After surgery
The first few days
When you are going home it is important to be careful, make sure you don’t fall or have an accident. You should be safe to transfer from bed to chair, chair to the toilet and you be able to wash and cope with meals. In particular, for the first few days make sure there are no accidents and be particularly careful with stairs and when reaching for things.
Sleeping
It is fairly common to advise patients to sleep on their back but more frequently we allow patients to lie on the opposite side to their surgery as it can be a lot more comfortable. It is important to place a pillow between your knees to make sure the hip is not abnormally abducted (crossed over the other leg) or moved into a rotation which again may cause a dislocation, but advice does vary quite considerably between surgeons and units. It is fair to say that advice and instruction will be given prior to discharge from therapists and staff as to how you can avoid potential dislocation and that is basically to avoid moving the knee too far up towards the chest and twisting the knee inwards.
How much exercise should I do?
Once you are home, during the day you should keep reasonably active, try to walk two or three times a day with your crutches.
Some patients like to get out of the house and walk for 10-15 minutes a day in the first few weeks but others take it a bit steadier and do most exercise inside.
There is no set protocol and patients increase their activities at slightly different rates. It is probably inadvisable to try and do too much too soon.
We usually advise our patients to take it fairly steady for the first six weeks to allow the repaired muscles around the hip time to heal. You can of course go out and about, travelling in a car as a passenger is normally possible from day one although we wouldn’t normally allow you to drive for the first six weeks.
Time spent on crutches is quite variable depending on the type of surgery. It may be from as little as three weeks, but many patients feel they need crutches for a lot longer.
Sometimes we ask patients to remain partial weight-bearing for up to 6 weeks. This should be discussed with your surgeon.
When coming off crutches we recommend using one crutch in the opposite hand to that of your surgery until you feel confident in the house then progress to using only one crutch outside. Some patients move to using a walking stick for a period but eventually you will feel confident enough with your new hip to discard walking aids altogether.
Follow-up
Patients are normally reviewed in the outpatient clinic between six and twelve weeks and if all is going well and the wound is fine we normally advise patients that they can drive, lie and sleep on their side and to do light exercise such as on an exercise bike or swimming. This is obviously the chance to talk to your surgeon about any queries or concerns you may have.
Returning to recreational activities
For patients who wish to return to medium level activities such as golf or gentle rambling then this can normally be started gradually at about 12 weeks. For those wishing to get back to higher level activities such as racquet sports, jogging, horse riding or any form of competitive activity then this would not normally be undertaken for six months and should be discussed in depth with your surgeon.
Physiotherapy
Many patients assume that extended or intensive physiotherapy is necessary after a hip replacement but this is often not the case. The main input from the physiotherapist is during the hospital stay to make sure you can use crutches properly and are safe to go home. Often patients do not need any physiotherapy after that period because their recovery is dictated by the general recovery and healing process and their activity and return to normal occurs as a natural process. Furthermore, the muscles around the hip can be exercised just as effectively in normal walking as with specific exercises that may put the hip at risk of dislocation.
There are various exercises which may be supplied to you by the hospital and these are often grouped into general health exercises to reduce blood clots, breathing exercises, muscle contractions and muscle strengthening and rehabilitation.
FAQs
How long should I use crutches after a hip replacement?
I would usually advise patients to use two crutches initially, one crutch at three weeks and by six weeks patients are often coming off crutches but this does vary.
Will I need physio?
Patients will have physiotherapy in hospital but this is not normally required afterwards because when patients get home we want to give the body time to heal.
When may I drive?
I normally allow patients to drive at six weeks assuming they have progressed as expected.
Can I sleep on my side?
We normally advise patients to sleep on their back for the first 6 weeks after total hip replacement. After 6 weeks, it is okay to sleep on either side as long as a pillow is placed between the legs to prevent the legs crossing. It may be too uncomfortable to lie on the operated side for some months however.
Can I do breast stroke?
Again, after 6 weeks it is perfectly possible for patients to swim. Some surgeons have in the past advised patients not to do the breaststroke due to the perceived risk of dislocation of the hip. However, we feel that the leg movements in breaststroke do not place the hip at risk and we are happy for our patients to do breaststroke.
