoollooggoouuss ttrraannssffuussiioonn:: An autologoustransfusion is one in which you donateyour own blood ahead of time. Your sur-geon's office will instruct you how tomake an appointment to pre-donateblood, or other arrangements can bemade. The process is extremely reliable,and your blood can be refrigeratedsafely for at least a month.The obviousadvantage of this option is that whenyour own blood is used there is no riskof contracting a transmissible diseasefrom someone else's.(Please note that it is possible for yoursurgical team to contract a transmissi-ble disease from you. If you have such acondition, please share this information

with your caregivers.)HHoommoollooggoouuss ttrraannssffuussiioonn:: A homolo-gous transfusion is blood that comesfrom a donor. While this often is bloodfrom an anonymous donor, a familymember or friend who has your bloodtype can donate a directed donor unitreserved specifically for you. All ho-mologous units of blood, whatever thesource, are tested by the blood bank fortransmissible diseases.EErryytthhrrooppooiieettiinn:: In some special circum-stances, your surgeon may recommendthat you receive erythropoietin, a hor-mone that is naturally produced by thekidney and also commercially producedin a laboratory for treating certain pa-tients with a low red blood cell count(anemia). Erythropoietin given to a pa-tient preoperative may reduce the needfor homologous transfusions (bankblood). Although costly, this medicationis usually covered by insurance.

� SSttoopp ssmmookkiinngg:: This is a good idea atany time, but particularly before majorsurgery in order to help reduce the riskof postoperative lung problems and im-prove healing.� EEvvaalluuaattee yyoouurr nneeeeddss ffoorr aatt--hhoommeeccaarree aafftteerr ddiisscchhaarrggee ffrroomm tthhee hhoossppiittaall::Most hip replacement patients will needhelp at home for the first few weeks, in-cluding assistance with preparing mealsand transportation.� TTeellll yyoouurr ssuurrggeeoonn aabboouutt yyoouurr ccuurr--rreenntt ssuuppppoorrtt sseerrvviicceess//ddeevviicceess:: If you arenow using a home service, bring thename and phone number of the serviceto the hospital. If you have medicalequipment such as a wheelchair, crut-ches, or walker at home, ask your sur-geon if you should make arrangementsto have the equipment brought to thehospital for the physical therapist tomake adjustments.� RReevviieeww yyoouurr iinnssuurraannccee:: Contact yourinsurance company well ahead of time tofamiliarize yourself with the benefitsavailable to you. For example, differentinsurance providers have different rulesfor determining the medical necessity ofrehabilitation, and most do not providea benefit for your transportation home.Also be aware that you will be billed sep-arately by the hospital, your surgeon,and your anesthesiologist and that dif-ferent insurance plans have different for-mulas for determining payments forthese services.

ReAdying youR Home

There are several things that you (or afriend or family member) can do beforeentering the hospital to make yourhome safer and more comfortable uponyour return:� In the kitchen and elsewhere, placeitems that you use regularly at arm levelso you do not have to reach up or benddown.� To avoid using stairs, consider tem-porarily changing rooms - for example,by making the living room your bedroom.� Rearrange furniture to give yourselfenough room to maneuver with a walkeror crutches.

� Get a good chair - one that is firm,has a seat high enough to allow yourknees to remain lower than your hips,and has arm-rests to help you get up.� Remove loose carpets and re-arrange electrical cords in the areaswhere you will be walking.� A footstool will be useful for keepingyour operated leg straight out in front ofyou when you sit.� Plan to wear a big-pocket shirt orsoft shoulder bag for carrying thingsaround.� Set up a "recovery center" in yourhome, with the phone, television remotecontrol, radio, facial tissues, wastebas-ket, pitcher and glass, reading materials,and medications within reach.

PlAnning AHeAd foR youR discHARge

Whether or not you require "rehab" fol-lowing your surgery depends on severalfactors, including your general state ofhealth. Most patients can be safely dis-charged directly home. If your surgeondetermines otherwise, a member of ourSocial Service Department will visit youa day or two after your surgery to giveadvice and help prepare the necessarypaperwork for entry into a rehabilitationfacility.

