Uncemented / Cementless Total Hip Replacement in India
Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts - the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the "ball" or head of the thighbone (femur). During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal. These artificial pieces are implanted into healthy portions of the pelvis and thighbones and affixed with a bone cement (methyl methacrylate).
An alternative hip prosthesis called a "cementless" total hip replacement has the potential to allow bone to grow into it, and therefore may last longer than the cemented hip. This is an important consideration for the younger patient. In some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cementless and would be called a "hybrid" hip prosthesis.
When is total hip replacement considered ?
Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or avascular necrosis (a condition in which the bone of the hip ball dies). Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons.
Circumstances vary, but generally, patients are considered for total hip replacements if : -
- Your pain is severe enough to restrict work, recreation, and the ordinary activities of daily living.
- Your pain is not relieved by anti-inflammatory medicine, the use of a cane or walker and restricting activities.
- You have significant stiffness of the hip.
- Your x-rays show advanced arthritis, or other problems.
What can I expect of a total hip replacement ?
A total hip replacement will provide pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your physician's instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.
The orthopaedic surgeon must be very precise in preparing the femur for a cementless impact. The implant channel must match the shape of the implant itself very closely. New bone growth cannot bridge gaps larger than 1 mm to 2 mm. Your surgeon may recommend a period of protected weight-bearing (using crutches or a walker) to give the bone time to attach itself to the implant. This protected weight bearing helps to ensure there is no movement between the implant and bone so a durable connection can be established.
Cementless femoral components tend to be much larger at the top, with more of a wedge shape. This design enables the strong surface (cortex) of the bone and the dense, hard spongy (cancellous) bone just below it to provide support.
The acetabular component of a cementless total hip replacement also has a coated or textured surface to encourage bone growth into the surface. Depending on the design, these components may also use screws through the cup or spikes, pegs, or fins around the rim to help hold the implant in place until the new bone forms. Usually these components have a metal outer shell and a polyethylene liner.
The pelvis is prepared for a cementless acetabular component using a process similar to that used in a cemented total hip replacement procedure. The intimate contact between the component and bone is crucial to permit bone ingrowth.
Initially, it was hoped that cementless total hip replacement would eliminate the problem of bone resorption or stem loosening caused by cement failure. Although certain cementless stem designs have excellent long-term outcomes, cementless stems can loosen if a strong bond between bone and stem is not achieved.
Patients with large cementless stems may also experience a higher incidence of mild thigh pain. Likewise, polyethylene wear, particulate debris, and the resulting osteolysis (dissolution of bone) remain problems in both cemented and uncemented designs. Improvements in the wear characteristics of newer polyethylene and the advent of hard bearings (metal-on-metal or ceramic) may help resolve some of these problems in the future.
Although some orthopaedic surgeons are now using cementless devices for all patients, cementless total hip replacement is most often recommended for younger, more active patients and patients with good bone quality where bone ingrowth into the components can be predictably achieved. Individuals with juvenile inflammatory arthritis may also be candidates, even though the disease may restrict their activities.
Preparing for Surgery
Preparing for a total hip replacement begins several weeks before the actual surgery. Maintaining good physical health before your operation is important and activities that increase upper body strength will improve your ability to use a walker or crutches after the operation.
The physician may order blood tests and urinalysis before surgery to make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected. Your Orthopaedic surgeon may ask you to see a medical doctor, especially if medical problems have been present in the past.
It is important that your teeth be in good condition. An infected tooth or gum may be a possible source of infection for the new hip. In addition, any blisters, cuts, or boils should be reported. If infection is found, surgery is generally delayed until the infection is cleared.
Will I need anything special at home ?
You will need a hand rails on the stairway into the house, an elevated toilet seat, and crutches or a walker. Optional things include handrails around the toilet, bath areas, and stairwells. Any scatter rugs should be removed and torn areas in the carpet or tile tacked down to prevent falling. In addition, watch out for small pets that may get underfoot!
When preparing for surgery, you should begin thinking about the recovery period after you leave the hospital. Discharge from the hospital is usually in about three to four days and a patient with a new total hip replacement is strongly encouraged to have someone at home to assist with dressing, getting meals, etc. for the first couple of weeks. If assistance from someone at home is not possible please let the discharge planner know.
It may be necessary to think about arranging a short-term stay in a skilled extended care facility, an acute rehab unit, or receive therapy at home with in-home care. To qualify for these options, you must meet certain criteria as directed by Medicare and/or your insurance carrier. If needed, outpatient therapy can be arranged in a facility near your home.
