What is a problematic total hip replacement?

There is no doubt a total hip replacement is the operation of the century. It is one of the top three interventions that can be performed in any branch of medicine including cataract surgery and renal transplantation surgery.

The problematic total hip replacement is one which continues to be painful or is unstable. Sometimes other issues such as a leg length inequality may be causing a problem.

The problem may be clinically silent and is sometimes only picked up on X-ray such as wear or osteolysis. Your surgeon will advise you if this is the case.

Patients can present with a vague non-specific pain in and around the hip. Alternatively, they can present with a more specific pain often related to the groin. Patients with instability or dislocation often present in a much more dramatic fashion by dislocating their hips and reduction is invariably required in hospital. Patients with leg length discrepancy often present early and may require a shoe raise to equalise their leg lengths. In rare situations, patients with an infection can become acutely unwell and require an urgent debridement of the hip.

What can cause problems?

The problematic total hip replacement can be divided into those extrinsic to the hip replacement, such as concomitant spinal issues leading to referred pain. Causes intrinsic to the hip replacement include:-

  • Periprosthetic infection
  • loosening, impingement
  • squeaking, trochanteric bursitis
  • dislocation
  • leg length discrepancy
  • septic or aseptic loosening
  • recurrent dislocation
  • prosthetic or periprosthetic fracture
  • adverse reactions to wear
  • debris such as osteolysis and metallosis.

What investigations may be required?

Identification of the underlying cause often requires a number of investigations including:

  • Blood tests (ESR and CRP)
  • Serial X-rays
  • Bone scan
  • Aspiration
  • MRI
  • Diagnostic injections under Ultrasound guidance.

Can the problem get worse?

If untreated the problem can become worse. Surgery is not always required.

Non-surgical management

Surgery is not always essential. Patient fitness and suitability to undertake a lengthy, complex and technically demanding procedure is carefully assessed in the office. If the risks:benefits ratio of surgery is deemed unfavourable, then there is an array of non-operative options one can consider.

In the case of chronic infection, one can encourage the host, ie the patient, to live in symbiosis with the infection by way of long-term suppression antibiotic therapy. In the case of leg length discrepancy, simple measures such as fitting a shoe raise can help solve the problem. In situations of chronic loosening, one can pursue measures such as activity modification followed by careful assessment and adaptation of the patient’s home environment. In cases of chronic instability, one can consider the use of a hip brace to see if this can help contain the hip on a long-term basis.

Potential complications

It should be borne in mind that complications may result from a condition with or without surgery. Complications of non-operative treatment include: worsening pain, increased stiffness, increasing deformity, adjacent joint disease, pain elsewhere, for example in knee, hip or lower back (due to abnormal gait and compensatory mechanisms). Complications can occur with any type of surgery.

Potential general complications: risks and complications of anaesthesia, bleeding, infection, blood clots, failure to fully correct a deformity, the need for further surgery, persistent pain, complex regional pain syndrome and wound healing problems, genito-urinary and cardiovascular complications.

Potential complications which are specific to the surgery mentioned above include:

Nerve damage/foot drop, intraoperative fracture, stiffness, instability/dislocation, loosening, wear, leg length discrepancy, the need for revision surgery, non-resolution of symptoms and partial resolution of symptoms.

If develop sudden onset of chest pain, breathlessness/ breathing changes or sweating please call 999 immediately since this could be an undetected clot which has travelled to the lungs. This is an emergency and requires immediate treatment. This is a very rare complication.

Postoperative period & recovery

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.

After your operation, a routine enhanced programme of recovery will commence. The main parallel work streams of this programme are as follows

Physiotherapy

Mobilisation is commenced on Day One. Gradually there is an increase in the frequency of transfers in and out of bed. This then progresses onto stairs and mobilisation to the toilet/shower and back. Before discharge, the patient is well rehearsed in the exercise routine and the very specific rehabilitation and weight bearing plan. It is extremely important to remain well motivated and perform your exercises after discharge to fully optimise your recovery.

Occupational therapy

Will focus more on activities of daily living, functional transfers and adaptation of the home environment.

Pain control

During the operation, spinal anaesthesia with local infiltration of anaesthetic around the hip is often used. After the operation regular oral medication is then used. Ask for extra if required. Before discharge required prescriptions are provided.

Wound care

It is perfectly ok to experience an ooze from the wound especially as one mobilises. Your dressing may require changing. Before discharge, the wound should be dry and arrangements will be in place for staple removal by your practice nurse.