Every patient is visited by a case man-ager who works with you, your surgeon,and your insurance provider to makeyour discharge from the hospital is assmooth as possible. Patients who are ad-mitted to acute (in-house) rehabilitationwill additionally be helped by a dis-charge planner. If you have any con-cerns about your ability to manage yourpersonal care, mobility, medications, orother recovery needs once you returnhome, bring them up with your casemanager and/or discharge planner: theyare trained to help you in these matters.

Please note that discharge time is 11:00 AM.

Once you are home, we continue to pro-vide care. Depending on your needs, amember of our Social Service Depart-ment can arrange for a visiting nurse, ahome therapist, or in some cases a homehealth aide to check on you severaltimes during the week for the first fewweeks after your surgery.

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The day beforeyour surgery

geTTing To THe HosPiTAl

If your surgery is at the Lutheran Medical Center:

Go to the Lutheran Medical Center at150 55th Street in Brooklyn, which is onthe corner of Second Avenue, and pro-ceed to the location you were told thenight before.

If your surgery is at NYU Hospital for Joint Diseases:

Go to NYU Hospital for Joint Diseases at301 East 17th Street in Manhattan,which is on the corner of Second Avenue,and proceed to the location you weretold the night before.

The day before your surgeryYou will receive a telephone call from the hospital after 5:00 PM on theweekday before your surgery telling you when to come to the hospital andexactly where to go. For example, if your surgery is on Tuesday, the hospi-tal will call you on Monday night; if your surgery is on Monday, the call willbe on Friday night. Your arrival may be scheduled for as early as 6:00 AM,so be sure to get a good night's sleep. It is important that you arrive on timebecause if you are late, your surgery will have to be rescheduled.

DDiieett:: You may eat normally on the day before your surgery, but do not drinkalcohol. DDOO NNOOTT EEAATT OORR DDRRIINNKK AANNYYTTHHIINNGG AAFFTTEERR MMIIDDNNIIGGHHTT..This is important so that it will not interfere with your anesthesia.The onlyexception is if your doctor specifically instructs you to take medication witha sip of water. Shower and shampoo either the night before or the morningof your surgery.

AnesTHesiAAnesthesia is the process of inducing apain-free, tranquil, sleeplike state foryour surgery. Your anesthesiologist hasseveral techniques to carry you throughsurgery comfortably and without pain.Some medical conditions may make onetechnique preferable. You should discussthis with both your surgeon and youranesthesiologist. Whichever technique ischosen, be assured that your operatingroom experience will be a painless andtranquil one.GGeenneerraall aanneesstthheessiiaa.. First you are givenmedication to induce a sleep-like state,followed by a gas anesthetic agent ad-ministered via a mask into your lungs.Throughout the operation you will be at-

tached to monitors that display informa-tion on your heart rhythm and rate, oxy-gen level in your bloodstream, bodytemperature, and blood pressure. Youranesthesiologist continually checks thesemonitors.RReeggiioonnaall AAnneesstthheessiiaa.. Some patients rejectregional anesthesia because they thinkthat they will be awake during the pro-cedure. This is not true. In regional anes-thesia, you also receive medications thatallow you to sleep peacefully throughoutthe operation. Unlike general anesthesia,when regional anesthesia is discontinuedyou will awaken almost immediately andwithout pain (because the anesthesia isstill working). Two types of regionalanesthesia are commonly used: spinal

and epidural. They may also be used incombination. When this type of anesthe-sia is used, you are monitored as de-scribed above for general anesthesia.