What sort of exercises can I do?
The best form of exercise in the first few months after surgery is simple walking. The hip muscles are very active during normal walking and as they are supporting the body weight (and often much more due to the mechanics of the hip) they have to contract very strongly.
There is no set amount of walking that patients should do as everyone is different in terms of their pre-surgery fitness and mobility. The most important thing to remember is to build things up gradually over the weeks and months. Some exercises do put the hip at risk and, in particular, those that involve bending the hip excessively (such as using a rowing machine, yoga, squats) risk dislocating the hip.
Running is another exercise that may be harmful to a hip replacement and if you are keen to get back to running you should discuss this in depth with your surgeon prior to surgery. Some types of hip replacement are more resilient to the impacts of running and it may be possible to tailor implant choices accordingly.
Will I be able to kneel?
After a hip replacement, many patients can kneel down. The safe way to do this is to perform a single-legged kneel whereby the patient kneels on the knee of the operated side only. This means that the other hip has to bend whilst the operated hip stays extended. The reverse is true after a knee replacement as it may be too painful to kneel on the operated side whereas a single-leg kneel is possible on the opposite side.
How long should I use high seats and equipment?
High seats, raised toilet seats and other equipment is normally provided by the occupational therapy or physiotherapy departments. It is normally advised to use these for around 6 weeks but occasionally it may be necessary to use them for longer.
Tying shoe laces?
After hip replacement some patients still find it very difficult or impossible to either put their own socks on, cut toenails and tie shoelaces. Generally, the stiffer the hip is before surgery, the more difficult it is to achieve flexion afterwards. We do not normally advocate forcing the amount of flexion due to concern about dislocation. One important point to remember is that when trying to reach your toes it is always safer to put your arms down between your knees rather than around the outside of your leg and this rotates the hip into a safer position.
Back to work?
When to return to work is a very common question but it is highly variable and depends greatly on the type of work. Someone who works from home using the computer would probably be able to continue with this almost immediately whereas returning to manual labour can take 3-6 months. It is advisable to talk to your surgeon about the expected time frame for return to work but as a guide most patients who are not on their feet all day at work and are not involved with any lifting or carrying return to work at between 6 and 12 weeks.
Bending and lifting?
Before you leave hospital the physiotherapist will instruct you in the precautions you should follow during the first 6 weeks. These are essentially restrictions on the amount of bending at the hip. We try to limit the hip flexion to 90 degrees (a right angle) to reduce the risk of dislocation whilst the tissues around the hip heal. Similarly lifting of heavy objects should be avoided in the post-operative period as this often involves significant flexion of the hip…
Skiing
Whilst skiing after hip replacement is possible it is likely that regular involvement in high activity sports such as this may shorten the life-span of the prosthesis. This may be a risk patients are willing to take but again this should be discussed in depth with your surgeon. The other risk with skiing is of fracture around the joint occurring after a fall. Clearly this risk is proportionate to the skill of the skier. An expert skier who knows their own limits and can safely stay within them is at much lower risk than a beginner who will certainly fall on multiple occasions.
Running, cycling & mountain biking
It is possible to get back to all these sports after hip replacement, however, running in particular may be harmful to a hip replacement and if you are keen to get back to running you should discuss this in depth with your surgeon prior to surgery. Some types of hip replacement are more resilient to the impacts of running and it may be possible to tailor implant choices accordingly.
Cycling does not really pose any great risk to the hip and is a very good non-impact activity. Positioning of the seat and handlebars is important however. The seat position relative to the handlebars should not be too high so that you have to flex forward excessively to reach the handlebars but equally the seat should not be so low that the hips flex too much when pedalling. It is a good idea to use an exercise bike before going out on the road so that you get your hip used to the movements.
Whilst mountain biking tends to have a slightly better riding position, the increased risk of falling off does put the hip at risk of periprosthetic fracture (fracture around the hip replacement). This risk is related not only to the skill of the rider and the technicality of the terrain but also to tiredness so it is important to gradually build up your rides and stamina.
