Hip Treatments in India

 
Total Hip Replacement

How the Normal Hip Works

The hip is one of the largest weight-bearing joints. It consists of two main parts: a ball (femoralhead) at the top of thighbone (femur) that fits into a rounded socket (acetabulum) in pelvis. Bands of tissue called ligaments (hipcapsule) connect the ball to the socket and provide stability to the joint.

The bone surfaces of ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily.


A thin, smooth tissue called synovial membrane covers all remaining surfaces of the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in hip joint.

Normal Hip Joint Normal Hip Joint

Normally, all of these parts of hip work in harmony, allowing moving easily and without pain.

Common causes of Hip Pain and Loss of Hip Mobility

The most common cause of chronic hip pain and disability is arthritis - Osteoarthritis, rheumatoid arthritis and post traumatic arthritis.

Osteoarthritis usually occurs after age 50 years and often in an individual with a family history of arthritis. It may be caused or accelerated by subtle irregularities in how the hip developed. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.

Rheumatoid Arthritis is an autoimmune disease in which the synovial membrane (lining of joint) becomes inflamed, produces too much synovial fluid, and damages the articular cartilage, leading to pain and stiffness.

Post Traumatic Arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as avascular necrosis. The articular cartilage becomes damaged and over time, causes hip pain and stiffness.

What is Total Hip Replacement?

In this surgery the damaged cartilage and bone is removed from hip ball and socket and replaced by new metal, plastic or ceramic joint surfaces to restore the alignment and function of hip joint.

Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of a highly polished strong metal cobalt chrome molybdenum or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).

Arthritic Hip Hip Replacement X-ray before THR X-ray after THR
Arthritic Hip     Hip Replacement   X-ray before THR   X-ray after THR

A non-cemented prosthesis has also been developed which is used most often in younger, more active patients with strong bone. The prosthesis may be coated with textured metal or a special bone-like substance, which allows bone to grow into the prosthesis.

A combination of a cemented ball and a non-cemented socket may be used.

I will choose the type of prosthesis that best meets your need.

When to Consider Total Hip Replacement?

Hip replacement surgery is indicated when:

  1. Hip pain limits your everyday activities such as walking.
  2. Hip pain continues while resting, either day or night
  3. Stiffness in a hip limits your ability to move or lift your leg.
  4. You have little pain relief from anti-inflammatory drugs.
  5. You have harmful or unpleasant side effects from medications.
  6. Other treatments such as physical therapy or the use of a gait aid such as a cane don't relieve hip pain.

What to Expect from Hip Replacement Surgery

An important factor in deciding whether to have hip replacement surgery is to understand what this procedure can and can't do.

Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.

Following surgery, you will be advised to avoid certain activities, including jogging and high-impact sports, for the rest of your life. You may be asked to avoid specific positions of the joint that could lead to dislocation.

Every bearing surface of hip prosthesis wears out in long term and lead to aseptic loosening. Over weight patient has higher rate of wear. In case of long term failure revision hip replacement can be done successfully.

Preparing for Surgery

Preparing Skin - Skin should not have any infections or irritations before surgery. If either is present, contact me or skin specialist to improve your skin before surgery.

Medications - Tell me about the medications you are taking. I will advise you which medications you should stop or can continue taking before surgery. The blood thinning medications to be stopped 7 days prior to surgery.

Dental Evaluation- Although infections after hip replacement are not common. Infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, you should consider getting treatment for significant dental diseases (including tooth extractions and periodontal work) before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.

Urinary Evaluation - - Individuals with a history of recent or frequent urinary infections and older men with prostate disease should consider a urological evaluation before surgery.

Social Planning - Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, bathing, shopping and laundry. One has to arrange help for all these purpose.

Home Planning

Here are some items and home modifications that will make your home return easier during your recovery.

  1. Securely fastened safety bars or handrails in your shower andbedroom .
  2. Secure handrails along all stairways.
  3. A stable chair for your early recovery with a firm seat cushion that allows your knees to remain lower than your hips, a firm back and two arms.
  4. A raised toilet seat.
  5. A stable shower bench or chair for bathing.
  6. A long-handled sponge and shower hose.
  7. A dressing stick, a sock aid and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip.
  8. A reacher that will allow you to grab objects without excessive bending of your hips.
  9. Firm pillows to sit on that keep your knees lower than your hips for your chairs, sofas and car.
  10. Removal of all loose carpets and electrical cords from the areas where you walk in your home.

Surgery and Stay in the Hospital

You will most likely be admitted to the hospital one day prior to your surgery and will remain there for total three day for one side (Unilateral) and five days for both sides (bilateral) surgery.

Tests – after admission several tests such as routine blood tests, a cardiogram, chest and hip X-rays, 2D Echo or dobutamine Stress Echo and urine samples will be needed to take medical fitness for surgery.

Medical and Pre-anesthetic Evaluation - This is needed to assess your health, risk of surgery and find conditions that could interfere with your surgery or recovery.

A through physician and cardiology check up is done prior to surgery. A member of the anesthesia team will evaluate you after your all tests are over. The most common types of anesthesia for hip replacement surgery is spinal and epidural anesthesia (which allows you to breath on your own but anesthetizes your body from the waist down) or general anesthesia (which puts you to sleep throughout the procedure and uses a machine to help you breath). The anesthetist team will discuss these choices with you and help you to decide which type of anesthesia is best for you.

Surgical Procedure - takes one to one and half hours.

Recovery and Physiotherapy

Postoperative Recovery - After surgery, you will be moved to the recovery room where you will remain for one to two hours while your recovery from anesthesia is monitored.

After you are awakening fully, you will be taken to your hospital room. High-risk patients are kept in ICU – Intensive Care Unit for 24 hours for observation of vital parameters.