The day of your surgery

OOnnccee yyoouu aarrrriivvee aatt tthhee hhoossppiittaall::� You will be provided with a gown anddisposable undergarments for your com-fort. Your own clothing and personal be-longings will be safely stored.� You will be asked to fill out an oper-ative consent form, to review it, and tosign it along with your surgeon and athird-party witness. (If this was done pre-viously, your surgeon will review the formwith you again.) Your surgeon will alsoplace his/her initials over the operativesite as an extra precaution.� Your anesthesiologist will go over withyou the type of anesthesia to be used foryour surgery. After that explanation, youwill be asked to complete, review, and signa consent form specifically for the anes-thesia. When the operating room is ready,you will be escorted there by a nurse.During your surgery, your family andfriends may wait in any of sev¬eral com-fortable hospital locations, including theNYU Hospital for Joint Diseases' waitingroom (C1 level),Tisch Hospital's solarium(15th floor), and the cafeteria (13th floorat NYUHJD, ground floor atTisch). Withyour permission, your surgeon will calland speak with them after your surgery.

THe dAy of youR suRgeRyOn the day of surgery:� You may brush your teeth and rinse your mouth - without swallowing any water.� Wear comfortable, loose-fitting clothing and flat, non-slip, walking or athletic shoes.� Leave valuable possessions at home or give them to a family member for safe

keeping. (See "What and what not to bring to the hospital," below.)

WHAT To BRing, And WHAT noT To BRing, To THe HosPiTAl

BBrriinngg ttoo tthhee hhoossppiittaall� Toiletries (toothbrush etc.)� Your cane or crutches, if needed� Eyeglasses - not contact lenses� Dentures/hearing aid. A container

will be provided for these, which you should keep on your bedside table or in a drawer - not on the bed or a food tray.

� A list of your medications, including the ones you have recently stopped taking at your surgeon's request

� Important telephone numbers� Small amount of cash - for

newspapers, etc.� Credit card or 2-3 checks - for TV

and telephone services� A book, magazine, or hobby item

for relaxation� This booklet

DDOO NNOOTT bbrriinngg ttoo tthhee hhoossppiittaall� Medications - unless askedby your surgeon� Valuables - jewelry, watch,wallet, large amounts of cash,credit cards (other than fortheTV etc. - see other column)

All hospital staff members re-spect your property rights, butwe cannot guarantee security foryour personal property.

suRgeRy PRePARATion cHecklisT

The night before your surgery:□ Shower (may be done day of surgery if time permits).□ Nothing to eat or drink after midnight.□ Review this Guide.□ Get a good night's rest.

The day of your surgery:□ Take routine medications with only a sip of water-

as instructed by your doctor.□ Brush your teeth and rinse - without swallowing.□ Wear comfortable clothing.□ Leave valuables at home or with a family member.9

ARTHRiTis of THe HiPArthritis of the hip is a condition in which the smooth gliding surfaces of your hip joint (articular cartilage) have become dam-

aged. This usually results in pain, stiffness, and reduced flexibility.The most common type of arthritis, osteoarthritis, typicallydevelops in older patients due to a lifetime of wear and tear. It can also occur in someone whose hip did not develop normally.Less common forms of arthritis include traumatic arthritis, which develops as a result of an injury such as a fracture in the

hip joint that does not heal properly, and rheumatoid or inflammatory arthritis, which results from an inflammatory condi-tion or autoimmune disease. Arthritis may also result from osteonecrosis, which may develop rather unexpectedly, resultingin the sudden onset of pain in the hip.

In total hip replacement surgery, the portions of the hip joint that contain the damaged surfaces are replaced with bio-compatible devices that provide a smooth and painless range of motion. Your surgeon will make every effort to restore yourhip to a condition that resembles its healthy preoperative status. You should discuss what realistic outcome to expect withyour surgeon.

NORMAL HIP

In an x-ray of a normal hip, the articularcartilage (the area labeled "normal jointspace") is clearly visible.

ARTHRITIC HIP

The joint space has con-siderably nar-rowed, with the result that the head ofthe femur (the "ball" at the top of thethigh bone) is in direct contact with thebone of the acetabulum ("hip socket"), acondition called "bone-on-bone."

TOTAL HIP REPLACEMENT

Implants anchored inside the femur andacetabulum form a new ball-and-socketjoint that is held in place by musclesand soft tissues. Implants may be se-cured to your bone by cement or theymay have textured surfaces to encour-age bone ingrowth.