Due to changes in insurance coverage, it is necessary for most patients to visit the hospital before their actual surgery date. This visit usually lasts several hours, so plan to spend most of the day.
The day begins in the clinic, where an interview by the nursing staff concerning past medical history and current medications will be taken, as well as a chest x-ray. You may be instructed to stop taking your anti-inflammatory medications (Ibuprofen, Naprosyn, Relafen, DayPro, Aspirin) one week before surgery. You will be attending a teaching session, which will provide you with information about your surgery. There will also be time for discussion and questions. Bring a written list of past surgeries and of the medications and dosages that you normally take at home.
During your pre-op visit, blood will be drawn and lab tests done to insure that you are in good general health. X-rays are taken if necessary. Chest x-rays and an EKG are obtained if you have not had one taken for six months or if otherwise indicated. After all of these tests and exams are completed, a nurse will talk with you to determine the type of anesthesia that is best suited for you. Before you leave the hospital, make sure your questions are answered.
If at any time you become ill, such as with a cold or flu, you need to call your physician. Remember we want you to be in your best possible health!
Deep Breathing Exercises : - You should exercise your lungs every day before surgery by inhaling deeply through your nose, then slowly exhaling through your mouth. Repeat this three times and then cough two times, every 30 minutes. These exercises are necessary to remove any excess secretions that may settle in your lungs while you are asleep during surgery.
Ankle Pumps : - You should pump your ankles back and forth 1000 times every day. This is your best defense against blood clots. Crutches/Walker Please bring crutches or a walker with you to the hospital, so we can make sure that the equipment is in good working order and set at the right height for you.
These exercises will be given to you with detailed instructions during your pre-op visit.
Are there any special instructions I should know about ?
A shower, bath, or sponge bath should be taken the evening before and the morning of surgery with the medicated liquid soap that was given to you at the time of your pre-admission testing. Nail polish and make-up should be removed. Unless instructed otherwise, do not eat or drink anything after midnight
Here is an outline of the precautions you should follow after surgery : -
- Riding in a car is permitted as long as you make frequent stops, at least once per hour, to get out and walk around.
- Always sit in a chair with arms. Avoid sitting on low chairs or sofas. Instead sit in a high chair or place a firm cushion on your furniture. Use the armrests on the chair to assist you getting up.
- Do not cross your legs. Always sit with your legs 3 - 6 inches apart.
- Have a pillow between your legs when turning in bed.
- Avoid low or conventional toilet seats. Use a toilet seat riser for the next 12 weeks to avoid excessive bending of the hips. When using a public restroom, you should use the handicapped facilities to ensure adequate toilet height.
- No tub baths, only showers, until hip precautions are discontinued by your physician.
- Sitting in the bottom of your bathtub is forbidden. Do not sit in a bathtub until your physician approves that activity. You may want to get a shower seat for your tub.
- Do not reach down to put on shoes and socks. You may want to get a long handled shoehorn.
- Avoid stooping, squatting or bending forward excessively for the first 6 weeks. Use a reacher if you need something very low.
- Do not turn your knee, hip, or foot inward when sitting, standing, or lying down.
- Avoid sitting more than 60 minutes at a time.
- All furniture that you sit or lie on must be at least 18 inches off the floor.
- It is recommended that you do not drive until three to four weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/out of the car.
- Sexual activity can be resumed per your physician's instructions.
- You can usually return to work within three to six months or as instructed by your doctor.
Guidelines at Home
What happens after I go home ?
Upon discharge from the hospital, you will have achieved some degree of independence in walking with crutches or a walker climbing a few stairs, and getting into and out of bed and chairs. However, someone is needed at home to assist you for the next two weeks or until your energy level and mobility has improved.
Medication : -
You may be sent home on prescribed medications to prevent blood clots. Your doctor will determine whether you will take a pill (Coumadin or coated aspirin) or give yourself a shot (Enoxaparin). If an injection is necessary, your doctor will discuss this with you. The nursing staff will teach you or a family member what is necessary to receive this medication.
You will be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises. Remember that preventing pain is easier than chasing it. If pain control continues to be a problem, call your doctor.
Exercises : -
You will be instructed in a home exercise program designed by your physical therapist. Remember that walking is not a substitute for your exercises. If an exercise is causing long-lasting pain, you should cut back on your exercises. If it continues to cause pain, contact your physical therapist or physician.
Activity : -
Continue to walk with crutches or a walker as directed by the physician or physical therapist. Your physician will determine how much weight you can place on your operated leg. Walking is one of the best forms of physical therapy and for muscle strengthening.
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