Nutrition, fluids and excretion

Immediately after the operation intravenous (directly into the veins) fluids are given. Medications such as routine antibiotics are also given via this route. Urine output is carefully monitored. A bedside commode may be needed during the first postoperative day.

Normal diet is introduced as soon as possible. The urine catheter is removed once mobile. Bowel habit should also return to normal before discharge.

Personal hygiene

On the first morning after the operation ablutions are performed at the bedside. Showering is then gradually introduced – at first with assistance and then independently.

FAQs

When can I stop using a walking stick?

This depends on the postoperative weight-bearing status. Sometimes protected weight bearing is required for six weeks after the operation. It can take a while before the muscles around the hip regain full control. Therefore normally you will be seen at six weeks after the operation before being advised to wean off any walking aids.

Why am I still not sleeping well?

During the first six weeks after the operation, very few people sleep throughout the night. Often you are sleeping on your back which is an unnatural position for some. When you eventually start sleeping on your side you may find it easier to place a pillow between your legs.

How far can I walk?

Following a routine primary total hip replacement, you should be able to walk the same distance as before the hip became symptomatic. Ensure that you don’t become tired, breathless or dizzy. With revision surgery, there is usually a more protracted recovery period.

Will security alarms at airports be set off by my new joint replacement?

Stainless steel replacements will set off the alarms. It may require you to have a word with the security staff to explain the situation. Titanium replacements usually go undetected.

What is an Anterior Cruciate Ligament Injury?

The Anterior Cruciate Ligament (ACL) is a very important stabiliser of the knee joint. Ligaments connect bone to bone, providing stability. An ACL injury results when this important ligament is damaged. It is the most commonly injured ligament in the knee.

What can cause it?

The classically described injury mechanism involves an indirect valgus (knee bent inwards) force coupled with a twist of the knee.

What are the symptoms and signs?

In the acute stage pain is a factor, however, this rapidly settles and the main symptoms are a feeling of instability or loss of confidence in the knee following repeated episodes of giving way.

There is often an instantaneous swelling of the knee following the injury. There may even be an audible ‘pop’ or ‘click’ heard at the time.

In summary symptoms following an anterior cruciate ligament injury include:

  • Pain
  • Popping sensation at the time of the injury
  • Swelling
  • Bruising
  • Limp

Once the acute swelling and bruising have settled, a thorough clinical examination is performed including the following special tests:

  • Lachman’s test
  • Anterior drawer +/- a pivot shift

Your knee surgeon Mr. Mann will also examine you to rule out or confirm the presence of any associated injury such as:

  • Focal meniscal injury
  • Osteochondral damage
  • Medial collateral ligament injury
  • Lateral collateral ligament injury
  • Posterior cruciate injury
  • Posterolateral corner injury
Can the problem get worse?

In isolated anterior cruciate ligament ruptures the natural history is often quite difficult to predict.

Some patients’ symptoms do settle with a dedicated course of ACL rehabilitation physiotherapy, which is directed towards neuromuscular optimisation of the knee joint.

A recent Scandinavian cohort/observational study, published in the British Medical Journal, showed that a significant proportion of patients do settle with just physiotherapy alone.

Non-surgical management

Acute phase

We recommend the PRICE regime:
Protection – minimise the risk of re-injury, for moderate to severe sprains, the use of crutches is recommended as well as the use of a knee brace
Rest – by avoiding walking on the knee while it remains painful and swollen (at least 48 hrs)
Ice – apply immediately or as soon as possible following the injury to minimise swelling (make sure ice is wrapped in a towel and you apply until area becomes numb, remove and discontinue the ice at this stage, continued application following numbing may result in tissue damage)
Compression – bandages and dressings help immobilise the injured knee, reducing pain and swelling
Elevation – of the knee to at least heart level to help minimise swelling and aid soft tissue healing

During the initial stages of this injury, it is often difficult to perform a meaningful clinical examination as the knee is too painful. Your surgeon will guide you according to the grade of your ligament injury.

Rehabilitation phase

Effective rehabilitation is critical to ensuring full recovery: resolution of painful symptoms, swelling and restoration of stability. It is also important as it will prevent the risk of chronic knee instability. Using an experienced physiotherapist can help with your recovery and rehabilitation.

The different stages of rehabilitation include:
Stage 1 –  this involves resting, protecting the knee and reducing the swelling (week 1)
Stage 2 – this involves restoring the range of motion, strength, flexibility and most importantly proprioception exercises of the knee (week 2-3)
Stage 3 – at this stage return to activities that do not require twisting or turning, and commence pool based exercises
Stage 4 – return to activities that require sharp, sudden turns (cutting activities) such as tennis and football (weeks to months)

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