Getting the mostout of your surgery

Many patients are un-derstandably concernedabout postoperative pain.Pain control has becomevery sophisticated. Usuallythe level of discomfort iseasily manageable with oralor injected pain medication.Some patients receive IV-

PCA - intravenous patient-controlled analgesia - for aday or two following sur-gery: this allows the patientto self-administer a safeand effective amount ofpain medication through anIV tube by pressing a but-ton. Similarly, in some casesan epidural catheter thatautomatically delivers painmedication may be left inplace for 24 hours follow-ing surgery.

getting the most out of your surgeryWhen your surgery is complete you will be taken to a recovery room,

where you will spend two to three hours before being moved to your regu-lar hospital room. Family and friends may visit you briefly in the recoveryroom. Depending on your anesthesia, your medical history, and other fac-tors, you may first be taken to a monitored bed environment (either the In-tensive Care Unit or the Post-Op Unit). Your surgeon or anesthesiologist willdiscuss this with you before your surgery.

Your care team will monitor your progress throughout your hospital stayto ensure your safe and efficient recovery. Among other things, they will pe-riodically check your vital signs—temperature, blood pressure, etc.—andchange the dressings that cover your incision.Your surgeon may also decidethat you can benefit from a blood transfusion, a blood-thinning medicationor automatic foot pump device to prevent clot formation, and/or an incen-tive spirometer that you breathe into to help keep your lungs clear: all thesethings will be attended to throughout the day by your care team.

youR cARe TeAm� Your surgeon� Nurses� Nurse practitioners� Physical therapist or occupa-tional therapist� Fellows and residents: licensedphysicians undergoing specializedpostgraduate training in orthopaedicsurgery� Internist: a specialized physicianselected by your surgeon to assist inthe medical management of your post-operative care� Pain specialists: a physician and anurse practitioner who specialize inpain management� Rehabilitation specialist: a physi-cian trained to determine the level ofcare you will require once you leavethe hospitalOne or more of the above care teamphysicians, depending on your needs,will visit you "on rounds" every daythat you are in the hospital.

PPaaiinn mmaannaaggeemmeenntt

Exercise and physical therapy

exercise and physical therapyThe day after your operation, your nurses, physical therapists, and other

caregivers will start you on a course of treatment that will prepare you forlife with your new hip.

On the morning following your surgery, a physical therapist will assist youto a standing position, and using a walker you will begin to walk on your newhip. In most cases you will be allowed to put all your weight on your new hip;this is called weightbearing as tolerated. Sometimes, because of the natureof your surgery, your surgeon may decide that at first you should place onlypart of your weight on your operated leg: this is called partial weightbear-ing; as time passes, you will be able to increase the amount of weight thatyou place on the operated side to weightbearing as tolerated. Your surgeonwill leave specific instructions with your physical therapist.

By about the third day after yoursurgery, you will be walking withgreater confidence using a walker orcrutches and be ready for discharge.Your occupational therapist will teachyou special techniques for dressing,bathing, and climbing stairs. Most pa-tients are surprised at how independ-ent they become, and how quickly.

For the first four to six weeks fol-lowing surgery, most of our patientsrequire and receive some form oftherapy: either home therapy, outpa-tient therapy, or therapy as part of

care in a rehabilitation facility.Regular exercises to restore yournormal hip motion and strength anda gradual return to everyday activi-ties are important for your full re-covery. Your surgeon and physicaltherapist may recommend that youexercise 20 to 30 minutes 3 times aday: morning, afternoon, and night. When you are discharged from the

hospital, you will be offered home as-sistive devices such as a reacher forgrabbing objects that can fall to thefloor and aids for putting on shoes

and stockings. A toilet seat elevation("High John" or commode) will alsobe provided because the standardhome toilet seat is low enough to putyou at risk of dislocating your hip inthe first weeks following surgery.(See "Preventing dislocation: The 90-Degree Rule" ) If you are planning totravel home by car or taxi, youshould arrange to have a firm pillowprovided for you to sit on.This willproperly elevate your hip as well asmake it easier to get into and out ofthe vehicle.