Tennis, squash & badminton
Most keen racquet sport players manage to get back to playing although this may take up to 6 months. Some sports involve higher impact than others and whilst it is possible to play a relatively sedentary game of tennis or badminton, squash does not really lend itself to being played slowly and oftentimes patients will realise that alternative sports are more appropriate.
Horse riding
Recreational horse riding should be perfectly possible after hip replacement. Mounting and dismounting pose the greatest risk (other than falling of course) and it may be that a high platform is required for this. Once in the saddle the hip position is a relatively safe one but may take some getting used to due to the relatively large amount of abduction (moving the legs apart) required.
Water sports
Sailing can vary from perching in a tiny dinghy to relaxing on a luxury yacht. The main issue is one of hip flexion. If you can sail your boat without extreme flexion of the hip, then things should be okay. It is certainly advisable not to go out on your own for the first few times however.
Surfing and windsurfing may also be possible after hip replacement however it is advisable to practise the required manoeuvres on dry land first (if possible) to ensure that you can do it. Again, the main issue is avoiding flexing the hip too far. Wiping out will obviously put the hip at risk of dislocation and you will probably only want to go out in relatively calm conditions. Water-skiing can involve extreme positions of the hip, particularly when water-starting and in a fall. As with snow skiing it is probably not a sport to take up as a beginner but someone who is already proficient may be able to return to a moderate level. Again, we advise discussing things though with your surgeon.
Outcomes
Total Hip Replacement
It is generally acknowledged that the results of total hip replacement both functionally and in terms of longevity are very good.
Most patients have resolution of pain or substantial improvement of pain and most patients get back to day to day activities.
Range of movement and function tend to be improved. Functional results are maintained over time.
In terms of how long joint replacement lasts, one method of measuring this is by so-called survivorship analysis. This is a mathematical method whereby one plots years against the ‘x’ axis and then looks at the number of failures that had occurred during a certain period.
Therefore, we can estimate what is the probability or chance of a hip or knee replacement lasting 10 years, 15 years, 20 years etc. and one can apply various other statistical techniques to look at the so-called 95 percent confidence intervals, i.e. high degree of confidence that those figures are applicable to the vast majority of patients.
This is a method which has been used in research papers and also in what is called Registry Information.
In Sweden, they set up a National Joint Registry in 1976 and various other countries including Norway, Denmark, Finland, Australia and more recently the United Kingdom have set up similar records. The National Joint Registry is a process whereby all operations are invited to be recorded from a country and therefore may be more representative of what actually happens compared to individual surgeons from various expert centres and therefore are looked at quite carefully by the Orthopaedic profession and increasingly from patients.
These Registries can be accessed:
The Registries have shown that the general results of joint replacement surgery have increased over time, i.e. in more recent periods the chances of a joint replacement lasting more than 10 years have increase and this is probably a reflection on better selection of implants and a better take up of surgical techniques. In broad terms the chances of a hip replacement lasting 10 years is in the region of 95 percent. In terms of 20 years the figures are not quite so robust but in the region of about 80 per cent for hip.
By visiting the various web sites, you will be able to see how different prostheses, in some cases different units and a whole host of other combinations can affect how well implants last.
Long-term follow-up
The British Hip Society recommends that patients be seen at one year and then at five yearly intervals, undergoing X-ray examination on each occasion. The reasons for this are continued post-operative surveillance are to ensure the well-being of the patient. It is believed that the surgeon is probably the best person to analyse the X-ray for any adverse signs that there may be in terms of the fixation, performance of the hip component and to make decisions about the action that may or may not be necessary. We frequently use questionnaires to follow up patients and these are sometimes sent in the post in-between follow-up appointments. Some institutions are under pressure to discharge patients back to their GP for follow-up of their hip replacement.
The National Joint Registry (NJR)
Since 2003 the National Joint Registry of England and Wales has been collecting data on patients undergoing total hip replacement. Currently data is being sent in on 80% of patients however the rate of data capture is increasing. The NJR are able to analyse this data to produce information regarding performance of implants and other techniques in relation to hip replacement surgery. (www.njrcentre.org.uk)