Post-operative Pain Management - A very special technique patient control analgesia (PCA) is used where a catheter is kept in epidural space and through PCA pump pain relieving medicines are delivered in controlled fashion. If patient need more dose patient can inject a bolus by them through hand press button given to them in post-operative period for 2 to 3 days.

There is no post-operative pain; hence this is painless joint replacement surgery.Other pain relieving medications are also given as injections or oral tablets to control pain.

Physiotherapy - To avoid lung congestion after surgery, you will be asked to breathe deeply and cough frequently.

To protect your hip during early recovery, a positioning or abduction splint, such as a V-shaped pillow placed between your legs, may be used.

Sitting and walking activities are important to your recovery and will begin on the day of surgery. Most hip replacement patients begin standing and walking with the help of a walking support and a physical therapist the day after surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.

Depending up on the type of procedure and implant (Uncemented or cemented) used weight bearing will differ from partial weight to full weight bearing.

Possible Complications after Surgery

The complication rate following hip replacement surgery is low.

Joint infection - occur in less than 2 percent of patients.

Blood clots - in the leg veins or pelvis are the most common complication of hip replacement surgery. I may prescribe one or more measures to prevent blood clots from forming in your leg veins or becoming symptomatic. These measures may include special support hose, inflatable leg coverings, ankle pump exercises and blood thinners. Early mobilization from bed is the key to prevent blood clots. That is one of the reasonsmy entirepatient starts sitting same day of surgery and start walking same or next day of surgery.

Leg-length inequality - may occur or may become or seem worse after hip replacement. I will take this into account, in addition to other issues, including the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.

Other complications - such as dislocation, nerve and blood vessel injury, bleeding, fracture and stiffness can occur.

Aseptic loosening - Over years, the hip prosthesis may wear out or loosen. This problem will likely be less common with newer materials and techniques. When the prosthesis wears, bone loss may occur because of the small particles produced at the wearing surface. This process is called osteolysis.

Recovery at Home and Post Surgery Instructions

The success of your surgery will depend in large measure on how well you follow my instructions regarding home care during the first few weeks after surgery

Wound Care - You will have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed about two weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. A bandage may be placed over the wound to prevent irritation from clothing or support stockings.

Diet - Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron and vitamins supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.

Activity- Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within three to six weeks following surgery. Some discomfort with activity and at night is common for several weeks. Your activity program should include:

  1. Securely fastened safety bars or handrails in your shower or bed.
  2. A graduated walking program, initially in your home and later outside.
  3. Walking program to slowly increase your mobility and endurance.
  4. Resuming other normal household activities.
  5. Resuming sitting, standing, walking up and down stairs.
  6. Specific exercises several times a day to restore hip movement.
  7. Specific exercises several times a day to strength your hip joint.
  8. May wish to have a physical therapist help you at home.

Avoiding Problems after Surgery

Blood Clot Prevention - Follow my instructions carefully to minimize the potential risk of blood clots, which can occur during the first several weeks of your recovery.

Warning signs of possible blood clots include:

Pain in your calf and leg, unrelated to your incision

Tenderness or redness of your calf

Swelling of your thigh, calf, ankle or foot

Notify me immediately if you develop any of these signs.

Preventing infection - The most common causes of infection following hip replacement surgery are from bacteria that enter the bloodstream during dental procedures, throat infection, urinary tract infection or skin infections. These bacteria can lodge around your hip prosthesis.

Following your surgery, you may need to take antibiotics prior to dental work, including dental cleanings, or any surgical procedure that could allow bacteria to enter your bloodstream.

Warning signs of a possible hip replacement infection are:

  1. Persistent fever (higher than 100 degrees orally).
  2. Shaking chills.
  3. Increasing redness, tenderness or swelling of the hip wound.
  4. Drainage from the hip wound.
  5. Increasing hip pain with both activity and rest.

Notify me immediately if you develop any of these signs.

Avoiding Falls - A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker or handrails or have someone help you until you improve your balance, flexibility and strength.

I will help you decide what assistive aides will be required following surgery, and when those aides can safely be discontinued.

Other precautions - To assure proper recovery and prevent dislocation of the prosthesis, you must take special precautions.

  1. Do not cross your legs.
  2. Do not bend your hips more than a right angle (90 degrees).
  3. Do not turn your feet excessively inward or outward.
  4. Use a pillow between your legs at night when sleeping until you are advised by me that you can remove it.

I will give you more instructions prior to your discharge from the hospital.

How Your New Hip is Different

You may feel some numbness in the skin around your incision.

You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time and most patients find these are minor compared to the pain and limited function they had experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. I will provide animplant alert card confirming that you have an artificial hip.

Follow up

It is very important to have regular follow-up, See me periodically for routine follow-up examinations and X-rays, even if your hip replacement seems to be doing fine.

Minimally Invasive Total Hip Replacement

Over the past several years, orthopaedic surgeons have been developing new techniques, known as minimally invasive hip replacement surgery, for inserting total hip replacements through smaller incisions. It is hoped, but not yet proven, that this may allow for quicker, less painful recovery and more rapid return to normal activities.

Minimally invasive and small incision total hip replacement surgery is a rapidly evolving area. While certain techniques have proven to be safe, others may be associated with an increased risk of complications such as nerve and artery injuries, wound healing problems, infection, fracture of the femur and malposition of the implants, which can contribute to premature wear, dislocation and loosening of your hip replacement. Patients who have marked deformity of the joint, those who are heavy or muscular, and those who have other health problems, which can contribute to wound healing problems, appear to be at higher risk of problems.

Information


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Dr L H Hiranandani Hospital,
Hillside Avenue,Hiranandani Gardens,Powai
Mumbai 400 076.India

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