Preventing dislocationTo minimize the risk of dislocating your hip replacement,

keep in mind the 90-Degree Rule: DDoo nnoott bbeenndd yyoouurr lleeggaatt tthhee hhiipp ppaasstt 9900 ddeeggrreeeess (a "right angle"). Also avoidcrossing your legs and squatting.

Thе 90-degree RuleAnother good rule of

thumb: If you can see theinside of your knee (on theoperated side), you're OK;if you can't, you're not OK.

Thе 90-degree Rule

Use only chairs with arms and use the armrests to get up.

To make sureyou do not

break the 90-Degree rule

while sleeping,keep a pillow or

two betweenyour legs.

Do NOT reach down toput on your shoes - usean elongated shoe horn.

Do NOT reach over in bed to pul up your blankets - use

your "readier".

yes! no!

Resuming your normal activitiesMost hip replacement patients experience a dramatic reduction in joint pain and a significant improvement in their abil-ity to participate in the activities of daily living. Be aware, however, that recovery takes time. Expect to feel a bit more tiredthan usual for a few weeks. Your surgery is a major event. Give yourself time to regain your strength and self-confidence.Stay active - just don't overdo it! You will notice a gradual improvement over time in your strength and endurance.Once you are home, you will want to keep track of the state of your new hip as well as your general health for severalweeks. In particular:� Take your temperature twice daily and notify your doctor if it exceeds 100.5°F.� Take all medications as directed.� Notify your doctor immediately if you notice tenderness, redness, or pain in your calf, chest pain, and/or shortnessof breath. These are all signs of a possible blood clot.Because you have an artificial joint, it is especially important to prevent bacteria from entering your bloodstream thatcould settle in your joint implant. You should take antibiotics whenever there is the possibility of a bacterial infection,such as when you have dental work. Be sure to notify your dentist that you have a joint implant; they are trained to pre-scribe antibiotics for you to take by mouth prior to an extraction, periodontal work, dental implant, or root canal work.

TAking cARe of youR suRgicAl incision

Your surgical incision will be closed usingsutures or staples that will be removedabout two weeks after your surgery. (Insome cases resorbable sutures are usedthat do not need be removed.) The fol-lowing apply to taking care of yourwound:� Keep the area clean and dry. A dress-ing will be applied to the site in the hos-pital and should be changed as neces-sary. Ask for instructions on how to chan-ge the dressing if you are not sure.� Notify your doctor if the wound ap-pears red or begins to drain.� Some swelling is normal for the firstthree to six months after surgery.

These exercises are important for in-creasing circulation to your legs andfeet to prevent blood clots.They alsoare important to strengthen musclesand to improve your hip movement.

Do not give up if some exercises feeluncomfortable at first: they willspeed your recovery and reduce yourpostoperative pain. All exercisesshould be done SLOWLY.

Not every exercise is appro-priate for every patient. Yourtherapist will check off the ex-ercises that are right for you.Unless otherwise indicated,do these exercises every dayin three sessions: morning, af-ternoon, and night.

early postoperative exercises

!Ankle pumps: Slowly move your footup and down. Do this exercise severaltimes as often as every 5 or 10 min-utes.This exercise can be done whileyou are either lying down or sitting in achair. You can begin this exercise im-mediately after surgery in the recoveryroom. Keep doing it periodically untilyou are fully recovered.

Bed-supported knee bends: Slide your heel toward your buttocks,bending your knee and keeping yourheel on the bed. Donot let your kneeroll inward nor letyour hip exceed 90degrees. Repeat thisexercise 10 times.

If at first you findthis difficult to do,you can use a rolled-up sheet or towel tohelp pull your ankle

Quad set: Tighten your thigh (quadri-ceps) muscle. Try to straighten yourknee while pushing the back of yourknee to the bed. Hold for 5 to 10 sec-onds. Repeat this exercise 10 times foreach leg (not just your operated leg).

Ankle rotations: Move your ankleinward toward your other foot and thenoutward away from your other foot. Donot rotate your knee - just your ankle.Repeat 5 times in each direction. Thisexercise can be done while you are ei-ther lying down or sitting in a chair.

Buttock contrac-tions: Tighten but-tock muscles andhold to a count of 5.Repeat this exercise10 times.

Abduction exer-cise: Slide your op-erated leg out to theside as far as youcan and then back.Repeat this exercise10 times.

standing knee raises: Liftyour operated leg toward yourchest. Do not lift your kneehigher than your waist. Holdfor a count of 2 or 3 and putyour leg down.

standing hip extensions:Lift your operated leg back-ward slowly. Try to keep yourback straight. Hold for a countof 2 or 3 and then return yourfoot to the floor.

standing hip abduction:Be sure your hip, knee, and footare pointing straight forward.Keep your body straight. Withyour knee straight, lift your op-erated leg out to the side.Slowly lower your leg so yourfoot is back on the floor.

standing exercisesSoon after your surgery, you will be out of bedand able to stand. You will require help until youregain your strength and are able to stand inde-pendently. While doing these standing exercises,make sure you are holding on to a firm surfacesuch as a bar attached to your bed, a wall, or asturdy chair.Repeat each the following exercises 10 times per session:

Resistive hip flexion: Stand facing awayfrom the door or heavy object to which the tub-ing is attached, with your feet slightly apart.Bring your operated leg forward while keepingthe knee straight. Allow your leg to return toits previous position.

Resistive hip extensions: Face the door orheavy object to which the tubing is attachedand pull your leg straight back. Allow your legto return to its previous position.

Resistive hip abduction: Stand sidewaysfrom the door or heavy object to which the tub-ing is attached and extend your operated legout to the side. Allow your leg to return to itsprevious position.

Advanced exercises and activitiesA full recovery will take time.The pain from your problem hip be-fore your surgery and the pain and swelling after surgery haveweakened your hip muscles.The following exercises and activitieswill help your hip muscles recover fully.elastic tube exercises. These exercises should each be done 10times morning, afternoon, and night, with one end of the tubingaround the ankle of your operated leg and the opposite end of thetubing attached to a stationary object such as heavy furniture.

Advanced exercises and Activities

By the time you come home from thehospital, you should be eating a nor-mal diet. Your physician may recom-mend that you take iron and vitaminsupplements. Continue to drinkplenty of fluids and avoid excessiveintake of vitamin К if you are takingthe blood-thinning medicationCoumadin. Foods rich in vitamin Кinclude broccoli, cauliflower, brusselssprouts, liver, green beans, garbanzobeans, lentils, soybeans, soybean oil,spinach, kale, lettuce, turnip greens,cabbage, and onions. Try to limit yourcoffee intake, and avoid alcoholic bev-erages altogether. You should con-tinue to watch your weight to avoidputting more stress on the joint.

Exercising on a stationary bicycleis an excellent activity to help youregain muscle strength and hip mo-bility. Adjust the seat height so thatthe bottom of your foot justtouches the pedal with your kneealmost straight. Pedal backwards atfirst. Pedal forward only after acomfortable backwards cyclingmotion is possible. As you becomestronger (at about 4 to 6 weeks)slowly increase the tension on thepedals. Keep in mind the 90-De-gree Rule. Do not raise your kneehigher than your hip. Pedal for-ward 10 to 15 minutes twice a day,gradually building up to 20 to 30minutes 3 to 4 times a week.

Take a cane with you until you haveregained your balance skills. In thebeginning, walk 5 or 10 minutes 3or 4 times a day. As your strengthand endurance improve, you canwalk for 20 or 30 minutes 2 or 3times a day. Once you have fully re-covered, regular walks, 20 or 30minutes 3 or 4 times a week, willhelp maintain your overall strength.

dieT WAlking sTATionARy Bicycle exeRcise:

BAsic AcTiviTiesGenerally, the following guidelines willapply:� Weightbearing: Be sure to discussweightbearing restrictions with yourphysician and physical therapist.Theirrecommendations will depend on the typeof implant and other issues specific toyour situation.� Driving: You can begin driving an au-tomatic shift car in four to eight weeks,provided you are no longer taking nar-cotic pain medication. If you have a stickshift car, this may take longer.The physi-cal therapist will show you how to slide inand out of the car safely. Placing a plasticbag on the seat can help.� Sexual relations can be safely re-sumed four to six weeks after surgery -provided you remember to observe the90-Degree Rule.� Sleeping position: Sleep either on

your back or on your side. In either case,keep a pillow (or two) between your legs(see "Preventng dislocation: The 90-De-gree Rule"). Be sure to use the pillow forat least six weeks or until your doctorsays you tan do without it.� Sitting: For at least the first threemonths, sit only in chairs that have arms.Do not sit on low chairs, low stools, or re-clining chairs. Do not cross your legs.Thephysical therapist will show you how tosit and stand from a chair, keeping youroperated leg out in front of you. Do not sitfor too long; get up and move around ona regular basis.� Return to work: Your surgeon will de-termine when you are medically fit to re-turn to work. In your first follow-up visit(usually four to six weeks after your sur-gery), if everything is normal, your sur-geon may give you the go-ahead to returnto work full-time. If your work is not too

physically demanding and you feel up toit, you can return to work even earlier, atleast part-time (perhaps a few hours onceor twice a week). Don't push yourself toohard. If your work is more physically de-manding, it may take more time (approx-imately three months) to return to work.� Other activities: Walk as much asyou like once your doctor gives you thego-ahead, but remember that walking isno substitute for your prescribed exer-cises. Swimming is also recommended:you can begin swimming as soon as yoursurgeon has determined that your surgi-cal wound is well healed. By threemonths, most patients can return to anactive life style, which could include golf-ing, bowling, bike riding, dancing, play-ing doubles tennis, and, in some cases,even skiing. Most surgeons discouragehigh-impact aerobic activities like jog-ging and basketball.

do's And don'TsPrecautions are necessary to prevent the new joint from dislocating and to ensure proper healing.Here are some of the most common:• DO cut back on your exercises if your muscles begin to ache-but don't stop doing them!• DO keep the leg facing forward at all times.• DO keep the operated leg in front as you sit or stand.• DO get into a car by "backing in" and sitting first, then bring both legs into the car -

but DON'T drive while on medications that could make you drowsy.• DON'T bend at the waist beyond 90 degrees.• DON'T bring your knee up higher than your hip.• DON'T cross your legs for at least eight weeks.• DON'T lean forward while sitting or as you sit down.• DON'T reach down to pull up blankets when lying in bed.• DON'T stand pigeon-toed.• DON'T try to pick up something on the floor while you are sitting.• DON'T turn your feet or knees excessively inward or outward.

Don't let your knee crossthe midline of your body.

Don't plant your foot androtate your new hip inward.

Don't bend all the wayover from the waist.

Rather, sit with both feet on thefloor, with your knees six inchesapart.

Rather, turn both your feetand your body.

Rather, use a device, such as along-handled grabber to reachdown.

no yes

getting around after your surgeryWalking with a walker or crutches: Stand comfortably

and erect, with your weight evenly balanced on yourwalker or crutches. Move your walker or crutches forwarda short distance.Then move forward, lifting your operatedleg so that the heel of your foot touches the floor first. Asyou move forward, your knee and ankle will bend andyour entire foot will rest evenly on the floor. As you com-plete the step, allow your toe to lift off the floor. Moveyour walker or crutches again, and reach forward withyour hip and knee for your next step. Remember, touchyour heel first, then flatten your foot, then lift your toes offthe floor. Walk as rhythmically and smoothly as you can, but don't hurry. Ad-just the length of your step and speed as necessary to walk with an even pat-tern. As your muscle strength and endurance improve, you may spend moretime walking. Gradually, you will put more and more weight on your leg.Walking with a cane or single crutch: A walker is oftenused for the first several weeks to help your balance andto avoid falls. A cane or single crutch is then used for sev-eral more weeks until your full strength and balancehave returned. Use the cane or crutch in the hand oppo-site the operated hip. You are ready to use a cane or sin-gle crutch when you can stand and balance without yourwalker, when your weight is placed fully on both feet,and when you are no longer leaning on your hands whileusing your walker.Climbing and descending stairs: Going up and down stairs requires both flex-ibility and strength and so should be avoided if possible until healing is com-plete. If you must use stairs, you may want to have someone help you untilyou have regained most of your strength and mobility. Always use a handrailfor support on the side of your unaffected leg and move up or down thestairs one step at a time:going up stairs:1. Step up on your unaffected leg.2. Next step up on your operated leg.3. Finally bring up your crutch(es) or cane(s).going down stairs, reverse the process:1. Put your crutch(es) or cane(s) on the lower step.2. Next step down on the operated leg.3. Finally, step down on the unaffected leg.

RememBeR To AlWAys leAd uP THe sTAiRs WiTH youR unAffecTed leg, And doWn THe sTAiRs WiTH youR oPeRATed leg.

There are risks in any type of sur-gery, not just hip replacement sur-gery The general risks of hipreplacement surgery - such as a badreaction to anesthesia or heart at-tack - are no greater than in mostother types of surgery. To help pre-vent your developing a blood clot,your surgeor may prescribe ablood-thinning drug (such asCoumadin or Lovenox). Alterna-tively, or in addition, pump-drivencompressive devices may be ap-plied to your legs following surgeryto reduce the chances of clot for-mation.The following are among the pos-

sible complications following hipreplacement surgery. While this listis not complete, it includes compli-cations you should be aware of.

dislocation. Every hip replacementrisks dislocation ("popping out"), es-pecially during first days and weeksfollowing surgery. Fortunately, thisis one complication that you can domuch to prevent. (See "Preventingdislocation: The 90-Degree Rule")

If you do dislocate your hip, no-tify your surgeon at once. Your sur-geon will instruct you on how toget help immediately - either athis/her hospital or the nearestemergency room. Every or-thopaedic surgeon knows how toreduce a dislocated hip replace-ment ("pop it back in"). To help pre-vent this from happening again,your surgeon may recommend thatyou wear a brace to reduce motion.Although the possibility of replace-

Risk factors and complications

ment hip dislocation never completelygoes away, the risk is greatly reducedonce the soft tissues that surround yourhip heal, after about three months.

AlWAys RememBeR THe 90-degReeRule And Avoid exTReme TWisTing

And Bending.

implant loosening and wear. The typicalhip replacement has a 90-95% probabil-ity of functioning well for more than 10years.This is still not forever. Over timethe implant may show signs of wear, or itmay loosen, and so may require a secondreplacement ("revision"). Continuing re-search promises to increase implant life-times and make replacement even easier

in the future. Feel free to discuss the cur-rent state of technology with your sur-geon regarding implant designs.

infection. Although infection in a hipreplacement is relatively rare, it is a se-rious complication that requires ur-gent, aggressive treatment. Manyinfections can be avoided. For example,standard dental procedures, includingroutine cleaning, carry the risk of bac-teria entering your bloodstream and in-fecting your hip implant.Taking anantibiotic approximately an hour be-fore your procedure can greatly reduceor eliminate this risk.The same rule ap-plies to medical procedures such assurgery or even a colonoscopy.

nerve or blood vessel injury. There is arisk of damage to nerves or blood vesselsin hip replacement surgery - as in anyother kind of surgery - but it is extremelylow. If you experience sudden numbnessor weakness in your leg or foot in thedays following surgery, notify yournurse or doctor immediately.

unequal leg lengths. In patients withhip arthritis, the leg with the arthritichip is often shorter than the other.While your surgeon will make everyattempt to make your legs the samelength, this is not always possible - oreven desirable.The vast majority of pa-tients will not notice any significantdifference.

david ginsburg, 68Total Hip Replacement 2008

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I had the total hip replacement, and the moment I woke up from surgery,I noticed that the arthritis pain I’d been suffering all these years was gone.